WJA B287o 1870 *>.f f \ V SPERMATORRHEA: ITS CAUSES, SYMPTOMS, RESULTS, AND TREATMENT. ROBERTS BARTHOLOW, A.M., M.D., Professor of Materia Medica and Therapeutics in the Medical College of Ohio; Lecturer on Clinical Medicine, and Physician to the Hospital of the Good Samaritan; Lecturer on Morbid Anatomy, and Pathologist to the Cincinnati Hospital, etc. _ '-HMlHPfON 6£N€RAL'S ul F(C£ ' HCV. -30.1301 NEW Y O-R K ; Jl^^ J_„ ...... ._ WILLIAM WOOD & CO., 61 WALKER STREET 1870. W37V, ig^o 9 TABLE OF CONTENTS. PAGE Preface to the Third Edition........................ i» Preface to the First Edition.......................... iv Preface to the Second Edition........................ yi Introduction....................................... 1 I. TRUE SPERMATORRHEA.................... 5 Causes.................................. 5 Physical.......................... 5 Masturbation.................. 6 Premature Puberty............. 6 Masturbation in Infancy......... 1 Phymosis..................... 8 Influence of Example........... 10 Lesions of Urethra............. 11 Lallemand's Yiews.............. 13 State of Nervous System........ 24 Moral.............................. 26 Symptoms............................... 28 Objective Symptoms of Masturbation..... 28 Subjective " " ..... 31 Objective " Spermatorrhoea... 32 Subjective " " ... 34 Genital Form......................... 36 CONTEXTS. PAGE Cerebral Form........................ 42 Spinal " ......................... 48 Results................................. 53 Weakness of Mind.................... 53 Irregular Action of Heart............... 54 Impotence............................ 56 Yaricocele............................ 55 ■ Irritable Testis........................ 58 SPERMATORRHCEA AS A SYMPTOM......... 62 Tabes Dorsalis........................ 63 Diseases of Brain and Cord............... 64 IMAGINARY SPERMATORRHCEA............ 71 TREATMENT................................ 74 Local......,............................. 74 Porte Caustique........................ 77 Injections............................ 82 Circumcision.......................... 85 Other Instrumental Means.............. S7 Systemic Treatment...................... 89 Remedies............................ 90 Anaphrodisiacs................. 90 Aphrodisiacs................... 96 Treatment of the Causes................ 99 Remedial Management.......... ] 03 Marriage............................. ll4 Formulae................................ Ug PREFACE TO THE FIRST EDITION. A shokt essay on the Pathology and Treatment of Spermatorrhoea, based upon a clinical lecture deliv- ered at St. John's Hospital, and published in the Cincinnati Journal of Jledicinc, having met with a very favorable reception from the profession, it has seemed desirable to give the subject fuller treatment from the same point of view. There have been but few special treatises on this disease of a reputable character. The work of Lallemand, Despertes seminales involontaires, Paris et Montpelier, 1837-41, is the source from which subsequent writers have drawn their information. A portion of this work has been presented in an English dress by two translators—Wood and Mc- Dougall. Additions to the translation of the last named have been made by Maris Wilson, and in this form it is the principal authority now in the hands of American physicians. The subject is also dis- cussed, necessarily in an incomplete manner, in vari- ous works on the practice of medicine and surgery. Besides these authorities, Mr. Acton has lately ad- dressed the general public in a work on the repro- ductive organs, in which he discourses more or less fully on Spermatorrhoea. VI PREFACE. I think it is a reproach to our profession that this subject has been permitted, in a measure by our own indifference, to pass into the hands of the unscrupu- lous pretenders, whose suggestive publications are amongst the crying evils of our time. Because the subject is disagreeable, and to a certain degree dis- reputable, competent physicians are loath to be con- cerned with it. The same unnecessary fastidiousness causes the treatment of this malady to be avoided in private practice; and the unfortunate patients, thus precluded from obtaining intelligent advice, fall into the hands of advertising specialists, who excite their worst apprehensions for a mercenary purpose. For this reason, and to obviate the sad consequences which result from spermatorrhoea, it is our duty to exert our best efforts in behalf of those afflicted with this malady. We should endeavor to attain to correct views of its pathology, and apply our knowledge to its cure—if for no other reason, for the good of our species. My little work will have done all that I can desire for it, if it assist the practitioner in forming correct views of the nature of spermatorrhoea, and enable him to conduct cases of this disease to a more suc- cessful issue than he has hitherto been able to accom- plish. PREFACE TO THE SECOND EDITION. A second edition of this monograph having been called for within less than a year after the publica- tion of the first, is a gratifying evidence of the appre- ciation of my labor by the medical profession. In the present edition, some typographical errors, overlooked in the first, have been corrected; a table of contents has been appended, and new matter has been added at various places throughout the volume. These improvements will, I trust, make the present edition still more worthy of the favor so largely ac- corded to the first. PREFACE TO. THE THIRD EDITION. I have to express my acknowledgments to the medical profession for the very great favor with which the two previous editions of this work have been received. As it now appears in this edition, the material has been rearranged, and in large part rewritten. Some illustrations have been introduced, and an appendix of formulae added. The value of the book will, I trust, be considered to be enhanced by these changes and additions. More enlarged experience since the appearance of the first edition, has not caused me to amend any of my views of the nature and true mode of treating spermatorrhoea. I am, indeed, more than ever con- firmed in the view that it is a neurosis, and that the treatment, to be successful, must be founded on this pathological basis. It. B. 27 West 8th Street, Cincinnati, Ohio. NOTICES OF THE FIRST EDITION OF THIS WORK. From the New York Medical Journal for October, 1866. " Lallemand's erroneous teachings on the Pathology and Treatment of Spermatorrhoea have been, for more than twenty years, the guide of the ma- jority of practitioners, and we are glad, at length, to see the subject ably and judiciously discussed in a special treatise, and the more correct views of modern investigators fully set forth. Viewed in this respect alone, the little work before us will accomplish a good purpose; but again it will be productive of a double good, for an enlightened comprehension of the sub- ject will lessen that aversion which too many practitioners entertain to. ward a subject at once disagreeable in itself, and to a certain extent disre- putable, and thus many an unfortunate and truly pitiable subject of this dis- tressing malady will be rescued from the hands of,the ignorant and pretend- ing charlatans to whose mercenary offers he is not unfrequently driven in desperation to resort by the indifference of the regular practitioner. The book supplies a want that has long been felt by the profession, and can be confident- ly recommended as a reliable guide to both student and practitioner, and as embracing the more recent and well-sustained advances that have been made, both in the pathology and therapeutics of the malady in question." From the Medical Record, November 1,1866. " This duodecimo, which is a philosophical revision of a by no means gen- erally understood subject, clears away much of the rubbish that has hereto- fore encumbered its literature. The writer, who substitutes for many of the vexed questions very tenable views of his own, makes no violent deductions, but states objections with candor, and arrives at his conclusions by logical sequences. We bespeak for the work a cordial reception on the part of the profession, and for the author additional laurels to a growing- reputation." From the Twenty-fourth Annual Report of the Managers of the State Lunatic Asylum,, Utica, N. Y., for the year 1866. Report of Dr. Gray, Superintendent, p. 33: " I would commend to the attention of the profession the admirable little work of Dr. Roberts Bartholow on Spermatorrhoea, recently published be Wm. Wood & Co., New York." NOTICES. From the Boston Medical and Surgical Journal, November 8,1866. " This little book is a well-written and judicious essay on Spermatorrhoea considered under the above divisions, which we can recommend to the pe- rusal of our readers. The valuable and practical instruction on treatment it contains will be found worthy of careful study by all who are consulted up- on this neglected affection." From the Philadelphia Medical and Surgical Reporter, Sept. 15,1866. " Dr. Bartholow's treatise upon Spermatorrhoea seems to us to have been judiciously conceived and well executed. Lallemand's ideas of the pathology and treatment of this affection have too long maintained the sway of routine. Central in those ideas, as all know, is that of the constant importance, in the production of Spermatorrhoea, of irritation or inflammation of the prostatic portion of the urethra, and of the seminal ducts. Hence his use of the ports- caustique. * Dr. Bartholow summarily disposes of all this, and asserts, we believe truly that the affection in question should take its place among the neuroses, as essentially a functional derangement of the excito-motor spinal system. He would limit the use of the porte-caustique to those conditions of inflammation ulceration, and hyperesthesia of the prostatic portion of the urethra, really proved to exist, and refractory to other less painful and dangerous methods ; or, for moral effect, to obstinate cases accompanied by severe hypochondria, or continued masturbation. Moral treatment of a larger kind, with appro- priate regimen, tonics, etc., will be of service in the greater number of cases. Circumcision, it is well urged, should not be omitted in two classes of cases: 1. Those in which the habit of masturbation is due to the hyperesthesia of the glans, produced by an elongated prepuce, and the irritation of retained sebaceous matter. 2. Those in which the same cause (a peripheral irritation) induces the venereal orgasm and involuntary discharge. " This treatise, however, goes very systematically over the whole subject. It is extremely well worth reading by all practitioners, as a good exposition of sound views. We will only mention, as particularly of interest, in addi- tion to what has been said—the denial by Dr. Bartholow of the frequency of ulceration or inflammation of the prostatic portion of the urethra in sperma- torrhoea, in this country, at least; his clear discrimination between the not uncommon mucous discharges and true diurnal seminal pollutions; and his testimony to the positively anaphrodisiac effects of bromide of potassium in appropriate cases. This remedy, he states,'will be effectual in proportion to the degree in which structural lesions are absent, or in other words, in pro- portion to the degree in which these morbid states are functional rather than organic.' The failures of Dr. S. W. D. Williams and others, are accounted for by the existence of organic causes." SPERMATORRHCEA: ITS CAUSES, SYMPTOMS, RESULTS, AND TREATMENT. INTRODUCTION. It seems to be necessary to define, at the out- set, what is meant by Spermatorrhoea. The sense in which this term is used not always being the same, confusion has arisen as to its real patholo- gical import. By some, following in a literal sense its etymological signification, this term is restricted to that condition in which there is a constant stillicidium of semen, without, of course, 1 2 SPERMATORRHOEA. the preliminary phenomena of erection and eja- culation. If this definition be accepted, sper- matorrhoea can be admitted to exist but rarely. According to a more widely received view, spermatorrhoea consists in the emission of semen without copulation, or in involuntary seminal losses of every kind. If the former definition be defective by reason of too limited scope, the latter is defective in a more injurious degree, because it embraces a physiological as well as a pathological state. The term spermatorrhoea should be restricted to that condition in which involuntary, seminal losses occur with sufficient frequency to produce a definite morbid state. It is very important to be accurate on this point, for nothing is more common than mistaken views in regard to the pathological importance of occasional spermal losses. A physiological con- dition is frequently confounded with the results of disease. The prevalence of this error is due chiefly to the false statements so persistently put forth by advertising specialists in regard to the evil consequences of nocturnal pollutions. I can- not too strongly impress on my readers, that.after INTRODUCTION. 3 the period of puberty involuntary seminal losses occur in the continent with more or less frequency, according to the activity of their sexual organs. The young man who, ignorant of its nature, hap- pens to this accident for the first time, is much concerned, especially if he have read the impure publications on this topic now so widely distribu- ted. In such a case the intelligent and humane physician may render a lasting service by an exact statement of the importance of these physi- ological emissions. Although many cases of so-called spermator- rhoea are physiological in character, we should not therefore assume that no morbid state is pro- duced by frequent involuntary losses. Spermatorrhoea is also a symptom of lesion of some part of the central nervous system. It has, then, but little importance as compared with the serious disease of which it is but an indica- tion. It follows from the foregoing considerations, in order to have a true comprehension of spermator- rhoea, it must be studied from several points of view. I purpose, therefore, to treat of the sub- ject according to the following scheme: 4 SP ERM ATORRHCE A. 1. True Spermatorrhoea. Its Causes. Physical. Moral. Its Symptoms. Its Results. 2. Spermatorrhoea as a Symptom. 3. False or Imaginary Spermatorrhoea. 4. Treatment. CAUSES. 5 I. TRUE 3p%&MAT0RRII(EA. OAU&ES. Physical.—The yice-: of masturbation is un- doubtedly the cfiief cause. The growth of the sexual apparatus,^ the period of puberty is ac- companied by abundant secretion of the seminal fluid, which accumulates in the reservoirs. The sexual instinct, then fully developed, exerts a powerful influence over the mind, whilst the reason is not in a sufficiently matured state to correct the mirages of the imagination. An accidental friction of the erect organ in these moments of delirium makes the unfortunate youth acquainted with a new and voluptuous sensa- tion.* Ignorant of the dreadful consequences which must ensue from the repeated perpetration of this act, the youth perseveres in his secret pleasures until arrested by realizing some of the sad effects upon the mind and body which follow. * Tissot. ISOnanisme. Dissertation sur les Maladies pro- duites par la Masturbation. Also, Fournier et Begin, Dic- twnnaire des Sciences Medicales, vol. xxxi., pp. 100-134. 6 SPERMATORRHOEA. Although the practice of this vice is not con- fined to boys of the nervous type, yet it finds in them victims the most willing, and the least able to resist the continually increasing demands of the habit. Boys of vigorous constitution, in whom the digestive and muscular systems are well developed, are less under the control of these erotic impulses, and are more able to resist the inroads of the habit when formed, because in them the exercises of youth and the satisfaction of the appetite occupy their minds. A premature and unnatural development of the genital apparatus may give origin to the vice of masturbation. Mr. South has related an ex- traordinary case of premature puberty, in which involuntary losses occurred:— "When he was about four months old, the hair on the pubes began to grow very thickly and black, at which time the penis increased in size, particularly the glans, so that it gradually extended beyond the prepuce, till about fifteen months, when it was entirely exposed; the pubes were then completely covered with black, curling hair.....Soon after this, she (his mother) noticed that his linen was stained two or three CAUSES. 7 times in the week.....She also states that since he has been in town (six weeks) the emissions have been more frequent than for some time previously."* Mr. South gives the following measurements of the penis of this ex- traordinary infant: length of penis when pendent from the symphysis pubis, three inches; length of penis when erect, six inches. This is probably the "most rare and curious" case of premature puberty on record; certainly it is the earliest period at which spermatorrhoea has occurred. Such an instance is wholly exceptional. Never- theless, a premature development of the sexual organs may constitute an occasional cause of self- pollution—the more especially if such develop- ment be not accompanied by corresponding growth of the other organs and systems of the body, and of the reason and moral control. Independently, however, of a premature de- velopment of the sexual apparatus, the vice of masturbation may be contracted at a very tender ao-e, a very instructive example of which has been narrated by Mr. Heckford. " I believe it is not * Medico-Chirurgical Transactions, vol. xii., p. 76. 