Sexual impotence

Preface To The Fifth Edition

Despite the brief lapse of time since the publication of the fourth edition of this book, additions and a few modifications in this new edition were imperative.

New and better instruments have made th deep urethra more accessible to a rational local treatment, but likewise have offered suggestions for varied mutilations.

In their time the ovaries were the object of the ' 'furor operandi," and it appears now as if the colliculus seminalis and the seminal vesicles must be substituted for them, and must be sacrificed to demonstrate brilliant technic.

Proceeding from one extreme to another, one encounters the beseeching demands of psychotherapy. That psychotherapy is new is not true, and that it is very often the true treatment is not new. Even psychotherapy for sexual neurasthenic troubles is nothing new. The author advocated it in the first edition of this book (published in 1888), when urology was in its toddling clothes, and at a time when the subject of sexual neurasthenia was strictly tabooed in polite medical society.

Even a superficial study of the history of medicine will convince any one that psychotherapy was

2 PREFACE

used at all times by the physicians of all nations. Fakers also, at all times, tried to take hold of psychotherapy, and some of them were exceedingly successful with many patients ; but in order to treat any case of disease, first of all a correct diagnosis must be made. No treatment of any kind should be entered upon before the indication is properly established. This being so obvious, it also proves irrefutably that it is either gross ignorance or a brazen and criminal impertinence that any one should have the temerity to subject a fellow human being to any kind of healing, mental or other, without having previously mastered the knowledge necessary to discriminate between the nature of a sickness in which mental healing can accomplish anything and other forms of diseases where different means must be used to protect the patient against suffering or even against premature death.

The Author.

San Francisco, California,

Physicians Building,

December, I9J5-

Preface To Fourth Edition

The enormous strides made during the past twentyyears towards a rational consideration of the many perplexing problems of the normal functions of the sexual organs and their pathology are most gratifying to the pioneers in this field. It is very significant that now even great surgeons, when removing a sufferer's prostate, condescend to consider the consequences to the man's sexual power.

The lion's share in this fortunate change of front must be awarded to the extraordinary progress that modern urology has bestowed upon modern medicine. This youngest medical specialty, at first spurned on all sides, is forging its way to the front.

Physiologists considered the urinary organs within the exclusive domain of internal medicine, and, besides, refused stubbornly to consider the functions of the male sexual organs. But urology broke into physiology and into internal medicine almost at the same time. The newest ally to the sexual part of urology appears in that great question, probably one of the most important that medicine ever tried to solve, the riddle of internal secretion. Physiology is compelled to join in the campaign by emphasizing that the sexual functions cannot be loftily ignored.

In consequence of the interesting and important discoveries made by the explorers of the bacteriologic flora of the various sexual organs and their appendages, reinforced by the local findings made possible

4 PREFACE TO FOURTH EDITION

by newly invented, excellent urethroscopes with which we can really see, even the most one-sided neurologists were compelled to acknowledge that many a neurasthenic in reality had an ampulla, a vesicula seminalis or two, a prostate or a verumontanum that need the urologist's help.

In this new revision I endeavored to reflect the gains made by urology. The chapters on anatomy and physiology had to be revised and enlarged in order to form a proper foundation for the modifications of our opinions on sexual neurasthenia, the influence of many diseases upon the sexual power, for our modest attempts at the understanding of internal secretion, of physiotherapy and for the most energetic protests against urological atrocities committed on the complicated and delicate structures of the deep urethra.

The reader will find most of the modifications and additions in the chapters on the treatment of sexual impotence, but none in those dealing with the sociological and ethical sides of our subject; thirty years of experience as a physician only strengthened youth's "glad inheritance, the inextinguishable love of truth."

The medical press of the United States, Canada, England and Ireland was very kind to this little book. I tried to heed some of the good advises given to me, but was unable to do so with all of them, some I could not, and a few I would not.

The Author.

San Francisco, California, 381 Bush Street.

Preface To Third Edition

The reading part of the medical profession in the English-speaking countries has pronounced judgment upon this monograph. The verdict is highly gratifying to the author. The first American edition was exhausted in less than two years. The comments of the medical press were almost without exception favorable. True, one anonymous critic was rather harsh, but the sting from his pen has been removed by the queer coincidence that the publishers of the paper which gave room to his assault offered in 1898 to publish my work. The critic himself is naive enough to admit that the handling of some phases of the question will be misunderstood, and we agree with him, as evidently he is a fair example of those few who misunderstood the book altogether.

