itself, the catheter should be used, and the bladder should be washed
out, kept clean, and disinfected. All the suggestions laid down for
catheterization and vesical injection in the section on Chronic
Cystitis are applicable here and need not be repeated. It is
particularly necessary to disinfect the catheter on each occasion
before it is introduced. This is best effected by washing the catheter
outside and inside with a 5 per cent. solution of carbolic acid in
water, and finally washing it outside with clean water, before its
introduction. If the bladder is over-distended, it should not, as a
rule, be entirely emptied at the first introduction of the catheter,
for fear of possible collapse, or, what is more to be dreaded, setting
up acute cystitis by suddenly taking off all the internal pressure from
the vessels in the walls of the weakened bladder, to which pressure the
circulation has become accustomed. If, therefore, the bladder is
emptied inadvertently, it is better to inject a few ounces of warm
water containing borax in solution (a teaspoonful to the pint), and
leave it in until the next catheterization. The quantity left in may be
reduced at each sitting. By careful attention to these means most cases
of over-distension due to atony or paralysis may be relieved without
the intervention of cystitis, or with so little that it does not become
a serious factor in the case.
The medical treatment of these cases is less important than the
mechanical. Under the latter alone and improvement in general health
curable cases often get well. Milk diet is of service, and iron and
tonics of considerable value in proper cases. Electricity has not
yielded satisfactory results in my hands, and I have not derived the
advantage from ergot which is often claimed for it. In cases of atony I
think I have seen good results sometimes follow the use of strychnine
internally in pretty full doses. The same remedy under the skin acts
more promptly and more effectively if it is to do any good at all. In
true paralysis of central origin the cure of the bladder depends upon
relief of the original disease and local treatment to the bladder.
Hysterical women sometimes feign paralysis in order apparently to
secure the sympathy and personal attention of the physician. The
application of the actual cautery above the pubes, and entrusting a
female nurse with the function of catheterization, is generally
effective treatment in these cases.
Hemorrhage from the Bladder.
After all sorts of wounds and injuries to the bladder, and in cases of
rupture of the viscus, blood is found in the urine. In certain medical
{135} conditions, in scurvy, hemorrhagic eruptive diseases, cases of
vicarious menstruation, it has been noticed. In strangury due to
cantharides, or in any condition of acute or chronic cystitis with
considerable spasm of the bladder, the urine contains more or less
blood. Especially is this true if ulceration exist at or near the neck
of the bladder, as in tubercular or cancerous cystitis.
In cases of stone in the bladder one of the cardinal symptoms is
vesical hæmaturia, while in villous growth often the only symptom of
the malady is repeated attacks of more or less profuse bleeding from
the bladder coming on unexpectedly, without obvious exciting cause, and
showing no regularity in the length of the intervals between the
hemorrhages or the intensity or duration of the latter. Outbursts of
unexpected hemorrhage are not uncommon in connection with some cases of
enlarged prostate and chronic cystitis, while these outbursts are the
rule, sooner or later, in most cases of true cancer of the bladder.
The DIAGNOSIS is often very important--that is, in a given case to
decide whether the blood comes from the bladder or from the kidney.
This may usually be ascertained by a very simple manoeuvre, especially
when the flow of blood is not excessive: a silver catheter of short
curve is introduced and the urine drawn off, the bladder gently washed
several times without moving the catheter, and the shade of red in the
wash noted. Now, the bladder being slightly distended with warm water,
the point of the catheter is moved somewhat roughly in all directions
and made to touch different portions of the wall of the bladder. The
water is now allowed to escape, and its deepened color will decide that
the hemorrhage has a vesical origin, for manipulations of a silver
catheter in a healthy bladder will not occasion a flow of blood. In
doubtful cases on two occasions I succeeded in locating the point
whence the blood escaped as follows: In one I passed a soft catheter,
and washed the bladder until the wash escaped nearly clean; I then
withdrew the catheter until the point reached the membranous urethra
(the bladder having been left full of clean water), and immediately
passed the instrument again and withdrew the contents of the bladder,
which were now brilliantly colored, thus locating the bleeding point in
the prostatic sinus. In the other case, that of a young man with
moderate stricture, whose urine was nearly solid with blood, I noticed
that no blood escaped by the meatus between the acts of urination;
therefore the bleeding point was posterior to the membranous urethra.
