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About Google Book Search Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web at |http: //books .google .com/I ■•Ti?t, 1 SEXUAL IMPOTENCE— KOBINSON All iha Bsoh* and P>i wa Publlah ar* 1 Whlla NOS. 1 TO 7 CONSTITUTE TKe Critic and Guide Si:X LIBB.AKY A. Complrtc Collpcird Works of Dr. A. JacobI, President of the American Medical Asso- ciation, in 8 :ip1endid volumes f IS.OO I. The Prevention of Sexuai Diseases. By Vic- tor a. Veckl. M. D. ...; 1^ 9. Nerer-Told Tales. A vivid presentation of the results of sexual Ignorance. Bj Wm. J. Robinson, M. D 1.00 3. Sexual Problems of To-dar- By Wm. J. Robinson, M. D a.OO *. Sex Morality. Pa»t. Present and Future j or Monogamy vs. Variety. Bj Wm. J. Rab- inson, M. D., Leo Jacob!, M. D., and oth- ers 1.00 5. Practical Eugenics: Pour Means of Im- Siroving the Human Race. By Wtn. J. loblnson, M. D M 6. The Venereal Peril. By Wm. L. Holt, M. D. Si T. The Social Evil. By Wm. L. Holt, M. D. .10 8. The Present Status of 606 or Solvarsan iS 9. The Treatment of Pollutions and Spermator- rhea. By Wm. J. Robinson, M. D HI 10. Scientific Medicine vs. Quackery. By Wm. J. noWnson, M. D 10 11. Tlie Hunter (Schreiner) and A Page Prom My Life (Robinson) M 19. The Ten Greatest Humanitarians of the I9th Century. A Symposium. By Victor Rob- inson is All sent prepBld on receipt of price. On personal check* add 10c for collection. THE CRITIC AND GUIDE CO. 13 Ml. M«rrU P.rh W Nvw Y«rh SEXUAL IMPOTENCE— ROBINSON A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SEXUAL IMPOTENCE (Ehjaf of the Deportment □! Genllo-Ui^laiT DiHueg and Dermatolaay. Bronx HooplUl and Dlipenauv;EdlurT)ie American Journal at Urolos^. Veneinal and SaiualDU- AND OTHER SEXUAL DISORDERS IN MEN AND WOMEN WILLIAM J. ROBINSON, M. D. SoctatTof Uedieal Sociolaay, FnoldentM UiaNinthnn ■tedical Sodatr. Bx-praaklaiit at th« Barlln Anr>i>-An(ria>n UcdlealSoeistr. FaUoviXtheNn e, Henbartif American Uadlcal Editota' Anoclatiaih .Lmerican Midlcal AshxUCIod. New York SUU Medical Soclely. M«d. p.(,(. Ip3 I PREFACE The author has always entertained somewhat peculiar ideas about books, and he haa not hesitated to express tbem. Those idea^ are crystallized in his motto which be bos put on the title page of every one of his books: " No book has a right to exist which has not for its pur- pose the betterment of mankind by affording eitlier useful information or healthful recreation." I will go even fur- ther and say that a book that does contain useful infor- matioii, but information which ia already contained in other books pre^'iously published, has no right to exist, unless the author at least presents the matter from a new point of view, or classifies it in such a manner 83 to make its comprehension more easy, more assimilable. It is uu- \ fortunately only too true, however, that thousands of books ' are published annually whioh have absolutely no raison d'etre, for they do not contain an atom of new informa- tion, nor does the arrangement of the subject-matter pre- sent any originality. They present merely a rehash of Bome other book or a resumfi of several. And without mincing words it must be confessed that many a book owes its existence to one reason only: the author's desire for fame or financial emoluments or both. That this is a Intimate reason, I will admit; but it must be a aec- ondary reason. The primary reason, the real mainspring « PREFACE for getting out a book should be service; it must be serring humanity, or a portion of it, bj giving it new infonuation or iuiormation hitherto inaccessible, information based upon personal first-hand knowledge, or presenting it in a new systematized popular form. Another point, which is more important than all other points combined : The author must be absolutely honest aud fearless and if his opinions happen to run counter to those generally accepted he must state tbem unheai- tatingly, without regard to consequences. I believe that judged by tJie above criteria, this book has a right to exist, for it contains some new information on the nature and treatment of sexual disorders, it presents the existing information in a clear, systematized form, so that the physician can make practical use of it in his daily prac- tice, and the autlior states his views on certain mooted sexual questjons with an unequivocal clearness and posi- tivenees which certainly leave no doubt in the reader's mind as to just what the author wanted to say. Will every physician, by the guidance of this book, be able to treat sexual impotence and other sexual disorders successfully I Yes, provided be possesses a modicum of common sense. No book, no system, no encyclopedia, no university will teach a man common sense if he is congen- itally devoid of it. But to any physician possessing a fair share of sound sense and judgment — and these qualities should be prerequisites to the practice of ^ PBEFACE medicios — this Tolmne sfaoold more o€ iiMiitiiinU>i Taliie. Id fact it is becaoae the Tuiow utidH in a which we pablished inaa time to tiaia in the hat £bv J years, did prove of eodi great pneticel nlne^ that i have decided U> rapood to the nmnfBavB w (sic) of the profession to get oat a etmtplete j tilatiae on sexual disorders aad their * ™**™— * One of the most Taloable and aaiqne features of the book I consider the nomeroos case rqnrts, which illustrate every phase of sexual disorder. Abstiwit descriptions of symptoms and treatment often leave but a faint impret- i uon on the reader's mind ; descnptioos of actual i viduat cases, giving the itidirtduat svmpt/^matology er I indiriAuU treamiait, oftm become indelibly impressed c the memoiy, so that when a phv?i«an gets a case, be finda I less difficulty ia understanding and classifying it, and it ia easier for hUn to order the correct treatment. I have not tried u> get oat a big boc^ tho it woold have lieen very easy to do so. It is easier to get oat a big book than a email one (Lei one which is small and never- theless covers the ground). I have carefully avoided padding. Thus for instance I hare not included a chapter oa the anatomy of the sexual organs, which every writer on Bemal disorders thinks it bis duty to do. And for a vety g!>oA reaaon: Our standard anatomies contain do- Boriptions of the sexual organs which are perfect in all details. If a writer wants his book to contain an an- 8 PREFACE atomical chapter he must copy from tho standard text-booka verbatim; in which case hi& chapter is useless; or, as he geuorally doea, he abbreviates, condenses, distorts, in which case bis anatomical chapter is worse than useless. The best thing a physician can do if he wishes to refresh hia memory in the anatomy of the sexual organs is to go and take out bis Gray, Fiersol, Cunningham, etc., and spend an hour or two among their pagoa. Tho same is true of tlie chapter on the physiology of the sexual organs. Nor bav© I even given the modus operandi and the various steps of the sexual act I did not tbink that any adult was in need of this information, and I have a lingering suspicion, that anybody who copies Rubaud's description of the sexual act (and every author does copy Rubaud, be- causo nobody has yet risen above his poetic flight in thla matter, and to attempt to excel him is a hopeless task), does BO to satisfy the salaciousness which allegedly re- sides to a certain extent in every person, male or female, and to help the sale of the book. De gustibus non est disputandum, but I do not like use- less padding, and I deiest useless salaciousness. One word about the language. I never could see why text-books had to be written in a cold, impersonal manner devoid of the human touch. I have preferred to write this book in the language whicli I have employed for so many years in my editorial and other writings: personal, clear, straightforward, conversational. I have found this PEEFACE d [ to be not only the most honest, but also the most impress- I ing, the moat convincing way of writing. It carries the I message straight home, and leaves a deeper impression on the reader's memory, than does the cold, solemn, imper- Bonal, BO-called literary style. Utilitarianism — practical usefulness — is the keynote of this book. I want the physician not only to understand wliat he reads; I want him to remember it. ■ PEEFAOB TO ITIE SECONB EDITION. The exhaustion of the first edition in less than two mouths from the day of publication shows unmistakably the need of a book of this character. It also shows that the profession is at last becoming alive to its shortcomings in the matter of sexual disorders and is b^inning to be will- ; to learn, ) edition has been revised and enlai^ed and a com- I'plele index has been added. May 1st, 1913. INTRODUCTION 17 PART I — MASTURBATION UPTEB DEFINITION AND PREVALENCE .... 23 Objects TTaed — Psychic Maaturbation — Mental Masturbatton — Wide-Spread Prevalence in Male Sei — Prevalence in Female Sex — Practiced at all AgeB — Frequency — Exists Among Criminals. THE CAUSES OF MASTURBATION ... 29 Servants — Other Cliildren — Accidental Fric- tion — Local Irritation — Constipation — Watch- ing Animals — Endourethral and Rectal Masturba- tion. THE RESULTS AND SYMPTOMS OP MAS- TURBATION 33 Exaggerated by Earlier Physicians — Some Deny Evil Effects — Physical and Psychic Symptoms : in Boya; in Girls; in Men; in Women — The "Maa- turbator's Face" a Myth — Masturbation Shreds. IT THE PROPHYLAXIS OF MASTURBATION 40 V THE TREATMENT OF MASTURBATION . 43 ^L In Small Children — When Necessary to Punish ^H They Must not be Spanked — No Pockets in ^^^ Trousers — Local Treatment — Psychic Treatment la CONTENTS CHAFTEB PAOB of Adults — Exaggerated Ideaa of Its Injurious Ef- fecU Must \k Removed — Medieiual Treatment — Dangers of tie Bromides — Thyroid — Atropine — Hydrotherapy. VI MARHIAQE AND MASTtTRBATION ... 51 VII MASTURBATION, LOCOMOTOR ATAXIA AND INSANITY ; . 55 Vlir REPORTS OF CASES 67 l.X CAN MASTURBATION EVER LEAD TO IN- SANITY? 63 X THE ALLEGED IIARMLESSNESS OP MAS- TURBATION . . . ' 71 XI THE OLD WRITERS ON MASTURBATION 75 XII COITUS INTERRUPTUS, CONDOM.ATUS PROTRACTUS, AND INCOMPLETUS ... 79 PART II — POLLVTIOSS AXD SPERMATORBHEA XIII POLLUTIONS: DEFINITION AND CLAS- SIFICATION 93 Diffen-nce Between Pliyeiologic and Pathologic Pollutions — Diurnal Pullulions — Retro-Poilu- lions or Pollutions Into the Bladder — Is There Such a Thing ss a Physiologic Pollution? XIV CAUSES OF POLLUTIONS 103 XV TOLLUTIOSS AND NOCTURNAL INCON- TINENCE OK URINE 106 XVI SPERMATORRHEA 107 XVII SYMPTOMS OP POLLUTIONS AND SPER- MATORBHEA 109 CONTENTS 13 CHAPTBE PAGE III PROSTATOIIRHEA 113 3X URETimORUnEA 115 THE TREATMENT OF POLLUTIONS AND SPERMATOHRHEA 117 Treatment Different for Plethoric and for Atomic Pollutions — Bromides Injurioufl in Latter — Pyschic Treatment — General Treatment — Local Treatment — The Use of Sounds or Dilators — Sonic Local Applications. BROMIDES AND MARRIAGE AS A PAN- ACEA IN POLLUTIONS AND SPERMATOR- RHEA 127 Advisable Only in Plethoric Pollutions — Ex- tremely Disastrous in Atomic Pollutions and Sper- matorrhea. fART III — SEXUAL IMPOTENCE IN THE MALE jtXII THE CAUSES OF IMPOTENCE .... 135 Masturbation — Pollutions — Spermatorrhea — Profitatic Congestion — Urethral Congestion — Gonorrhea — Stricture — Narrow Meatus — Or- ganic Caue<«^ Abnormalities of the Testes — Atrophy of the Testes — Neuralgia of the Testes — Hydrocele — Hernia — Varicocele — Diseases of the Prostate Gland — Atrophy of the Prostate Gland — Kiimosis — Age — Sexual Excess — Sex- ual Abstinence — Coitus Interruptus vel Reservatua — Marital Dislike — Drugs — Constitutional Dis- eases — Typhoid Fever — Tuberculosis — Obesity — Alcoholism — Worry — Fright ^ Intellectual Pursuits — Riding — Automobile Riding — Paro- a I I CONTENTS CHAPTEB 'AOB XXIII THE PROPHYLAXIS OF SEXUAL IM- POTENCE 155 XXIV THE TREATMENT OF IMPOTENCE . . 159 General Considerations — Tlie Usual Case of Im- potence — Sexual Rest — Cold Water Injections — TTie Psyclirophore. XXV MEDICINAL TREATMENT 167 Strychnine — Alcohol — Cantharidin — Other Drugs — Organotherapeutic Preparations — Hydro- therapeutics — The Diet. XXVI EXTERNAL APPLICATIONS .... 175 Ointments — Vacuum Pumps — Electricity — Exercise — Splints. XXVII PSYCHIC IMPOTENCE 181 XXVm REPORT OP CASES 18S XXIX SEXUAL IMPOTENCE AND ATHLETICS 203 XXX A SUMMARY OF THE MOST COMMON TYPES OF SEXUAL DISORDERS .... 208 PART IT — SEXUAL NEURASTHEinA XXXI DEFINITION 881 Etiology — Sj-mptoinatology — Sexual Symp- toms — Urinary Symptoms — The Shiver — Pains and Aches — Circulatory Symptoms — Digestive Symptoms — The Spt^ial Senses — Work — The Mood. XXXII THE PROGNOSIS OF SEXUAL IMPO- TENCE AND SEXUAL NEURASTHENIA. . 238 XXXIII THE TREATMENT OF SEXUAL NEU- RASTHENIA 212 CONTENTS CHAPTKR XXXIV REPORTS OP CASES XXXV THE RELATION BETWEES IMPO- TENCE AND SEXUAL NEURASTHBSIA . SO I I PAST r—STERIUTT XXXVI GENERAL CONSIDERATIONS . . . 27f XXXVU CAUSES OF STERILITY IN MAN . S81 Aspermia — Azoospennu — Oligoepennia — Necroepennia — Epididvmitifl — Stricture — Ei- hatution of Ejaculatory Center — Con^nJUl Fonc- tional A»periata — Anpiired pgrchic AfpennatiiB — Roentgen Rays — Inbreeding — Intense Intel- lectnal Application. XXXVIII THE TREATMENT OF MALE STEK- ILITT 289 Removal of Nodalar Epididymes br Absorbent Ointments — Martin's Operation — Hot Bathi, Diet and Tonics. XXXIX STERIUTY IN WOMAN 300 XL TREATMENT OF STERILITY IN THE FE- MALE 306 XU SEPARATELY FERTILE BtT MUTUALLY STERILE 309 PART ri — SEXUAL DISORDERS IN WOMAN XUI DIFFERENCE BETWEEN THE SEXES . 313 Frigidity — Treatment of Frigidity — C«e Be- porta of Frigidity. SLOl VAGINISMUS 322 CONTENTS PAGE XLIV ADHERENT CLITOEIS OB PHIMOSIS IN THE FEMALE 326 INJUniES TO THE FEMALE IN COITUS 338 PART YU — PHIAPISM XLVI DEFINITION AND VAIilETIES . . .339 XLVII ETIOLOGY OF PKIAPISM 341 XLVIII HEPORT OF CASES, WITH POINTS ON THE TREATMENT 343 PART VIII — MISCELLANEOUS TOPICS XUX IS MASTUliBATION A VICE .... 353 L TWO KINDS OP PREMATURE EJACULATION 356 LI THE FREQUENCY OP COITUS .... 358 UI "USELESS" SE.XUAL E.XCITEMENT . .368 UII THE RELATION BETWEEN MENTAL AND SEXUAL POWER AND ACTIVITY . . 371 I.IV " OMNE ANIMALE POST COITUM TRISTE " 380 LV SEXUAL VIGOR AND BIG FAMILIES . . 388 LVI SEXUAL PERVERSIONS 385 Satyriasis — Nymphomania — Homosexuality — Fetishism — Freud's PBychana]3*8iB — Sadism — Masocjiism — Bestiality — Pygmalionism — NaT- eiseism — Exhibitionism — Necrophilism — Voy- eurs — Frotteure, LVII THE PREVALENCE OF SEXUAL IMPO- TENCE AND OTHER SEXUAL DISORDERS . 395 PART IX — PRESCRIPTIONS . . .401 INTRODUCTION In their totalitj, tlie diseaaes and diaorders of the aamal ajstem and the aberratioas of the sex instiiKt have Sem the cause of more Boffermg anil more misenr to tlie liQiiiaD race than anj other cU^ of di^eaieak, of course, of the vast majority. A omall percentage in tlieir anxiety to get cured do overcome their false mod- esty and tell the doctor everything. The radical and emaiieijiatod women, whose ranks arc con^itantly increase- ing, arp also learning to speak to the doctor with the same frankness that men do. So that we are beginning to get 8ume data. Kevertheless we are obliged to go principally by oiir impresaious in this regard. And uiy decided im- pression is that masturbation is not nearly so commit in the female sex as it is in ihe male sex. And I will even go further, and say that those who claim that 100 per cent of all gtrls and women masturbate i.e., have mastur- hatwl at one time or another, do nut know what they are talking ahout. Either this, or tbey deliberatoly exag- gerate for the purpose of making a sensation. Ten to twenty per cent would be a liberal figure, and probably rather above than below the actual truth. There are some furious masturhators among women —just as the nympho- maniac woman is worse than any man in this respect. »o there are worse masturbators among women than among men — but that does not militate against the fact (hat their number is much smaller. Age. No age is exempt. Infants three montlis old of either sex, men and women of sixty and over have been known to masturbate. I have known n man of 7fi who was an incorrigible maatnrhBtx)r, using different ways and meana to bring about an orgasm and ejaculation. But of course the period at which masturbation is practiced most frequently is in the years immediately preceding and fol- lowing puberty — the period between 10 and 24, or to make the limits narrowed, between 12 and 18. Under 10 I MASTURBATION 27 or 12 the sexual inatinet is not yet fully awake and children under that age who masturbate do so primarily ou ac- count of some local irritation; while after 18, the young man haa usually learned of the injuriousness of the habit and begins to indulge in regular sexual relations, and after twenty-four is apt to be married. Frequency. The frequency with which boys and girls addicted to the habit practice it varies greatly. Some will indulge in it once or twice a week, some once a day; still others will indulge 2, 3 or 4 timee in one day, and then will refrain altogether for a week, or two or even three. The stories of Ixiys and girls indulging 10 or 12 times an hour may be trur, but they must be extremely rare and belong to the domain of the psychopathies. The most ex- treme case I have had under treatment, was that of a young man who masturbated when he got the "attack," 10 to 20 times in 24 hours. The ejaculated fluid during the last few times would he thin and very scanty, just a few drops, he would feel a burning and scalding instead of & pleasurable sensation, and still he would keep on and on until he'd fall completely exhausted and " dead," He would be in a wretched condition for three or four days, then he would begin to recuperate, and he would be all right for six or seven weeks. And ha would not mastur- bate, not even have any desire to do so, until the next attaclc. This patient was completely cored, and he will be referred to again, in the chapter on treatment. Women do practice the vice with a frequency which is almost in- credibla But on investigation all such extreme cases will be found to be nymphomaniacs, that is they belong to the .domain of psychopathy, and that is a separate chapter. SEXUAL IMPOTENCE We haTe known one " normal " woman, however, who masturbated six to ten times a day, two to three times a week. She was a complete nervous wreck when she ftp- plied for treatment. An adherent inflamed clitoris was the causo. . _^-^ Station in Life. No station in Ufo is exempt. It is prevalent in the very lowest as weW as in the highest strata of society, among the most savage as among the most cul- tured nations. Some high class schools and colleges are hotbeds of masturbation. Though probably less prevalent ~in ancient times than now, it was well known in antiquity, I _.ju»d in_th© decadent period of Rome the evil was most * widespread. Even animals deprived of their mates prac- IIto It. donkeys in captivity become confirmed mastur- bators, and Voltaire thoiiglit tJiat of the animal kingdom monkeys were the only animals addicted to the vice. But, we now know belter. Dogs masturbate frequently, and horses sometimes indulge in the habit to such an e.xtent I that their health is materially injured. Note. — In continental Europe the word onanism is in general use instead of masturbation. This use is etymo- logically incr)rrect, as the term onanism (Onan, see the Bible) should be applied to withdrawal only. I have never liked the terms onanism and onanist, and use exclusively masturbation and masturbator. CHAPTER TWO THE CAUSES OF MASTUBBAtlON Q«neral. Wbat leads boya aiid girla into masturbation? The original primary cause is of course the existence of the sexual instinct. But what are the immediate causes? One groat cause is initiation by other boys. The habit of masturbation would bo much less widespread than it ia, } if boys and girls were not taught it by other boys and girle, or servants, or nursemaids, etc. One masturbating i boy will Boraetiraea infect an entire class, and from ono ! class it spreads into other classes. A very large number [, however, according to my investigations, start the habit I by themselves, unintentionally, and withont any special [ cause. In fact I believe that the vast majority of boya would masturbate if they never were seduced or initiated by others. Through seduction the boy acquires the habit I much earlier than he otherwise would, but acquire it he I -would eventually, anyway. The dei'oloping sexual in- stinct which is revolutionizing his entire body and psyche, which fills him with vague longings and strong though ill defined desires would eventually lead him into the habit. A boy will lie in bed, will get warmed up, through an ao- I eidental pressure or friction there will be a slight eree- I tion with a new, hitherto unexperienced, pleasurable sensa- J tion, the hoy will touch the organ again - — and before he knows just how it happened, an ejaculation has talten I place and the mischief is done. He has had a novel ex- 30 SEXUAL IMPOTENCE perience and he is as a rule not slow in repeating it The friction of the genitals against the clothes, particularly if tight, or eliding down banisters or climbing poles is often the first step towards niasturbatiou. I have known cases where the first ejaculation took place during a friendly wrestling and rolling on the floor between two or several boys. These two causes — initiation or se- duction by others and a«?idental initiation — arc tbo most important. AH other causes are socondary, but they must be mentioned, in order that we may avoid them in trying to institute an eflUcient system of prophylaxis. Local. Irritation about the genitals due to any cause, phimosis, an accumulation of smegma under the prepuce, eczema on or about the genitals, prurigo, pruritus of nn- defined etiologj', urticaria, scabies, soatxvorms, in short anything that will cause the child to handle or scratch the genitals will bo conducive to masturbation. Consti- pation, which causes the boy to strain and thus sometimes induces an erection, is sometimes the inital cause. Sleep- ing in l>ed with another person is very bad. Uncon- sciously during the sleep an erection and ejaculation may be induced. The copulation of animals, generally dc^, in the streets, always watched with lascivious curiosity by boya of all ages, has a very injurious effect More than one patient told me that that was the first thing that excited hia sexual curiosity, gave him precocious knowl- edge and led him into the habit of masturhation. Ob- scene pictures and posters, lewd pornographic literature, gotten out with the deliberate purpose of debauching boya and girls, vulgar shows, have an undoubted pemiciouB effect on the youth of both sexes. They awaken the sex- ual instinct prematurely, keep it always at high beat, with the result of inducing not only masturbation, but other sexual irr^^laritiea aa well. ^^ hong, immovable sitting in one plare, in school or else- ^^Lwbere, is very injurious for children, induces congestion ^^hbout the genitals, and by the irksome nervousness which ^^Fit causes may he a direct cau-'^c of masturbation. ^H The Objects Used for Masturbation. The various ob- ^Vjects used for performing masturbation form a curious chapter in htunan perversity — or ingenuity. While the hand, being the most handy, is by far the most freriuently used, there comes a time when the hand apparently ceases to give the desired satisfaction and stronger stimuli are used. And instead of external friction, endourethral and ^^ rectal masturbation is indulged in. The objects used ^^Uor this purpose comprise lead pencils, penholders, cathe- ^^Rers, steel sounds, glass tubes, glass rods, wax candles ^" {gas lighters), paper cutlers, cork screws, ladies' hatpins, canea, broomsticks, etc., etc Medical literature contains numerous reports of various foreign bodies used for mas- turbatory purposes. In the American Journal of Urology for January, 1908, Dr. L. Buckle reports an interesting case of rectal masturbation in a man of seventy which ^m'll be referred to later on. In the same journal for December, 1909, Dr. Franz PTeiBZ of Budapest reports the removal of a wax bougie I the bladder by dissolving it with benzin. The can- Jle was used in the urethra undoubtedly for masturbatory lurposes, though the man claimjed, as they always do, that he inserted it to facilitate urination. Aa to the objects used by women, both married and M SEXUAL IMPOTENCE unmarried, for the purpose of masturbation, their name is in truth legion, and it is sometimes hard to believe that a sane human being could use the things that we are oc- casionally called upon to remove from the female geni- talia. Ij?aving out the various objects, often in the shapo of the membrum virile, which from the most ancient times were manufactured specially for the purpose of female masturbation, tbe commonest object is the woman's moat handy implement, the hairpin or hatpin. And we often have to remove hairpins and hatpins from the fe- male bladder and vagina. Corks, ointment jare, pocket knives, rubber balls, paraffin candles, pessaries, perfume bottles, spoons, billiard balls, apples, carrots, etc., etc, are a few of the things which the poor girls and women uso to induce an orgasm and which, slipping beyond their control, must occasionally, to their intense humilia- tion, be removed by the Land of the physician. Tliey often suffer in silence for a long time, and only when the suffering hoconies unbearable, or when the people about them begin to notice that there is something wrong with tbem, do they appeal reluctantly to the physician, Tn one case the object — a small stick capped with a piece of sponge — which slipped beyond the girl's control remained in the vagina for nearly three months, before the girl applied for help. I had quite some difficulty in re- moving it, as it had become imbedded in the tissues, and produced a severe ulceration and a profuse horribly ill- smelling discharge. CHAPTER THREE THE KESULTS AKD SYMPTOMS OF MASTITBBATION It IB no longer a subject of dispute that the eril resolts ' masturbation were terriblj, shamefullr, stupidly, if you will, exaggerated by the older doctors. Whether they were trnly convinced that the resulta of masturbation were as horrible as they portrayed them, or whether they did it with the pious intention of frightening those addicted to the habit and to prevent new rictims is immateriaL Probably both hypotheses are correct. The older physi- I'iana were not given to scientific analysis and they were constantly guilty of the post Hoc, propter hoc fallat^. ^K They saw a tabetic patient or a lunatic who had been or ^^■ms masturbating and they immediately jumped to the ^^ponclnsion that that man had tabes or was insane because ^^Bm masturbated excessively. It didn't come to tbeir mind ^vtfiat it was possible that the man masturbated excessively ^^leeanse he was getting tabes or beeanse he was a Innatic. As to the lurid colors in which they pictured the dire consequences of masturbation, they had a more disastrous effect than the habit itself. I admit that it might have prevented a small, insignificant number of men from fall- ine victims to the habit. T admit that it might have frightened a number of people into breaking loo$« from the habit, hut it is just as certain that on a very large number of masturbators it had a most disastrous effect. 24 SEXUAL IMPOTENCE Much mora diaastroua, I repeat, than Hie habit itself. Suppose a boy or joung maji had read that masturbation meant invariably either an early grave or locomotor ataxia, or general paralysis, or violent insanity. Suppose that in spite of his utmost efforts to break the habit, he vraa unable to do so. Is it any wonder that ftuch a man actu- ally fell into the condition of hypochondria, became gloomy and morose, lost his appetite and sleep and became a physical and ne^^'ous wreck 1 The doctors then had an- other example of the terrible effects of masturbation — but it wasn't. The wreckage was simply the result of their distorted descriptions of what masturbation would do. But it will not do to deny altogether or even to mini- mize the evil results of masturbation. I studied the subject dosely for many years and I have alt<>mpted to eliminate varioiis accessory causes, and I have come to the inevitable conclusion tliat masturbation per se does produce very in- jurioUH, occasionally even disafltrous results. That the results are produced by the masturbation and not by the imagined fears of its evil results, or by the shame and moral degradation, etc, is clearly established by the fact that these same evil results are produced in children who have never heard that the habit is injurious, and who, though instinctively practicing it in solitude, do not in any way feel shamed or degraded by it. Those who deny any evil results of masturbation might here interpellate the question: Are you sure that those boys and girls in whom you noticed the evil results of masturbation were perfectly healthy and normal before they became addicted to the habit? Are you sure that MASTURBATION they did not have some nervous laint in their constitn- tioB before? No, we are not sure. Bnt the queetion is one of mere casuistry. What is a perfectly normal boy or girl ? Is there any such thing ? Has not everybody some taint in his or her constitution ? The fact remains that masturbation produces extremely injurious physical and psychic results in a large number of boys and girls, who, but for that habit, would have remained healthy and uninjured. Further on I give some examples of the evil effects of this habit, where there can be no doubts as to the real etiological factor. The injurious effects of masturbation are both physical and psychic, and are almost of the same character in both boys and girls, though they are more severe in boys. These symptoms are: anemia, chlorosis, general lassitude and languidness, inability to study or concentrate the mind on any kind of work, weakening of the memory, general loss of self-confidence, avoidance of company, a dra^ng gait, unwillingness or inability to look people straight in the eye, a pale, dingy complexion with, frequently, pim- ples and blackheads on the face and dark rings aroimd the eyes. Urinary symptoms are quite common. They ex- press themselves in frequent micturition, dribbling of urine and nocturnal incontinence. While it is true that nocturnal incontinence often precedes the masturbatory habit and is probably one of the expressions of a uro-gen- ital neurosis, it is also tnie that some maaturbators begin to wet the bed only after they have indulged in that habit for some time and that nocturnal incontinence is very dif- ficnlt to cure as long as the habit persists. X have known ) ytmng men and women at the age of twenty and 36 SEXUAL IMPOTENCE over, who still suffered with that extremely annoying and huiuiliating affliction, of wotting the bed every night, or almost every night. Tlie more remote and far-reaching results of this habit arp, in men: pollutions, spermatorrhe*, impotence, sex- ual neurasthenia and, the worst of all, complete aversion to the opposite sex. So that they remain either single through life, or if they marry, their wives are unhappy and have to seek relief with other men, or to demand a di- vorce. The effects in women are also sexual neurasthenia, sexual apathy or frigidity, and complete aversion to or loathing of the male sex. They become completely un- Bcsed. It is tLey who constitute the saddest and most disagreeable specimens of the sour, crabbed old maid. And many of them remain old maids even after they are married. For they suffer with premature ejacuUiiiona. That is they have their orgasm almost immediately on the man's approach, and then they ropol the man, unless they have mifflcient will-power to conceal their real feelings. The profession is not familiar with the fact that women may also be impotent They do not indeed suffer with impotentia coeundi (except when physically malformed), but they certainly do suffer frequently with ejaculatio praecox; and after the orgasm a further continuance of tho act becomes extremely repulsive to many. Many di- voree* are due to precipitate orgasm in the woman, the resolt of previous and perhaps still continued masturha- tion. A potil ileal baa hern written alwiit the changes in tho oxienial genitals of women who bavc been masturbating. I will say right here that in a large percentage of mastur- MASTURBATION 37 bating women — the larger percentage — absolutely no sigoe of any kind can be discovered; no more than any signs can be discovered in masturbating boys and men, Jducb has been written about the enlarged clitoris in girls who have masturbated. As a general statement I deny it most emphatically. An enlarged, hypertrophied clitoris is found in some mnaturbators, but only in a small per- centage of cases. And then we cannot be sure that the large clitoris did not exist before the girl began to mas- turbate, and that it was not the cause of the masturhation. Masturbation does not cause an enlargement of the penis in boys; why should it cause an enlarged clitoris in girls 1 It may be somewhat congested and swollen, but congestion and swelling is not hypertrophy; it generally subsides after soothing and cooling compresses. The labia majora and minora may be elongated and thickened, somewhat blnish, or deeply pigmented, almost black ; and where tlie masturbation is practiced excessively, violently, furiously, with the use of the nails or foreign objects, there may be scratch marks, lacerations, scabs and scars. One symptom is quite common: a gaping of the vaginal orifice. In women who have given up the habit, or in cases where the masturbation has been practiced for many years, the hy- pertrophy of the labia is followed by atrophy. Krafft-Ebing well says of masturbation that " it strips scent and beauty from the bud, which should unfold to a , perfect flower, and leaves behind only the coarse-minded, animal instinct for sexual satisfaction. If such a ruined individual arrives at the procreative age, be lacks the esthetic, ideal, pure, and ingenuous attraction, which attracts to the other sex. The glow of the sensual per- ■■liliiii ml Am yoDtlrfal •» W frfai ai to aoj Baianl Monl inteNoane." Ub HMlKtalar^ ftn. la format jcars ve aaed to htm wmA n^ a good dnl ibort the amteriMUoT'e Isoe. TW "BlMiUmt*' «f tW oat aad «at qudcs utd aeau- ^■i^ «W wake tli«r linae br Kuin^ p0°P^ ^^ ^'^ a fMi dnl to v^ abottt it It is assnted that Uw nua- tBifainK* &a» b Hitamdt aad peosliar, aad tlie solitai^ TiROBWfcadMelmfljdHraMiBaBopettboafc. This iidlbaiib Vka a, ■attaHatar thiala that this b tlw mmt, th^ haa^T bj' Ub aotfcoaaCMai eoadact, bjr a aer- ie hiimnlf any. In exo»- , Uw tympte MM of a gtaw l nmrdowB mmy be dwhr eridatt. Tbe black rings •MiMd A* «!j«i, ia pri* |iaitMaUrl«-. often Iril an on- toblikBUt tala. Bat aot aay m»* m tbut in pxtieaits ■afcriag with paOataaM aad ipanaatoffrbm or indnlgiDg b — riw tatareoana. And a laig* avaibcr of maa- tBzbaien sfpear p i e liu ea ef perfeci baahk, aad tbeie is Bot a trwat of aajtbiag ia their fmem to brtrar tbeir babit "Dm u iiwirtowt , beeaaae tbe onlr troahle soase oua- i wpari mpg is tbe fcar tbat people eaa see in ■ vbat tbe matter with tbom U If asmm] tbat t Aa ease, tbat tber* t) tbecOale^T nothing ia ^ftoe to betrar tbcso, their tnwUe disap)>ean and 'ad eaer and oontnL MASTURBATION Masturbation Shreds. The experienced physician will I often diagnose masturbation with certainty from a mere I examination of the urine. The urine of the confirmed and [ excessive masturhator often contains numerous small fine I shreda. They differ from gonorrheal shreds in that they I are much shorter — l/i; to Ys inch long — are quite thin, I liave no tendency to curl or roll up, and are free from I gonococci. These shreds betoken an inflammation of the I posterior urethra and are present only in those musturba- I tors who have practiced the habit to