May this new edition meet with the same success as the previous ones, and without a murmur we shall endure if it meets with the same enemies.

The Author.

Preface To The First American Edition

When the first German edition of this work was published, in 1889, there was some commotion in the ranks of old and young medical fogies, who were indignant that any one dared to resist their intellectual tendencies, refused to worship their superannuated gods.

The second German edition found the ranks of the same kind of professional formula-riders and bigots solid, though somewhat thinned.

I have taken the liberty of preserving the independence of my altruistic opinions, and shall continue to fight against false and hypocritical quasi-scientific pretentions. The circumstance that my work has been given earnest consideration by authorities like Casper, Eulenburg, Fiirbringer, Krafft-Ebing, and others makes it easy to bear all the acrimonious aggressions dictated by the bilious nature of some of the " Dii minorum gentium."

I wish to thank Professor A. A. D'Ancona, who kindly revised the manuscript and helped me in many other ways.

The Author.

Preface To The Second German Edition

In the lapse of seven years passed since the publication of the first edition of this work, we can record but very little progress in the theoretic as well as the practical development of our subject. We know today just as much — or, better, just as little — about the physiology of the sexual act as we did seven years ago.

Quite new, indeed, is an abundance of newly* : forged names for old pathologic conditions. Some authors try to perpetuate themselves in this way. We can only hope that most of these new names will be short-lived.

The therapeutics of sexual impotence has received some valuable additions, and we have in the method of suspension a frequently efficacious, and in hypnotic suggestion an occasionally efficacious, remedy.

It affords me special satisfaction that my monograph has not proved to be an ephemera, in spite of the many adversaries the liberal interpretation of some pertinent questions has encountered.

The Author.

San Francisco, California, 1896.

Preface To The First German Edition

To write on the much-scouted subject of sexual impotence is a venturesome undertaking under all circumstances; but to write without the customary affectation and without any hypocritical excuses, to speak the bare truth, surely requires even greater courage. Many an eminent medical man may have felt a secret desire to take the risk, but refrained from carrying out the resolution through fear of endangering his professional reputation. Some one not counted among the magnates of the medical realm may feel licensed to plunge to the very bottom, "to see what the gods have covered with darkness and horror," and may dare to relate to his colleagues what he sees and hears, without alteration or retouching.

"No physical or moral suffering, no wound, however putrid it may be, should frighten him who devotes his life to the science of man; and the sacred ministry which obliges the physician to see everything, to know everything, gives him also the right to relate everything." 1

It must be admitted that the subject has never

Preface To The First German Edition 9

received the attention its preeminent importance deserves. Everywhere in the world it seems to be considered the proper thing to treat the affair with supercilious nonchalance. Few medical men in Germany can boast of ever having had an opportunity to hear a clinical lecture on sexual impotence ; and the complaints and criticisms of authors prove that elsewhere the question receives no greater attention. "The subject is thus not yet emancipated from the tenacious grasp of the most rampant charlatanism." 1

"Let us be frank from the first steps of our researches, because hypocrisy is the worm which in modern society attacks and corrodes the highest and most powerful plant of this life's garden." 2

This somewhat serious neglect is no doubt to be attributed to the circumstances that those suffering from impotence can hardly be subjects for treatment in hospitals, and that the observation of the details and symptoms of the disease is attended with unusual difficulties; nay, is hardly possible at all.

Recent indications seem, however, to point to a better future. Men of prominence in the learned world, with Eulenburg, Krafft-Ebing, Fiirbringer, Edw. Martin, Lydston, Sturgis, and some others at the head, do not think it beneath their dignity to busy themselves with the solution of the perplexing problems of the sexual life, and it is to be hoped that before long the conventional medical lies with which every book, every pamphlet on the subject is swarm-

1 Campbell Black, On the Functional Diseases of the Urinary and Reproductive Organs. London, 1875, p. 6.

2 Mantegazza, Fisiologia deH'amore. Milano, 1882, p. 75.

IO PREFACE TO THE FIRST GERMAN EDITION

ing, will disappear and Mantegazza's satire 1 become obsolete.

