Impotence.—Some misapprehension as to the signification of this term is prevalent, owing to the extent of weakness and the morbid conditions to which it has been applied. The wrong application has been very common; i. e., in using it to describe a condition of sexual neurasthenia and temporary suspension of the sexual powers, from moral shock. A young man who exercises a doubt as to his ability to copulate may, upon the occasion, be unable to procure an erection; and yet he may, after a time, secure his own confidence; or, when he the least is thinking of it, be in full possession of his potence. The first attempt at coition, after matrimony, may be unavailing for this reason, and no trouble occur at any time afterwards.

The penis may be erect at first, and become flaccid before intromission can be effected. Even this does not constitute, but may be only a result of, nervous shock or impression produced upon the mind and sexual instinct, from embarrassment, that may occur to any young man who is not self-confident, and is no evidence of any permanent disease.

Impotence, as it should be defined and considered, is the manifestation of a disease in which there is permanent and actual impairment of the nerve-centres and, as a phenomenon of such centric changes, inability to procure an erection of the penis, at any and all times, sufficient to perform the act of coition. This is a chronic malady, of slow advent, and when once established there is very little tendency to recovery. The chagrin manifested in a man who is impotent is at all times striking. He feels that to be impotent is to be worse than dead. Men pride themselves on their ability to perform coition, and feel the loss of sexual power more than mind. Money and time are, therefore, expended exorbitantly to recover this lost power, that they may feel themselves men once more.

The flabby organ is the centre of attraction. He handles it, and dotes upon what has been in by-gone years, and mourns over his misspent fortune only for the possibility of his obtaining relief from his genital affliction through its influence.

The disease is complicated with spermatorrhoea at nearly all times, and may be considered only an advanced period of the same neurosis. The same conditions and types of diseased manifestations are to be studied in impotence as in spermatorrhoea. Then, to spermatorrhoea we add the phenomenon, impotence, and the accompanying changes, and we quickly comprehend the position.

The condition is a loss of excitation-power of the nerve of Eckhard, whereby all physiological irritation becomes impossible. This nerve arises from the sacral plexus, any irritation of which, in a healthy state, causes a flow of blood to the corpus cavernosa and spongiosa of the penis; but the constant stimulation of this nerve produces a loss of irritability and paralysis of the parietes of the arterioles of the erectile bodies of the penis, and no relaxation of their valves occurs at any time: a perfect vascular inactivity is the result. These arterioles anastomose with corporal venules which are very tortuous and sacculated and supplied with very large openings and very small outlets compared with the magnitude of their calibres; but the often turgesced condition of these venules causes a dilated condition of the outlets, and any blood that may be conveyed into the corpora through the arterioles will flow out so fast through the dilated venule outlets, that the turgescence necessary to produce erection is impossible. Again, the innate contractility of the trabecular substance must antagonize, to a considerable extent, the erectile tendency of surrounding tissue.

Then there is another condition so closely connected with impotence that a mention of it will not be out of place. Impotence consists in a lack of power to effect an erection; but there is a condition, not always impotence, where the person has lost all desire for copulation, and will not make an effort to obtain an erection. He does not attempt to concentrate his will-power, and does not desire any relation whatever with the opposite sex, although he may have been a debauchÉ in his early life. When such a condition has been congenital, there would be reason to suspect deformity or congenital defect. Such person may not be impotent, and if the desire returns it manifests itself in the genitals as soon as the mind is allowed to dwell upon erotic thoughts; and if erection does not occur impotence is present.

The loss of semen often subsides in the aged, and atrophy of the testes is not an uncommon result; but some people live to be very old, and are never troubled with senile-impotence.

