[Reprinted from the Boston Medical and Surgical Journal of March 8,1894.] ON SPERMATORRHOEA AND INCIPIENT HY- PERTROPHY OF THE PROSTATE, AND A PROPOSED METHOD FOR ITS TREATMENT. A long time is always necessary to collect facts; and as it is better, moreover, that they be collected from widely-spread sources, I have not hesitated to communicate the few cases noted below (interesting in themselves, but still more through the great groups of diseases to which they belong), in the hope that more attention may be drawn to prostatitis, especially to that form I have found in spermatorrhoea, and to in- cipient hypertrophy of the prostate. During the past summer six or seven youths, be- tween the ages of nineteen to twenty-eight years, came at very nearly the same time under treatment for spermatorrhoea, -post masturbationem. All had been previously treated by the " usual methods," but with- out improvement. The " usual methods " were per- sued also by me with physical and psychical improve- ment in view, besides exercises in the open air, bathing, encouragement, sedatives, cold-water spinal douche, etc.; moreover, sond a demeure ; but all in vain. The cases were in many respects alike but also in some points very unlike. Concerning the usual symptoms it may be mentioned that the frequency of the ejaculations varied between two or three and ten or twelve a week. The condi- tions of the prostate were the most interesting part in these cases. Its amount varied considerably, from be- BY RICH. HOGNEB, M.D. 2 ing increased so that the apex could not be approached with the finger, to being rather diminished so that it was palpable everywhere with a very slight movement of the finger; and the consistency was in the former case more or less fleshy (sometimes giving the impres- sion of swelling around a firmer part) ; in the latter, more hard, without any swelling at all. The former groups (four or five cases) belonged, as to duration and symptoms, to the milder ones; the latter to those of longer continuation and severity, where the ejacula- tion often occurred without feeling. In all the cases the prostate was found to have an increased sensitive- ness or pain to the touch, either over the whole organ or over a portion of the same, in one case apparently only in the region where the lateral lobes begin to di- verge, a pain which I have not yet found in uncompli- cated cases of masturbation. The symptoms suggested chronic prostatitis in different stages, occupying most frequently the whole organ, and - with regard to the frequent ejaculations - in my opinion, especially the muscular elements. And why would this not be so ? The prostate, an organ both muscular for ejaculations and follicular for secretions, becomes during the sper- matorrhoea more strained than under normal conditions. In spite of spermatorrhoea, the " patients " often con- tinue with masturbation; and the prostate muscles, moreover, appear to remain (if I may use the expres- sion) in a kind of " half-primed " state, or one of "con- stant expectation," and to be in a sickly, irritable con- dition, with the result that sometimes only the least influence is necessary to produce ejaculation. A hy- pertrophic gland is in a hyperaemic semi-inflammatory condition; and a muscle which is unnaturally strained often becomes the seat of inflammation. In the sper- matorrhoeas are found, therefore, the possibility for both a folliculitis and a myositis of the prostate, per 3 continuitatem affecting each other. The discharge from prostatic follicles forms a part of the sperma just as certainly as the secretion from the vesiculi seminales ; then why should not a follicular prostatitis be primary as well as a spermato-cystitis ?1 The prostate gland has surely a double function (secretive and ejaculatory), while, on the contrary, the vesiculi seminales have chiefly only one (secretive) ; therefore the prostate be- comes strained proportionately in double measure dur- ing spermatorrhoea, while the vesiculi seminales are so only in one function. Therefore, it seems to me, that the prostate can be primarily diseased as well as the vesicles. In his treatise Dr. J. Lloyd says 2: "In the majority of cases where prostatitis is thought to complicate a urethritis it is the seminal vesicles which are the seat of the inflammation, and not the prostate at all." When Dr. Lloyd thinks that the urethritis spreads through the ejaculatory ducts, why should it not be carried through the fifteen to twenty excretive follicu- lar ducts which empty below on pars prostatica urethrce? I will not speak further on this subject, but maintain that with spermatorrhoea (which is here especially treated of) the prostate gland is just as directly affected as the other genital organs. The intention is not to draw general conclusions from a few cases; the attempt has been rather to ex- press my impressions and reasons why the prostate be- gan to be treated with massage as in other cases of myositis ; while nerve-pressure 8 was given at the same 1 On Spermato-Cystitis (inflammation of the seminal vesicles). By Jordan Lloyd, M.D., F.R.C.S. Lancet, October 31,1891, pp. 97, 974, etc. 2 Loc. cit., pp. 975, 976. 