Disorders of the male sexual organs

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O LIMtAftlES 5

HEALTH SCIENCES LIBRARY

DISORDERS

Preface

Considering the importance of a properly regulated sexual function to the happiness and well-being of man, it is remarkable that hitherto so little scientific study and attention should have been devoted to investigations upon that subject. It has been and still is quite customary for the medical man, after listening to the recital of the complaints of one suffering from a sexual disorder, to tap him on the head, with the remark, "Here, my man, here is the seat of your trouble." In a certain percentage of cases such a diagnosis may be correct ; if it is, however, it is of the " snap " variety, and whether it be correct or at fault, it rarely serves to impress the patient, who goes away either feeling that his case has been slightingly considered, or that his adviser is possessed of little knowledge. The rich harvest reaped by advertising mediums and quacks in this department is in great measure due to the unsatisfactory manner in which these cases are handled by the regular profession. One of the aims of this work is to show that pathological and physiological factors in connection with the apparatus actively employed in the sexual act are oftentimes the direct causes for sexual and other allied disiv PREFACE.

turbances. In fact, it seems probable that the factors just mentioned prevail in the majority of these cases, psychological and neurotic conditions, the latter chiefly of a reflex nature, being in the minority. The psychological side of this question, the side in fact which represents by far the smallest percentage of cases, is the only one which has been thoroughly investigated. Able writers, among them Hammond, Tarnowsky, von Kraflt- Ebing, and others, have so forcibly represented their ideas from the standpoint of the alienist that the general reader, in the absence of evidence in other directions, has naturally concluded that their writings in large measure cover the entire subject.

The neurotic standpoint has been considered chiefly by Ultzmann in his work on Oenito- Urinary Neuroses, and by Guyon in his article on "Sexual Neurasthenia." These articles, although of much interest, and representative of accepted theories, are, as it will be my endeavor to demonstrate, really very defective in that practically all sexual disturbances, aside from psychological ones, are classed as neurotic.

Pathological and physiological factors are ignored, although Ultzmann at the end of his book does allude to Trousseau, who held as an undemonstrated theory that pathological conditions of the seminal vesicles accounted for the symptoms in some of those cases.

My opinion is that trouble located in the sexual apparatus, and primarily, at least, largely independent of nervous conditions, is the chief cause of sexual disturbance in the male ; and that the various neuroses and

PREFACE. v

psychological conditions stand in the order named as other causes.

It, therefore, follows that every case of this nature shonld be carefully examined from the three different standpoints enumerated, and a differential diagnosis given.

Before attempting to approach nnderstandingly the main issue, it is necessary thoroughly to understand the anatomy of the region under consideration ; and as the general anatomical works have not paid sufficient attention to this particular, it has seemed well to devote a chapter to that subject, in which, among other things, the mechanism of ejaculation is considered.

I am greatly obliged to Dr. James Ewing, of this city, for his report on the " Histology of the Seminal Vesicle and the Vas Deferens," which report is annexed to the chapter on Anatomy.

In forming my plans and in collecting my material for this work I have many thanks to give to Dr. E. L. Xeyes, with whom I have been associated for many years.

109 E. Thiety-foueth St., New Yoek, February, 1895.

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Illustrative Instances 180

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Chapter I. Anatomy

In order thoroughly to understand the subject about to be considered, a systematic study of the vesico-rectal anatomy of the male is essential. The term vesico-rectal anatomy as used here is intended to apply, first, to the relation which the bladder bears to the rectum, and secondly, to a consideration of the important structures which are attached to or go to make up the vesical neck. These structures in great measure may be said to occupy the recto-vesical space. JSTo attempt will be made to study the special anatomy of the bladder or of the rectum, or to consider the general relations which these organs may bear to the pelvic structure or to the abdominal organs.

Should one wish to acquaint himself with the medical literature on this subject, including some reference to the embryology and comparative anatomy of the seminal vesicles and the vasa deferentia, he will find such information, together with a full list of references, in Dr. O. Guelliot's excellent work Des Vesicules SSminales, Anatomie et Pathologic, Paris, 1883, A. Coccoz, editeur.

