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 {142} 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
{143} 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 {144} 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.
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 {145} 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, {146} 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.
{147}
DISPLACEMENTS OF THE UTERUS.
BY E. C. DUDLEY, A.B., M.D.
The title of this article is not to be taken in a restricted sense,
inasmuch as the uterus is anatomically so connected with adjacent
organs that the displacements of the uterus cannot be intelligently
considered or satisfactorily presented without at the same time
incidentally taking into account the displacements, causative,
resultant, or concurrent, of the ovaries, Fallopian tubes, rectum,
vagina, and bladder.
Normal Location and Position of the Uterus.[1]
[Footnote 1: The importance of a distinction between location and
position will become apparent hereafter: by the former is meant the
situation of the organ regardless of its attitude, by the latter is
meant the attitude alone. To change an object from one place to another
is to change its location; to turn it over or bend it upon itself is to
change its position.]
In the works on anatomy and gynecology which we are accustomed to
consult the uterus is represented as having a straight or nearly
straight canal--as lying about midway between the symphysis pubis and
the hollow of the sacrum, its axis corresponding to that of the pelvic
inlet. They generally agree that its position is one of slight, and
only slight, anteversion; some admit that slight anteflexion may not be
injurious, but most would pronounce the organ anteverted or anteflexed
to a degree that would endanger health if by conjoined manipulations
its anterior wall could be felt through the anterior wall of the
vagina. The classical idea of the normal position of the uterus
presupposes a distended bladder and rectum occupying the anterior and
the posterior thirds of the pelvic cavity. Such an arrangement would
leave for the uterus only the intermediate space, and would constitute
a condition seldom or never realized in health.
Suppose a straight line coincident with the vesico-vaginal wall (Fig.
1) to be continued through the cervix to the sacrum. This line
represents approximately the antero-posterior diameter of the pelvis.
The length of the vesico-vaginal wall is two and a half inches, and,
supposing the cervix to be just midway between the symphysis and the
sacrum, the distance from its posterior wall to the sacrum must also be
two and a half inches. Add to the sum of these two parts of this
antero-posterior diameter one inch for the cervix, and the
antero-posterior diameter of the pelvis becomes six inches instead of
the normal four and one-third; which proves that the cervix must
normally be much nearer to the hollow of {148} the sacrum than to the
symphysis. Since the length of the vesico-vaginal wall plus the
diameter of the cervix measures three and one-half inches, it follows
that the distance from the posterior wall of the cervix to the hollow
of the sacrum must be the difference between four and one-third and
three and one-half inches, or five-sixths of an inch.
[Illustration: FIG. 1. The Classical Representation of the Pelvic
Organs.]
Again, suppose the uterus (Fig. 1) to be carried bodily upward and
backward, its axis remaining the same, until the cervix reach its
normal position near the hollow of the sacrum; then would the body of
the uterus impinge upon the bony sacrum. It is therefore clear that the
anteversion must be the normal position, because the uterus and sacrum
would otherwise occupy the same space.
Fig. 2 represents, according to Schultze,[2] the location and position
of the virgin uterus and its surroundings, the bladder, rectum, and
vagina being empty and collapsed. The angle of about 90° which the
cervix forms with the vagina measures the forward inclination of the
cervix, but is subject to slight variations in consequence of the
physiological {149} movements of the uterus. The body is furthermore
bent forward upon the cervix, so that its anterior surface rests upon
the empty bladder. The angle of the normal anteflexion, according to
careful measurements by Schultze, is about 48°; Fritsch says that 90°
is the physiological limit. This question will be further considered
under the subject of pathological anteflexions.
[Footnote 2: _Archiv für Gynäkologie_, 1875, Band viii. p. 134, and
_Lageveranderungen der Gebarmutter_, Berlin, 1881.
Ely Van de Warker makes a full and critical study of the normal
movements of the unimpregnated uterus in the _N. Y. Medical Journal_,
xxi. p. 337, and of the normal position and movements of the
unimpregnated uterus in the _American Journal of Obstetrics_, xi. p.
314. His conclusions substantially agree with those of Schultze.
Frank P. Foster (_American Journal of Obstetrics_, xiii. p. 30)
presents a valuable paper giving a résumé of the literature, with
original observations, in which he takes exceptions in part to the
views of Schultze.]
[Illustration: FIG. 2. The Correct Representation of the Pelvic
Organs.]
Normal Movements of the Uterus.
Strictly, the uterus can have no absolutely normal position or
location, because it has a certain normal range of movements which
depend to some extent upon respiration, intra-abdominal forces, and
locomotion, but more especially upon the varying quantity of material
in the rectum and bladder. Its normal position, then, varies within the
limits of its normal movements. If the body of the uterus rest upon the
bladder, it must rise as the bladder becomes distended, and,
conversely, if the urine be drawn through a catheter while the woman is
lying on her back, the uterus, notwithstanding the opposing influence
of its own weight, immediately follows the receding wall of the bladder
and returns through an angle of 45°, or possibly even 90°, to its
accustomed position. The dotted lines in Fig. 2 indicate the degree of
version and flexion consequent upon the varying quantity of fluid in
the bladder.
{150} The full rectum forces the uterus in the opposite direction,
toward the symphysis, and thereby counteracts the influence of the
bladder. This anterior movement is, however, somewhat limited, and is
confined to the cervical portion, except when the body has been forced
back into close proximity with the rectum by the over-distended
bladder.
Normal Supports of the Uterus.
The uterus is maintained in its normal position and location by the
following agents:
_a_. The uterine ligaments;
_b_. The pelvic floor.[3]
[Footnote 3: For a description of the female pelvic floor see Hart's
_Atlas_.]