excess, or in a pro- l traded manner, etc. These shreds may be present in any I condition of prolonged sexual excitation without gratifica- [ tion. As to the question whether masturbation may give rise to ran organic cicatricial stricture, I should not wish to be \ dogmatic even here. I have seen strictures in young men (who had never had any venereal disease, and where mas- ' turbation seemed to be the only etiologic factor (of course they could have been congenital). There is no reason why a low grade inflammation kept up for yeara may not give rise to cicatricial changes. Still, well au- thenticated cases of organic stricture with masturbation as the sole cause must be very few in number. It is also well to bear in mind that a somewhat inflamed urethra fur^ nishes a favorable soil for micro-organisms, and that the ^^ urethra of the excessive masturbator is more vulnerable ^^■knd therefore more prone to bacterial infection of yarioua CHAPTER FOUR I THE PROPHYLAXIS OF MASTURBATION The Prophylaxis of Masturbation. I£ the adage " aD ounce of prevention is worth a pound of cure " is true of any disease or habit, it is true of masturbation. One could say that the best and most etfective cure of mastur- bation consists in preventing it In considering the prevention of masturbation we must really consider the entire subject of the bringing up of the child. In fact we ought to go still further and con- sider the child's heredity — its parents. For strongly neurotic parents very often mean a. neurotic condition in the cliild and a neurotic condition is often the strong- est predisposing factor in masturbation. But as we can- not change the child's parents, we must try to see what we can do with the diild itself. The keynote of prevention consists in careful watching of the cliild and watching it from its earliest infancy. We know that not infrequently stupid or vicious nursemaids, wet nurses, and even governesses ignorantly or deliber- ately induce the liabit in cliildren under their charge. This must of course be prevented. Even children of the age of nine, ten, eleven should never be left alone with- out any eupeirision. Too close friendship between boys or girls, particularly of different ages, should be looked upon with suspicion. Boys of fourteen, fifteen or six- teen do not, aa a rule, make good companions for boys of 40 I MASTURBATION 41 ten or eleven. Several boys or girls should never sleep in the same room without supervision by an older person. The Bleeping of two in the same bed whether it be the sleeping of two children or the sleeping of an adult and child should under no circumstances be permitted. I ad- mit of no exceptions to this statement. It makes no dif- feraice whether the other person is a mother, a father, a brother or a sister. Leaving any deliberate element out of tlie question, the thing is dangerous, for very often un- intentional, unwitting masturbation is initiated thereby. The child, boy or girl, should sleep alone on a rather hard mattress. The covering should be light. A cover- let may be put over the feet. The child should always Bleep with the arms, ruil under, but on the cover or blanket. If this is done from childhood, it is very easy to get used to this way of sleeping and many cases of masturbation are avoided thereby. The child should not be permitted to loll in bed. It must be taught to get out of bed as soon as it wakes. The general bringing up must be of a strengthening, hardening character and this applies both to body and will. But I will not go deeper into this part of tlie subject as this comprises the general subject of oduciition. Nor will I deal viith the subject of sex- ual enlightenment of the child, because that is also a sub- ject in itself. I will merely state here, that when a child reaches the age of nine, ten, eleven, twelve or thirteen (we must use discrimination and judgment, for some child- ren of nine are as developed as others of thirteen), we must tell them that it is bad and injurious to handle one'a genitals, and we must warn them to shun any companions vho wish to initiate them into any manipidations of the 43 SEXUAL IMPOTENCE genitals, or who show a tendency to talk about the sexual organs and sex matters. I would say that hot baths are very injurious for young children in this respect. There is no question that a hot bath has a very decided stimulating effect on the sexual desire of both adults and children, male and female, and I have had several patients of both sexes tell me that their first masturbatory act was committed while in a hot bath. And of course tbo sensation having been very pleaaant they kept on repeating it. One little point about boya' clothes. Their trousers should be made without pockets, for boys often begin mas- turbation by fiddling about with their hands in their pockets, ami masturbation is very frequently performed through the i>ockets. They will often make a hole in the lining for that purposa Other points in prophylaxis will surest themaelves. Any factors whioJi, in considering the etiology of mastur^ bation, we saw arc apt to cause tlie habit, should naturally bo removed. Thus for instance phimosis, eczema about the genitals, strongly acid urine, seatworms, etc., should bo treated and removed. Thai anything which has a tendency prematurely to awaken the sexual instinct should be rigorously avoided goes without saying. Musical comedies and certain vaude- ville shows exert a pernicious influence in this respect. I do not demand any censorship over our theater, but I am 8imj)ly stating facts. Many of my patients told me that tlieir first masturbatorr act took place while witnessing some musical show. Libertarian that I am, I would never- tbeleas strongly ui^ parents to keep their boys away from sensuous musical comedies and obscene vaudeville acts. J ^^ tees CHAPTER FIVE THE TREATMENT OF MASTURBATION The Treatment of Masturbation. lu the treatment of .turbation, pointa of the first importance to consider the age of the patient, bis or her general physical and mental make-up, the degree of the addiction to the habit, and the presence or absence of any local causative conditions. Mastorbation in Children. Masturbation in infancy and early cbildiiood forms a cliapter in itself. Here the treatment is chiefly prohibitive and punitive. You can- it reason and argue, and explain the injuriousnesa and fulness " of the habit to a boy or girl of three or or nine. You must simply watch them, prevent them from indulging in it, and punish them sharply if they are caught at it. I believe that with children, to whom rea- soning and moral suasion make no appeal, physical pun- ishment is the only alternative and is morally fully justi- fiable. Only there must bo no spanking, for spanking has a distinctly sexually exciting effect on many children, While the nates are the most sensitive port in this respect, any part of the body may be responsive. And some chil- dren, as has been found out, will deliberately do certain mischievous, forbidden things, in order to be spanked, be- tbe spanking causes them sexual excitation and sat- in the chapter on Prophylaxis, boys' trousers i SEXnAL IMPOTENCE ^ should have uo pockets. The masturbating child'a arms should bo put in long sleeves, which sliould be so planed or tied, tliat tho child's hands could not reaeh the genitals. In some cases, il is also necessary to put on long drawers, buttoning in back, and spread the iegs apart attaching them to the bedclothes or the bedpost, 80 that one thigh cannot lie rubbed against the other. There are also special- ly made npplianees of metal, made different- ly for male and female children, which are put on over the geni- tals, and protect them BO that the child can- not handle them (see illustrations). In two or three caaea I have found it necea- sary to apply rapidly a red hot wire to the child's genitals, to the prepuce in a boy, to tho labia majora in a little girl. Whether because it was too painful to handle the parts, or because the shock of the application made a strong impression, or whether it was tho fear of a repetition of the same treatment, but this little rather brutal procedure proved effective: the child ceased to masturbate. A MASTURBATION 45 nectio It should not be necessary to state it, but nevertheless it lUSt be mentioned as a reminder, that wherever there is & .1 cause, which is supposed to be responsible for the isturbation, it must be removed. A phimosis must be fated, and complete circumcision is sometimes very bene- al ; an adherent) clitoris must be freed ; seatworms roust banished at once with santonin, chenopodium, or rectal iona of salt and quassia. Eczema or any other >nnatosis of or about tlie genitals must bo cured In the promptest possible manner. Psychic Treatment. When an adult — say from thir- teen on — comes or is brought to us, we mu-it first of ftli up our patient. If he is unaware of the possible ive results of the habit, or if having heard of such re- Its be is skeptical about them nnd is inclined to make t of them (we come across such patients too), thpn it duty to impress upon the patient's mind the iousnesa of the habit and the possible very dangerous, life-long consequences. The possibility of impotence must be presented to him, and this generally has a deterrent ef- fect. But wo must guard against senseless ax agger ations. For they are apt to miss their object entirely, and by mak- ing the patients lose confidence in our statements, may do ►re harm than good. ^Vhen the results of masturbation painted in too lurid colors, the effect may also prove itrary to what we expect, on account of the depressing iufliienee on the patient'a mind. Tie may imagine that he is irretrievably lost anyhow, and that it is therefore use- to make any atlempta at reform. When on the other hand we find the patient deeply af- and humiliated by his habit, when we find that he 3 46 SEXUAL IMPOTENCE has Bluffed himself wilh the daiiinable quack and semi- quack " literature," whieh pictures the most moderate in- dulgence in masturbation aa the vilest of crimes, the deadliest of sina, the most injurious of habits, leading ineritablj to paralysis and insanity, when we find that the patient considers himself as one of the vilest wretches, the lowest of sinners, unfit to go among decent men (we have seen just such tj-pea), then it becomes our duty to strike an entirely different tone. It is sometimes even necessary to go slightly to the other extreme. We have to tell him that there la nothing criminal, sinful or vicious in the habit per se. that it is a vice merely in the sense in which every habit which weakens the body and the mind is a vice, for instance like alcoholic indulgence is, no more, no ksa; we have to explain that if everybody who ever indulged in masturbation was to be considered a crim- inal, then practically all mankind was so to be regarded, because about 115 per cent of all males have masturbated at one time or another. We also have to explain that the injuriousnesa of masturbation lies not so much in the habit itaeif, but in the excessive indulgence in it. We have to ex- plain to him that not everybody who practices the habit is invariably injured by it. Tens of thousands of men ■who practiced it in early youth and have given up the babit are in perfect health now. It all depends upon the person's constitution, the age at which he started, the fre- quency of the indulgence, etc. It is remarkable what a good effect such talk ha» on this class of people. They leave the office different men. They become imbued with a new hope, a ne^v determination to conquer the habit. Their self-reepect is increased, their will-power is strength- MASTURBATION 47 ened, and with a little additional help from the doctor, they often, succeed in restraining themselves, where they failed before. And a few successes in this direction tend to still further strengthen their self-respect and will-power, lind very frequently a timid, shambling, self-contemptuoua -jnasturbator is converted into a strong, self-confident man in the short period of two or three months. I remember one patient, -as perfect a specimen of man- Iiood externally, outside of his sexual organs, as one wanta to see. Hie physical health was not in the least impaired by tie habit. No neurastlienio symptams of any kind. And nevertheless that man suffered tortures, beeause he had read tliat there were certain peculiarities in every mas- turbator's face, by which the habit could be diagnosticated without fail. And be feared that everybody or almost everybody knew that he was a masturbator. When I as- sured him that it was all rot, that there was no such a fades except in extreme eases of debilitated youths, that lie looked the picture of health, and that with the strong- est magnifying glass no telltale marks could be discovered in his face, he heaved a tremendous sigh of relief, " You have lifted a great burden from my head," he said (a very common expression). And his improvement was continu- ous from that time on. Hediciaal and Other Treatment. Psychic or psyebic- «uggee>tive treatment is important, but not all sufficient. Having put ourself into the proper relation to the patient, having gained his entire confidence, and having secured for him the right perspective of his condition, we proceed with the other adjuvant treatment. Medicinal treatment can seldom, be altogether dispensed I SEXUAL IMPOTENCE with. It ia a great help. Among drugs the bromidea play here an important rola I have expressed myself elsewhere (see chapters on Pollutions and Spennatorrhea) about the pernicious effects of the bromides, particularly if given in too large doses, for too long a period. I know all their dangei^ and unpieaaant by-effects But, never- tlielcsa, in masturbation we are often unable to do without them, and I prescribe them on tlie principle of choosing the lessor of two evils. Most patients do not possess sufTioi^it will-power to break themselves of the habit, without any extraneous aid. If they did they would not have to go to the doctor (and those who do possess it don't go). And Bo we must help them. And the bromides are such a help. By doproasing the libido soxualis, by soothing the general nervous irritability, by inducing or improving the sleep, they make it easier for the patient to resist any desire to masturbate. And as masturbation is to a great extent a habit, if the patient snreoeds in not indulging in it for some time, it becomes easy for him to break himself of it al- together. But of course the bromides must be given with care and judgment. Given in too large doses and for too long periods without interruption, thoy may completely and pennanently extinguish the sexual desire, and the ability to have erections. As to the size of the doses and the choice of the bromides the physician must judge for himself. The potassinm bromide is the most effective, but also the most injurious. The bromides of Hirontiiim and Bodium are the best It is often necessary to give sixty grains of tho combined bromides per dose, three times a day. With improvement in the condition, i.e. when the patimt telb us that bis'erections are not so frequent, and ^L day. Wit! ^^L patimt tell I I that bis desire to masturbate has diminished considerably, the size and frequency of the doses are to be reduced. It is always beat to give the bromides in some digestive ve- hicle, aneb as essence of pepsin, peptenzymc, lactopeptin, (See last diapter for prescriptions.) There is no ques- tion that if so administered the bromides are much better bomc: there is less digestive disturbance, less liability to bromic acne and even less depression. I have found the administration of adrenal suhetance useful in conjunction with the bromides ; the adrenal has a tonic effect and counteracts the depressing effect of the bromides. Another substance that I have been administering with ■ig^al effect in some cases is thyroid extract. It is my be- lief that the extreme or so-called furious maaturbatora suffer with some thyroid deficiency. This affects their mentality and will-power. The thyroid has a good effect on their general metabolism and on their mentality. Of course the thyroid must be administered with discrimina- tion, and the effects must be carefully watched. I have also lately administered pituitary extract and pituitrin with what seemed to be good results, bnt I have not admin- istered it in a snificiently large number of cases, to justify me in prononncing a definite opinion. Small doses of atropine (1-500 to 1-200 grain) also seemed fo me usefnl in diminishing posterior urethral and Tesical irritability. As masturbation and nocturnal incon- tinence of urine go so frequently together, and as atropine is 80 useful in the latter, I thought it might also prove 111 in the former; and it apparently does. Small doses tincture of iron with still smaller doses of tincture of 50 SEXUAL IMPOTENCE cantharides (Tr. Ferri Cbloridi 3 vi, Tr. Cantharidia 3 two to seven dropa according to age in a little water, or lemon syrup, ter in die) have alao proved useful in my bands. Hydrotherapy. Among otlier meaBurea in the treat- ment of mastiirbation, bjdrotberapy plays an important part. Cold rubbings, cold sponginga, cold doucbea to the back, cold dips, do excellent service in strengthening both the physique and the -will-power. Care must be taken of couree that the akin reacts properly after each hydro- therapeutic procedure. Local ablutions of the genitals are best avoided, aa the subsequent drying of the parts may act as a stimulus to masturbation. The use of cold ure- thral and rectal psychrophores by the physician (see the chapters on Pollutions and Spermatorrhea) ia sometimes very beneficial. CHAPTER SIX HABRIAOE AND MASTURBATION Let us assume that we bave to deal with a young man I of twenty, twenty-two, or twenty-five, who ia strongly sex- I ual. We have used all the means at our command, he I lias cooperated with us, and used all his will-power to I break himself from the habit. And he has succeeded in I a way. That is, while Iwfore he was in the liabit of mas- 1 tnrbating every day, or twice a week, he has now restrained I bimsolf for nearly two months. But this restraint has I cost him a terrific struggle and he had to use up an im- mense amount of energy. He was unable to attend to his studies as well as he should, he was irritable and he slept poorly, but he triumphed over hia habit, and he felt re- warded. One evening, however, he does not know bow it happened, he fought hard enough against it, but it hap- pened; and be then indulged in it again excessively fop two or three weeks. Again treatment; again abetinenoe for a longer time, and then again a " fall." And it is becoming more and more difficult for him to devote him- self to any mental work. Or the case may be somewhat different. By the expenditure of a tremendous amount of nerve force, aided by the bromides and other measures, our patient has succeeded in overcoming his habit. But he finds to bis consternation, that he is now having pollu- tions, they are becoming more and more frequent, and they are weakening him terribly. SI 52 SEXUAL IMPOTENCE In otlier words, what are we to do in the case of pa- tients who are bo strongly sexcd, that, with the best will and with the best treatment, they cannot break themselves of the habit, eXTOpt for a short time only, or who begin to suffer with sucli frequent pollutions, that we have a right to fear for their sexual power? In such cases it becomes our duty to advise our patients regular sexual relations. If we are mire that their sexual power is not impaired and if olher conditions permit, we inay advise marriage. Bnt, while I shall have the oppor- tunity to discURs this point in a later chapter at greater dc-tuil, I caimot refrain from stating here, that this thought- less advice to get married is responsible for a great deal of misery and that members of our profession have a good deal to answer for in this reepect. To advise a confirmed masturbator to get married without being sure of the in- tegrity of hia sexual potency and without his having given proof that he can break himself of the habit at least tem- porarily is nothing short of criminal. For marriage is not in every instance & cure for masturbation. There are plenty of cases of married people, who keep up the habit even thourjh indtilgtng in regular senial rclaiions; and there are others, who have a dislike, a loathing for regular interonnrse, neglect their wives, and continue the habit with nndiminisLed persistence; and the same is tnie of women who are confirmed mastnrbators. Tliey often loath their husbands, dislike sexual relations and remain slaves of their old habits. It is therefore more honest, more de- CCTit, more honorable, more moral, to advise a masturbator to attempt first illicit relations; if he finds that his sexual MASTURBATION 53 power IB good, that while satisfying his sexual desires nor- mally he has no desire for masturbation, then it is safe for him to get married. If on the other hand he finds that hi3 erections are weak, his ejaculations precipitate or premature, or what is perhaps sadder still, that normal intercourse does not satisfy him, and that his longing for his old habit remains undiminished, then no harm has been done to anybody, the man knows that he is not in a fit condition to marry, and that he must treat himself, and treat himself, until by another trial he has found that his condition has become changed. Marriage has been too thoughtlessly recommended as a cure for masturbation, for pollutions, for spermatorrhea, even for a lack of libido and for homosexuality. This was due to the general ignorance of the profession in matters sexual. Let us hope that all those who study this book will be more careful in the future, and will not dispense the matrimonial advice thoughtlessly and indiscriminately. If I write on this subject so frequently and so emphat- ically, it is because I know the inside histories of too many unhappy homes. " Get married." And he gets married ' and he finds either that he is unable to perform the sexual act at all ; or if he performs it, that it docs not satisfy him. And he curses the physician for his advice. And I state it as my positive opinion that the ignorance of our profession of the physiology, pathology and psychology of the sex in- stinct, and the careless, thoughtleaa counsel so often given without any consideration of the possible consequences, is responsible more than anything else for the contempt in which the medical profession is held by a lai^ number of 64 SEXUAL IMPOTENCE the laity, and for the alaiming antagonion to it in many qnartera. Thoughtleea advice to a oonfinned maatnrbator or to an impotent to get married may result in the lift-iong nnhappineaa of two indiTidnaU. I CHAPTER SEVEN HASTUBBATION, LOCOMOTOR ATAXIA AND mSANITY SypMlia is now so universally accepted aa the sole etiolo^cal factor in locomotor ataxia, that to suggest any other possible etiology is considered unscientific and un- orthodox. That syphilis is by far the most important cause of locomotor ataxia, more important than all other causes combined, I fully admit. But I deny that it is the sole factor, and it seems to me, that they wlio deny the pos- sihiliiy of any other factor ore the ones that are unscieutiflc I have had, we have all had, a nxmiber of cases of patients who absolutely deny any venereal history, and in whom no symptoms of venereal disease could be found, but as they have exposed themselves to the possibility of venereal infection, there is always a legitimate excuse for doubt. One can always say, perhaps the patient Lad the disease, but it was so slight and it ran such a mild course, the ex- tenial manifestations of it being so trifling, that they over- looked it. And as tho Waasermann reaction was not in use several years ago, we could not positively take the word of those who asserted that they were not syphilitic. But I have bad in my practice three cases in whom any possibility of infection is excluded. For the men never bad any sexual relations of any kind whatever. The only etiology which I could discover, and which they them- Belves gave, was excessive masturbation. One was in an 56 SEXUAL niPOrENCE sdvanood »tag» of locomotor ataxia, the other two were in Uie ioitial Rtagm. Hcru the believer in syphilis aa the sole causo of locomotor ataxia might object, that it is pos- fliblo that thoao patieuta had a hereditary taint, that they sufft'rod from horeditary syphilis; but repealed Wasser- inaiiii reactions were nt^ative; their parents were appaiv ently porfeclly well, and none of their brothers and sisters ahowwi any Bifrns of eitlier syphilis or of locomotor ataxia. I thcri'fore stand by my opinion, that exccasive mastur- bation alone, without any syphilis, may occastottalttf be the oaiisp of locomolur ataxia. That in the presence of syphilis it may act as an exciting, accelerating cause, goes without BBving. That those tbrce patients to whom I have jnrt referred were nervous or noiirotic from childhood, I will ftdmit, and tliat it is possible that in " perfectly" healthy and " normal " jK'oplc, masturbation alone will not cause locomotor ataxia, I will also admiL But, as I have said elsewhere, a " perfectly " normal individual is an aria rara, and wo never kttow who hua and who has not some taint in him or her. The |)oiut of practical importance remains that mastur- bation alone, wiUiout syphilis, may in certain individuals be tlie eauso of locomotor ataxia. Can masturbation lead to insanity? This question is 'oncbed upon in chapter nine, among the case reports, to liicli the reader is referred. 1 CHAPTER EIGHT BEFOBTS OF OASES Fib my intenlion to present in eacli part of ttie book a number of cases from actual practice, giving their etiology, symptom atoli^y and actual treatment. Actual cases always leave a more vivid and more lasting impree- sion than abstract descriptions. And many points which ■were either left out or only alluded to in the other chap- ters will be touched upon in the reports of the cases. It Ib therefore just as important to read and' analyze the case reports &s it is the rest of the text. Cue 1. I put down this case first, not because it pre- sents any unique features, but for the reason that chron- ologically it is the Jast. I saw this patient only this morn- ing (November 28, 1012). He was sent to me by Dr. Herman Cohen of this city. He claims to have mastur- bated from his earliest infancy. Even when in the cradle he would rub his thighs, or handle the genitals. Ilis mother saw it, but being an ignorant woman she did not think there was anything wrong or injurious in it. Hia various motions simply seemed to her funny — all this he learned from her later on. Whether be masturbated be- tween the ages of two and seven he doesn't distinctly re- member. He thtnlcB he did. But from the age of seven he masturbated right on without any interruption up to two weeks ago, when he got -married. He is now 28 years old. He masturbated regularly from three to seven times 67 SEXUAL IMPOTENCE a week. Sometimes even more than once a day. To the question, didn't ho know tiiat it was injurious, he said he heard it was a bad hahit, but as tt didn't seem to hurt him, and as he was so used to it, he didn't make even ao attempt to give it up. At first be would get an erection during masturbation, but during the last ft-8 years, no erection would take place and the ejaculation would take place in the flaccid condition. He masturbated up to the day he gut married, but for tlie last two weeks he has abstained. That is, bo thinks ho has. He attempted intercourse every night, but though he could get absolutely no erection, be would have an ejaculation. Naturally, under these circum- Etanoea he could abstain from masturbation. 1 asked him if the question did not at all present itself to him, that he might be impotent, and he answered in an emphatic negO' live. He did nol know thai there u-as stich a thing aa gexval impotence. He thought that every man when he got married was all right. I have not mentioned it, but it is self understood that this patient never attempted inter- course until his wedding night. In former years I would have doubted the fellow's sincerity, aa to his belief that every man was all right, but I bad had several patients, who wore tho most astonished persons after their wedding night, who assured me earnestly that they never heard that men could be "no good" for marital duties, any more than women could bo " no good." The density of the igno- ntnco on sexual subjecis among the people is something appalling. And since I have had physician-patienta who ahowed the same ignorance I have ceased wondering at anything. Examination showed a pale, extremely anemic, some- I MASTURBATION ■what jaundiced undernourished individual, with weak and irregular pulse, with the genital organs undersized and cold, with the prostate hypersensitive and the prostatic urethra exquisiiely tender and painful. The mere gentle passing of a small bougie & boule caused hira to faint Bway, and it was an hour before he could leave the office. When I told him that it might take months of painstaking treatment before he would regain his virility, and that it was also possible, that he would never regain it, he broke out into sobs, and blubbered like a child — or a fooL What bothered him, most was that his wife was still a virgin. If only not that, he would be satisfied. For this way, t. e., her being a virgin, he cannot even consider her bis wife. Among the lower classes it seems a disgrace, and EOt a misfortune, for a married woman to remain a virgin. What fools these mortals be. In this case the causative relationship between the mas- turbation and the impotence, which I fear will be per- manent, is quite clear. There is no otlier etiology. \Dtiring ■proofreading Jan. 17, 1913], Just as in practice apparently trifling cases sometimes prove ex- tremely obstinate and recalcitrant to treatment, so "We sometimes have surprises the other way. Patients vhom we thought hardly amenable to treatment occa- sionally gratify us by the remnrkabiy rapid progress and improvement which they show. If it were not for these occasional pleasant surprises the practice of medicine would he a sorry vocation. The case just reported is an illustration in point. I liad very little hope of the patient's improvement and so wrote to the doctor, and in fact told the patient that I 60 SEXUAL IMPOTENCE would much prefer not to treat him. But he begged and entreated and said that my refusal to treat him would be equivalunt to n death sentence, so I undertook his treat- ment; and he has been making unexjtectedly rapid prog- re»s. The treatment was at first general, consisting of or- ganic preparations of iron, glycerophosphates, strychnine, alternate warm and cool baths. The local treatment con- sisted in passing a psychrophore (through which hot water and then cold water was passed) through the previously anesthetized urethra. The attempt to pass a psychrophore without anesthetizing the urethra again resulted in a faint- ing spell. lie has been but seven weeks under treatment. Hia general health has improved, he has gained weight, feels stronger, and what is more important, he has succeeded in having nn erection with penetration. For the first four weeks of the treatment he abstained entirely. From the way things look now, this patient may be brought to a fair degree of sexual vigor. (Additional note for the second edition. April 13, ima.l The man's improvement has been uninterrupted. Ilia wife in now in the fourth month of pregnancy, and he performs the sexual act to his and her perfect satisfaction. He tells me that if I gave him permission he would indulge every nigbt. Tie feels himself capable of doing it. After all wo physicians do some good. We cannot con- vert all weaklings into IlOTCuIeses, but if we convert a certain numl)er of impotents, to whom life is a torture and K burden, into normal human l>eings capable of enjoying life, then our existence is juslified. Cue 3. Physician, 3-2 yeara old, from South Carolina, J 63 SEXUAL IMPOTENCE chrophore and bathing the genitals with cold water, im- proved the condition so that he was able to perform $ati»- factory intercoiirae once. An attempt the second time, oo the night following failed, however. The treatment waa continued, the colliculus seminalis was cauterized, and h^ was again able to perform tlie act satisfactorily. He ia now continuing the treatment on himself as well as he e*n, and bo wTites me that he can have satisfactory rela- tions once a week or once in ton days. Not oftcner. I wrote bim to be satisfied and not to overexert himself, I am sure that with proper care be will be all right for good, in fact, be may gradually gain in sexual strength- I have seen many such cases. [Note to second edition.] A letter received from him a few days ago informs me that everytliiug is bighly satis- factory to both parties. OaM 3. This case was referred to in the section on the fre Gave up the habit. Komial sexual relatione from twenty- one to twentj-fouT. Became eugagcjd at that age, mar- ried at 25. Never had any venereal disease. Led mal sexual life for the firet three years, during which time his wife gave birth to two children. After the second child began to practice coitus interruptua. A year or a year and a half later began to notice weakened crectiona and premature ejaculations. At the same time began to Buffer with " dyapopaia." Had severe heartburn, annoys ing abdominal distention after each meal, constipation. Legs felt hot and heavy, was unable to walk three blocks without getting tired and out of breath. Frequent at- tacks of cardiac palpitation. But the most annoying and distressing symptoms were the change in bis character, according to his wife's statement From cheerful he be- came gloomy, timid and full of various anxieties. Tl»^ cbange in his mood and character was ascribed to his stmn* ach trouble, for which he went from one doctor to another- for treatment. When he came to consult me, he had suffering for five years. lie came for treatment for hia impotent, but had no idea tliat.his gastro-intcstinal trou- ble had any relation to it To me the history pointed nn» mistakably to coitus interruptus as the sole causa peccana. I gave him a placebo, and told him that no treatm^it would be of any avail unless he began to lead a normal Vila serxialis. Otherwise his condition would bo going from bad to worse. My advice was followed, and in six months, without any COITUS INTEREtrPTnS HP H coi ^^nlier treatment, he was a well man. In six months more he was imrecognizable. He waa as well as he erer was, His wife's health, which had also been somewhat impaired, became normal too. A case like this is of more value than all kinds of ab- stract argumentation. Case 3. Mrs. X., 32 years old, married eight years. Supprb health before marriage. Coitus intemiptus since the bridal night, as they didn't think they could " afford " to have cliildren. The first two or three years she did not seem to experience any ill effects. Gradually she began to lose desire for conjugal relations, and the lack of desire siibseqiiently became a loathing. She would have severe pains in the ovarian region, pain in the neck, headaches, would be depressed and irritated in the morning, with throat and mouth dry, and severe palpitation. She grad- aaliy developed insomnia, began to lose flesh, became quarrelsome, and cried hysterically at the slightest provo- cation. Lately she developed severe gastric symptoma — burning in the stomach before and after eating — and a permanent taehycardia. Pulse always over 100. Legs tremble at slightest exertion or e.xeitement. Well-defined anxiety neurosis, and talks of death and suicide. Ob- jectively nothing could be found, except the rapid pulse. Coitus at the present time only about once in two weeks, and always feels worse after, A talk with the husband elicits