ment also causes abnormality in the color of the urethra!
mucous membrane. With experience we can easily demon-
strate a condition of chronic congestion which must be
seen to be appreciated. Moreover, it takes considerable
experience in posterior urethroscopy before the enlarge-
ment of the verumontanum can be recognized, as the
normal verumontanum varies in size within very wide
limits; thus in the colored race, for instance, the normal
verumontanum is usually of very large dimensions, corre-
sponding to the large size of the entire sexual apparatus.
As a general thing it may be stated that we must consider
the verumontanum in its relationship to the posterior
urethra in any particular individual. In other words, a
rather large-sized verumontanum would not be considered
abnormal in an individual having a very wide prostatic
urethra, while a verumontanum that completely fills the
prostatic urethra, touching the walls of the urethra on
either side, with hardly a trace of a lateral sinus is to be
considered enlarged. (See diagram.)
As already stated, we find congestion of the prostatic
urethra in all these cases, but this pathological picture may
230
Disorders of the Sexual Function.
Lateral aulcus.
Urothral wall.
* Verumontanum.
1. Normal verumontanum.
Lateral sulcus.
. - - Urethral wall.
Verumontanum.
2. Moderately enlarged verumontanum,
Lateral aulcus.
_ - Urethral wall.
- Lateral sulcus.
Urethral wall.
- verumontanum. ' - Verumontanum.
3. Very enlarged verumontanum. 4. Atrophic verumontanum.
Diagrammatic pictures of normal and diseased verumontanum.
Withdrawal 231
be brought about by many other conditions than the one
under consideration. One cannot make a diagnosis of the
practice of withdrawal by merely looking through the
urethroscope.
The pathology in the female is similar to that in the
male, but on account of the normally more passive part
taken by the female during the act of coitus the results
are much less severe, though at times we find sequelae just
as severe as in the male.
In the female, with the commencement of coitus, there
is a general hyperemia of all the pelvic organs. In a nor-
mal coitus with fully developed orgasm, and the expulsion
of the secretions from the genital glands, a deplethorization
occurs, and the organs are left in their natural condition.
If, however, the act is interrupted by withdrawal on the
part of the husband, the orgasm either does not take place
at all, or takes place incompletely, the sexual glands do
not completely empty themselves, in other words, the
female does not really "come"; the pelvic organs remain
hyperemic and, after this state of affairs has continued for
a time, a condition of chronic congestion of the pelvic
organs takes place, with all its disastrous results.
It should be mentioned that, in even so-called normal
coitus, the woman does not receive the consideration she
deserves in a vast majority of cases. From a very large
clinical experience and study, I have come to the conclu-
sion that probably not one of five men know how to per-
form the sexual act correctly. As a general thing, even
in so-called normal coitus, the man only considers himself
and not the woman at all. We find that when the desire
232 Disorders of the Sexual Function.
for connection and erection occurs, he immediately goes at
it, whether the woman has the desire or not, and in many
cases when she is but half-awakened. As soon as he has
completed his part of the act, he stops and removes the
penis. As a result, at the commencement of coitus, the
woman is not fully excited, and only becomes half-way
excited during the act, and remains excited because she has
not nearly completed her part of the act when the husband
ceases to perform.
In questioning many women I have been told that they
experience little pleasure during the sexual act, but become
excited afterward. Such women have no real orgasm and
no perfect deplethorization. This state of affairs has been
described many years ago by Sturgis, 119 but has not re-
ceived the consideration it deserves. We see, therefore,
that in even so-called normal coitus, in the vast majority
of cases, there is left a certain amount of congestion in the
female pelvic organs, a condition which becomes much
worse if the husband practises withdrawal.
Symptoms. The symptoms may be divided into local
and reflex. The sexual symptoms have been partly given
in discussing the pathology. Briefly there is first a state of
rapid ejaculation. The patient notices that the sexual act
is more rapidly completed than before. This condition of
overexcitability increases in severity until ejaculation takes
place at the moment of complete erection or even before it.
