keeps attention fixed on the genital organs."
As a general rule it may be* stated that the earlier the
habit has been started, after adolescence has been estab-
lished, the worse is the effect and the more severe are the
general symptoms. The cases which have begun the habit
only after marriage, and have gone into the habit as a
result of rapid ejaculation or other forms of impotence or
withdrawal on the part of the husband, will very often
result in no ill effect whatsoever, especially where the
women have for several years experienced normal coitus.
Indeed, so mild are the symptoms, if any, in these cases,
that so great an authority as Rohleder 107 actually advises
titillation of the clitoris by the husband until orgasm is pro-
duced after coitus interruptus in those cases where both
parties do not want to have any more children and by
mutual consent practise withdrawal. The reason for this is
easy to find. In the unmarried, the female has to draw
very largely upon her imagination to produce an orgasm
in psychic masturbation, while in one who has already
experienced coitus, especially if practised during coitus or
48 Disorders of the Sexual Function.
after coitus interruptus, the strain on the imagination is
practically nil. Those practising purely psychic mas-
turbation, especially if unmarried, have the worst general
symptoms.
Taking it all in all, the symptoms are similar to those
just described in the adult male, though not nearly as
severe. In some cases, however, they are very intense.
The young unmarried female adult is shy and retiring, and
does not seek or enjoy the company of the opposite sex.
She is easily embarrassed, and morbid blushing is often a
very prominent symptom. Her sexual character is often
entirely altered. If she marries, after she has practised
masturbation for a long time previously, she gets no enjoy-
ment out of the sexual act. The cause for this has already
been explained on page 42. Very often normal coitus is
not sufficient to bring her to the orgasm, and she has to
resort to titillation of the clitoris during or just before or
after the act. The reflex symptoms vary greatly and are
too numerous to be mentioned, but prominence must be
given to vague cardiac symptoms, such as palpitation, and
also in some cases a feeling by the patient of blood rushing
powerfully through the carotids and a feeling of throbbing
in these parts. Very often these patients seek their physi-
cian for these cardiac symptoms, and if the latter is not on
his guard he may be perplexed or even make a wrong diag-
nosis of functional cardiac disease. This actually happened
with a patient of mine, who consulted a very prominent
cardiac specialist, and, although the latter found no organic
heart trouble present, entirely failed to realize the real origin
of the trouble, and actually had the wedding of the patient
Masturbation in the Adult Female. 49
postponed for an entire year, sending the patient to the
country to rest up. In the above case, the patient entirely
recovered without any treatment whatever, as soon as she
was married. She remained well for over four years, dur-
ing which time she gave birth to two children. Then all
her symptoms returned, and upon close inquiry I was
informed that for several months past she did not allow
her husband to have normal coitus with her on account of
fear of pregnancy, but only permitted him to insert the
penis against her thighs without even touching the external
genitals.
This was virtually similar to masturbation. Upon
getting her to stop this method of abnormal coitus, all her
symptoms again vanished. Should such a patient actually
have in addition a real organic heart condition, accompanied
by some valvular murmur, one can easily see how much
more complicated the position becomes, and how the physi-
cian must be on his guard to properly interpret the
symptoms.
Among the other more common general symptoms may
be mentioned backache and headache. These symptoms,
however, are so very frequently met with in women, that we
must be careful first of all to rule out other possible patho-
logical factors. It would be very sad to let a woman go
on for years with a renal calculus, a retroflexion or other
organic trouble and blame the symptoms upon masturbation.
Similarly, as in the male, headache is very often due to
eye-strain and dizziness, to a catarrhal or stenosed con-
dition of the eustachian tube, causing a retraction of the
tympanum. All these conditions must be thought of.
50 Disorders of the Sexual Function.
Diagnosis. Just as in other medical conditions, the
diagnosis may be very easy if we have the possibility of
the condition in mind, and exceedingly difficult if we
never dream of such a condition. We must not be led
astray by social or other conditions. Just because the
female is a college girl, is refined and educated, and an
ardent churchgoer, is absolutely no reason for not suspect-
ing masturbation as a possible cause of obscure symptoms.
