Sexual debility in man

II Sexual Debility

IN MAN

Formerly Clinical Professor of Venereal Diseases in the Medical Department of the

University of the City of New York; Sometime Visiting Surgeon to the

Venereal Division of the City (Charity) Hospital, Blackwell's

Island ; Member of the American Association of

Genito-Urinary Surgeons, Etc.

Author of" Student's Manual of Venereal Diseases'''; one of the authors of "A System of Legal Medicine."

—Martial.

NEW YORK

E. B. TREAT & COMPANY

241-243 West Twenty-third Street

U^l

Copyright

F. R. STURGIS

Go tbe SEXUAL CRIPPLES OF THE UNITED STATES

WHOSE INFIRMITIES HAVE IN PART

CONTRIBUTED TO HIS SUPPORT,

THIS BOOK IS GRATEFULLY DEDICATED

BY THEIR OBLIGED FRIEND,

THE AUTHOR.

Preface

The writer does not for one moment delude himself with the belief that this book will supply a long-felt want. The principal reason for writing it is to introduce to the reading medical public sundry opinions the writer holds upon sexual weaknesses in men, which, although they may be at variance with ideas generally received in this country, he is convinced from experience are correct.

Thus in the chapter on Masturbation he has combated the old and time-honored belief that indulgence in this habit is the necessary prelude to both physical and mental degeneration, and, while not glossing over the dangers which may, under certain conditions, result from the habit, he has attempted to point out the folly of the hysterical denunciations which have been heaped upon it by pseudo-philanthropists and ignorant medical men. The question of castration in the case of masturbating lunatics has been brought up afresh for discussion, and the author has frankly stated his reasons for believing that, under certain circumstances, such a procedure would not only be justifiable, but proper. He has also separated Spermatorrhoea from Pollutions, aiming to show that the two are absolutely distinct and separate diseases; that spermatorrhoea is not the finale of pollutions, but is a disease sui generis > the symptoms, course, and treatment of which are entirely different from the latter. He has also striven to correct the foolish and ridiculous idea that the man

10 PREFACE.

afflicted with spermatorrhoea is foredoomed to impotence and sexual uselessness.

In the chapter on Prostatorrhcea he has attempted to lay down the natural history and symptoms of this variety of disease, and has protested against the loose and unscientific method of regarding it as practically the same as prostatitis, with which latter disease, in his opinion, it has absolutely nothing in common.

The illustrations have been carefully prepared from nature by Dr. Frederic E. Sondern, of New York, to whom the writer desires to make his acknowledgments and thanks. They are true to nature, except that the plate of " normal human semen " is a composite one. It has been made from several preparations, because in no single specimen was it possible to find combined all the various elements which enter into the normal semen. Whatever fate, however, may be reserved for the book, whether approval or disapproval, the writer can say with Montaigne, " C'est icy un livre de bonne foy, lecteur."

16 West Thirty-Second Street, New York City.

Table Of Contents

CHAPTER PAGE

I. Anatomy of the Sexual Organs in the Male, . . .11

II. Physiology of the Sexual Organs in the Male, . . 27

Chapter II. Physiology

The physiological action of the various organs, the anatomy of which has just been considered, will now be taken up ; and, in the first place, let us see what part the penis plays in coitus. Without erection of this organ entrance into the vagina cannot occur, and without intromission sexual intercourse, strictly speaking, is not possible, although vaginal entrance is not necessary for the impregnation of the female.

What, then, are the physiological processes by which erection occurs and the organ is prepared for its share in the copulative act ?

Erection is induced by (i) an increased flow of blood to the virile member ; (2) by a diminished flow of blood from the organ; or (3) by a combination of both these conditions. The former of these may be induced by stimulation of a nerve centre or centres, whether the same be cerebral or spinal, or by peripheral irritation of a nerve branch ; and the latter by compression of the veins of the penis by certain muscles or by mechanical compression from the erection itself (Hyrtl). Loven states that the principal cause in producing an erection is active dilatation of the arterioles of the cavernous and spongy portions of the penis, and not simply retardation of the flow of blood from the parts. This Eckhard believed to be due to excitation (in the dog) of two nerves (nervi erigentes) which rise from the sacral plexus from between the first to the third of the sacral nerves. Stimulation of these nerves produced erection and ejaculation, while their section was followed by loss of both erection and emission. Eckhard also produced erection by stimulation of the lumbar and cervical portions of the spinal cord, the pons Varolii and the crura cerebri, and he therefore believed that these erigent nerves originated in the cerebrum and passed through the pons and crura to the cord.