Under the first heading is included the study of the fascia enveloping the bladder and rectum in common, its important venous plexus, and the reflexions of the peritoneum. Under the second heading are included the vasa deferentia, the seminal vesicles, the prostate, and the deep urethra, reference being paid to the relation which these different parts, especially the vesicles and the prostate, bear not only to one another, but also to the bladder proper and the rectum. As none of the anatomical writers have apparently devoted themselves sufficiently to these particulars, it was found necessary to make numerous dissections to illustrate special points. The most important of these dissections have been photographed and reproduced here, so that exactness and correctness of statement may be assured. These pictures have been arranged sequentially, so that a successive study of them together with the accompanying description may lead the reader on to a thorough understanding of the subject.

Plate I. This represents a dissection en masse of the entire visceral contents of the male pelvis. This mass, as is well seen in the engraving, is securely bound together by a dense fascia of its own, which is in its turn connected by a loose fibrous meshwork to the fascia propria, which lines the cavity of the pelvis. It is in this loose fibrous meshwork that extravasated fluids burrow so freely. The figure itself is about one-half the natural size, with the rectum and bladder both almost collapsed. A represents the anus, and B the inner end of the gut, section having been made just above the peritoneal deflection (see Plate IV.). The space between AB shows the rectum in a state of contraction. C is the urethra in its membranous portion. D is the bladder. E is the prostate. (The three radiating lines are used to designate the extent of that organ.) F is the peritoneum. G points toward the space lined by peritoneum between

— the bladder and rectum (see Plate IV.). H' H" represent respectively the anterior and posterior limits of the pampiniform plexus, which important group of veins consists chiefly of two lateral plexuses, one on either side of the prostato- vesicular region entwined in the meshes of the general enveloping fascia. The largest veins lie in the crease between the prostate and rectum. These lateral groups of veins communicate with one another quite freely below around the rectum and above around the urethral structures. There can, however, be but little direct intercommunication, through the recto-vesical space, between the prostate and the rectum, as a later dissection (Fig. 1) shows a lymph-space in that region and an absence of large veins. In removing this dissection from the pelvis the firm attachments above and below are the only ones to offer any real resistance, the intermediate space occupied by the loose fibrous meshwork being most easily broken down. This loose meshwork allows of great variation in size of the pelvic contents. The attachments above, although firm, are very elastic, and are made up of the peritoneum and the sub-peritoneal fascia, which last forms a connection with the fascia propria of the pelvis. Below the attachments are firm and strong, and those connecting the lower prostatic region with the pubic arch are especially dense and unyielding. The attachments of the rectum, which are partly muscular and partly fibrous, have already been carefully investigated by numerous anatomists, and do not come within the scope of this work.

Plate II. represents the other side, the left, of Plate I. Here the outer layers of the enveloping fascia have been dissected off, thus bringing into view more distinctly the contour of the different organs. The pampiniform plexus lies in the outer layers, and consequently no longer appears in this picture. A, B, C, D, E, and F, represent in Plate II. the same as in Plate I. I is the left ureter, J the left vas deferens, K the left seminal vesicle. The triangle X, Y, Z, exposing the vas deferens and the seminal vesicle, has been formed by splitting apart the fibres of the enveloping fascia, which in this region are very firm. In the natural order of things, therefore, the upper arm of the triangle, X Y, should be in fibrous contact with the lower arm, Z Y, the vas deferens and the vesicle being hidden from view. It will be seen that the enveloping fascia is thin and delicate over the bladder proper, while it is dense and very strong over the prostate and over the prostato-rectal space. Inspection will, in fact, show that this fascia is most dense over the prostate and very adherent to its muscular fibres. It is from this portion of the fascia that the strong suspensory ligament connecting with the pubic arch has its insertion. It is well to state here, for the sake of clearness in alluding to the prostate, that that muscular body, as will be shown later on, entirely encircles the vesical neck, and does not occupy simply a position below it, as seems to be commonly supposed. Radiating from the dense fascia covering the prostate are numerous strong fibrous bands extending backward and downward, thus binding the prostatic region to the bowel much more firmly than to the bladder proper. Filaments from these fibrous bands on either side are given off, which envelop each seminal vesicle in a fibrous sheath something like the covering of a cocoon. Any pull brought to bear on these radiating fibrous bauds, as it can be seen, would occur during a muscular contraction of the prostate, would stretch and consequently narrow the sheath containing the seminal vesicle, thus giving that sac a squeeze. This point will be referred

PL.

