[Reprinted from the Charlotte Medical Journal, October, 1893.] The Erectile Tissues-Their Physiology, Pathology, and Treatment. BY J. J. CALDWELL, M. D., IIIO N. FULTON AVENUE, BALTIMORE, MD. There are certain parts of the body, male and female, which, when excited, become swollen and turgid with blood and firm to the touch. The sensibilities, and indeed all of the actions of such parts appear exalted when in a state of erection. The most pecu- liar phenomenon in this state is the sudden and remarkable accu- mulation of blood in the erectile tissure at the time and as the im- mediate cause of the erection. This action was formerly explained by the existence of a certain force peculiar to erectile tissue called "nervi-erigentesbut the researches of later physiologists have discovered a peculiar mechan- ism in the tissue itself, by means of which the elongation is pro- duced, viz : it depends upon pressure exercised on the veins or sinuses of the tissue by certain bands of muscular fibres ; and hence the accumulation of blood as the arteries convey it freely and rapidly to the tissues. These muscular bands are supplied by nerves in much the same way as the vessels from centers located in the spinal cord, and are often called the "nervi-erigentes?' But no matter whether the congestion is produced by the action of the vaso-dilator or the vaso-motor apparatus, or by direct or indirect action on the muscular apparatus of the erectile tissue, we must in any case refer any influence transmitted to the parts in question to the spinal cord. This leads us back to a genito-spinal center in the cord, vaso-motor, but as we have seen before, no nervous center can act of its own motion, or originate action de novo, they must be excited to action. This being so we must look about for a suitable excitant influence to act upon the vessels so as to cause, in one way or the other, congestion. For a long time it has been regarded as probable that the spinal cord has a direct influence on the organs of generation ; but it was Budge who made the definite experimental observation in regard to the influence of the lower 2 part of the spinal cord on the motions of the generative organs. He laid bare the spinal cord in a male rabbit and at the same time exposed the testicle, the vas deferens and seminal vessel of one side. By irritating the exposed lumbar portions of the cord he found in numerous experiments that irritation of that part which corresponds to the fourth lumbar nerve produced active motions in the vas deferens and seminal vessels, the motion beginning at the testicle and being propagated toward the corresponding seminal vessels. The irritation on no other part of the cord produced such effects. These observations on the male, which have been often repeated with the same results, have also been made on the female; and movements of the uterus have been excited from corresponding points of the cord, therefore, the development and escape of the seminal fluid and graafian vesicle are attended with no small de- gree of nervous excitement. Actuated from the same spinal center, both male and female, organs of generation become more and more congested and irritable as these phenomena increase, so that every impression, even every influence affecting these parts must be re- flected to and from the spinal cord, from these to the brain and to the external genitals ; hence we may readily perceive the relations existing between potency and the vaso-motor tonus of the genito- spinal centers, or impotency and the plexuses of these centers. In the latter case there could be no erection or there would be a great loss of the fluctuating powers of the genital organs, i. e., enfeeble- ment of secretions, erections and ejaculations of the male and a want of activity and ovulation and menstruation on the part of the female. Hence, all of the procreative powers are more or less de- pendent upon the aforesaid vaso-motors. The inhibitory action exerted by these sensory centers throughout the cord play a vitally important influence over the circulation, viz : periodical and rhyth- mical action of the heart and respiration, blushing, rage, pallor, and suffusion. Says John Hunter : "There is not a natural ac- tion of the body, whether voluntary or involuntary that may not be influenced by the peculiar state of mind at the time." Impotency in man may be caused by absence, want of develop- ment, malformation, or mutilation of the penis ; by mental in- fluence, any violent emotion operating protractedly or during co- ition, as want of confidence, fear of consequences, anxiety, grief, disgust, over excited desire. 