The penis is at all times flaccid, if impotence be complete. Often partial impotence will reveal itself, deviating peculiarly in its character. Sometimes a man will, while entertaining erotic thoughts, have an erection of the penis which is perfect in all appearance, and when brought in contact with a female cannot sustain or even procure the erection, and yet the erotic desire be just as intense as if he be able to perform the act in a proper manner. These cases are practically impotent, but the disease has all to do with the mind; and as soon as the mind can be so corrected that self-control may be exercised as well as self-confidence, just so soon will the impotence disappear; and once the act is performed normally, the trouble will be at an end. But there is a condition in which all the powers of mind and body, exercised to control, will not impart either the power of erection or the erotic desire—only a longing for that once felt erotic desire exists. The condition often exists in which the patient cannot control the mental impressions, so as to effect that peculiar concentration of the nervous force which gives energy to the sexual organs; and yet there may be no disease of such nerves themselves. It is the same condition that will cause the mental operations to fail during any course of anxiety, or turbulence of the emotions. A speech-maker may fail in his efforts at first, even after he considered himself prepared for every emergency; but as soon as allowed to collect his scattered mental evolutions, he may compose himself.

Inability to perform the sexual act while suffering from any mental derangement, or misunderstanding one’s own mental elaborations, is not impotence; but there must be impairment of the integrity of the nerve-substance that evolves the force that sustains the sexual organ in its erect attitude, and also supplies the so-called physiological irritation. If we attempt to name this peculiar disease from other stand-points, we shall become confused; as it would only demonstrate a function-disease, which is an impossibility and leads to confusion.

I have seen cases of so-called impotence from intestinal worms: while impotence is not generally considered a symptom of worms, yet this is a case which recovered as soon as the worms were expelled. I have known two cases that supposed they were permanently impotent, both of which obtained relief after the expulsion of a tÆnia solium.

These were cases of symptomatic impotence; which only means phenomena that may exist in remote structural disease, or by mechanical pressure, as from foreign bodies, lumbricoide, tapeworms, etc., pressing or directly or indirectly infringing upon the nervous track that conveys the force which supplies the erectile tissue of the penis. This is a paralysis of the vaso-motor variety, in which the impotence is only a symptom: the disease must be studied under nervous diseases.

To comprehend and study true impotence, the student will be attracted to the brain and spinal cord; as there only can the pathology be carefully comprehended.

Nearly all the descriptions of this perplexing malady have been confined principally to the chronic flaccid penis and the general nervous phenomena most likely to co-exist. I must say that our knowledge is very limited beyond the superficial sources of information; and we have to content ourselves with simply describing the appearance, for the real disease itself; not but what structural changes exist in the sexual organs, worthy of note, but such changes are only secondary.

Depending upon organic disorganization of the nerve-substance, we have all grades of loss of sexual power, from the simple chronic premature ejaculation to advanced and perfect paralysis of the organ. Any male who, from exhaustion of nervous force, cannot perform the act of copulation in a normal manner, may be said to be in a degree impotent. If he be able to effect intromission and then unable to complete the act, from premature ejaculation—providing this is a common occurrence—he may be said to be impotent. The continent may undergo premature ejaculation and not be impotent. Neither is flaccidity likely to follow ejaculation from such cause.

The more advanced cases of impotence are not even capable of procuring erections; and often semen is discharged in the flaccid condition without the knowledge of the patient: such may be the result of spermatorrhoea and impotence combined.

The long-continued and frequent indulgence of masturbation must be a most frequent cause of impotence. I have only observed a very few whom I knew to have brought upon themselves this condition without the habit of masturbation; and even then I am not positive in knowledge. Yet they were rare debauchÉs, with money to squander and appetites so salacious that the almost constant contact with women was their custom. On the other hand, it seems that a male human being is constructed for endurance of his sexual organs. A notorious polygamist in practice, once living in the city of Elmira, New York, was known to lavish his smiles on his “kept women,” whom he numbered by scores, and still he was potent till he died in advanced life. We must have a most excellent example in the famous President Young whose wives, we are inclined to believe, must have kept him on the qui vive, as his children bear evidence, as well as the fascination and attractiveness of his young wives.