" Difficult problems cannot be solved if we run away from them or if we avoid them ; and still many a physician, many a philosopher, tries to solve the most burning questions of modern society in the manner of the baby who believes he can escape the threatening dog by closing his eyes."

Vecki.

Contents

I. — Anatomy. 30

II. — Physiology of the Sexual Act 50

Sexual Maturity 50

Chapter I. Anatomy

We shall now give a rough sketch of the male organs of reproduction. For more minute study we refer the reader to the great number of excellent anatomical works.

The male genitalia have been divided into different sections; but as this separation contributes in nothing to the clearness of the subject, we shall simply discuss the different organs in their turn.

The testicles (testes, testiculi, orchides, didymi) are a pair of oviform, glandular organs. We shall first consider the coverings which protect and support them. Proceeding from the outside inward, we find first the outer skin starting from the perineum, from the inner surface of the upper thighs, from the root of the penis, and from the pubis, and forming the scrotum or purse. The whole of the scrotum appears asymmetrical, hanging a little lower on the left side. The slight enlargement of the cutis forming the median raphe, which runs from the perineum forward to the inner surface of the prepuce is not exactly in the median line, but draws somewhat to the left. This raphe separates externally the whole genital apparatus into two halves, thus indicating the inner division.

At the scrotum we find the epidermis, cutis, and

3° tunica dartos. The epidermis is distinguished by the amount of pigment it contains ; the cutis, by a strong growth of hair, sudoriparous glands, and. a rich rete of lymphatics. The tunica dartos is a fibrous, fleshy membrane, consisting of rather strong, smooth, muscular fibers, elastic, without fat, and ligamentous in character. Still proceeding inward, we next come to the tunica vaginalis communis, which envelops the testicle and spermatic cord. That part which surrounds the spermatic cord is loose and spongy, containing here and there adipose tissue, and is intimately connected with the spermatic cord and the scrotum. This portion of the tunica vaginalis communis consists of three layers — an inner, an outer, and a median muscular layer. These layers or membranes are not in all parts distinctly separated from one another, because the musculus cremaster which separates them runs in isolated flat bundles down the spermatic cord; between the bundles the two layers run into each other. These isolated flat fasciae of the cremaster pass in a fan-like manner downward, twining around the testicle. These muscular bundles have the power to draw the testicle upward and outward. Contraction of this muscle ensues reflexly from violent movements of the abdomen; also as the result of independent action. The testicle may, besides, be raised through the contraction of the muscular fibers in the tunica dartos. Immediately enveloping the testicle we find the 'tunica vaginalis propria, which may be divided into two layers — namely, the parietal membrane, which is connected with the tunica vaginalis communis, and the visceral membrane, which is united with the albuginea of the testicle and the epididymis.

As the testicles produce the sperm, they are the most important part of the male generative organs. The testicles lie side by side in the scrotum, hanging down between the thighs, below the symphysis pubis, each in its own compartment, and separated from its fellow by a median membranous partition — the septum scroti. The testicles are in the abdominal cavity until the seventh month of fetal life, when they descend through the inguinal canal into the scrotum.

The left testicle is slightly larger than the right one and hangs a little lower, this arrangement being very appropriate, as it prevents friction of the testicles in case of the sudden pressing together of the thighs.

In the testicle we have, first of all, to distinguish between the testicle proper (Henle calls it testicular gland, others call it main or chief testicle) and the epididymis.

The testicles are oviform in shape, flattened laterally, with the greatest diameter four to six centimeters in length, directed obliquely from above downward, forward, and outward. The weight of the testicle is fifteen to 24.5 grams, its cubic contents twelve to twenty-seven cubic centimeters, its length five centimeters, its breadth 2.5 centimeters, its thickness three centimeters. Weight and volume, length and breadth, are subject to great variations in different individuals, and fluctuate considerably even in the same individual. In spite of Henle' s 1

1 Handbuch der Anatomie. Braunschweig, 1874, p. 366.

opinion to the contrary, my experience teaches me that this fluctuation in the volume of the testicle corresponds to the amount of seminal fluid contained. It is true that the testicle does not collapse immediately after coition, but observation has convinced me that the volume increases after unusual abstinence; so that I feel sure that contraction of the scrotum is here not the main cause of variation.