3 With " nerve-pressure " is meant, a local pressure on a nerve (trunk, branch or plexus), given in such a way that the nerve is pressed for some seconds firmly between the tip of the finger and a more or less deep-lying bone, while at the same time the hand is made to tremble so that under the pressure of the finger the vibration 4 time, and in some cases, moreover, gymnastic move- ments so applied as to lead the blood from the pelvic viscera. Massage was given once or twice daily per rectum (while the patient was recumbent with elevated pelvis, at the same time placing his fists under the buttocks), partly while the sound (solid No. 10) lay within, partly after it was withdrawn, and continued as long as possible, that is, only a few minutes, as long as the physician can endure it. As a conductor during the massage the sound is of great value, because it makes the prostate more approachable and steady ; moreover, it causes the massage to be so much more effective by reason of the double pressure, which is given by the finger per rectum and the instrument per urethram, a pressure which becomes more local than that between the finger and ramus pubis, against which the organ otherwise is resting when the sound is removed. The cases treated became so much better after two to three weeks that the subjects considered themselves well. The severest was an upholsterer, twenty-eight years old, who had tried " all kinds of remedies " for five or six years, but without success. The patient had a spermatorrhoea appearing each or every second night, and sometimes as many as three times in eight hours. The powers of body and mind were depressed ; but the patient was able, however, to continue his work. The prostate was not swollen, but rather small and hard; but what impressed one most was its ex- cessive tenderness, equally spread over the whole organ. Massage and nerve-pressure were employed once daily ; also a promenade three-quarters of an hour long before and after each treatment. After two is transferred to the nerve. The movement is intended to create a molecular irritation or change by means of which one seeks to trans- form the abnormal condition - as far as it can depend on a centro- spinal change - to a normal one. 5 weeks the treatment was discontinued, because one ejaculation a week seemed to the patient to be " noth- ing." The general health had improved considerably. The tenderness in prostate had disappeared. In comparison with these cases was one with incipi- ent hypertrophy of the prostate, a man thirty-three years old, who had been married five years, who sought a consultation ostensibly for the reason that for two years past " it had dropped so long " after urination. No stone; no stricture. The urine was clear, passed perhaps more frequently than formerly. The bladder discharged its contents wholly; and still there was a desire soon after to urinate again, so that the patient did not feel comfortable before he had passed some drops more. The prostate gland, of exceedingly fleshy consistency, was considerably enlarged as a whole. The apex of the right lobe was especially difficult of approach by the finger. The lateral lobes felt knurly, especially the right one, in the upper part of which, moreover, a stringy mass of lobes was felt proceeding from the lower inner part to the upper forward part, and gave the impression of enlarged, perhaps somewhat dislocated vesiculi seminales ; which mass of lobes as well as the prostate as a whole was noticeably tender to the touch. It took a long time to introduce the catheter; also it had to be inserted deeper than usual, and the posterior part of the urethra was excessively tender, bleeding easily. Gonorrhoea had never existed; neither spermatorrhoea ; but the man had, nevertheless, masturbated. Among formerly employed methods was used - but without success - electrolysis. The treatment now was with massage alone, with and without the sound, on the prostate gland twice daily (except Sundays). After two months' time the patient's dropping " dis- appeared, so that it was " nothing to speak of," and 6 the prostate became diminished so much that it could almost be considered normal, was rather hard and not swelled at all. The knurly character of the left lobe had disappeared, and only a suspicion of unevenness remained in the right lobe. The stringy mass already mentioned had disappeared, and instead somewhat en- larged ordinary vesicles were felt above the right lobe of the prostate. The tenderness had also disappeared. That especial importance was attached to making the sound, orificium urethrae and the fingers aseptic, scarcely need be mentioned. Several years ago I had already tried to treat the diseases mentioned, with the use of the sound (then without massage), but no particular success was met. The signal success resulting from last summer's expe- rience may, therefore, be ascribed alone to the mas- sage. As stated, the changes of the prostate, in the cases of spermatorrhoea examined, have been regarded as a prostatitis and treated as such; and also the condition in the case of incipient hypertrophy of the prostate referred to, in which the prolonged dropping (a symp- tom common, moreover, to the senile prostatic hyper- trophy), seems to me to indicate that the changes in the prostate even spread to the musculi detrusor and sphincter vesicas, both of which connect with the pros- tate muscles. Therefore the case can rightly be considered as hy- pertrophia prostatas prce senilis or incipiens, which was arrested by massage. But if, instead, the prostatitis had continued, it is probable that the prostate would have become in time harder, and fibrously hypertrophied, that the urinary troubles would have increased, and that the subject would finally have had a regular hypertrophia pros- tatas senilis. 