8 SPERMATORRHOEA. generally known," says Mr. Heckford, " that this vice is practised not only by adults of both sexes, but also by young children, and even infants in the cradle. The following notes, kindly given me by Dr. Hughlings Jackson, are a sufficient guarantee as to the correctness of this assertion, at least as regards one case. . •,,-.- The foliow- ing is the narrative of Dr. Jackson :—A woman came to the Hospital for Epilepsy and Paralysis, on account of fits. She took the opportunity of asking my advice about her child. The boy was fifteen months old; he was delicate, and had never been able to stand; but the special cir- cumstance about which the mother wished to hear my opinion was the peculiar position of his legs. The right leg was almost always placed high up over the other, and he kept it moving in a sawing way towards the pelvis. The penis was in the way of friction, and was quite stiff when I ex- amined it. He was much annoyed at my inter- ference with the movements of his leg, making resistance and crying. . . . The boy had con- genital phymosis, but he did not cry when he made water. Mr. Hutchison was kind enough at my request, to circumcise him. . . . After CAUSES. 9 this the habit ceased, for a time at least, and the child much improved in health." * I have had lately under observation a case, a boy four years of age, who had practised the habit for two years. He exposed the penis to friction between the thigh and abdomen. His mother informed me that he was much excited during the act, and at its termination passed into a nervous state, preceded by a shudder. He had frequent epileptic convulsions. Circumcision, although it interrupted, did not cure the habit, for the boy resumed it again after the wound heal- ed. Threats, punishment, and restraint were alike unavailing to prevent the perpetration of the act. A very influential cause in determining the habit of onanism is a redundant prepuce. Around the corona glandis, in the sulcus, are situated a number of sebaceous glands, the secretion of which, if allowed to accumulate, excites irritation and itching. Erection and the venereal orgasm follow the friction which is innocently used to allay the itching. Moreover, when the glans is habitually covered, it becomes morbidly excita- * London Hospital Reports, vol. ii. p. 58. 1* 10 SPERMATORRHOEA. ble, and the least friction develops the special sensibility of its nerves. According to Simon* (de Mete) various causes besides the foregoing increase the excitement of the genitals at puberty, among which he enume- rates prolonged sitting, as at school, which fa- tigues the spinal column and causes an accumu- lation of blood in the inferior parts of the trunk. " For the same reason," says Simon, " that clerks and persons who ride much on horseback or in car- riages are exposed to hemorrhoids, boys will expe- rience excitement of the genitals in consequence of engorgement of the testes and spermatic cord." Patients frequently refer the origin of the habit of masturbation to the influence and example of older boys. In public institutions, where many boys of the more depraved sort are collected to- gether, this may sometimes occur; and even in the better class of boarding-schools a bad boy, given to this vice, may induce others to commence it; but generally speaking, the remark of Quin- tilian is true : JVon accipiunt e scholis mala ista, sed in scholas afferunt. The masturbator takes * Traite d? Hygiene appliquee d VEducation de la Jeunesse Paris, 1827, p. 164. CAUSES. 11 into the school those organic tendencies which lead to the perpetration of the vice. Possessing the erotic temperament, slight causes will suffice, at school or at home, to awaken the special sen- sibility of the sexual apparatus. Under what circumstances soever the vice of masturbation may be contracted, it is usually continued, and with increasing frequency, until weakness of the genital organs and various func- tional derangements are produced. The habit is discontinued, either because of some evident ill consequence which alarms the patient, or he is informed of the serious results which must finally ensue from his violation of a natural law. But the unfortunate victim finds that the cessation or diminution of the habit does not restore him to the natural state. He cannot rid his imagination of the erotic fancies which have so long possessed it. During sleep lascivious dreams beset him, accompanied by the venereal orgasm and the sem- inal loss. During the day erotic ideas constantly invade his mind, and partial erections occur, fol- lowed by a tenacious discharge which slowly escapes from the urethra. It is probable, also, that spermatorrhoea may 12 SPERMATORRHCEA. result from excesses in natural coitus. Cases apparently originating in this way have fallen under my observation. The history of these cases is as follows: After very free indulgence symp- toms have occurred indicating the necessity for abstinence. This sudden and forced continence puts the mind of the individual and his genital apparatus in the same condition as that which occurs after the habit of masturbation ceases. The relation which spermatorrhcea bears to certain structural alterations of the genito-urinary organs requires to be carefully investigated. Very contradictory opinions have been expressed on this point. By surgeons it is regarded as an affection—an inflammation or an irritation—of a part of the genito-urinary apparatus, and the surgical treat- ment is based upon this pathological doctrine. One of the most recent and able of surgical au- thorities* treats of it under the heading of " functional disorders of the testicle." The mod- ern surgical writers in general adopt this view, especially those accessible to the American * Holmes's System of Surgery—Art., Diseases of the Male Organs. Vol. iv., p. 539. London. 1864. CAUSES. 13 reader.* The work of Lallemandf is the prin- cipal source of these pathological views. It will be proper, therefore, to present an outline of this author's doctrines before presenting our own. Views of M. Lallemand.—This author regards the following as playing an important role in the production of this disorder: Blenorrhagia and stricture of the urethra, the former affecting the prostatic part of the urethra and the orifices of the seminal ducts, and the latter producing dila- tation of the ducts by the efforts of micturition ; gouty and rheumatic affections occurring in these parts; accumulation of sebaceous matter under the prepuce, constituting a source of irritation; venereal excesses and masturbation, which act principally by provoking inflammation or irri- tation of the ducts ; prolonged erections excited * Gross's System of Surgery, p. 831-2, vol. ii. Phila. : 1865. Erichsen's Surgery, p. 1224. A Practical Treatise on the Disease of the Testis, etc., by Curling. Phila. Ed., p. 326, et. seq., etc., etc., etc. f Des Pcrtes Seminales Involontaires, op. cit. Also, Obser- vations sur les Maladies des Organes Oenito- Urinaires. Pre- miere Partie. p. 158 et seq., 1825, by the same author. The influence of a "hobby" is well seen in the growth of M. Lallemand's opinions and practices during the fifteen years' interval between these works. 14 SPERMATORRHOEA. by erotic ideas or lascivious publications; the use of diuretics, of ergot, of cantharides, etc.: the abuse of alcoholic drinks, of coffee, and of tea ; constipation ; ascarides in the rectum; he- morrhoids ; Assures of the anus; heating and irritation of the anal and perineal regions by habitual sitting, or prolonged horseback riding. The organic peculiarities which predispose to spermatorrhoea are, according to this author— excessive length of the prepuce ; hypospadias ; extraordinary size of the meatus urethras; flac- cidity of the corpora cavernosa; smallness, tardy descent and lack of firmness of the testes; relaxation of the cord and of the scrotum ; vari- cocele ; congenital induration of the prostate, and great development of the pelvis with femi- nine characters. When the nocturnal pollutions are due to ex- cesses, to abuse, to the presence of ascarides in the rectum, they produce, according to Lalle- mand, grave disorders in a short time after their appearance. After a little, all the phenomena of excitation which precede or accompany the orgasm diminish, and finally completely disap- pear ; the act of emission occurring without CAUSES. 15 erection, pleasure, or any particular sensation. The semen loses little by little its color, its odor, and its spermatozoa, and comes to resemble, more and more, either mucus or the prostatic fluid. This progressive diminution in the exci- tation of the genital organs, and this increasing alteration in the sperm, correspond with a re- markable augmentation in the gravity of the general symptoms and in the difficulties in the treatment. At the same time the vesiculse semi- nales acquire the power of contracting under the influence of a less energetic excitement. Then, also, fulness of the bladder or rectum, a warm, soft bed, lying on the back, warm drinks, exci- tants, etc., provoke emissions more or less easily. The effects are much more serious when to the nocturnal are added diurnal pollutions. Some patients suffer only from nocturnal pollutions, but such cases are rare. The diurnal pollutions, according to Lalle- mand, are produced by all those causes which increase constipation and favor the excitation of the genital organs; such as prolonged sitting, the jolting of a carriage, riding on horseback, etc. In some subjects the pollution does not 16 SPERMATORRHOEA. take place passively during the efforts of defeca- tion, and by the simple effects of compression, but by the proper action of the ejaculatory appa- ratus. These cases are unusual. In all the others the semen is emitted without the sensible phenomena of ejaculation. The evil effects are determined by the abundance of the loss; but some persons support the losses better than others. The varieties of noctural and diurnal pollutions manifest themselves successively or simultane- ously. The specific character is the sudden ex- pulsion of semen in notable quantities at varia- ble intervals. A symptom which has close rela- tion to spermatorrhoea, and which ordinarily ac- companies it, is impotence. In all cases of noc- turnal or diurnal pollutions, the first symptom discovered is a notable diminution in the energy and duration of the erections, and an increased readiness of ejaculation. M. Lallemand gives the following result of his microscopic examinations of the excreted matters in the different varieties of seminal loss : " When the evacuations are rare and the semen has pre- served its distinctive characters, the animalcules CAUSES. 17 present nothing remarkable either in respect to numbers or dimensions. But when the sperma- torrhoea has assumed sufficient importance to influence the rest of the economy, the semen be- comes more liquid, and the animalcules are less developed and less vivacious, although their number may not appear to be diminished. When the erections commence to diminish, the semen is more aqueous; the dimensions of the sperma- tozoa are sometimes one-fourth or one-third their normal size, their caudal prolongation being dis- tinguishable with difficulty, with a power of 300 diameters." * The central idea of M. Lallemand's theory of' the pathology of spermatorrhoea, is the produc- tion, by various causes, of an irritation or inflam- mation of the prostatic portion of the urethra and of the seminal ducts. This view is not supported by anatomical evidence. Although cadaveric examinations, as is well said by M. Eaige- Delorme,f have resulted in the discovery of di- verse alterations of the genital organs in cases in which seminal losses were presumed to have ex- * Op. cit., II. p. 404. f Dictionnaire de Medecine, vol. xxviii., p. 506. 18 SPERMATORRHOEA. isted, these alterations were so connected with important diseases of other parts of the genito- urinary apparatus, that little reliance can be placed in them as indicative of spermatorrhoea. These alterations consisted in ulcerations of the orifices of the ejaculatory ducts ; injection and ulceration of various parts of these canals; ana- logous alterations of the vesiculae seminales; purulent depots in the vesicles, in the vasa de- ferentia, in the epididymis, in the body of High- more, and in the testicle. It is impossible to as- sociate these lesions with spermatorrhoea, since in all the cases cited they were accompanied by more or less grave alterations of the urinary pas- sages. One cannot avoid the reflection in look- ing over Lallemand's cases, published in his work on the genito-urinary organs in 1825, and in his work on seminal losses in 1839, that his cases as well as his theory were constructed to justify his practice. There is no proof that the anatomical lesions described by this author were causative of spermatorrhoea, or that they were even accom- panied by it. On the other hand, the observa- tions are numerous enough in which these altera- tions occurred without the production of sper- CAUSES. 19 matorrhcea. The truth is, undoubtedly, that there is no specific anatomical element in all that Lallemand has submitted, to be associated indis- solubly with that disorder, and to which it may be attributed. In support of our opinion, we may cite the high authority of Mr. Thompson,* who asserts that inordinate sexual indulgence cannot have the effect to produce prostatitis un- less gonorrhoea be already existing. I may also refer, in opposition to the views of Lallemand, to my personal observations. As pathologist to the Cincinnati Hospital, and dur- ing the time of my military experiences, I have had numerous opportunities to ascertain—if it exist—a causative relation between the lesions ol the generative apparatus and spermatorrhoea de- scribed by Lallemand, but hitherto have failed to observe this connection. To place this question beyond controversy I have lately made a most careful dissection of the sexual apparatus of a young man dead of a double pneumonia, who was known to have practised masturbation in an ex- treme degree for many years. Besides a catarrhal * On Enlarged Prostate: Its Pathology and Treatment. London, 1858, p. 195. 20 SPERMATORRHOEA. condition of the mucous membrane of the seminal and prostatic ducts, and of the vesiculce seminales, there was literally no lesion of these organs. I therefore reject this position of Lallemand as un- tenable, and as leading to improper methods of treatment. The views of Lallemand in regard to the alter- ations in the spermatozoids, and their destruction in advanced cases of spermatorrhoea, are hardly more tenable than his doctrine of the structural alterations peculiar to this disease. Liegeois, who has examined this question, remarks : " My own observations (six cases) are not at all in ac- cordance with the description given by Lalle- mand. Azoospermia, existed in only one of my patients. The other five, though the involun- tary emissions were frequent, and the virile faculties had materially diminished, though the affection had lasted from two to ten years, I have never found any change in the aspect, the consist- ency, or the odor of the seminal fluid, not even in the number or the configuration of the sperma- toza.* " This accords with my own observation. * The Seminal Secretion in Disease. Medical Times and Gazette, Nov. 6, 1869. CAUSES. 21 Spermatorrhoea is, in the view of the author, a neurosis. Although structural alterations may be coincident, they are not causative. It is cer- tainly true, however, that lesions of various parts of the generative organs may increase that dis- order of their nervous apparatus which finds ex- pression in frequent involuntary seminal losses. In order to a just comprehension of sperma- torrhoea, our inquiry must start from the physi- ology of the normal coitus. The seminal ejacu- lation is a reflex act. The sensation excited by friction of the erect and turgid male organ is transmitted to the cord, and the impression is reflected over the testes, vesiculae seminales, ure- thra, and appended muscular apparatus, produc- ing the seminal ejaculation. The whole consti- tutes the venereal orgasm.* It approximates in many of its phenomena to epilepsy, and is accompanied in some persons with an epilepti- form seizure. This is more particularly exhibited * Carpenter's Physiology, 5th ed. p. 794. Kirke's Physi- ology, p 411. On this point the reader may consult with great advantage the elaborate work by Luys entitled Re- cherches sur le SysUme Nerveux Cerebro-Spinal, sa Structure ses Fonctions et ses Maladies. Paris, 1865, pp. 296 and 339. 