Having noted that the testicle is an oviform body flattened laterally, we observe further two points, the upper and the lower, and two margins (anterior and posterior) connecting them; also two flat surfaces, an inner and an outer. The superior point and the posterior margin are covered by the epididymis and the beginning of the seminal cord.

Directly investing the testicular gland itself is the tunica albuginea. This is a dense, fibrous membrane, brilliantly white, 0.6 millimeter thick, containing numerous ramifications of veins and small arteries, and becoming considerably thicker and more vascular toward the posterior margin. From its inner surface it sends off numerous bundles of connective tissue, and, at almost regular intervals, stronger flat transverse bundles, dividing the tissue of the testicle into numerous conical lobules, the number of which is placed by different authors at from one hundred to three hundred. Each lobule contains a great number of very fine tubules, called spermatic canals, or vasa seminalia. These have a volume varying, according to the degree of distention, from 0.1 to 0.2 millimeter. They inosculate with one another, and are very tortuous, so that it is 3 difficult to disentangle them. Their number is estimated at eleven hundred.

As we have stated, the tunica albuginea becomes much thicker toward the posterior margin, this enlargement forming what is called the corpus Highmori. Here the seminal tubes collect, three to six inosculating, and grow less and less tortuous until they become almost straight and form the rete vasculosum (seu Halleri) testis. From this rete start about twenty larger tubes running almost in a straight line, and passing through the tunica albuginea into the epididymis; there they form lobuli again, giving rise to that single tube with manifold convolutions which constitutes, in the main, the parenchyma of the epididymis.

Besides the seminiferous tubules, the parenchyma of the testicle contains comparatively large winding vessels with thick walls and a cellular mass, of the function of which we still know nothing positive, and which many anatomists and physiologists consider to be connective tissue. Before entering the epididymis the seminiferous tubules change in structure and become simply excretory ducts.

The epididymis properly considered is merely an excretory duct of the testicle. It is a body weighing generally 1.5 grams, its cubic contents being 1.78 cubic centimeters. Its upper end is globular in form and tapers off to pass into the vas (recte ductus) deferens. The epididymis is also invested with a tough albuginea, which has the same structure as the albuginea of the testicle, but is not so thick, its thickness being only 0.04 millimeter. The inner surface of the albuginea of the epididymis also sends off septa of connective tissue into the parenchyma, dividing it into lobules, though superficially only.

The unfolded vas (recte ductus) epididymis has a length of about six meters, with a diameter of about 0.44 millimeter, and gradually dilates as it approaches the vas deferens. Besides this principal duct, the epididymis contains also one to three small blind canals, the vasa aberrantia and the so-called hydatis Morgagni, which are said to be remnants of embryonic conditions.

At the lower point of the testicle the canal of the epididymis is turned directly upward in order to reach the orificium cutaneum canalis inguinalis; it is then called the vas deferens, and, together with the vessels and nerves running in the same direction, forms the seminal cord (plexus spermaticus seu pampinif ormis) . The so-called vas deferens is no vas, but a duct ; we shall drop the misleading name and term it ductus deferens.

The tortuosity of the epididymis continues into the first part of the ductus deferens, but the tube becomes gradually more nearly straight, its walls at the same time increasing in thickness and extent. The total length of the seminal duct is about fifty to sixty centimeters. According to Henle, 1 the straight part is about three millimeters in diameter, one-sixth of which is taken up by the lumen, so that the thickness of the wall is 1 . 5 millimeters. On this thickness depend the firmness and cylindrical form of the ductus deferens.

Before the seminal duct unites with the seminal vesicle it forms the spindle-like ampulla of Henle. The lumen in this place becomes almost doubled in extent, the thickness of the wall increasing also. The mucous membrane is folded, and resembles a great deal that of the seminal vesicles.

The ampulla is a very important part of the sexual organs, but has so far never received proper consideration. At the end of the ampulla the vas deferens grows thinner again, and has outlet in the inferior pointed end of the seminal vesicle lying at the outer part of the base of the urinary bladder, between the bladder and rectum. The end of the ductus deferens forms with this pointed end of the seminal vesicle the ductus ejaculatorius.

