A system of practical medicine. By American authors. Vol. 4

by Unknown

From the preceding considerations it follows that the treatment, whether it be local or general, must at the outset be of a calming and sedative nature, the end in view in the great majority of instances being to overcome the exaggerated irritability of the genital nervous centres and the abnormal sensibility of the deep urethra. By the indiscriminate employment of strychnia, cantharides, phosphorus, and cold ablutions great harm is done, and the management of involuntary seminal emissions is brought into disrepute.

Of the local remedies to overcome the hyperæsthesia of the prostatic urethra, there is not one entitled to so much confidence as the nickel-plated conical steel bougie, passed at intervals of four days, and at once withdrawn for the first few insertions, after which, with the decrease of the sensibility, the intervals should be shortened, and it should be retained longer, until it is inserted every forty-eight hours and permitted to remain in the canal for a few minutes. The size of the first instrument is to be gauged by that of the meatus if it be normal, and if it be found necessary during the course of the treatment the orifice should be enlarged, in order that bougies of progressively increasing sizes may be introduced until they correspond to the full calibre or distensibility of the urethra, as indicated by the urethrameter. Unless these precautions be observed the measure will not bring about the desired result.

As a rule, the bougie will meet the indication, but in exceptional instances a small, circumscribed area of tenderness remains, which comprises the sinus pocularis, and which proves rebellious to instrumentation. Under these circumstances it becomes necessary to apply a drop or two of a solution of nitrate of silver to the spot, which is best done with a small syringe attached to a perforated bulbous explorer. The ordinary forms of porte-caustique charged with the fused nitrate are objectionable, as the remedy does not come in contact with the orifices of the ejaculatory ducts contained within the sinus pocularis, and its application cannot be properly controlled. From an ample experience I can confidently recommend the use of a thirty-grain solution, repeated every four days. Provided the patient be kept in bed for a few hours, the pain and desire to urinate will not last more than thirty minutes. When the affection proves to be more than ordinarily obstinate, flying blisters, made by pencilling cantharidial collodion first on the one side of the perineal raphé, and, after the surface has healed, on the opposite side, will prove serviceable.

In addition to these measures great assistance will be derived on retiring from the hot sitz-bath, or from a sponge or cloth dipped in water at a temperature of at least 105° F. and applied to the perineum and lower part of the spine. Cold applications are to be studiously avoided.

Of the general remedies, not a single one is comparable to bromide of potassium, which not only diminishes the reflex excitability of the cord and suspends sexual desires and the power of erection, but corrects the acidity of the urine and exerts an anæsthetic effect upon the mucous membrane of the urethra. I am in the habit of administering from three to four scruples of the salt at bedtime, and if I find that it sets up signs of bromism I diminish it for a time, and afterward promote its excretion by the kidneys by combining with it about fifteen grains of bitartrate of potassium. Should the patient be anæmic, the dose should be reduced to one drachm, and three grains of quinine along with twenty-five drops of the tincture of the chloride of iron should be ordered every eight hours. When, on the other hand, the patient is robust and plethoric or in full health, I frequently add to the bromide ten drops of veratrum viride or tincture of gelsemium, or administer the bromide in half an ounce of the infusion of digitalis.

Another remedy which diminishes the reflex mobility of the genito-spinal centre, at the same time that it reduces the secretion of the seminal fluid, is the sulphate of atropia. Given in the average dose of the one-sixtieth of a grain on retiring, so that the patient may sleep through its disagreeable action, it will be found to be an invaluable addition to the treatment.

When the bromide of potassium and atropia do not agree with the patient, I substitute the monobromide of camphor and extract of belladonna in the proportion of ten grains of the former to one-third of a grain of the latter. In the remaining anaphrodisiacs, such as lupulin, camphor, and conium, I have not the slightest confidence.

Under the plan of treatment thus outlined the majority of cases of nocturnal and diurnal pollutions recover; but if the spinal genital centre still remains too impressible, galvanization with the anode to the lumbar region and the cathode to the perineum will prove highly serviceable. When the condition is one of spermorrhagia, after the hyperæsthetic symptoms have subsided the relaxed and paralyzed orifices of the ejaculatory ducts may be restored to their normal condition by the continuous current, the negative reophore being placed in the rectum and the positive on the perineum or the lumbar vertebræ. Should galvanization fail, the induced current may be passed through a negative catheter electrode in the prostatic urethra to the anode resting on the perineum or spine; but this mode of application requires great caution, and a feeble power should be employed at the commencement. For this reason the rectal is preferable to the urethral reophore. In the absence of electrical apparatus the tonicity of the muscles of the ejaculatory ducts may be greatly improved, and even restored, by the use of the cooling sound, by the application of a thirty-grain solution of nitrate of silver, and by cold sitz-baths. In these cases half a drachm of the fluid extract of ergot after each meal, or fifteen drops of a mixture composed of six drachms of the tincture of the chloride of iron and two drachms of the tincture of cantharides, will also prove valuable. The operations of castration and excision of portions of the vas deferens need only be mentioned to be condemned.

To sum up the results of my experience in the management of seminal incontinence, I may add that the steel bougie, bromide of potassium, and atropia are especially adapted to cases of nocturnal and diurnal pollutions, and that after the hyperæsthesia has been relieved electricity, ergot, and strychnia are the most reliable agents in spermorrhagia. The end having been accomplished, moderation in sexual intercourse should be enjoined if the patient is married; continence in thought and action should be observed if he remains single; and matrimony should be advised if his circumstances and inclination warrant it. Marriage should not, however, be encouraged if the emissions are not arrested, as I have met with several cases in which the patient was rendered miserable by this act, from the fact that he deemed his case beyond all hope, as the emissions still continued.