These nervi erigentes, so named by Eckhard, and apparently adopted by the Germans alone, are really only one, or perhaps two nervous filaments which spring from the sacral plexus of the sympathetic, and supply the bladder, the prostate and the membranous portion of the urethra. Irritation of the peripheral ends of these nerves produces erection by inducing dilatation of the large arteries supplying the penis, and Eckhard, in 1863, considered that they were vasodilator nerves. Loven, in 1 866, showed that the irritation of these nervi erigentes produces dilatation not only of the large arteries which supply the penis, but also of the delicate twigs which ramify in the corpora cavernosa, and he considered that their action was to dilate the arteries and to permit the blood to circulate freely through the trabecular of the corpora cavernosa.

Eckhard, in continuing his experiments, believed that if the nervus pudendus was irritated the nervi erigentes would also become irritated, and that an erection would ensue. This he proved by experiment, by irritating the prepuce of a dog, and he, moreover, found that if the nervus pudendus was cut no erection would ensue, and this was confirmed also by Gunther's experiments on stallions.

Budge, by electrical irritation of the pedunculi cerebri in a rabbit, produced erection and emission. Eckhard repeated Budge's experiment, and furthermore showed that irritation of the pons Varolii and the cervical portions of the spinal cord produced both erection and emission.

Eckhard therefore concluded that the centre of erection resided in the brain ; that the nerves presiding over this function passed from the spinal cord down to the sacral portion of the cord, and there emerged as the nervi erigentes.

It must be borne in mind by the American reader that these nervi erigentes are not distinct nerves, as the nervus pudendus is, but merely filaments of the sacral plexus of the sympathetic ; probably some branches from the hypogastric plexus of the sympathetic also assist in this function, so that, as matters stand at present, erection seems to be seated in the brain, and in the cervical and sacral portions of the spinal cord.

Goltz, in 1873, proved that erection might take place from irritation of the lumbar and sacral portions of the cord, without any communication existing with the brain, by dividing the spinal cord of a dog at the junction of the dorsal and lumbar portion, and it was found that erection followed on irritating the prepuce, on pressing the belly in the region of the bladder, and on pressure on the bladder through the rectum. It is not stated whether an emission took place also. He furthermore found that erection was produced by electrical irritation of the hind feet.

This point is indirectly proved by Sarbo's case, in which a man fifteen years before his admission to the hospital had inj ured his spine by a fall. Chronic myelitis ensued, which was characterized by incontinentia alvi et vesicae, with paraplegia and anaesthesia, and total absence of erectile power in the penis. Anaesthesia extended over the mucous membrane of the rectum, perineum, scrotum, and penis. Upon his death the autopsy showed degenerative changes, with loss of nerve substance in the cord from the fifth lumbar to the fourth sacral vertebra, and microscopical examination showed evidences of chronic myelitis.

Nor is this all: cerebral stimulation not infrequently produces partial erection with and without ejaculation of the semen, as is seen in cases of hanging and in deaths from suffocation (Devergie, Orfila, Ollivier, d' Angers). Gould and Pyle give a case in point where an Italian "castrata" is said to have been in the habit of partially hanging himself to get an erection. Lallemand's case of a soldier who, from a fall on the lumbar region, was completely paraplegic, shows that the spine is not the only cause of erection, because, notwithstanding his injury, he had violent and persistent erections with ability to copulate and to masturbate.

I myself believe that erection of the male organ of generation is produced by excitation of both the brain and the spinal cord, but which of the two is the more active agent in the function is not yet determined.