He who considers every case of nervousness in a young
girl as due to the development of the menstrual function,
overwork at school or college, etc., will never make a diag-
nosis of masturbation. Again, one must not forget to think
of it as a cause because the woman is married and has
children, for, as above stated, while it is rather rare for
married men to masturbate, it is not at all uncommon in
married women. It often requires considerable tact to get
the girl or woman to confess, but in the majority of cases
we can get the history if we only think of the possibility
of the habit.
An excellent method, which I have very often found to
work like a charm, is to catch the patient off her guard.
In married women an examination of the genitals is easy
to obtain, and we can often make our diagnosis from that
alone. If we are reasonably sure of our diagnosis, we say
to the patient, in a matter of fact way, "Of course you
fool with yourself occasionally." No answer to this ques-
tion, or a delayed negative answer, is as good as a confes-
sion. In single girls a genital examination is not advisable
as a rule, but the intelligent mother can be instructed what
to look for and to watch the girl. A private talk with the
Masturbation in the Adult Female. 51
young lady, with the above question, especially after a
careful general examination of the heart and other organs,
will also generally bring about a confession. Many people,
especially the young, have a rather exaggerated idea of the
knowledge and possibilities of diagnosis by a physician, and
so it is not unusual for a young girl to think that a physi-
cian by listening to her heart can find out that she prac-
tises masturbation. The disciples of Freud have little
difficulty in getting at the sexual history of their patients.
Whenever a young girl likes to sit by herself, and does not
care to mix either in play or study with her companions,
and especially if she does not care for the opposite sex, or
if she is a dreamer, we should suspect masturbation. On
the other hand, as already stated, even if we have correctly
made the diagnosis of masturbation, we should not allow
ourselves to fall into the opposite error, of blaming all her
symptoms upon this habit, but should also consider the pos-
sibility of errors in refraction, digestion, assimilation, gyne-
cological, neurological, orthopedic and other conditions
being present simultaneously. In practically every case
where a foreign body is found in the female urethra or
bladder it has been introduced from without and mastur-
bation is the direct cause.
Treatment of Masturbation in the Female. Local Treat-
ment. All local irritations of whatsoever nature must be
removed. Eczematous and intertriginous conditions about
the genitals must be relieved. It makes no difference
whether the local condition is the cause or the consequence
of the masturbation. Even if not the cause, it serves to
keep up the habit, to attract the attention of the patient to
52 ^Disorders of the Sexual Function.
her genitals, and retards a cure. Gymnastic exercises which
might bring into play thigh friction, also sliding down the
bannisters and similar amusements should be interdicted.
Operations on the genitals do no good unless some distinct
condition, aside from the habit, presents itself.
General Treatment. "Confession," says Howard
Kelly, 64 "however fragmentary, is a long first step toward
recovery." For this reason I have laid such great stress
upon being upon the alert and upon the lookout for the habit
and so getting a confession from the patient, by taking her
off her guard. Both as a preventive and as a curative meas-
ure, we must positively interdict coffee, tea, and alcoholics.
In bad cases we may administer bromides, but for a short
period only. We must not rely upon them as a curative
measure.
The most important agency in curing the habit is, in
the first place, to remove all psychic conditions which stimu-
late the sexual imagination. Under this heading come
erotic literature, impure plays, moving pictures, etc. In
the second place, we must substitute some good habit for
the bad one. Howard Kelly 64 rightly says that our motto
should be : "To replace is to conquer." Any outdoor hobby
such as swimming, golfing, and tennis is good. In trying to
break the habit, we must use very much tact. We must not
talk in vague hints, but place the issue fairly and squarely
before the patient. We must help her to help herself. We
must try to develop her will-power and self-control. Noth-
ing is so good for these patients as hard work, no matter
of what kind, as it keeps them occupied. Any inclination
to be by themselves should be discouraged.
Masturbation in the Adult Female. 53
Long marriage engagements should be greatly discour-
aged, for they keep up in both parties a state of sexual
erethism which easily leads into masturbation.
Yet one word more in regards to masturbation in adults.