the information that he practiced coitus intermptus only with his wife as ho did not wish to have any chil- dren, but that during all these years he also had relationa with other women in a perfectly natnral way. His po- tency and general health are unimpaired, and it did not 1 84 SEXUAL IMPOTENCE oome to his mind that the eoitns intermptus had anything to do with his wife's having become a wtmIl OoitoB intermptus forbidden abeolntely, and a complete aexoal rest for two months ordered for the wife. After that resomptioQ of normal intercoorse. Also general tooic treatment, massage and hydrotherapj. Improvement nnmediate, but it was ten months before the last symptom, trembling of the legs, disappeared. Cwe 4. Miss A., a school teacher. Coitus infemiptOB for the last three years. Pree<3it5 sexual neurasthenic and by«terica) symptoms. Anxiety neurosis pronounced. la always afraid something is going to happen, though she can not gire any account of what that something is or can he. Thifl, however, I admit is not a proper case to draw any oonciusions from, because here the fear of impr^natioo, on acooant of her unmarried condition, is so great that in itself it ii capable of causing all those symptoms. She was advised to give up all sexual relations, for a time at least, which advice was followed with decided im- provement in all symptoms, both somatic and psychic. She soon married, her sexual life was normal and her health remained good. CiM 8. ^(iaa B. This case is similar to the previou* one, but is more conclusive. She is also a school teacbeTf and tb« indulgence in coitus intermptus produced such Hvere distnrbancee, that she thought she would be obliged to give np school. She learned of a different method of prevention, and since slie gave up coitus interruptus, her health has improved in every respect; in fact she states it is belter than it ever was. OkM 6. A very remarkable case. Patient came into 1 COITUS INTEREUPTUS 85 feel my landa only two moaths ago. Family history excellent, himself always full of the " joy of life," though somewhat high strung and "nervous," Married nine years. Has two children. The second labor was so difficult that it nearly cost his wife her life; she had some sepsis after the second child, and has never been perfectly well since. For the last five years coitus intemiptus. For the last two years complete lack of libido, as if " he was not a man at all," Practices intercourse only ouce in five or six weeks, bid the intercourse is not followed by any ejacula- tion; only later in the night when he falls asleep there is an abundant pollution. In the morning he feels extremely exhausted and depressed. He feels so " imhappy," that he would like to cry, go away and see nobody. To see or talk to people is a torture to him. The last year has been suffering off and on with obstinate insomnia; for a month or two he will sleep well, then for a month or more he will suffer with the most obstinate insomnia, for which he has been taking doses of veroual ; following the veronal, he will feel more depressed than ever. The anxiety neurosis is y pronounced. Wants to die and is very much afraid die. Imagines everybody knows what is the matter ith him. Pulse generally about 80, but under the least excitement runs up to 100-108. Distention of the stom- ach after eating. Constipated. Had never consulted a physician for his condition, as he felt ashamed. Investi- gation revealed the fact, ascertainable in bo many of these patients, that at first the attempt at withdrawal cost him " superhuman " effort. He would have to gnash his ith, and strain every muscle in his body, while doing it, Iradoally it coat him less and less effort, but the ejacula- SEXUAL IMPOTENCE tions becamo also gradually retarded, until as stated above they ceased altogether. All this pointed uumistakably to coitus intorruptus being the direct cause of his condition, I laid out a course of hjdroUierapcutic and general tonic treatment, forbade intercourse absolutely for six months. I saw the patient yesterday. The improvement in his psychic condition is remarkable. He feels a new man. For the first time in months he felt a stirring within him of hia old libido, and he feels confident that he will get well. And so do I, Though the patient irf not well yet, sufficient time has not yet elapsed for a final result, still I consider it worth while reporting, as showing what coitua interruptus may do even with an apparently perfectly normal and healthy man. Those who have not seen and are therefore skeptical about the very injurious effects of coitus interruptus are apt to raise an objection to the effect that the cases I have given were probably not perfectly normal to begin with, that they were probably of a nervous temperament, that their parents were neurotic, that they had a hereditary taint, etc. I am not going to discuss this point very heat- edly, because, as I said elsewhere, I do not believe in a per- fectly normal human being. Where is that mythical thing a perfectly normal, a perfectly healthy man or woman i The apparently perfect specimen sometimes contains deeply hidden a very dangerous mouldy spot. And who can tell that some of our ancestors did not pos- sess some physical or mental defect, which he transmitted to his gratid-grandchildren! This is all childish talk. We have to take humanity as it is. In discussing human nosology and pathology we do not deal with the exceptions COITUS INTERRUPTUS 87 ^B«t eilher end of the scale; we leave out the five percent at either end and take the middle ninety. Or aay ten percent at either end and take the middle eighty. And on the middle ninety or eighty percent coitus interruptua pro- duces an effect aa described. Coitus Protraotua (and Interniptus Protractus). Some men in a desire to prolong the pleasurable sensation of the sexual act, or out of chivalry for their partner who may be very slow in reaching the orgasm, intentionally prolong I the act aa long as possible, using their utmost will-power ■ to delay the ejaculation. They may thus become prac- fcticed in making the act last five or ten minutes (all the I of uninternipied coitus lasting half an hour or an WKte silly fables of brainless braggarts). Or they r repeatedly withdraw the organ (when near the point of culmination) and thua prolong the act for an hour or more. To this method the term intemiptus protractus is applied. Both methods are extremely injurious. And the worst cases of paralytic impotence in my practice were in men who had practiced the above methods. And again, unscientific aa it may sound, I believe that prolonged in- dulgence in such practices may lead eventually to locomotor ataxia. That it would have a tendency to act in this di- rection in a person who has had syphilis I have no doubt. A syphilitic may have tabes without coitus protractus, but he is twice as likely to have it with it. The same is true ^ of coitiis ah ore. The woman who insists upon such methods of gratlfioa- I iion should be gently but firmly repressed. If she per- I Bisl^, she should be gotten rid of as soon as possible — Lvbethor wife c 88 SEXUAL IMPOTENCE Coitus Incomplettu. Incomplete or rather pleted coitus. Some men have a curious notion that any loss of Beinen is injurious and weakening to the system. They believe that by retaining the semen it is reabsorbed by the oi^anism, and revilalizes it, energizes it, and what nut. Under this mistaken and pernicious impression these people learn to perform intercourse without any ejacula- tion. As soon as thoy feel there is danger of a eemioal emission, they withdraw. By the exercise o£ will-power they gradually leam to prolong the act considerably, but without bringing it to a climax. It is well known that for years this method of sexual relations has been practiced by tiie members of the Oneida community, and we find it in use sporadically here and there. I cannot find worda strong enough to condemn this practice. While there are isolated individuals who arc apparently not hurt by this unnatural method — you can always find isolated instances of people who arc apparently not injured by the most un- hygienic and ordinarily most injurious practices — still, as a general thing, it is about the most damnable practice imaginable. I have bad two patients who had attempted this method for one and three years respectively. They were both extremely neurasthenic, their prostates were en- lai^ed and atonic and the posterior urethra was intensely congested in both cases. The effect on the woman of this method of coitus varies. Some do not seem to mind it, Jn fact even appreciate it highly, but sooner or later neurasthenic symptoms do not fail to make their appearance. Some women feel irritated and unsatisfied by any swde of coitus which does not cul- COITUS INTERRTJPTUS 89 ninate in the uubiudered and unobstructed discbarge of spermatic fluid. The Treatment of Coitus Interruptua. The only trea1>- ment of the various abnormal methods of coitus is their im- mediate discontinuance. As to the results of coitus in- terruptus, protractua, etc., they express themselves in vary- I iag degrees of impotence and neurasthenia, and the reader I referred to the chapter on The Treatment of Pollutiona md Spermatorrhea, The Treatment of Sexual Impotence and The Treatment of Sexual Neurasthenia. It ia well to emphasize, however, tliat where the symptoms are not Tcry severe they often disappear without any treatment IBD the mere discontinuance of the abnormal method. ^^b r< ^^d COITTTS CONDOHATUS We are frequently asked as to the injuriouaneas or non- ■ injuriousness of the use of condoms. While much leas liarmful than withdrawal, it ia not by any means entirely free from evil effectit. The percentage of people, however, in whom coitus condomatus proves unmistakably injurioua K rather small. But small as it is, it must be counted with. he principal bad effect is a feeling of irritation and oaatiafaction. I mean a general ner\'ous irritation. 1 some cases there is also a slight local urethral irritation. n prolonged use the ejaculation sometimes becomes eon- derably retarded. This is in itself a phenomenon which is rather welcomed by both the man and the woman. But in a few cases, the ejaculation finally ceases to take place altogether, and this leaves the man in a very unsatisfied, lADBted condition. J 90 SEXUAL IMPOTENCE On the woman coitus oondomatus has, as a rule, no evil effect Some women, however, are left by it in a very irritable, unsatisfied condition, a condition of disgust Some b^n to loathe it so, that they prefer not to have any coitus at all than to indulge in coitus condomatus. Some get into a sort of frenzy during the act so that they pull off the condom, and this r^ardless of conse- quences ; t. e., the spectre of pregnancy. PAET II POLLUTIONS AND SPERMATORRHEA CHAPTER THtETEEN POLLHTIOHS: DEFINITION AND CLASSIFICATION » I The etymological meaning o£ polhitiona is defilement, nncleanncss (from Latin, polluo — defile), but the briefest and I believe the best definition of pollutions in the med- ical sense is : Involuntary seminal emissions. Whether tliey occur in the night or in the daytime, or rather in sleep or during waking hours, the element of involuntariness )B09t be present. Pollutions may occur at any time, from the beginning to the end of man's sexual activity, that is between the ages of ten and eighty. I know of cases in which pollutions occurred even at an earlier age, in sexu- ally precocious boys. Rut ordinarily they b^in to mani- fest themselves at the age of twelve or thirteen. PlijrBiologic and Pathologic PollutionB. Pollutions are generally spoken of as physiologic and pathologic. Some sexologists claim that in the strict sense of the term there is no such thing as a physiologic pollution, I will touch, however, on this point later, and will maintain the divi- sion of pollutions into physiologic or normal and pathologic or morbid, aa a matter of convenience. What are the characteristics of normal pollutions? How and under what circumstances must they occur to be entitled to be olaasified as physiologic? The conditions of normal pol- Intions are as follows : 94 SEXUAL IMPOTENCE 1 cy (this ■ ,ion. I 1. They must occur during sleep. 2. They must not occur with unilue fretjucncy point will bo discussed further). 3. They must be accompanied by a strong erection. 4. They must be accompanied by an erotic dream. !). The ejaculation must be aocompanied by a voluptu- ous sensation. 6. And last, but not least, the pollutions must not have any debilitating or depressing effect on the patient. He must feel in the morning refreshed and buoyant as after a normal coitus. In other words, pollutions to be designated as physiologic must have practically the characteristics of normal inters course. As soon as they bejpn to deviate from the condi- tions which we have outlined, they begin to he patholo^c, and the greater tlieir deviation the greater their pathol(^a significance. Pollutions that occur during waking hours or too fre- quently, or that arc not accompanied by erections, erotic dreams or voluptuous sensations, or that leave the patient on the following day depressed, languid, unable to work or concentrate, with a dull feeling in the head or pain in the neck and spine, etc., are distinctly pathologic and must be treated energetically and without delay. I used the term " undue frequency " ; I know it is an un- satisfactory expression, one of the expreaaions employed when we wish to avoid specific statements. What is the proper frequency and what is undue frequency? Are wa justiiied in establishing a normal inter\'al, and say that any smaller interval is abnormal ? We are. I am as well aware as one can be of the vast differences existing in the POLLUTIONS AND SPERMATOREHEA ^RtK^ual spheres of different men, and nevertheless we are justified in accoptiug a certain criterion, a certain aver- age. If pollutions occur not oftener than about once in two weeks, or at the very most once a week, and if they do not cause symptoms of weakness and depression they we within the limits of the normal. If they occur twice a week or oftener they are pathologic, even if they leave the person in a buoyant, refreshed condition. For we have here a great danger, the danger of the polluHon-habit. While there are people who can and do live for years in good health with the pollutions occurring with about the same frequency, the general tendency of pollutions, if left ^■untreated, is to increase in frequency and to lose in in- ^^■touity, and in the erotic elements, i.e., their tendency is ^^Pto pass from physiologic into pathologic. And it is the part of wisdom to treat them while they are still in the former stage. We stated that the pollutions are apt to pass, sometimes imperceptibly, from the physiologic into pathologic First, they increase in frequency. They may become as frequent as onco every night, or even oftener. They may occur three or four times a night. (I have now a patient under treatment who had had ten to fifteen pollutions a ■ ireek for several months.) Then with the increase in quency, the erection and the voluptuous sensation be- jome less and less, until they disappear altogether. 1 in the beginning the patient would wake imme- liately before or during the ejaculation, he has now the mllutions without any sensation; he now awakes only ftten the pollution is all over, or only in the morning 1 the stains on liis underwear and bed linen does he become aware that he has had a pollution. The dreanu which were strongly erotic and pleasurable gradually loss thia qnality and may aaauine an entirely non-sexual eiiar- aoter. In one of my patients the frequently occurring pollu- tiona were always preceded by a dream of a mathematical nature. IIo would dream that he liad to multiply two large numbers, and the painful and unsuccessful efforts to complete the problem would result in a pollution. Aj»- other patient would try to repeat a certain poem by heart, and the pollution would follow tlio failure to remember the lines. Another patient would dream that he had to catch a train or a steamer; the slow movement of the trolley-car which was to bring him to the train or steamer would exaflperate him and result in a pollution. These pollutions kept up for over a year, repeated every two or three nights, and had brought him to the state of a " ner\-oua wreck " when he came for treatment. It will be observed that the non-sexual dreams resulting in a pol- lution generally represent some unsuccessful, some un- pleasant effort. It is never a snccessful, ]>lea3ant expe- rience (i.e., of a non-sexual character) that results in a pollution. The dreams may assume the character of some sexual perversion, and then the pollutions may occur without any dream whatever. The ejaculation which at first caused an intensely pleasurable, voluptuous sensation, also gradually loses this quality, to be eventually followed by no sensation at all, 1 this is finally succeeded by an unpleasant feeling of "ning and scalding in the urethral canal. POLLUTIONS AND SPERMATORRHEA 97 ^V The most important point, however, is the effect of the pollutions on the physical and mental condition of the patient. These will be considered after we have consid' ered diurnal pollutions and spermatorrhea. Dinmal Pollutions. Diurnal pollutions are seminal emissions oeciirring during the da^. But a better term would be " waking pollutions," because it is not the time ^■tflf the day that is important, it is the sleeping or waking ^^bondition of the patient. While sleep pollutions may un- ^^Her the conditions we have enumerated be *' physiologic," ^Hnking pollutions never arc. Every diurnal or waking ^Klollution is unquestionably abnormal, and at the appeal^ ance of the first one, energetic measures must be taken to avoid 8 second one. Diurnal pollutions signify a neu- rasthenic condition, an irritable condition of the nen'oua centers, a weakness or hyperesthetic condition of the gen- ital organs. Long continued and frequently repeated sleep pollutions are often, though not necessarily, followed or accompanied bj waking pollutions. The latter may, how- ever, arise in people who suffer but moderately with the former. Whether diurnal pollutions can occur in people whose sexual organs and centers have not been weakened by nocturnal pollutions or masturbation is an open ques- Ition. I have had a young patient who assured me that piB very first pollution was a day pollution, which took place while he was witnessing a certain musical comedy show, and that only after that pollution he began to suffer with night emissions, but I am not so sure that the mas- turbatory element could be entirely excluded in this case. UWhile I believe the patient that he never had night emia- Bjons or masturbated before that time, I believe that there t)8 SEXUAL IMPOTENCE was aome perhaps unconsciouB friction which helped to bring on the emission. If diurnal pollutions continue for any length of time, a lesser and leaser stimulus is required to bring them about. Mere proximity to a woman, the touching of woman's clothes, examination of female attire, underwear or corsets in show windows or in the advertising pages of magazines, the sight of nude pictures or statues in the museums, of questionable theatrical posters on the billboards, the wit- nessing of any musical comedy or even drama or opera dealing with sex (like " The Easiest Way " or " Salome "), the reading of any pornographic trash, or even high class literature of a realistic character, such as that of Zola or Maupassant, bicycle riding, dancing, or horseback riding is apt to bring on a pollution. Being manicured or get- ting a shave or shampoo is sufficient to do it. An too warm covering, cold feet from insuf- ficient covering; dallying with women, reading salacious literature or witnessing obscene shows, in short keeping the mind centered on sexual subjects, is an undoubted cause. Another important point: medical treatment will some- times aggravate pollutions. This is particularly true of metal sounds and of silver nitrate instillations; any ir- ritating injection, particularly if administered at night, I is apt to bring on a pollution in those predisposed to it. Physicians must therefore use a good deal of judgment in treating patients, predisposed to or suffering with pol- lutions, in whom urethral instrumentation or strong pos- [ tenor instillations are necessary. The treatment must be [ very mild in the beginning. Prostatic massage seems I sometimes to be a cause of pollutions, but not frequently. 1 CHAPTER FIFTEEN POLLUTIONS AND NOCTURNAL INCONTINENCE OF CBINE The connection between noctural incontinence of nrine or ^ bed wetting and pollutions, apemiatorrliea and sexual impo- tence 13 an interesting and important one. The urinary incontinence and the sexual weakness are often exprea- 8 of the same primary condition : a motor neurosis, an I atony of the genitourinary tract. For years I have made it a point to ask every patient suffering with any form of sexual weakness as to his bed wetting in childhood. And I was surprised at the frequency with which the patients answered the question : — sometiniea after a little hesita- tion — in the aifinnative. Some suffered with that in- firmity to quite an advanced ago, 12, 13 and 15 ; and some were unable to get rid entirely of that annoying and humiliating habit even in adult life. As I wrote in a former article of mine, I was so struck by the relationship between bed wetting and sexual weakness, that I thought I had made quite a discovery and was about to announce it aa such in our medical journals. But on searching through the literature on the subject, I found that the t clinical observer Trousseau had noticed the connec- tion many, many years ago, and others even before him. So I failed to become a discoverer. As I remarked in the above referred to article many so-called recent discoveries were discovered long ago, only the discoverers don't know SEXUAL IMPOTENCE it, because thej don't take the trouble to search through the old literature. The relationship between incontinence of urine in child- hood and sexual weakness in later life is not merely of academic int«re6t; it has a deep practical signilicance, and its lesson is that every case of incontinence in a boy should be treated persistently until the boy is cured. By neg- lecting incontinence you may be marring the whole future life of your diild. Urinary incontinence is a signal that the boy's gen i to-urinary apparatus is not in perfect order, and it is a sin not to heed the signal. Of coureo nocturnal enuresis in girla must alao be treated eneiigetically, as it is here also an expression of a neurosis. Wliile it may not spell impotence, it often portends mas- turbatitm and sexual neuroses. CHAPTKR SIXTEEN SPEBMATORBHEA Spermatorrhea means literally a rimniiig of semen. lile we do but rarely meet with those terrible casea sscribed by Lallemand and Tissot, in which the semen i oozing from the patient continuously, still the eases : true spermatorrhea which wo encounter occasionally ! very sad indeed. At the least provocation, whether it be mechanical friction, tight trousers, some discomfort, a full rectum or bladder, some picture or mental imago, the act of micturition or defecation, or even without any ascertainable provocation, there is a discharge of semen, real spermatozoa-containing semen. And all this with- tout any libidinous thought or voluptuous sensation, without even the patient's consciousness. He will feel the meatus wet or sticky, and on examination this fluid will be found to contain spermatozoa, though they may be few in number, lomewhat deformed and but slightly motile. Spermatorrhea is the last link in the chain of abnormal seminal losses. First, we have " physiologic " sleep pol- lutions, then pathologic sleep pollutions, then diurnal or waking pollutions and finally spermatorrhea. Spermator- rhea may also supervene without antecedent pollutions, namely in excessive, " furious " masturbators, especially when they attempt to break the habit. But even while ) habit is still being kept up, spermatorrhea may make tots appearance. 108 SEXUAL IMPOTENCE Tlio mosturbator irritates and weakens the erectile atid ejaculatory centers; at the same time he induces aiich a congestion of the posterior urethra and atony of the seminal vesicles and ejaculatory ducts, that the condition of sper- matorrhea is eatablished. Whether spermatorrhea may supervene upon sexual excesses, i.e., cxceasive normal in- tercourse, is very doubtful. I have seen some cases of atle^d spermatorrhea following sexual excesses, but on examination the "spermatorrhea" proved to be prostator- rhea. True spermatorrhea may also occiir in the course of severe spina] disease. Thus Furbringer saw a case of spermatorrhea in the course of a severe myelitis. J I CHAPTER SEVENTEEN SYMPTOMS OF POLLUTIONS AND SPERMATORRHEA The range belivcen pollutions, which occur occasionally a iplief to an overfilled sexual sj-stem, and the sper- latorrhea of the extreme dc^;roe, which threatens the pa- 's mental and physical integrity, is so great, that the mptomatology 13 neeocially when llie feces are hard and the patient has to fitrain, a few drops of seminal fluid appear at the meatus. Thia is due to the contraction of the perineal muscles and the seminal vesicles, and may appear occasionally even in perfectly healthy men. Defecation spermatorrhea is therefore tJie mildest form of tlio disorder, and, if it o&- cure only with defecation, is not of much pathologic im- port, though the patients are badly scared. Micturition spermatorrhea, when the semen is lost at the end of micturition, when the patient contracts his perineal and abdominal muscles in an attempt to void the last drops of urine is more serious, and sliould always be treated, l>ocause this form is already indicative of considerable atony of the seminal vesicles and ejaculatory ducts. So in the order of their sorioiisness we have: defecation spermatorrhea, mictnrition spermatorrhea and general ape nnator rbee. , how- I : least ■ PBOSTATORRHEA Prostatorrhea signifies the running or loss of prostatic fluid. It may occur only during defecation — the most frequent variety, — during micturition, after a brisk walk, I or in atony of the prostate practically at any time, and witiout any cause. The importance of prostatorrhea arises partly from the fact that it is always taken by the patient (who is, of course, not expected to know the difiference), and not infrequently also by the physician, for true spermatorrhea. While prostatorrhea is a much less serious disorder than sper- matorrhea, still il« significance must not be too much un- , derestimated. Our knowledge of the prostate — one of iie most interesting glands in the body — and of its secre- ioa is still very imperfect, but the suspicion is getting ronger and stronger in scientific circles that the latter ^plays a much more important role than has been attributed {to it. That the prostatic secretion is important for the ritality, for the very integrity, and fertilizing power of ie spermatozoa we know; but the prostate may also be lOntributing some infernal secretion of the highest im- (Ortance, And the frequent loss of prostatic fluid such ) takes place in prostatorrhea cannot be a matter of in- idifference. The fact remains that many patients who snf- r with prostatorrhea, frequently feel as wretched, as de- l and debilitated as do patients suffering with Bper- 113 i 114 SEXUAL IMPOTENCE matoirbea — and this even after they bave been assured and have become convinced that tbeir disorder is not of great importance. The positive differentiation between prostatorrhea and true apermatorrbea can be made by the aid of the microscope only. The invariable characteristic of spermatorrhea (except in cases of azoospermia) is the presence of spermatozoa. In prostatorrhea the fluid is thinner, has a ueak alkaline reaction, and the microscope shows the presence of lecithin corpuscles or granules and of Bottcher'a crystals, and no spermatozoa. Spermaturia means semen in the urine. We find this condition in retro-pollutions, or pollutions into the bladder, which we discussed before, and in true spermatorrhea. In these two conditions the semen is present in every portion of the urine. In the condition known as micturition spermatorrhea, the semen is present in the last portion of the tirine only. The first portion may be entirely free from sem^i. I CHAPTER NINETEEN UBETHBOBRHEA Much Jess iinportaat than either spermatorrhea or proa- itorrhea is the condition known as urethrorrhea. While le etymology of the word is a most harbarona one, it 'las acquired a definite meaning and we may as well re- tain it instead of trj-ing to introduce a new term. By urethrorrhea we understand a clear, transparent, non- bftcterial and non-infectioua raucous discharge from the urethra. It is in short simply an increase in the amount of the normal discharge of the normal urethra. It may occur habitually after a perfectly cured gonorrhea of long standing. It is not infrequent in excessive raasturbators. The special kind of urethrorrhea which scares and sends to the doctor so many young men is jirelkrorrhea ex libi- dine. In many men, young and old, any sexual excite- ment ia apt to make a few drops of a clear, glycerin-like, Bomewhat tenacious fluid appear at the orifice of the urethra. This ia the increased secretion of the glanda of lattre, Cowper and Morgagni, and if appearing but occa- .iionally ia of no aignificance. But the patients get fright- ened and are sure that they are losing their semen, and are apt to become very hj'pochondriacal and even pay- chically impotent. An examination under the microscope flbowa the fluid to consist of simple mucus and a few tithelial cells. Neither spermatozoa, nor lecithin gran- nor Bottcher's crystals are present. In normal pa- i 116 SEXUAL IMPOTENCE mfficient 1 ticnts, a mere explanation of the real condilion is sufficient to remove all worry. In sexual neurasthenics the matter, however, is not so simple. Yon can explain and explain, they still remain convinced that something terrible la the maiter with them, that they are losing their " nature " and their manhood. While, as stated, urelhrorrhea ex libidiM, if occurring occasionally is of no signiticance, it does not mean that it should not be attended to; for it carries in it the danger of all deviations from the noniial: if neglected, if the causes responsible for the urethrorrhea be not removed, the condition may become aggravated, the secretion be- comes larger in amount, more watery, turbid, the urethral mucous membrane loses its resistance and a bacterial in- fection may take place. That the causes responsible for the urethrorrhea, such as long engagoments with unsatis- fied sexual desire and fnietrated excitement, may also bring about a hyperemia of the posterior urethra, with premature ejaculations and relative impotence, goes with- out saying, but these conditions are concomitant effects of the same cause; they are accompanying phenomena, and not the result of the urethrorrhea. I I CHAPTER TWENTY THE TEEATMENT OF POLLUTIONS AND SPERMATORRHEA The statement that it is the patient and not the name the disease that is to be treated has become threadbare It is true, however, and of no class of diseases it more true tJian of sexual diseases. He who intends treat sexual diseases by set formulas, by presorlptions copied from old text-books, courts failure from the outset. It is of the utmost importance, it is an absolute sine qua non of successful treatment to determine the stage of the idisease, for the remedies that will prove of great benefit 'in the " plethoric," irritable stage, will aggravate the con- dition, a^ravate it very much, if administered in the atonic, '* paralytic " stage, and vice versa. It is so important to impress upon the reader's mind this distinction that I will spend a few moments in illus- trating my statement with one or two examples : The average practitioner knows in a general vague way that potassium bromide is useful in pollutions. Yes, it is. But in what stage ? It is useful m healthy individuals, leading a more or less continent life and when the pollu- tions are accompanied by erotic dreams. In this condi- tion the bromides may sometimes prove remarkably benefi- cial. When the pollutions occur, however, with great frequency, with very weak erections, or even without the person's consciousness, the bromides are positively penu- 117 i i 118 SEXUAL IMPOTENCE cjous. They are juat as pernicious and injurious In sper- matorrhea. And still tbej are prescribed indiscriminately. Dozens and dozens of times have 1 seen patients complain- ing that since taking a certain treatment their condition became worse. On examining their medicine I would in- variably find potassium or sodium bromide. The same is true of strychnine. Strj-phnine is very usefnl in the atonic stage, but if administered in the plethoric or irritable stage it will prove injurious. Even cold batlis or cold ablutions may prove harmful and may increase instead of diminishing the seminal emissions. In abort, it is absolutely necessary to individualize, and individualization of every case should be our watchword. And these remarks will serve to illustrate how much bene- fit may be expected from the " lost-manhood " treatments advertised by the various charlatans and harpies that prey upon the credulity and weakness of mankind. Psychic Treatment. The treatment of any case of sex- ual disorder must be of three kinds: psychic, general and local. By psychic treatment I mean explaining to the patient his exact condition, taking away his exaggerated fears, and making it clear to him that with a little patience and help from his side, he can be cured, completely cured. We all know what exaggerated notions — - fostered by (]tmck literature — our lay and even medical patients en- tertain ahont seminal losfws. A patient who notices a drop or two of semen — ■ which may not be semen at all, but prostatic fluid — exuding from the meatus after de- fecation, is Bttro that he is on the straight road to the insane asylum. Of course these depressed tiioughts in- fiuence his entire system and a vicious circle is soon estab- POLLUTIONS AND SPEKMATOKRHEA 119 lisfaed. When you explain to him, however, that in one normal connection he loses more semen than he can loee in the other way in a week or two, and when you explain to him tliat the loss of a few drops after defecation ia al- most entirely a mechanical phenomenon, due to the prea- ■ sure of hardened fecea on the seminal vesicles, to the contraction of the muscles, et*., hia feara are allayed and he enters upon the treatment more hopefully. 