they finally recover with the exercise of a little patience. The worst outlook is when the emissions are passive, or occur without the orgasm, or during urination and defecation. In this class of cases not only are the ordinary remedies applicable to the other varieties demanded, but measures will have to be resorted to to overcome the paralyzed and dilated orifices of the ejaculatory ducts. Although the prognosis is not as favorable, I have never seen an example of spermorrhagia that did not finally yield to treatment.

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

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

In the section on the etiology and pathogeny of seminal incontinence attention is called to the fact that hyperesthesia of the prostatic urethra is nearly always present. While it is undoubtedly true that the genital nervous centres may be highly impressible without the intervention of hyperæmia, inflammation, and abnormal sensibility of the prostatic urethra, it is none the less true that those lesions are the most constant and most important of all the causes which excite and maintain the dis

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

From the preceding considerations it follows that the treatment, whether it be local or general, must at the outset be of a calming and sedative nature, the end in view in the great majority of instances being to overcome the exaggerated irritability of the genital nervous centres and the abnormal sensibility of the deep urethra. By the indiscriminate employment of strychnia, cantharides, phosphorus, and cold ablutions great harm is done, and the management of involuntary seminal emissions is brought into disrepute.

Of the local remedies to overcome the hyperesthesia of the prostatic urethra, there is not one entitled to so much confidence as the nickelplated conical steel bougie, passed at intervals of four days, and at once withdrawn for the first few insertions, after which, with the decrease of the sensibility, the intervals should be shortened, and it should be retained longer, until it is inserted every forty-eight hours and permitted to remain in the canal for a few minutes. The size of the first instrument is to be gauged by that of the meatus if it be normal, and if it be found necessary during the course of the treatment the orifice should be enlarged, in order that bougies of progressively increasing sizes may be introduced until they correspond to the full calibre or distensibility of the urethra, as indicated by the urethrameter. Unless these precautions be observed the measure will not bring about the desired result.

As a rule, the bougie will meet the indication, but in exceptional instances a small, circumscribed area of tenderness remains, which comprises the sinus pocularis, and which proves rebellious to instrumentation. Under these circumstances it becomes necessary to apply a drop or two of

a solution of nitrate of silver to the spot, which is best done with a small syringe attached to a perforated bulbous explorer. The ordinary forms of porte-caustique charged with the fused nitrate are objectionable, as the remedy does not come in contact with the orifices of the ejaculatory ducts contained within the sinus pocularis, and its application cannot be properly controlled. From an ample experience I can confidently recommend the use of a thirty-grain solution, repeated every four days. Provided the patient be kept in bed for a few hours, the pain and desire to urinate will not last more than thirty minutes. When the affection proves to be more than ordinarily obstinate, flying blisters, made by pencilling cantharidial collodion first on the one side of the perineal raphé, and, after the surface has healed, on the opposite side, will prove serviceable.

In addition to these measures great assistance will be derived on retiring from the hot sitz-bath, or from a sponge or cloth dipped in water at a temperature of at least 105° F. and applied to the perineum and lower part of the spine. Cold applications are to be studiously avoided.

Of the general remedies, not a single one is comparable to bromide of potassium, which not only diminishes the reflex excitability of the cord and suspends sexual desires and the power of erection, but corrects the acidity of the urine and exerts an anesthetic effect upon the mucous membrane of the urethra. I am in the habit of administering from three to four scruples of the salt at bedtime, and if I find that it sets up signs of bromism I diminish it for a time, and afterward promote its excretion by the kidneys by combining with it about fifteen grains of bitartrate of potassium. Should the patient be anemic, the dose should be reduced to one drachm, and three grains of quinine along with twenty-five drops of the tincture of the chloride of iron should be ordered every eight hours. When, on the other hand, the patient is robust and plethoric or in full health, I frequently add to the bromide ten drops of veratrum viride or tincture of gelsemium, or administer the bromide in half an ounce of the infusion of digitalis.

Another remedy which diminishes the reflex mobility of the genitospinal centre, at the same time that it reduces the secretion of the seminal fluid, is the sulphate of atropia. Given in the average dose of the one-sixtieth of a grain on retiring, so that the patient may sleep through its disagreeable action, it will be found to be an invaluable addition to the treatment.

