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

by Unknown

3. Spermorrhagia.—In the third phase of the affection, which is still more uncommon than the second variety, there is a continuous passive loss of semen, without erection or sensation—a condition which depends upon paralysis and dilatation of the orifices of the ejaculatory ducts, and which is most conspicuous during the acts of micturition and defecation. The existence of spermatorrhoea, in the restricted sense of the term, is denied by some authors, but I have myself met with it in five instances, and typical cases have been recorded by other modern writers.

CLINICAL HISTORY.—Seminal incontinence usually supervenes upon the interruption of sexual intercourse, especially when the subject has been accustomed to excessive venereal indulgence, or, as more frequently happens, upon the abandonment of the habit of masturbation. Any one of these varieties may exist separately, but they gradually pass into each other, and are variously intermixed in the advanced grade of the affection. In the mild type there is increased frequency in the occurrence of nocturnal pollutions, ejaculation taking place at intervals of several days or for two or three nights in succession, when there is a respite for a week or ten days. The emissions are associated with disturbances of the nervous system, referable to the brain or spinal cord or to the cerebro-spinal axis, of which mental lassitude and muscular debility are the most common signs. When, as the result of the increase in the irritability of the ejaculatory centre and of the progressive weakness or exhaustion of the entire nervous system, the case goes on from bad to worse, it usually pursues the following course: Abnormal frequency of the nocturnal pollutions is associated with pain in the back, headache, muscular fatigue, and incapacity for sustained mental effort. With the increase in the number of the emissions erection becomes imperfect, ejaculation on coition is frequently precipitate, and the patient complains of dulness of perception, impairment of memory, mental dejection, a dull pain in the occipital region, weakness of vision, vertigo, palpitation of the heart, trembling and numbness of the limbs, shortness of the breath, flatulence, constipation, and other signs of gastric derangement. Diurnal pollutions are now superadded, and intercourse is impracticable, either from failure of erection or from premature ejaculation. The general symptoms, too, are more serious. The patient constantly broods over his condition, assumes that he has permanently lost his virility, and the mental anxiety and dejection verge upon or merge into a condition of sexual hypochondrism. The gait is unsteady; the hands and feet are habitually cold; he is subject to wandering neuralgic and rheumatoid pains; passes restless nights; loses flesh and color; shuns society; imagines that every one recognizes his condition, and fears to look one in the face; and is utterly incapacitated for mental or physical exertion. With the still further increase of the irritable weakness of the genitalia and nervous centres the semen flows continuously out of the urethra, and its discharge is augmented during defecation and micturition. Finally, the man becomes a confirmed hypochondriac, and should he have inherited a tendency to insanity, epilepsy, ataxia, or other nervous disorders, he may lapse into one of these conditions.

In the early stage of seminal incontinence, when the nocturnal pollutions overstep the natural limits, the ejaculated fluid is unchanged. When, however, the pollutions are more frequent and diurnal discharges coexist, the semen is watery and scanty; the spermatozoids are smaller, comparatively few in number, and their movements are liable to be abolished in less than an hour, while spermatic crystals form more rapidly and more abundantly than in health. In the worst cases, or those characterized by diurnal and nocturnal pollutions and by the presence of semen in the urine, the spermatozoids are either entirely absent, or, if they are present, they are motionless, stunted, or variously deformed. In these advanced cases the ejaculated fluid, which consists principally of the secretions of the seminal vesicles and the prostate, frequently undergoes fatty degeneration, as indicated by granular epithelium, by molecular detritus, and even by oil-globules in the protoplasm of the altered zoosperms. The entire absence of spermatozoids, constituting the condition known as azoospermatorrhoea, is of infrequent occurrence.

