The neuroses of the genito-urinary system in the male with sterility and impotence

Front matter

RC ZIZ.

tntlifCitpotlmigcrk

Hibrarp

Preface To Revised Edition

Although it is now several years since Ultzmann wrote these monographs, and we must greatly regret that he did not live to revise his own work, yet his knowledge of the subject was so profound that comparatively little has been added to it during the interval, except in certain points relating to sexual disorders. In the present edition a supplementary article treats somewhat more at length the nervous form of impotence. A few notes also have been added to the book. It is believed that this new matter brings the subject down to the present day.

^3)

TRANSLATOR'S NOTE.

This translation, published with the author's permission, is of the two monographs, " Ueber die Neuropathien (Neurosen) des mannlichen Harn- und Geschlechtsapparates " and " Ueber Potentia generandi und Potentia coeundi." It is hoped that a wider circulation than has heretofore been accorded in this country to the sound pathological teachings and successful methods of treatment of so eminent an authority as Prof. Ultzmann will throw light on the management of this very difficult and refractory class of cases.

Inasmuch as the two parts treat of kindred

subjects there is some necessary repetition in

the original. This has been to some extent

avoided by slightly abridging the second part.

The omissions are indicated by references to the

first part.

G. W. A.

Part I. Page

Introduction, T

The Urine in Genito-Urinary Neuroses, . 1 2

Classification, 24

1. Sensory Neuroses:

(a) of the Urinary System, . . 25

{b) of the Sexual System, . . 31

2. Motor Neuroses:

(a) of the Urinary System, . . 43

(&) of the Sexual System, . . 81

3. Secretory Neuroses:

(a) of the Urinary System, . . 103

(b) of the Sexual System, . . 104

PART II. Introduction, Ill

Sterility, Ill

ISTOTES, 161

Etiology, 166

Pathology, ^4

Prognosis, .118

Treatment, I'TO

Open Knowledge Commons

THE NEUROSES OF THE GENITO- URINARY SYSTEM IN THE MALE.

TPHE neuroses of the male urinary and sex- -*■ ual system belong among the more frequent forms of disease. Although the nervous diseases of the urinary system, as well as those of the sexual organs, may occur alone, still we find not infrequently several forms of nervous disease of both systems in the same individual, usually united by one and the same setiological origin, so that it seems best to treat of the neuroses of the urinary and of the genital organs in the same connection.

The aetiology of this class of disease may vary greatly. Now it is to be sought in local changes of the so-called neck of the bladder (prostatic urethra), and now in general disturbances of nutrition.

The general disturbances of nutrition appear sometimes in consequence of chronic brain and spinal affections, or they consist in that exalted, abnormal reflex excitability, sometimes inherited and congenital, usually, however, associated with anaemia and a feeble constitution. Per-

8 Neivroses of the Genito-Urinary System

sons of a perfectly normal constitution may nevertheless acquire an exalted reflex excitability, which disposes to neurosis of the genito-urinary system, if they weaken their organism by overstrained physical, but especially by exciting mental, activity long kept up. Not infrequently, indeed, we find nervous vesical tenesmus (cystospasmus) in persons who have exacting night work to do, or in individuals who, in addition to severe mental activity, hold an unusually responsible position, as with cashiers, secretaries, and such persons. Even so also the cares of life engender the most varied neuroses in the urinary system. Still further, shocks to the general nervous system, great fright, pain, and grief, give rise to nervous disturbances as well of the urinary as of the sexual functions. The immediate influence of the central nervous system on the urinary apparatus may even be observed in children, when they from fear of threatened punishment pass urine involuntarily in their clothes. Likewise we see vesical tenesmus with polyuria show itself in individuals who keep themselves in a state of long-continued excitement ; as, for instance, candidates before severe examinations, when the result is uncertain, or in persons who have engaged in a mercantile speculation of doubtful outcome. Great and unexpected loss of property, such as sometimes occurs in unfortunate stock operations, or the death of a beloved person, may also cause the most varied nervous phenomena in the urinary and sexual apparatus. Thus I have often seen in the case of seriously damaged business-men frequent micturition, polyuria, sometimes even slight glycosuria, and, further, sexual impotence, emissions, and spermatorrhoea suddenly appear.