22 SPERMATORRHOEA. in the act of masturbation, in which the excita- tion of the genital organs is more intense, the imagination more inflamed, and the orgasm more profound. There is a great expenditure of ner- vous force in a single act of coitus—much more so in the unlawful excitation—manifested by the languor, weakness, and mental feebleness which occur for some time afterwards. Of course, these effects will be experienced in a much greater de- gree when the orgasm is frequently repeated. The generative apparatus of the male and female has a very intimate relation with the ner- vous system. It is the impression which the individuals of each sex make upon the organs of sense that excites those desires which have coitus for their object. There is a corresponding in- fluence of the genital organs upon the nervous centres ; for when semen accumulates in the reser- voirs, the organs of generation transmit an in- fluence to the cerebro-spinal centres, givino- rise to sexual desire. " The glans penis," says Kobelt,* " is the prin- cipal point of reunion of the sensitive nerves of * De Vappareil du sens ginitcd. Strasbourg: 1851 ; quoted by Luys. CAUSES. 23 the virile organ ; no other part which it regu- lates can be compared with it in this respect. In respect to richness in nerves, the glans penis yields to no other part of the economy, not even the organs of sense." According to Kobelt,* the division of the dorsal nerve of the penis, in the most powerful and erotic stallion, deprives the animal of sexual desire as completely as castration. " Anatomically regarded," says Handfield Jones, " it is very remarkable how closely the different nervous centres, or parts of a nervous centre, are connected by commissural fibres ; and from a pathological point of view, the same con- nection is very manifest. The general exhaus- tion induced by excess in venery; the production of neuralgia in weakly persons by bodily exer- cise ; the effect of muscular exertion in causing drowsiness—are examples which show how ex- cessive consumption of nerve-force in one part weakens it also in others,''1 etc. Experience has abundantly shown that the lesions resulting from masturbation are those due to expenditure of nervous force and derange- * De Vappareil du sens ginital. Op. cit., as quoted by Luys. 24 SPERMATORRHOEA. ment of the intimate and harmonious relation existing between the sexual system and cerebro- spinal centres, and not to a mere loss of seminal fluid; for under no other circumstances is so small a discharge from the body accompanied by such serious results. This conclusion is further strengthened by the more important effects which follow masturbation than spermatorrhoea, al- though the mere seminal loss in two cases may be exactly equal. A marked feebleness of the intellectual facul- ties is observed after abuse; other parts of the nervous system also participate in the debility of the encephalon. The organs of sense, especially that of vision, lose their sensibility to their appro- priate stimuli, and their functional activity is lowered. By masturbation, by excesses in venery, a condition of hyperaesthesia of the glans and urethra is induced, and the reflex act of ejacu- lation becomes abnormally excitable. Under these circumstances erotic ideas are readily ex- perienced, and so promptly does the reflex func- tion of the cord respond, that the seminal loss may occur without a decided venereal orgasm. CAUSES. 25 This is the essential pathological condition in spermatorrhoea. By frequent involuntary losses a habit is induced, and power diminishes. This idea has been well expressed by Handfield Jones:— " It seems a well-established fact that the nervous tissue, both in the centres and in the peripheral extensions, becomes more excitable and mobile in proportion as its power becomes weaker. The motor nerve is more readily thrown into action, though the impulse it communicates is weak, and cannot be long sustained." * The physiological origin of spermatorrhoea must not be overlooked. As I have already in- dicated, adults in full health have emissions, when continent, more or less frequently, accor- ding to their sexual peculiarities. This sponta- neous evacuation is an effort of nature, under these circumstances, to supply the lack of use of a physiological function. That such occasional loss is physiological rather than pathological, seems confirmed by the good effects which ensue from it upon the mental and physical constitu- tion of the individual. The inquietude of * Functional Nervous Diseases, op. cit., p. 48. 26 SPERMATORRHOEA. mind, the headache, and the hebetude of body which are experienced anterior to the evacua- tion become relieved thereby; the muscular movements are then more easily executed; the headache ceases, and the mental operations are more rapid and clear. In some subjects, how- ever, these evacuations may become so frequent and excessive as to constitute a pathological state. This occurs in clergymen, in studious persons of sedentary habits, and in those whose nervous apparatus has been deranged by dyspepsia. The excessive use of such stimulants as coffee and tobacco by continent persons who have weak digestion, slight muscular development, and a preponderating nervous system, powerfully con- tributes to the conversion of a physiological into a pathological spermatorrhoea. Moral.—Foremost amongst the moral causes must be placed the indulgence in lascivious thoughts, which acts by maintaining a state of turgescence of the sexual apparatus. During this condition of excitement semen is abundantly secreted, and accumulating in the vesicular seminales, must find an outlet by the nocturnal loss. Frequent repetition of this ex- CAUSES. 27 citement induces that condition of irritability of the sexual organs, the essential cause of sperma- torrhoea. Similar to this in all respects is the effect of that venereal excitement caused by taking liberties with the opposite sex without the gratification of desire. The intimate relation which exists between parties " engaged to be married," if long continued, frequently produces the same condition of genital weakness. 28 SPERMATORRHOEA. SYMPTOMS. The signs and symptoms of spermatorrhoea may be divided into the objective and subjective ; the objective being those which are recognised by the physician ; the subjective those of which the patient himself only is conscious. It is not always possible to separate the symptoms due to masturbation from those of spermatorrhoea. There is a practical utility in placing them side by side for the purpose of comparison. The two conditions are so frequently united, and the con- nection between them of cause and effect so inti- mate, that the symptoms of both may be compre- hended in the experience of the same individual. It is to be remarked that the voluntary seminal losses by unnatural means are much more active in producing the various secondary phenomena of this disorder, than the involuntary. The for- mer are manifested, also, by more positive ob- jective signs. Objective Symptoms due to Masturbation.— Objectively considered, the masturbator is recog- nised by a marked facial expression, by a charac- SYMPTOMS. 29 teristic mannerism, and by a peculiar mental state. The facial expression consists of a pale and sallow tint of the skin; unusual development of acne, especially on the forehead; a dark circle around the orbits; dilated and sluggish pupils; lustreless eyes, and an oblique line extending from the inner angle of the lids transversely across the cheek to the lower margin of the malar bone. The face has a haggard, troubled, furtive expression. These signs of themselves are by no means conclusive, for they may be pro- duced by other causes than masturbation. This observation is especially true with respect to acne. This eruption occurs at puberty, more or less abundantly in different temperaments; and hence it would be very unjust to accuse young men of practising onanism in whom no other evidence of the fact existed than the presence of this eruption. The manner of the masturbator is peculiar. He is listless, shy, retiring, and easily confused; he avoids society, preferring solitude; there is a want of steadiness and decision in his locomo- tion ; his inferior extremities seem deficient in 30 SPERMATORRHOEA. power, and all his movements betray a mind ill at ease. His mental operations are confused; his speech is embarrassed, awkward, and without direct- ness ; his memory is defective, and he is absent- minded and given to reverie. If the habit has long existed, and been excessively frequent in repetition, epilepsy may be produced ; or serious mental disorder, as delusional insanity, dementia, etc., may occur. The state of the genital organs varies with the length of time the habit has been indulged. In some young subjects, there will be observed an extraordinary development of the organs, owing to premature excitement; but the dispro- portion is not maintained. With the progress of the habit the penis becomes relaxed, the erec- tions feeble; the corpora cavernosa either atrophy or their vessels lose their tonicity, whereby an apparent diminution in bulk takes place; the corpus spongiosum and the glans also shrink, so that the prepuce appears unnaturally elongated. The testes may increase in size, become tender and " irritable," or they may undergo a certain degree of atrophy; the latter is the more usual SYMPTOMS. 31 result. In addition to these signs, a strong and sometimes overpowering spermatic odor is ob- served about these parts, and may diffuse itself in the atmosphere around the patient. Subjective Symptoms due to Masturbation.— Pains in the lumbar region, a sense of weight and aching in the loins, around the anus, and in the testes, are experienced. The appetite is ca- pricious, the digestion feeble, and the bowels are constipated, or constipation alternates with diar- rhoea. The mind is deficient in power of attention; the imagination is constantly pervaded with vague erotic dreams, the moral sense is blunted, and the perceptions are dull and confused. Pains in the head, in the occipital and frontal regions, and a sense of fulness, and in serious cases alarming vertigo; pains in the course of the principal nerves, and an extreme nervous susceptibility are experienced. The organic ner- vous system manifests a functional disturbance in harmony with the disorder of the nervous sys- tem of animal life. Gastralgia and abdominal 32 spermatorrhoea. pain and uneasiness are in some cases very dis- tressing symptoms. The distinctiveness of the foregoing symptoms will be determined by the extent and duration of the habit, and by the constitutional peculiarities of the patient. The more highly developed the nervous system, and the more it preponderates in activity over the muscular and digestive sys- tems, the more serious the effects. Objective Symptoms of Spermatorrhoea.— These are in many respects similar to those due to masturbation. The same cause, indeed, is in operation, but is much less powerful. The facial expression is not so marked. Acne is not common. The discoloration of the eye-lids is decided only in cases of very frequent seminal loss. The face is usually pale, sallow, and thin, anxious or sad in advanced cases. The manner is more or less retiring, subdued, and melancholy. Effeminacy, and sometimes extreme pusillanimity, are observed. Society is distasteful, or is abso- lutely avoided. Memory and power of attention are defective, and the patient is subject to fits of SYMPTOMS. 33 depression and melancholy, and is absorbed in the contemplation of his infirmity. These mental effects are frequently greatly disproportioned to the real importance of the malady; they are increased by popular works on this subject, for the perusal of which these patients have a prodigious pen- chant. They imagine themselves possessed of every infirmity portrayed in these works, and are not unfrequently driven to the verge of insanity by their apprehensions. Hypochondria is a very constant mental symptom ; but true mental alien- ation is not, by any means, so frequently observed as in masturbation. The genital organs are relaxed, the scrotum pendent, the veins of the spermatic cord varicose, the erections deficient in power and duration, and the seminal fluid is thin, watery ; the spermatozoa are deficient in size and activity, and are imper- fect in development. The urine is pale, of low specific gravity, and loaded with urates. An evident feebleness, of the general system exists, manifested by a quick, weak pulse, cold hands and feet, hurried respiration, and loss of flesh and muscular vigor. 2* 34 SPERMATORRHOEA. Subjective Symptoms of Spermatorrhoea.— Weakness in the back and pain extending up- wards to the scapula; pain along the spermatic cord, in the hips, around the anus, and pain in micturition, are experienced by the patient. He has a variable appetite, and suffers from dyspep- sia, borborygmi, constipation, and diarrhoea. He complains of weakness in the knees, with pain and soreness of the calves, and loss of power in the in- ferior extremities. His sensations in these parts may be perverted. He has also headache, or a sense of fulness in the head; he can fix his mind on any subject with difficulty ; his attention wanders, and he is given to day-dreams and to erotic visions. The importance of the foregoing symptoms will be governed by the frequency of the spermal losses. They are felt in the greatest intensity on the morning succeeding the nocturnal emissions. The essential symptom in spermatorrhoea is the occurrence of seminal losses. Lallemand, and succeeding writers following liim, divide these into nocturnal and diurnal pollutions. The noc- turnal occur at night in an erotic dream, with a more or less decided venereal orgasm ; and their symptoms. 35 importance, in a pathological point of view, will be wholly determined by the frequency of their occurrence, and the evident derangements of the organism which precede or accompany them. The diurnal pollutions, according to Lallemand, occur principally in micturition and defecation; passively in some subjects, owing to a superabun- dance of semen in the vtesiculse seminales; in others with a certain pleasure and a definite ejacu- lation ; and in others, habitually, without sensa- tion, with a feeble or scarcely perceptible ejacu- latory effort. The first variety can hardly be re- garded as pathological. It is peculiarly unfortunate that these views of M. Lallemand, with reference to diurnal pollu- tions, have obtained such general credence. The minds of patients become so impressed with the conviction that every mucous flow from the urethra is seminal, that it is difficult to overcome it. They parade this symptom and dwell upon it, believing that it has the pathological significance which Lallemand and his followers have ascribed to it. The various symptoms of spermatorrhoea may be comprehended in three groups: genital; cere- bral ; spinal. 36 SPERMATORRHOEA. In the first, or genital form or phase, which is the most common, there are excessive sensibility of the sexual apparatus, and greatly increased reflex excitability of the cord. In the cerebral form there are associated with the preceding condition certain disorders of the mind—melancholia, delusional insanity, and ma- nia. In the spinal form the functional derangement of the cord is either excessive and pronounced, or has resulted in organic lesion. I.--GENITAL FORM. The sexual organs are relaxed ; the testes ten- der, painful, and sometimes wasted; the erections feeble and the seminal flow watery. Slight causes—an erotic idea, gentle friction, a volup- tuous dream—will produce a feeble erection fol- lowed by a quick emission with but little sensa- tion. Whenever an erection and an emission oc- cur, there is an evident orgasm, but not nearly so pronounced as in the normal state. After every erection without seminal loss, there is a mucous flow from the urethra. A mixture of this mucus with the semen produces the so-called SYMPTOMS. 37 watery semen. The same mucous discharge is not unfrequently observed after urination and defecation. It alarms the patient, because he has been led to believe that it is seminal. These are the cases to which M. Lallemand applies the term " diurnal pollution." If a proper examination of this fluid be made, it will be found not to contain spermatozoa. It is a thick, transparent, albu- minous fluid, alkaline in reaction, and presents under the microscope the cellular elements noted in Fig. 1. We need hardly remark that the pre- sence of spermatozoa (Fig. 2.) is essential to prove the existence of semen. No other test is at all applicable to the determination of this question, than the microscopic. It cannot be denied that spermatozoa may be found in the urine or mucous secretion from the urethra, if a nocturnal emis- sion, or an emission produced by natural or un- natural means, have recently occurred ; but these fluids should be examined, when this source of error may be eliminated. We are glad to have an opportunity of quoting in support of our opinion so able an observer as Prof. Flint,* who * Practice of Medicine: H. C. Lea. Phila., 18G6. 