A practical treatise on disorders of the sexual function in the male and female

Front matter

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H"SALTH

Open Knowledge Commons

Preface

The great majority of cases of sexual disorders which come to the observation of the practitioner, and which are at the same time amenable to treatment, are those which fall under the heading of sexual neuroses, and it is these, therefore, which require our chief consideration.

Some time ago, while preparing a paper on Sexual Neuroses^® which was subsequently read at a meeting of The Harlem Medical Association of New York City, I asked several genitourinary specialists to discuss the paper, but was met with the reply either that they were not at all interested in the subject, or that they were so ignorant of the theme as to be unable to discuss it. One of the gentlemen went so far as to doubt the very existence of such a condition as sexual neurosis. Thus, although some of these gentlemen had made an enviable reputation for their achievements in genitourinary work, not only in this country, but also abroad, they had entirely neglected this portion of the specialty, and I was therefore compelled to resort to the services of a neurologist to open the discussion.

As a matter of fact, it must be stated that most of the literature on sexual neuroses comes, not from genitourinary specialists, but from neurologists. Nevertheless, valuable as the work of neurologists has been in this direction, the genitourinary specialist finds much that is lacking, and this

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for very obvious reasons. What neurologist, for instance, is able to perform a posterior endoscopy, or to interpret correctly the conditions thus seen in the posterior urethra? How many neurologists, if any, are there, who can correctly interpret by rectal examination the difference in the feel of the prostate and seminal vesicles, as pathologically influenced by masturbation and withdrawal on the one hand, and gonorrhea, tuberculosis or senility on the other? These matters are clearly beyond their domain, yet how necessary are these data for a correct understanding, and for the proper treatment of the conditions under consideration! As I will show, and repeatedly emphasize hereafter, the apparently simple procedure of massaging the prostate is really an art, and I do not hesitate to state that many genitourinary specialists, especially those who do not treat sexual neuroses, do not know how to perform it properly. That being the case, how then can we expect the neurologist, with little if any training in genitourinary work, to perform it? Yet this method of treatment in sexual neuroses is of the utmost value. The application of silver-nitrate solution to the delicate urethral mucous membrane (which is especially hypersensitive in the sexual neurasthenic), either by instillation through the urethral syringe or by direct application to the diseased area through the posterior endoscope, is an art that requires special training in intra-urethral manipulation, and is clearly outside the domain of the neurologist. Many other examples might be given to explain why the treatment of sexual neuroses belongs to the genitourinary rather than to the neurological specialist, but the above illustrations are sufficiently striking without further examples.

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In discussing this very point with a neurologist, I was informed that he considered himself perfectly competent to treat impotence in the male. His method of procedure, he informed me, was to send his patient to a genitourinary specialist for examination, and if the latter found nothing abnormal, he would treat the patient by the administration of bromides or tonics or spinal douches, etc., sometimes also passing a cold sound into the urethra.

I have cited this little episode in order to bring out another important point in connection with sexual neuroses. The failure to find any gross lesion in the genitourinary tract by the ordinary method of examination is by no means a guarantee that the neurosis in question is not caused by reflexes from these organs. Any^ of the distinguished gentlemen mentioned in the first paragraph of this preface could easily have given a clear bill of health to the genitourinary apparatus in any particular case, and yet the latter might nevertheless be the cause of marked neurotic symptoms affecting remote organs of the body. The genitourinary specialist who but occasionally peeps through the posterior endoscope, or one who even employs it more often, but has not paid particular attention to sexual neuroses, and consequently is familiar only with the gross lesions in the posterior urethra, which are the sequelae of chronic gonorrhea, would doubtless be surprised to be told that some insignificant lesion, such as a slight congestion in the region of the verumontanum, which to him might seem entirely unworthy of notice, might be the very cause of the most profound reflex symptoms, while, on the other hand, the most gross pathological lesions, such as vi Preface.

polypi or cysts, are apparently borne without protest, either by the genitourinary apparatus or by the general nervous system.

It should be remembered, in this connection, that the major portion of the sexual neurasthenics come, not to the genitourinary clinics, but to the neurological clinics. And one who is fully familiar with the feel of the gonorrheainfected prostate, the tuberculous, the carcinomatous, or the senile prostate, might still be entirely unfamiliar with the prostate of the sexual neurasthenic. I repeat, therefore, that the finding of nothing abnormal, in the ordinary genitourinary examination, counts for very little in the diagnosis of sexual neuroses. And, as for the treatment of impotence by the passage of a cold sound into the urethra, it is like the giving of digitalis for heart disease, — it does good where it is strictly indicated, but its indiscriminate use is merely guesswork.

I do not wish it to be inferred, however, that I underrate the value of the work of the neurologists. Far from it. They have done most excellent work, indeed the most important work in sexual neurasthenia. The works of Freud and his followers, of von Krafft-Ebing, Havelock Ellis, Hamm.ond and Max Herz are but a few examples of their achievement in this direction. As already mentioned, most of the sexual neurasthenics find their way into the neurological clinics, complaining of the most divergent symptoms, in many cases not at all suspecting that their sexual apparatus has anything to do with their symptoms. It is the work of the skillful neurologist to differentiate these symptoms from those of other organic or

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functional neuroses, and this obviously cannot be done by the genitourinary specialist. But once having made the diagnosis, or rather having excluded other nervous ailments as a possible cause of the symptoms, I believe it to be no more their province to make intra-urethral applications than it is their duty to prescribe glasses for a headache they have fotmd to be due to eyestrain, or to do gyneco^- logical operations for neurotic symptoms resulting from pathological female genitalia.