Never advise marriage as a cure. The marriage state is
too sacred and too serious a condition to be used either as
a preventive or as a cure for masturbation. Such vague
hints as "Nothing will cure your nervousness as marriage"
are both unscientific and undignified from the conscientious
physician. Besides, such hints may not be without danger
to the weakling. I have heard of at least one female who
took to illegal coitus because her physician said that mar-
riage was necessary to her health.
In married women who have taken up the habit as a
consequence of unsatisfied desire due to the huband's im-
potence, withdrawal or any of the other conditions above
mentioned, the cure of the husband and his proper instruc-
tion in sexual matters is essential. Although Sturgis 119
many years ago called attention to these conditions, they
have not received the consideration they deserve. It may
seem ridiculous to some physicians to be told that normal
men ought to be instructed into the proper method of hav-
ing coitus, yet to the sexologist nothing is more common
than the dense ignorance on this very matter found among
so-called "normal men."
Although this subject will be more fully discussed, in
describing the evil consequences of withdrawal, a few words
may not be amiss in this connection.
The husband is to be made aware of the fact that the wife
has a well-marked sexual sense and desire, and her desire
54: Disorders of the Sexual Function.
and passion should be taken into consideration in his mari-
tal duties. He should be informed that sexual intercourse
is just as important to her as to him, and the lack of it
is just as injurious to her as to him. He should be in-
formed that it is just as necessary for his wife to "come"
that is, to have complete orgasm as it is for him; and
that to simply excite his wife either by withdrawal or too
soon removal of his penis, and to leave her moaning with
an excited but uncompleted passion, is sure to lead to trouble.
The husband should be taught that before commencing
coitus his wife should be fully awakened and, by all the
arts of love and affection, be stimulated into passion, so
that during the act she should if possible be as passionate
as he is. If he should get through before her, he should
not merely consider himself and his own comfort, but leave
his organ in her vagina until she has had her orgasm. He
should be the true lover and not merely the beast. If suf-
fering from impotence, or rapid ejaculation, these should
receive the proper treatment. He should be taught that
coitus interruptus is not normal coitus, and is sure to react
injuriously on both parties. If all men were properly
instructed, there would be less complaint of frigidity of the
wife on the part of the husband, and also less complaint on
the part of the wife that sexual intercourse only results in
pregnancies for her.
CHAPTER IV.
IMPOTENCE IN THE MALE.
Definition. Impotence and sterility. Organic impotence. Defini-
tion. Etiology and pathology. Symptoms. Diagnosis. Prognosis.
Treatment. Rudimentary penes.
Definition. Impotence in the male is that condition in
which the man is unable to perform the sexual act. It
may be either complete or partial. In the former he is
absolutely unable to perform the act, while in the latter he
may still be able to have a more or less complete erection,
but either the erection is so weak that it subsides at the
moment of intromission or even before intromission, or, in
addition to this weakness, there may exist such a hyperir-
ritability of the parts or sexual centers that the entire pro-
cess of erection and ejaculation lasts but a very short while
and is finished at the moment of intromission, or a very
short while after intromission, or even before the penis has
had an opportunity to enter the vagina.
Impotence in the male must be strictly differentiated
from sterility in the male. In sterility there is an impos-
sibility of impregnating the female, while in impotence
there is an impossibility of performing the sexual act. The
sterile man is not necessarily impotent. He may be fully
able to properly perform the sexual act, but, on account
of an old double epididymitis with occlusion of both vasa,
not one drop of his testicular secretion can reach his penis.
In bad cases of hypospadias and epispadias the man may
have proper erection and ejaculation, but, on account of
(55)
56 Disorders of the Sexual Function.
the abnormal opening of his urethra, not one drop of his
semen enters the vagina, and sterility is the result. On the
other hand, it is also possible for a man who is partially
impotent not to suffer from sterility. He may have pre-
mature or very rapid ejaculation and only be able to deposit
his semen at the very entrance of the vagina, without even
real intromission, and still pregnancy may result. As a
general rule, however, the impotent man is also sterile,
inasmuch as (except in very exceptional cases) he is unable
to deposit his semen deep enough into the female genitalia
to cause impregnation.