1 do not advocate ridiculing the patient's fears or telling him that his condition is " nothing." The latter ia absurd, for the condition is not " nothing," hut it is necessary to put things in their true perspective. Always explain to the patient his condition honestly, truthfully; this will gain you his willing, intelligent cooperation — and half of the battle is then won. The Oeneral Treatment In night poUutionsi, occurring in healthy individuals, accompanied with erections and erotic dreams, the bromidea are of unquestionable value. I generally prescribe 10 to 15 grains of strontium bromide or sodium bromide at 4 p. m., the same dose at 8 p. M., and 20 to 30 grains on going to bed. Occasionally, I combine the bromide with hipiilin and camphor mono- bromide, and in still more obstinate instances with hyoscya- mine. A favorite combination of mine is tJie following: R Strontii bromidi , gr. v Camphorae monobrom gr. ii. Lupulini optimi gP- ^ Hyoscyaminae hydrobr. . gr. I-IOO M.f. caps. No. 1. Tales doses xx. Sig. : One at 8 p. M. and one on going to bed. Why this combination should be so efficient I do not 120 SEXUAL IMPOTENCE know. But that it ia efficient, I do know, I know from the results in hundreds of cases in my personal prac- tice, and I know it from reports of physicians in various parts of the country. I Lad printed tills formula once in The Critic and Guide, and very soon after its ajtpearance, physicians — and lajTnen too — began to write to me of its marvelous efficiency. It is here that the physician so often sins in ordering ablutions with cold water. Cold water is followeortant as the moral and geuoral treatment is, it is but adjuvant to the local treatment — urethral and rectal — which is most important, and in most cases indis- pensable, Irf)cal Treatment. We now come to the local treatment. As we statci! before, the prostatic portion of the urethra is exquisitely sensitive in the vast majority of cases, being responsible for a largp share of the svmptoma. Our first endeavor must therefore be to diminish this sensitiveneaa. Steel sounds, or better still, Kollmaun's dilators, are excel- lent for (his purpose, but their introduction is, per ae, so painful, and creates such spasm, that we are often unable to use them without the employment of a local anesthetic POLLUTIOI^'S AND SPERMATORRHEA 123 Cocaine is, of course, sure and positive in its effects; its use, however, ia so often accompanied by disagreeable or even dangerous bj-efFe«rt8, especially when used in the urethra, that I have practically given up its use and em- ploy some of its substitutes, generally eucaine or alypin. I believe that instead of subjecting the urethra to re- peated local anesthetizations, we can do better if we " harden " the urethra so that it loses its senaltiveneas, and we are enabled to pass sounds without the necessity of local anesthesia. The best substance for " hardening " — diminishing the sensitiveness of the urethra — is and re- mains silver nitrate. But in its use I differ from the niajority of my confreres. The usual method of instilling 10, 20 and even 50 per cent solutions I consider cruel, brutal and injurious. The reaction is often excessively severe, and I have seen excruciating pain, bloody dis- cbarge and complete retention of urine resulting from them. I use the nitrate of silver differently. I usually start with a 1 to 5,000 and sometimes even with a 1 to 10,000 solution. I insert a soft-rubber return catheter (Mitchell, or one with several perforations throughout its upper two inches) almost to the neck of the bladder (or within an inch from it) and inject from two to eight drams of the above solution. In this strength the silver nitrate causes no pain, no strangury, no disagree- able symptoms of any kind. Gradually I increase the strength to a 1 in 3,000, 2,000, 1,000, and finally 500. It is seldom necessary to go above that. When the patient reaches this strength, all the congestion, sensitiveness and irritability of the urethral canal are generally cured. And not infrequently his trouble, for which he came to be 12i SEXUAL IMPOTENCE treated, is cured too. We arc now able to employ, if necessary, further nieclianical manipulations, which then eall forth little reaction. The urethral canal has lost ita sensitiveness and can bo handled much more easily than without the preliminary silver nitrate treatment. Where, however, there is a localized inflammation of the posterior urethra, where the colliuulua seminalis is hyperlrophied and intlained, there we must use stronger solutions. These solutions ranging in strength from two to ten per cent are beat applied by the means of a Guyon syringe, one to three drops being sufficient for an instillation. Or they may be applied on a cotton swab thru the endoscope. Where the colliculus seminalis is distinctly seen to be the sole part affected it may be cauterized with a 20 per cent solution. But some very impleasant after- effects sometimes make their appearance after such a cauterization, namely: severe strangury and dyxuria, hemorHiage, complete retention, etc. Generally speaking, the very strong solutions of silver nitrate, or the galvano- cautery, are to be reser^'ed for exceptional cases only. The Use of Sounds or Dilators. As stateo11iitions. To give tliis advice in the stage of atonic pollutions, or in Ihe stage of sper- matorrhea, is folly, and if the advice is to get married, then the folly becomes criminal folly. I have seen too many sad tragedies resnlting from this thoughtless advice. A patient feels he is becoming physically and mentally weakened from excessive nocturnal or diurnal pollutions. He consults bis family physician. He gets a prescription for some bromides, or bromides and lupulin; he takes it for a time with the only results that he gets pimples and a disordered stomach. The pollutions keep up the same way or become worse. Ue again consults the physician. "Well, I can do nothing for you; the only thing for you to do is to get married." Tlie man haa already somebody in view, or ho looks around and finds somebody. Tie may have no inclination to get married, his plans might have been entirely differ- POLLUTIOJre ANB SPERMATORRHEA 139 t ones, b\it as his life and health depend upon it, he gets [-married. And he finds that he is impotent. And the f pollutions may not stop either. And here the physical condition combined with the agony and humiliation of not being able to satisfy his wife, may throw him into tlie deepest slough of despond; may convert him quickly into the worst type of sexual neurasthenic. And we have a [ disrupted home or suicide. Many of the cases of suicide > immediately or soon after marriage, of which we read in ' the newspapers, are of this character. If we are to advise a man suffering with pollutions to attempt intercourse, then we should advise him to have illicit intercourse — [ and I say this without hesitation, all the tenth or four- teenth-century obscurantists to the contrary notwithstand- ing. If such a man attempts intercourse with a prostitute or a lady friend and he finds himself relatively or com- pletely impotent, then no damage is done. The man has suffered a fiasco, he knows he must treat himself and that's J all there is to it. But if, following the pernicious advice I of a thoughtless or incompetent physician, he gets mar- I ried, the mischief is done and it cannot be undone so easily, [ if at all. It is almost incredible how careless — or is it real igno- rance ? — many physicians are on this point. I feel deeply on the subject, because I see the tragedies only too frequently. Only this week a physician came to consult me. He was suffering with almost nightly atonic pollu- tions, and either as a result of these or independently of them, with severe gastro-inteatinal disturbances. The I specialist who treated him for the latter urgently advised [ liim to get married. He told him he could not get well i-M SEXUAL IMPOTENCE unless he did get married. The doctor felt, that it would perhaps be a risky thing, and came to get my opinion. He is 36 years old and has never had intercourse in hia life. That fact alone is suspicious. An examination showed the penis and testicles small and shrunken, in fact infantile in size, and this with several other points in his history, left me no choice but to put an emphatic veto on any thought of marriage at the present time. It may re- quire two or three years of very complex treatment — hygienic, general and local — before he may pennit him- self to entertain any matrimonial thoughts. This case 19 not by any means unique. I know even of cases where the patient told the doctor that he attempted intercourse and found himself completely impotent — he was either unable to get an erection or the ejaculation was instanta- neous, and nevertheless the doctor's advice was: " get mar- ried." The woman in the case is not taken into consideration at all, &» if she was not a living human being at all, but an inanimate object, a mere vessel. Leaving out the im- morality and the cruelty of the advice — for one must be callous indeed not to think of the prospective wife's wretched possibilitic!), that she may become a worse suf- ferer than the husband — it is time for the profession to become aware of the fact, that marriage is not a panacea for all sexual disorders, that in itself it will not restore all sexual cripples to health and vigor, bul on the contrary it is apt to render them worse. The cripples must first be cured, or practically cured, before they may be advised or even permitted to marry. It 18 just as criminal to advise a man suffering with A POLLUTIONS AND SPERMATORRHEA 131 atonic pollutions or spermatorrhea to marry as it would be to do so in the acute stage of gonorrhea or syphilis. I have stated that the treatment hy bromides is often ineffective, often injurious, and sometimes the more in- jurious the more effective it is. That the bromides are often ineffective is known to everybody. Sometimes in spite of frequent and constantly increasing doses the pol- lutions go on just the same, or they even increase in fre- quency, tho they generally diminish in intensity. In other cases the bromides are effective. That is, the pa- tient under their administration ceases to have pollutions. Is this accomplished without injury to the patient's gen- eral and sexual system ! In many cases, yes. The bromides seem to depress the sexual function just suffi- ciently to rid the patient of a too frequent repetition of the pollutions. No damage seems to result, for when such patients decide to assume or to resume sexual relations, they find their power unimpaired. In other cases, how- ever, the result of the bromides is very disastrous. The pollutions become very rare or cease altogether. But they eschange their pollutions for something much more serious: They become temporarily or permanently, rela- tively or completely, impotent. Entirely too dear a price to pay. These are not theoretical consideration or im- aginary fears. I am used to weighing evidence, to being skeptical about patients' asaertlons and guarding against the post hoc propter hoc fallacy. And I can assert posi- tively, after eliminating all doubtful eases, that I have seen a considerable number of coses in which the impo- tence could be traced positively to the use — or abuse, if 133 SEXtTAL IMPOTENCE you will — of the bromides, particularly the bromide of potassium. The bromides and marriage are very dangerous remedies to prescribe in sexual disorders. They mnsl be used with the greatest care and discrimination. They are more dan- gerous than morphine or atropine. And in the hands of the injudicious they are sure to bring pain and disaster. Note to Second Edition : I note in to-day'a (April 15) papers the following news item : Nuwi-T maretbd; kills himself. Fbiladolphia, April 14. — Howard S. Ludwig, 32, a local real estate dealer, who was married in Newark on Satur- day to Miss Violet Richardson, who is now at Wenona, N. J., shot himself throngh the temple at the Broad street station to-day. He is aaid to be dying. Despondency is said to have prompted the act. Such items are quite frequent. And to me they have practically one meaning. When a man comjnits suicide the day after, or several days after, his wedding, it gener- ally means that he found himself impotent. He is prob- ably also a neurasthenic and tbe chagrin and humiliation is more than his weakened nervous system can stand. PAKT III SEXUAL IMPOTENCE IN THE MALE CHAPTER TWENTY-TWO THE OATTSES OF IMPOTENOE I have nevtT subscribeJ fully to the Latin maxim, Qui bene diagiwscit, bene curat — he who diagnoetieates well, cures well. For unfortunately there are only too many cases where the diagnosis is perfectly obvious, while the method of treatment leaves very much to be desired. Nev- ertheless none will dispute the statement that of two men equally proficient in treatment, the better diagnostician will have the larger percentage of successes. Probably iu no class of cases is the ascertainment of the underlying cause of the trouble so important as it is in the Bad affliction which is designated as sexual impotence. Very often the mere finding of the cause is more than half of the battle won. The causes being very numerous and complex, great patience and judgment are required in talcing the patient's history, and in no other class of diseases is the patient's complete confidence so absolutely necessary as it is here. And without it we are often help- less. The causes of impotence are aa follows : Uasturbation. This is a very common cause, because, es I have stated before, practically every human male begins his sexual life with masturbation. And while the habit, if commenced fairly late and practiced moderately, in the majority of cases leaves no ill effects, there is no question that if commenced at the age of ten, twelve or SEXUAL IMPOTENCE fourteen and indulged in immoderately, it may lead to relative or complete impotence, temporary or permanent. Foliations. What we aaid about masturbation applies with equal force to pollutions. Pollutions of rare occur- rence or of moderate frequency are harmless. Eut if frequent and long continued they may ultimately lead to impotence. Spermatorrhea. We do not meet frequently with cases of true ajiermatorrhea, but when we do, we generally also have to deal with relative or complete impotence. And very often spermatorrhea and impotence are twin phenom- ena in sexual neurasthenia. Prostatic Gongestioo. An inflamed or congested pros- tate 13 often the cause of impotence, but not inv*ariably so. On the contrary, in some cases an inflamed and irritable prostate may lead to an increased libido sexualis, and ap- parently also to more vigorous erections. But only for a time. Eventually a pathologic prostate leads to relative or eoropleto impotence. Drethral Con^stion. Congestion of the prostatic ure- thra is a frequent and well-established cause of sexual impotence. ITio hypersensitiveneea of the urethral mu- cous membrane is sometimes exquisite, and renders an erection impossible or imperfect and ejaculation prema- ture. The most common cause of such urethral conges- tion is a severe chronic gonorrhea, but it may be due to masturbation, prolonged abstinence, etc. Qonorrliea. Gonorrhea, as already mentioned, is one of the great causes of sexual impotence, ranging probably next to masturbation in this respect; not, however, gonor- rhea, by itself, directly, but by its sequelae. Just as by its SEXtTAL IMPOTENCE IN THE MALE 13T causing epidydimitis and orchitia it 13 one of the principal factors o£ sterility or of impotentia generandi, so by ite causing congestion of the posterior uretlira, prostatitis, etc., it is one of the principal factors in relative sexual impotence and ejaculatio praecox. Stricture. This sequel of gonorrhea plays & decided role in causing relative sexual impotence, that is, imper- fect erections and premature ejaculations. The causative relationship between stricture and impotence cannot, in my opinion, be the subject of any doubt, for the result of the treatment of stricture and the improvement in the potency is so marked and has been noticed by me so fre- quently, that to speak of a mere coincidence would be absurd. Many patients know the beneficial effecta of pass- ing a sound, and they claim that dilatation of their stric- ture is invariably followed by improvement in their sexual power. Narrow Meatus. By some of the older writers a very narrow meatus was considered as one of the causes of im- potence, relative or even complete. I have never seen an instance where this could be considered a causative factor, but I have seen a number of instances where a narrow meatus was cut liberally with deleterious effect on the po- tency, just as we often see cases where a free meatotomy has an injurious effect on the force and regularity of the urinary stream. Organic Causes. There are certain organic conditions of the penis and testes which render intercourse either phys- ically impossible or very difficult, or at least unsatisfactory. But most of those conditions are of a purely academic or theoretical interest; they are so rare that a physician may SEXUAL IMPOTENCE II case during his enlire practice. Such, for in- aro: cong^uitnl absence of the penia or its loss from ulceration ; liypertropliy of the penis, its size being so large that it cannot be iutrotlnccd into any vagina ; double pouia ; bitid, or split, penis; webbed penis, where the organ ia unite«l l« the scrotum ; tumors ; plastic exudations ; torsion, whore the penis is twisted or bent in a. vicious direction, so that intromission is difficult or impossible; hermaphrodit- ism; fracture, and various other conditions. Epispadias, or the eondition in which the urethra opens on tlie upper •iirface of Uie penis, and hypospadias, wliere the opening ia on the under surface, are usuallv, but not necessarily, ac- coiiipatiied by impotence: it depends a good deal on the extent and the location of the defect. Where a good deal of tissue is lacking either in the corpora cavernosa or in the corpus spongiosum, no erection is possible. The rela- tion of these two anomalies to impregnation will be men- tioned in the section on sterility. Abnormalities of the Testes. Complete congenital ab- sence of the testes is of course accompanied by lack of libido and lack of i>otentia, both of coeimdi and of genei^ sndi. As a general rule ihia ia also tnie of crjptorchids, where both testes are in the abdominal cavity. This rule, howe^■e^, has decided exceptions. In Prof. Lang's clinic, in Vienna, I saw a young crjptorchid who had power- ful erections and perfect potentia coeundi, lie was in the clinic for multiple chancres — two on the penis and one on the abdomen — which he had contracted in regu- lar intercourse. Monorchids often are sterile, but all the individuals encountered in my practice were sexually potent. They came for treatment because they and their SEXUAL IMPOTENCE TN THE MALE 139 wives wanted children, and not because they had any com- plaint about their potency. Atrophy of the Testes. When atrophy of the testes is caused by a general constitutional or by local disease, or by masturbation or sexual excess, it is accompanied by loss of libido and by impotence. But this is not invariably truo when the testes are lost through accident or castra- tion. As a. general thing, loss of the testes does lead to complete impotence, but there are numerous exceptions. And the usually prevalent opinion that ennuchs are in- capable of sexual intercourse has been sho«TX to be errone- ous. Some castrates are very powerful in this respect. They havo strong erections and " seminal " emissions, the emissions in such cases coming principally from the pros- tate gland. It must be borne in mind that the prostate gland is an imimrtant sexual organ, and plays an important role in the sexual act. Its role has been underestimated too long. Neuralgia of the Testes, of the spermatic cord, of the urethra, of the neck of the bladder may be a causative fac- tor in deficient erections or in premature ejaculation. But it is a rare condition, and, as a rule, readily curable. HTdrocele. If excessive, this may become a mechanical cause of impotentia coeundi. If long continued, it may cause atrophy of one or both testicles, and thus be also the indirect cause of loss of libido and of potentia gener- gndi Fortunately the condition of hydrocele is easily removed. Hernia. A scrotal hernia may be and often is a me- chanical cause of impotence. The penis is not sufficiently large to protrude, so to say, above the scrotal mass. The I I b. 140 SEXUAL IMPOTENCE testicles may also be injured, as in the case of a large hy- drocele. Varicocele. In the mind of the laity, the relationship between varicocele and impotence ia well established; this opinion has been fostered by the quacks, who diagnose varicocele, whether it exist^s or not, and who advise an op- eration for this affection as a cure for all ills of a sexual nature. We are not so sure of this causal relationship. We do not deny that it may exist, but we have not been able to assure ourselves of it. Wo have seen men with vari- cocele who were impotent, we have seen men with varicocele who were perfectly normal sexually, and we have seen men with varicocele who had an abnormally strong libido and potentia. I have, of course, seen cases where an operation for varicocele resulted in the cure of impotence, but my impression was that the impotence in those instances was purely psychic, and in psychic impotence any procedure which impresses the patient may result iii a cure. Where the varicocele, however, is well pronounced and extreme, it may, by establishing a vicious circle, be the cause of impotence, and should bo removed before other treatmoit is attempted. DiseaseB of the Prostate Oland. Any abnormality of the prostate, such as hypertrophy, prostatitis, is apt to lead to sexual impotence. In prostatitis, the same as in pro- static congestion, mentioned at the beginning of the chap- ter, it is usually temporary, and relief of the prostatic con- dition removes the impotence. It is well to bear in mind that in prostatic trouble, diminished sexual power or pre- mature ejaculation may exist simultaneously with an in- creased libido. SEXUAL IMPOTENCE IN THE MALE 141 Atrophy of the Prostate Qland. This condition is rare and it cannot be considered alone a cause of impotence ; for the prostatic atrophy is generally accompanied with general atrophy of the genital organs. PhimosiB and preputial calculi may be serious hindrances to the proper perfonnance of the sexual act. They are a frequent cause of premature ejaculations. I mentioned preputial calculi. Sometimes it is not calculi, but just dirt, and the amount of it under some prepuces is simply incredible, I treated, not long ago, a bookkeeper, thirty-nine years of age, who had recently married and found that he waa not in a fit condition. Intercourse was painful and ejacu- lations premature. The conglomeration revealed on re- tracting the prepuce, as well as the odor, was something frightful. He told me that never in his life had he re- tracted his prepuce once I He didn't think it was either necessary or possible to do it. Besides — he taught a class in a Sunday school — he considered it sinful to bother with his genitals. He was chaste and clean until his wed- ding day (chaste, yes; but clean — certainly not!). The mere removal of the preputial concretions ameliorated his condition considerably. Cleanliness about the genitals, either in the male or in the female is not yet so universal as it should be. Age. This is, of course, a very important factor, for all men become impotent if they only live long enough. But if we attempt to answer the question, at what age do men become impotent, at what age is impotence physio- logic, normal, we find we cannot do so ; for, in the aexnal 142 SEXUAL IMPOTENCE sphere more, perbaps, than anywhere ciso, is each man a law unto himself. In many men the sexual power begiasi to decline at the ag;e of 40 and becomes extinguished at the age of 50. Many men are jiiet as powerful at 50 anoteu(!e, but only fright having aomo connection with the sexual act. We know of an instance where a man was interrupted in the act, by tiie husband of tho woman and several detectives who broke in the door, and he was practieally impotent for nearly a year. Each time when on tho point of performing the act the fateful night would come lo hia mind and the partial erection would promptly subside. Intellectual Pnrsoits. Nature resents burning the can- dle at both ends, and it is very rare that people who devote all tlieir time to severe intellectual work do not pay for it by sexual weakness or impotence. This refers to purely intel- lectual work — mathematics, science, research, philosophy, and so on. Particularly is it apt to attack those who are engrossed body anil soul in certain " prublems." ITie case is well known of a mathematician who, during each attempt at intercourse, would bo disturbed by an abstruse mathematical problem and the attempt would fail. It was nece^ary to put him under the influence of alcohol before he could consummate the act. Another instance of the aid that Bacchus often renders Venus. A medical investigator told us that, while interested in a certain question which took away every minute of his spare time, he lost both de- sire and ability for over eighteen months. Pursuits that belong to tho art^*, — belles lettres, poetry, the dramatic art, sculpture, painting, and so on, have a rather opposite effect; they increase the sexual desire and perhaps also the sexual power. l_Sldui|r. Horseback and bicycle riding may aggravate At IMPOTENCE IN THE MALE 153 an existing prostatitis or a posterior iiretbral congestion, and thus may contribute to premature ejaculation. But it cannot be considered a direct, immediate factor of sexual impotence, ajid I consider the stories of officers having be- come impotent, as tlie result of long horseback rides, mere fables. Automobile Riding:. Fast automobile riding has re- cently been brotight forward as a cause of impotence, and there are good grounds for believing that this is a real, and not a fanciful, cause. The Jarring, the constant worry and anxiety which are inseparable from fast and furious automobile driving, induce a state of neurasthenia that is responsible for the impotence. The impotence is generally of a temporary character and yields to treatment at once, when the sport, or rather the furious speed, is given up. Parotitis. The eouneetion of the parotid glands with the testicles (and ovaries) is as well established as it is Btrange. That it may cause orchitis and epidydimitis, which may result in siertlily, is well known. But I have not come across a single instance in which I could with cer- tainty establish a connection between the impotence and the parotitis, as there were usually several other factors in these conditions which in themselves were sufficient to account for the impotence. I do not deny, however, that such causal relationship may exist. There are a number of other causes which directly and indirectly influence the force of the erections and the ejacu- lations, etc. Thus, for instance, gravel has a decidedly injurious effect, and is often the cause of ejacnlatlo praecox. The Bame is true of constipated people with full recta, where the feces press upon the prostate gland. I have had a num- SEXUAL IlLPOTENCE ber of such c&ses in m; practice, where the mere device of cleansing the rectum by cold-water enemata produced a meet rapid and favorable effect on the sexual act. Intense libido is very frequently the cause of premature ejaculation. Thia intense libido is often manifested on the wedding night, when the couple have been long en- A word may be said here about long engagements as a causative factor in impotence. They are not only in- jurious, as being apt to cause intense libido — which is only a temporary trouble — but they may result in more or less permanent impotence, by virtue of the severe proa- tatic and posterior urethral congestion which they may cause. Tlw X-ray. Working with the x-ray without proper protection is liable to cause impotence, but the impotence is generally an impotontia gcnerandi and not coeundi. At the present time we do not see such (raaes as often as we did at first, when we did not know the power of the x-ray in this direction. Psychic and Mental Causes. That many psychic and mental phenomena may act as inhibitors of the sexual act is well known to everybody. We mentioned worry, frights, marital dislike as occasional causes of impotence. JJut this kind of impotence is usually of a temporary, transient character, aiid disappears with the removal of the cause. There is another kind of impotence, to which alone the term psychic impotence should be applied, where the patient without any apparent or discoverable cause, imag- ines, is afraid, su^^sts to himself that he is impotent and on account of this alone finds himself bo. This variety of impotence will be discussed in a separate chapter. k. CHAPTER TWENTY-THREE THE PROPHYLAXIS OF SEXUAL IMPOTENCE Alas ! Wlien tlie patients come to us for treatment, it is too late to speak of prophylaxis. It isn't lectures that they want on how they should have avoided hecoming im- potent. They want to get cured. But in no class of dis- orders is the adage: An ounce of prevention is better than a pound of cure, more true than it is in sexual impotence. And young men arc beginning to appreciate the importance of a proper sexual life, and even when in perfect health, , they now come to us asking for counsel and guidance; they , want to know what pitfalls to avoid, in order not to get into sexual troubles of any kind. Fathers who are per- ! haps themselves victims of youthful indiscretions, who 1 have suffered sexually through ignorance and secrecy which . in their times surrounded every question connected with Bex, are coming to us to Icam how to watch over, protect, guide and instruct their children. A few words on the pro- phylaxis of impotence are therefore not out of place. To prevent impotence, we must of course avoid or remove I all the causes which cause impotence. Wo have seen that masturhation is one of the great causes of impotence, and [ we must use our utmost efforts to prevent or cure the maa- "turbatory habit in our boys (see Section on Masturhation). If masturbation could be eliminated, a very large percent- I age of impotence would he prevented. Nocturnal enuresis must be treated persistently, unfla^ SEXUAL IMPOTENCE ginglj, until a cure has been established. To neglect it i§ criminal. Pollutiona, if they show the slightest tend- ency to become too frequent or atonic in character, muat lie treated energetically. That diumal pollutions and spermatorrhea must be treated goes without saying. Not to treat tlieni is positively to open the door to impotence where it di>es not already exist. Incompletely cured posterior gonorrhea is one of the som- ber factors in impotence, and the physician who treats gon- orrheal patients has a great moral responsibility. The danger is not alone of leaving active or dormant gonococci which may in months or years to come infect and wrevk the life of a healthy young wife; there is also a danger of leaving an uncured hj-peremic patch in the posterior urethra, which may in time to come be the direct cause of sejnuil impotence. We must do everything in our power to change the public's and the medical profession's riewB about gonorrhea. We miist impress upon everybody that gonorrhea on account of its complications and sequelae is an exceedingly serious disease and that the greatest care must be taken not to contract it. And if one has been un- fortunate enough to contract it, he must be imbued with the seriousness of his trouble, and ho must treat himself until, by every test at our disposal, he is pronounced cured. And the question comes up, whether in view of tJie serious- ness of gonorrhea, we are not justified in instructing young men, who cannol or will not abstain, in the beat and most efficient means of venereal prophylaxis. Another important point is the question of continence. Believing as we do that in quite a large number of caeea absolute continence is apt to lead to impotence, it is our ^ A SEXTTAL IMPOTENCE IN THE MALE 157 duty to permit, and in certain instances to advise and to urge the patient to have normal sexual relations. For in a certain percentage of cases this is the only way to avoid impotence and sexual neurasthenia. And I consider it necessary to emphasize that to advise continence in people past middle age is particularly laden with grave danger. Of course, sometimes we must do it, because it is the lesser of the two evils; but very often men of between fifty or sixty, or even forty-five, who have for some reason or other been eoutinent for a year or two find their power completely if not irrevocably gone. As in some cases we must advise against continence, so in others we mnst give a severe warning against sexual ex- cess. While excessive normal sexual coitus does not lead to impotence as frequently as does masturbation or exces- sive pollutions, still cases of impotence from that cause are not 90 rare. We are apt to come across it particularly in newly married young men, who had Iwen completely absti- nent for a year or so before marriage ; they often give full license to their pent-up passion, performing the act several times a day for days in succession, with the resnlt, that after a while they become relatively or completely impotent. The impotence is generally temporary, but I have known cases where after some incredible excesses the condition of impotence became permanent. Any excess in middle age \a also particularly dangerous. And at every opportunity we must raise our voice against coitus interniptus as a fruitful cause of impotence. If we could guard our boyhood and manhood against masturbation, pollutions and venereal infection, and if our social-economic conditions were such that all adults ^L ti^ntineiit ^H Cll98e(] fill SEXUAL IMPOTENCE if we find, aa we usually do, a congested posterior urethra, we treat it with sounds, inatillationB of silver nitrate (2 to 5 per cent), instillations of hjdrastine, internal admin- isrration of ei^otin and styptol or Btypticin, etc. Cold wa- ter sounds (psyehropliorea) are an important part of the treatment. If we find nn enlarged and inflamed colliculua inalis, we treat it the same way, or in exeeptional cases we cauterize it with a 10 to 20 per cent solution of silver nitrate. But this must be left to the experienced operator only, for the reaction of this cauterization is sometimes very severe, causing strangury and retention for 8, 12 or even 24 hours. To guard against or to overcome this re- tention, we give good doses of sodium bromide and fluid ex- tract of hyoscyamus, hyoscyamine, in doses of 1-60 grain; also large amounts of linseed tea and oil of santal or the various preparations of this oil fsanlyl, gonosan, etc.). If we find an uncured posterior urethritis, or a granu- lar patch, we must treat them according to well-known principles: silver nitrate instill at lona, irrigations or appli- cations; touching the spot through the endoscope with di- luted tincture of iodine (diluted to 1 or 2 per cent) or a 2 per cent solution of copper sulphate. If there is prostata ilia, or vesiculitis, the prostate or ttie vesicles must be mas- saged (but gently, gently, sir!) twice a week, and hot rect-al tubes inserted once or twice a day (see below). If there is a stricture, it must Iw dilated or in extreme coses cut. If the patient's impotence is due to pollutions or sper- motorrhea, these must be treated vigorously. As the treatment of pollutions and spermatorrhea has been dis- cussed fullv, we will not allude to them here, but will refer d SEXUAL IMPOTENCE IN' THE MALE 161 the reader to the chapter dealing with the treatment of thoee disorders. Where we find tho cause to be sexual overindulgence or coitus interruptUB, the causes must of course be removed, discontinued. But it is a mistake to think that the mere removal o£ the cause will cure all patients. Undoubtedly, it may in some instances; it will improve them in others. But as a rule some damage has been done, and besides removal of the cause, the patient will need some local and general treatment, which will be discussed presently. And so with all other causes. While it is unfortunately not true that ohiala. causa toUiliir effeclus, for the cause has succeeded in leaving some very distinct marks, still we certainly cannot hope to accomplish much aa long as the cause lasts. For instance, if a man's impotence is due to some terrible worry, then you may treat him as much as you want, you will not cure him of his impotence as long as tlie worry continues. You may improve his gen- eral health, you may even cause some improvement in his libido, but the potentia will be but slightly affected. Where the impotence is due to excessive intellectual la- bor, you have to step that. I know an intellectual worker who is very weak sexually in the winter. In the summer, when he goes to the Thousand