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X to later on in considering the mechanism of ejaculation. In this figure the exposed seminal vesicle seems to lie below the vas deferens. This is due to the split, X Y Z, made in the fascia. "When the edges of this split are drawn together the vesicle will be found to have been drawn up and to lie outside of the vas deferens. In Plate II., also, the loose muscular structures and fat about A and C have been dissected off, exposing the internal sphincter and the corpus spongiosum.

Plate III. is a rephotograph of Plate II., the only difference being that a cord, the insertion of which can be seen, has been tied to the middle of the lower arm, Z Y, of the triangle, X Y Z, and gentle backward traction applied so as largely to obliterate the angle of the triangle by bringing up the proximal half of the lower arm of fascia to its corresponding upper arm. This is done to show the reader more clearly the strong fibrous bands of fascia which radiate from the prostatic sheath as well as their true direction. It would, perhaps, also have been well to have attached another cord to the end, Z, of the lower arm, in order to have shown the full length of these fibrous bands ; but, with the explanation at hand, such was hardly thought to be necessary.

Fig. 1 shows the neck of the bladder dissected off from the rectum and then drawn upward, bringing plainly into view the V-shaped anterior recto-vesical space sufficiently to expose the entire lower portion of the prostate and the base of both seminal vesicles. A represents the rectum, C the urethra, E the lower portion of the prostate, K K the bases of the seminal vesicles, L the wedge-shaped fold of firm fascia, which has been cut through below the prostate and pulled downward, thus exposing to view the bases of both seminal vesicles. M represents the lower surface of the

MALE SEXUAL ORGANS.

triangular space, abd, the upper surface of which is made up of the fascia covering the lower portion of the prostate and is represented by the triangle b C d. The

Fig. 1.

Showing the lower portion of prostate and base of the seminal vesicle.

sides of these two triangles are the cut edges of the general enveloping fascia. The seminal vesicles are wholly excluded from this space, although in the picture the fascia excluding them has been cut through in order

PLATE IV

Showing the deflections of the pelvic peritoneum.

to show both their positions and the posterior border of the prostate. This triangular area is really a lymph-space, allowing great mobility to the prostate with reference to the rectum. There is no venous plexus in connection with the floor or roof of this space, although in cutting through the general enveloping fascia forming its lateral borders, a necessary procedure in making this dissection, numerous large veins going to make up the pampiniform plexus are wounded. A knowledge of this dissection is very important in connection with the operation advocated by Zuckerkandl for the extirpation of the seminal vesicles, a subject which will be considered later on.

Plate IV. is to show the peritoneum in its connection with the pelvic viscera. A is the anus, B is the rectum cut across just above the point of peritoneal deflection. The bladder is moderately distended. At the bottom of the vesico-rectal peritoneal cul-de-sac, and to the right, as appears in the figure, a pin is to be seen stuck through the peritoneum. The pin penetrates just above the apex of the left seminal vesicle. This shows that, although in this dissection the peritoneum at the deepest portion of the cul-de-sac reaches down to the vesicle, still that it is not deflected over that organ, and cannot consequently be considered one of its coverings. Comparing this dissection with others, it appears that the peritoneum rarely comes in closer contact with the seminal vesicle than is shown in this figure, while in some instances, as will be seen in considering Plate V., the cul-de-sac is not deep enough to allow of any peritoneal contact.