The seminal vesicles are really hollow glands of a very irregular form, resembling a very knotty, somewhat flattened club. Even in the same subject the two vesiculae seminales differ in form and size. The length of the vesiculae seminales varies from four to 8.5 centimeters, their diameter from 0.6 to 0.7 centimeter. The superior end is blunt, usually having a hump-like protuberance, which, looked at from the outside, resembles a small hunch. The entire surface looks uneven or rough, the little hunch-like prominences corresponding to depressions on the inside.

The interior of the seminal vesicles is still more peculiar, and varies just like the exterior. The mucous membrane is of a yellowish tint, infolded, has little pits, and forms depressions and longer or shorter diverticular. The organ has altogether a cellular appearance. In the mucous membrane there are some peculiar glands, which, though the granular epithelium is different, have a structure similar to that of the mucous glands, but produce a secretion essentially different from mucus, as it does not congeal in acetic acid. 1

By the union of the deferential ducts with the vesicular seminales the ejaculatory ducts are formed about the superior margin of the prostate gland, but with numberless variations in the share provided by the individual organs in this formation.

The parietes of the ductus ejaculatorius are about 0.4 millimeter thick, the lumen one millimeter in diameter. While the lumen runs from two to three centimeters forward and downward through the prostate, it diminishes in volume; the mucous membrane, which at first resembles that of the vesicula seminalis, losing gradually its folds and its glands, as well as its yellowish tint. The two ejaculatory canals also frequently exhibit variations with respect to form, course, convergence, and mutual contact. Even coalescence of the two ducts into one may take place. The ejaculatory canals lead into the prostatic part of the urethra near the verumontanum or colliculus seminalis, opening by circular mouths. The fact, minutely described by Henle, 2 that the muscular membrane of the ductus ejaculatorius within the prostate assumes the character of a cavernous tissue seems to me of special importance.

1 Compare Barnett's very interesting anatomico-surgical study: The vesiculse seminales. Transactions of A. Urol. Ass., 1909, pp. 65-68.

The prostate, shaped like a chestnut or flattened cone, embraces with its anterior surface the neck of the bladder and the first portion of the urethra, its posterior surface resting on the anterior wall of the rectum. This posterior part of the gland is divided into two lobes by the ejaculatory duct. The texture of the prostate is firm, the borders rounded off. The superior border or margin which surrounds the bladder is broader, slightly bent in the middle, while the inferior margin tapers off. The greatest diameter of the prostata measures thirty-two to forty-five millimeters; from the base to the point it is twenty-five to thirty-five millimeters; its thickness, fourteen to twenty-two millimeters. Its weight is estimated at seventeen to 18.5 grams.

According to Henle, the prostate comprises three different organs, or, rather, structures — a number of racemose glands, the glandula prostatica; a closing muscle of the bladder, composed of smooth muscular tissue, the sphincter vesicas internus; and a transversely striped closing muscle of the bladder, the sphincter vesicas externus. Besides these, we have to notice in the wall of the ductus ejaculatorii, of the sinus prostaticus, of the urethra, and of the colliculus seminalis, the peculiar structure which sends off shoots into the substance of the prostata and also the exterior coat of the glandular portion, together with the separating walls or septa starting from it. Walker, 1 however, claims that the whole muscular

1 George Walker, A contribution to the study of the anatomy and physiology of the prostate gland . . . , Johns Hopkins Hospital Bull., Oct., 1900.

structure of the organ is arranged primarily to compress the prostate, and not to act as a vesical sphincter.

Some superficial authors seem to think that the anatomy of the sexual organs is a closed chapter and should only be treated in text-books. Kolischer 1 evidently is not of the same opinion and emphasizes that Zuckerkandl and Tandler have called attention to the fact that our usual terms describing the prostatic anatomy and the pathology of prostatic hypertrophy are in need of a thorough revision. Our accepted division of the prostate in two lateral and one median lobe does not correspond with the anatomic facts, and that what we call "the surgical capsule" of the prostate is a misnomer. Zuckerkandl and Tandler agree with Freudenberg's statement that the prostatic capsule of the surgeons consists of compressed prostatic tissue.