I believe the old classification of impotence into impoten-
tia cceundi, and impotentia generandi, the former designating
impotence of coition and the latter impotence of impregna-
tion, has been the cause of much confusion. It is far better
to limit the term "impotence" to define impossibility of
performing the sexual act, and "sterility" to impossibility
of impregnation.
Impotence may be classified, according to its pathology,
into (I) Organic Impotence, (II) Functional Impotence,
and (III) Psychic Impotence.
I. ORGANIC IMPOTENCE.
Definition. Organic impotence is that condition in
which the impotence is due to some anatomical defect in
the sexual organs.
Etiology and Pathology. Any condition which may
cause a lack of development of any portion of the sexual
apparatus, or an atrophy or degeneration of these parts, is
an etiological factor in this form of impotence. Among
Impotence in the Male. 57
such conditions may be mentioned mumps, which in bad
cases may cause a complete atrophy of both testicles so
early in life, as to preclude the development of sexual powers.
Injuries or other conditions which may result in complete
castration before puberty will also interfere with the de-
velopment of sexual sense and power. Lack of develop-
ment or absence of the penis, either congenital or by destruc-
tion of this organ through injury or disease, must result in
impotence, although the. sexual desire may still be present.
In certain forms of spinal syphilis as well as in locomotor
ataxia the erection centers may be completely destroyed
and impotence will follow. Injuries to the spinal cord may
cause impotence, either by direct destruction of the erec-
tion center or by destruction of those fibers which convey
the impulses to and from these centers to the peripheral
organs. In the same way injuries to the cerebrum may
likewise cause impotence. Severe injuries to the urethra
may result in such distortion and shortening of the urethra
that it is impossible to stretch normally in erection, result-
ing in curvature of the penis and impotence. Cicatricial
contractions of the tissues of the penis, as the result of
burns or other traumas, may also mechanically interfere
with erection.
It must however be emphasized that while complete
absence of the penis must of necessity lead to impotence,
yet a small, undeveloped penis does not necessarily lead to
that result. There are many cases on record in which men
with almost rudimentary penes were able to perform the
sexual act more or less properly. The same may be said
of hypertrophy of the penis. There are indeed very few
58 Disorders of the Sexual Function.
penes, no matter how large, for which intromission is not
possible. Sturgis 120 gives an extreme case (mentioned by
Hyrtl) of a Swiss smith whose penis was the size of a
child's body. Of this case Sturgis remarks "Gearly such
an unlucky wretch would be compelled to a life of celibacy,
for no mortal vagina would be capable of receiving such
a membrum virile." It is also remarkable how much of
the penis can be destroyed by ulceration or other causes
without resulting in impotence. Among other penile curios-
ities which may have that effect may be mentioned peno-
scrotal fusion, and bifid penis, while neoplasms of the penis,
may from their size render the person impotent. Plastic
exudates either in the corpora cavernosa or corpus spongi-
osum may also interfere with erection. Shortness of f renum
has likewise so interfered with erection that impotence re-
sulted until relieved by operation.
Among other conditions interfering with intromission
may be mentioned enormous hydrocele, large scrotal hernia
and elephantiasis. In these conditions the penis may be so
enveloped by the surrounding parts that it appears absent,
and cannot protrude enough for intromission even in erec-
tion. After gangrene of the penile integument or after
destruction of portions of the penis from chancroidal ulcer-
ations, scarring and contraction may result to such an
extent as to interfere with erection. Among the rare con-
ditions causing organic impotence may be mentioned horny
growths of the penis, elephantiasis of the penis and scro-
tum, preputial calculi, ossification of the penis, and, lastly,
fracture of the penis, either as a result of coitus or of
"breaking" a chordee.
Impotence in the Male. 59
Walsh, 133 in the American Journal of Urology for May,
1913, reports an unusual condition causing impotence in
the male. In these cases erection was normal, but there
was absolutely no ejaculation. Nocturnal pollutions, how-
ever, did occur, and massage of the prostate produced a
normal-appearing fluid which contained actively motile
spermatozoa. On attempting to introduce the posterior
urethroscope an obstruction was experienced in the pos-
terior urethra. The posterior urethra was dilated by sounds
until the urethroscope could be introduced. It was then seen
that there had previously existed a band of tissue connect-
ing the two ejaculatory ducts which was torn by the sound
dilatations. After this the patients became perfectly normal.