The exciting cause of impotence must combine a constant and long-continued sexual debauch with the depraved chain of thought that must necessarily accompany such degradation; and the practice of self-pollution must be the most fruitful of all causes.

Treatment.—In the management of impotence, the patient’s persuasive influence must not in any way change the intentions of the physician, or the fast hold of his mind, which is so indispensable to a cure, will be lost. The patient is always in great haste, and constantly urging the physician to make rapid progress. Too great firmness cannot be exercised, and promises of speedy cure will invariably fail. Time is one of the most important of all elements in the treatment, as opportunity is afforded for the recuperative powers of nature or physical forces to become poised.

Perfect confidence in the medical adviser is prerequisite to success, as by this alone can the patient’s mind be manipulated, and his hope constantly stimulated. If he has been much exercised in mind about his case, from reading “self-abuse” literature, moral treatment will be required to dispel from his mind the pictures there wrought. Not always can the virile organ be restored to its normal vigor, but elevating the general health should be first considered, and the patient’s mind kept constantly thinking about his improving physical condition, instead of watching for the first erection as he will most naturally do.

When the foregoing conditions cannot be secured, no benefit will result to the patient. In no disease has mental influence so much to do with recovery, as in impotence; and I do not hesitate to say, where I can control my patient’s mind, that I can always effect a very satisfactory relief. Employment is indispensable, and must be persisted in. The patient should have no time to play, or brood over his disease, but must be engaged so constantly that he will be even fatigued after he has finished his day’s toil, and will sleep long and soundly from his exhaustion. The most nutritious diet should be selected: meat, eggs, oysters, milk, etc. Cold bathing at night, before retiring, is a very important measure; as, first, it washes the parts of a cold, clammy sweat, and the chill from the water after reaction, produces a naturally warm feeling, and his attention is not attracted to the parts by their otherwise doughy, unnatural feeling; and secondly, the tonic properties of cold are of lasting benefit. The bathing should extend to the back, perineum, scrotum, penis, and down the thighs. Such constitutional measures should be resorted to as will favor any of the imperfect processes in the body. The means should favor assimilation of food and normal excretion, and the avoidance of stimulating diet and alcoholic liquors.

For the neurosis upon which impotence depends, I have accomplished very much by a single combination of medicine (see formula No. 1), that this preparation has been, as it were, a “stand-by” for many years; the patient gradually improving under its use, in nearly every case. I can affirm that it has been tested in hundreds of cases, in a great majority of which marked improvement has taken place, and many have been permanently cured. Many were cured before I became familiar with the importance of electricity in the treatment of such cases; but since having extensive experience with the various methods of applying electricity I confess I could not do well without it.

As to the beneficial results following galvanism and Faradisation, there can be no question; but as to which of these forms should be applied, I am not always able to say. I have used galvanism without benefit, a certain length of time, and changed to Faradism with immediate improvement; and vice versa.

I do not opine that either form, if used mildly, will often do harm; and where improvement does not follow after a reasonable length of time, I would advise a change. When the patient is wakeful and restless, a pleasant effect is produced by Faradisation, which is often a favorable sign, and may be continued with exalted expectations. In very advanced cases, the galvanic current will oftener establish an improvement, when a change to the Faradic current will continue the improvement. I consider no means of the physician demanding so much judgment and experience as electricity; and in the skilled operator’s hand much good may be realized from its use.

A very natural manner of applying Faradisation in impotence, as well as other forms of sexual neurosis, is to seat the patient upon a large wet sponge, to which the negative is connected, bringing the scrotum and perineum well in contact with the sponge, and stroking the spinal column well with the positive, also using a wet sponge. The operator will be governed by the patient’s sensibilities, as to time of sitting and strength of current. The current should not be painful or very unpleasant; and if twenty minutes produces any uneasy sensation, the next application should not be continued longer than ten minutes.

The galvanic current may be used in a similar manner.

Beard & Rockwell’s method of general Faradisation is a most excellent one for alternate applications.