There has existed for some time a peculiar state of affairs with regard to sexual neuroses. On the one hand, as mentioned in my opening paragraph, there are very many genitourinary specialists who are so engrossed with the major surgical work of the specialty, such as kidney, ureteral, prostatic and bladder surgery, that they do not care to bother with the less exciting and very often tedious work of treating sexual neuroses ; while, on the other hand, we have the neurologist, who by his training is particularly well adapted to study this subject, but hasi not the genitourinary training for urethral diagnosis and treatment. For this reason it came to pass that, although I have done special genitourinary work for over twenty years, and have worked in many clinics both here and in Europe, it was not in these genitourinary clinics that I became acquainted with sexual neuroses, but only after I had associated myself for several years with the neurological clinic of Dr. I. Abrahamson of the Mount Sinai Hospital Dispensary, and studied these cases, employing the urethroscope wherever necessary, and frequent palpation of the prostate and seminal vesiclec in the sexual neurasthenic, that I have been viii Preface.

able to make a special study of the various forms of these conditions. In other words, one of the objects of the present) work is to bridge the gap between the neurologist and the genitourinary specialist.

I desire to express my thanks to Dr. I. Abrahamson for his uniform courtesy in referring to me considerable clinical material from his neurological clinic at the Mount Sinai Hospital Dispensary, and also for valuable suggestions in connection with his own specialty. My thanks are likewise due to Dr. Charles Herrman for placing at my disposal the cases of enuresis which came to his attention at the Vanderbilt Clinic, and to the Medical Record (New York), the New York Medical Journal, The Urologic and Cutaneous Review, and the Interstate Medical Journal, for their courtesy in permitting the use herein of articles of mine heretofore published in those periodicals.

In the following pages I will not go into the purely neurological aspects of the subject, except in so far as they become necessary to elucidate. I will not discuss such conditions as psychoanalysis or the various forms of sexual degeneracies or perversions. These belong strictly to the neurologist, as their pathology belongs rather to the field of abnormal psychology thanj to the genitourinary apparatus. Nor will I discuss herein the purely venereal diseases, gonorrhea, syphilis, and chancroid, as these form a distinct class by themselves and are generally, and properly, accorded a separate treatise. The subject of Sterility has also been omitted, as I have treated it in a separate work, to which the reader is referred.

The subjects to be discussed in this work will be Mas-

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turbation, Impotence, Pollutions, Priapism, Clitorism, Clitoris Crises, Satyriasis, Nymphomania, Frigidity, Vaginismus, Dyspareunia, Dyspareunia in the Male, Absence of Orgasm in the Female during coitus. Enuresis, Withdrawal, Continence, and Some Unusual Forms of Sexual Neuroses. Most of the material herein represents the result of original investigation and study, never before published. Some of the subjects discussed have never before found their way into English medical literature, and some have never been discussed at all ; so that even their names had to be invented by me. Especial attention is given throughout to treatment so as to make the book as practical as possible. It has also been my intention to make the discussion of each subject complete in itself, so that readers who happen to be interested in some particular subject only, need not be referred to other chapters of the work.

Max Huhner,

320 Central Park West, New York City, N. Y.

CHAPTER I. Masturbation. page

General considerations. Masturbation in boys and girls before adolescence. Etiology. Pathology. Precocious cases. Symptoms. Diagnosis. Importance to teachers and parents. Course and prognosis. Importance of early recognition. Prophylactic treatment. General treatment. Uselessness of constant watching. Restraining apparatus. Pseudo-masturbation in infants. Description. Etiology. Author's opinion 1

CHAPTER II. Masturbation in the Adult Male

General considerations. Pathology. Psychic masturbation. Symptoms. Exaggerations of many authors. Fallacies in taking histories. Importance of ruling out other conditions. Masturbation in married men. Course and prognosis. Illicit intercourse not a cure for masturbation. Treatment. Importance of gentle massage. Conclusions. Masturbatio interrupta. Masturbatio incompleta. Impotentia masturbationis 13

CHAPTER III. Masturbation in the Adult Female

General etiology. Etiology in unmarried adults. Etiology in married adults. Impotence in the male and coitus interruptus as causes. Methods employed in masturbation. Psychic masturbation. Pathology. Physiology of normal coitus in the female. Local symptoms. General symptoms. Course and prognosis. Reflex symptoms. Diagnosis. Local treatment. General treatment. Marriage not a cure for masturbation. Importance of instructing the husband 38

CHAPTER IV. Impotence in the Male

Definition. Impotence and sterility. Organic impotence. Definition. Etiology and pathology. Symptoms. Diagnosis. Prognosis. Treatment. Rudimentary penes 55