Erection of the penis is also produced by impressions primarily originating outside of the nerve centres or any portion of the nervous system. Thus, dalliance with women, and erotic images, during either waking or sleeping hours, are sufficient to stimulate the sexual appetite and provoke erections with emissions (nocturnal and diurnal emissions), about which I shall speak later; and among other physical causes may be mentioned friction of the genitals, balanitis, hemorrhoids, gonorrhoea during the early and inflammatory stage, stone in the bladder, worms, and a full bladder.

Regarding the purely mechanical aspect of erections, Kolliker and others think it is due to a relaxation of the muscular fibres in the trabeculse of the corpora cavernosa and the corpus spongiosum and in the middle coats of the arteries of these parts, in consequence of which the spongy tissues of these organs are filled with blood, as water is sucked up by a sponge. The rigidity of the penis occurs as soon as the muscular fibres are completely relaxed, and the venous sinuses are filled without the return of the blood being impeded or the venous circulation being interfered with. But to that view is the objection that, inasmuch as the veins are larger than the arteries, the blood would be sent out of the penis faster than it was sent to it, ergo, there must be some check placed upon the exit of the blood, else no erection would occur. This check is produced by the action of the musculi bulbo-cavernosi, ischio-cavernosi, and the adductor prostatas upon the venae dorsalis et profunda^ of the penis; and this point is confirmed by Hunter's experiments on a dog, in which the compression of the vena dorsalis penis produced fulness and extension of the penis (vol. iv., p. 32). The more complete the erection becomes, the more marked is the compression of the veins, and the latter is further completed by mechanical pressure exercised upon them by the turgid virile member. In all this function the so-called erector penis muscle, according to Hyrtl, plays no part in erection, but when erection is complete then the contraction of this muscle draws the penis tightly up against the belly.

Still another theory has been advanced by Kohlrausch which is supported by Hyrtl, to wit, that more stress should be laid upon the twisting of the veins at their points of exit from the corpora cavernosa et spongiosum in their relation to the outgoing veins through the enlargement and change in the shape of the penis, than upon any muscular compression.

All these theories are plausible; all are possible, and it is highly probable that all are concerned in producing that condition of the penis so conducive to pleasure for the male and so necessary for the propagation of the species.

It is a matter of general acceptance that micturition and erection are not possible at the same time, and this physi- 3 ological fact has an important bearing upon the function of erection and of ejaculation.""" The erectile tissue of the bulbus urethras extends between the muscular tissue and the mucous membrane of the pars membranacea urethras, and reaches as far backward as the colliculus seminalis. When the erectile tissue of the bulb in common with the erectile tissue of the rest of the sexual organs becomes turgid, the colliculus also becomes swollen with blood, and this increase in size encroaches upon the narrow portion of the prostatic urethra and shuts off the canal from the bladder, thus preventing this latter viscus from emptying itself of its contents. But, in addition, it also prevents the semen from flowing backward into the bladder, directing it forward toward the anterior portions of the urethra, and in this it is assisted by the position of the ejaculatory ducts, which point forward and open in front of the colliculus (Kobelt).

PHYSIOLOGY OF THE TESTES.

The testicles secrete the spermatozoa (PI. V.), the fructifying principle of the semen, by division and enucleation of the testicular cells, together with a thin alkaline fluid, the liquor testis, in which these bodies are conveyed to other portions of the sexual apparatus. The production of spermatozoa probably goes on through the life of the adult male from the age of puberty, 14 (Riittel, Liegeois), up to quite advanced old age, having been found in the semen of old men, S? (Curling), 92 (Riittel), 96 (Casper). As old age advances, although the capacity of secreting spermato-

* Every rule has its exception, and this exception Salzer gives in the case of a man who was afflicted with priapism of seven weeks' duration, in which the urine was passed in jerks with difficulty, and only when the patient was in the knee-and-elbow position. Still this exception does not invalidate the correctness of the statement made above.

zoa still continues, it is very much restricted both as to the amount and to the fruitfulness of the fluid, but exceptions to this will be noted later on. Many observers have examined the seminal fluid of old men who have died in public institutions, and have collated and published the results of their investigations.

