Such conditions as vesical calculus, cystitis, and urethritis
must likewise be excluded as possible causes, and we must
diagnose, if possible, whether the underlying cause has its
seat in the cerebrum, the lumbar centers, or in the genito-
After all, however, over 90% of the cases
are idiopathic, i. e., we can find no pathological condition
either in the local genitourinary organs or in the assimila-
Prognosis. No matter how obstinate these cases may
be, most of them recover at puberty. The younger the
child, the better the prognosis, for where the condition con-
tinues beyond puberty it is more likely to be very obstinate.
Even here, however, most cases are cured with proper
treatment and great patience and perseverance on the part
of physician and parents. Enuresis in idiots, imbeciles, or
sufferers from other grave cerebral conditions is apt to
remain incurable. The prognosis as a general thing de-
pends more upon the patience and perseverence of the
214 Disorders of the Sexml Function.
physician than upon any other factor, since 90% of
the cases are idiopathic, without discoverable cause to work
upon. The physician must not get discouraged because the
child does not respond to treatment for a long time; nor
must he stop treating the child because it apparently re-
sponds very favorably to his first medication. Such response
is very apt to be temporary only, and he must therefore have
patience with both classes and keep them under treatment
and observation for a long time. The parents should also
be told that long treatment and observation are necessary
to effect a permanent cure.
Treatment. Several years ago, through the courtesy of
Dr. Charles Herrman, at that time Chief of the Pediatric
Department of Vanderbilt Clinic, New York City, I made
a special study of the enuresis cases coming to that insti-
tution, and made myself acquainted with all the available
literature on the subject as well.
I was struck with the fact, however, that while many
wonderful and quick cures are mentioned, many of these
cures failed entirely or relieved the patient only temporarily
when I gave them a trial.
As I became more experienced in the management of
these cases, the explanation of these reported "cures"
became clear. There is a very marked psychic element
about enuresis, and any new therapeutic agent, be it elec-
tricity, silver-nitrate instillation, passing a sound, or a new
prescription will temporarily stop it. Most of these "won-
derful" cures mentioned are also quick cures, having been
reported by the physician, after he had tried them for a
few weeks only, and before the psychic element had worn
off. For this reason, a cure with any new remedy ought
not to be reported until at least six months have passed,
to ascertain whether the result is permanent.
General Treatment. The general treatment is very im-
portant and should be carried out, no matter what regu-
lation treatment is applied. In many cases, it is useless
to attempt to treat enuresis without due regard to diet,
mode of living, and other factors to be described presently.
In the first place, we must look for any local or gen-
eral irritation, and treat this condition. This includes such
sources of irritation as long, tight, or adherent prepuce,
hyperacid urine, rectal worms, vesical calculus, vaginitis,
urethritis, or any of the other conditions mentioned under
Etiology and Diagnosis. These, however, amount to about
10% only of all cases of enuresis.
The child should sleep upon its side, for many children
wet the bed only when lying flat upon their backs. For
this purpose, wherever necessary, a towel may be tied
around the child's body, with the knot so placed as to
press upon its back when lying upon the back. The dis-
comfort of this knot will compel the child to lie upon its
side. I do not think it necessary, however, to blister the
sacrum in order to keep the child off its back.
It is also advisable to have the pelvis of the child
elevated during sleep. This has the effect of causing the
urine, which accumulates in the bladder during the night,
to gravitate toward the fundus, that is, away from the
trigonal region. It is the irritation of the urine against the
trigonal region which often starts the reflex of urination.
The elevation of the pelvis can easily be accomplished
216 Disorders of the Sexual Function.
either by raising the foot of the bed or by putting a pillow
under the child's pelvis.