Plate V. Here B represents the rectum cut across above its peritoneal deflection. G G point into the recto-vesical peritoneal cul-de-sac, which is represented in a state of moderate distention, it being packed with cotton-wool. D is the posterior wall of the dependent bladder, which has been dissected off from its peritoneal covering, F, and from the enveloping fascia, E' E', which last has been cut away from the sides of the bladder and then dissected off posteriorly. E E are the posterior lateral borders of the prostate. The figure shows, especially on its left side, very distinctly how intimately the muscular fibres of the prostate at E are blended with bands of the enveloping fascia at E'. We have already seen in Plates II. and III. an outside view of this same blending. It can also be seen to a certain extent how each vesicle lies imbedded in a fibrous sheath (allusion to which has already been made in studying Plate II.), which sheath is attached to and made up of the firm bands of the enveloping fascia which radiate backward and downward from the prostatic covering. Two cords attached to the upper cut edges of the elastic enveloping fascia, and exerting moderate lateral traction, are sufficient to roll back the fibrous sheaths that have already been dissected oif the vesicles, and consequently to expose the anterior surfaces of those organs which otherwise would have been hidden from view in a dissection such as this one. I is the right ureter. G' shows the bottom level of the vesico-rectal peritoneal cul-de-sac. On each side the limits of this cul-de-sac are marked by the vasa deferentia. So in this dissection the peritoneum does not come in contact at all with the seminal vesicles. Another point which this figure shows is the slightness of the attachment of the bodies of the seminal vesicles to the posterior wall of the bladder, and at the same time the firmness with which they are bound to the prostate and to the sheath of the rectum, thus allowing

PLATE V.

Showing the vesicles in their fibrous sheaths, the bladder having been dissected off and turned downward.

ANATOMY.

them little or no motion independent of the prostate. This is important, for otherwise, if the body of the vesicle could move independently of the prostate there would result a bending of the ejaculatory ducts just posteriorly to their entrance into the prostatic body such as would necessarily interfere with the ejaculatory act.

Fig. 2.

Posterior wall of the bladder showing vesicles and prostate.

Fig. 2 (much reduced in size) shows the posterior Avail of the bladder and a posterior view of the seminal vesicles and the prostate, all the enveloping fascia having been dissected off. C, as usual, marks the urethra,

E the prostate, K the seminal vesicle, I the ureter, and J the vas deferens. The posterior Y-shaped vesical space between the diverging vasa deferentia, through which recto-vesical puncture for relief of retention of urine is sometimes made, is very distinct. The so-called lateral lobes of the prostate show up well together with the deep intermediate sulcus, in the bottom of which are the two vasa deferentia, which here come so closely together that they touch. It will be seen in examining the lateral lobes of the prostate that they have no defined posterior border, but that the muscular fibres which compose them extend backward and become so blended with the musculo-fibrous tissue constituting the lower portion of the seminal vesicles that it is impossible to say just where one ends and the other begins. If these muscular bands which extend back from the prostate to the wall of the vesicle are observed carefully, it will be seen that their fibres are so arranged that when a prostatic muscular contraction takes place there would be exerted a strong pull on the lower half of the vesicle, which pull would be sufficient, if coincident with a tightening of the fibrous sheath of the vesicle, such as we have seen in Plates II. and III. would result from a contraction of the lateral and upper portions of the prostate, to give the whole seminal vesicle a strong squeeze. It is reasonable to suppose when such a muscular contraction takes place in the prostatic body, that it is general in character, thus exerting pressure over the whole area of the vesicle. The posterior lateral lobe of the prostate is evidently a grouping of muscular fibres arranged especially to exert traction on the corresponding seminal vesicle. Subsequent figures, especially Plate VI. and Fig. 7, as will be seen, support this statement. Examination will show that the contour of the seminal vesicle

ANATOMY.

is not regular, such as one would expect if the interior consisted of a single oblong chamber, but that it is irregular, presenting an appearance similar to that of an

Fig. 3.

Posterior wall of tile bladder, showing the vesicles in their fibrous sheaths.

oblong bag into which had been crowded a flexible cylindrical body. The reason for this appearance will be evident later on in studying Fig. 7. The distal porlions of the vasa deferentia, as can be seen, are considerably smaller in circumference than the proximal portions where they converge. Attention will again be called to this point later on.