Duplay examined 51 cases; in 37 spermatozoa were found; in 14 none were found. Of the 37 fruitful instances, in 26 spermatozoa were found along the entire tract of the seminal passages ; in 3 in the vas deferens only; in one instance only were these cellular elements found in both vesiculae seminales, none being seen in the vas. In 7 cases spermatozoa were found in one vesicula seminalis only (four times in the right, three times in the left). In 7 of these men the semen was found as abundant and apparently as normal as in the average adult.

The ages of these 37 men ranged from 60 to 82, and in the 7 cases mentioned where the semen was so abundant the ages ranged from 73 for the youngest to 82 for the oldest.

Duplay also noted that even if a considerable degree of atrophy existed the testicles could yet secrete spermatozoa, and that this function probably continues up to the time of death.

Dieu also published a series of cases which he had examined. His cases amounted to 105, ranging in men from 64 to 97 years of age. It is noteworthy that one of these old men hanged himself at the age of 84, when an abundant seminal emission took place in which spermatozoa were numerous. In these 105, in 41 only were spermatozoa found in the semen; in 64 they were absent. In 14, between the ages of 64 and 70, 9 showed spermatozoa; 5 showed none. In 49 cases between the ages of 70 and 80, 22 had spermatozoa, 2y showed none. In 38 cases between the ages of 80 and 90, 10 showed spermatozoa, 28 had none ; and finally in 4 cases between the ages of 90 and 97 no spermatozoa were present in the semen.

Simmonds gives the result in 1 3 old men who were over 70 years of age, whose genital organs he had an opportunity to examine post-mortem. The oldest one was 87 years of age, in whom the spermatozoa were very abundant. In 10 of the 13 the spermatozoa were numerous. In 1 (a case of arterio-scierosis), the man being 76 years of age, azoospermia was present. In 2 cases there was oligospermia.

While from these figures it would seem as though the secretion of spermatozoa may diminish as old age increases, it will be seen that this is not necessarily the case. Hence, we can conclude with Simmonds that even in the most advanced old age spermatozoa are almost constantly found in the semen.

The function of the testicles is seemingly to secrete the fructifying principle of the seminal fluid, and this may go on to old age, but other portions of the sexual apparatus are concerned and assist in making up the semen as we see it in daily life. As bearing upon this point, whether the spermatozoa are secreted solely by the testicles, an interesting case has been reported by Princeteau. Instances are given throughout medical literature where castrates are reported to have become fathers of children, and by castrates I mean men in whom both testes are wanting. In such cases the old adage, that accidents will happen in the best -regulated families, occurs at once to our minds, and the belief is strong that the putative fathers were not the real ones. In such reported cases the semen has not been examined microscopically, but in Princeteau's case it ap parently was. The case was that of a young man who had lost both testes by ablation for tuberculous disease of these organs. No trace of either of these bodies could be discovered on palpation. Nevertheless, this young man had frequent erections, indulged in coitus, and ejaculated a fluid which contained spermatozoa, of which Princeteau showed preparations (dont le presentateur montre des preparations). How soon after the operation the semen was collected is not stated. This case does not admit of discussion. If there has been no mistake in the report, then we must revise our belief that the testicles are the only organs of the sexual system which secrete spermatozoa. I shall revert to this point again when I come to discuss the subject of cryptorchids under the head of sterility.

PHYSIOLOGY OF THE VESICUL^E SEMINALES.

For a long time it was believed that the vesiculae seminales acted only as receptacles for the collection of the semen as it was secreted by the testes, and when they filled up that a spasmodic contraction emptied them, producing a seminal emission. John Hunter early called attention to the fact that these bodies were not for the sole purpose of acting as reservoirs for the semen, but stated it as his belief that they were "glands secreting a peculiar mucus." Kayser, in his inaugural dissertation in 1889, reviewed the various experiments and teachings that had been held upon the subject of the physiological importance of the vesiculae seminales, and he came to the following conclusions, which may be summed up as follows : " The seminal vesicles are organs whose walls secrete an albuminous fluid which is collected in the vesicles themselves. These vesicles serve as receptacles for their own secretion, the physiological importance of which is not yet well known. In the con tents of these seminal vesicles spermatozoa are found, sometimes more, sometimes less, but they are never so regular nor so abundant as to authorize one to say that the seminal vesicles are also storage- places for the spermatozoa.' '