The explanation given by Walsh is that, during erec-
tion, the posterior urethra, or at least that portion adjacent
to the ejaculatory ducts, should be capable of distention to
receive the contents of the ducts. On account of the pres-
ence of the band of tissue, however, this was impossible.
The fluid could not enter the urethra and ejaculation was
impossible. During sleep, however, when the penis is not
at all or only partially erected, there is no tension put on
the urethra causing the mouths of the ejaculatory ducts to
close, and consequently the seminal fluid escapes easily. The
same held good in massage of the prostate.
Horse-back riding as well as bicycle riding may cause
impotence if done excessively and for a prolonged period
of time. Moderate exercise in this regard has no such
effect.
Symptoms. The chief symptom is the impotence itself.
In many cases partial erection can take place, and in some
60 Disorders of the Sexual Function.
cases erection takes place, but is exceedingly painful. As a
result of any form of impotence there often follow a whole
train of nervous symptoms, in some cases bordering on
insanity and not infrequently leading to suicide. But as
these symptoms are common to all forms of impotence,
whether organic, functional, or psychic, they will be de-
scribed later on.
Diagnosis. The main point in the diagnosis is to find
the original cause, for, after all, impotence is but a symp-
tom of some other disease.
Prognosis. This depends upon the etiological factor,
and the possibility of removing the impediment by operation
or other means. Many of the causes just mentioned are
very easily remedied by operation, while others are clearly
beyond our control.
Treatment. A glance at the various etiological factors
will indicate the method of treatment in many of these cases.
One point should be emphasized, however, in the manage-
ment of cases with small or rudimentary penes. For some of
these cases, ingenious apparatus have been invented enabling
the penis to enter the vagina, especially if the woman be
instructed to take an astringent douche before coitus. It
has also happened that after frequent coitus with the aid
of such apparatus, the penis has actually increased in size
and developed sufficiently for coitus without any artificial
aid.
CHAPTER V.
IL FUNCTIONAL IMPOTENCE.
Definition. Sexual vigor a relative term. Etiology and pathology.
Libido, erection, ejaculation, orgasm. Mechanism of coitus in the
end-organs. Theory of verumontanum in coitus. Nervous mechanism
of coitus. Pathology of impotence from excessive coitus. Pathology
of coitus interruptus. Pathology of impotence following masturba-
tion. Gonorrhea and impotence. Pathology of ungratified sexual
excitement as a cause of impotence. Cases with obscure pathology.
Author's opinion. Symptoms. Disturbance of the libido. Disturbance
of erection and ejaculation. Author's opinion on paralytic impotence.
Disturbance in the orgasm. Cases of congenital weakness. Impor-
tance of recognizing the etiology in the former class. Local symptoms
accompanying impotence. General symptoms. Psychic symptoms.
Diagnosis. Importance of examining wife. Importance of thinking of
organic nervous conditions. Prognosis. Treatment. Intelligent treat-
ment of posterior urethra. Importance of posterior endoscopy. Sex-
ual stimulants. Original experimentation.
Definition. Functional impotence is that form of im-
potence in which there exists no gross pathological change
in the structure of the sexual apparatus, but in which the
mechanism of copulation is disturbed through an interfer-
ence with the function, of the sexual centers or the nerves
and peripheral end-organs.
In this class of cases there is found neither the absence
of important organs nor the marked pathological conditions
mentioned under Organic Impotence. Generally speaking,
the sexual organs are sound. I have emphasized the word
"gross," to indicate that the condition is not without a
pathological basis, and that, in a not infrequent number of
cases, the endoscope will reveal areas of congestion, inflam-
mation or even erosions in the posterior urethra, and in
(61)
62 Disorders of the Sexual Function.
many of them an examination will show congestion of the
prostate and seminal vesicles. The condition must be con-
sidered functional, however, because these lesions do not
act by imposing a mechanical impediment to either ejacu-