Fig. 3 (much reduced in size) represents a dissection quite similar to that of Fig. 2. Here, however, the peritoneum, F, has been only partially dissected up from the posterior vesical wall and the vasa deferentia, J J, have not been dissected free from it. The general enveloping fascia also has not been removed so freely, and at E' E' it is plainly seen showing its intimate attachment to the prostate. Its connection with the bodies of the vesicles does not appear here, as these organs have been dissected from their fibrous sheaths. It is well to examine the fascia, E' E', in this figure, in connection with the same fascia, E' E', in Plate Y. In Fig. 3 the fascia has been cut through behind the seminal vesicles, while in Plate V. the cut has been in front ot them. The vertical furrow in the base of the prostate is due to an accidental cut into the muscular substance of that body.

Fig. 4 is the same as Fig. 2, except that in Fig. 4 the dissection is completed so as fully to expose the lower portions of the seminal vesicles and the ejaculatory ducts. This has been accomplished by dissecting off the musculo-fibrous attachments of the prostate from the lower portions of the vesicles, and then, by splitting across transversely in the line of the ejaculatory ducts down to the prostatic urethra, the lower portion of the posterior prostatic body from the upper portion. The free dissected portion of the prostate is then rotated vertically downward. C represents the under portion of the floor of the prostatic urethra in the neighborhood of the caput gallinaginis, on either side of which the ejacu-

ANATOMY.

latory ducts communicate with the urethra. Ea Ea represent the anterior section of the prostatic lobes, Eb Eb the posterior section, which has been rotated from

Fig. 4.

Eb

Posterior wall of the bladder, showing the ejaculatory ducts.

Ea Ea, with C as an axis, 180° downward. The seminal vesicles in their entire length, the junction of the vas deferens with its vesicle and the ejaculatory ducts lying parallel and in close apposition, appear quite plainly. The ejaculatory ducts, although entirely independent of one another, are firmly bound together in a common fibrous sheath, which has been largely dissected away in this figure in order to show their individuality. This sheath, however, has been left intact in Fig. 5. The common sheath containing the ejaculatory ducts is not attached laterally to the muscular substance of the prostate, but lies free in a lymph-space the walls of which consist of another and larger fibrous sheath incorporated into the substance of the prostate. This larger sheath has been called the infundibulum of the prostate. ZiST ET show the roof of the infundibulum, and N' shows its floor. The walls of the ejaculatory dncts are very elastic. It is thus evident that when the muscular fibres of the prostate contract, causing a direct pull on the body of the vesicle, that the length of the ejaculatory ducts, by reason of their lying free in a lymph-space, is shortened, their walls relaxed, and the capacity of their canals increased.

Fig. 5 shows the posterior view of the vasa deferentia, the seminal vesicles and their ducts, together with the small section of the urethra which includes the openings of the ducts. The left vas deferens and vesicle are normal in size and natural in appearance; the right, however, happens to be in a state of atrophy, which condition will be alluded to later on in considering the pathology of the parts. The increased circumference of the lower portion of the normal vas deferens over the upper distal portion is clearly brought to view. In this lower portion, also, the cord is not cylindrical, but is somewhat flattened on its anterior and posterior surfaces. In this figure the common sheath enveloping the ejaculatory ducts has been left intact, so bind-

ANATOMY.

ing them together as to give the appearance of a single duct rather than two. Each duct has been catheterized through its urethral opening by means of a bristle, which, however, does not appear in this figure. Each bristle passes upward and outward, entering the cavity

Fig. 5.

The vasa deferentia, the seminal vesicles and their ducts.

of the corresponding seminal vesicle, and by no amount of manipulation was it found possible to make one of these bristles enter the canal of the vas deferens. Fig. 7 will also show that the bristles by entering the cavity of the seminal vesicles took their natural course.

MALE SEXUAL ORGANS.

Fig. 6 is chiefly to show the floor of the prostatic urethra. To accomplish this a cut has been made through the roof of the membranous and prostatic

Fig. 6.

The floor of the prostatic urethra.

urethra, and extending backward through the lower portion of the anterior bladder-wall. The cut edges have then been moderately separated. O represents the posterior median limit of the trigonum ; E, the upper portion of the prostate; C, the membranous urethra. Back of this is the prostatic urethra. In the median longitudinal line, the elevated ridge of which is seen, is the caput gallinaginis or verumontanum with the parallel depressions on either side. Those depressions form the prostatic sinus. At about the middle, and on the summit of the caput gallinaginis, is a little oval, flattened area, with edges quite well defined. This is the sinus procularis, and it is in the forward sides of this body that the openings into the ejaculatory ducts are situated. The sinus procularis is small and hard to show in a photograph. Still, careful inspection will make it out mostly posterior to the pointers, PP, which mark the mouths of the two ejaculatory ducts. Attention is called to the thickness of the prostate above the urethra. This arrangement of the prostate, however, will be taken up more particularly in Plate VT.