With this view physiologists of the present day are inclined to agree ; and while the vesiculae seminales do secrete a fluid peculiarly their own, which is one of the principal ingredients or component parts of the semen, they undoubtedly also contain spermatozoa, and it is probable that they also act partially as receptacles for the spermatozoa, for upon this ground only can the statements that castrated men are occasionally fruitful be accounted for, supposing them to be complete castrates, to wit, that spermatozoa have been lodged and detained for a certain length of time in the vesiculae, to be later on expelled during the act of coition.* The secretion of these bodies is thick, glairy, and albuminous, resembling synovial fluid (Hyrtl) ; it probably constitutes the bulk of the seminal fluid, and is made up of globular, granular bodies, with or without nuclei, and epithelium, both cylindrical and ciliated. That they are true secreting glands also derives force from the fact that in some animals (the horse, the bear, and others) " in which the vesiculae seminales are large and of apparently active functions, they do not communicate with the vasa deferentia, but pour their secretions separately, though it may be simultaneously, into the urethra " (Kirke). Furthermore, in castrated men these bodies do not usually atrophy, but go on secreting, and this is probably the reason why such crippled persons are enabled to have sexual desires and erections and to enjoy coitus, as is not infrequently seen in both animals and men. In men spermatozoa are sometimes found in these organs, but they are seen more abundantly in the lower portions of the vasa deferentia than in the vesiculae.

* This is tenable without regarding them as reservoirs for the semen.

As regards the place which the secretion of these vesicles holds in the sexual economy, the experiments of Steinach and Rehfisch are interesting. Steinach's experiments were made upon rats, in whom he extirpated the seminal vesicles. After the wounds of operation had healed up these rats were allowed to cohabit with females of their own species, and there seemed to be no loss of sexual power, so far as coitus was concerned, in these crippled animals as compared with sound ones, but it was found that their power of fecundating the females was very materially diminished. For example : Four rats were the subject of one experiment. They were allowed to cover 14 females. Of these 14 only 5 became with young, and gave birth to 19. Nine females therefore were sterile. In order to make sure that the fault did not lie with the females, these 9 females were put to rats which were not crippled, with the result that they all had young. Now, when it is considered that rats are very prolific and usually have five litters a year, each litter having ten young, it will be seen that these crippled rats were very decidedly handicapped as regards the question of fertility.

Steinach then experimented by extirpating both the prostate and the seminal vesicles, and he found in this series of experiments that the rats were totally incapable of fertilizing. Their copulative power remained good, but they were totally incapable of impregnating any female. Three male rats were experimented on in this case, and the number of females was 12. In all, 42 attempts at impregnation were made, and all of them were unsuccessful. These rats were then killed, and their vasa deferentia were found filled with spermatozoa, so that these rats although sterile were not azoospermatic.

Rehfisch's experiments were made upon rabbits, the secretion from the seminal vesicles, from the epididymes, and from the vasa deferentia being used, each one separately, for each separate experiment. Artificial impregnation was attempted upon female rabbits which were in heat, and the result in all of these experiments was negative. In the secretion from all of these parts healthy and viable spermatozoa were found.

These experiments would appear to indicate that the seminal vesicles are not storage-places for the spermatozoa. It is true they are found there, and, I think, more frequently than Kayser is inclined to admit. Simmonds' post-mortem examinations show that pretty clearly, and they also show that the secretion of all of these glands is necessary for the life, the health, and the mobility of the spermatozoa. Besides this, it shows that the secretion from any single one of the sexual organs, or of the organs concerned in the elaboration and manufacture of the semen, is not sufficient to produce impregnation in the female, even though the fluid may be perfectly fruitful and full of spermatozoa. It is necessary that all shall be combined in order to produce fertilizing semen. It is furthermore probable that each component part of the semen is kept distinct and apart until at the time of the emission in coitu, when they then become commingled and each one plays its part in rendering the semen fertile, and the absence of any one of them interferes materially with the good health and productiveness of the secretion.

PHYSIOLOGY OF THE VAS DEFERENS.