38 SPERMATORRHOEA. remarks on this subject—" In the most of these cases the fluid is either the liquor prostaticus or a secretion from the vesiculse seminales. The microscope affords the only mode of determining that the fluid is seminal. Were this mode of ex- amination generally adopted, cases of spermator- rhoea would be extremely rare." We quote further some excellent remarks on this subject from Hassell: * " Care must be taken not to con- found the discharge of urethral gleet with the seminal fluid; the distinction is easy, since the former is distinguished by the absence of infuso- ria, by the presence of scaly epithelium, and by the escape being in general continuous. Some- times the gleety discharge occurs only after sexual excitement and lasts but for a short time, when, of course, its character is more apt to be mistaken. The prostatic fluid might also be mistaken for semen; in this the spermatozoa would also be absent, and in addition, the micro- scope would reveal in it the presence of the pro- static cylinders, and perhaps, also, of the peculiar lamellated concretions of phosphate of lime, which * The Urine in Health and Disease. London: 1863. SYMPTOMS. 39 are found in the prostate in such numbers. Like the mucus from ordinary gleet, that from the prostate may also be continuous, but more fre- quently it appears only after violent efforts at de- fecation, when a small quantity of matter may be expressed, forming only a drop or two, of a thick, stringy, and transparent fluid, which appears at the orifice of the urethra." Dr. Chambers,* in a lecture delivered at St. Mary's Hospital, ex- pressed his conviction that this mucous flow from the urethra has no more pathological signifi- cance than the leucorrhoea of woman. He further asserts that true spermatorrhoea is a rare, almost unknown disease, but he evidently here refers to that constant stillicidium of semen to which Lallemand gave the name diurnal pollutions, and which many writers consider, but erroneously, the true spermatorrhoea. Again, Dunglisonf says, " the presence of such a fluid in these cir- cumstances, by no means shows that it is sperm. * Lecture on Gonorrhoea and Imaginary Spermatorrhoea. delivered at St. Mary's Hospital, June 14, 1861. Lancet, 1861. f Cyclopaedia of Practical Medicine. Am. Ed., Vol. II. p. 212. 40 SPERMATORRHOEA. Indeed, it probably rarely is so, and is nothing more than the mucous fluid from the prostate or Cowper's glands." It seems a labor of super- erogation to multiply authorities on this point. There can be no question that this mucous fluid is derived from the prostate, vesiculse seminales, Cow- per's glands, and from the follicles of the urethra. The frequent excitement accompanied by in- creased blood supply, to which these parts are subjected, must induce a greater secretory acti- vity in their glandular appendages. Hence we should expect to find blennorrhagia in cases of masturbation or spermatorrhoea. The urethra is red, injected, and exceedingly sensitive, and con- siderable irritation is referred to the region of the neck of the bladder and prostate gland. No other anatomical lesions can, with propriety, be attri- buted to spermatorrhoea. If any other be pre- sent, they are merely accidental or accessory and not essential. In this category may be placed those lesions described by Lallemand: thicken- ing and stricture of the urethra, ulceration of the seminal ducts, suppuration in the prostate, etc. SYMPTOMS. 41 The phenomena of the genital form will be better exhibited by an illustrative case. Case i.—This was a patient, aged 32, who had practised masturbation with great frequency as a youth, but on learning the evil consequences had resolutely abandoned the habit. He afterwards suffered from frequent nocturnal emissions, and had, finally, such sensitiveness of the genital organs, that the slightest excitement produced a feeble erection and ejaculation. After micturi- tion and defecation he had a thick, tenacious dis- charge, which gave him great concern. He had, also, considerable irritation of the bladder, pain and aching about the anus, in the back and loins. He was pale and thin ; his appetite was capricious, and he suffered much from constipation, pain in the abdomen, borborygmi, and flatulence. His pulse was quick ; hands and feet cool and damp. His special senses were unimpaired; he had no mental aberration in any form; he was despond- ent and brooded over his sexual condition, fear- ing impotence. Although more easily fatigued than usual, he was still capable of very consider- able exertion. His sexual desire was not materi- ally lessened, for he had contracted a marriage 42 SPERMATORRHOEA. engagement with which he feared to comply. His fears had been aroused by advertisements in the newspapers and popular wTorks on his malady, for the reading of which he had the usual propen- sity. His organs were not materially damaged. The prepuce was long and the penis lax; the left testis was somewhat atrophied, owing, pro- bably, to a varicose condition of the veins of the cord on that side. The cases of the genital form of spermatorrhoea vary very much in importance. They occupy all possible intermediate gradations between the pale and emaciated subject who suffers from nightly pollutions and severe gastric and cardiac symp- toms, and the plethoric subject whose weekly nocturnal loss is an expression of a necessity of his sexual nature. II.—CEREBRAL FORM. The most serious mental effects are produced by masturbation. This vice, commenced at the period of puberty, interferes seriously with the development of the brain and the evolution of the mental faculties. We have already seen that this sad habit is contracted by those in whom the SYMPTOMS. 43 nervous apparatus predominates in activity over the muscular and digestive, and in whom the imaginative faculties are more highly cultivated than the reason and judgment. The mental effects of spermatorrhoea are also marked in those cases which we have denominated the cerebral. It is to be remarked that the mental phenomena of spermatorrhoea are not always in proportion to the seminal losses. In the cerebral form, in ad- dition to those lesions of the sexual spinal system, of the digestive apparatus, and of the circulation, described under the genital form, there are certain disorders of the mind. That spermatorrhoea will produce in one class of cases mental disorders, and not in another, indicates either that some predisposition to these disorders existed, or that the habit of self-pollution was merely an expres- sion of mental alienation. The lascivious images which pervade the minds of boys possessed of the highly developed nervous organization of mastur- bators are those of delusional insanity. In one case the spermatorrhoea is a symptom of mental disorder; in the other, the spermatorrhoea is an ex- citing cause—the predisposition already existing. There is, however, a cerebral phase of sperma- 44 SPERMATORRHOEA. torrhoea which may be separated from the two preceding classes. It is characterized by indis- tinctness of vision, dilatation of the pupil, ambly- opia, diplopia; diminution in the sensitiveness of the auditory apparatus; feebleness of voice; mental preoccupation, hebetude of mind, confu- sion of ideas, and a profound melancholy. " Pa- tients who have been laboring under sperma- torrhoea for a series of years are much more liable to hypochondriasis and cerebral affection than to tabes dorsalis," says Romberg.* Not only do long-continued and excessive seminal losses pro- duce these cerebral symptoms, but they may occur in those unhappy individuals who have acquired very false and highly-colored views of their condition from popular works on the sub- ject. The termination of such cases is in suicidal monomania, delusional insanity, etc. In that variety of the cerebral form in which a decided predisposition must be admitted to exist, to disorder of the intellectual faculties, there are found various forms of mental alienation. The chronic form is the most common, which cor- *Vol. II., p. 400. SYMPTOMS. 45 responds to the melancholia of Pinel, or the lype- mania of Esquirol, terminating in dementia. Several of the most characteristic cases which have happened under my observation correspond to the delusional insanity of Bucknill and Tuke. * Many writers are disposed to underrate the im- portance of this tendency in spermatorrhoea. To the influence of quack advertisements and popu- lar works, which, of course, greatly exaggerate the evils of this disease, is ascribed the melan- choly, the hypochondriasis, and other mental disorders which occur in the course of it. The statistics of any of our large insane asylums will illustrate the influence of masturbation in the production of mental alienation. We have al- ready given the opinion of Romberg on this point. Mr. Holmes Coote, in a discussion which followed Dr.* Drysdale's paper on the "Medical Aspects of Prostitution," read before thellarveian Society of London, remarked that " he still enter- tained the opinion that there were worse evils appertaining to human weakness than prostitu- tion, lie had opportunities of witnessing the fact that among the young there was no cause * Manual of Psychological Medicine. Phila. Ed., p. 103. 46 SPERMATORRHOEA. of insanity more common than indulging in habits which he would not further particularize, but which were known to result in the most com- plete bodily and mental prostration." * Dr. John P. Gray, the distinguished Superintendent of the State Asylum at Utica, New York, thus speaks f of the influence of masturbation in the production of insanity :—" The records of this institution show five hundred and twenty-one cases admitted directly attributable to this vice, and I am well convinced that the number is greatly understated." We might add confirma- tory testimony from a variety of sources, but the foregoing is sufficient for our purpose. The cerebral form is exhibited in the following typical cases: Case ii.—Was a young man admitted to St. John's Hospital as a private patient; set. 30 ; five feet five inches high; leuco-phlegmatic tem- perament; beard scanty; hair thin. At the time of admission he could not give a rational account * British Medical Journal, Feb. 17, 1866. f Twenty-fourth Annual Report. 1867. SYMPTOMS. 47 of himself. His eye was wild; pupil very much dilated; face pale, thin, and haggard. He walked unsteadily because of disturbance of cerebral cir- culation ; he was "dizzy." At night he was given up to various hallucinations; he did not sleep, but spent the night in talking in a wild and incoherent manner, in wandering about his room, and beating upon the walls. During the day he was quiet, but his conversation was dis- connected, his ideas wandering, and his speech confused. His appetite was capricious, his bowels constipated, and he had suffered greatly from bor- borygmi and abdominal pain. From his brother it was ascertained that he had been greatly addicted to natural and unnatural venereal ex- citement, and had suffered lately from frequent involuntary losses. The state of his genital organs confirmed this. Case hi.—Was similar to the preceding—a young man who had passed several years in the military service, during which time he had in- dulged very freely in the vice of masturbation. He was led to St. John's Hospital by a comrade; he could not walk without support, in conse- 48 SPERMATORRHOEA. quence, he said, of " lightness of his head." He had neither delirium nor hallucinations, but he was reduced to a state of mental feebleness bor- dering on dementia. He was pale, thin, and had little appetite; his vision was indistinct; his pu- pils were dilated, and his hearing was dull and indistinct. All of his senses, indeed, were in a state of torpor. He admitted a degree of self- abuse, extending over several years, too revolting to be narrated, and had lately, after discontinu- ing it, suffered from a pitiable degree of seminal weakness.* III.—SPINAL FORM. Impairment of locomotion and spinal paralysis have long been associated with venereal excesses. The progressive spinal paralysis, the tabes dorsalis of the Germans, and the ataxie locomotrice pro- gressive of Duchenne, was formerly confounded with the effects of masturbation and excesses in venery. The differential diagnosis will be a sub- ject for future consideration. * Both of these cases formed the subject of a Clinical Lec- ture at St. John's Hospital, before the class of the Medical College of Ohio. Session of 1865-1866. SYMPTOMS. 49 In the spinal form of spermatorrhoea there are weakness of inferior extremities, altered—dimin- ished or perverted—and referred sensations, in- continence of urine and faeces, and sometimes paraplegia. These symptoms are additional to those described as pertaining to the genital form ; they may also be superadded to the cerebral. In the following typical case, it will be seen that the spinal symptoms were distinctive. Case iv.—A travelling showman, set. 35, came under my care, suffering from weakness, with perverted sensations of both inferior extremities. He had an ill-conditioned ulcer on the right leg; slight pressure, as of riding on horseback, induced intractable ulcerations of buttocks and thighs. He had also, to a limited extent, incontinence both of urine and faeces. The sensibility of the skin, as to touch, pain, pressure, and the electric current, was diminished. He had a sense of formication in his legs and tingling in his feet. The tendo-achillis of each side was a little short- ened. He volunteered the information that ear- lier in life he had been much addicted to onanism, and that since the habit was discontinued he had suffered from frequent nocturnal emissions. His 3 50 SPERMATORRHOEA. mental powers wereUnknpaired. He had the unavoidable depression and janxiety arising from his very miserable physical condition, and nothing more. •:;, \ In what does the spin-al lesion consist in these cases ? We have stated Jhat the important patho- logical condition in the *^enital7 form of sperma- torrhoea is a morbid excitability of the reflex faculty, with congestion, probably of the cord. In the spinal form there is probably some struc- tural lesion inappreciable by our ordinary means of investigation, a molecular change, possibly, or the nervous phenomena are of the reflex charac- ter. We have, however, no anatomical facts on which to base the former opinion—our knowledge of these cases being entirely clinical; but the symptoms and the results of treatment seem to confirm our view of the pathology. Schroeder van der Kolk,* also, has made some observations which tend to establish the same view. Says this able observer: " Onanism is commonly consid- ered, and often correctly, to be a cause of epi- lepsy; but onanism and excitement of the sexual * On the Minute Structure and Functions of the Spinal Cord and Medulla Oblongata. Syd. Soc. Translation, p. 268. SYMPTOMS. 51 organs are, to a greater degree than is usually supposed, the result of irritation and congestion of the medulla oblongata. The opinion formerly advanced by Gall as to the localization of the sexual impulse in the cerebellum, has been suffi- ciently refuted, and the close relation between the medulla oblongata and the action of the geni- tal organs, is generally received by physiologists. Let it suffice to call to mind the occurrence of erection and emission in persons hanged, how the sexual action is exalted in idiopathic mania with irritation of the brain and medulla oblongata; how frequently, after injuries of the part, erection and emission, or perhaps impotence is observed. •* * * # jn the case 0f epilepsy I have just recorded this influence was very evident; the emissions disappeared for a time, when the sensi- bility and over irritation of the medulla oblongata had again discharged themselves in a fit. * * It is but a short time since a similar case occurred to me, of a young man who was unable to con- tinue his studies regularly on account of epilepsy, apparently originating in onanism. A few days ago I received a report, that for the last three months, after an issue had been by my advice 52 SPERMATORRHOEA. established in the neck, neither the involuntary pollutions, which in this case also were very fre- quent, nor the epileptic attacks, which commonly returned every two or three weeks, had again appeared, while the patient's head had become much clearer, and he was able to continue his studies." On the other hand Gull relates* a case of com- plete paraplegia, produced by sexual excess, in whicli no structural alteration of the cord could be detected, even by the most careful microscopic examination. This case is justly regarded as ex- ceptional. * Guy's Hospital Eeports, 1858, p. 174. RESULTS. 