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

by Unknown

Among the remaining exciting causes of pollutions are diseases of the anus and rectum, as hemorrhoids, morbid growths, ascarides, fissures, ulcers, pruritus, and painful eruptions. The nerves of the rectum and anus being derived from the same region as those of the genitalia, it is not surprising that the ejaculatory centre should respond to an impulse transmitted from them. In habitual constipation straining at stool may also excite an emission through the consentaneous action of the muscles of the abdomen, rectum, and seminal vesicles; but this is only observed when the orifices of the ejaculatory ducts are paralyzed and patulous.

ANATOMICAL CHARACTERS.—There are no records of the morbid appearances which appertain to seminal incontinence in its early stage, but that the hyperæsthesia of the prostatic urethra depends upon chronic or subacute inflammation is rendered certain by the concomitant symptoms, by exploration with the sound, aided by the finger in the rectum, and by the results of treatment. In the advanced stage, post-mortem inspection has disclosed stricture of the urethra, injection of the mucous membrane of the deep portion of the urethra, dilatation and excoriation of the orifices of the ejaculatory ducts, and suppuration of the prostate and the seminal vesicles. The changes which occur in the nervous centres are unknown.

DIAGNOSIS.—The microscope affords the only positive mode of determining whether the fluid which is discharged from the urethra during pollutions, or constantly moistens that canal in spermorrhagia, or is expelled at stool or with the urine, or is brought away by the bulb of the explorer, is seminal in its character. Should spermatozoids be detected, there can be no doubt as to its true nature, but their absence is not an evidence that the case is not one of spermatic incontinence, since in the condition known as azoospermatorrhoea the exhausted sexual apparatus furnishes a thin, transparent, watery fluid which may be entirely devoid of fertilizing elements, and contains cylinder epithelial cells, epithelium which has undergone fatty or colloid degeneration, a few lymph-corpuscles, an abundance of fatty detritus, and a few small shining bodies which are the remains of the badly-evolved spermatozoids. Under these circumstances, the history of the case, the fact that the subject is or was a masturbator, and the associated nervous symptoms are aids in forming a diagnosis; and this is especially true of cases in which a fluid is expressed at stool, and which in the majority of instances is the altered secretion of the prostate. Under the microscope the thin, more or less milky prostatic fluid will be found to contain cylinder epithelium, numberless colorless and refracting granules of lecithin, and minute yellowish concentric amyloid concretions; and, after it has slowly dried upon the slide, crystals of phosphate of magnesium or of ammonio-magnesian phosphate will make their appearance.

Should a microscopical examination be impracticable, we may assume that the discharge which occurs during defecation in the subjects of too frequent nocturnal pollutions is an evidence of coexisting prostatorrhoea; while we may frame the rule that the flocculent sediment contained in the urine and the discharge at stool of persons suffering from both nocturnal and diurnal pollutions, and a slight continued discharge from the urethra represents semen. In the last event we may moreover assume, especially if the patient be impotent, that the orifices of the ejaculatory ducts are relaxed.

PROGNOSIS.—Nocturnal emissions are very amenable to treatment, particularly when they are kept up by appreciable local lesions, the only cases which are, as a rule, rebellious being those in which the pollutions are associated with chronic inflammation of the seminal vesicles. In expressing an opinion in a given case the physician should, however, be influenced by the severity of the signs of nervous exhaustion. If the general symptoms point to involvement of the cord alone, the prognosis is far better than when signs of cerebrasthenia are present; but the outlook is bad if, in addition to cerebral and spinal exhaustion, the patient is a sexual hypochondriac. Nocturnal pollutions occurring during the progress of acute or chronic general disorders are also, as a rule, readily checked. The prognosis in the same class of cases is, moreover, far better when the usual local lesion—namely, morbid sensibility of the prostatic urethra—has been induced by gonorrhoea rather than by masturbation; and it is also more favorable when the pollutions occur in mature years from sexual excesses than when they are due early in life to masturbation.