Islands, doing nothing but loafing, fishing and gardening, he is all right. The so-called organic causes of impotence, deformities and malformations of the penis, are of little interest, be- cause they are rare per se, and as causes of impotence they are still rarer. And besides the method of treatment is self-evident. Epispadias and hypospadias are to be cor- rected surgically, varicocele if really annoying and a prob- 162 SEXUAL IMPOTENCE able contributorj cause to the impotence should be re- moved, ft hydrocele is to be tapped, a large scrotal hernia is to bo operated on, etc. The Usual Case of Impotenee. But let us now consider sexual impotence proper, that is sexual impotence with- out underlying gross pathological lesions, without even a clearly asc<.'rtainable cause, or witli a probable cause which has long since ceased to exist, or one which is ap- parently congenital. Cases of this type of impotence constitute a large percentage of the practice of the special- ist in sexual disorders. A man comes in. His age is anywhere between 25 and 55 ; he may be younger or older but we will take the average case. He may or may not be married. Yes, he has masturbated somewhat, but mod- erately, when a boy, but he had given up the habit long ago. He has indulged in intercourse, moderately. He may or may not have had a gonorrhea. No, he doesn't work hard. No, he can't say he is worrying. Every- body has some business troubles, some annoyances, but " nothing special." Appetite fair, sleeps well, attends to his job or hia business as usual. In fact he says he feels all right in every way. But for the last few months, or for the last year or two, his sexual power has been getting weaker. The erections do not come when he wants them to, or they come at the slightest provocation but are feeble, subside quickly, and the ejacula- tion takes place very quickly, sometimes ante porins. That's the whole kernel of the matter, and that is the complaint of ninety per cent of our impotent patients; weak or deficient erection and ejaculatio praecox. The libido may or may not be impaired, and the voluplas of I SEXUAL IMPOTENCE IN THE MALE 165 the orgasm may or may not be diminished, though in the majority of cases it is. How shall we treat such patients? That is what we are going to consider now. Sexual Rest. First of all I order a complete sexual rest. As to the length of that rest, that depends upon the age of the patient. In young people, I do not hesitate to make it two, three or in severe cases even six months. It cannot hurt them, and the rest alone sometimes effects the cure; if not completely, the greater part of it. In people after 45, afflicted with sexual weakness, it is rather dangerous to prescribe long periods of absolute continence, for we find that in some cases the weakening instinct goes to sleep altogether. In cases after 45 or 50 I simply order moderate and regular intercourse — once in two or three weeks (please hear in mind that I am speaking here of the " pure " impotent without patches in his urethra, — without prostatitis, etc., without symptoms of neuraa- thenia) . Cold Water Injections. Then I inject cold sterilized water in the urethra (a half per cent boric solution or normal saline solution is sometimes preferable). But the water must be cold, and of this you may inject three or four 100 cc. syringefuls, telling the patient to urinate after each syringeful. This has a very nice tonic effect. It stimulates the posterior urethra and seems to strengthen the openings of the ejaculatory ducts. In mild cases a few of these treatments will alone effect a remarkable improvement. But in the majority of cases we need of course other means. The PByohrophore. The psychrophore or cold water fc_ A SEXUAL IMPOTENCE sound is a very useful instrumenf. This is a hoUmv double current metal sound (seo illustration) which is introduced into the urethra and bladder. One end is connected with a rubber tulw leading to a large glass reservoir (or foun- tain syringe) filled willi cold water; to the otiier end a rubber tube ia altaeheti, which leads into a waste pail. At first the waler may be of room temperature, just as it e^mcB from the hydrant; but aflor a few niinut^'s, it ia best to lower Uie tMuporoture of the water by pultiug some ice into tlie reservoir. The sitfings at first last 4-5 minutes, but gradually they are increased to 15-20 minutes. The tonic and beneficial effect of tbe psychrophore is beyond SEXUAL IMPOTENCE IN THE MALE Fquestion. But in conjimi^tion with the urethral psychro- phore, it is always advisable to use a rectal or prostatic p8ychroj)hore. Of these we have a large variety, as can be seen by the illustralions. The reetul psychrophore may I be used synchronously with the urethral, or in alternate ■ treatments. It is necessary to mention that in some cases ty/e are able to use the rectal psyelirophore only, because some patients are exceedingly sensitive to any uretliral instrumentation. No matter how careful, gentle and asep- tic you may be, they will develop a chill, the urine may get turbid, and they may feel generally worse. With the rectal psychrophore no audi untoward effects take place. In some cases, a very few however, the psychrophore alone, the mere contact of the cold motal with the urethral mucous membrane or the prostate, does not have the de- 166 SEXUAL IMPOTENCE sired e£Fect. And in aucli cases irrigating the urethra or rectum with cold water sometimes acts much more quickly and surely. For this purpose wo have a large number of uretbral and rectal irrigators (see illustrationa). Sometimes we wish to use hot water instead of cold; we find occasionally that alternating heat and cold has a very happy effect. Por this purpose, we need only fill the reservoir with hot water, or we can have two reservoirs, one filled with cold, the other with hot water, and we change the attachments accordingly. CHAPTER TWENTY-FIVE BIEDICINAL TBEATIOENT As ia the treatment of most chronic diseases, drugs play but a secondary role in the treatment of sexual inipotenca If I had the choice between local and hydrotherapeutic treatments on the one hand and drugs on the other, I would unhesitatingly select the former. But I should not like to be deprived of the aid afforded by the latter. Impotence and sexual neurasthenia are such complex disorders, that ■we have no right to discard any help, which any agency, material or immaterial, offers us. And drugs form a very valuable adjunct in the treatment of sexual disorders. If they are apt to he neglected, it is not so much the fault of the drugs, as of their users, who are not familiar with the proper dosage, indications and contraindications. It is unfortunately only too true that our urologists and sex- ologists know next to nothing about pharmacology and medicinal therapeutics. And this is a great pity — for the patients' sake, especially. Strychnine. Strychnine is ono of the few drugs from which we can expect positive results. But it is not to be given in a routine way. Its effect must be watched ; other- wise it may do harm and not good. In fact as we have seen above in discussing the etiology, it may even very much a^^avate the condition; it may convert impotence of a very mild d^ree into one of a severe type. I was the first, I believe, to call attention to the po- le? SEXUAL IMPOTENOE ^ tentially injurious effect of strychnine in sexual weakness. Very soon after my paper made its appearance, I b^aa to receive letters from various parts of the country, cor- roborating my statements. Some physicians wrote that they hai] noticed that effect upon themselves ; others wrote that they noticed it on several of their patients. But of course they hesitated to come out in print with their ob- servations for fear they would be laughed at. And again they thought it might be a pure coincidence. To repeat then, strychnine must be administered with watchful cau- tion. For instance, if the patient feels irritable after it, if his spine and legs feel hot, or if the slight pain in the back is aggravate^!, then it is a signal to discard it. But if we bear in mind the necessity of watching the patient, we can get excellent results from strychnine. Its effect in increasing the erections, tlieir strength and dura- tion, is in some cases extremely gratifying. I usually administer it per 03 in doses Ho or Ho grain faccording to the weight of the patient) 3 times a day. No results need be expected from smaller doses than J^o grain. Sometimes wheB it is necessary to make at once an im- pression on the system, I give it hypodermically, and do not hesitate to inject as high as M2 grain. As to the discussion which salt of strychnine is tlie best to use, the sulphate, nitrate, phosphate, valerate, etc. (in some European countries the nitrate is the favorite), I do not take any stock in it: it is the strychnine, the alkaloidal base, that does the work, and not the acid radical. I often alternate strychnine with the second alkaloid from nux vomica, namely, brucine. Brucine ia mild in its action and may be given in doses of ^ to H grain 3 d SEXUAL- IMPOTENCE IN THE MALE 169 times daily. Give the strjcbniiie for a week or ten days, then stop it altogether for 3—4 days, and give the brucine for a week, then commence again with the atryclinine. Very often the compound syrup of hypophosphites acta more quickly and more beneficially than strychnine alone. Alcohol. Next to strychnine wo have to mention alcohol. A glass or two of beer, a glass of wine or champagne, taken late in the evening wlien intercourse is intended, lias sorao- timos a very happy effect. (But lw>ar in mind again, that 1 am speaking here of impotents who are not neurasthen- ics.) Cantharidin. Cantharidin, administered carefully in very small doses (14oo gr.) and gradually increased ae^ cording to the tolerance of the patient (strangury must never take place; if it does, you have overstepped the limit), is very useful. That it has a selective action on certain portions of the genito-urinary canal nobody will doubt, who has taken a good dose of it, or who has admin- istered it without due caution to others. And its effect in initiating erections, in maintaining them, in increasing the libido will not bo doubted by anybody who has had considerable experience with this curious and powerful active principle of the Spanish fly. Of course in admin- istering the crude and variable cantharides or even the tinc- ture we often court failure — or unexpectedly severe ac- tion. Other Dm^. Atropine and ergotin as well as cotar- nine phthalato or hydrochloride (styptol and stypticin) are useful s>nnptomatically, and I often prescribe them. The glycerophosphates I believe are useful. But as generally prescribe them in combination with strychnine - J une ■ ^L Qot ! A ^^ haro to SEXUAL IMPOTENCE it ia hard to determine the exact ahare of credit due to each. The same is true of lecithin. About phosphorus (in the elementary state) I will aay this: Some consider it valuable; maybe it is, maybe it is not. All I can say is that I have never been able to convince myself of its value. And 1 prescribed it in many cases. I will say the same of yoliimbin and miiiracithin, and the extract of muira puama. Quinine is often prescribed by Italian physicians, but tbis is undoubtedly due to the fact that BO many people in Italy are malarially tainted. People who never had malaria should not bo dosed with quinine. Cocaine is distinctly injurious. Wbile it may at first pro- duce a little exhilaration and increased libido, it will soon make bad matters worse. At any rate only a lunatic will play with such a hundred-edged sword as cocaine. A good dose of tinctura capsici or tinctura zingiberis is often very effective. Aa to damiana, the dnig which was lauded as the drug for sexual impotence, the drug which has brought thousands of dollars into the coffers of deceived or unscrupulous manufacturers, I will say that it is utterly worthless. It is no more an aphrodisiac or tonic than licorice is. How it ever gained the reputation aa an aphrodisiac, ia one of those mysteries, which will have to go unexplained. Unless there was a well devised plot to fleece tlie gullible profession and the still more gullible public, I cannot understand its one time vogue. Orjfanotherapeutic Preparations. As to the organo- therapeutic preparations, I wish they had justified the expectation? which were put on them. Alas, they have not! And still, this is probably the path which we will have to follow in our search for a genuine sexual stimu- d SEXUAL IMPOTENCE IN THE MALE 171 lant-tonic. There is no reason why we should not be able to obtain an efficient prostato-teaticular extract to be used bypodermically or intramuBCuJarly, Of the various prep- arations on the market, I can only say that I have given them a trial, but have been unable to arrive at any definite conclusion. Sonietirae-s there seemed to be a good result, but just as often if not oftener there was complete failure. Poehl'a expensive apermin preparations, both for hypo- dermic injections and for internal administration, I have used in several cases, but have not been able to see the sligbteet result from them. As to Bro%vn-Sequard'a elixir of life, it is unnecessary to state that it has failed to accomplish what its enthusiaatie originator thought it would, might or did accomplish. However, I have given small doses of suprarenal, thyroid and pituitary extracts with what seemed to me undoubted benefit. The thyroid seemed to influence the general me- tabolism very favorably, while the tonic effect of the adrenal was clearly seen. Of course, these opotherapeutic substances will be prescribed with care and only when the physician can see the patient frequently. Under no cir- cumstances are the prescriptions calling for them to be repeated without the physician's distinct order. Hydrotberspeatios. Hydrotherapy plays an important role in the treatment of sexual impotence, only second to the role it plays in neurasthenia. The various baths are of great and undoubted value. I am not a believer in the indiscriminate use of cold water, in any condition. In certain neurotic conditions, in certain stages of pollutions, and even in " perfectly " normal people cold water has Bometimea a deleterious effect. So even cold water we 172 SEXUAL IMPOTENCE ^ cannot order iudtscriminatcly. Some can stand cold ab- lutions, douches, etc., oa\y, if they have their feet in hot water. With the restrictiona indicated above, cold water in various forms is extremely beneficial. The best forma to be recommended are cold ablutions, the sponge bath, the shower or douche and sitz bath. The latter is particularly useful. The sponge bath may he taken, if the patieut ia very sensitive, with the feet in hot water, lie dips the sponge in cold water, rubs each part of the bfidy briskly, and then dries himself with a rough towel until the skin is dry and glowing. If the rt^ular full tub bath is used, tho patient is to jump in, stay but a few seconds, come right out and dry himself. What we want is just the shock ; we do not want to use the full hath as an anti- pyretic A very beneficial form of bathing is river, lake or sea bathing, particularly the last. Unfortunately these forms of water can only be used in certain seasons of the year and in certain localities. I have also used carbon dioxide and oxygen baths (Pero- gon) with good reaulls. Vapor laths and Turkish baths are generally useless, if not injurious. They are not permissible even in obese patients, because I do not believe in vapor and hot air baths as a means of reduction of superfluous flesh. The pound of water that the patient loses while in the bath, he makes up very soon after he leaves it, by drinking exces- sively. An occasional Turkish bath in autotoxemic con- ditions and for the sake of cleanliness may be permitted. Another form of bath which is very beneficial and which contains no water at all is the air bath. I have been recommending it for many years. Almost from the cradle d SEXCAL IMPOTENCE IN THE MALE 17S to the gr&ve the human body does not come in full, free, immediate contact witJi the outside air. Which is a pity. I find it very beneficial for impotent patients and for others as well, to walk about perfectly nude in their room for at least 10 or 15 minutes daily. If they are sensitive to cold, they may perform some exercise while taking the air bath. In warm weather some people I know spend hours attending to their work in a perfectly nude condi- tion, and claim to be very much benefited by it. Sun- baths I consider injurious. The Diet. The diet should be generous and liberal. The patient should eat plenty of e^s, oysters, raw and fried, meat and fish. I often make my patients eat two to six raw eggs a day, two or three the first thing in the morning, before breakfast, the rest during the day. It is beet to drink the egg directly from the shell. Make a hole at the top, put in a pinch of salt and sip if. Caviar is also reputed to be beneficial. Spices and condiments are not only permissible, but desirable. Saffron, pepper, mus- tard, cardamon, cinnamon, nutmeg, ginger have an un- doubted effect in stimulating the libido and tlie erection center; and where lack of libido and weak erections or weak erections with retarded ejaculations are tho only complaint, they may and should be used liberally. Unfor- tunately, these spices have also the effect of stimulating the ejaculation center, and where ejaculatio praecox is a prominent or chief symptom, they must be eschewed or used only with great circnmspection. Aa to alcoholics, I spoke of them when considering drugs, for alcohol should be considered as a drug and not as a beverage. There is one spice or condiment of which I hesitate to speak, be- i '174 SEXUAL IMPOTENCE cause it is held in such contempt and disdain in this coun- try. I refer to garlic. There can, however, be no ques- tion as t^ its pronounced aphrodisiac effect. In fact it stands at the very head of the list. But many of our Anglo-Saxons would perhaps prefer their impotence to the allernattve of having to eat garlic. The nations, however, who have no such loathing against the bulb of allium saiivum, the Italians and Jews for instance, often make use of garlic as an aphrodisiac; some do it without delib- eration, instinctively, so to say. I have tried in several instances to administer, instead of the garlic the distilled oil or the artificial oil of garlic, which is chemically allyl sulphide (CoH,oS). I administered it in capsules, but the effect was not quite the same. Onions (raw) have also a stimulating aphrodisiac effect, but less pronounced than garlic. It should not be necessary to say (and still I aay it be- cause I have found out that in lecturing and writing mis- understandings are only too frequent, and it is better to emphasize a little too much than not enough), that this rich and liberal diet Is not to be recommended to obese people or to people who are beginning to travel that way. It is not wise to stimulate their appetite too much, for too much food of whatever kind means additional tissue. CHAPTER TWENTY-SIX EXTEBNAL APPLICATIONS I often prescribe axtemal applications to the penis, A stimulating ointment appears to be beneficial. The fol- lowing formula has been prescribed by me for many years : ^ Camphorae gr- x Oleoresinac capsiei gr, ii Olei sinapis ,. . .gtt. ii Pctrolati 3 ii A very small quantity (about the size of half a pea) I is rubbed in aroim^d the root of the penia at night. The ' sensation of warmth lasts for a long time, and in cases of frigidity or diminished libido exerts a beneficial effect Tbe penis is to be washed off in the morning with soap and water, and some talcum applied, so as to avoid irrita- tion. I was told by two or three patients that a dru^ist was selling an ointment which was very good for impotence. As Lam not in the habit of sneering at anything ^vithout » investigation, and as I always like to consider su^estiona no matter from what source they may come, I investigated the matter and found that it was an ointment made from crushed and strained garlic and lard. A small quantity of this was rubbed into the penis and on the back and while the result is of course temporary, it is imdoubtedly ^H beneficial. ^H There are various mechanical appliances which are used ^H 175 176 SEXUAL IMPOTENCE on the genitals with apparent benefit. One consiBts of a vacuum pump and cup; both tlio penis and scrotum are enclosed in tlie cup and a parlial vacuum is produced, which is maintained for 10 minutes to half an hour. I cannot exactly see the rationale of the action of this pas- sive hyperemia, but Zabludow>ky of Berlin claimed good results with it, and my patients say they are benefited by it and ask for it. Another little appliance is for the penis alone; this I have not found so useful, thougli where the organ is very shrunken its use is not irrational. ?fo sufferers are so afllictod with credulity and ^illibil- ity as are the victims of sexual impotence and the market is flooded wilh various appliances which are guaranteed to be sure euros. It goes without saying, that moat of them are worthless frauds. One of the worst of these frauds is a certain little appliance which the manufactur- ers have had the impudence to call Cier'a Ereetruss, thus giving the impression that the thing has Prof. Bier'a ap- proval, or is his invention. I have met intelligent physi- cians who really thought that Bier recommended that piece of iron wire in sexual impotence. It costs the man- ufacturer about 5 cents apiece, and they have the hardi- hood to sell it for $10.00 list, or to physicians for $5. And there are medical journals, which are advertising this fraud. But I am sure thai most of them are do- ing it through ignorance. Did they know the worthless- nesa of the thing, and the questionable methods of introetween forty and seventy, who come around regularly aliout once a year for a few treatments. They claim that their potency ia always better after the treatments, but the effect be^ns to wear off in six or eight months. After a few local treat- ments combined with general Ionics and hygienic advice they are again all right. And I am sure that by these wise and )iropbylactic proce contrary to the belief and writings of some confreres, psy- chic impotence does not play a very important role in the I various kinds of sexual impotence. A man quite normal in I all respects does not all at onc« imagine that be is unable t to consummate sexual intercourse. I probably see more [ cases of sexual impotence than any other physician in j America, and I will say that imagination plays a very I msignificant role in the etiology of impotence. Many cases I -which had been diagnosed by other physicians as psychic I were on careful examination found to have an inflamed [posterior urethra, or eolHculua, or an atonic prostate; or I there were points in their history — masturbation, exces- I wve venery or complete continence — which fully ac- I eotmted for their impotence, for their lack of libido, for 1 inability to get an erection or for their premature ejacula- Ition. And I am sure that if all patients were carefully ^examined and their histories minutely inquired into tlie rnumber of cases of purely psychic impotence would be get- I ting gradually smaller. I do not at all wish to be understood as denying the ex- listence of psychic impotence, but I do asert that its im- lportanc« has been and still is greatly exaggerated, and ■ from analyzing cases reported by the older -(vriters and as 1 result of experience with patients sent to me by other SEXUAL IMPOTENCE physicians, I am sure that psychic impotence has often beea diagnosed incorrectly. And then the term ia used too in- discriminately. If a man is unable to have a desire or get an erection with a certain woman, who is distasteful to him, or who has dirty underwear on, or who has a bad odor from her mouth, then this is not psychic impotence: it is simply lack of a proper stimulus. And if a man who is burning with desire for a certain woman gets an immediate ejaculation with that woman, while he is nor- mal with other women for whom he does not care so much, then this is not psychic impotence: it is simply over-stim- ulation of the ejaculatory center. As to the cases which have been reported of men who could perform the act only under peculiar conditions, as for instance with women dressed in riding habits, or in full evening dress, or in a Turkish costume, or only at certain hours of the day, or only in rooms furnished in a peculiar manner, or in certain grotesque positions, or only when maltreating women or be- ing maltreated by them, they belong in the domain of men- tal abnormalities and perversions, and medicai treatment is of little avail in such cases. lieaides they are very rare and even the busiest specialist in sexual disorders sees them hut at rare intervals. That there are psychic ele- ments, such as fear of detection, unclean room, neceaaity for hurrying, fear of venereal infection, fear of impreg- nating the woman, lack of responsiveness or unconcealed aversion on the part of the woman, which will temporarily render a man impotent, so that he can get up no erection, ie fully admitted of course. But this is not psychic impo- tence. These are temporary afTairs, and the causes being removed, the impotence disappears. I apply the term psychic impotence only to a restricted SEXUAL IMPOTENCE LN THE MMV. 183 class. A man perfectly beattby sexuallr and not oeuna- tbextic gets it into Ills bead that he vrill not be abk to aocom- pliab intercourse. It may happen to a man wbo was abso- lutely continent before marriage,*' or he may have abstained for two or three years, or be may have read in some quack or semi-scientific book that all those who at one time maa- torbated become Lmpotent; in short, for one reason or another he gets that idea fixed into his mind, and though the woman mar be everything his heart or fancy desires, and though his libido may be intense, be fails to get an erection. At oUier times when alone, when waking in the morning, bia erections may be strong and of long duration. Suoli are cases of true psychic impotence. On examination no pathologic lesions are found and the miraculous results of a placebo show the true nature of the disorder. The Treatment of Psychic Impotence. No rules can be laid down for the treatment of psychic impotence, A ph^ician with good judgment and tact will accomplish everything, a physician without these qualities will accom- plish nothing. We must size up our patient, ponder care- fully over his history and act accordingly. But as a rule it is not well to pooh-pooh the patient's notions, and tell him that there is nothing the matter with him and that he will be all right A generous supper with some wine and liqueurs often proves the best remedy. It is good to have a confidential talk with the wife, and if she is not a prude or a cold-blooded animal, her cooperation will prove valu- * In snme men nlio liavo been c^ompletoly abatinoiit until niarriBg«, the Mix instinct may tiecome very much repressed. The; develop a condition analogoni to what we call Frigidity in the female, and to tbia condition we may apply the t«rm Psychic Impotence. SEXUAL IMPOTENCE able. Suggestion ie a necessary adjunct, and it is beet to give him some treatment — electric or vibratory — and prescribe a placebo which he ia instructed to take with religious regularity. It is a good idea to order the patient to abstain abso- lutely from all attempts at intercourse for a month or two, taking in the meantime some indifferent sort of granulea. As a rule almost without exceptions, where the impotence is really psychic, the physician's iujimction is broken long before the appointed time. Thus, for instance, a recently married patient comes to you and complains that ho is entirely impotent; after you have listened to his history, have esamiued his genitals by inspection, palpation, etc., have examined the prostate, have examined the urethra, colliculua seniinalis, etc., by the urethroscope and have made up your mind that you have before you a case of psychic impotence, you prescribe 200 or 300 granules of a very small dose of some mild tonic; say 1-60 gr, of arbutiu or of brucine or 1-6000 grain of oantbaridin; you order him, to take one granule 3 times R day after meals and abstain absolutely from any attempt at intetxwurse until all the granules have been taken, that is for two or three months. You will find in a vast major- ity of cases that before half of the granules had Iteen taken, the patient disobeyed the order and consummated the act to the perfect satisfaction of both parties. He will tell you, perhaps somewhat sheepishly, that he had a strong desire and couldn't help it, or that the wife demanded it. But I must add that this scheme works well only in tha case of married men, where the opportunity for gratifying a A it;-.'Uk< »^ SEXUAL IMPOTENCE IN THE MALE 185 suddenly awakened desire is always at hand. In the case of non-married people, the lack of opportunity ai the proper moment often frustrates our efforts. And such an oppor- tunity must be created. CHAPTER TWENTY-EIGHT EEFOKT OF OASES Case 1. Age 22. A typical case. Suffered with bed- wetting until the age of ten, Masturhatwd moderately and intermittently from the age of thirteen to about eixteea. At about fifteen began to suffer with night emissions ; first every two or three weeks, then every week, then twice a week and even oftener. Felt tired and languid in the morning, i.e., afltT an emission. Some six months pre- viously applied to a physician, who gave him bromides and advised him to attempt intercourse. He did, but had an immediate ejaculation, without any erection. Three or four more attempta proved just as unsuccessful. In the meantime the pollutions kept up with the same fre- quency. Wlien he came to me he was thin, pale, emaci- ated, with an awkward gait, and a restless wandering look. His memory was weak, and he was painfully lack- ing in power of concentration, lie had passed the junior examination in the New York College of Pharmacy, but in the senior year he found it impossible to prepare the lessons, and left college, until his health should improve, lie had a woe-begone expression and his outlook on hia future was decidedly pessimistic. I assured him in the most positive terms that I could cure him unquestionably, provided he would put himself entirely in my hands, and without reasoning or questioning do whatever I ordered. He was only too ready to accept the terms. Such weak k. A 1 SEXUAL IMPOTEN'CE IN THE MALE 187 characters need a superior will and they at once feel better as soon as they know tliere is a stronger personality to guide them and to order their life. Unrestrained, un- fettered liberty is not everybody's ideal. I examined him, and though I had given him no treatment that morning, he left the office in a much better, more hopeful mood than when he came. The first two months the treatment was general — I told him he should forget that he had any sexual organs — and consisted in iron, nux vomica, syrup of hypophospliites, glycerophosphates, warm and cold baths, rectal enemata of cold water, plenty of meat, raw egga in the morning, etc. He gained about ten ponnds, his anemia disappeared and he looked and felt brighter. I then proceeded with local treatment. The posterior urethra was quite sensitive and so was the prostate. The urethra was treated with steel sounds, Kolhnann's dilators, urethral psychrophores, instillations of hydrastine, and of silver nitrate ; the prostate was very gently massaged twice a week, followed once a week by faradization and once a week by hot and cold rectal applications. He was also given rectal suppositories consisting of ichthyol, antipyrin and atropine, to be used each night on going to bed. After six montlis' treatment he attempted intercourse, which, however, was not fully satisfactory. The erection was strong, but subsided quickly and waa followed by a premature ejaculation. Treatment was continued off and on for anotlier year; it was interrupted ft>r three months during my annual vacation in Europa At the end of this period the man was perfectly well. He was an en- tirely different man both physically and mentally. In- tercourse was perfect both as far as erection, duration and SEXUAL IMPOTENCE sensation were concerned. He married six moutha later and is living a happy married life. This case is not in any way unique. On tbe contrary it is a common, every day case, and well illustrates what can be done by persistent judit-ious treatment Had be fallen into improper bands, or bad he married before a. complete euro bad been effected, be would have had a life of misery to look forward to, misery for himself and for bis wife; and knowing bis sensitive character and bis tend- ency to pessimism and melancholia aa well as I do, I feel quite certain that sooner or later he would have t«nninatcd that life of misery by his own hand. It is the good luck of the patient that he was well-to-do and could afford pro- longed and expert treatment. But what are the poor — workingmen, clerks, small business men, etc.— to do, when they are afflicted with impotence? Tbe hospitals will not receive them, and the treatment dealt out to such cases in the dispensaries is worse than useless. Oose 2. Twenty-eight years old. Masturbated from the age of thirteen or fourteen; occasional intercourse from the age of twenty-four. Weak 3e.