3 By fevers and other severe diseases, the sexual organs remain- ing feeble after general health is restored. By injuries to the back part of the head from falls, blows, concussion, etc. ; these being generally incurable, loss of power and wasting of testes and penis follow. By injuries and diseases of the spinal cord, which remove the power to copulate though desire remains and semen may be secreted. By excessive use of tobacco, which impairs digestion, and weakens nervous and muscular systems. Opium eating is in- jurious in like manner and from the same cause. By abuse of the sexual functions, removing the power of erection. Onanism or excessive sequal intercourse. Spermatorrhoea. Impediments to escape of semen, such as stricture of urethra in which the ejacu- lated fluid regurgitates into the bladder. Abnormal openings in the urethra (hypospadias and epispadias) so that the semen is not ejaculated into the vagina. By excessive obesity and large scrotal hernia. Impotence in women may be due to firm adhesions of the labia pudendi; excessively developed and persistent hymen ; absence, malformation, or an impervious condition of the vagina; oblitera- tion of this canal through inflammation. A double vagina impedes but does not prevent copulation. Super-sensitiveness with spas- modic closure of the vagina (vaginismus). Tumor of the vagina, or uterine tumors which have passed into the vaginal canal. Elon- gation of the cervix uteri; engorgement or induration of labii uteri; obliteration, obstruction, or great narrowing of os uteri or cervical canal. Closure of uterine cavity by tumors, cancers, etc. Malposition of the uterus. Acute retro-flexion and ante-flexion. Inflammation affecting the uterus. Occlusion of the fallopian tubes, disease of fimbriated extremities. Irremediable procidentia of the uterus. Large recto-vaginal or vesico-vaginal fistula, or complete rupture of perineum allowing improper escape of seminal fluid. Uterine cancer, even when the vagina is involved, impedes but does not prevent intercourse and fecundation. Sterility in man arises from certain diseases, such as tubercu- losis, diabetes, albuminuria, some forms of obstinate dyspepsia ; in advanced stages the secretion of seminal fluid is usually stopped. Some cerebral defect, owing to which the functions of the testicles have never been called into play. Disease of testicles, tumors, cancers, repeated attacks of varicocele, though as only one gland 4 is usually affected, these conditions scarcely produce sterility. Malposition of testes, these organs being retained in the abdominal cavity copulation being feasible with the crypsorchis, but the semen ejaculated being destitute of spermatozoa. Obstructions in the ex- cretory ducts of the testicles ; such as temporary or permanent ob- struction after epididymitis, with power of copulating, but ejacu- lated fluid being destitute of spermatozoa. Obliteration of ejacu- latory canals from abscesses near prostate leading to atrophy of the testes. Abuse of tobacco, opium, and alcoholic drinks, and syphilitic taint as well, may destroy vitality of spermatozoa. Sterility in women arises from amenorrhoea ; from exhaustion or excessive general weakness ; too frequent or imperfect sexual excitement, and those versions, displacements, congestions, hyste- rias, paralyses, tumors, which are the prolific results of masturba- tion. Absence, arrest of development, or disease of ovaries, only occasional, not absolute cause, as both glands are seldom diseased at the same time. Leucorrhcea, especially when the discharge is abundant and acrid, by causing destruction of the spermatozoa be- fore they reach the ovule. Syphilitic taint occasionally destroys vitality of ovule. In the absence of all obstructions or indications of disease, with apparent perfect moral and physical adaptability, there are cases of sterility still existent, regretable and baffling, which if not irremediable, their hope and succor rests solely in the studious skill of the neurologist. How momentous a medico-legal precaution may be the services of such an expert in family imbro- glios, dubious and unjust dismemberments of estates, prevented litigations depending upon the want of that 'glory'-an heir-is attested frequently by memorable and gratifying solutions. TREATMENT. While these tissues in their pathologic state may demand sana- tory means and applications as comprehensive as sexual neuras- thenia, with its mental hygiene electro-theraputy, baths, massage, counter-irritants, and the like, along with the well known older remedies, I include as valuable and reliable, for the actions they are sought to produce, the following remedies : Damiana, yerba santa, saw palmetto, liquor sedans, vanilla, black haw, pichi, stylo- santhus elatior. A few cases may illustrate and break the monotony of more general assertion. 