Was it in the prostate, the bladder, or the kidney? To decide this I
passed a soft catheter and washed the bladder until the wash flowed
clear. I then injected some warm water, withdrew the catheter, and
caused the patient to empty the bladder. The flow was brilliant with
blood. In both these cases I effected a cure by one application of
solid nitrate of silver through the urethra to the prostatic sinus.
The TREATMENT of vesical hæmaturia is the treatment of the cause,
which, if possible, must be ascertained. For the symptom itself the
internal use of iron, turpentine, opium, gallic and tannic acids, are
of service. I have not derived any advantage from ergot. Locally, rest
in bed, ice over the region of the bladder, and avoidance of straining
at urination are generally all that is necessary. I have had good
results from injecting the bladder with a solution of alum, gr. i-ij to
ounce j of warm {136} water, and cures have been effected by injecting
nitrate of silver in solution. It is not well to inject iron in
solution, since this substance makes a hard clot, and a soft clot is
preferable. When the bladder fills up with a solid clot of blood, the
best treatment, according to my experience, is to administer opium
freely and diluent drinks. The urine slowly dissolves the clot, which
has already arrested the hemorrhage, in most cases by its pressure, and
the blood flows away as a dark coffee-ground material, sometimes nearly
black. If the catheter is used, the clot broken up or dissolved with
pepsin or other substance, and washed or pumped out, a new clot is apt
to form at once; and although this treatment is based on high
authority, and is often practised successfully, it is a question
whether the patient would not in many cases do as well, or better, by
being let alone, soothed by opium, until the urine dissolves the clot
and nature relieves him.
New Growths in the Bladder.
These belong strictly to the province of surgery, but they fall also
under the notice of the physician. Tubercular disease may involve the
whole mucous surface or only the neck of the bladder; cancer may
infiltrate its walls or grow out as a solid tumor in the vesical
cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and
cysts, simple and hydatid, have been encountered; villous growths, both
benign and cancerous, may occur. These morbid deposits give rise either
to recurrent hemorrhage or to varying grades of chronic cystitis. The
diagnosis is often difficult, the treatment generally palliative. Much
has been done of late in an operative way for the relief of tumors of
the bladder, and some brilliant results have been secured by operations
through the perineum as well as above the pubes. A tumor of moderate
size may be detected by the searcher within the bladder, and often may
be grasped in a lithotrite and measured. Such a tumor can generally be
plainly felt by conjoined palpation in a thin subject, one hand pressed
firmly down behind the pubes and two fingers of the other hand passed
into the rectum. Recently, Sir Henry Thompson has advocated vesical
exploration for purposes of diagnosis through a median incision in the
perineum, as for median lithotomy, and has practised it a number of
times with a large measure of success. I have made the same exploration
several times, and have encountered and successfully removed one tumor.
The expedient is worth bearing in mind for use in any obscure cases. It
is probably less objectionable and more likely to yield valuable
information than the exploration by introducing the whole hand into the
rectum (Simon's method).
{137}
SEMINAL INCONTINENCE.
BY SAMUEL W. GROSS, A.M., M.D.
DEFINITION.--By the term seminal incontinence, which is synonymous with
involuntary or abnormal seminal emissions, pollutions, and
spermatorrhoea, is meant the involuntary discharge of semen beyond the
limits of health. Although usually described as a distinct disease, it
is symptomatic of, and, as a rule, primarily dependent upon, weakness
or exhaustion, along with exaggerated irritability, excitability,
impressibility, or mobility of the centres which preside over erection
and ejaculation. Hence it should be regarded as a motor neurosis, and
not as a functional disorder of the testes.