It is now generally conceded that the physiological function of the prostate is almost exclusively a genital one. The prostatic fluid mixes with the spermatozoa, the product of the seminal ducts and the seminal vesicles to make up the fluid which we call semen. The muscular part of the prostatic gland causes the action of the ejaculatory ducts and probably prevents the ejaculated semen from flowing into the bladder. Herrick 2 says that the former idea, the prostate greatly aiding in the control of the

1 A prostatic study, Jour. Amer. Med. Assoc, July, 6, 19 12, p. 8.

2 Prostatic hypertrophy and its radical cure. Med. Record, Aug. 15, 1903, p. 243.

bladder is given up, as in eunuchs with atrophied prostates, or in children in whom they are not developed, and in women in whom they are absent, urinary control is not interfered with, and in many cases of complete prostatectomy incontinence is the rare exception.

The main substance of the prostata is the real gland, which does not reach complete development until after puberty, as the glandular ducts and vesicular develop greatly at the expense of the substance of the connective tissue, which predominates before puberty. They give to the whole gland a yellowish-red tint and a spongy appearance.

The relative proportion of the muscular fibers and the glandular substance in the prostate varies considerably in different individuals. Morris 1 considers the muscular element, comprising both striped and unstriped fibers, to represent about one-half of the entire mass. In one subject the glandular spaces may be predominant, and in another their contractible coatings, so that in one person the secreting function of the prostate may predominate, and with another the motory. 2 Unfortunately, we have, as yet, no observations to determine what influence this difference in the structure of the prostata has on the sexual life.

The excretory ducts within the prostata unite into an indefinite number of stems, which open into the urethra at the colliculus seminalis anterior to the

1 Human Anatomy. Philadelphia, 1899, p. 1022.

2 Ruedinger, Zur anatomie der Prostata, des Uterus masculinus und der Ductus ejaculatorii. Muenchen, 1883, p. 4.

mouths of the ductus ejaculatorii. Two of the largest stems open almost symmetrically, side by side, quite close to the openings of the ductus ejaculatorii ; the others, from seven to fifteen in number, open rather more in front, asymmetrically and with variations.

The secretion of the prostata is of the nature of mucus, but is only slightly congealed by acetic acid. It is rather significant that even the chemical reaction of the prostata' s secretion is not an undisputed item. While Furbringer and Finger claim that the motility of the spermatozoa is impaired by an alkaline catarrhalic secretion of the prostata Schultz 1 found the secretion of the prostata in men of normal sexual conditions to be of alkaline reaction.

We now pass to a short description of the real organ of copulation, the penis, which, with its corpora cavernosa, is perforated by the urethra.

The urethra, which runs from the neck of the bladder to the exterior orifice of the penis, is divided into three portions — the pars prostatica, pars membranacea, and pars cavernosa. The course of the urethra resembles the letter S — i.e., it has two bends or curves, of which the posterior retains its shape even during erection. The length of the urethra varies very much, and is from fourteen to twenty two centimeters, the pars prostatica = 2 to 2.8 centimeters, the pars membranacea = i.5o to 2.50 centimeters, and the pars cavernosa = 10.5 to 16.7 centimeters. There is a similar variation in the lumen of the urethra. It is narrowest in the pars

1 Wien. klin. Wochenschrift, xvii, 43, 1904.

membranacea, and of varying width, but least extensible, at the orificium externum.

In the pars prostatica the lower wall stands out, forming the colliculus seminalis (caput gallinaginis, verumontanum, crista urethralis) . This is the most important part of the urethra, with regard to the subject we are treating, as it is the seat of many diseases. The caput gallinaginis begins, according to Henle, at the urethral mouth of the bladder, with two longitudinal folds, converging toward the median level space; along with these two there is occasionally a third, the median fold. The caput gallinaginis may begin with a greater number of smaller folds. This crest reaches its greatest extent, in height and breadth, at about the middle of the pars prostatica, immediately before (under) the sharp bend; it then decreases again even less abruptly, its transverse diameter diminishing at the same time. The anterior end extends, in the form of a narrow ridge, far into the pars membranacea, and often divides, toward the end, into fork-like branches at an acute angle.

This description is very definite, indeed, but indicates clearly the great variations we meet in the structure of the crista urethralis. These differences become still more numerous in consequence of disease or the frequent use of instruments. Age also has a great influence on the formation of this organ, so that variations are met with at every autopsy as well as at every endoscopic examination. The same thing may be said of the measurements of the breadth and height, stated to be about three millimeters.