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CHAPTER V. Functional Impotence. page

Definition. Sexual vigor a relative term. Etiology and pathology. Libido, erection, ejaculation, orgasm. Mechanism of coitus in the end-organs. Theory of verumontanum in coitus. Nervous mechanism of coitus. Pathology of impotence from excessive coitus. Pathology of coitus interruptus. Pathology of impotence following masturbation. Gonorrhea and impotence. Pathology of ungratified sexual excitement as a cause of impotence. Cases with obscure pathology. Author's opinion. Symptoms. Disturbance of the libido. Disturbance of erection and ejaculation. Author's opinion on paralytic impotence. Disturbance in the orgasm. Cases of congenital weakness. Importance of recognizing the etiology in the former class. Local symptoms accompanying impotence. General symptoms. Psychic symptoms. Diagnosis. Importance of examining wife. Importance of thinking of organic nervous conditions. Prognosis. Treatment. Intelligent treatment of posterior urethra. Importance of posterior endoscopy. Sexual stimulants. Original experimentation 61

CHAPTER VI. Psychic Impotence

Definition. Etiology. Pathology. Symptoms. Misdirected libido. Inhibited libido. Diagnosis. Prognosis. Treatment. Impotence in the female. Definition. Etiology and Pathology. Obstructive impotence. Neurotic impotence. Symptoms. Diagnosis. Prognosis. Treatment 99

CHAPTER VII. Pollutions in the Male

Definition. Author's definition. Diurnal pollutions. Nocturnal pollutions. Defecation spermatorrhea. Urination spermatorrhea. Urethrorrhea. Prostatorrhea. Confusion in terms of various authors. Etiology. Prostatic massage a cause of pollutions. Results of masturbation a cause. Normal pollutions. Pathology. Physiology of coitus. Local pathology. Pathology of defecation spermatorrhea. Opinions of various authors. Author's opinion. Pathology of urethrorrhea. Symptoms. Quack literature. Pollution dreams. Practical importance of pollution dreams. General symptoms. Diagnosis.

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Prognosis. Prophylactic treatment. General treatment. Bromides. Deep instillations. Psychrophore. Pollutions in the female 106

CHAPTER VIII. Priapism

Definition. Etiology. Priapism in children. Priapism in adults. Essential priapism. Pathology. Causes which act upon the erection center. Causes which act by removal of inhibition. Causes which act directly upon the tissues of the penis. Symptoms. Diagnosis. Course and prognosis. Treatment. Clitorism. Clitoris crises. Differentiation from pseudo-crises 137

CHAPTER IX. Satyriasis

Definition. Increased sexual desire not satyriasis. Etiology. Theory of von Krafft-Ebing. Pathology, Author's opinion. Symptoms. Chronic satyriasis. Diagnosis. Prognosis. Treatment. Importance of treatment 150

CHAPTER X. Nymphomania

Definition. General considerations. Etiology. Heredity. Pathology. Symptoms. Illustrative cases. Nymphomania and sterility. Diagnosis. Course and prognosis. Treatment.. 159

CHAPTER XI. Frigidity

Definition. Total, partial, congenital, acquired. Frequency of condition. Frigidity different from lack of orgasm. Etiology and pathology. Normal frigidity. Acquired frigidity. Intellectual frigidity. Congenital frigidity. Heredity. Pathology. Frigidity and sterility. Author's discussion on sexual passion. Symptoms. External characteristics of frigid women. Diagnosis. Prognosis. Treatment. Necessity of instructing husband 166 xiv Contents.

Absence of Orgasm in the Female During Coitus.

Definition. Orgasm not synonymous with voluptuous feeling. German definition. Etiology. Pathology. Physiology of normal coitus in the female. Symptoms. Relationship to sterility. Author's opinion. Diagnosis. Prognosis. Treatment.... 196

Chapter XV

Definition. Classification. Etiology and pathology. Enuresis and epilepsy. Symptoms. Psychic element. Diagnosis. Prognosis. Treatment. "Wonderful cures." General treatment. Folly of punishment. Regulation treatment. Treatment of obstinate cases. Author's experiments. Treatment by re-education. Different methods of treatment by various authors 208

CHAPTER XVI. The Evil Consequences of Withdrawal

General considerations. Importance to general practitioners. Definition. Etiology. Pathology. Physiology of normal coitus. Pathology of withdrawal. Importance of experience in posterior endoscopy. Effect of withdrawal on female organs. Ignorance of the male about coitus. Symptoms. Local symptoms. Reflex symptoms. Illustrative cases. Diagnosis. Course and prognosis. Treatment 224

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CHAPTER XVII. Continence. page

General considerations. Importance to general practitioner and every specialty. Social and economic considerations. Prevention of spread of venereal disease. Prophylactic treatment of venereal disease. Chances of infection from illicit coitus. Abortive treatment of venereal disease. Is continence physiological? Views of physiologists. Views of various authors. Masturbation and continence. Sexual perversion due to continence. Author's opinions. Views of neurologists. Continence and impotence. Coitus not merely for purposes of procreation. Continence contrary to nature. Author's deductions. Improvement in morality as compared to the past. 252