Plate VI. represents a longitudinal section through the vesical neck. To accomplish this two vertical cuts have been made. The upper one above the urethra and bladder divides the structures in the median line. The lower one is not in the median line, but to one side, passing along the prostatic sinus. The smaller section has been pulled back out of view, so the picture represents the larger one. The seminal vesicle which shows is the outer side of the left. This vesicle projects considerably beyond the line of the lower vertical incision, which has cut through the lower wall of the bladder just above it, and it would have been in large measure removed with the smaller section had the lower vertical cut been carried downward sufficiently to reach it. Q is the band of fascia which marks the posterior limits of the prostate above the vesical neck. The elevated, flattened area, the sinus procularis, extending along the summit of the caput gallinaginis, shows up in Plate VI. rather better than in Fig. 6. A study of the upper and lower sections through the prostate is most instructive, for it shows not only that that structure encircles the vesical neck, but also that about as much of it lies above the prostatic urethra as below it. In other words, this body occupies the position of a broad muscular ring about the neck of the bladder. The upper portion of this encircling band is seen to be placed relative to the urethra somewhat anterior to the lower portion. The convoluted contour of the seminal vesicle is distinct, together with the bands of prostatic muscular fibre which are inserted into its lower portion. 1ST marks a fibrous line which extends through the lower section of the prostate. This fibrous line is the outer wall of the prostatic fibrous sheath, the infundibulum, which, as we have already seen in Fig. 4, encircles the ejaculatory ducts as they pass enveloped in their own common sheath through the prostate. These two sheaths are, as also seen in Fig. 4, separated from one another by a lymph-space. The direction of the fibrous line, N", from the seminal vesicle toward the anterior portion of the caput gallinaginis shows the course of the ejaculatory ducts and to what extent they are imbedded in the prostate. The space between the fibrous sheath covering the body of the seminal vesicle and the lower bladder- wall is seen to be filled with delicate connective tissue, which in. fleshy individuals contains much fat. In fact, tissue such as this fills in all the otherwise vacant places in the recto-vesical space posterior to the prostate, serving the purpose, as it were, of a packing-material. In most of the engravings representing this space this delicate connective tissue has been removed in order to make the dissection

AXATOMY.

distinct. A consideration of this connective tissue becomes important in certain inflammatory conditions, as will be seen in studying the pathology of this region.

Fig. 7.

View of the interior of the seminal vesicle and of its ejaculatory duct.

The median posterior position occupied by the ejaculatory ducts, as seen in this Plate (VI.) as well as in Fig. 4, shows how impossible it would be to wound these parts in the operation of lateral lithotomy. This is important, as the chance of wounding them, especially in children, has been one of the stock arguments for many years advanced against this surgical procedure.

Fig. 71 (somewhat below the normal size) shows the interior of a seminal vesicle and the commencement of its ejaculatory duct. An incision has been made into the connecting vas deferens and the shaft of an ordinary sized hair-pin forced down its duct. The end of the hair-pin shows in the picture protruding through the entrance of the vas deferens into its vesicle. This entrance is round and just large enough to allow the shaft of the hair-pin to pass through easily. Above this entrance, for an inch to an inch and a half, the calibre of the canal of the vas deferens is somewhat larger — probably large enough to take a catheter twice the calibre of the hair-pin. This enlarged area has been called the ampulla of Henle. Higher up than this, however, the canal grows much smaller, so that the shaft of an ordinary dress-pin is a tight fit. At the very top of the figure, just above the apex of the seminal vesicle, a small section of the shaft of the hair-pin can be indistinctly seen as it penetrates the vas deferens. At this point, however, the duct was not large enough to admit of the passage of the hair-pin shaft without being extensively ruptured, and this rupture extended for some