>iiiality in general. Lately began to notice dirainiabing potency: weak erec- tions, premature ejaculation. Never bad venereal disease. Examination discloses very narrow prepuce; patient states that he had not retracted it for years. Ketraction, which was accomplished with considerable difficulty, discloses an accumulation of smegma, of a foul, sickening odor, and several preputial calculi ; several small ulcerations on tbe superior surface of the glans. Thorough cleansing with soap and warm water, then with peroxide ; then touching the ulcerated spots with a 10 per cent solution of silver J SEXUAL IMPOTENCE IN THE MALE 189 nitrate; ordered washing with peroxide of bydrogen three times a day, then dusting with an antiseptic powder. In a week the balanoposthitia completely healed. Ordered abstinence from intercourse for two months. In the mean- time warm Hitz-batlis at night, and cold baths in the morn- ing. No internal treatment of any kind. At the end of that period tried intercourse with perfectly satisfactory results — in fact more satisfactory from every point of view than ever before in his life. lias given up masturba- tion entirely, and lives a norma! sexual life. Case 3. Age thirty-five. Single. Lived a normal sexual life from the age of 22, having intercourse regu- larly once a week to once in four weeks. Never had any venereal disease. For the last year notices premature ejacnlation and diminishing libido. Feels well otherwise, Ijeads a sedentary life. Investigation discloses the fact that he has always suffered somewhat from constipation, but that the condition has become considerably worse dur- ing the past year, and he has also begun to develop hemor- rhoids. The prostate not enlarged, but somewhat painful to the touch, and slight pressure causes prostatic secretion to appear at the meatus. I consider the condition due to constipation and prostatic atony. Treatment: an enema of warm water with soapsuds at night, followed by an injection of 8 ounces of cold normal saline solution, retained in the rectum for ten minutes. In the morning a mild saline lax- ative, alternate with rhamnus purshiana, and aloin, Btrychnine and belladonna pill-s. Massage of the prostate once a week, for four weeks. No treatment of the urethra. After six weeks' treatment, complete recovery. Case 4. Age thirty-two. Married one year. All- ] SEXUAL IMPOTENCE around athlete. Masturbated from the age of 15 to 18, when, being informed of the injuriouaneBa of the habit, he gave it up definitely. Intercourse at the age of 20, and two years later contracted a gonorrhea, which lasted eight months, and was accompanied by prostatitis. Became en- gaged at the age of 28, from which time until his marriage — a period of three years — abstained from intercourse. Immediately after marriage fonnd that the performance of the act was unsatisfactory, but as bis bride did not seem to be dissatisfied, he delayed attending to himself. Lately, however, he has noticed a distinct aversion on her part to his approaches, and has also perceived that intercourse left her irritable and complaining of backache, headache, etc. Hia complaint is lack of libido, premature ejaculation, sometimes even before intromission, a scalding feeling during the emission, and a sense of lassitude after the act. But while the purely physical desire for the act was di- minished, the menial desire remained as strong as ever; if anything it was increased. Findings on examination: posterior \irethra exquisitely painful, prostate somewhat enlarged, bogpy and painful, abimdant secretion readily expressed. Testicles and epididymis not enlarged, but tender to the touch. No gonococci, no shreds in the urine. Treatment consisted first of all in forbidding any attempt at sexual intercourse " until further notice." I gave him to understand that this was a conditio sine qua non, and told him that I would not take hia case unless this con- dition was absolutely complied witL He agreed. I then gave him one milligram (1-C-t grain) of atro- pino sulphate three times a day. This relieves congestion of the posterior urethra and the neck of the bladder very I SEXUAL IMPOTENCE IN THE MALE 191 markedly, a fat-t unfortunately not well-known to the medi- cal profession. A week later I began cautiously the pass- ing of 8t€el sounds; started with 18 French, increasing the size gradually, until at the end of three months T was able to pass 29 French easily. The sounds were passed twice a week; besides, he had his prostale massaged and faradized once a week; once a week he had 30 minims of a 1-1000 silver nitrate aohition inatiUed into the pos- terior urethra and once a week the solution of strychnine and hydrastine. At the end of three months' treatment, he was advised to attempt intercourse. There was a very decided improvement in every respect, but it was not per- fect. The ejaculation was still somewhat premature. I told him he would have to continue practically the same treatment for three months more, during which time he must abstain. He obeyed for two months; at the end of that time he broke the injimction and had relations with his wife, which were highly satisfactory to both parties. He continued treatment for another month, and he has been in perfect health since. Case B. Age 74, As typical a human wreck as one would care to see. Wrinkled, jaundiced, with a dragging gait, false teeth, dyed hair and an extremely offensive breath, but well dressed and dandified, he gave at once the unmistakable impression of an old incorrigible roue. He wanted mo to give him a thorough examination and see what I could do for him, I found him suffering both with chronic gonorrliea and tertiary syphilis. The urine con- tained pus cells and numerous shretls; the prostate was enlarged and very painful ; and evidences of tertiary syphilis were seen everywhere When I explained to him SEXUAL IMPOTENCE n ^^ first hia condition, and told bim that he \cou1d need long and careful treatment before he could hope to be in good shape, I discovered to luy disgust that he was not interested eilher in his gonorrhea or in his syphilis. All be cared about was to be " fixed up " so that bis sexual power should be normal again. He indulged all his life very frequently, but during the last year or so he felt bis sexual powers waning. I asked bim if he did not tbink it was about time to leave his sexual power aloue, whether he was not too old to bollipr about it, and h© felt quite offended. I asked bim if be thought it right to indulge in sexual rela- tions when his victims ran the risk of venereal infection. But he was as rotten morally as he was physically. He didn't care. " They " got paid, and they bad to take their chances. A doctor is supposed to treat everybody who appeals to bim for aid and the author surely does not often assume the role of judge, especially of what is called " vice," but in this case he did feel disgusted and I told him plainly that I would not treat him; that if I could restore his sexual power in one troatnient, I would not give him that treatment for a tliousand dollars, and that I considered it a very excellent thing that he was losing his sexual power, for he would thus perhaps cease to he a menace to many women and, tbroiigh them, many men. And I even told him that I considered such a man as ho much worse morally than any street walker, and ihiit it was not phvaical. but moral treatment that he needed. And with tliflf we parted. Case 6. Age twenty-four; married four months. Waa perfectly normal until marriage, and perfectly normal the first three months after marriage. During the last month 4 SEXUAL IMPOTENCE IN THE MALE 193 gan to notice that the erections were weak and imperfect, ejaculations irregular; sonietimea very quick, at other times prolonged, but in each case the semen was thin and watery. Examination discloses a strong, passionate fel- low (Hungarian). Used to indulge frequently (2 to 4 times a week), hut fearing infection abstained for 4 months before marriage. From the wedding night indulged ex- cessively 3 to 10 time6 in the 24 hours, without skipping a day (even during menses). While at first the wife ob- jected to such frequency, after 5 or 6 weeks she became not only a willing partner, but her demands even exceeded the supply. It did not come to this patient's head, tliat he was indulging in killing excesses, and that these excesses might have somethiug to do with his b^inning impotence, I gave him a lecture; then I prescribed for his wife 60 grains of the combined bromides pro die, and told him that he must abstain absolutely for a month, and after that indulge not oftener than once a week ; later on he might permit himself twice a week. I also gave him a placebo — 1 ounce of ac. phosphor, dil. — 5 drops in a little water after meals — ■ which be was to take r^^Iarly for a month. At the end of the month he reported restoration to perfectly normal health. In the first attempt the ejaculation was premature, but in the second it waa normal, and has re- mained normal ever since. He leads a moderate sexual life as outlined by me. The wife was inclined to object at first — she thought that once every night would not hnrt him, but a confidential talk, in which I explained to her that excess now might mean premature decay later on, put matters right. Married women are not selfish and they make sacrifices much more readily than men do. There IM SEXUAL IMPOTENCE ^ is no question that in sexual matters, man is a selfish brute — generally speaking. Of course there are esoeptions on both sides. Que 7. Age twenty-five, complaine of frequent mic- turition, slight scalding of the urine, erections on the slight- est provocation, such &a standing iip in the subway trains close to a woman, frequent " mucous " discharge from the urethra, almost nightly pollutions, and immediate ejacu- lation on attempting intercourse. Has never bad venereal disease, but investigation discloses the fact that he has been a furious masturhator from the age of seventeen, lie masturbated daily, and sometimes several times a day, between 17 and Ifl, after that about 3 times a week. At the same time he began to have pollutions. He went to a physician, who instead of e.xamining him, gave him some allegedly aphrodisiac pills (containing that humbug dami- ana, phosphorus and nux vomica) and told him to go with women. Any attempt, as stated above, always resulted in ejaculation ante iiUromtssionem. On examining him I found the verumontanum extremely congested and sen- sitive; it bled at the slightest touch. This was an ideal case for cauterization, and I instilled 3 drops of 50 per cent solution of silver nitrate by the aid of the urefhro- scojw. The pain was excruciating, the strangury fol- lowing it was severe, for the next 24 hours he passed a few drops of blood at each attempt to uriiiato, and the erections were acute. But I was not frightened ; I waa familiar with these symptoms, and I knew that was exactly what was needed in this case. I ordered strontium bro- mide internally, morphine and atropine suppositories to relieve the strangury, as well as hot sitz baths. In 3 days J SEXUAL IMPOTENCE IN THE MALE 195 ■ifll the symptoms following the application were gone, and ■ the patient felt better in every respect. Not only his local ■ symptoms, such as frequency of urination, and the general I'feeling of irritability in the urethral canal were improved, I but his general morale bad undergone a change for the r better. In ten days after the first application I undertook I another, but this time I preceded the silver nitrate with a Ifohition of alypin nitrate. The reaction was very alight. Fin a week I gave him an instillation of silver nitrate — five drops of a 10 per cent solution, and without alypin. The reaction was more intense than after the second treat- ment, but incomparably milder than after the first. And I this, str&nge as it may seem, completed the treatment I iftxpected to give him infernal treatment, baths, electricity, Mc., but I found it was unnecessary in his case. After the third treatment, his pollutions stopped, he had no desire to masturbate, his irritability disappeared, and ho felt as lie said, using the hackneyed phrase, a new man. I ther»- fore started to wait with any additional treatment. But lie did not need any. In about a month after the last treatment he attempted intercourse. He effected intro- mission readily, though ejaculation was premature. But after two or three more attempts, everything was normal. tHere we have a complete case, where all the sexual troubles — pollutions, irritable and weak erections and pre- mature ejaculations and the resulting general irritability — were due to a purely local cause, and were all removed liy exclusively local treatment. Such cases are not very common, hut they are more frequent than ia generally Im- agined, and should always he home in mind. Caas 8. This caae ia in almost every particular like the 1 196 SEXUAL IMPOTENCE preceding ease, except that on accoimt of tlie e-xtremelj narrow meatus I had to do a meatotomy, and that five Etillationa of silver nitrate were required before a cure wag effected. This patient married eoon (about three months after the completion of the treatment) and his sex- ual life has been normal in every way. About a month after marriage, he began to feci a little irritation and burn- ing feeling in the posterior urethra {I ascribed that to excessive intercourse) and the desire to masturbate also seemed to come back, but one instillation of silver nitrate with a few doses of strontium bromide relieved all symp- toraa, and after that he needed no furtber treatment. Case 9. Age 25, strong, ruddy faced, plethoric, emi»- sions about twice a week, intercourse about once in two weeks. Erections strong, but ejaculation very premature, the voluptns of the orgasm, however, ia undiminished. Never had any venereal disease. Eats heartily and usu- ally has wino with dinner. Examination shows every- thing normal I recognize that this is a case of plethora, excessive elaboration of seminal fluid. I ad\'ised him to cut out wine entirely and to reduce his diet somewhat. Medicinally, I prescribed the combined bromides, 30 grains 3 times a day. After 6 weeks' treatment he reports c pleto improvement in his condition. Emissions reduced to about once in ten days, while intercourse is in every way satisfactory. Cau 10. Ago twenty-four. This is a sad case. Younge&t of three brothers. Tlicv hatl a vicious maid in their employ for many years. From the history T bare no doubt that she must have been a n^^inphomaniac. She to masturbate him when he was nine years old. At d ffll IMPOTENCE IN THE MALE 197 I first lie liked the aensation, but after a year or two lie I rebelled, but she actually forced him to it, and he waa I to such au extent under her domiiiatioii that he was afraid f to resist hor. Between the ages of 13 and 1-t she forced I him to have natural intercourse w-ith her, and she com- pelled him to keep it up for two years, practically every J day, without exception; occaaionatly even twice a day. I After that he began to have great difficulty in getting an. [ erection; she commenced to force him to have coitus per This was going on once or twice a week for nearly a year. He then became very sick and anemic, a cough developed and tuberculosis was feared. He was sent away to the country for several months. When he returned the maid was gone. (Perhaps because there was no other male in the house.) He believes that the vicious female had I done exactly the same thing to his two brothers. One of them died at the age of 28, he did not know exactly of I vhat, the other brother married, but began to live \m- happily with his wife right after marriage, and now lives Beparated from her. He himself has had nothing to do with women since he became free from his tormentor. He never experienced any desire for intercourse. He used to I have occasional, though rare, pollutions of a thin, watery fluid, but even they stopped. Eecently he met a beautiful young girl, with whom lie is in love, and he came to find out if he was fit to get married. I examined him. The penis was as small as that of a boy 6 or 7 ; small, shrunken, livid ; and the testicles were difficult to find. When found, they were felt to be of extremely small size. There was also bilateral varicocele. I told him as gently and as sympathetically aa I could that I did not think treatment SEXUAL IMPOTENCE would be of anj avail in his case. It was a case of com- plete exhaustion of the sexual center and atrophy of the testicular glands due to terrific abuse of the immature sex- ual organs in caxlj childhood. I should add that palpa- tion per roL'tum showed the prostate also to be considerably smaller than normal. He was a nice, pleasant fellow, and I thought it my duty to speak frankly to him, though in as delicate a language as possible. In spite of all I said, he asked me urgently to try and see what I could do for him. iris life depended on it. For four months I ex- hausted every possible means, but aa I knew beforehand, all was in vain. I told him it was useless to try any further. And I told that for him to marry an ordinary woman would mean a calamity for both. There are women, however, who are absolutely devoid of any sexual deeire and who nevertheless crave for the companionship and tile company (the two words are not synonymous) of a good man. If he should happen to find eueh a woman, he could explain to her his condition, and they could estab- lish a comfortable and perhaps even a happy — in its way — household. He thought at first to begin to study for the priesthood — he is a Catholic and it would not be hard for him to remain true to his vowa of celibacy and chastity. He changed his mind, however, and is devoting his time to the study of philosophy, history, economics, etc., and he is relatively salisfiod. And he is now keeping company with an estimable yoimg woman who seems to be all mind, and for whom terrestrial tilings apparently pos- 8 no charm. Oaae 11. Age 3.5, married 13 years. The story was 1 told hesitatingly, with many pauses, but briefly it is as A I I I SEXUAL IMPOTEN"CE IN THE MALE 199 follows: A case of love at first sight. Always passion- ately attached to his wife, and even now would gladly " sacrifice Lis life " for her. But nevertheless during the last year began to notice a coolness towards her, and a lack of desire for intercourse; could go for months without the slightest difficulty. Erections slow and rather imperfect; ejaculation, however, not markedly premature, but the pleasure of the act is slight. Had never had intercourse with any woman except his wife, either before or after marriage. Has been having longings for other women, but lias strenuously and successfully resisted extra-marital intercourso, I suspected that his trouble was psychic, and not physical. Still I examined him. Found absolutely nothing abnormal. And told him so. Told him 1 did not think treatment would be of any avail in his case. Still he insisted that I make a trial. After a month's treatment no improvement And though he requested that I treat bira further, I refused. He went to a neurologist who treated him for four months without any improvement. On the contrary, he became worse and the lack of libido l>ecame more marked. He came back to me. I thought it was my duty to have a frank honest talk with him. I told him his case was not unique. I explaineil to him as delicately as I could, that while monogamous marriages were for the best interests of society, still man was by na- ture jmlygamous ; monogamy was an artificial condition, which while it suited most men perfectly, was very irk- some and even unhealthy to some. Especially to those who never had any ante-nuptial relations with other women. I told him that I had many such cases; after one or a few eictra-marital relationships, their libido, their power and 200 SEXUAL IMPOTENCE asain their love for their wives returned and they were again in perfectly normal condition. He asked me: Would I adrise him to attempt extra-marital relatione ? I an- swered him, I would advise him nothing. It was not my province to advise in sueh cases. My province was to tell the truth as I knew it and to explain matters, from a purely scientific standpoint, without any religious or moral Was. But the conclusions from my explanation my patients must draw themselves. Whether he did draw conclusions and act upon them or not, I do not know. Is it morally right ever to tell a patient that his im- potence is purely psychic, and is due to his dislike for his wife, thus perhaps putting him on tlie way to extra- marital relations, or is it better to conceal the truth ! In other words, should a physician always state the facta to the patient, as he finds them, or should he bo controlled in his statements and his advice by his own and his patient'a moral and religious opinions? This is a question which will bear considerable discussion. Oaae 12. Twenty-five years old. Never had sexual re- lations. Complains of lack of libido and very frequent pol- lutions; they occur almost nightly, without any erotic dreams or erections and leave him weak and depressed in the morning. But what annoys him still more, is a feel- ing of coldness, chilliness, in the lumbar region, around the loins, in the perineum and about the genitals. He al- ways feels cold in tho lower part of the body. In the sum- mer it is not so bad, though there is an unpleasant sensa- tion about there, but in the winter no matter how warm he may dress the feeling of chilliness is there. His feet are A SEXUAL IMPOTENCE IN THE MALE 301 very cold at night, and lie Laa to sleep in woolen socks and cover himself very wannly. Examination shows that it is not imagination. The small of the back, the genitals, the upper portions of the thighs actually, feel cold to the touch. He has been treated by a number of physicians. One gave him bromides (H). another one strychnine, a third tried electricity, but he felt not the slightest improve- ment. The only thing that gave him some comfort was a flannel abdominal bandage. I saw that there was some- thing wrong with the circulation in the lower half of his anatomy and suggested daily massage and hot sitz baths. He could not afford massage, but he could manage to take the baths. I advised him to take one every night, as hot as he could stand it, putting twice or three times a week about two ounces of mustard in the bath. After the bath he was to wash his genitals with cold water, to prevent un- due relaxation of the blood vessels. He began to experience the beneficial results of this simple treatment, which was not accompanied by any medicinal measures, after one month. His pollutions became rarer, but began to be ac- companied by erotic dreams. My idea was that improving the circulation, increasing the amount of blood, would stimulate the sexual spinal centers and improve the nutri- tion of the genital organs. I did not consider medicinal or local treatment indicated in his case. I only increased bis diet, having him consume generously eggs, oysters, meat, etc. My line of reasoning proved correct. After six months of the baths, which were during the last two months supplemented by home exercise and brisk walks, ho began to liavo strong libidinous desires and his pollutions, while J SEXUAL IMPOTENCE L . ae BtroDgly erotio. An attempt ut iutcrcourse isfaotory. He married six months later, aud, le not over- vigorous, he is sexually normal, indulging « a week with perfect satisfaction to himfielf and bia CHAPTEE TWENTY-NINE SEXUAL IMPOTENCE AND ATHLETICS It is but natural that when, we see a niddy, well-devel- oped, well -nourished and thorouglilj heal thy- looking in- dividual, we should think of him as healthy in every re- spect. It is but natural that when we see a six-footer with splendidly developed biceps musclea, who is an all-around athlete, we should think of him as possessed of a powerful sexuality. It is natural that baseball players and prize- fighters and policemen and military men should make a fanciful appeal to the imagination of the feminine half of mankind. But, cruel as it may be to do so, the illusion must be destroyed. A powerful athlete is not necessarily sexually powerful or even sexually normal. Just as a man may be in excellent health and still suffer with weak eyesight or poor hearing, so a strong, well-nourished athlete may be sexually very weak or even absolutely im- potent I bare seen so many athletes who suffered with one form or another of sexual weakness that I began to ques- tion if there was not some causal relationship between the physical exercise and the impotence. This may seem a very revolutionary notion — that physical exercise and training should be productive of sexual weakness. But it is not 80 revolutionary at all — for please remember that more than two thousand years ago the ancieot Greeks, who were certainly acute observers, used to 203 i 204 SEXDAL IMPOTENCE ^ Bay that all professional atUletea were sexually impotent! Tiiia is a subject very well wortli iuveetigating and dis- cussing — particularly investigating. And 1 should be pleased to have phyaicians who have come across cases of sexual impotence or sexual weakness in athletes give me brief reports of their cases. But an important point is to be borne in mind. Wo must carefully distinguish be- tween real sexual weakness and sexual weakness which has supervened as a result uf sexual excesses. For these eases belong to two entirely different categories. If a strong, healthy, athletic fellow, endowed with a very strong sexuality, indulged daily one or more times for several years and has become impotent, then it isn't his athletics that is to blame for his weakness, but bis ex- cesses. The kind of cases I have reference to are illustrated by the following brief reports: Case 1. A. A., 28 years old. Was always fond of sports and athletics. Splendidly developed. All organs and functions in perfect condition. Formerly a leader and instructor in the Y. M. C. A. gymnasium. Married six months. Masturbated but very little at the age of 15, but having learned of the sinfulness of the habit gare it up entirely. Had pollutions about once a luonlh or once in two months. Had occasional sinful desires, but would overcome them by brisk long walks or violent exercbea. Gradually his will became bo strong that it became easier and easier for him to repress his desires. On his wedding night he discovered, what he never thought of suspecting, that he waa impotent. Libido is present, erection comee readily, but is weak and subeidee almost immediately; SEXUAL IMPOTENCE IN THE MALE 305 ejaculation takes place before immisio is accomplished. Hia wife ia still a virgin, Wliile this condition worries and humiliates him, his general health continues as good as ever. (In this case a complete cure was effected, ) Case 2. A. B., 30 yeara old. Policeman. The pride of the squad. Six feet four inches tall, a splendid specimen of animal manhood. Muscle plus, brain minus. Appe- tite enormous, bowels always regular, has never been sick a day. Libido practically nil — as far as be is concerned wouldn't care if he never went near a woman. But he sometimes yields to the temptations of sirens on the beat or the taunts of friends, and then he finds that it takes him very long to get an erection. Orgasm very weak and devoid of voluptuous sensation. Takes the thing good- naturodly, and would not come for treatment if he had not made up hia mind that it was time for him to get married. Cue 3. A. B, C. Eiqiressman. Powerfully built. Healthy in every respect. Drinks and smokes moderately. Can lift heavier trunks and do more work than any of his companions. 29 years old. Has never had inter- course. Tried it three times, but each time the attempt ended in a fiasco. Twice he had an erection, with almost immediate ejaculation ; the third time all efforts to induce an erection proved futile. OaM 4. A. D. Physician, 35 years old. No healthier and handsomer disciple of ^sculapius ever takes part in the discussions at the meetings of the American Medical Association. Feels healthy in every respect — has always participated in games and sports. Condition: Libido A S06 SEXUAL IMPOTENCE very weak (exclusively mental) and absolute impotentia erigendi. Caae 6. A. E. Cousin of Case 4. Civil engineer. All-round athlete aiid thorough horseman. Condition Bame as in previous case. Here we have cases from different stations in life which well illustrate the co-existence of sexual weakness with perfect physical health, nay with a thorough, athletic, a bove-t he-normal development of the body. Per contra, we often see poorly developed weaklings, suffering with various diseases, who are very powerful sexually, both as regards libido and potentia. Case 6. Mrs. X. Twenty-nine years old. Married one year. Husband complains that she is perfectly frigid^ like a wooden Indian. He ia very much disappointed, as what attracted him to her was her well-developed muscular body, healthy outdoor complexion, fine bust, etc. Every- thing in her suggested strong sexuality, which always had a great fascination for him. She was a fine pedestrian, fond of all outdoor B|)ort9, and enjoyed magnificent health. Was never sick in her life. And still she was completely anesthetic. Confidentially she tells me that she never un- derstood why other women were so crazy for men. Assures me that she has never masturbated, and I fully believe her. Whether her sex instinct is simply dormant and will awake later — in some women it awakes quite late, at 35 or even later — or whether she will stay forever frigid, remains to I Been. But the case is illustrative that in women as well as in men a strong well-developed body does not always go with a strong sex instinct. I know many healthy, buxom women who are sexual nullities. On the oMMV OAX IMPOTENCE IN THE MALE 207 hand, I am often afraid of the tMn, pale, anemic, some- what dingy-complexioned girl or woman, for she is very apt to be a passionate, burning, iinqnenched, if not un- quenchable, volcano. Her very thinness, paleness, anemia I dingy complexion are often the result of her strong passionate nature remaining xmsatisfied or only partially satisfied. It is well to bear in mind that the sexual function is a function per se, having its own centers in the brain and Bpinal cord, and its strength or weakness is not necessarily related to or dependent upon the strength and weaJtnesa of the body in general, and a splendid specimen of hu- manity may be and frequently is a pitiable failure in reius eexualibus. 'blAi, CHAPTER THIHTY A 8UMHABY OF THE MOST COMMON TYPES OF SEXUAL DISORDERS Tho types of sexual disordprs whicli come under the eyes of the sexual specialist are endless in their variety, diver- fiity and complexity of their symptoms. He may sen a thousand cases, and not two of them exactly alike. One hundred cases may he classiiied tinder the same diagnosis, and still they may, and usually do, present certain dif- ferences and peculiarities, which recjuire modifications in the treatment, modifications which are sometimes of a dia- metrically opposite character. The types of sexual derangement proper, that is de- rangement connected with the sexual act, which the sexual specialist sees mast frequently are of seven kinds, (a) Lack of lihido. The patient complains that he has no desire for women and doesn't care at all for sexual relations. He is able to have erections, but when he does have intercourse, tho act affords bim no pleasure, (h) The same as (a) only in addition to the lack of libido, he u unable to have any erections, (c) Has a normal or even strong libido, but is unable to have any erections, (d) Has normal libido, normal erections, but the ejaculations ' are premature or precipitate, taking place soon or i mediately after or even before intromisaion. (e) The patient has normal libido, nonnal erections, normal ejac- ulations (though as a rule they are premature), but his complaint is that be derives no pleasure from tbe act; M SEXUAL IMPOTENCE IN THE MALE 209 when the discharge of the semen takes place he has no Beasation whatever, as if the urethral canal were anes- thetic. In some cases, the matter i8 even worse, for in- stead of a simple lack of sensation, there is a feeling of scalding or burning, during the passage of the semen, (f.) There is libido and good erection, but the ejaculation takes abnormally long, until he and hia partner are exhausted, or fails to make its appearance altogether, (g.) The man has no libido, no erection, no ejaculation, and if by various manipulations a slight ejaculation is effected, it affords no pleasurable sensation whatever. Sex does not exist for him. The, above five classes of cases will constitute a large proportion of the sexual specialist's practice. The rest will be cases of masturbation, night pollutions (very many), day pollutions (comparatively few), prostatorrhea, upe- throrrhea, spermatorrhea, painful ejaculations, sterility, which we find is due either to aspermia or azoospermia or necrospemiia, disagreeable effects following the sexual act, such a3 severe headaches, migraine, nasal congestion rendering breathing difficult, cardiac palpitation, pain in the back of the neck, pain in the back, confused mind and inability to work or concentrate the mind, heavi- ness in the legs, sharp shooting pains in the urethra or the prostate, neuralgia of the testicles, etc; and last but not least, cases of sexual neurasthenia (vast numbers). The balance will be mode up of cases of priapism, excessive li- bido (satyriasis, nymphomania), fetichism, sadism, maso- chism and homosexuality, and the various severer psycho- pathies, which take the patient out of the normal class, and render him a fit subject for an asylum for the insane. 210 SEXUAL IMPOTENCE r-». I will present briefly and Bynoptically a few cases from my practice, which will form a sort of summary of the varieties of sexual weakness. Here and there, I will in- clude a hint about the treatment and the result of tho treatment. Oaa« 1, Twenty-four years, very intellectual. Mastur- bated from 1-1 to 19, about 3 times a week. He then read in a quack booklet about the terrible results of this Wee, and he gave it up suddeuly. Almost immediately after he began to have polhitions, once, twice and three times a week. When this kept up for altout six months he con- sulted the family physician. Tho latter told him it was " nothing," it was a perfectly normal phenomenon, and prescribed potassium bromide in large doses. This helped the pollutions; they were reduced in frequency to about once a week or once in ten days. This condition lasted for several days after he discontinued the bromide. But then the pollutions came back worse than before: four to five times a week, then every night and sometimes two or three time.-* a night. He again began to take the bromide, but this time it had no effect. If anything, it made matters worse. It certainly depressed him and ruined hia digestion. Other remedies — chloral, lupulin, camphor monobromidc were tried with no effect. Neither his maa- turbation nor his pollutions bad affected him much. But now he was getting anemic and began to emaciate. The family physician was again consulted and this good man gave it as his deliberate opinion that the only thing for the patient to do was to get married. The patient de- murred and consulted another physician, who gave the A SEXUAL IMPOTENOE IN THE MALE 211 same advice. In about six months the patient got mar- ried. He found that be was able to have sexual relations, though the erections were not very strong and the ejacu- lations were somewhat premature, he thought. At least they took place long before the wife was satisfied. But he soon noticed that intercourse had a disastrous effect on him. He would feel on the following day, and for two, three days after, as if he had been hit on the head with a club. He would be unable to concentrate his mind on any kind of work ; he would feel a " vacuum " in his brain ; the spine " would be painful and weak, the legs heavy and hot, and he would feel ^vTetche<^, anxious and quarrelsome. After three or four days Ihe symptoms would gradually paaa away. Appetite poor, bowels constipated. I saw that in this case the brain was overworked and the body under- nourished; his body could ill afford the drain made on it by intercourse and by the loss of semen. I ordered less mental work, and more or less forced feeding. Plenty of eggs, milk and m^eat. Complete ab- stinence for six months. Passed sounds and psychrophores once a week, once in two weeks. In two months he re- ported himself as feeling well. Intercourse had no bad effect on him. I told him to be very moderate. He dis- obeyed and in a short time he came back for treatment. .\fter he was practically well, I told him that there were types of men (intellpctual workers particularly) who could not have sexual relations oftener than about once in two weeks, and he must limit himself to that frequency. He 1 212 SEXUAL IMPOTENCE has been living witlijn these limits and is feeling well. Case 2. Thirty-aix years old. As far aa ho can re- memlter has nevur had any sexual desire, has never maa- tnrbated, has never had any emissions, Onee or twice by handling the genitals got some erection, which quicltly siihaidcd. Examination shows small, well coiilrncted scro- tum, but no testicles can he felt, Crj'ptorchid or anorchid. Penis normal and of good size. Cue 3. Complains exactly the same as preceding case, hut examination shows the presence of two very small testicles. Also a congenital impotent. Caw 4. !Masturhated as far as he remembers from the age of seven ; maybe before. Kept it up right until about two weeks ago, when he got married. Sexual organs small and shrunken. Complete impotentia erigendi, but libido present. Completely well after eight months' treatment. CsM 5. Twenty-eight years old. Has masturheted steadily for 15 years (at least), since the age of 13, on an average 4 to S times a week. Testicles large and " puffy," hut penis so small tliat it shrinks completely within the prepuce and is hardly visible. For the last two years the erections during the masturbatory act have been getting weaker, and now the seminal discharge takes place wiiii the penis in an almost flaccid condition. Uasn't had a night emission in years. Never attempted intercourse, on account of strict religious bringing up. lie consulted a physician, who advised him to get married " right away," But he has his doubts about the sound- ness of the advice and came to consult me. Some laymea have more common sense than some physicians. As he showed all the signs of impotence, I told him to get the d SEXUAL IMPOTENCE IN THE MALE 213 matrimouial idea out of his Lead " right away," If witli persistent treatmeiit, and occasional illicit relations, he should become fairly normal in a year or so, he should consider himself lucky. O&se 6. Twenty-five years old. Masturbated for ten years, on the average one day in the week, but three or four times during that day. From the age of 21 has also had relations about once a month. Is now losing the desire for sexual relations, but cannot give up the solitary habit Has no night emissions, but any excitement, not necessarily sexual, brings on a discharge (slight) of spermatic fluid. Cold baths, psychrophores, AgNOj instil- lations brought about a complete cure in less than four months. Case 7. Has a normal desire, but very great difficulty in getting an erection. Takes sometimes an hour of various manipulations and coaxing before an erection is obtained. After that he is all right. Masturbated for about 12 years steadily, practically every day or every other day, but has given up absolutely for the last nine months. Has not had a single night emission during that time. Strychnine internally. Counterirritant ointments to the penis, silver nitrate instillations and Zabludowsky's suction pun