It is advisable likewise to have someone note the time
the child wets the bed during the night, and then to wake
up the child just previous to that time on succeeding nights,
and have it empty its bladder. This is an excellent method
of procedure, but entails a large amount of inconvenience
on the part of the parents, unless they happen to be wealthy
enough to afford a special night nurse. To avoid this
staying up and watching on the part of the parents, an
ingenious device has been suggested, which consists of hav-
ing one pole of a battery in contact with the diaper cover-
ing the child's genitals, and so arranged that as soon as
the diaper is wet, a circuit is completed which rings an
electric bell waking up the child or parent. I have had no
personal experience with this method, and cannot therefore
state whether it is practical.
It is always advisable to have the child empty its
bladder just before retiring, and, if not inconvenient, to
do so again before the parents retire, just before midnight.
It is absolutely useless and often harmful to punish a
child for bed-wetting. It is far better to reward it for
the nights when it does not do so. In enuresis diurna it
is well to appeal to the child's pride, for in some of these
cases the enuresis is kept up as a matter of habit, some-
times from sheer laziness on the child's part. In cases
of contracted bladder, it is well to develop its capacity by
having the child retain its urine at longer and longer inter-
vals during the day, or by gradual distention of the bladder
with fluid, by the physician, through a catheter.
When the urine is normal, it is best to reduce the
quantity of fluid taken by the child during twenty-four
hours by at least 25%. If, however, the urine is hyper-
acid, this reduction would only make matters worse, by
increasing the relative hyperacidity.
A diet rich in sugar or starch is to be strictly avoided
and often an antidiabetic diet is of distinct value. Red
meat should be given only once during the twenty-four
hours. The last meal should be taken not later than 6 P.M.,
and should be "dry" and not very heavy. At this meal we
may allow cereals, butter, sugar, ice-cream, milk-toast, fruit
After 4 P.M. no fluid is to be given to the child at all.
This rule must be rigidly enforced, except for the first
week, when a little fluid may be permitted, the quantity
of which is to be gradually reduced until the child is used
to the regimen.
Regulation Treatment. For the regular treatment of
enuresis, nothing has thus far superseded belladonna pushed
to its physiological limit and persisted in for a long time.
I can do no better than recommend the method of admin-
istration advocated by Kerley, which I have followed with
good results in most cases. One must follow his scheme
as closely as possible, however, and parents must be warned
in advance concerning the physiological effects of this
drug, so that they may stop it at the right time.
Kerley 66 recomends a i : 500 solution of atropine, each
drop of this solution representing gr. VBOO f atropine. Of
this solution he prescribes i drop twice daily, at 4 and 7
P.M. increasing the dose until the physiological effect (di-
Disorders of the Sexual Function.
lated pupils or redness of the skin) is produced. The
administration must, however, not exceed a maximum of
i drop for each year of the child's age. Thus, a child 3
years old should never receive more than 3 drops of the
solution twice a day; one 6 years old should never receive
more than 6 drops twice a day. As a general thing, the
physiological effect will be produced before this maximum
is reached. Kerley gives the following scheme for a child
5 years of age:
t. 7 P.
' 2 di
We must not be discouraged if no improvement appears
for two or three weeks. The diurnal cases respond more
quickly than the nocturnal, that is to say, if the child suf-
fers both by day and night, it will first cease its involun-
tary evacuation by day, and it will not be until some time
later that any improvement will be noted by night. The
first improvement noted at night will be a diminution in
the number of wet nights. It may take a few weeks before
the child has an entirely dry week, but when this occurs
the treatment must not be stopped, else the child is sure
to have a relapse. If the child has had two dry weeks,
we may reduce the amount of drug by one-half and keep
up this amount for six weeks. If there have been two dry
months, however, we may stop the drug entirely, keeping
up the dry suppers for three months longer. In diurnal
enuresis (without nocturnal) the same scheme should be
followed except that the atropine should be given after
breakfast and after lunch instead of at 4 and 7 P.M., while
strychnine should be given at the same time.
Treatment of Obstinate Cases. Most of the so-called
obstinate cases are cases in which the above method of
treatment had not been persisted in long enough, the physi-
cian or patient having become discouraged. Kerley has
shown what can be done in so-called incurable enuresis.