CLASSIFICATION.--Involuntary seminal losses embrace three conditions,
which constitute as many varieties of the affection, and which may
exist separately, or pass into one another, or be combined. These
varieties are, first, nocturnal losses or pollutions, which occur
during sleep, and are generally attended with an erection, erotic
dream, and pleasurable sensation; secondly, diurnal pollutions, which
take place when the patient is awake, are excited by trivial mechanical
or psychical causes, and are associated with imperfect erection and
diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea,
in the strict acceptation of that term, which is characterized by a
constant escape of a slight amount of seminal fluid, without the
orgasm, pleasurable sensation, or impure thoughts, or during
micturition and defecation.
1. Nocturnal Pollutions.--By far the most common of the varieties of
seminal incontinence is the first, or that in which the emissions occur
during sleep under the influence of an erotic dream, and which may,
therefore, be regarded as an exaggeration of the normal or
physiological condition. In health, provided the subject leads a
continent life, the number of emissions varies greatly, and as they are
merely reflex signs of distension of the seminal passages, they are not
pathological nor are they attended with ill effects. The knowledge of
this fact is of great practical importance, as it frequently enables
the physician to assure his patient that the emissions are not
abnormal, thereby relieving his mind of a great weight. It is, of
course, to be remembered that the frequency of nocturnal pollutions
depends upon age, climate, habits, temperament, constitution, diet, and
predisposition, and that young men who suffered during childhood from
nocturnal incontinence of urine are particularly obnoxious to them.
Their frequency also varies greatly in the same person, and it is
scarcely possible to determine what constitutes the standard {138} of
health merely by the intervals of their repetition, since a number
which would be normal in one person would be abnormal in another. In
men, however, who possess sound nervous systems and who do not trouble
themselves with sexual matters an emission every fortnight is a sign of
excellent health; and even if they should occur at intervals of several
days, they are not inconsistent with temporary good health. The latter
statement is well exemplified by a case which came under my observation
in 1882. A druggist, twenty-seven years of age, had had for six years
from three to live emissions a week, and occasionally two during a
single night, attended with erections and voluptuous dreams, without
the slightest evidence of impairment of his health. In all such cases,
however, as well as in those in which the emissions have occurred at
longer intervals for a number of years, it only requires a little
longer time for general symptoms to manifest themselves.
Nocturnal pollutions are to be regarded as pathological when they occur
in married or single men who indulge in regular intercourse; when they
are followed by backache, headache, enfeeblement of the functional
powers of the brain, mental depression, and bodily or mental lassitude;
when they take place without erections or dreams; when they accompany
or follow acute or chronic diseases; when they coexist with diurnal
pollutions or spermorrhagia; and, finally, when they are complicated by
one of the varieties of impotence, which may be the only indication
that the emissions are abnormal or one of the effects of impairment of
the functions of the genital nervous centres. The associated symptoms
of myelasthenia and cerebrasthenia vary very much in degree in men of
apparently the same amount of vigor and tolerance, and in whom the
pollutions occur with equal frequency, or they may even be absent
altogether.
2. Diurnal Pollutions.--Ejaculation of semen during the day is
fortunately of comparatively infrequent occurrence, since it indicates
a more serious condition than do losses of seminal fluid occurring when
the patient is asleep, the genital organs and the centres which preside
over them being highly impressible or in a state of irritable weakness.
In what may be regarded as the lesser form of the affection the
ejaculation is due to slight peripheral irritation, induced, for
example, by friction of the clothing, crossing of the legs repeated
several times, horseback exercise, driving over rough streets, riding
in railway-cars, or even shaving, combing the hair, or shampooing the
head; while in the more aggravated variety an emission is induced by
psychical irritation, such as reading libidinous books, the sight of
indecent pictures, dwelling upon sexual ideas, or the mere sight of a
female. In the former of these varieties there is a fair erection, but
the sensibility is blunted; in the latter the erection is flabby or the
penis is flaccid and there is little if any pleasure.
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 {139}
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 {140} 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 {141} 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.