53 RESULTS. I have already sufficiently shown that various forms of mental derangement may accompany frequent involuntary losses. I need not waste space by recapitulating the observations on this topic. An ordinary result of spermatorrhoea is weak- ness of mind. The brain acts slowly and imper- fectly because a large part of the produced nerve- force is consumed in the frequently repeated ve- nereal orgasm. These patients are dull and list- less. To accomplish a given amount of intel- lectual labor, they find that an unusual effort is necessary. They are given to reverie, and to vague and shadowy dreams in which erotic phan- tasms play. They take little interest in business and in the affairs of life, and to this cause is to be attributed, in many instances, unexpected fail- ure in business and professional pursuits. They are men of dreams instead of men of ideas and action. This condition of the mental and moral forces is a more frequent result of sperma- 54 SPERMATORRHOEA. torrhoea than mental derangement, properly speaking. I have not observed any disorder of the special senses beyond the diminished sensibility due to increased consumption of nerve force in the sexual system. The respiration becomes more or less irregular. Frequent deep inspirations, sighing, and a dry cough are often observed. Dryness of the fau- ces, especially of the posterior wall of the pha- rynx, and huskiness of voice also occur. I can- not say that I have observed phthisis to be pro- duced by spermatorrhoea, neither do I believe that such result is probable; but, on the other hand, it is certainly true that if a tendency exist, hereditary or acquired, to this disease, frequent involuntary losses may promote its development, as indeed any cause may, which lowers the vital forces. Irregular action of the heart is most common. Pains are felt in the precordial region, the rhythm of the heart's movement is altered, and a subjective sense of fluttering is felt. These phe- nomena are frequently accompanied by a sense of constriction of the throat—a globus hysteri- RESULTS. 55 cus—a tendency to shed tears, and the emission of a plentiful quantity of pale urine. The most serious results of spermatorrhoea are those produced in the generative organs them- selves. Amongst these are impotence, " irritable testis," varicocele, and a state of hyperaesthesia of the spermatic plexus. Impotence should not be confounded with loss of procreating power. A man is said to be impotent when he is unable to perform the act of coitus. Capacity for sexual intercourse may exist without the power of pro- creation. The practice of masturbation, or sper- matorrhoea, more usually results in impotence than in a mere loss of procreating power. Long-continued excitation of the generative organs, whether by natural or unnatural means, so inflames the imagination and exalts the reflex faculty that emission occurs before intromission of the male organ can take place, or after very imperfect coitus. The latter is the more usual condition for which the physician is consulted. Patients are peculiarly fearful and sensitive on this point. The morbid apprehension under wdiich they labor, greatly increases their incom- petence. In some instances, without being at all 56 SPERMATORRHOEA. seriously damaged in their sexual function, they are rendered temporarily impotent by the mere dread of failure. The London quack, Dr. Gra- ham, understood the influence of the imagina- tion upon the sexual congress. " Amongst the furniture of the ' Temple of Health' was a ce- lestial bed, provided with costly draperies, and standing on glass legs. Married couples who slept on this couch were sure of being blessed with a beautiful progeny. For its use, one hun- dred pounds per night were demanded, and nu- merous persons of rank were foolish enough to comply with the terms." * The impotence of spermatorrhoea is not a per- manent condition, unless serious cerebral or spi- nal complications have occurred. Ordinarily, the capacity for coitus returns with the cessation of the seminal losses—the evidence of a healthy functional state of the spinal cord. The loss of procreating power is not a frequent accompani- ment of seminal weakness; the difficulty is in the intromission of the organ. Every practical physician is cognizant of instances of men whose * A Book about Doctors. Jeaffreson, p. 338. RESULTS. 57 semen had fertilizing power, but who were almost incapacitated for the sexual congress, by reason of a great excitability of the reflex faculty. The same condition may exist as a result of long continence in ardent temperaments. But these cases only require a little time and famili- arity with the object of desire. Excluding from consideration those organic deficiencies which may produce impotence, as foreign to the purpose of this work, it will suffice to allude to varicocele, and so-called " irritable testes," when they are due to sexual abuses. It is exceedingly doubtful whether varicocele confined to the left testis ever results in impo- tence. Some instances have occurred under my observation in which this disease produced atro- phy of this testis, accompanied by a painful state of the right organ, and eventually resulting in almost complete extinction of sexual desire. In those exceptional and rare cases, where the vari- cocele is double, and atrophy results, impotence necessarily occurs. To the increased activity of the testes in secre- ting semen, has been attributed the varicose con- dition of the spermatic veins in spermatorrhoea. 3* 58 SPERMATORRHOEA. This view is hardly tenable. As the varicocele occurs on the left side almost invariably, in con- sequence of an anatomical peculiarity, and as it is not a constant nor even a frequent complica- tion, we may consider its presence, in general, as - accidental. Opposed to this view, we should not omit mention of Mr. Hutchison's * opinion, that varicocele is of spinal origin. Dr. Hughlings Jackson f has reported a case which seems to confirm this opinion of Mr. Hutchison. The relation of " irritable testis " to impotence is much more immediate. By this term, Sir Astley Cooper,:}: to whom we are indebted for the most of our information on this subject, in- tended to express a state of hyperesthesia of the spermatic plexus. One or both testes are pain- ful, sometimes exquisitely so, tender to the touch, and occasionally swollen. The epididymis and spermatic cord also become so painful that the weight of the testes gives intolerable pain; and pain is experienced in the back and loins. Not- * London Hospital Reports, vol. i., p. 77. f Lancet, March 31, 1866. % Observations on the Structure and Diseases of the Tes- tis.—Chapter iv. London: 1830. RESULTS. 59 withstanding these symptoms, the testes are not hot and inflamed ; the swelling is paroxysmal, and is not accompanied by fever. The general health is much impaired, partly in consequence of the suffering endured, and partly by reason of the disturbance of the nervous and digestive sys- tems. The patient has a poor appetite; he suf- fers from indigestion ; he is hysterical and de- spondent, and is unable to sleep. Impotence is a usual attendant on this state. Venereal ex- cesses, masturbation, and spermatorrhoea, are the causes. At least we have frequently observed it to accompany spermatorrhoea, and in this case it proved the most troublesome and distress- ing symptom.' The following case very wrell illustrates the signs and symptoms of this mal- ady occurring in connection with seminal trouble. Case v.—An Israelite, aet. 25, was admitted to St. John's Hospital, nnder the following circum- stances : He had been married a week, but proved unable to consummate the sexual act, in consequence of which he was placed by his friends in a hospital to undergo treatment. He presented these symptoms: He was pale and 60 SPERMATORRH OE A. sallow; his tongue coated; his appetite was poor; he had much abdominal pain, especially about the umbilicus, and he was constipated. The testes were very tender, constantly painful, especially when pendent, and the cord was also painful. The testes were subject to periodical attacks of enlargement, which lasted a few days and then subsided, there being, however, no red- ness nor increased heat, but only increased ten- derness. He experienced various nervous symp- toms ; among others he had a well marked glo- bus hystericus, and he shed tears on the least provocation. He admitted to very great sexual indulgences for several years, which were fol- lowed by spermatorrhoea. Since the occurrence of irritability of the testes, he had been entirely without sexual desire. He admitted that he had not been able to effect the sexual congress since his marriage.* Even when it does not result in impotence, hyperesthesia of the spermatic plexus produces ' * This patient left the hospital after a stay of four weeks He visited me recently, to assure me that he was restored to sexual soundness. RESULTS. 61 distressing nervous symptoms of a hysterical character. The various pelvic pains, occurring in spermatorrhoea, and referred to the prostate, neck of the bladder, rectum, perineum, and testes, are probably due to the same cause. 62 SPERMATORRHOEA. II. SPERMATORRHCEA AS A SYMPTOM. Various disorders of the nervous system, ac- companied by frequent spermal losses, were, for- merly, confounded with the results of seminal weakness. This wTas especially the case with the disease known as tabes dorsalis, which in the time of Hippocrates was assumed to be caused by ve- nereal excesses. In the work De Morbis * occurs the following passage: Tabes dorsalis a spinali medulla oritur, max- ime vero recentes sponsos et libidinosos corripit. Febris sunt expertes, bene comedunt, et colliquan- tur. Quod si ita affectum perconteris, dicet, sibi videri ex superioribus partibus a capite velut formicas in spinam descendere; quumque urinani aut stercus reddit, ipse semen genitale copiosum et liquid um prod it / necque genitura intus con- * Dr. Adams, the learned author of the Sydenham So- ciety's edition of the works of Hippocrates, thinks the book De Morbis emanated from the Cnidian school. SPERMATORRHCEA AS A SYMPTOM. 63 cipitur et inter dormiendum cum uxore dormiat, nee ne semen prof undat, etc. (Lib. ii., cap. 19.) Celsus also alludes to similar effects produced by nimiaprofusio seminis which tabe hominem consumat* Under the same designation similar effects have, since the time of Hippocrates, been ascribed to masturbation and venereal excesses by various German, French, and English writers. By Rom- berg^ however, the term " tabes dorsalis" is restricted to a nervous disease, identical with the progressive locomotor ataxia of Duchenne. On the other hand, so recent an authority as Dr. Meryon ^ adheres to the ancient idea of tabes dor- salis, defining it as a " tractable form of paraly- sis, not unfrequently seen in youth and early manhood, which may be traced to the vicious and enervating habit of masturbation." In progressive locomotor ataxia there occurs a peculiar degeneration of the posterior columns of * De Medicina, lib. iv., p. 187. Edit. Milligan, Edinburgh: 1831. f A Manual of the Nervous Diseases of Man. Edition of Syd. Society, translated by Sieveking, vol. ii., p. 395. X Practical and Pathological Researches on the Various Forms of Paralysis, p. 44. London: 1804. 64 SPERMATORRHOEA. the cord : a gelatiniform degeneration of the nerve fibres and a hyperplasia of the intervening con- nective tissue. " Progressive abolition of co-or- dination of movements and apparent paralysis, contrasting with integrity of the muscular force, are the fundamental characteristics," says Du- chenne,* of this disease. According to this au- thor, it is divisible as respects its symptomato- logy into three periods: " 1. Characterized by three symptoms—pains, ocular troubles, and anaphrodisia; 2d, by disor- ders of motility and of sensibility in the inferior extremities ; 3d, the extension of the same symp- toms to the upper extremities." Before anaphro- disia, and the disorders of voluntary movement, symptoms referable to the generative organs are present. These symptoms are satyriasis and spermatorrhoea. In five cases of progressive loco- motor ataxia, of which I have preserved full notes, more or less decided increase of the sexual appetite occurred in the inception of the disorder. Involuntary seminal losses are observed at the same time, and they attract the attention of the * De l'Electrisation Localisee, etc. Deux. ed. Paris: 1861, p. 547. SPERMATORRHOEA AS A SYMPTOM. 65 patient more than any other symptom then pre- sent. It is in consequence of this fact that pro- gressive locomotor ataxia was so long confounded with the results of excesses in venery. Trous- seau* has especially called attention to these sex- ual symptoms which attend upon the first stage of this singular affection. In some observations on this topic, Topinard f thus speaks of the symptoms in progressive loco- motor ataxia, belonging to the generative organs : " Four symptoms present themselves : sperma- torrhoea, satyriasis, anaphrodisia, and impotence. The first occurs amongst the most remote ante- cedents of the first period, throughout which it continues. The nocturnal pollutions, at first ac- companied by erections and a sensation of pleas- ure, at last become passive. After the sperma- torrhoea, or without having been preceded by it, there occur after some months or years, pro- gressive diminution of desire, difficulty in pro- * Clinique Medicale de l'Hotel Dieu de Paris. Tome Deux., p. 534, et seq. f De l'Ataxie Locomotrice et en particulier de la Maladie appelee Ataxie Locomotrice Progressive. Paris, 1864, p. 171. GQ SPERMATORRHOEA. curing satisfaction, and at last absolute impo- tence." Eisenmann reports a case (Topinard) in which priapism existed thirty years. " During thirty years of his life, priapism had tormented this patient, and was only calmed by continually in- creasing and enormous doses of opium." In order to exhibit the relation of the genital symptoms to the other phenomena in cases of progressive locomotor ataxia, I subjoin an analy- sis of the symptoms of the first period in the five cases of which I have preserved notes : The disease commenced in No. 1, at 35. He is 5 feet 6 in. in height; has a light complexion, light auburn hair, blue eyes, and the lymphatic temperament. The first symptoms manifested themselves in No. 2, at 40 years of age; he is now 65. He is 5 feet S in. in height, of nervous temperament; has blue eyes, and his hair, now gray, was originally auburn. No. 3 experienced the first symptoms at 43; he is now 46. He has also a fair complexion, blue eyes, and light auburn hair. No. 4 was 42 years of age when he began to experience the pains ; he is now 45. He is 5 feet 10 in. in height, and has a dark SPERMATORRHOEA AS A SYMPTOM. 67 complexion, dark eyes and black hair. No. 5 experienced his first symptoms at 37, ten years ago. lie has reddish hair and beard, bl-ue eyes, and a strongly marked nervous temperament. No. 1 had satyriasis, spermatorrhoea, tingling and numbness of the feet and legs, and amaurosis and double vision. The satyriasis was soon suc- ceeded by anaphrodisia and impotence. The dimness of vision and the double vision suddenly disappeared at the commencement of the second period. He did not experience those peculiar pains so commonly present in this disease. The whole duration of the first period, commencing with the satyriasis, was only three months. The symptoms of the first period in No. 2 were simi- lar in character, but extended over a much longer period. The state of the sexual appetite in the beginning could not be accurately ascer- tained, but anaphrodisia soon occurred, and abso- lute impotence was the final result. Violent pains, supposed to be rheumatic, preceded the other symptoms. These pains are localized in the inferior extremities, and especially in the left hip, so that disease of this articulation was sus- pected. No derangement of vision occurred at 68 SPERM ATORRH CS A. any period. No. 3 experienced, for more than a year, sharp pains in the extremities, and also deep-seated pains in the trunk, before the ataxia manifested itself. These pains, being sudden in onset, fugitive in character, and irregular in their recurrence, were supposed to be neuralgic. A decided decrease in sexual desire, and imperfect sexual congress were observed, but complete ana- phrodisia did not occur. Dimness of sight, but no other ocular trouble, has thus far been present in this case. In No. 4, two years of neuralgic pains preceded the other symptoms. The pains had the two characters so frequently noticed in this disease : the first, deep-seated, dull, and heavy, pretty nearly constant; the second, sharp and sudden, temporary. The dull and heavy pains experienced in the lumbar region, in the thighs, and in certain parts of the trunk, pre- ceded the others, which attacked the legs and thighs. No ocular derangement occurred in this case. Spermatorrhoea, anaphrodisia, and impo- tence, however, were experienced early. No. 5 began to have pains in the lumbar region in 1857, and soon after severe attacks of neuralgia along the course of the sciatic. These were sue- SPERMATORRHCEA AS A SYMPTOM. 69 ceeded by sharp, sudden, and fugitive pains in both inferior extremities. The patient compares these pains to electric shocks. Anaphrodisia and spermatorrhoea did not occur until two years after the pains had been experienced. He admits that at the pres- ent time he is completely impotent. Derange- ments of vision manifested themselves in two years after the commencement of his malady. These consisted in amblyopia and double vision. They disappeared suddenly—in a night, he says— after continuing for several months. After the first period has passed there can be no difficulty in coming to a conclusion as to the relation of the spermatorrhoea to the other phe- nomena. Various other affections of the nervous system are accompanied by involuntary seminal losses. Diseases of the medulla, cerebellum and pons, of the spinal cord, epilepsy, chronic mania, may have this as a more or less pronounced symptom. In the early stage of diabetes, before impotence results, spermatorrhoea is sometimes present. In all cases in which the involuntary loss is a symptom merely, it is of little consequence from 70 SPERMATORRHOEA. the therapeutical point of view; the centric lesion, of which it is a sign, is the point of importance to which our attention should be directed. IMAGINARY SPERMATORRHOEA. 