He put some of these patients on the above method of
treatment, and although some of them did not show im-
provement for several months, still he persisted, continuing
to treat them without interruption for an entire year. They
were entirely cured, and although he kept them under
observation for six months longer, there was no relapse.
Several years ago, I had under treatment a bright boy
of 9 years of age who had suffered from enuresis for
about six years. He was kept under continuous treatment
of one kind or another for a period of over two years,
with but little improvement I carefully followed out the
above scheme with no result whatever. The reason that
it failed was possibly due to the fact that the boy seemed
to have a tolerance for the drug. I then increased the drug
until he received over twice the maximum dose for his
age, yet there was absolutely no sign of a physiological
effect either in the pupils, the skin, or the pulse. I tested
his bladder capacity and found it even above normal, for
he could easily hold over 10 ounces of urine during the
day. I tried strychnine, thyroid, stypticin, cantharides, but
220 Disorders of the Sexual Function.
all without result. The only thing that had some slight
effect was deep instillations of silver nitrate into his pos-
terior urethra. After two years of treatment his parents
became discouraged, stopped everything, and I have not
heard whether anything further was done.
While studying these cases at the Vanderbilt Clinic, I
experimented to ascerain what could be done in so-called
obstinate cases, by treatment directed to the urethra. I
gave deep instillations of weak silver-nitrate solution into
the deep and anterior urethra, and was rather surprised to
see how well these children will admit of such instrumen-
tation, if the procedure is done with due gentleness. In a
few of these obstinate cases, I have had some permanent
successes; in others, however, no beneficial result was
obtained. On the other hand, I have never seen the slight-
est harm follow this method. Curiously enough, my best
results were obtained in females, by instilling silver nitrate
into the urethra with a sound syringe.
I have often noticed that adults, after the prostate had
been massaged, experienced difficulty in starting the stream
of urine. The massage seems to have an inhibitory effect
in most cases. Acting upon this experience, I thought that
massage might possibly have a similar effect in enuresis,
and accordingly tried this procedure upon a series of cases
at the Vanderbilt Clinic, though without any beneficial
result whatever. In one instance, I had a rather peculiar
experience, but, as this was an isolated case, it is difficult
to say whether it was merely a coincidence or the result
of the treatment.
The case was that of a little boy about 8 years of age,
Enure sis. 221
whose enuresis had been reduced by belladonna treatment
before he was referred to me to one bed-wetting every two
weeks. Further belladonna treatment, likewise before he
came to me, did not relieve this semimonthly bed-wetting.
I started to massage his prostate once a week, with the
result that almost immediately the enuresis increased to five
wet nights a week, and later on to every night. After that
the case proved very obstinate, even though the massage
was stopped after but three treatments.
It would take me far beyond the limits of this treatise
to state all the methods and drugs which have been em-
ployed for the relief of obstinate cases of enuresis. A few
of the more important ones, however, may be mentioned.
On the theory that enuresis is a habit spasm, it has been
recommended to treat the condition by re-education. Ac-
cordingly, Herrman 49 treats his patients as follows:
"He has the patient urinate at regular stated times, but
on each occasion he is directed to void a little, say, 2
drams ; then stop, void 2. drams more, and stop again. This
is continued until the bladder is emptied. This procedure
exercises the mechanism which controls urination; and the
patient trains and educates himself in the voluntary execu-
tion of the act. After this has been done under the direc-
tion of the physician for two or three times, the patient
can continue it by himself."
Williams reported remarkable results from the use of
desiccated thyroid. He administered gr. y 2 of dried
thyroid twice daily to children between 2. and 6 years of
age, and somewhat larger doses to older children.
Ruhrah 109 also tried this drug in cases which seemed to be
222 Disorders of the Sexual Function.
suffering from thyroid insufficiency, and states that he has
had considerable success in a series of cases. The results
were very prompt, coming on within a week of treatment,
sometimes even after the first or second dose. In fact,
according to him, no response can be expected unless the
result is prompt. In this connection Williams noticed a
marked increase in weight while children were taking the
thyroid, in one case, a gain of five pounds in a single
week. According to Ruhrah, the thyroid need not be con-
tinued for a long time.