A troublesome complication is often constipation of the bowels, which may be overcome by the judicious use of rhamnus purshiana. Not too much general bathing, but local bathing, as directed above, with stimulant friction, is always beneficial.

Turkish baths, so often ordered, must be avoided, as great general debility and languor often follow their use. No undue warmth can be made use of, either in dressing or bathing, as the neurosis, upon which all these unnatural phenomena depend, is aggravated.

The general treatment of neurosis, in impotency, differs very little from that in the neurosis of spermatorrhoea, as the conditions are very similar if not identical; only degrees of the same organic cerebro-spinal changes. The beginning is perhaps only a neurasthenia, but gradually increasing in intensity to spinal anÆmia, or congestion, finally softening.

Any changes of the genitals must be treated according to principles mentioned under treatment of structural changes of the genitals.

Clinical Illustrations.—It must not be expected that all cases will be confined to one definite condition, or to one combination of phenomena that may be grouped together and named. No one will so fully comprehend this as the practical physician. Cases are constantly under the care of the medical man, suffering with conditions too numerous to mention, complicated with many strange lesions. Every case must necessarily be studied from its own merits, in and of itself, or success will not follow.

It is not uncommon to come in contact with spermatorrhoea and impotence, both together, also complicated with organic disease of testicles, prostate gland, and anus or rectum. At the same time the brain and spinal cord may be drawn upon by a variety of organic lesions. By this we shall see that a report of clinical cases will bear more upon the practical than the theoretical, as regards adapting doses to nosology.

Case.—J. S. consulted me in ’74. He was suffering from spermatorrhoea and partial impotence. He had tenderness over last lumbar vertebra and sacrum, anÆsthesia of the genitals, dyspepsia, bowels constipated, and at times very languid; was brooding over his loss of power and involuntary discharges of semen, which were nocturnal, generally accompanied by lascivious dreams. The urethral sound revealed tenderness along the urethra and extreme soreness of the prostate gland. His semen was thin and spermatozoa scanty and imperfect. He was thin in flesh, and anÆmic. His erections were imperfect, and he could not perform the act of coitus. He was a masturbator. I directed pills, formula No. 2, and continued until bowels became regular; also No. 1, which was continued one year without change, with cold local bathing and brisk friction over bowels, back, perineum and scrotum. His recovery has been very satisfactory.

Case.—J. W., when he first visited my office for examination and advice, was emaciated, pallid, with his eyes sunken. He was careworn and haggard in his expression, suffering from pain in his back and limbs, almost constant pain through the top of his head; palpitation, with accelerated pulse; formications over his back and in his finger-ends; bowels constipated, and urine smelled strong like a horse’s; tender spots along the spinal cord. The testicles and scrotum were doughy and constantly moist and cold. His scrotum was long and pendant: his penis was blue and flabby. He could only obtain partial erections, very occasional. He lost semen often. His urethra was very tender, also the prostate gland. He was restless and wakeful during the night. I directed local cold bathing, Faradisation, formula No. 1, for his general neurotic condition; pills—formula No. 2—for constipation. He took chloral every night, to produce sleep, for 3 months; tr. staphisagria, small doses, for prostatic irritation, and occasional opium suppository. I discharged him after sixteen months, when he married, and now has a healthy child.

Case.—R. confided to me his history, which was, he had been a debauchÉ and masturbator. He was tall, slender, anÆmic, beard thin; was suffering from too much medicine, which he had received from unprincipled specialists, as he had been three years in their hands. There was spinal anÆmia, judging from the spinal soreness, and formication at times. He thought he would become paralyzed, as his hands and feet often became numbed. He was impotent, and often lost semen. His urine contained spermatozoa. As soon as his mind could be put at ease he began to improve, under formula No. 1, with cold local bathing, as directed, with Faradisation. I discharged him after thirteen months.