71 III. IMAGINARY SPERMATORRHOEA. It is important to bear in mind that involun- tary seminal losses, to constitute a disease, should occur with sufficient frequency to produce definite symptoms. Many patients who come to a physi- cian for advice and treatment for this affection, are not really suffering from the seminal losses, but from an imaginary ailment. Experiencing an occasional seminal loss, and ignorant in regard to the ph}Tsiological condition, they imagine them- selves the subjects of spermatorrhoea. Brooding over their presumed " weakness," they fall into a h}7pochondriacal state, and soon experience the whole train of wretched symptoms depicted in popular works on the subject. Every subjective sensation, no matter what its origin, is referred to the debilitating effects of the spermal losses. As an evidence of the attention which these ap- tients give to their sensations, and of their mental and moral peculiarities, I subjoin a written state- 72 SPERMATORRHOEA. ment handed to me by one of them, on presenting himself at my consultation-rooms: " Ringing in my ears occasionally. " Fulness and weight in stomach at all times. " Considerable wind in the stomach. " Want of strength in thighs and groins. " Dull, heavy feeling in back of head at night and after dinner. "Drowsiness after supper, so that I cannot read. " Great want of clearness and want of strength of vision. " Weakness of voice, and sometimes thickness of speech. " Very sensitive to the least rudeness, and very apt to become nervous and low-spirited from being harassed or worried in any way. "Heart palpitates somewhat violently at times. " Digestion is very imperfect. " Dryness of the scalp. " Have been very subject to having boils on my legs, which always were of a dry nature. " Apt to have pimples on forehead and neck." All of these symptoms he referred to seminal emissions, occurring at intervals of three weeks. His health was robust, and he was actively en- IMAGINARY SPERMATORRHCEA. 73 gaged in business ; but the corners of his mouth were depressed, and his countenance had an air of deep dejection. Cases of this kind are very numerous, and difficult to manage. No explanation or demon- stration satisfies them. One apprehension al- layed, they quickly take up another, returning at last to the sexual disorder. They exhibit a real pleasure in dwelling upon this infirmity, and in talking with endless iteration over all the dis- gusting details connected with it. Certain masturbators, struggling to free them- selves from the trammels of the vice, but too weak of will to resist it wholly, please themselves with the delusion that the act is involuntary, because it is indulged in during the dreamy con- sciousness of the half-waking state. They con- sult the physician under the guise of having involuntary evacuations. 4 74 SPERMATORRHOEA. IV. TREATMENT. A correct view of the pathology of sperma- torrhoea is necessary to its successful curative treatment. If spermatorrhoea be a purely local disease—an inflammation and ulceration of the prostatic por- tion of the urethra—local treatment only will be required. If, however, the essential condition consists of an increased reflex excitability of the spinal cord, due to frequent peripheral irrita- tion seated in the urethra, then the local must be regarded as accessory to the general treatment. The relative importance of these two views as to the causation of the disease, should be definitely ascertained. A particular plan of treatment is followed by the adherents of each view. A wTise therapeutist will not reject whatever is beneficial in either plan. The local treatment consists in the applica- tion of the porte caustique to the prostatic portion of the urethra ; the use of injections of the nitrate of silver, sulphate of copper, acetate of lead, etc.; treatment. 75 certain mechanical expedients; the internal ad- ministration of copaiba, cubebs, and other reme- dies of this class; cold hip-bathing, and injec- tions of cold water into the rectum, etc. The most important of these measures is the use of the porte caustique. This instrument has been largely employed since its introduction for this purpose. Few practical surgeons at the present day will assent to the dictum of Lallemand, that " two-thirds of the cases of spermatorrhoea would be beyond the reach of medical assistance, if it wer.e not for the good effects produced by the ap- plication of the nitrate of silver to the prostatic portion of the urethra." It is very desirable, however, to ascertain its real importance and the limits of its application. The Porte Caustique.—This instrument, which is so closely associated with the name of Lalle- mand, had an existence long anterior to his em- ployment of it. Ambrose Pare devised an instru- ment for cauterizing the urethra," which is the progenitor of the modern instruments for this purpose. It consisted of a silver canula and a stylet of the same metal, having at its extremity a tampon of linen which was dusted wTith pow- 76 SPERMATORRHOEA. dered caustic. Loizeau is said to have cured King Henry IV. of France of an induration of the urethra (organic structure) with a similar in- strument. Wiseman, of England, and after- wards Hunter, employed the nitrate of silver in a porte caustique, but the latter substituted a caustique holder for the linen tampon. Sir Everard Home * was a warm advocate for the proceeding of Hunter. The instrument of Du- camp was the more immediate progenitor of Lal- lemand's. It was a porte caustique composed of a gum elastic canula, the stylet being an ordinary bougie, and of a caustic holder of platinum which was attached to the bougie. Amussatf in 1824 also invented a porte caustique, the canula being of silver, and the stylet, of the same metal, con- tained at its extremity a platinum point for lodg- ing the caustic. About the same time Lallemand proposed his instrument, and a discussion arose * Practical Observations on the Treatment of Strictures of the Urethra and Esophagus. Second Edition. London: 1797. P. 116 et seq. f Lemons du Amtissat, sur les retentions cT urine, etc. Paris: 1831, p. 115 et seq., from which many of these particulars have been obtained. TREATMENT. 77 as to the value of each instrument respectively. Differing in merely mechanical arrangements, the object to be attained in the use of them was essentially the same. The application of the caustic was employed in cases of thickening of the canal, ulceration and stricture due to chronic inflammation. We find in Lallemand's treatise on the disease of the genito-urinary organs,* the germ of those ideas put forth in full maturity fifteen years later in his work Des pertes se- minales involontaires. After a discussion of the changes produced by blennorrhagia, he proceeds as follows: " It may be easily conceived that irritation of the mucous membrane of the prostatic portion may extend itself to the ejaculatory canals, the vesiculae seminales, etc.; and the proof is, the engorgement of the testicle which so frequently accompanies stricture. The results of this irrita- tion of the seminal reservoirs and ejaculatory ducts are, that the act of coitus is promptly fol- lowed by the ejaculation ; that the patients have * Observations sur les Maladies des Organes Genito-urinaires, Premiere Partie. Paris: 1825, p. 158. 78 SPERMATORRHOEA. frequent nocturnal pollutions, and that in some cases the voluptuous sensation is accompanied by a more or less acute pain. Still further, the irri- tation augmenting, the seminal emission takes place with an incomplete erection, or is expelled with the last drops of urine....... Governed by analogy and by direct experiences, I have not hesitated to apply to these parts the nitrate of silver; the mucous membrane takes on a new action; a benign inflammation sup- plants the chronic inflammation ; tone is restored to the tissues, and the mucous secretion progres- sively diminishes." The original idea of Lalle- mand, following Pare, Hunter, Ducamp, and others, was the treatment of these chronic inflam- matory affections'of the urethra resulting in stric- ture, ulceration, and abscess. The extension of the method of cauterization to the treatment of spermatorrhoea was an after-thought. Very di- verse views have obtained since as to the utility of the porte caustique. It has not, in general, produced that favorable impression upon these cases claimed for it by its advocates. Not only does it often fail to cure the patient, but the ap- plication of the caustic is frequently followed by TREATMENT. 79 most serious consequences.* In all cases it pro- duces great irritation, frequently strangury and bloody urine, and sometimes severe urethritis and cystitis. Too long contact of the caustic may induce induration and organic stricture, a very serious complication of the case. Notwithstand- ing these sometimes unfortunate results, some surgeons adhere to it, and a few claim all that Ducamp, or Amussat, or Hunter, or Home, did in former times. Mr. Acton, for instance, is a zealous partisan of the porte caustique, contend- ing [p. 225] that, as far as his own experience is concerned, it " fully bears out" the statement of Lallemand as to the infrequency of any ill consequences arising from its use. We should not, therefore, reject this practice of cauterization entirely. Under what circumstances may we re- sort to it? There appear to be two classes of eases in which it is indicated : 1st. Those in which chronic inflammatory changes exist as a complication of spermator- rhoea. * Thompson, On Enlarged Prostate: Its Pathology and Treatment, etc. Op. cit. 80 SPERMATORRHOEA. 2d. Those in which the moral effect of the application is desirable. We have already, we think, conclusively estab- lished that the lesions of the prostatic portion of the urethra, described by Lallemand as constant to spermatorrhoea, are only accidental. They are produced by inflammation arising in the course of gonorrhoea, as appears evident enough indeed, on the perusal of the cases given by Lallemand in his treatise on diseases of the urinary organs. At all events, it is not at all common to find such changes in the urethra of patients suffering from seminal weakness in this country. A hyperaes- thetic state of the canal, especially of the pros- tatic part, is, on the other hand, a most usual condition. Romberg* has very well indicated the cases of the second class to which the use of the porte caustique is adapted : " Spermatorrhoea, to which not unfrequently hypochondriasis is to be attri- buted, requires special attention, and if all other remedies fail, we must have recourse to cauter- ization of the urethra, which has a moral as well * Manual of the Nervous Diseases of Man. Op. cit. Vol. i., p. 188. TREATMENT. 81 as a physical effect, by withdrawing the patient's attention from his malady." It is not improbable that to this "moral effect" is to be attributed much of whatever good is accomplished by the use of the porte caustique. We would limit the application of caustic, then, to those conditions of inflammation, ulcer- ation, and hyperesthesia of the prostatic portion of the urethra, which proved refractory to other less painful and dangerous methods. For the moral effect, wTe would limit it to those obstinate cases accompanied with severe hypochondria, in which the fancy of the patient referred all the suffering to the region of the prostate, and to the cases of youths who persevered in the vice of masturbation. The use of the porte caustique is not attended with difficulty. Certain precautions, however, are requisite to avoid injury to the parts. In the first place, it is necessary to ascertain the length of the canal, which may be done by introducing the catheter and observing the moment it enters the bladder. The length of the urethra from the meatus to the bladder is then marked on the canula. The curette is now charged with melted 4* 82 SPERMATORRHOEA. nitrate of silver and placed in the canula, which is oiled and introduced the desired length. The operator, however, will perceive when he enters the sphincter of the bladder by the sensation of the passage of the enlarged extremity of the in- strument. Now when this enlarged extremity is withdrawn through the sphincter the sensation will be quite distinct, and the operator will know that he is in the prostatic part. It is only neces- sary to withdraw the outer canula half an inch and rotate rapidly the curette, withdrawing it quickly into the canula. Before the operation is performed the patient should empty the blad- der, and he should not make water for some hours afterwards. The recumbent position should be enjoined, diluents and alkalies prescribed, and a moderate diet directed. Should there be much pain, opiates, morphia, or chlorodyne may be pre- scribed, or an anodyne suppository, or an enema of starch and laudanum may be introduced. For several days afterwards considerable irritation is experienced, even when most care has been exer- cised. Injections.—If cauterization be desirable, it may be accomplished by injection. This is cer- TREATMENT. 83 tainly as effectual and much safer than the pre- ceding operation. A special instrument, such as Mr. Acton's glass syringe, may be employed, or the universal syringe (Fig. 3), which may be fitted to a silver catheter, will suffice for the purpose. The catheter must be introduced into the bladder, and then withdrawn into the pros- tatic portion of the urethra. The solution of ni- trate of silver, of sulphate of copper, of acetate of lead, or, preferably, of tanno-glycerine ( 3 j.— 1 }•), may now be injected and allowed to apply itself thoroughly to the mucous surface. Not more than 3 j of the solution should be used at a time, and too great force should be avoided lest the fluid be thrown into the bladder. The strength of the nitrate of silver solution should not exceed gr. x.— | j. Before the injection is made the pa- tient should be required to empty the bladder, and should avoid emission of urine after as long as possible. Injections by an ordinary penis syringe are sometimes recommended, but they are entirely futile. It is difficult, if not impossi- ble, to make efficient application in this way to the prostatic part of the urethra. 84 SPERMATORRHOEA. (Fig. 3.) (Fig. 4.) The instruments and appliances referred to in the text may be obtained from Mr. Wm. Autenreith, No. 71, West Sixth street, Cincinnati, Ohio. TREATMENT. 85 A great many instruments have been devised for making application to the prostatic part of the urethra. It would be a waste of space to mention them all. The universal syringe and catheter answer most purposes. I have had con- structed, in imitation of many that have been devised, a syringe which is very useful for this purpose. It consists of an ordinary hard-rubber syringe having a nozzle the diameter of a No. 6 catheter, and seven inches in length. The nozzle terminates by an olive-shaped blind extremity, behind which are a number of orifices for the escape of fluid. (Fig. 4.) The injected fluid flows from within outward, and is prevented by the bulb in front from escaping into the bladder. Catheterism is beneficial in that state of hyper- esthesia of the prostatic part of the urethra which is so commonly present in cases of sper- matorrhoea. The mere stretching of the canal by a full-sized bougie or catheter has the effect to diminish the excessive sensibility of the parts, and the moral effect of the introduction of the instrument is not inconsiderable. Circumcision.—When the prepuce is long the glans penis is kept moist and the epithelial layer 86 SPERMATORRHOEA. becomes exceedingly delicate and susceptible. The abundant sensitive nerves of the glans are thus placed in the most favorable condition for the reception of impressions ; an irritation expe- rienced there is promptly, and with heightened impulse, conveyed to the cord, and hence, in the act of coitus, the emission takes place too quickly. So too, in sleep, the venereal impulse takes its origin, frequently, in these nerves thus endowed with an exaggerated sensibility. For these rea- sons, the operation of circumcision is frequently necessary in the treatment of spermatorrhoea. It wrould, probably, be well for society if the Jewish rite were made universal. It is a well-known fact, that, although the Jews suffer from gon- orrhoea, they are rarely affected with syphilis. My observation justifies me in asserting that it is uncommon to meet a Jew afflicted with " seminal weakness." The freedom with which they expose themselves to contagion, and their great sexual activity, would, certainly, favor the occurrence of these disorders, if circumcision did not prove a protection. A knowledge of this hygienic fact, probably, existed at a very remote period of anti- TREATMENT. 87 qnity, for, according to Herodotus,* the Egyptian priests " practised circumcision for cleanliness, considering it better to be cleanly than comely." The editor of Herodotus in a foot-note expresses the belief that " this institution reaches to the most remote antiquity; we find it existing more than 2,400 years before our era, and there is no reason to doubt that it dated still earlier." At first con- fined to the priests, it afterwards extended through all ranks of society, as the benefits of the practice became known. In all probability the Jews obtained it from the Egyptians. Other instrumental methods.