Lumbar puncture has been recommended by some
authorities, but Allaria 2 states that he has obtained results
just as good with pseudo-lumbar puncture. The procedure
in both is the same, except that the solution is injected into
the subcutaneous tissue instead of into the spinal cord.
Allaria states, however, that marked results are not ob-
tained by either method, and that whenever they occur
they are really due to the psychic effect.
Radcliffe 98 has obtained good results from taka-diastase
in cases associated with glycosuria.
Burnet 19 has called attention to the fact that enuresis
coming on at long intervals may be merely an expression
of nocturnal epilepsy and be cured by bromides.
Coutts 29 highly recommends the tincture of lycopodium,
in doses of gtt. 20 to a dram t. t. d. He says it is almost
a specific, but I have had considerable difficulty in obtain-
ing tincture of lycopodium, many druggists claiming that
no such preparation exists. In one case in which I tried it,
however, the result was excellent.
Electricity has been recommended by various author-
ities. I have tried it on several occasions and sometimes
with success, but believe that in the latter the influence
was purely psychic.
THE EVIL CONSEQUENCES OF WITHDRAWAL.
General considerations. Importance to general practitioners. Defi-
nition. Etiology. Pathology. Physiology of normal coitus. Pathol-
ogy of withdrawal. Importance of experience in posterior endoscopy.
Effect of withdrawal on female organs. Ignorance of the male about
coitus. Symptoms. Local symptoms. Reflex symptoms. Illustrative
cases. Diagnosis. Course and prognosis. Treatment.
Foreword. The practice of withdrawal is one of the
oldest and most wide-spread of sexual sins. Although
many years ago Bangs 7 and others have called attention to
the evil consequences following this practice, and I 56 have
recently reported some interesting sequelae in the same
connection, the subject is of such great importance, and is
so little appreciated, that I have decided to devote an entire
It must be emphasized at the outset, that the evil effects
of this practice are not of interest merely to the genito-
urinary specialist, the neurologist, and psychiatrist, but
they are even of more im/nediate interest to the general
practitioner. There is hardly an organ in the body whose
functions may not be deranged through reflexes from the
genitals arising therefrom. Besides the symptoms of gen-
eral neurasthenia, I have elsewhere 56 reported a case of
symptomatic sciatica which resisted all treatment for a long
time until it was referred to me. I was able to bring
about a cure in a short time by local treatment to the
patient's prostate, the condition being due to withdrawal.
The patient had previously made no mention of this at all
in giving his history, not thinking it had any relation to
his "sciatica." Another case, which will be reported here-
in, presented symptoms which suggested cardiac disease.
These symptoms, lasting for years, and baffling the diagnos-
tic abilities of several excellent internists, were due to no
other cause than to reflexes starting from an insulted sex-
It is for just this reason that the general practitioner
must be interested in this condition and constantly bear it
in mind as a frequent etiological factor. The patient does
not know or suspect that this practice can harm; nor does
he corne to the physician saying that he practises with-
drawal and has such and such symptoms. Far from it.,
He may come complaining of headache, or frequency of
urination, or fainting spells, or attacks of vomiting, or
excessive perspiration, etc., and it is only after tactful and
painstaking cross-examination (especially in women) that
the etiological factor of withdrawal is elicited.
Definition. Coitus interruptus, or "withdrawal" (by
some called Onanism), is the voluntary interruption of
coitus by withdrawing the penis from the vagina before
ejaculation takes place. We must include herein any
attempt on the part of the patient to withdraw the penis
before completed coitus, whether successful or not.
Etiology. The object of the procedure is to prevent
impregnation by having the ejaculation take place outside
of the female genitals. In most cases there is a deliberate
understanding between husband and wife to do this, and
in other cases it is only the wife, who does not wish to
be annoyed with the inconveniences attendant upon child-
226 Disorders of the Sexual Function.
bearing, who compels her husband to resort to this pactice.