When discussing the anatomy of the vas deferens, it was suggested that this portion of the sexual apparatus of the male should properly be regarded as a portion of the vesiculas seminales, and its physiological function, so far as it has been observed, seems to be akin to that of those organs. It secretes much the same sort of fluid, and in the vasa deferentia the spermatozoa are not infrequently found, perhaps about as abundantly as they are in the vesiculae seminales (Davy) ; more so, according to Kayser. The secretion of these organs, if they are considered as separate from and independent of the vesiculae seminales, forms one of the constituents of the semen, and cannot be considered, any more than the vesiculae, as storage-places for the elaborated semen. Indeed, it is an open question whether the testes produce the spermatozoa in greater quantity than is needed for immediate use ; it is a matter of everyday experience that if coitus be indulged in frequently and consecutively, the number of spermatozoa diminish and finally disappear entirely, to reappear in increased quantity after the testes have had a period of rest and an opportunity to secrete their peculiar product (Black, Lode).

The only dissentient to this view so far as I know is v. Gyurkovechky, who states that he is convinced from his experience, which he claims to be abundant, that " in persons who are accustomed to frequent indulgence in sexual intercourse, and who have the strength so to indulge, the number of spermatozoa where coitus is frequently repeated is increased instead of being, as stated by the majority of authors, diminished; indeed, after repeated coitus the spermatozoa are found to be abundant, well developed, viable, and capable of great energy of movement. It is difficult to say why this should be so, but perhaps the explanation may be that in the first coitus the spermatozoa which are ejaculated are the poorest ones, which have been retained in the vesiculae seminales, while subsequent connections bring out the spermatozoa which are lodged in the vasa deferentia, and finally those which are directly secreted by the testes are emitted." This is a very singular theory, albeit an ingenious one, and I should be the more ready to accept it but for the fact that my own experience, so far as it goes, is decidedly in favor of the views of the older writers. In other words, I find that where coitus is repeated and frequent the spermatozoa diminish in amount, viability, and energy of movement, and a condition of oligospermia ensues, and that rest and abstinence from coitus produce a return to the normal condition with an increase of spermatozoa. Quot homines, tot sententice.

PHYSIOLOGY OF COWPER'S GLANDS.

Some authors regard these organs as assisting in the elaboration of the semen, the secretion being ordinary mucus (Kolliker), and is thin, transparent, adhesive, and colorless. This I consider doubtful, as the discharge, in health, is not very abundant, and I incline to the view taken by Hyrtl, that their proper function is to provide a lubricating and protecting coating for the urethra.

PHYSIOLOGY OF THE PROSTATE.

As has already been said, the prostate is composed of muscular and glandular tissue, the former predominating in the proportion of 3 to 1 (Hyrtl). Its relation to the testes is close and intimate, for during the period preceding the age of puberty, while the testes are yet undeveloped, the prostate is small and hardly recognizable on examination, but as soon as the testicles become active and commence to assume their functions the prostate gland increases in size and secretes a fluid (the prostatic fluid), which goes to make up one of the constituents of the semen, though by no means as important a constituent as it has been the custom to consider it. When the testes begin to assume their functional activity it has been seen that the cells proliferate, forming the spermatozoa, and the same thing happens in the prostate — the cells of this organ also proliferate, developing into true glandular or secreting cells, which pour forth a fluid rich in mucin (Griffiths).

The secretion of the prostate is a thin, slightly turbid fluid, with a feebly acid reaction, and contains amyloid bodies of various size, lecithin (PI. II., Fig. 5), mucin, and epithelial cells (PL II., Fig. 4), generally of the cylindrical variety (PL II., Fig. 4). Upon drying, or by the addition of a drop of ammonia, peculiar crystals are formed, such as are seen in Plate I., known to the French as Charcot's, and to the Germans as Boettcher's crystals (PL I.).* It has the peculiar seminal odor, resembling the smell of fresh chestnut blossoms ; it is that portion of the semen which gives this fluid its characteristic odor, and seems to be principally instrumental in producing coagulation of the secretion from the seminal vesicles during the process of ejaculation (Camus and Gley).