A much larger contingent in these nervous cases, however, is furnished by those manifestations of disease which have their origin in local changes in the urinary system, and which consequently are to be looked upon as reflex neuroses. In this connection, the most harmful influence on the urethra and on the prostate is exercised by the gonorrhceal process. A gonorrhoea, which runs a normal course, begins at the orifice of the urethra, and ends at the beginning of the sphincter vesicae externus. If, however, an abnormal course sets in, if the gonorrhoea extends beyond the isthmus urethrse, then, in the first place, the prostate is involved by sympathy ; it becomes catarrhal ; and if prostatic catarrh once becomes chronic, then various nervous symptoms gradually arise, now in the urinary, now in the sexual system. Likewise localized hypersemia occurs, and even prostatic catarrh, around the verumontanum after gross excesses in venery and after masturbation. In this case, through long-continued and too often 1* repeated sexual excitement, the congestion of the prostatic urethra and especially of the caput gallinaginis is so long kept up that ir. has finally become localized there as a chronic affection, and a catarrhal condition of the prostatic ducts, of the sinus pocularis, and of the ejaculatory ducts has established itself. This hyperiemic and chronically inflamed condition of the prostatic urethra sometimes has, as a consequence, a general exalted reflex excitability, a high degree of nervousness, and sometimes we find in men phenomena which usually appear only in intensely hysterical women. Since many women, ill with nervous and hysterical affections, suffer from abnormalities of the uterus associated with cervical catarrh, it will not seem strange to us if men who suffer from chronic congestive or inflammatory processes of the prostate present similar nervous phenomena, especially as the prostate with the utriculus masculinus is, in men, that organ which finds its analogue in the female uterus.

The exact connection between the nervous system and the functions of the urinary and sexual apparatus is still very little understood; yet we know from Eckhard and Goltz that the centres for the nerves which preside over erection, for instance, are to be sought in the lumbar region of the spinal cord. Also the secretion of semen, the action of the vasa deferentia and of the vesiculse seminales, are under the influence of the spinal cord.

The prostate and the uterus are both structures very rich in nerves, and they are innervated by one and the same nerve-plexus. The hypogastric plexus of the sympathetic, which is reinforced by filaments from the sacral ganglia and from the pudendal plexus of the sacral nerves, innervates the uterus in women by means of its accessory plexus, the plexus uterinus, and in men the seminal vesicles and prostate, together with the bladder, by means of the plexus vesicalis. In the uterus, according to Kilian, the nerves are found in greater number in the cervix, and according to Klein, we find especially numerous nerve-trunks in the prostate between the sphincter urethrse and the circular striped muscular fibres of the cortical layer, which extend along the urethra, and hold scattered between their fibres numerous ganglion cells. The prostate also contains in its cortical layer ganglia and Pacinian corpuscles, which are elsewhere only present in organs very sensitive and rich in nerves. Since the hypogastric plexus of the sympathetic is in intimate connection with the pudendal plexus of the spinal nerves, and this latter presents a subordinate plexus of sacral nerves, which again, on their side, stand in the closest relation with the lumbar nerves; so, when in organs very rich in nerves, such as the uterus and prostate, the peripheral terminations of the nerves are kept in a constant state of excitement by chronic inflammatory processes, it appears very clear that by transmission of this irritation to other nerves in the area supplied by ramifications of the nerves belonging to the plexi mentioned, neuroses of the most varied cliaracter may appear in the genito-urinary tract. In like manner worms — Oxyuris vermicularis, — eczema, and catarrhal ulcers of the anus produce by transmission neuroses of the urinary and sexual apparatus as well as general reflex excitability.

The pathological-anatomical records in this connection are very scanty. Kaula has collected several autopsy reports, and has found organic changes as follows: sometimes the results of chronic, in part suppurative, inflammation, with ulceration, in the pars prostatica urethrce, which extends to the ejaculatory ducts and the vesiculse seminales, sometimes changes in the ejaculatory ducts, widening of their orifices and dilatation of their lumen, sometimes strictures, inflammation of the neck of the bladder, total or partial hypertrophy of the prostate, or, on the other hand, atrophy of the prostate (Curschmann).