—We may classify under this head various mechanical appliances to prevent involuntary seminal discharges. A use- ful expedient of this kind is a leather ring armed with metallic points large enough to be worn without discomfort until erection occurs, when the pricking will arouse the patient. This in- strument may be employed by those who have decided erections and the emission with a distinct orgasm. Trousseau f recommends the introduc- * Vol. ii., chap. 37, p. 53. \ Clinique Medicate de VHotel Dieu, etc., op. cit., vol. ii., p. 646-8. 88 SPERMATORRHOEA. tion of a pear-shaped cylinder of wood into the rectum to compress the prostate and seminal ducts. This barbarous contrivance, as it seems to me, cannot prevent venereal excitement and erec- tion, although it may prevent emission, or force the semen backward into the bladder. Trousseau, however, speaks warmly in its praise, and adduces evidences of the good effects of the practice. Any theoretical objection which we may entertain must yield to the demonstrations of clinical obser- vation. Accordingly, I will, when a suitable case presents itself, give this method of treatment a fair trial. Meanwhile, having no experience of its use to narrate, we propose to put our readers in possession of the experience of M. Trousseau. He observes that this apparatus has been of real service, and that more than one case, rebellious under all methods of treatment, yielded com- pletely and promptly to this means. He alludes especially to the rapid return of the virile power in the cases treated in this way. In the same category may be classed the method of acupuncture. This consists in passing long needles into the prostate, vesiculae seminales, and sometimes into the testes and vasa deferentia. TREATMENT. 89 Lallemand thinks it unfortunate that acupuncture has fallen into disuse ! We can hardly join in his regrets. A general objection may be urged against all of those mechanical appliances, that they fix the attention of the patient upon his infirmity, thereby retarding recovery. Another remedy, proposed in Trousseau's clin- ical lecture on spermatorrhoea, is forced dilata- tion of the anus. This practice was recommended to him by Dr. Adolphe Richard, who operated on a case in Trousseau's presence, with a most fortunate result. Four months afterwards Dr. Richard received a letter from the young man, announcing that the good effects continued. The frequent passage of rectal bougies, increased to the utmost capacity of the anus, is, sometimes, very beneficial. The internal medicines intended to act locally, are chiefly copaiba and cubebs. They need only be mentioned to be condemned, for the irritation which they produce in the mucous membrane of the stomach and kidney will more than counter- balance any possible good which they can accom- plish in the urethra. Enemas of cold water and other medicaments and suppositories are capable 90 SPERMATORRHOEA. of much more useful results. We have found urethral suppositories, especially, of great utility in those cases of so-called " diurnal pollutions," which consist essentially of urethral leucor- rhcea. The medical treatment has consisted in the main in efforts to improve the general health by appropriate tonics, as iron, quinine, strychnia, sea-bathing, douches, etc.; by suitable dietetics; by improved hygiene, etc. Conjoined with these measures anaphrodisiacs are employed as they seem to be indicated. Remedies employed in the Treatment of Spermatorrhoea.—It will be convenient to dis- cuss under this head the actions and uses of the most approved remedies. Anaphrodisiacs.—One of the oldest of these remedies is camphor. Camphora per nares castrat odore mares, was an aphorism of the school of Salernum. It is not, however, a very valuable remedy. To produce the desired anaphrodisiac effect large doses are necessary; it frequently fails, and its action upon the stomach is unpleasant, TREATMENT. 91 giving rise to a sense of heat and burning, and followed by disagreeable eructations. Lupulin is much employed by many distin- guished therapeutists. Thus it is a favorite remedy with Lebert,* who gives it in combina- tion with camphor. It has considerable efficacy as an anaphrodisiac, but, like camphor, it is un- certain. Belladonna, or better its alkaloid, atro- pia, is much more efficient than camphor. Our indigenous remedy, gelsemium, is still more powerful in its action on the sexual organs. The fluid extract of either of these agents may be com- bined with other anaphrodisiacs, or they may be given alone. The tincture of belladonna and the tincture of gelsemium may be prescribed with advantage together. The most important agent of this class, the most efficient and certain, and the least distressing in its immediate and remote effects, when freely admin- istered, is the bromide of potassium. The ana- phrodisiac property of this drug is now almost universally acknowledged, but the conditions of its success and failure have not been as definitely determined as is desirable. There are yet some *Op. cit., vol. ii. p. 587. 92 SPERMATORRHOEA. sceptics who disbelieve in this property of the bromide of potassium. One of the most recent and pretentious of them is Dr. S. W. Duckworth Williams.* The cases submitted by him in proof of his views serve very well to illustrate the conditions under which the bromide of potassium fails to produce its characteristic effects. We accordingly reproduce them in Dr. Williams's words, as they are very suitable to our purpose. " Dr. Crichton Browne, in a pamphlet on ' The Action of the Bromide of Potassium upon the Nervous System,' published since I commenced writing these remarks, is very much inclined to allow it strong anaphrodisiac properties, although I cannot quite perceive on what data. He owns that he had had no opportunity of trying the bromide of potassium in simple nymphomania, although he used it without effect in one patient who was in a state of mania, following upon melancholia, and in whom there was presumed to be excitement of the sexual feelings, on account of the extraordinary obscenity of language which * On the Efficacy of the Bromide of Potassium in Epilepsy and certain Psychical Affections. Churchill, London, 1865. (Pamphlet.) TREATMENT. 93 she used. Now, I have tried it in every variety of uterine affection that has come within my reach, including nymphomania, satyriasis, menorrhagia, amenorrhoea, dysmenorrhoea, etc., etc., but without perceiving the least benefit accrue..... I had under treatment at one time two cases that seemed especially well adapted for favoring the anaphrodisiac properties of this medicine. They were both strong, healthy girls, the one a lady, the other a domestic servant. Both were admitted into the asylum at Northampton, suffering from simple mania without any positive delusion. They wTere lively, excitable, restless, and ex- tremely volatile, often able to command their faculties sufficiently to converse calmly and rationally for a few minutes on any ordinary sub- ject, but liable at any moment to burst out laugh- ing or into a fit of tears without any visible cause, or to begin to rave and scream, or swear; both were fine, handsome, fully developed young women ; both were most indecent in language, voice, and gesture, and both openly practised self- pollution. The bromide of potassium was given to them in doses of gr. v. bis die in a little pure water, and increased up to gr. xx., and although 94 SPERMATORRHOEA. both were much affected by its use, and both became pale and thin, and reduced, and their cir- culation powerfully controlled (indeed, in one case the pulsations were reduced from 90 to 60 beats in a minute), nevertheless they persisted in their bad habits, and their sensuality became, if possible, more confirmed. The administration of the medicine was persisted in for nearly twelve months in both cases. " Another case in which I tried it was that of a married lady, nearly 40 years of age, in a state of chronic mania, and at the same time I made some observations as to the influence of the bro- mide on the heart's action. This lady was ex- tremely amative, fell in love with every person of the opposite sex she encountered, and was in the habit of writing the most obscene letters to all her male acquaintances. Her pulse was habitually about 90—tolerably strong and full. Being of a strong constitution, I commenced by giving gr. xv. bis die. About an hour after the third dose her pulse was 76; two hours from that time it had almost regained its accustomed frequency, but in an hour's time from the fourth dose it was reduced to 70, and on one occasion TREATMENT. 95 during the first week it was nearly as low as 60. Combined with this decrease in the circulation there was, as might be expected, marked languor and ennui almost amounting to debility, and she seemed inclined to maintain the recumbent posi- tion constantly; but I cannot say that her las- civious wishes or ideas were in the least dis- turbed, or that her advances were marked by more delicacy ; au contraire, 1 am not quite sure that she was not worse." The experience of Dr. Williams, which seems so entirely opposed to that of other observers, is easily interpreted by a knowledge of the condi- tions which retard or altogether prevent the action of the bromide of potassium. In some investiga- tions, published recently,* I attempted to define these conditions. My conclusions were embodied in the following: " Its physiological effects are not very decided, and are readily modified by any local disturbance. " Its therapeutical action is still more decidedly influenced by local morbid processes. * Experimental Investigations into the Actions and Uses of the Bromide of Potassium. Cincinnati Lancet and Ob- server, 1865. 96 SPERMATORRHOEA. " It is indicated where a sedative to the nervous system is required, e. g.—in insomnia; too great reflex excitability; nervous and spasmodic affec- tions of the larynx and bronchi; sexual excite- ment, and in an irritable state of the sexual organs. " It will be effectual in the foregoing conditions, in proportion to the degree in which structural lesions are absent, or in other words, in propor- tion to the degree in which these morbid states are functional rather than organic." These conclusions, the result of observation and experiment, afford us a satisfactory solution of the cause of failure in the use of the bromide of potas- sium in cases such as those described by Dr. Wil- liams. The cases of sexual excitement in mania are due, as is shown by Schroeder van der Kolk, to structural alteration in the medulla oblongata, the centre, according to this author, of the sexual impulse. The bromide of potassium can have no influence over these structural alterations, and hence cannot control the manifestations of sexual excitement which depend upon them. Aphrodisiacs.—These are indicated under cer- tain circumstances. The tincture of cantharides TREATMENT. 97 is sometimes beneficial in cases of great atony and relaxation—those characterized by profuse mucous discharge, so-called diurnal pollutions, very feeble power of erection, and absence of sexual desire. It is contra-indicated where much hypersesthesia of the prostatic portion of the urethra exists. To prevent its irritant effects, or at least to reduce them to the minimum, opium, or cannabis indica, or chlorodyne, may be advantageously combined with it. The red or amorphous phosphorus, or phosphide of zinc, may be given in the same class of cases as suggested for the tincture of cantharides. Nux vomica is adapted to those cases in which it is desired to restore the functional activity of the sexual organs, after the state of quiescence induced by the prolonged administration of anaphrodisiacs. Cimicifuga (actea racemosa) has seemed to me to possess considerable aphrodisiac power, and has proved useful in cases of long-standing spermator- rhoea accompanied by nervousness and anxiety, and diminished sexual desire. Galvanism, especially the induction current, and static electricity, are often decidedly aphro- disiac, and are probably applicable to more numerous cases than any other remedy of the class. 5 98 SPERMATORRHOEA. Duchenne * (de Boulogne) operates in the fol- lowing manner: One rheophore properly insulated is introduced into the rectum, and placed in con- tact with the basfond of the bladder ; the other is passed to the prostatic part of the urethra. In this way a current can be made to traverse the vesicular seminales and ejaculatory apparatus. Benedikt f applies " the copper pole to the lum- bar vertebrae, and passes the zinc pole along the spermatic cords, over the different zones, trans- versely, of the penis, and along the perinaeal region antero-posteriorly. . . Beside this, usually three times in two weeks, the copper pole is applied by means of a catheter-shaped rheophore to the orifices of the ejaculatory ducts, and the zinc pole is passed along the spermatic cords." Ergot has been much extolled in those cases in which emission takes place quickly with feeble erections. Tonics.—Iron, quinine, the vegetable bitters, the mineral acids, are indicated in anaemic cases. The hygienica, air, exercise, bathing, travel, etc., are valuable adjuncts to the remedial measures. * De l'Electrization Localisee. Paris, 1861, p. 97. f Elektrotherapie. Wien, 1868, p. 446. treatment. 99 The Therapeutical Management of Sper- matorrhoea comprehends— First, the treatment of the causes. Second, the treatment of the malady. The Treatment of the Causes.—We have al- ready expressed the opinion that venereal ex- cesses, and especially masturbation, are the causes of spermatorrhoea, in a vast majority of cases as they occur in this country. Hence it is impor- tant to recognize this vice at an early period, to prevent the immediate and remote consequences of its continued perpetration. We have already seen that this vice is con- tracted chiefly by boys in whom the nervous pre- ponderates over the muscular and digestive sys- tems, and that certain moral and social circum- stances, and organic peculiarities, increase the tendency to it. These influences must, as far as possible, be repressed. Of course, it is not with- in the power of the physician to alter those in- herent mental and physical defects which exer- cise such a baneful influence ; but much may be done to diminish the activity of the nervous sys- tem, and to restore the balance between it and 100 spermatorrhoea. the other systems. Therefore, to the physical culture of boys possessing these inherited peculi- arities too great importance cannot be attached. The development of the muscular and digestive systems should be promoted by every agency. Open air exercise, constant physical employment, avoidance of confinement and idleness, cold bath- ing, etc., are the means necessary for this pur- pose. Lebert * places chief reliance upon these hygienic means in all cases of masturbation and spermatorrhoea. The principal organic peculi- arity promotive of this vice, is phymosis. Where this condition exists, the operation of circumci- sion is proper. A long and contracted prepuce hinders the development of the penis, and by retaining the moisture and secretions of the part, increases the sensibility of the glans. Ignorance of the character and tendency of the habit favors the perpetration of masturbation. Parents and public teachers have a sad duty to perform in this connection which they naturally shrink from. In a large majority of cases, the habit would be discontinued, if the dreadful con- sequences of it were plainly set forth to the * Op. cit., p. 784, vol. ii. treatment. 101 unfortunate victims. This becomes especially necessary in boarding schools and in other public institutions where numbers of boys are congre- gated. It is also very important to prevent suggestive novels, and books of every description having a tendency to excite erotic ideas, falling into the hands of these youths. As a general rule it is sufficient in cases of masturbation to set forth clearly the dangers of the practice; to institute a thorough system of physical culture ; to reduce the mental work ; to keep the body occupied; to correct, if possible, any organic imperfection which may be remedied (phymosis), in order to effect a cure. In some inveterate cases this may not be sufficient. The habit may be so confirmed, the instincts so low, and the moral obliquity so great, that no means other than physical restraint will prevent the perpetration of the act. The mechanical appli- ances may be assisted by anaphrodisiacs. Mr. Heckford* has recently published a paper showing the great value of " ciicumcision as a * London Hospital Keports, 1865, vol. ii., p. 62. Already quoted. 