7 The spermatorrhcea with its abnormally exaggerated secretion and ejaculation (probably from the beginning tropho-neurotic and neurotic, but afterwards just as much musculo-glandular in its pathogenesis), it seems to me that a serious circulus vitiosus is established; a nervous irritation has increased the secretion, and this, in turn, the ejaculations, that is, caused the muscular strata tojbe unnaturally primed or active, which has an influence on the innervation of the prostate, this on the secretion in the follicles and in the remaining genital organs, etc. To this is now added, moreover, the men- tal depression and the great loss of the specific " vital energy" of the sperma, which in turn also contributes to the diseased condition. Massage was destined in this case to break a link in such a chain. If prostatitis has been found in spermatorrhoea, then one must imagine the stages preceding, developed by degrees through the masturbation, that is, stages of irritation which finally (through accidental injuries, taking cold, a hurt, etc., or most commonly through continued straining) merge into a regular inflammation. The condition can be the same after exaggerated, nat- ural ejaculations and even so in the irritated condition of the prostate following gonorrhoea. In short, several causes, especially sexual ones, seem to be found, which very early call forth a condition of irritation in the prostate, which from one reason or another is easily transformed into prostatitis muscularis, which, more- over, as in other cases of myitis, etc., untreated, con- tinue through life and increase by degrees ; and herein, I consider lie, in great measure, the causes of the fre- quently occurring " hypertrophia prostatse senilis," so much the more, as we can easily imagine here a new " circulus vitiosus." When the prostate has grown to a certain degree, it causes a hindrance to the passage of urine. The walls of the bladder become hypertro- 8 phied through a process in all respects like a myitis of exceedingly long duration. The affection of the mus- cles of the enlarged bladder extends also to the pros- tate muscles (these muscles being so closely connected), and so the hypertrophy of the prostate increases, also the difficulties of urination. That such a long-continued muscular prostatitis is transformed into hypertrophy and not into atrophy certainly depends on the great quantity of blood, physiologically located in the genital region. W. White says4 that one must, from the theories concerning prostate hypertrophies, provisionally accept that of Velpeau (Thompson) : " The growth or growths, which make up the enlargement in prostatic hyper- trophy are analogous to those fibro-myomata so fre- quently found in the uterus." It seems to me, rather, they are analogous to metritis hypertrophicans. Either may be the case. But just as the fibro myomata cer- tainly have been preceded by an irritation, just as the metritis (partialis or universalis) which are treated with massage with the greatest success according to Thure Brandt's method, just so surely have we even seen an incipient hypertrophy or a prostatitis removed by massage. As metritis often depends on something connected with the sexual life (such as, for example, after colds or hurts, especially during, or immediately preceding or following menstruation, after partus, after infectious coitus, etc.), we have here, also, a similarity between the probable stages of both fibro-myomata or at least of metritis hypertrophicans and the hypertro- phia prostatas senilis; the latter of which, for reasons mentioned, seems to stand in relation to the sexual life, an assumption which is further strengthened by the fact, that a bilateral castration diminishes the senile prostatic hypertrophy. 4 The Present Position of the Surgery of the Hypertrophied Pros- tate. By J. William White, M.D., Annals of Surgery, August 1893, p. 156, etc. 9 When White asks, " In what cases is a purely ex- pectant treatment proper?" he answers, "Only in those in which enlargement has produced no symptoms, and catheterism is easy and shows no residual urine." I will answer, on the contrary, that every enlargement, every tenderness of the prostate should he treated, in the attempt to prevent hypertrophy, which the surgeon can so beautifully operate upon, but with uncertainty of cure. It is unfortunately true that one seldom finds a per- son willing to be treated - at least for any length of time - for a sickness which has not appeared ; but I believe, if my comprehension of the beginning of "old men's troubles " is the right one, both that it is the duty of the physician to warn the young or middle-aged man (who, moreover, has already noticed, perhaps, the dropping and prolonged urination) of what can follow if he lives; and that there will be many who would gladly undergo preventive treatment. If we find, even accidentally, during the examination, the prostate in stadio irritationis or in statu myitico, then the time has come to attempt a treatment. At present I know no better treatment than massage ; but if science finds a less laborious one, so much the better. It is assumed that hypertrophia prostatae senilis must have its curable stages. May attention be called to this, and testimony from many directions throw light on all sides of this important subject!