The Urine in neuroses in general, and especially in those of the genito-urinary system, offers sometimes such characteristic conditions that an exact knowledge of them materially aids in diagnosis. First of all it is to be noticed that patients who are affected with neuroses not infrequently suffer at the same time with polyuria. They urinate often, yet have no pain or inconvenience except that they have to produce so much urine. The urine of polyuria is of a pale straw color, and clear, with a low specific gravity (urina spastica, nervosa, diluta). Yet sometimes there is a great quantity of urine without the specific gravity of the urine being diminished in a corresponding proportion. In this case there is at the same time an increased excretion of solids, a diabetes insipidus. This I have observed in a 13-year-old anaemic and excitable boy, who daily passed 7 litres of colorless urine, almost as clear as water, of which the specific gravity was 1.005. The 24-hour quantity of solids amounted to 81 grammes. The patient was always thirsty, and was at any time ready to pass 400 or 500 c.c. of urine. Sugar was not present.

It has been known since Claude Bernard that a puncture in the floor of the fourth ventricle, and, indeed, in a small circumscribed spot between the origin of the vagi and that of the acoustic nerves, produces polyuria, and at the same time glycosuria. It has also been found that certain changes in the central nervous systern are accompanied by polyuria and glycosuria.

If the puncture fails to cause glycosuria, there is still usually polyuria. It is not uncommon also to find polyuria in patients who are suffering from an affection of the central nervous S3'stem. Lecorch^ and others have found that in diabetes mellitus there is an increased excretion of nitrogenous urinary constituents, that is to say, an accompanying azoturia or diabetes insipidus; and I have had repeated opportunities to convince myself that the light forms of diabetes mellitus, which can be cured by an exclusive meat diet, excrete considerably more urea and uric acid after the so-called cure than other healthy men ; in other words, they still suffer from azoturia. In the case of a diabetic patient who passed in 24 hours 4 litres of urine containing 5 per cent, of sugar, the sugar disappeared in a short time under an exclusive meat diet; yet the 24-hour amount of solids in the urine was 100 grammes, or about one-third more than normal.

Polyuria in neurotic cases cannot always be explained in the same way, still it is generally associated with irritability. By experiments on animals we find, according to Claude Bernard, that after each puncture the abdominal viscera appear highly congested.

Much more seldom we find in nervous troubles a diminution of the amount of urine, that is, oliguria and even anuria. Anuria in comparatively healthy persons without disease of the kidneys I have never observed but twice, and both times in hysterical women. In these cases

1 could draw from the bladder with the catheter a very small quantity only of urine ; the anuria lasted from one to two days. Benedikt reports such a case in a hysterical woman, which lasted eight days. I have not yet seen nervous anuria in men.

Sugar is not infrequently found temporarily in small quantities and even to the amount of

2 per cent, in the urine of neurotic patients. A patient affected with impotence and general reflex irritability I once found to have transient glycosuria with 2 per cent, of sugar. Further, in several cases after violent mental disturbance a mild glycosuria ensued which lasted days and weeks. I have also not infrequently observed the presence of small amounts of sugar in the urine in chronic brain and spinal diseases. Leudet has found sugar in the urine in the greatest variety of cerebral diseases. Also, after a blow on the head, after certain drugs (curare, morphine), sugar is found temporarily in the urine. A light symptomatic glycosuria, - which is usually transient, is a common occurrence in diseases of the nervous system, and the same importance is by no means to be attributed

16 Neuroses of the Ge)dto-Urinary System

to it as to diabetes mellitus. I knew an old man who had 3 per cent, of sugar in his urine about ten years ago. He had no other diabetic symptoms, and he visited Karlsbad yearly. Gradually paralysis of the bladder had come on, and three years ago retention of urine suddenly set in. I was consulted at this time, and no longer found any sugar, nor have I since then, up to his recent death (of interstitial nephritis), been able to find any sugar in his urine. In this case the glycosuria appears to have been associated with the development of paralysis of the bladder. That glycosuria of a mild form is also found in diseases of the liver and portal vein is a well-known fact, which need not be considered here.

Very often, in cases of neurosis, the freshly passed urine has a neutral and sometimes even a faintly alkaline reaction, although the patient may have ingested neither alkalies nor mineral water, nor anything, indeed, which could explain the reaction of the urine. Such a urine is usually of a pale wine-yellow color and clear ; and only when the reaction is decidedly alkaline does it seem to have a slightly cloudy turbidity.