The patient states that as soon as his penis has entered,
ejaculation takes place and the whole thing is over in a
moment. He consequently obtains little pleasure from the
sexual act. Later on ejaculation takes place so rapidly that
Withdrawal. 233
the penis has no time to enter the vagina (premature ejacu-
lation). In the final stage the centers are completely
exhausted, refuse to act, no ejaculation takes place at all,
and erection is either weak or entirely absent; in other
words, there is complete impotence, the libido may be-
come diminished, absent, or not at all affected. This last
condition is particularly unpleasant, as the patient has nor-
mal desire, but a complete lack of ability.
I desire again to emphasize the fact that not every case
reaches this final stage, and that the time it takes to reach
any of the conditions above enumerated varies within very
considerable limits. In some cases it is remarkable to note
the amount of abuse the sexual apparatus will stand before
it rebels. Patients also vary widely according as the sexual
or the reflex symptoms predominate. Sometimes frequency
of urination results on account of the congestion of the
posterior urethra.
Coming to the reftex symptoms, we find an entirely dif-
ferent state of affairs, and it is more particularly to these
that I would direct attention. The sexual symptoms are
not a source of confusion to any great degree, because the
attention of the physician is at once directed to the sexual
apparatus from their very nature, and the patient is treated
accordingly, either by his regular attendant or is referred
by him to the specialist. When, however, we come to the
reflex -symptoms we find them to be of widely divergent
character, and many of them do not in any way suggest
their sexual origin. There is hardly an organ in the body
whose workings may not be disturbed by the reflexes coming
from the abused sexual mechanism. These patients do not
234 Disorders of the Sexual Function.
come with their symptoms to the genitourinary specialist
or to the neurologist, but to the general practitioner, the
orthopedist, the gastroenterologist, the cardiac specialist,
etc. They do not suspect the cause of their trouble, and
unless the attending physician is on his guard and con-
stantly bears in mind the possibility of this condition in
doubtful cases, he may easily be led astray.
It would take us far beyond the limits of this treatise,
to enumerate all the symptoms that may be brought about
by this condition, and which are generally classified under
the general term of "sexual neurasthenia." I will there-
fore mention only a few which are very interesting or very
unusual types, and which came under my own personal ob-
servation either in my private practice, in the neurological
department of Dr. I. Abrahamson at Mount Sinai Dis-
pensary or in my own department of genitourinary diseases
at Mount Sinai Hospital Dispensary, and in the Harlem
Hospital Dispensary.
Cardiac Symptoms Due to Unnatural Sexual Practices.
Mrs. X. came to me complaining of a slight leucorrhea.
The following history was obtained after careful and tact-
ful questioning: She had suffered for two years prior to
her marriage, about six years ago, from marked cardiac
palpitation, together with a ringing in the ears and a feeling
of throbbing in the region of the temples. Believing she
had heart disease, she consulted several physicians, who
failed to give any relief. She postponed her wedding and
finally consulted a prominent internist in New York City,
who found her heart normal and prescribed a tonic, but
this likewise did not alleviate the symptoms. Finally she
Withdrawal. 235
married, whereupon all her symptoms disappeared and re-
mained away for about four or five years, during which
time she gave birth to two children. Within the past year
or two, however, all her former symptoms returned with
increased severity. This time they were accompanied also
by marked swelling of both ankles, a morning edema under
both eyelids, which disappeared during the day, and by
urine of low specific gravity, with a diminution in the per-
centage of urea as well as a diminution of the total quantity
of urea passed in twenty- four hours. The patient was now
certain that she was suffering from both heart disease and
kidney disease.
A vaginal examination disclosed a slight laceration of
the cervix and some endocervicitis which was sufficient to
account for the leucorrhea. I was struck, however, with
the enlarged condition of the labia minora.
After careful and tactful interrogation, she finally told
me that she had practised masturbation before marriage,
and on further questioning, she confessed that for the last
few years she had not desired an increase in her family and
had prevailed upon her husband to practice withdrawal.
Later on she had allowed him to have coitus only between
her thighs, not permitting any intromission.