102 SPERMATORRHOEA. remedial measure in certain forms of epilepsy, chorea, etc." In the very instructive cases given by Mr. Heckford, the convulsive affections de- pended upon masturbation. As the operation of circumcision is easily per- formed, and is without danger to life, it should not be omitted from the treatment in two classes of cases : 1. Those in which the habit of masturbation is due to the hyperaesthesia of the glans produced by an elongated prepuce and the irritation of the retained sebaceous matter; and 2. In those cases in which the same cause (a peripheral irritation) induces the venereal orgasm and involuntary discharge. Although we do not deny the possibility of'it, we regard it as rather improbable that a mere peripheral irritation, such as an irritable or in- flamed state of the prostatic portion of the urethra, or a balanitis, will of itself produce the reflex phenomena of spermatorrhoea. Such irritation, however, will undoubtedly increase the morbid excitability of the reflex faculty, if it have already been aroused by such causes as masturbation and venereal excesses. • Ceasing an ill habit may suffice in many cases TREATMENT. 103 to cure these local irritations. The operation of circumcision should be performed when the pre- puce is long, the glans moist, and epithelium very sensitive. The frequent application of cold water to the glans, when in this condition, is of great service. The tanno-glycerine ( 3 i.— 3 i.) may also be applied daily to the glans with advantage. Similar measures may be adopted for an irritation in the prostatic part of the urethra: daily injec- tions of cold water; the injection through a silver catheter in the manner already recommended, of the tanno-glycerine, or of a solution of nitrate of silver. But the irritable state of the prostatic portion is more properly an effect rather than a cause of spermatorrhoea; accordingly we post- pone the further consideration of it until we come to treat of the therapeutic measures proper to the malady itself. Remedial Management.—Remedies should be employed with reference to the pathological states of the several phases of spermatorrhoea. In the genital form there are associated with the peripheral irritation increased reflex excitability and derangement of the primary assimilation. There may be a condition of plethora, or more or 104 SPERMATORRHOEA. less emaciation ; much more usually, the latter : the therapeutical methods are indicated in this brief pathological summary. In those rather ex- ceptional cases, in which the spermatorrhoea is the result of plethora and forced continence, it may only be necessary to impart to the patient correct views of the importance of the losses, which, influ- enced by current publications, he will be very apt to exaggerate. If his vessels are full, his bowels are constipated, aud his digestion active, he will be benefited, if somewhat reduced by saline cathar- tics, by liquor potassce, by a less liberal diet, by abundant exercise, and by diminishing the num- ber of hours devoted to sleep. Many cases of so- called idiopathic spermatorrhoea occur in studious persons of sedentary habits, whose nervous system has been rendered unduly excitable by prolonged mental work with enfeebled digestive powers. These are relieved by mental rest, by some phys- ical employment, and by attention to the state of the digestive organs. Activity of the sexual system may be associated with this excitable state of the nervous system in studious persons; when, of course, the anaphro- disiac remedies will be required. It has happened TREATMENT. 105 to me to meet cases of this character in clergymen who led a life of celibacy. A judicious employ- ment of the hygienic means together with the medical, and especially a candid statement of the real importance of the infirmity, will be followed by most satisfactory results. A vast majority of the patients who present themselves for treatment do not belong to either of the foregoing classes. They are those in whom seminal weakness has been induced by masturba- tion, or by prolonged excesses in venery. They have frequent nocturnal emissions. The reflex excitability of the cord is so much increased, that the feeblest irritation procures a prompt emission with little of the venereal orgasm, and the frequent discharges of nervous force affect the supply to all the organs—whence come palpitation, indiges- tion, constipation, irritable bladder, pain in the back, mental feebleness, and debility. The peri- pheral irritation and the reflex excitability must be diminished. These important objects may be accomplished by means partly hygienical and partly medicinal. The patient should cease his excesses, whatever they may have been, and avoid all sources of ex- 106 SPERMATORRHCEA. citement, whether the reading improper publica- tions, suggestive novels or works upon his own malady, or the society of women of easy virtue. The liberties between the sexes permitted by cus- tom in many places and in certain circles of society without extending so far as the gratification of de- sire, are so very injurious to young men with " seminal weakness," that they should be absolute- ly interdicted. The mind of the patient should be freed, as far as possible, from any association with his disagreeable infirmity. Hence constant and agreeable employment, physical rather than men- tal, or an association of the two, is especially de- sirable. The bromide of potassium will powerfully contribute to the success of these measures. Forty to sixty grains may be given every night until sexual desire is entirely suspended. This remedy has a decided power to allay urethral irritation, as we have found, not only in the cases for which it is now recommended, but in gonorrhoea after the acute stage has subsided, and in gleet. We ob- serve that Mr. Hutchison * has committed himself to the same opinion. In that very distressing com- * London Hospital Reports, vol. ii., p. 340. TREATMENT. 107 plication of spermatorrhoea—hypersesthesia of the spermatic plexus—the bromide of potassium is, also, very effective. If decided anaemia exist in these cases of the genital form, iron and quinia may be given during the day, conjoined with lupu- lin, should it be desirable to increase the ana- phrodisia. We have seen that dilatation of the inter-rachi- dian vessels probably exists in advanced cases. This view seems confirmed by the fact that the in- voluntary emissions occur much more certainly when the patient is lying on his back—a position favoring congestion of the cord. Hence manage- ment of the position in bed is not to be neglected. The patient should lie upon his side, and if unable to continue in this position when asleep, should adopt some mechanical appliances to com- pel it. Tying the hand to the bed-post so that the position of the back cannot readily be assumed may suffice in some instances. Or, Lallemand's contrivance may be adopted: this consists of a thin sheet of lead to which a piece of wood is fas- tened, attached by a girdle to the loins. Or, Mr. Acton's expedient, which is nothing more than a towel tied about the waist with a large knot be- 108 SPERMATORRHOEA. hind. Or, lastly, the leather ring armed with me- tallic points, which will arouse the patient when erection occurs. The principal remedial agent for inducing con- traction of the inter-rachidian vessels is ergot. The drug should be fresh, or carefully prepared ergotin or fluid extract should be used. Gelse- mium may be used for the same purpose. It is probably more effective even than ergot. Cold ' to the spine, not too prolonged, or alternate hot and cold douches, may be usefully conjoined with the ergot. It should be remembered, how- ever, that cold to the spine is a powerful aphrodisiac. If the patient experience the tenacious dis- charge from the urethra, consisting of the secre- tion from the prostate, Cowper's glands, and folli- cles of the mucous membrane, he will undoubtedly believe himself to have " diurnal pollutions," and will be correspondingly alarmed. If the discharge do not cease during the course of treatment just recommended, it will be necessary to adopt some special means to arrest it. These special means con- sist in the local application in the manner already indicated of tanno-glycerine, of solutions of nitrate TREATMENT. 109 of silver, or the use of the porte caustique. We should not forget, however, that caustic applica- tions are considered by Henry Thompson * as a cause of prostatitis. Our duty is not ended in a case of sperma- torrhoea, with the production of a state of ana- phrodisia and the curing of irritation in the urethra. We must restore the patient to the proper performance of his sexual functions, and this must be accomplished in such a way that he wTill not lapse into his former infirmity. The bromide of potassium and the ergot must be sus- pended, and tonics and special excitants must be employed. Extract of nux vomica or strychnia with iron, is a useful combination under these circumstances. Cimicifuga and gelsemium are also indicated, if there be any decided nervous phenomena present as a complication. Galvan- ism should not be neglected. In these cases, Duchenne's method should be practised : i.e., one rheophore in the rectum ; the other passed into the prostatic part of the urethra. Benedikt re- ports great success by his mode of applying the * On Enlarged Prostate : Its Pathology and Treatment. London, 1858, p. 195, op. cit. 110 SPERMATORRHOEA. currents. Sometimes static electricity is of great service. The patient is placed on an insulated stool, in communication with the prime con- ductor, and sparks are drawn from the genitals. During the whole period occupied by this treat- ment certain accessories must not be disregarded. Simple but nutritious food must be taken; the supper should be light, and eaten four or five hours before retiring, and alcoholic stimulants should be avoided. The habitual use of tea, cof- fee, and tobacco should be discouraged. Fluids and articles of food having a diuretic action should be sparingly used, since erections occur when the bladder becomes full. Laxatives are indicated if constipation exist, but not otherwise. In that phase of spermatorrhoea which we have denominated the cerebral, in addition to the derangement of the sexual-spinal system there ex- ists some form of cerebral disorder. If the sexual troubles are mere symptoms of mental derange- ment, the treatment of them is merged into that for insanity. If, on the other hand, the mental derangement is the result of seminal losses or abuse, the treatment of it becomes associated necessarily with that for the cause. The cases TREATMENT. Ill given in the extract from Dr. Williams's pamphlet belong to the first class; the typical cases pre- sented under the head of the cerebral form are instances of the second. The first are not amena- ble to the action of anaphrodisiacs, whilst the second are. Usually the mental derangement has proceeded no further than hypochondria, melan- cholia, or trembling delirium (delusional insanity) corresponding to delirium tremens of alcoholis- mus. In all of the psychical affections of sperma- torrhoea, the bromide of potassium is very effi- cacious. Ergot shonld be administered in con- junction with it, and counter-irritants (firing, setons, blisters) should be applied to the nape of the neck, on Schroeder Yan Der Kolk's plan, and also as recommended by Romberg. The early recogn ition of mental disorders arising from abuse is very important. With the anaphro- disiacs—bromide of potassium, lupulin, and cam- phor—and moral agencies, should be conjoined the operation of circumcision. Physical con- straint may also be resorted to, but this is a temporary expedient which more usually fails than succeeds. Division of the vasa deferentia in inveterate cases has been recommended, and we 112 SPERMATORRHOEA. have seen it performed in an inveterate case. Nothing but a failure in the means alread}7 pro- posed will justify the performance of this opera- tions, as in its practical results it is equivalent to castration. The operation is readily enough per- formed. The duct can be easily felt and separated from the rest of the spermatic cord, when it may be divided by the subcutaneous section. In the spinal form of spermatorrhoea the treat- ment will be influenced by the condition of the cord. If the loss of power, the altered and re- ferred sensations, the paraplegia, be merely func- tional derangements, or due to a " dynamic alteration," strychnia, cimicifuga, faradization, douches, hot and cold, to the spinal column, will be indicated. Bromide of potassium is hurtful in the paraplegia of sexual excess. It is, how- ever, especially applicable to the treatment of the epilepsy and chorea of spermatorrhoea. The striking results obtained by Mr. Heckford, and my own observations, warrant, me in strongly urging the operation of circumcision, in those convulsive disorders due to masturbation. In the typical cases of the spinal form narrated under that head, I found the extract of belladonna of signal advantage. TREATMENT. 113 Treatment of Impotence.—The, temporary im- potence of spermatorrhoea requires time and fami- liarity with the object of desire. If it consist of nothing more than such a degree of excitability of the reflex faculty, that intromission cannot be accomplished, or that the seminal discharge takes place after very imperfect coitus, then the treat- ment recommended for the genital form of sper- matorrhoea may be pursued. In the impotence dependent upon spermator- rhoea of long standing, hot and cold douches to the spine, galvanism or static electricity, and a properly conducted system of physical training and exercise, are the most-appropriate measures. Special excitants may be employed in conjunc- tion with these means: strychnia, phosphide of zinc, cannabis indica, cantharides, etc. ; but these remedies will not be successful unless the general health has been restored by proper hygiene and suitable haematinics. When the impotence de- pends upon " irritable testis," a judicious course of bromide of potassium should precede the use of the other measures. Some of these cases may be very quickly cured by an induction current passed through an insulated metallic sound in- 114 SPERMATORRHOEA. troduced into the bladder. The occasional pas- sage of a full-sized catheter, I have found in not a few instances, to produce energetic erec- tions. The question of the propriety of marriage often involves considerations of great delicacy. Many cases are undoubtedly curable in this way. Marriage will always have a fortunate result in the cases of spermatorrhoea of physiological ori- gin. In true spermatorrhoea, marriage may be enjoined when the genital apparatus is not so impaired in function as to prevent intromission. Regular intercourse, not too frequently repeated, will prove of signal advantage in these cases. At first sexual contact may be unsatisfactory in consequence of the greatly increased reflex exci- tability of the ejaculatory apparatus; but power increases by judicious use of the organs. Singular as the opinion may appear, I can- not refrain from stating that marriage has re- sulted unhappily more frequently in cases of imaginary spermatorrhoea than in the other forms described. When the supposed existence of this trouble becomes a predominant idea, and moral and medicinal treatment cannot destroy or TREATMENT. 115 weaken it, marriage will only confirm the delu- sion, for the first attempts proving failures, the patient will give himself up to the most abso- lute conviction of incompetence. 116 SPERMATORRHOEA. FORMULAE. INJECTIONS. Argenti Nitrat., gr. x. Aquae Distil., § j. Solve. Zinc. Sulphat., gr. xij. Morphiae Sulphat., gr. iv. Atropiae Sulphat., gr. ss. Aquae Distil., § j. M. B. Acidi Tannici, 3 j. Glycerini, § j. M. 5. Acid. Tannici, 3j. Tinct. Iodinii, 3 ss. Glycerini, § j. M. FROMUL^E. Anaphrodisiacs. 3. Lupulin., gr. vj. Pulv. Camphorae, gr. iij. Ext. Belladonnae, gr. j. ft. pil. No. vi. S. One 3 times a day. I*. Atropiae Sulphat., gr. ss. Aquae Distil., § ss. M. S. 3 to 5 drops 3 times a day. V. Tinct. Gelsemii, 3j. Tinct. Belladonnae, 3 ij. M. S. 15 drops 3 times a day. I*. Tinct. Gelsemii, 3j. Tinct. Cimicifugae, 3 vij. M. S. 30 drops to a teaspoonful 3 a day. 118 SPERMATORRHOEA. Potassii Bromidi, § j. ft. pulv. No. viii. S. One dissolved in water every night. Potassii Bromidi, § j. Ext. Gelsemii Fl. 3 ij, Syrp. Simpl. 3 i. Aquae Cinnamomi, § iij. M. S. A teaspoonful 3 times a day. IJ. Potassii Bromidi, § j. Ext. Belladonnae Fl. Ext. Gelsemii Fl. aa 3 ij. Syrp. Simpl., § iss. Aquae Menth. P., § ij. M. S. A teaspoonful 3 times a day. Aphrodisiacs. Tinct. Cantharidis, 3j. Tinct. Cannabis Ind. FORMULAE. 119 Sol. Morphiae Bi-mec, aa 3 ij. M. S. 15 drops 3 times a day. n. Zinci Phosphidi, gr. iij. Conserv. Rosae, 3 ss. ft. pil. no. xxx. S. One night and morning. B. Tinct. Nucis Vom., 3j. Tinct. Acteae Rac, 3 iij. M. S. 20 drops 3 times a day. B. Syrp. Ferri, Quiniae, et Strychniae Phos., 1 ij. S. A teaspoonful 3 times a day. 3. Auri Terchloridi, gr. j. Ext. Nucis Vom., gr. v. ft. pil". No. xx. S. One 3 times a day. 120 SPERMATORRHOEA. Urethral Suppositories. Iodoformi, Acid. Tannici, aa, gr. vj. 01. Theobrom., q. s. ft. supposit. ureth. no. vi. 3. Acid. Tannici, gr. vj. Ex. Belladonnae, gr. j. 01. Theobrom., q. s. ft. supposit. ureth. no. vi. 3. Plumbi Acetat., gr. xij. Morphiae Acetat., gr. j. 01. Theobrom., q. s. ft. supposit. ureth. no. vi. 3. Morphiae Sulph., gr. iij. Zinci Sulph., gr. vj. 01. Theobrom., q. s. ft. supposit. ureth. no. vi. The End. NATIONAL LIBRARY OF MEDICINE NLN DHSlbDflS 3 NLM045160853