th sexes — all tliese are factors which prepare a seji- ually neurasthenic soil. But more important than any of the causes enumerated above is our moral-religious code concerning the sex in- stinct, which surrounds every sex manifestation with se- crecy, and surrounds the satisfaction of the instinct outside of wedlock with great and h umiluiting ditBculties. The re- pression of every sex manifestation is one of the greatest causes of sexual neurasthenia. As to heredity, I do not ascribe to it the same importance that other physicians da I have expressed my opinion SEXUAL NEURASTHENIA 223 lany times before, that the importance of heredity as a factor in disease has been greatly exa^erated, and in my opinion heredity plays but a very subordinate place in sexual disorders. It may be admitted, however, that chil- Idren of neurotic and otherwise tainted parents are more apt to fall victims to various sexual irregularities, which may lead to sexual neurasthenia, and that on the other liand injuries which would have but little effect on de- scendants of healthy stock may bring irreparable disaster to nature's unstable step^^hildren. Is any one of the OBUses mentioned in rubric one in itself sufficient to induce sexual neurasthenia? Is masturbation alone, for instance, sufficient to do it? Yes. If indulged in to great excess, it may without the aid of any other factiirs bring about sexual neurasthenia. But let us leave out the extreme ieoceeses, the so^allcd furious masturbation. Let us take tile various moderate degrees. Why does A who prac- ticed masturbation pretty steadily, 3-4 times a week for several years, escape practically witliout any damage, find- ing on attempting intercourse his powers unimpaired, and his nervous system unaffected, while B who practiced mas- turbation only once or twice a week for about two years finds himself a confirmed sexual neurasthenic? Because La was bom of healthy untainted parents and lives an easy, ftopen-air, praetieally care-free life, while B has inherited ■A nervous constitution, has always led an indoor life and I lias studied hard from childhood, using up his last bit of II reserve force in competitive examinations. Why does C make a joke of his chronic protracted [onorrhea, his only regret being that he cannot indulge tally as often as he would like to, while D is thrown S34 SEXUAL IMPOTENCE into the deepest distress, aiid tbo little hardly visible morn- ing drop makes a gloomy hypochondriac of him? The same reason. And so it is with all causes which wo have enumerated above. They may in themselves in exceptional cases cause sexual neurasthenia, but they are much more likely to do it if they are operative in a man who has inherited a nervous constitution, and who lives tho higli-presaure, un- hygienic life of our modem civilization. The Symptomatology of Sexual Nenrasthenia. Aa indicated at liic bediming of the chapter, the sjTnp- toms of sexual neurasthenia are exceedingly numerous and varied. We could start at tho top of the head and go down to tho soles of ibe foet, and wo would find that every organ in between may be attacked, and may show symp- toms varying from annoying to agonizing. But we will begin with the sexual and urinary symptoms, as they are more immediately and more frequently concerned. Krafft-Ebing divides sexual neurasthenia into three stages. In the first stage tho geniti>urinary organs are locally affected and we have the various functional dis- turbancce of coition and urination and pains in and around the genital organs. In the second stage the neurosis baa extended to tlie lumbar cord and the patient complains of various symptoms pointing to spinal irritation. In the third stage we have a general neurasthenia. We will not adhere to this division, because while schematically very convenient, it is but seldom observed in practice. The sjTnptoma of these various stages are generally interwoven, and those of the so^alled second or third stage may make I ir appearance before those of the first. We will there- fore follow a more practical method. Sesoal STmptonui. Disturbances of the sexual system form of course a prominent feature of sexual neurasthenia. Tho patient tells us he is impotent and his organs have Ehrunk away. When we tell him to undress, we find in reality the penis verj' small, retracted, sometimes so com- pletely " drawn in " as to be hardly visible, cold, livid and very hard. This hardness is rather characteristic; the hardness is sometimes that of cartilage. The scrotum is also well contracted and retracted, so that it is sometimea difBcult to feel the testicles. The testicles are either nor- mal in size or in extreme cases, especially where the neurasthenia is the result of excessive masturbation, con- siderably reduced. They are generally very sensitive to the touch, sometimes to such a degree that the gentle grasping of them between the fingers will make the pa- tient deathly pale, his face will be covered with cold per- spiration and he is ready to faint, and sometimes does faint. The small size of the penis is partly real and partly psychic. That the small size of tho penis which we no- tice on examining the patient, is partly due to psychic causes, is seen from the fact, that it is generally only during the first examination that its shriveled condi- tion is so apparent. It is the " shame " and nervous- neaa before the new physician. At subsequent examina- tions the difference in the size of the organ is quite noticeable. The same thing occurs at any attempt at intercourse, especially with a strange woman. To tho patient's ex- treme mortification, at the critical moment, the penis in- 226 SEXUAL IMPOTENCE stead of getting erected, gels slirunken and shriveled and practically disappears. In otlier cases on the other hand we find the external genitals greatly relaxed. The penis is rather large but soft and flabby, while the scrotum and testicles hang low down, and there is generally a slight varicocele on the left Bide. Pollutions are frequent, and are generally atonic; in the further progroas of the disease they become diurnal, and may be accompanied by spermatorrhea. Impotence is either absolute, the patient being unable to get any erec- tion, or he has feeble imperfect erections, which subside quickly. The ejaculation is in the vast majority of cases premature, generally taking place even aiUe intromis- sionem; in a certain percentage, however, it is retarded, the patient being able to efifect intromission, but the erec- tion subsiding before ejaculation has taken place. A pe- culiar symptom the patients complain of is a burning, scalding sensation during ejaculation. The pleasurable voluptuous sensation which the normal man experiences during the passage of the semen is in them completely ab- sent and the burning, scalding feeling combined with subse- quent depression renders the act of coitus a very unpleasant function. And still they have an irritated, impleasant feeling, what I would call a pseudo-libido, which forces them to indulge again and again. Others, however, in whom the libido is very weak or completely extinguished, may abstain for years from any sexual relations. Masturbation, severe and uncontrollable, is often com- plained of. It may seem strange that mastiirbation which vc gave aa one of the causes of neurasthenia should here SEXUAL NEURASTHENIA j be considered as one of the symptoms or reaulia of it I But there is nothing incongruous in this. In many dis- eases, and in. sexual disorders par excellence, a vicioua circle is generally established and the original cause be- cotnee but one link in the chain of symptoms. Masturba- tion is one of the principal causes of sexual neurasthenia; but after masturbation has succeeded in bringing about the neurasthenia, the patient's will is wealcened, and he may become a helpless slave to the hahit. While at the be- ginning the patient could control himself more or less, and the masturbatory act afforded him pleasure and satis- faction, he now indulges in it because he cannot help himself, because he seems to he impelled hy a force majeure, and in spite of the fact that the performance of it gives him no pleasurable sensation, but on the contrary gives him a burning, unpleasant feeling in the urethra, and leaves him depressed and disgusted. On some neurasthenics the effect of intercourse is very profound. It leaves them for a day, for several days, and sometimes several weeks, completely exhausted, both mentally and physically. Their brain is fagged out, they cannot concentrate on anything, their legs are weak, they fatigue quickly on walking, and suffer with severe cardiac palpitation. Besides the functional disturbances in the sexual act, numerous symptoms manifest themselves in the genital organs which are very annoying to the patient and very trying to the physician. The skin of the penis and of the scrotum is hypersensitive and the patient often com- plains of various sticking or neuralgic pains. There is generally extreme sensitiveness to cold. Pains in the tes- SEXUAL IMPOTENCE tiplos are frequent as well as in the prostata. Sometimes the pains arc only shooting and last bnt a second, at other times they are very persistent and may extend to the pro9- tate, kidneys, legs and even feet. In some cases there is very severe itching about the genitals, the most careful examination failing to elicit any basis for this pruritus. Sometimes instead of the genitals the itching is confined to the amis. A very disagreeable and resistant symptom is hyperidrosis and broraidrosia of and about the scrotum. The odor of the perspiration is in some cases extremely offensive. The " hanging drop " symptom is to some pa- tients the most maddening of all. Patients who suffer neither from urethrorrhen nor from spennatorrhea (in these disorders the drop is present) will imagine that their meatus is wet and that there is a drop there. Dozens of times they will examine the organ to find it perfectly dry, and stilt they will continue to ho tortured by this apparently alight, but to them, very disagreeable symp- tom. That the urethra, particularly near the meatus and in the prostatic portion, feels extremely sensitive, we have already seen in the chapters on masturbation, pollutions, etc We have also seen that on the other hand in the later stages of the disease the urethra may become almost completely anesthetic to such procedures as passing a sonnd, for instance. Urinary STinptonu. The act of urination is very much difiturbod. The patients urinate very frequently, par- ticularly in the daytima TLey may have to get up nights, but that only in extreme cases. As a rule they sleep through the night very well and this is one of the SEXUAL IfEURASTHENIA Ieh&racteriBtic symptcoiis of the frequency of micturitioQ in neuraathenios, which distinguishes it from frequency of micturition in other disorders, such as hypertrophy of the proatate. The frequency of urination is sometimes very great. Some patients have to urinate every hour, some every ten or twenty minutes. There is a little dribbling of the urine after each act and the patient will not feel fully relieved. They always feel as if there were some urine in the bladder which they are unable to void. While in many cases the urination is painless, in others there is associated with the frequency considerable dysuria and even strangury. Xervous retention of urine does occur, but is rare. The difficulty or inability to start the act of urination is another symptom worth while re- ferring to. Some patients may have their bladder full of urine and still be unable to micturate in the presence of the physician. They must go in a separate room or be- hind a screen, and only then they are able to do it. Some can only start the act of urination at the sound of run- ning water. The Shiver. The shudder to which we referred to in the chapter on pollutions is here very prominent. It is either localized in a small portion, usually the center, of the spine, or it takes place throughout the entire spine. Occasionally the entire body would participate in the shiver, so that the knees suddenly flex and the head shakes. Since I became familiar with this symptom, I have made it a point to inquire of each sexual neurasthenic as to its presence, and in the largest percentage of cases the an- swer would be in the affirmative. Patients who present this symptom do not have it constantly. It appears with 230 SEXnAL IMPOTENCE ^ some urinations; it is absent with othera. In trying to solve this point — wliy patients experienced it at some urinations and not at others — I made a microscopic ex- amination of a large number of specimens of urine, and I have discovered the following peculiar fact; When- ever tlie patients experienced the shiver, the urine con- tained semen and spermatozoa; whenever the shiver waa not experienced the urine was usually free from sperma- tozoa, and it is my opinion that the shiver occurs erience3 on urination. Duo to the constipation and the intestinal fermentation, indican ia usually present in large amounts, sometimes to SEXUAL NEURASTHENIA 231 Bueli a degree that on makiii^ the indican test, the urine turns actually black. Of course the urine also presents the various appoar- ancee of underlying conditions : post-gonorrlieal shreds, the masturbator's shreds, the " cloud " of spermatorrliea, etc. Pains and Aches. Pains and aches in the spine, in the back, are among the moat frequent, one might say ihe most frequent, and moat annoying symptoms of the neurasthenic. Usually, it is not a pain, but just a con- stant dull ache in the small of the back or the middle of the spine, wliich is so exasperating that ninny patients say that they would gladly exchange it for an acute pain. The patient feels like nibbing his back against a door post, or a bedstead, or any other hard object and feels greatly relieved after a rough kneading or slapping or mas- saging of the back, or applying a counter irritant to the aching region. Sometimes the pain is limited to one side, in the kidney region, and may simulate renal colic so closely, as to bring the patient near the operation table. Circulatory Symptoms. Among the symptoms on the part of the circulatory system the most frequent is palpi- tation of the heart. The least excitement or muscular effort is apt to cause it. In the night time if the patient wakes with a start, which be often does, the heart will beat very tumultuously. The pulse is frequent, often over 100 per minute, small, occasionally intermittent Tliere is a feeling of discomfort in the cardiac region; it is not a pain, but the patient feels like rubbing, press- ing or supporting the precordium. Sometimes, though rarely, there is a real pain, simulating angina pectoris. And all these symptoms of course without any heart le- 232 SEXUAL IMPOTENCE Bion ; though again of course a sexual neiirasthpnie may also have heart disease, but that is another matter. On account of the poor and irregular circulation, the patient's feet are often cold and clammy, so that he must sleep with his stockings on, even in fairly warm weather. His hands may also be cold and clammy and perspire readily. The blushing at the le-ast provocation, and the frequent congestion of the bead, abo find their explanation in the disturbed circulation and innervation. The respiratory tract is not affected. Some authors have described a dyspnea or asthma peculiar to sexual neurasthenics, but 1 have not come across any such in- stances in my practice. If the heart is subject to severe palpitation then the patient is naturally apt to become short of breath, but this dyspnea is then merely a part of the cardiac symptoms. Digestive Symptoms. The digestive disorders occupy a prominent place. The appetite may vary from bulimia, which is quite common, to complete anorexia. And it is worth noting, that in spite of hia excessive appetite, the bulimic patient may emaciate almost as much as tlie patient without any appetite. For the assimilation is poor, and the patient's metabolism is very rapid, Symp- tomB of dyspepsia are seldom absent: coated tongue, heavy breath, heartburn, which may be extreme, the patient de- claring that he fools as if he bad a burning coal in his stomach, hyperacidity, afterwards followed by hypoacidity, constipation, rarely diarrhea, belching of ga^, borborygmi; occasionally there is some difficulty in swallowing. The dilative disorders are important, for it is they that gen- erally send the patient first to the physician. A patient SEXUAL NEURASTHENIA Ihaa DO hesitancy in consulting a pliysician about a diges- tive diaorder, while he will wait for years — until hie condition is uniniatakable and intolerable — before he will seek advice for a sexual trouble. The Special Benaes. To the symptoms of the special senses we will refer briefly. The eyes as we mentioned al- ready are easily fatigued, and the patients frequently suffer with eyestrain. Muscae volitantes, floating specka before the eyes, is not an infrequent symptom, e.xtremely annoying to the patient. Itself the result of the neuras- Itbenia, it often helps to aggravate it. The patients are extremely sensitive to noise. The tooting of automobile horns, the noise of vehicles, loud music, the chimes of church bells are a veritable torture to them. The sense of smell may be hyperacute, and sometimes there is a per- Teraion of that sense: the patient will all at once smell iodoform, musk, etc. The sense of taste is but very sel- dom affected, though it may be in a very bizarre manner. ■ Work. In the extreme stages of neurasthenia the pa- tient can do no work, either mental or physical. He cannot force himself to do any original mental work, it is an utter impossibility for him; and when he does force himself to do some routine mental or physical work, he I gives out very quickly, and has to rest or lie down. In the earlier stages, he may be able to do very good and very intense work, but only by spurts. He cannot do anything steadily, calmly, placidly. He is not a plodder, and he cannot work systematically. If he writes a book, he is very likely to write the last chapter first, then a chapter from the middle, then the preface, then he may throw away the whole thing, and start on some entirely 234- SEXUAL IMPOTENCE different work altogether. But in the end, when he fits the pieces together, and fills up the gaps, he finda that ho has probably at^compHshecI more than the plodding systematic worker would. IIo will whip himself up, work without interruption sixteen to eighteen hours a day for several days in succession, and then his mind will become a blank, and be will be unable to do any mental work for several weeks. I am speaking here of mental workers, because they form a largo percentage of sexual neura-sthenics, and becaxise ray practice is largely among the intelligent classes, writers, artists, etc It should be borne in mind, that some of the world's greatest writers and poeta were sexual neurasthenics, but only neurasthenics in the earlier stages. Extreme neurasthenics do not write, and what they do write is not worth reading. Some reader might stop here and ask : Isn't it possible that the long, rapid, hurried work exhausts the patient and is in itself responsible for many of the neurastbenie symp- toms? And I will answer: It is. Cause and effect, I will emphasize once more, arc closely interwoven in human pathologj', and whatever the cause which urges the patient to consuming, long-boured labor, there can be no question that this labor itself tends to still further aggravate his original condition. But I do not believe that hard mental labor, within rational limits, vriW by itself cause sexual neura£thenia. There must be some additional favoring predisposing causes. I said, n-illun rational limits. Of course, if a man works sixteen to eighteen hours a day steadily for many weeks, and has no freeh air, and on account of that enta poorly, and on account of the cerebral congestion induced by the hard mental work sleeps poorly, J I SEXUAL NEURASTHENIA he may break do\vn, get general nourasthcDia, which will in its turn bring about sexual neiiraatlienia. But this ia work beyond rational limits. The Mood. The mood of the sexual neurasthenic ia txtremely variable. The least pleasant occurrence or ex- pectation lifts him up to the skies, the least unpleasantness throws him into the abyss of despond. But most of the time he is afraid of something. If you ask him to a his fears, to tell you himself what exactly he is afraid of, he is unable to do it, but still he is afraid that some- thing bad is going to happen to him. He is either going to lose bis business or his position, his rival is going to get ahead of him, or some misfortune ia going to happen to a member of hia family, or the house is going to be burglarized, or he is going to be arrested, etc. Sometimes the fear is vague and has no object, the patient ia just depressed and afraid, and for this reason he avoids people in general. If the neurasthenic is not far gone, then a misfortune, an attack, a shock, or some great emergency may stir him to action, may awaken the rest of his dormant powers, and he may for a time surprise his friends by his unwonted strenuous activity. But unless he is at the aame time subjecting himself to tlie proper treatment, he generally relapses into a condition of exhaustion, which is worse than the condition he was in previously. One of the forms the fear is taking, is tlie fear of disease, i.e., the fear of getting sick. It ia either the fear of typhoid, of heart disease, of Bright's disease, etc., but most generally it is the fear of locomotor ataxia or gen- ■ eral pareais. This is particularly the case with our semi- H cultured who have read a lot of quack literature, or who 236 SEXUAL IMPOTENCE have heard from their friends with little knowledge that those diseases were the result of youthful indiscretions. How many times have I heard the question: "Doctor, have I locomotor ataxia ) " addressed to me by people with whom there was nothing the matter organically, and who did not present a single ataxic symptom. They feel like newborn, or as if a heavy load had been lifted from their brain, when they are assured and when it is proved to them that their fear is utterly groundless, Tho neurasthenic has often liypochondriac ideas, but he is not a true hypochondriac. A true hypochondriao complains of ills and diseases for which tliero ia no foun- dation, of which be has not a trace. The neurasthenic generally has grounds for his complaints, only he exag- gerates his troubles; he magnifies a mild symptom into a terrible one; a slight disorder becomes a very painful one to him. But again how can we know ? Perhaps, bis sensitiveness is so increased, that what seems to us inaig^ nificant does cause him severe pain. For we must bear in mind, that the neurasthenic is generally hyperestbetio and his power of rei^istance is groatly lessened. Phobias. The extreme cases of sexual neurasthenia may develop various phobias — fears of crossing the street, fear of being in a crowd, of being in a theater, of look- ing down from a great height. I have seen several caseB in which the last symptom was very pronounced. One of my patients was a well-known chemist, who did ex- cellent work and who stood very higli in the profession. Nobody ever suspected or ever will suspect that there was anything the matter tvith him and still ho was a sexnal neurasthenic and be hud a horrible fear of being in a d SEXUAL NEUEASTHENIA 2371 [ high place. He was a member of the Drug and Chemical Club, who have their clubhouse in the top story of a I skyscraper in William Street. And he would suffer I agonies if he would be invited by liia partners and friends to sit down, to dine near a window. His legs would shake, and the time of the meal would seem interminable. When by himself he would select a table as far away from a window as possibia Finally, he gave up going to the clubroom at all. Ho is however perfectly cured now and not only is he not afraid to stand near a high window, but last summer he climbed the Alps and crossed many I glaciers — and laughed at his former fears. The phobias are on the border line of psychoses; they form stepping stonea to them. And sexual neurasthenics ■ do sometime develop genuine psychoses. But here there ^ is, as a rule, something else tlie matter: there is generally , hereditary taint. And after they develop a genuine peychosis they no longer belong to us. They belong to I the domain of the alienist. i CHAPTER THIRTY-TWO I THE PSOOKOSIS OF SEXUAL IMPOTENOE ASD SEXUAL NEURASTHENIA Leaving out of consiileration the congenital and senile varieties, the prognosis in the majority of cases of impo- tence is favorable. That is, the large majority of cases of ordinary Bcxiial impotence are curable. But it might as well be stated here as elsewhere that sexual impotence, equally with chronic gonorrhea, is a luxury in which a poor man cannot indulge. It is not a poor man's disease. The treatment of it is long and as a rule costly, and tho poor man can not afford it. If a poor man is stricken with typhoid or pneumonia or cancer, there are plenty of hospitals for Lim to go to. No hospital will accept a patient who is suffering " merely " with sexual impotence, while the treatment that tliis class of cases receives at the dispensaries and at the hands of most general prae- titiouera is positively worse than useless. I make this statement with a full imdorstanding of the seriousness of its import. A bromide mixture, perhaps a little strychnine, or some worthless " aphrodisiac " tablets, is all the patient gets — and that without a considera- tion of the stage of the disease, the variety, without an endoscopic or microscopic examination. No wonder these patients keep on getting worse, become discouraged and drift into tbe bands of advertising quacks, or heart- brdten and despairing decide to live out their daya 23S J I SEXUAL NEURASTHENIA 239 without treatment. Sometimes suicide closes the scene. But when a man is well to do, if he is his own master, if he has nothing to worry about, if he can afford treat- ments as often as necessary, which, however, should never be more often than twice a week, if he can have the various baths and hydrotherapeutic measures that may be necessary, if he can take a vacation if the doctor considers it indicated, if he can take an ocean trip or spend a month or two at the seaside or in the mountains if that is considered nec- essary, then we can restore the vast majority of our sexual impottnts and sexual neurasthenics to good health. We may not restore them to their youthful vigor, but we can bring them to a condition which will be quite satisfactory to themselves and their wives. And in some cases we may even put the patient into a condition of vigor, su- perior to that that he ever was in before in his life. Pa- tients who never had a satisfactory erection or experienced ■ proper orgasm before or always suffered with premature ejaculations, can with proper and patient treatment be made into " new men." It is the patient himself who generally uses this phrase: " I feel like a new man.'' Never " guarantee " or even promise a cure. Only quacks guarantee cures. The only class of patients to whom a qualified though emphatic assurance of cure may b© given is the class known as psychic impotents. Here we may assure a cure for two reasons: first, because a cure can be effected in practically every case and second - — and. this is the more important reason — the positive assurance of a cure is a part of the treatment. As soon as you assure the patient that you can cure him, he gains confidence in himself, and he may become sexually potent M SEXUAL IMPOTENCE in an incredibly short time. But in cases rcetiug oa a definile patholt^c basis we are not justified in making positive promises which may be difficnlt or impossible of fulfillment. I never do. I only promise the patient to do the best I can for him, and I let him decide as to wliethor he cares to be treated or not. Of course not all physicians can afTord to exhibit the independence towards patients, which is very un- fortunate. I have seen patients HufferinB with paralytic impotence or crvptorchidism or absolute aspennatism, who were promised complete cures, to be made into perfect men, hy their physicians. Such things tend to throw discredit upon our profession. To give no guarantees, to refuse to nxakc any promiseB, (o refuse altogether to treat some patients, to show yourself financially independent, to make tlie patient understand that you are not after his fee and that to you personally it is a matter of indifference whether you treat him or not, is not only right morally, socially and professionally, but it is necessary for the successful treatment of your patient. For no sooner does an impotent, and particularly a ncu- rasth^iic patient perceive or suspect that you are anxious to make money out of him, than your usefulness iy completely gone. You better give up the case at once. One word more: Physicians as a rule make unsatis- factory patients. This is true of all diseases, it is pftiv ticularly true of sexual disorders. They are too impatient, they are too skeptical, they do not follow inslructiona religiously, and they do not want to stand any pain. Thoy ■re afraid of pain much more than the lay patient I SEXUAL NEURASTHENIA 241 have had an exceptionally large number of medical pa- tients to treat and I confess I do not rejoice at the an- nouncement that Dr. So and So wishes to come up for treatment ■ CHAPTER THIRTY-THREE THE TREATMENT OF SEXUAL NEUSASTHENIA To treat sexual neurasthenia suecessfnlly we must of course know the cauBe of the neuragthecia, and the tjpe of neurasthenia we have to deal with. The Two Types. To attempt to put each variety, each different tjpc, of sexual nourastheuia in a special nibrio and designate it by a special label, would be a thankless task. For the varieties are numbcrleas and run into each other by imperceptible gradations. But still wo are jua- tified in recognizing two principal types of this disease. And the type to wbieh our patient belongs will materially influence our prt^nosis and treatment To define the two types briefly: In the first type the neurasthenia is pro- duced by the impotence, or the neurasthenia and the im- potence are the results of local causes ; in the second type the impotence with its concomitant sjnnptoms is the restilt of tbo neurasthenia. To put it in other words: In the first type we have the sexual trouble or abnormality first, the neurasthenia after; in the second type we have the general neurasthenia first and the sexual trouble after. And we must remember that there are numerous inter- mediary types, that is eases in which both causes are exerting their evil influence at the same time. To give two illustrations; Cue 1. Age 30, almost completely impotent (very weak erections and immediate ejaculations), and typically Sift SEXUAL NEURASTHENIA M3 n en r asthenic. History shows excessive early masturba- tion, then rather free sexual indulgence, then three at- tacks o£ gonorrhea ; the last one about two years ago. The impotence has been coming on gradually during the past year, and the neurasthenic symptoms, as far as he re- members, during the past 6-8 months. His financial con- dition is excellent, he is entirely independent, be has nothing to worry about, his life runs in rather pleasant channels. Has always been gay and jolly, but lately has been feeling as if life was not worth living. Even before examining the patient I make my mental diagnosis of definite local trouble, with neurasthenia as a consequence. Of course, the impotence, in a man with theatrical con- nections, who was in the habit of having " all the actresses and chorus girls he wanted," and who now, imdor one pretext or another, must avoid them, is alone sufficient to induce neurasthenia. On examination I find an ex- tremely congested posterior urethra, a swollen collieulua seminalis, also a slight stricture and an enlarged and ex- tremely sensitive prostate; light pressure brings forth abundant catarrhal secretion. I give him a very en- couraging prognosis, and massage of the prostate, urethral sounds and dilators, the psychrophore, instillations of weak silver nitrate solution, and then cauterization with the same solution but 20 per cent strong, bring about in six months a complete cure of both the imiwtence and the neurasthenia. There was practically no treatment of the neurasthenic symptoms proper. — Here we have a clear case of sexual neurasthenia resulting from local condi- tions, and disappearing with the cure of the local condi- tioos. 