Considering this case in retrospect we at once note a
definite history. It is a history of reflex cardiac and circu-
latory disturbance during masturbation, followed by mar-
riage with normal sexual relationship for several years,
during which children were born and during which time
all the symptoms vanished. This in turn was followed by
a period of abnormal sexual relationship, in consequence
236 Disorders of the Sexual Function,
of which, the symptoms immediately returned with increased
severity. I sent this patient to a prominent internist, tell-
ing him of my suspicions. After careful examination, the
latter confirmed my diagnosis, finding the heart, kidneys
and blood-pressure normal. I explained the cause of the
symptoms to the patient and, although she was skeptical,
she promised to follow instructions, with the result that
all her symptoms rapidly vanished.
Cases like the above have been described by Max Hertz
End others, but, as we have seen, they are often overlooked
and in the one just presented, the condition baffled the diag-
nostic skill of many physicians as well as that of a prom-
inent consulting internist. Had this patient in addition
had some real valvular lesion accompanied by a murmur,
it can be readily understood how much more obscure the
case would have been and how easily all her symptoms
might have been ascribed to a cardiac condition.
Symptoms of Sciatica Due to the Practice of With-
drawal. Although this case has been reported by me else-
where, 56 it is such an unusual type, that I feel justified in
repeating it here.
The patient, A. W., a painter, had been treated at
various neurological clinics for over a year for sciatica of
the left side. He had had the usual treatment. His pre-
vious history is briefly as follows: Patient complains of
pains in the left lower extremity; is excitable; has severe
tenderness in the left sacroiliac joint. He was treated by
electricity, including the high-frequency current, hot air, hot
baths, as well as iodide of potassium, but all without avail.
He finally had to stop working at his trade, as he could
Withdrawal 237
not climb ladders or work on scaffolding. His general
condition was poor and he looked much emaciated. He
was then referred to me for examination. I found the
prostate enlarged and tender ; but especially the left seminal
vesicle (the side of the sciatica) was very much enlarged
and nodular. This, with his emaciated condition, and in
the absence of a history of gonorrhea, made me suspect
tuberculosis. However, an examination of the secretion
of his vesicles and prostate obtained by massage, as well as
his urine, failed to show any tubercle bacilli. I cystoscoped
him also, and found his bladder normal. I treated him
by massage of the prostate and seminal vesicles, at first
once a week and later every other week. After six treat-
ments he felt much better, and after ten treatments was
entirely cured and could do all the work necessary in his
trade. The local condition of his prostate and seminal
vesicles also became normal, and his general condition
markedly improved.
In this case it must be borne in mind that there had
been absolutely no improvement for over a year, and that
while under my care the patient received absolutely no
treatment, medical or otherwise, except massage of the
prostate and vesicles. The etiological cause in this case
was the practice of withdrawal, of which, however, the
patient made no mention in giving his history, not thinking
that it had anything to do with his condition. This case
recalls to my mind the good results obtained by Fuller in
the treatment of chronic arthritis (even in non-gonorrheal
cases) by drainage of the seminal vesicles.
Nervous Exhaustibility Due to Withdrawal. This is a
238 Disorders of the Sexual Function.
very common condition and is merely inserted to illustrate
a common type of sexual neurasthenia: M. L., aged 39,
married, but separated from his wife; complains of loss of
memory, lack of concentration of interest, and other gen-
eral nervous complaints. These symptoms are common to
the most diverse nervous conditions, and it was only after
more minute interrogation that the following important
facts were brought out in the patient's sexual history, which
contained the clue to the etiology, and to which the patient
in the first instance attached little importance. It was
elicited that the patient had lost all sexual desire and that
for some time previous to his separation he had practised
withdrawal. Upon examination, a very enlarged and tender
prostate gland was found, and the posterior urethroscope
showed a remarkably congested prostatic urethra.
Patient was treated by massage of the prostate and by
the application of 10% silver nitrate to his verumontanum
through the urethroscope.
The improvement was very gratifying and very rapid.
After a few treatments the patient himself remarked that
he was regaining his former energy.