Aspermatism.—Since Roubaud’s description of this condition, and especially the application of the above term, much has been said in regard to the causation and true nature of this peculiar deficiency. Whenever sexual orgasm occurs in the male, after puberty, without ejaculation, the condition known as aspermatism may be said to exist, and may be considered as a symptom of disease. This may be partial or complete. I have known a number of individuals who failed to ejaculate semen at the time of sexual orgasm, and the semen would pass away in jets some time after the penis had become flaccid. These cases exist where there is no sign of organic stricture of the urethra, or any other organic trouble within the prostate gland or ejaculatory ducts.

Dr. Van Buren is the author of a paper which appeared in the New York Med. Journal, November, 1868, in which he attempts to establish the cause as a spasmodic condition of the urethra, forcing the seminal fluid, by reflux action, into the bladder. I can not, at present, think that this is always the case. Only a little attention to physiology will familiarize any person with the calibre-contractions that follow a column of urine from the bladder to the meatus. This same muscular contraction exists in the veins, and is what constitutes the venous wave. The same wave exists in the ejaculation of semen; and where the muscles that perform accelerating movements are paralyzed, the natural consequence must be, that the fluid will remain in its reservoir until its place is supplied by new, and a portion is forced out along the urethra, which drips away when the penis returns to flaccidity. Then, I can but regard this condition, often, as one of paralysis, in which are affected the muscles of ejaculation and acceleration. This condition often exists where the genitals are not impaired as to potence. That such a condition is present, should not be declared until after bougies have proven, to entire satisfaction, the absence of organic stricture or spasmodic contraction.

When such a lesion has come on gradually and is of long standing, the prognosis is very unfavorable; as relapses will most generally occur with the slightest indulgence. But when the condition has made its advent suddenly, from inflammatory causes, the prognosis is very favorable. A gonorrhoeal orchitis will often produce this condition, which is only transitory, or of a few months’ duration. This is only symptomatic, and very much unlike the true aspermatism of a neurotic origin.

A very extraordinary case has of late engaged my attention and curiosity. No case of the kind have I been able to discover, in medical literature or in the practice of my medical friends.

Case.—A young married man consulted me with an affliction (as it were), much to the discomfort of himself and to the great injury of his wife. He never had passed the sexual orgasm, nor ejaculated semen during coition. He is very erotic, and has no difficulty in performing the marital act, but it is followed without the slightest satisfaction. He continues in the act of coition until exhausted, and retires with the wife very much in the same condition after repeated sexual orgasms. He informs me that one hour is not an uncommon length of time for him to occupy in the act of coition, participating in the sexual beatitude during the entire period, until gradually becoming exhausted, when the pleasure dwindles away, but his penis remains erect for some time after. He says that he has often applied cold water to facilitate flaccidity.

After the organ has been reduced he sometimes can detect semen, or prostatic fluid, on the glans and meatus, and he is very soon ready to perform the act again. I have often discovered spermatozoa in his urine. His testicles are well formed, and his penis is normal in appearance. He has never had a venereal disease, and has no stricture. Treatment has given no relief as yet. It will be observed that satyriasis is prominent in this case.

Galvanism will often be found of great service as a paliative measure, with phosphide zinc and nux vomica. If a few years’ continence can be obtained, a better prospect for recovery may obtain. When galvanism is used, an insulated electrode should be passed to the orifices of the ejaculatory ducts, with the anode attached, and the cathode applied to the cord with wet sponge. I have derived some benefit from localized and general Faradisation, after the manner heretofore mentioned.

FORMULÆ.

No. 1.

Misce. Sig.: Dose, 20 drops, three times a day, in water.

A nerve tonic and stimulant.

No. 2.

Sig.: Dose, one to two, to be taken every night, and regulated to suit case, as to quantity.

Used to overcome constipation of the bowels. The iridin being slowly soluble prevents the irritation so commonly known to follow the use of podophyllin. Hyoscyamus may be substituted for the iridin or added to the formula.