Carbonate of ammonia, the ordinary alkali of other alkaline urines, is not present. On the contrary, there is a fixed alkali, generally the carbonate of soda. Cazeneuve and Livon have succeeded in making the urine of dogs alkaline in every case by dividing the spinal cord in the cervical region. According to Maly, the acid reaction of the urine is brought about by the separation of acid salts in the urinary system (in the renal tubules) by the process of endosmosis, from the alkaline mixture of inorganic salts as found in the blood serum. Yet according to the theory of secretion as taught by Baumann and lately by Heidenhein and Wittich, the renal epithelium is the structure which should separate the fixed constituents of the urine. In accordance with this view it may also be assumed that the renal epithelium is the structure wliich prepares acid urine from alkaline blood, as indeed is accepted also by Kiihne. At any rate the whole secretion of urine, as we have already shown, is under nervous influence ; it is no wonder then if in nervous affections, as a rule, a disturbance or change in the secretion of urine is brought about, so that a neutral or even faintly alkaline urine is excreted.

An essential result of the neutral or alkaline reaction is the turbidity which such urines assume on heating, the earth}/ phosphates being precipitated. Heller has already remarked this phenomenon, and has designated it as a characteristic occurrence in diseases of the nervous system. Heller calls these earthy phosphates precipitated by heat "bone-earth" [Knochenerde], because the precipitation shows a chemi-

18 JVcuroscs 0) the Grenito-Urinary System

cal compound which is presented by the earthy constituents of bone. Phosplioric acid forms with lime and magnesia three classes of salts, according to its basicity. First, acid salts, when one equivalent of acid unites with one equivalent of base ; these salts are readily soluble, and are present in all acid urines. Second, basic salts, when one equivalent of acid unites with three equivalents of base ; these salts are insoluble, and exist in alkaline urine in the form of an amorphous sediment. Lastly, neutral salts, when one equivalent of acid unites with two equivalents of base ; these salts are somewhat less soluble than the acid salts, and are found in neutral urine. If these salts are m solution in neutral urine, the simple warming in a test-tube is enough to precipitate them. If, however, they are in the sediment, they appear crystalline in contrast to the basic earthy phosphates. Since, on heating the urine, albumen is also precipitated, the character of the white precipitate must be shown by the addition of a drop of acetic acid ; the earth}"- phosphates are immediately dissolved, while a precipitate of albumen remains unchanged on the addition of acetic acid. If the precipitate becomes dissolved with an active development of gas, it consists of a mixture of carbonic and jjhosphatic salts of the alkaline earths ; if it dissolves without the production of gas, it consists of phosphates alone.

Sometimes there is an increase of indiean in the urine in neurosis. In persons who practise masturbation there is sometimes a large quantity of indiean found in tlie urine, and even the emissions of these persons, wlien dried on their linen, show spots which are bordered with a marked indigo blue or violet color. After excesses in venery, as after sexual excitement in general, we find large quantities of indiean in the urine. This is also a common occurrence in nervous and hysterical women. It is well known that in diseases of the central nervous system, especially in cerebro-spinal meningitis, very large quantities of indiean are found in the urine (Oppolzer). Indiean is usually present in the urine in solution, yet not infrequently indigo is also found in blue and bluish-black scales and flakes in the urinary sediment. In the nitric acid test for albumen the presence of a large amount of indiean is shown by a narrow blue or bluish zone resting on the ring of brown coloring matter on the border between the colorless nitric acid and the urine. If this bluish zone is distinctly seen, a beautiful separation of indigo may be obtained by the Jaffe test. Jaffe's test is performed in the following manner : about ten cubic centimetres of urine and an equal quantity of strong hydrochloric acid are mixed together, and to the mixture are added one or two drops of a cold saturated solution of In'pochlorite of lime. The indigo immediutely becomes separated, and colors the mixture bluish-black or violet. If now, according to Senator, a few cubic centimetres of chloroform are added, and made to flow through the mixture by repeated shaking of the test-tube, the chloroform takes up the indigo, and is colored a beautiful blue. It is well known that indican appears in the urine in large quantities in diseases of the abdomen (in peritonitis, constipation, incarceration, etc.). I have seen, in a fatal case of peritonitis in the clinic of Prof. Lobel, a urine colored violet by the large amount of indigo, not unlike red wine in appearance and with a deep-blue sediment.

Albumen is also sometimes found in these cases, yet relatively seldom and only in small amount. This mild albuminuria is ordinarily merely transient, and is only found after great excitement, just as it occurs, for example, after an epileptic fit. Albuminuria, indeed, may be produced by injury to the floor of the fourth ventricle, and Coe even maintains that the albuminuria of pregnancy is also only a neurosis of the kidneys. Still, this last opinion is to be accepted with great caution, since, even if this explanation be the right one in cei-tain cases, yet it certainly does not hold in the majority of cases of albuminuria of pregnancy.