As stated at the beginning of this chapter, the etiology
might seem very easy when read in connection with the
diagnosis placed at the head of the history, but it is a far
different state of affairs when the patient attends the
neurological clinic, mingling with many organic and func-
tional nervous cases, giving no sexual history of himself
except such as is painstakingly elicited by the examiner.
Pain in Skin of Penis, Complete Impotence and General
Neurasthenia Due to Withdrawal. This patient came to
Withdrawal. 239
the dispensary complaining only of severe pain in the skin
covering the penis, without urethral pain; further investi-
gation of his history, however, brought out the fact that
he had reached the final stage of impotence, with complete
exhaustion of both the erection and the ejaculation centers
due to withdrawal.
D. D., male, age 45 ; married eighteen years ; father of
4 children; last child borjj eighteen months ago; came into
my clinic at Mt. Sinai Hospital Dispensary, complaining
only of severe pain in the skin of the penis. The pain was
strictly limited to the penile integument, and did not at
all affect the perineal integument. The patient also com-
plained of vague pains in the abdominal region. He had
no pains whatever in the urethra and no pains connected
with urination. He gave a doubtful history of urethritis
ten years earlier, but did not remember whether he had
any urethral discharge at that time. Endoscopy of the
anterior urethra showed a normal urethra with several con-
gested follicles. His meatus was too small for posterior
urethroscopy, and the patient objected to meatotomy.
Investigating his history more minutely, the following
facts were disclosed. He has been absolutely impotent for
two years past, and can neither have an erection or ejacu-
lation. Previous to this, he had suffered for about six
years from rapid ejaculation and feeble erections, which
constantly became more and more feeble until the present
state of impotence ensued. This condition of feeble erec-
tion and rapid ejaculation did not prevent him however,
from impregnating his wife, who gave birth to a child
eighteen months ago. About eight years ago, and while
240 Disorders of the Sexual Function.
still sexually active, he had suffered from frequent noc-
turnal pollutions, at least once every night and somtimes
two or three a night. In fact, he even suffered from
pollutions when indulging in coitus. For the past four
years he has not had any wet dreams whatever, even
though he has had no coitus at all for two years. The
patient admitted to having practised withdrawal for four
years, starting about eight years ago. Besides the urethral
findings just mentioned the examination revealed a slight
mitral murmur, abdomen negative, slightly enlarged axil-
lary, cervical and inguinal glands. His prostate is moder-
ately enlarged.
In this case, besides the general neurasthenic symptoms,
we have elicited from the patient a perfect history of the
course of events consequent upon withdrawal. This is an
extreme case. It presents a history of withdrawal for a
period of four years. At first erection and ejaculation are
good, but the patient suffers from frequent pollutions
(overexcitability of the ejaculation center). This is fol-
lowed by a history of gradually weaker and weaker erec-
tions, together with rapid ejaculation (extreme excitability
of ejaculation center, with gradual weakness of erection
center). Finally, there is neither erection nor ejaculation,
nor are there even wet dreams. In other words there has
been a complete paralysis or exhaustion of both the ejacu-
lation and erection centers. These facts may be translated
into pathological parlance as follows: The erection center
is being continually bombarded by reflex stimulation, due
both to the distention of the seminal vesicles caused by
incomplete emptying, and to the chronic congestion of the
Withdrawal. 241
deep urethra, due to withdrawal. As a result, impulses are
being continually sent to the ejaculation centers until the
latter becomes so hyperirritable that at night, when the
inhibitory influences of the cerebrum are lacking, the slight-
est additional stimulation such as the heat of the bedding,
etc., is sufficient to bring on erection and ejaculation (i. e.,
numerous wet dreams). As the disease progresses the
erection center finally becomes so extremely hyperirritable
during coitus, that it sends impulses to the ejaculation cen-
ters even before it is completely filled up with impulses
from the glans penis, the seminal vesicles and the cerebrum
(see Fig. 4, page 67). In other words, the erection center
has lost its function of holding back these impulses until the
proper time, and the condition of rapid ejaculation is the
natural sequence. Finally, both the erection center as well
as the ejaculation centers become completely exhausted and
no longer respond to any stimulation from the penis, sem-
inal vesicles, or the cerebrum, no matter how strong such
stimuli may be. When that stage is reached there is neither
erection nor ejaculation; the patient is absolutely impotent
and cannot even have a wet dream.