Economic stress is the reason generally given, and it is
indeed rare for the woman to avoid pregnancy on account
of the pains of labor. There are many other reasons given
by both parties why they desire to avoid pregnancy, but
the economic reason is the one most common.
Pathology. To understand the pathology of withdrawal
it is necessary to have a clear idea of the physiology of
normal coitus, for, as in other conditions, the pathology
is but perverted physiology.
The physiology of normal coitus in the male has al-
ready been given on pages 62-69, and the pathology of
coitus intcrruptus in the male has also been given on pages
70-73. Only a brief description of the essential points of
the physiology of normal coitus as well as the pathology
of coitus intcrruptus will therefore be given here.
At the commencement of normal coitus, the seminal
vesicles are more or less completely distended and impulses
are sent from them to the erection center. The latter also
receives impulses from the cerebrum as well as from the
glans penis during the friction of coitus. (See diagrams,
page 67.) Normally the erection center does not send out
impulses to the ejaculation centers until it is completely
filled up with the impulses it has received from the cere-
brum, the seminal vesicles, and the glans penis. In this
way ejaculation does not take place until an appreciable
time after the commencement of coitus. The result is that
the seminal vesicles are almost completely emptied and the
erection center is left in a condition of complete quietude.
The desire for coitus therefore does not come back for a
long time, until the seminal vesicles have again become
completely distended, by which time the erection center as
well as the ejaculation centers have completely recovered
from tbeir state of temporary exhaustion. This time varies
normally in different individuals. As a further result of
normal coitus, the mucous membrane of the prostatic
urethra, which just before and during coitus has been
markedly hyperemic, has lost its congestion. The mucous
membrane having resumed its normal condition, does not
send impulses to the cerebrum until it is again rendered
hyperemic at the next coitus.
Let us now see what happens to all these parts as a
result of the repeated practice of withdrawal. If the act
of coitus is stopped before it is completed, the seminal
vesicles have not been able to completely empty themselves,
or to empty themselves as completely as during a normal
coitus, and are thus left more or less filled. The mucous
membrane of the prostatic urethra has not been able to
completely deplethorize itself, and thus remains more or
less congested after the act. As a result of all this, im-
pulses are sent much sooner from the distended vesicles
and the prostatic urethra to the erection center and the
cerebrum, so that the desire for coitus is felt sooner than
after normal coitus. The act is therefore repeated more
frequently than it would have been in that particular
individual after a normal coitus.
The seminal vesicles, being never completely emptied
during withdrawal coitus, are constantly sending impulses
to the erection center, while the mucous membrane of the
prostatic urethra, being in a condition of chronic conges-
228 Disorders of the Sexual Function.
tion in consequence of repeated acts of withdrawal, is
likewise sending continuous impulses to the same center
whether coitus is indulged in or not. The result of these
continued impulses sent from both sources, as well as the
repeated demands made upon the center itself from the
oft-repeated acts of coitus, is, that the erection center does
not completely recover itself, and finally remains in a state
of hyperexcitability. It thereupon loses its inhibitory func-
tion, and sends out impulses to the ejaculation centers the
very moment it receives them. We thus get the clinical
condition of rapid ejaculation or even premature ejacula-
tion at the very commencement of coitus, with little or no
erection. It must be remembered, however, that all this
does not occur as a result of a single act of withdrawal,
but only after repeated insults to the sexual apparatus, and
it is often only after years of this practice that the harmful
effects above described become evident. This condition of
rapid ejaculation and later of premature ejaculation is the
first stage of impotence. In the latter condition the erec-
tion center has become so hyperirritable that it sends out
impulses to the ejaculation centers at the very first prepa-
rations for coitus, and ejaculation takes place before the
penis has become sufficiently erect to enter the vagina. As
a final result of a more or less prolonged period of hyper-
irritability of the erection center, the latter finally becomes
completely exhausted and refuses to send out any impulses
at all. The condition then becomes one of complete impo-
tence, in which neither ejaculation nor erection can take