An examination of the genital organs discloses elongation of the prepuce in nearly one-fourth of all cases; a rigid and pointed penis in one-tenth; relaxation of the scrotum in about one-eighth; irritable testes in 1 example out of every 25; varicocele in 1 case out of every 50; coldness of the genitalia in 1 case out of every 17; a feeling of heat in 1 case out of every 33; and irritability of the bladder in 1 case out of every 25. It will, moreover, be found that seminal incontinence is complicated by feebleness of erection, with precipitate ejaculation on coition, in 22 per cent. of all cases; by the occurrence of ejaculation on attempting intercourse, before penetration, simultaneously with erection, or even before erection, in 16 per cent.; and with total impotence in 5 per cent. of all cases. Prostatorrhoea is also a not infrequent complication, while urethral strictures and hyperæsthesia are nearly always present.

ETIOLOGY AND PATHOGENY.—Seminal incontinence is not a separate entity, but one of many symptoms of general or local disorders, or of both combined. In the majority of instances it must be looked upon as a neurosis, diurnal and nocturnal pollutions representing a motor neurosis with spasm of the seminal vesicles, and spermorrhagia indicating a motor neurosis with dilatation and paresis of the orifices of the ejaculatory ducts. In all of the varieties there is increased susceptibility of the cerebral and spinal genital centres to factors which in healthy persons are not productive of ill effects.

Like other nervous disorders, involuntary seminal emissions sometimes manifest themselves in several members of the same family through several generations, being the result of inherited predisposition. In this class of cases the subjects are of a nervous, excitable, or irritable temperament, somewhat anæmic, and possibly suffered during infancy from nocturnal enuresis. Among the predisposing causes the most common is indulgence in erotic fancies, which terminates in increased reflex impressibility of the centres which preside over the genital organs.

The affection is, however, usually acquired, being met with particularly in single subjects toward the termination of the second decade and between the second and third decades. Of these cases, at least nine-tenths can be traced to masturbation, while the remainder will be found to have had gonorrhoea or to have masturbated, suffered from gonorrhoea, or indulged their sexual propensities in various ways. Seminal incontinence is not common as the result of sexual coition, and it is highly probable that when married men are affected the sexual excess is engrafted upon a previously vicious habit. From a practical point of view, it is of the first importance to be aware of the fact that one or more strictures of the urethra will be found in 80 per cent. of all cases, and that decided hyperæsthesia of the prostatic portion of the urethra is present in 94 per cent. of all instances.

The rational explanation of morbid seminal emissions seems to be as follows: Under the influence of erotic ideas, masturbation, sexual excesses, or unsatisfied sexual excitement produced by dallying with women, exaggerated irritability of the genital organs is induced, and is followed by subacute or chronic inflammation and abnormal sensibility of the urethra, particularly of its prostatic division, which terminate, in cases characterized by diurnal pollutions and spermorrhagia, in relaxation and dilatation of the orifices of the ejaculatory ducts. As the natural result of the constant excitability of the terminal filaments of the nerves distributed to the prostatic urethra, these nerves are alive to the slightest impressions, act as peripheral sources of irritation, and induce permanent increased mobility or irritability of the cerebral and spinal genital centres, through which the motor nerves of the ejaculatory apparatus are thrown into action, and an emission ensues.

Seminal incontinence is an occasional accompaniment of injuries of the spine, and it is also met with during the progress of or convalescence from acute and chronic diseases which are marked by disturbances or exhaustion of the central nervous system. Thus, it may be symptomatic of phthisis, variola, typhus, progressive muscular atrophy, and incipient bulbar paralysis, ataxia, and paraplegia; while the habitual use of opium and chronic alcoholism predispose to its occurrence.

Of the local causes referable to the genitalia, by far the most important and most frequent are hyperæsthesia and inflammation of the prostatic portion of the urethra, which are generally induced by masturbation. These lesions constitute the primary source of the trouble in the large majority of cases, and tend not only to excite reflex pollutions, but to maintain the disorder by keeping the mind occupied with sexual matters. Other common local causes are found in congenital narrowing of the meatus, organic stricture of the urethra, a redundant prepuce, balanitis, and the accumulation of smegma. Among the more infrequent etiological factors may be mentioned herpes of the prepuce, congenital shortness of the frenum, spasmodic stricture, polypus of the deep urethra, spermato-cystitis, and epididymitis.