When the bromide of potassium and atropia do not agree with the patient, I substitute the monobromide of camphor and extract of belladonna in the proportion of ten grains of the former to one-third of a grain of the latter. In the remaining anaphrodisiacs, such as lupulin, camphor, and conium, I have not the slightest confidence.

Under the plan of treatment thus outlined the majority of cases of nocturnal and diurnal pollutions recover; but if the spinal genital centre still remains too impressible, galvanization with the anode to the lumbar region and the cathode to the perineum will prove highly serviceable. When the condition is one of spermorrhagia, after the hyperæsthetic symptoms have subsided the relaxed and paralyzed orifices of the ejaculatory ducts may be restored to their normal condition by the continuous current, the negative reophore being placed in the rectum and the positive on the perineum or the lumbar vertebræ. Should galvanization fail,

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the induced current may be passed through a negative catheter electrode in the prostatic urethra to the anode resting on the perineum or spine; but this mode of application requires great caution, and a feeble power should be employed at the commencement. For this reason the rectal is preferable to the urethral reophore. In the absence of electrical apparatus the tonicity of the muscles of the ejaculatory ducts may be greatly improved, and even restored, by the use of the cooling sound, by the application of a thirty-grain solution of nitrate of silver, and by cold sitz-baths. In these cases half a drachm of the fluid extract of ergot after each meal, or fifteen drops of a mixture composed of six drachms of the tincture of the chloride of iron and two drachms of the tincture of cantharides, will also prove valuable. The operations of castration and excision of portions of the vas deferens need only be mentioned to be condemned.

To sum up the results of my experience in the management of seminal incontinence, I may add that the steel bougie, bromide of potassium, and atropia are especially adapted to cases of nocturnal and diurnal pollutions, and that after the hyperesthesia has been relieved electricity, ergot, and strychnia are the most reliable agents in spermorrhagia. The end having been accomplished, moderation in sexual intercourse should be enjoined if the patient is married; continence in thought and action should be observed if he remains single; and matrimony should be advised if his circumstances and inclination warrant it. Marriage should not, however, be encouraged if the emissions are not arrested, as I have met with several cases in which the patient was rendered miserable by this act, from the fact that he deemed his case beyond all hope, as the emissions still continued.

DISPLACEMENTS OF THE UTERUS.

By E. C. DUDLEY, A. B., M. D.

THE title of this article is not to be taken in a restricted sense, inasmuch as the uterus is anatomically so connected with adjacent organs that the displacements of the uterus cannot be intelligently considered or satisfactorily presented without at the same time incidentally taking into account the displacements, causative, resultant, or concurrent, of the ovaries, Fallopian tubes, rectum, vagina, and bladder.

Normal Location and Position of the Uterus.'

In the works on anatomy and gynecology which we are accustomed to consult the uterus is represented as having a straight or nearly straight canal-as lying about midway between the symphysis pubis and the hollow of the sacrum, its axis corresponding to that of the pelvic inlet. They generally agree that its position is one of slight, and only slight, anteversion; some admit that slight anteflexion may not be injurious, but most would pronounce the organ anteverted or anteflexed to a degree that would endanger health if by conjoined manipulations its anterior wall could be felt through the anterior wall of the vagina. The classical idea of the normal position of the uterus presupposes a distended bladder and rectum occupying the anterior and the posterior thirds of the pelvic cavity. Such an arrangement would leave for the uterus only the intermediate space, and would constitute a condition seldom or never realized in health.

Suppose a straight line coincident with the vesico-vaginal wall (Fig. 1) to be continued through the cervix to the sacrum. This line represents approximately the antero-posterior diameter of the pelvis. The length of the vesico-vaginal wall is two and a half inches, and, supposing the cervix to be just midway between the symphysis and the sacrum, the distance from its posterior wall to the sacrum must also be two and a half inches. Add to the sum of these two parts of this antero-posterior diameter one inch for the cervix, and the antero-posterior diameter of the pelvis becomes six inches instead of the normal four and one-third; which proves that the cervix must normally be much nearer to the hollow of

1 The importance of a distinction between location and position will become apparent hereafter: by the former is meant the situation of the organ regardless of its attitude, by the latter is meant the attitude alone. To change an object from one place to another is to change its location; to turn it over or bend it upon itself is to change its position.