Gastrointestinal Symptoms and Impotence Due to With-
drawal. A. R., referred to me by Dr. Abrahamson in May,
1913, was 55 years old, married twenty years, and the
father of 7 children, his last child having been born seven
years ago. It may be stated in passing that in order to
obtain a confession of withdrawal from some of these pa-
tients I inquire, as a routine procedure, for the date of the
birth of the last child or the date of the last miscarriage.
If it appears that many years have elapsed since the last
it
242 Disorders of the Sexual Function.
pregnancy, I ask why his wife has not become pregnant in
so long a time, and directly suggest withdrawal as the
probable cause. The patient, thus taken off his guard, gen-
erally confesses to the practice, whereas he would probably
have denied it if questioned directly.
This patient complained of belching, of regurgitation
of food, and of vomiting. Upon further questioning he
also complained of seminal losses during defecation, and
of impotence for five years past. He admitted to practising
withdrawal for the past seven years.
On account of his age and very emaciated appearance,
I did not feel justified in ascribing his gastrointestinal
symptoms to withdrawal until I had had him examined by
an internist for possible carcinoma or other gastrointestinal
disorder. However, the internist found the gastrointestinal
tract practically normal, and I thereupon instituted a course
of treatment to be hereinafter described, which had the
result that after two months the patient was able not only
to have normal coitus for the first time in five years, but
that all his gastrointestinal symptoms left him, he gained
in weight, and again felt in perfect condition.
Diagnosis. The diagnosis can only be made by bearing
in mind the possibility of such an etiological factor in con-
ditions otherwise obscure. One often has to be very tact-
ful in order to elicit a confession of this practice, especially
in interrogating the female. It is often useless to ask
either party directly whether they indulge in it, as they
may often deny it. As a practical point, I have found it
expedient to catch the patient off his (or her) guard, either
before or after examination. I inquire, in my routine
Withdrawal. 243
manner, how long the patients are married, how many chil-
dren (or miscarriages) they have had, and the date of the
birth of the last child or pregnancy. This generally arouses
no suspicion. Then, if I see from the history that the
parties have had one, two, or more children in the first
few years of married life, and none at all in the last four
or five years, I ask why, and immediately suggest with-
drawal or other preventive means. Generally the patient
will then confess to the practice. We must not neglect to
suspect it, however, even if there has been a recent preg-
nancy, because the practice is not successful in many cases,
and pregnancy may result in spite of it.
Having made the diagnosis, we must not fall into the
opposite error of blaming all the patient's symptoms on
withdrawal, but constantly keep in mind the possibility of
errors in refraction, in digestion or assimilation, etc., as
possible causes for some of the symptoms.
Course and Prognosis. The course of the disease is
often a direct reversal of the course of onset. The general
neurasthenic symptoms frequently disappear with remark-
able and startling rapidity. Even when they disappear more
slowly, the patient himself notices the improvement between
each successive visit. It is in the sexual symptoms that
we often observe the reversal in the course of symptoms
mentioned above. Thus, in those cases which had gone
on to the stage of complete impotence, the first attempts
at coitus may be marked by premature or rapid ejaculation.
But this must not discourage a patient, as it is a sign of
improvement in that particular case, since a partial coitus
is an improvement on none at all. Finally, the lengths of
244 Disorders of the Sexual Function.
coitus increase until the normal is reached. The patient
must be told that his first attempts will naturally be weaker
than normal, and must be assured that in a little while
they will become entirely normal. At this stage he must
also be cautioned not to abuse his newly developed power,
but to have coitus at rather long intervals for a while, and
only when he has strong desire. He should be cautioned
particularly against experimenting himself, by making at-
tempts at coitus without any desire at all, simply to see
if he can effect it. In those cases which were characterized
at first by the presence of frequent pollutions and later on
by an entire absence of all pollutions, there may be a reap-