The urinary sediment, too, in the neuroses is sometimes very characteristic. Oxalate of lime is very often found, and indeed not infrequently in large quantities. The oxalate of lime appears in the form of colorless crystals, usually the quadrate octohedron and its combiuation with the prism, but not infrequently the divingbell or hour-glass forms and spheroids of oxalate of lime are seen mixed with the octohedra of

Fig. 1.— Oxalate of lime. 300 diameters.

various sizes. I have seen much oftener and much greater quantities of oxalate of lime in the urinary sediment of cases of neurosis than of renal calculi. I attribute, therefore, much less importance, in the formation of renal calculi, to the oxalate of lime than to the sharppointed uric acid. For years together in cases

22 JYeuroses of the Genito- Urinary System

of neurosis I have seen the heaviest sediment of oxahite of lime without symptoms of beginning renal calculus appearing at the same time

Another not uncommon urinary sediment, which appears only as a result of a neutral or faintly alkaline reaction of the urine, consists of amorphous or finely granular carbonate of lime

Fig. 2. — Finely granular carbonate of lime and crystalline phosphate of lime. 300 diameters.

mixed with amorphous phosphate of lime. The white, finely pulverized sediment is dissolved on the addition of a drop of acetic acid, with the formation, sometimes of few, sometimes of many, bubbles consisting of carbonic acid. Sometimes also, mixed with the amorphous sediment, small, colorless, wedge-shaped crystals are found, the bases of which appear bevelled ; these consist of crystalline phosphate of lime. The crystals appear sometimes single, and sometimes so grouped together that several crystals lie side by side with their apices converging to a single point. Moreover, whole rosettes or sheaves are seen, of which the bases of the crystals form the periphery, while the apices unite at the middle point of the rosette or sheaf (Fig. 2). A rare sediment, sometimes found mixed with the crystalline phosphate of lime, is the crystalline phosphate of magnesia. This appears usually in the form of long quadrilateral tablets, of which the opposite corners appear rounded off. All these forms of crystalline earthy phosphates are also found in the urine after the ingestion of fixed alkalies or of mineral waters containing such.

Spermatozoa are likewise not uncommon in the urinary sediment of men. They are found in large numbers in the urine in spermatorrhoea, yet single spermatozoa appear also in the sediment in other neuroses of the urinary system (Fig. 3).

Finally, as already mentioned, indigo in small blue or bluish-black scales and flakes is found in the urinary sediment. Sometimes mdigo is present in such large amount that the sediment appears blue. This, however, is a very rare occurrence. In one case of tabes and paralysis

24 Neuroses of the Grenito- Urmari/ System

of the bladder I liave had the opportunity for a long time of observing the blue sediment of precipitated indigo ; this glaucuria suddenly disappeared. The same patient suffered also with temporary glycosuria with two per cent, of sugar, without simultaneous polyuria or other diabetic symptoms. If at the same time urates, especially urate of ammonia, are present in the

Fig. 8. — Amorphous carbonate of lime, crystalline phosphate of magnesia and spermatozoa. 300 diameters.

urinary sediment, they decompose the indigo, and appear sometimes colored blue, sometimes violet in their otherwise characteristic forms.

The Neuroses of the Urinary and Sexual Organs may be divided into three wellrecognized groups, according as they affect —

1. Sensation.

2. Motion.

3. Secretion.

Following this order, the neuroses of the urinary apparatus will be treated first, and then those of the sexual organs.

1. (a) The Sensory Neukoses which stand in the closest relation to the urinary apimratus are sometimes confined to the urethra and bladder alone ; sometimes, however, they appear also in the form of cutaneous hypersesthesia in the vicinity of the urinary organs. In the urethra the patients sometimes feel a troublesome burning, which is especially severe in the pars pendula and about the fossa navicularis. This burning is either constant, or it occurs only during, and for a short time after, micturition. At times the patients complain of an increased sensitiveness, of a feeling of rawness of the urethra (Jiypercesthesia urethrce). Not infrequently, however, the sensitiveness of the urethra increases to a periodically recurring shooting pain, which, according to the account of the patients, gives rise to a feeling as if a red-hot wire had been pushed into the urethra from behind toward the glans penis (neuralgia urethrce). These neuralgic pains often come on during and after micturition ; during micturition especially when the penis is slightly compressed with the fingers.