Even when the emissions occur during the day from trivial psychical or mechanical causes, ample experience has convinced me that the prognosis is far better than many writers would lead one to believe. These cases are, however, less tractable than those of nocturnal pollutions, but they finally recover with the exercise of a little patience. The worst outlook is when the emissions are passive, or occur without the orgasm, or during urination and defecation. In this class of cases not only are the ordinary remedies applicable to the other varieties demanded, but measures will have to be resorted to to overcome the paralyzed and dilated orifices of the ejaculatory ducts. Although the prognosis is not as favorable, I have never seen an example of spermorrhagia that did not finally yield to treatment.

TREATMENT.—Certain hygienic and moral rules must be observed in the management of all the varieties of seminal incontinence. The diet should be plain, nutritious, and digestible; the evening meal should be light and dry; and spirits and malt liquors, as well as stimulating articles of food, should be eschewed. As the morning fulness of the bladder is very liable to produce an erection, that organ should be thoroughly emptied on retiring; and as pollutions usually occur toward morning, the patient should set an alarm-clock one hour before the time at which he has generally observed that the emissions take place, in order that he may be awakened to relieve the bladder of its contents. He should also sleep upon a hair mattress without much covering. Everything calculated to induce a flow of blood to the genitalia, such as horseback exercise, driving over rough roads, and railway travelling, should be interdicted. Masturbation and sexual intercourse must be abandoned, and the subject should be informed that the enforced rest of the organs will possibly result in temporary increased frequency of the pollutions. Chaste associations should be cultivated, and erotic thoughts and desires be banished. To attain this end the mind and body should be kept pleasantly occupied by gymnastic exercises and the study of any subject which the patient may fancy. If, however, he be not in full health, or if there are commencing or marked signs of spinal or cerebral exhaustion, mental and physical exercise should be taken in moderation.

In the treatment of involuntary seminal emissions a thorough examination should be made of the genital and associated organs, with the view of detecting and getting rid of any reflex or eccentric lesions or causes which predispose to, or even excite and maintain, them in impressible subjects. If the patient has a redundant prepuce, it should be removed; if the meatus be contracted, it should be enlarged; while balanitis, herpes, hemorrhoids, rectal fissure or ulcer, or pruritus should be treated in the usual way. In not a few mild cases, particularly those dependent upon phimosis, a contracted meatus, or a stricture just behind the orifice, it will be found that operative interference is quite sufficient to bring about relief. Habitual constipation, which is met with in about one-third of all instances, demands particular attention, either by enemata of temperate water or a pill composed of one-tenth of a grain each of aloin and extract of belladonna, administered every eight hours.

In the section on the etiology and pathogeny of seminal incontinence attention is called to the fact that hyperæsthesia of the prostatic urethra is nearly always present. While it is undoubtedly true that the genital nervous centres may be highly impressible without the intervention of hyperæmia, inflammation, and abnormal sensibility of the prostatic urethra, it is none the less true that those lesions are the most constant and most important of all the causes which excite and maintain the disorder, especially in masturbators, in whom, moreover, strictures may be looked for in about eight-tenths of all cases. As a rule, the coarctations will be formed just behind the meatus, but others may be present posteriorly. Be this as it may, a knowledge of their existence is of the first importance, as they aggravate the morbid condition of the prostatic urethra and serve to keep up a peripheral source of spinal neurasthenia.

For the detection of a stricture the exploratory or acorn-headed soft bougie should be resorted to, as it is the only instrument with which coarctations of large calibre and granular patches can be accurately defined, and with which abnormal discharges can be withdrawn for minute examination. One being selected which fills the meatus, it is warmed and well oiled, and inserted as far as the bladder. Should its introduction be arrested, smaller sizes are successively employed until one will pass without difficulty. On its withdrawal the abrupt shoulder of the bulb coming in contact with the posterior face of the stricture imparts to the touch a sensation as if it had jumped over a band, while a granular patch conveys the impression of a limited roughness of the canal. Hyperæsthesia of the urethra is readily determined by the nickel-plated steel bougie, and its existence should never be based upon the passage of the soft explorer alone, as the latter is productive of far more pain than the former. In conducting these examinations a contracted meatus or a stricture just behind the orifice should first be divided, in order that the instruments for exploration may correspond to the normal calibre of the urethra. Unless this point receives attention the examination will be likely to prove valueless. Should one or more strictures be present, the case must be referred to a surgeon.