244 SEXUAL IMPOTENCE Oase 2. Almost complete impotence and sovcro sexual neiirastbeiiia. Presents a goodly number of the symptoms described in the chapter on Bymptomatolngy. The liis- tory sho\vs moderate masturbation between the ages of 14 and 17, then moderate indulgence between 21 and 25 at which age he married. Never had any venereal disease. Lived a regular, moderate life and was perfectly potent for 10 years. The impotcnco first showed itself in a di- minished libido, then gradually tlie erections became very weak and the ejaculations premature, lias to urinate very frequently. Questioning brings out the fact that the last throe years have been very hard for hiin. All bia savings, which were considerable and which he invested very profitably in real estate, were swept away during the panic, so that now at the age of tbirty-eight he finds him- self aa poor as ho was at the ago of twenty, and baa to hustle for a living, when be thought he would bo able to take it easy. Then a boy in whom they bad great hopes turned out badly, and is a source of humiliation to the family, Ilis wife aJso died a year previously. I at once recognized that I had to deal here with a case of neunw- thenia to which the impotence and the other sexual and urinary a^-mptoms were secondary. An examination shows the genital organs, the urethra and the prostate normaL Here I know the treatment will h&ve to he principally of a gi>noral tonic and psychic character. If I do give him local treatment, it will be cither for its psychic effect, or it will he only by the means of the psychrophore, because that has a general tonic effect. Bearing these two general types of sexual neurastheois in mind, the treatment of this disease becomes relatively SEXUAl NEURASTHENIA 245 I Biinpla Where the local symptoms predominate or where they are the cause of the disease, they must be treated energetically, before we can hope for a cure. At the same time general tonic treatment, proper diet and hygiene must not be neglected. Because, even if we do cure the local symptoms which brought about the neurasthenia, it does not necessarily mean that we have cured the latter. In many cases removal of the cause removes also the Bymptoms ; but not in all ; a local patch in the urethra ■which brought about neurasthenic symptoms may be cured, and the neurasthenia may persist, because the nervoua system has in the meantime become so weakened or irri- tated that it requires treatment before it is brought back to its normal condition. While if the sexual trouble ia secondary to a general neurasthenia, we have to turn our principal attention to the latter, without however alto- gether neglecting the former. The local conditions or sexual disorders which may be responsible for sexual neurasthenia have all been de- Bcribed, and their treatment discussed. It is useless there- fore to repeat that if we find a granular patch in the urethra it is to be treated and how it ia to be treated, or if the patients have pronounced prostatitis, that that ia to be treated, etc. We also discussed the treatment of the more or less local neurasthenic symptoms. But a few additional w*ords may not be amiss in regard to the gen- eral treatment of the general neurasthenic condition. It is here that psychic treatment is of great importance. The very first step in successful psychic treatment is the relation between the physician and patient. It goes with- out flaying that this must be one of complete and iin- S46 SEXUAL IMPOTENCE questioning confidence on tbe one hand and real sympatliy on the other. If the physician finds that the patient is skeptical or even snapicioua about his methods of treat- ment, and if ho is unable to ciiangc this attitude quickly into one of complete confidence and reliance, he might as well give up the casa He will not cure or bratefit hia patient. Without confidence everything will be going wrong; even the local treatment, which in hundreds of cases has done you good service will in tlie suspicious aud antagonistic patient seem to do actual injury. With com- plete confidence everj-tbing goes smoothly. The first opportunity you have to establish or to in- crease the patient's confidence in yon, is when you take hia history. An experienced physician knows of course many or most of a neurasthenic patient's symptoms, and it is remarkable how his confidence in you, and his respect for you grows, if while taking his history, you yourself, with- out asking him, recount his symptoms. The fact that you seem to read him like tin open book is an important factor in creating in him a high opinion of you. Neat, the examination must be very thorough — every part of the urogenital system amenable to examination should be examined, digitally, by t!ie urethroscope, bougie, micro- acopically, etc. Then a thorough general examination is to be given ; llie urine examined, the heart listened to, the blood pressure taken, the reflexes test^id, etc. This thor- ough examination has a double object; first you may find out things which you did not suspect, and second it shows the patient that you understand your profession, that you take an interest in your patients, and that you are thorough; all of which increases his confidence in d [ SEXUAL NEURASTHENIA 24V you — a sine qua non iu treating neurasthenic patients. After having ascertained tlie patient's exact condition we have a good talk witli hiiu — and a gocMl deal depends upon that talk. How many times have I seen a patient leaving the office looking ten years younger than when h© came in, with a spring to his walk that he didn't have for years and a hope in his breast where everything was hope- less and cheerless for months, perhaps for years ! How many times I heard them say: " Doctor, you have lifted B heavy burden from my mind, and I feel again that life 18 worth living." Some even go bo far as to exclaim ; " Doctor, you have saved my life." In this preliminary talk I explain to the patient the nature and stage of his dis- ease — I have always believed in doctors taking their pa- tients into their confidence — we tell him that we can help him only if we have his fnll cooperation. We tell him that wo cannot guarantee to cure him — only quacks guarantee cures — but we will try our best and hope we will be successful. But of one thing we can assure him posi- tively, that we will quickly benefit and improve him. We know that his will-power is weakened, — this is one of the characteristics of neurasthenia, — but we exhort him to col- lect all the little will-power that is left in him and that is perhaps lying dormant and to help us to cure him. I cannot improve his financial condition, I cannot remove ths various external factors which cause him to worry and to be unhappy, but I show liim the utter futility of simply worrying. I tell him that if he thinks that worrying will improve matters, that he may go on worrying from morn- ing to night and from night to morning. But that use- less, purposeless worry only makee matters worse, and is 2-18 SEXUAL IMPOTENCE very often nothing but a habit, the same as " fussing " and getting angry is a habit, from which one can break him- self or herself, if lie or she has a really earnest desire to do so. One would be surprised to see, what effect this commonplace, one might say, platitudinous little talk has. A goodly number of patients have told me that this waa the turning point in their life. And many go away firmly resolved not to worry, once worry does no good, but simply to do the best they can. And this is already one good [Mint gained. Having gained the patient's confidence and assured our- self of his cooperation, we make an outline of the treat- ment proper. In some run-down neurasthenics, the first thing to do is to put them to bed for a week or two, and feed them up. It is almost a conditio sine qua non. Of course where the patient cannot possibly afford it, we have to do without it, but the treatment is so much longer, the results are so much slower in coming, that we should do our utmost to convince the patient to take this pre- liminary rest. The entire nervous system and tho heart take a good rest, and the results of the other treatment are so much more striking. The diet should be nutri- tious, but not stimulating. Alcoholics should be eschewed. Plenty of milk, eggs and meat, but spices and condiments sparingly. While the patient is in bed, he should be given general massage, alcohol rubs or cold water spong- ingB. If he cannot stay in bed, he should at least take the massage and the rubs. After the patient has had bis rest, hydrotherapy will play an important role. At first we may have to order warm baths only ; but gradually the temperature of the baths should be reduced, or the d SEXUAL NEURASTHENIA 94» warm bath should at leaal be followed by a cold douche. A thorough dry rubbing should follow each bath. At first the rubbing shoidd be given by another person, but as the patient gains in strength, he should attend to him- eelf. It givea him a certain kind of exercise. Exercise ia generally prescribed for all kinds of neurasthenic pa- tients, but in my opinion exercise with dumbbells and clubs, in a closed room, is of little benefit to neurasthenics. It often does more harm than good. Walking in pleasant and if possible new places is beneficial, but it must be doae in moderation, increased gradually, and fatigue is to be avoided by all means. Driving or autoraobiling, sternly repressing any temptation of giving in to the crazy speed mania, is very beneficial, but under no circumstances should the patient himself hold the reins or the lever. There must be no strain, and the driver or chauffeur must be so competent and reliable as not to give rise to any nervousness on the patient's part. Sea, river or lake bath- ing ia positively beneficial. Of course in the banning a very strong surf must be avoided, and the patient must never be chilled. Bathing on cold, gloomy or drizzly days is therefore bettor tabooed. If the patient must work for a living and must stick to an occupation which is distasteful or even hateful to him, we are helpless. But if the patient can afford it, he should select a congenial occupation, and if he can afford the time or the luxury of a hobby, he should be advised to indulge in it. It is even advisable to make him create himself a hobby. Sometimes no measures will benefit a sexual neuras- thenic until he has made a. complete change of environ- sso SEXUAL IMPOTENCE meat, climate or country. And there 13 no single meflsura so beneficial in sexual neurasthenia as is an ocean voyage. Its effects are sometimes truly remarkable. I have knovn cases, where an ocean trip across the Atlantic and Med- iterranean, with a couple of weeks traveling in Europe, brought about a complete cure of both the sexual neuras- thenia and tlio sexual impotence which was a result of it. And this without local or any other treatment, l^t if tiiere is anything which shows conclusively the neces- sity for individualization, iudi\'idualization, and again in- dividualization id the treatment of sexual neurasthenia, it is the effect of ocean trips. For just as beneficial aa an ocean voyage is in indicated and properly selected cases, so injurious it may prove in improper cases. I have known patients who were very greatly injured by an ocean voyage. If a man in the extreme stage of neurasthenia, unfamiliar with any European language, goes to Europe alone, without wife, relative or friend, has a rou^ voyage, is perhaps deathly seasick, has nobody to take a walk or to exchange a word with, then you cannot expect him to come homo cured of bis neurasthenia or impotence. The likelihood is, that both will he aggravated. But this does not militate against sea voyages being one of the sovereign remedies in Hoxual neurasthenia. But I will reiterate tliat it must !)e ordered witJi discrimination, in properly selected cases, at the proper time of the year, and only a rule in company with somebody^ a loving and con- geuinl wife, or a congenial cjimpanion. That is all that is necessary to say about the general treatment of neu- rasthenia. As to the conditions causing neurasthenia, or the SEXUAL NEtTRASTHENIA 251 various symptoms caused by it, their treatment has been discussed and the reader is referred to the respective chap- ters, particularly the chapters dealing with the treat- ment of pollutions and spenuatorrhea and imijo- tence. The dm; treatment of neurasthenia playa a secondary role and what we said about drugs in the treatment of impotence applies with almost equal force here. Except that we would emphasize the great value of strychnine. Some consider it the sovereign remedy in neurasthenia. Somebody has said: what morphine is in painful condi- tions, strychnine is in neurasthenia. I give it here, the same as in impotence, in large doses, and fre<]uently hypo- derraically. It is Iiere that the compound syrup of hy- popliosphites, the compound glycerophosphates and similar preparations prove signally beneficial. Arsenic often works wonders. The following simple combination is very good: 9 Arseni Trioxidi gr. 1-30 Strychnine Sulph gr. 1-20 _ Calcii Glycerophosphatis . . . . gr. iii MassEe Ferri Carbon gr. li M.f. pil. vel. caps. No. 1. D.t.d. xxx. Sig, : One t. i. d. p.c I-ecithin is useful and small doses of the thyroid and adrenal gland sometimes prove singularly and mysteriously beneficial. Perhaps we have no right to use the word mysteriously, for there is hardly any doubt now that, in a certain number of cases, sexual neurasthenia wnth all its symptoms may he caused by some disease or deficieni^ of the thyroid. ^Ix IXUAL IMPOTENCE ; we must always remember in tlie dnig treat- rastheniu ; to change the treatment frequently . .^ only tho form — from solid to liquid or vice — or the vehicle), aad to intermit every week or two ra or three days altoEether. CHAPTER THIRTY-FOUK BEP0ST8 OF CASES i Of course nobody \v\]l imagine that any one patient is likely to have all tlio symptoms enumerated above. Though we have had patients, who at i>arioiis times pre- sented practically the entire catalogue, still the vast ma- jority will only show some of the symptoms, perhaps half , dozen or a dozen. While some sexual disturbance is present in all patients — this ia a conditio sine qua non, for a perfect sexual sys- tem excludes the diagnosis of sexual neurasthenia — they are sometimes strongly overshadowed by the symptoms of the other organs. Tlius in some cases the urinary dis- turbances will be so severe, as to make one think of tuber- culosis of the bladder, hypertrophy of tlie prostate or stone in the kidney. In others the gastro-inteatinal symptoms will predominate. In fact they will he the sj-raptoms that will bring the patient to the doctor, and they will go from one gastro-enterologiat to another, swearing at the specialists and scoffing at medical science because they are not benefited. In still others the circulatory symptoms will be so severe as to leave no doubt in the patient's {and in the average physician's) mind, that it is a case of heart disease (and if the patient is so unfortunate as to get into the hands of a physician who gives digitalis for every heart case, then he is sure to get worse, for digitalis is very bad for this class of patients). In still another 251 SEXUAL IMPOTENCE large percentage of cases the cerebral and general nerrouB s;mptoiua will be in the foreground. The description of a few actual cases will help to make the picture of sexual neurasthenia clearer, and serve to impress it on the reader's mind; they may help him to arrive at a correct diagnosis in instances where he floun- dered before. Cue 1. Lawyer by profession, 5 feet 10 inches tall, weiglit 120 pounds. Extremely emaciated — just skin and bones. Has the greatest difficulty in attending to his bueineas, but whips himself up to do it Every onco-in- a-while however ho is obliged to stay home a day or two. Severe and frequent lieadaches. Very pronounced dark rings around the eyes. One can see that the man lives on hia nervous capital. Appetite very good, almost raven- ous; slight belching and constipation alternating with slight diarrhea. The sjTnptom, however, which annoya the patient most, and for which he came to c(«isult me, is frwjuoncy of urination. He has to urinate every half hour, Ri>metime8 every hour, but some days every 13-20 minutes. Ife had been treated for this trouble, locally, by another geni to-urinary specialist for about six months without any benefit. Tliat specialist suspected tuber* ciiloeiii of the bladder, which is not so surprising because tlio patient's motlier died of tuberculosis and he himself was coughing slightly and gave the impression of a con- Bumptivo, The doctor did not inquire into the patient's sexual life, and tlie patient did not think it was necea- aary to refer to it. On asking him how it was in the L time. T rercived the answer that while he did not sleep well, be had no trouble with his urination. Seldom A I 'SEXUAL NEURASTHENIA 256 that he had to get up even once. As will be noted by those who read the " Symptomatology of Sexual Neuraa- thenia" carefully, this is almost a patltognomoiiic sign of this condition. I \vent closely into his sexual history. He masturbated frequently from about 13 to 22, he then. tried to break himself of the habit, and began to suffer with pollutions. Between the ages of 22 and 25 he would have two to three pollutions a nigfat, and would mas- turbate about once in two or three weeks. At the ago of 25 he b^au to have intercourse; it wasn't very satia- factory, and he would indulge only once in about three op four months. At 28 he got married — was told by hie doctor it would bo a good thing for him. Foimd him- self practically impotent — just a feeble erection and an immediate ejaculation. Attempts intercourse about one© a month — his wife is very "good," and doesn't mind it. But he still suffers with pollutions, about once or twice a week. An examination showed the posterior nrethra congested and sensitive, and the prostate extremely BO. The gentleet touch of the gland made him nearly faint With very little local treatment, but by internal medication and the application of general measures as outlined in the chapter on treatment (first of all the pa- tient was put to bed for two weeks, and then he went to the eonntry for two months), he began to improve rapidly, put on twenty-two pounds in four months, and is now a perfectly well man. That is, perfectly well as far as his nrinary trouble and general neurasthenic symptoms are concerned: his sexual power still leaves much to bo de- sired, but he is improving right along, hia pollutions have stopped, the erections last considerably longer, and in time 266 SEXUAL IMPOTENCE he may be restored to practically DOrmal sexual power — though he will never be vigorous in this respect Case 2. Well nourished, inclined to stoutness, suffers with extreme dyspepsia and flatulence. la " no good " for two or three hours after any substantial meal, no good physically or mentally. Feels so heavy that he must lie down; falls asleep soon, and wakes up in. a much woreo condition, with the fac« congested, heart palpitating, and all " a tremble." Severe persistent headaches. There is no pain in the stomach, but the organ is extremely dis- tended after each meaL The ache in the back is con- stant. The tongiie heavily coated. Has been treated by at least half a dozen physicians — general practitioners and specialists in stomach diseases. Has had gastric lavage, which made matters worse. Bismuth subnitrate and sodium bicarbonat« are the only drugs from which bo gets relief. It is settled with him and his physician that he is a sufferer from chronic gastro- intestinal trouble and that all he can expect is relief. He came to consult me on account of premature ejaculations which he had been noticing of late, but he hasn't a glimmering of a suspicion that his gastric trouble can have any connection with his sexual sphere. I begin to take his sexual his- tory. He is forty. Mastnrbated moderately between the ago8 of 13 and 38; after that had moderate intercourse. Married at twenty-fiva His wife has been rather exact- ing from the first day. For the first five years had nat- ural relations, the wife using a douche occasionally. Had three children in the firat five years. After that, that is for the last ten years has been practicing coitus ttUer- rujdus, and practicing it frequently, for, as mentioned, d I SEXUAL NETJEASTHENLA. his wife was a rather exacting woman ; vp to a year or so ago his sexual power was very good. Even now the erec- tions are good. His gaatro-intestinal troubles date back about eight or nine years. To me this was a plain clue. To my mind the coitua interruptus was the cause of both the gastro-intestinal symptoms and the commoncing im- potence. The course of events and the rapid and remark- able success of the treatment fully justified my diagnosis. I ordered complete abstinence for a month, and then only natural coitna about once in five days. But I emphasized that the coitus had to be perfectly natural from the be- ginning to the end ; he was not to use even a condom. The treatment I prescribed was of the mildest — just some arbutin granules. More as a placebo than anything else. For I wanted to be sure what effect natural coitus would have by itself. The change within two months was re- markable. The ejaculations improved, the headaches dis- appeared, the gastro-intestinal symptoms became much milder, and in six months more he was a well man. Case 3. Has masturbated since the age of twelve. At the ago of 23 had intercourse for the first time, and during the very first initiation night got a severe gonorrhea, with numerous complications, which lasted about five years. In fact, it is not quite cured now, and he is now thirty- six. He still has numerous large shreds in the urine, the posterior urethra is congested, inflamed and bleeds readily, the prostate is enlarged, tender and a large amount of ppofltatic fluid of a catarrhal character is expressed by the gentlest massage. Has never attempted intercourse since his first venture which had such disastrous results, but suffers with pollutions 4-8 times a week, sometimea i SEXUAL IMPOTENXE 2-3 times in one nlgbt. Also masturbates occasionally, chiefly whea excited or annoyed by something. During the last six months the poUutions, which are completely atonic and unaccompanied by any dreams, have increased in frequency, and he now also has diurnal pollutions and a frequent oozing of semen. (This on e.\amination proves to be chiefly prostatii- fluid, but now and then it contains spermatozoa; it is thus a case of true spermatorrhea.) The patient is a truly pitiable object. He was the owner of a dnig store, but he could not keep it up, and it was sold at auction. He started clerking in small drug stores, but couid not keep a position for any length of tim& Now he is " reliering" and makes his 6-8 dollars a week, as be cannot work more than 2-3 days out of the seven. He is timid, afraid of everybody, never looks anybody in the face, walks with a shuiHing gait, is afraid that everybody can notice at once what is the matter with him, is sus- picious and quarrelsome, his memory is exceedingly weak, talks slowly, hesitatingly, has severe headaches, pains all along the spine, bis legs bend under him, fatigued after tbfl least exertion, appetite exceedingly poor, constipated, the face jaimdiced and pimply, breath heavy. Is afraid people are after him and want to ruin him and cries readily when he tells me his troubles. Claims that he doesn't sleep at all, no, never sleeps at all, not even for an hour (which of course T don't believe). Claims that be wishes to die, but is afraid lo ride in an elevated train, because the train might full down and he might be killed. (But 80 it is with many hysterics and neurasthenics: They wish to die, i.e., they say so, but they have a deathly fear of anything that might help them to realize their wisb.) SEXUAL NEtniASTHENIA 969 He had been under my treatment for a year, before he bf^an to show any signs of improvement in his general condition. Hia sexual libido remained about the same, but the pollutions practically ceased. He was called out West by a brother and I lost track of him. Case 4, Miss A. Thirty-three years old, from a fine Tvell-to-do family. An extremely sympathetic girl, with a delicate face, on which the lines of suffering are clearly and painfully visible. Sbo is very ehlorotic, lipa bloodless, complexion dingy, chest flat, somewhat stoop-shouldered. Complaint: Terribly nervous and hysterical. Has been suffering for ten years or more. I am informed tbat at about the age of twenty she was stout and exceptionally healthy. She began to lose ground gradually. She has become so nervous that the least little thing makes her cry for hours at a time. Her appetite is wretched, and her in- somnia is extremely obstinate. She has been going from doctor to doctor, who had given her every variety of iron preparations, strj-chnine, arsenic and bromides; for the in- somnia she was given gradually increasing doses of sul- phonal, trional and veronal. But all these were of no avail whatever. Not that they did not do her much good, but they did not do her any good, except the hypnotics, that procured her an occasional hour or two of sleep. She was sent away to a we!l-kno\vn sanitariimi, and while the hydrotherapeutic measures seemed to improve her condi- dition, the improvement was but temporary. During her hysterical attacks she would scream in a most unearthly fashion, tear her hair, knock her head against the bedpost, and then would fall exhausted as if in a dead faint. All about her would get frightened, throw cold water on her, SEXUAL IMPOTENCE give her aromatic spirit of ammonia, c*c. At first they would run for the doctor, but now they are used to tbeee attacks. She has developed recently a pronounced anxiety neurosis. She is afraid of some great calamity. She ia also afraid to bo in the dark, to be alone in the room, to cross the streetji, to be in a crowd. Her people are afraid that her mind was going to give way, but I don't find it bo. She is very rational, and a bond of Bympathy is soon es- tnblisbed between iis. Discreef, sympathetic questioning brings out deeply hidden secrets. Seeing that I know her trouble, she tells me what she says she never told to any other living person. For the last ten or twelve years she has been suffering the torlurea of hell from unsatisfied sex- ual longings. The desire would become at times so strong that she simply would not know what to do with herself, (the would become as insane, and this would often end in a hysterical attack. Close investigation brought out the fact that she never masturbated. Whether the various doctors who treated her knew or suspected what was the matter with her or not she doesn't know. She thinks that two or three of them knew. She also told nie that she was an- noyed or tortured night after night by numerous dreams, some bizarre, some horrible. While I recognize the im- mortal merits of Freud in having focused forcibly the attention of our profession — and of the intelligent laity — on the relation between sexual abstinence and the varioua neuroses, I am but a luke-warm Freudian in the realm of dreams. I l>eliove that in the dream interpretation Freud and still more so some of his disciples go to extremes, and say things which are foolish, absurd, bizarre, fantastic and groteaque. But in this case it did not require a Freudian d I SEXUAL NEUEASTHENIA 261 interpreter to see that the dreams were all plainly and grossly sexual. I told my patient that it was uaeless for her to come to me for treatment ; I refused to prescribe for her and told her that there was no drug in or out of the pharmacopeia, no physical measure, no electricity, no hydrotherapy, no psychic influence that would be of the least avail to her. There was but one remedy that would help her and that remedy she knew as well as I. And with that we parted very good friends. She thanked me for my frank talk and was glad that I did not give her any medicine. She always felt that in her case they were just a humbug. There are thousands of such cases going from doctor to doctor, re- ceiving arsenic, bromides and hypnotics, or vibratory treat- ment or high frequency currents, when as a matter of fact all they need, and the only thing they need, is a normal, natural vita sexualis. But how many doctors have the courage and honesty to refuse to " treat " these cases, but just tell them the truth f Case 5. Stout, buxom healthy woman of thirty-five. Married ten years. By appearance nobody would suspect there was anything the matter with her, but has been suf- fering for the last two years with obstinate ingomnia, which has been gradually getting worse. Is irascible and given to fits of deep depression and melancholia. Investi- gation discloses the fact that her husband, who is ten years older than she, has been gradually getting weaker sexually and is now almost impotent. His erections are good, but the ejaculation is precipitate. The first years of their married life ho was quite normal, though not very vigorous. I tell the couple that it is he and not she who needs treat- 263 SEXUAL IMPOTENCE meQt. Six months' treatment of ihe husband bring him back to a fairly nonnal condition, and with hJa improva- nicut there la a complete change in her temper and de- meanor and she declares herself quite happy. Case 6. The history of this case was related to me by a fellow practitioner, Dr. A. S. A beautiful refined young woman fell in love with a refined artistic young man. There was objeetion to their union, so she eloped with him and they got married. Very soon she began to ail with all kinds of ailments, physical and psychic, for which all treatment proved useless. The husband, whom she loved devotedly, died suddenly and left her unprovided. After stniggling for two or three years, trying to make an independent living, she got an oflier of marriage from an ordinary well-to-do business man, much beneath her intel- lectual and socially, and several years older than herself. She felt no love for him, but she was tired of struggling, she wanted a home, and she accepted. Very soon after marriage her health and spirits underwent a remarkable transformation. She was improved in every respect, and her neurasthenia disappeared without a trace. The doctor's confidential questioning brought out the fact that her first husband was quite weak sexually, almost impotent, while her present husband was very vigorous in this respect And what is more her feelings for her present husband also underwent a transformation! She is quite in love with him now, KEUSASTinilTIA AFTER OIVIITO UP MASTOEBATIOK. Cue 7. Age 24. Came to me complaining of extreme depression and anxiety. la in constant fear that some- d SEXtJAL NEURASTHENIA 263 thing terrible would happen to him. He is going to get dangerously ill, he is going to lose hia job or he is going to be arrested. " Have you done anything that might make your fear of being arrested justified ? " No, he has com- mitted no wrong, he has done absolutely nothing to bring him within the clutches of the law, and nevertheless he is afraid. He is also afraid he may commit suicide. A close questionaire elicits the fact that he had been mastur- bating for about ten years. He did not feel any particu- larly evil results until about a year ago, when the volup- tas connected with the act was becoming markedly dimin- ished, and he would get headaches afterwards. About four months ago be read an article in a medical jour- nal about the evil results of masturbation, and that the habit WU3 apt to lead to complete impotence. He deter- mined to give it up. It was not particularly difilicult for him to do. He " fell " twice or three times after hia de- cision, but for the last three months he did not indulge in the habit even once. But very soon after he broke him- self of the habit, he began to feel great psychic depres- sion, which has been increasing in intensity. Of course he was very much surprised and chagrined. He thought that after giving up the habit he would at ouce feel better; instead he has been feeling worse. I explained to him that this was not such a rare occur- rence. Many masturbatora feel very much depressed after the sudden giving up of the habit. It is the same with all habits. The alcoholist, morphinist and cocainiat suffer in a similar maimer on the sudden withdrawal of their drugs. The depression may be of a degree danger- ous to life. Bad as a habit may be, if the body gets used 9M SEXUAL IMPOTENCE to that habit during a number of yeara, the sudden break- ing of the habit may have unpleasant results. Apparently the body gets a certain stiniulation from the masturbatory act, the absence of which stimulation brings about the depression. We see the same thing in people who have been used to regular intercourse; if they are obliged for some rea^n to give up sexual relations for any length of time they may feel very depressed and despon- dent. I am not referring to ordinary unpleasant sensa- tions connected with complete abstinence in healthy people, who had been leading a regular sexual life, but to the deep psychic depression, which sometimes assumes dangerous degrees. This is a point with which the general profession is not familiar, and I take this opportunity to bring it to its no- tice. When we tell a patient that his case is not the only one in the world, that it is not unique, that it is something which we see oft«n, that there is notbing mysterious in it, we thereby alone help our patient considerably. He feels relieved and hopeful. I told the patient he should not worry, should persist in refraining from masturbation, prescribed the compound symp of hypophosphites and cannabis indica, and ordered warm baths, followed by cold ablutions; in a short time the patient was free from His depression, and some weeks later be was li\-ing a normal moderate sexual life, " TUIED DAY " DEPKESSIOK'. Case 8. Dentist, 34 years old, very intelligent, married ten years. Has not been feeling very well for the last five or SEXUAL NEURASTHENIA six years. Has a big practice, which keeps him in the office the entire day from 9 a. m. to 8 or 9 p. m. The culiar feature of his case, however, is that Tuesday is his worst day. He is quite sure that it is not imagination with him. He thought at first it waa purely accidental, hut the thing has heen going on for nearly two years, and it has happened every Tuesday, with the exception of two months in the summer and the improvement in this period he as- cribed to treatment he received. His condition on that day he described as most wretched and miserable. His head felt empty and he had an iron band aroimd it, his throat was dry, his legs were hot and heavy and it was very diflEi- cult for him to stand and to attend to his work. He had to lie down several times during the day. He felt a severe pain in the back, or rather a nagging, drawing sensation which compelled him to nib it, to have it massaged, to ap- ply counterirritant plasters or ointments. And his mental condition was worse than his physical. He felt terribly depressed and anxious, and while he did not care to commit suicide, he was sure that he didn't care whether he lived or died. I asked him if he was sure that he felt that way on Tuesdays only, and he answered emphatically in the affirmative. He said he hoped that I at least would not doubt his veracity or consider him crazy, as some doctors whom he consulted had done. He consulted, according to his statement, at least half a dozen physicians, among them one eminent internist and one specialist in neurology and psychiatry. The results of the treatment were either nil, or merely palliative and temporary. Nobody asked him about bis sexual life. From a description of the symp- toms I saw that I had before me a sexual neurasthenic. I 1 J SEXUAL IMPOTENCE asked him how often he indulged in sexual intercourse and he aaid once a week. Further inquiry elicited the fact that that once was always on a Sunday, Week days he worked hard until late in the evening, and he came home very tired, but Sundays he worked only until 1 p. m., and the aflemoon he spent leisurely, and it was in tlie afternoon or evening that he would indulge. It became a habit with them, to which they, his wife particularly, were looking forward. This explained the whole situation. Our pa- tient belonged to that numerous class of sexual neuras- thenica in whom the symptoms of exhaustion and depression come on the third day after coitus. In some neurasthenics the depressing effeer of men who would not think of going to a reatment if not forced to it by chivaliy to their SEXUAL IMPOTENCE wives or by the direct demands of tlieir wives. Some- timea these demands are not couched in very gentle lan- guage either, and sometimes they are accompanied with threats, either open or implied, that they would have to look around for another man. Case 3. Mr. and Mrs. A. A happily married couple. No more harmonious couple could be found anywhere. They are united by the bonds of mutual affection and re- spect. Anil still though married for a number of years they have lived a continent life. Mr. A's sexuality is ex- tremely weak and rudimentary, while Mni. A's ia distinctly negative. That is she has a dislike for sexual relations of any kind. They became aware of their feelings in this re- spect williin the first weeks of their married life and they decided to live like loving friends. Though they generally share the same bed they do not attempt any ae.\ual rela- tions. And while they are both impotent they are both free from any neurasthenic symptoms, are contente