2 B

26 Neuroses of the G-enito-JJrinary System

The cutaneous hypersesthesia is ordinarily confined to the skin of the penis itself and that of the mons veneris. Yet sometimes patients complain of the most varied sensations in the whole abdominal region, in the nates and the thighs ; now a burning, stinging, or great tenderness of the skin, again a feeling of numbness and weakness. In some patients there is at the same time an increased general reflex irritability, and these cases often present symptoms which would onl}^ be looked for, in such a degree, in hysterical women.

As to cetiology, the patients generally ascribe their trouble to a gonorrhcea which, indeed, has commonly been one of long standing, and accompanied by swelled testicle or inflammation of the bladder. On examination of the prostate i^er rectum nothing abnormal is felt.

The urine shows either no abnormal condition, or it contains one of those constituents which have just been described. Thus not infrequently the earthy phosphates are precipitated by heating. At the same time, also, it is common to find in the urine, in greater or less amount, shreds [Tripperfaden], and especially those thick and short ones, sometimes resembling large-headed nails, which usually come from the prostatic urethra. It is also well known that in the various diseases of the prostate, hypersesthesia or neuralgia of the urethra occurs. Thus I have found, at least, the highest degree of sensitiveness of the penis, and especially of the glans, in patients who were affected with a neoplasm in the region of tlie prostate and neck of the bladder. On examination with the sound a greatly increased sensitiveness is sometimes met with in the prostatic urethra.

Hypersesthesia and neuralgia of the bladder are common accompaniments of spasm of the bladder, and will be treated of later in that connection, among the motor neuroses.

All these neuroses of sensation, occurring in consequence of gonorrhoea, are generally reflex neuroses, and readily occur in connection with catarrhal prostatitis. The expulsion of numerous thick and short shreds with the very beginning of micturition, and the absence of even the least secretion from the urethra (goutte militaire), make it certain that the diseased portion of the urethra is in the region of the external sphincter ; consequently in a place which is ordinarily closed by muscular action, and is only opened during micturition. Improvement therefore ensues forthwith when the pars prostatica urethrse and the prostate itself are subjected to local treatment. Next to warm sitz baths and full baths, enemata of warm water or camomile tea, at a temperature of 28° Reaumur [95° Fahr.], twice or three times daily, will prove

28 JV^euroses of the Crenito- Urinary System

most efficient in connection ■with local treatment of the prostatic urethra. This latter should be so carried out that, by means of instruments, astringents and even nitrate of silver are introduced into the prostatic urethra.

I usually employ in the local treatment of the prostatic urethra a short, metallic catheter (Fig. 4), v^'hich I have had made for this purpose. The catheter is 16 cm. long, and has a calibre of Charriere No. 16. The vesical end has the ordinary curve of the metallic catheter, is smoothl}'- rounded, and is perforated like a sieve. The outer end is furnished with a round plate and a piece of rubber tubing (Fig. 4). The catheter is introduced to such a depth that its point is just within the membranous portion of the urethra (consequently anterior to the prostate). The disk prevents the catheter from slipping in more deepl}^, and at the same time serves to close the external meatus. A mark on the disk shows alwaj-s, in introducing the catheter, the direction of the vesical end. The catheter having been in this manner introduced into the membranous urethra, an ordinarj'' syringe, containing 100 grammes of fluid, is attached to the tubing on the end of the catheter, the latter is steadied with the left hand, and the whole contents of the syringe is slowly and with gentle pressure driven through the prostatic urethra into the bladder. If the end of in the Male.

the catheter is in the membranous portion, all the fluid can be injected through the prostatic urethra without difficulty, since the catheter is already partly within the external sphincter, which therefore offers no resistance. If the point of the catheter, however, reaches only the bulbous portion, then the fluid cannot be driven through the prostatic portion even under strong pressure ; it will either flow out beside the catheter, or will painfully distend the urethra.

These injections through the prostatic urethra should be given once every day, or, at least, every other day. For the first and second injection I use 100 grammes (a syringe full) of a 1-4 to 1-2 per cent, solution of carbolic acid, then I change to a 1-2 per cent, [sulphate of ] zinc solution ; and, as soon as the patients bear the injection well, I increase