5 Case 28-Persistent Spermatorrhoea.-Mr. H., of North Caro- lina, aged 30, married several years without issue owing to his per- sistent spermatorrhoea, which incapacitated the full act of copula- tion and deteriorated the vitality of his semen. Upon presentation I found that his urethra along the whole canal was very irritable, particularly so along the prostatic portion; that the organ was continually weeping spermatic and prostatic fluid, and that he suffered ejection during the slightest irritation, mentally and phys- ically, and that he was melancholy and foreboding, and that his skin was cold, clammy and sallow. His general health was very much broken. He had married with the hope of benefitting these unhappy symptoms; but this was a great mistake-one that is made by many laboring under like conditions. Instead of marriage, such parties should seek as a remedy the advice and treatment of the intelligent, scientific physician-one honest and reliable, making these cases a special study. Unfortunately for the community, the advertising quacks have had the majority of these delicate and all-important cases as their greatest source of revenue. Upon passing the sound I found the urethra very ten- der, with a spasmodic stricture located at or near the prostatic gland. The passage of the sound was continued twice a week to dilate the urethra and to lessen its irritability. During the emis- sion of semen, and just previous to that act, he observed a peculiar sensation or warning similar to the aura of epilepsy. Hence I placed him upon the bromides and atropine at night, and adminis- tered the nitroglycerine pills gr. each), one three times a day, and ordered warm baths and careful diet. The effect of this treat- ment was to arrest his trouble and to, gradually restore him to physical and mental health. After this treatment had been con- tinued for several months, I placed him upon tonic treatment, consisting of the fluid extract of damiana, belladonna, nux vom- ica and tincture of cinchona compound, with occasional applications of electricity to the spine. This, together with a select diet, added greatly to his vigor and procreative powers. All unnatural dis- charges have long since ceased with a fair promise of being blessed with offspring, his wife being several months advanced in preg- nancy. The number of such cases throughout the land is legion, and ever will be until our communities are taught to value scientific and special treatment. 6 Case 13-Neurasthenia.-Mr. D., a young gentleman, aged 25,, a student at law, who also performed the duties of a clerk in an office controlling a large practice. His studies and duties proved too arduous an undertaking, and soon broke him down mentally and physically, being of a nervous and ambitious disposition. He suffered greatly from nervous dyspepsia and general nervous ex- haustion. He lost flesh, lost sleep, and was tremulous and depressed, and suffered frequent seminal losses night and day. Upon examining the urethra, it was found to be irritable, with a continuous weeping discharge. No stricture was found. The penis was small, flabby and cold. I ordered him a vacation and admin- istered atropine with bromides until the nervous irritation had subsided. I then gave a tonic consisting of liquor sedans and saw palmetto during the day, with doses of pichi and hyoscyamus at bedtime, as required, making applications of the Faradic current locally and generally every few days. This treatment was kept up during the summer vacation, until late in the autumn, when he returned to his vocation, generally better and greatly restored in his nervous system. With better sleep, good appetite, and genital functions normal, the use of electricity was continued a term longer when he left my care, with the advice to be more moderate in all things. Case 144-Neurosis of Genitalia with Nervous Paralysis.- Mr. K., aged 33, was referred to me because of suffering from gen- eral nervous prostration. He is tall, athletic and active; he had lately lost his color and vivacity; and had acquired an unaccount- able dread of persons ond places. He was almost a monomaniac in the fear of on-coming "loss of manhood," or paralysis of his procreative powers. Upon examination I found it was his custom to endure prolonged and arduous mental work, neglecting the reg- ularity of sleep, diet and recreation. He had a fine constitution and physical development. His genito-urinary organs were intact and well developed, and proved readily amenable to treatment by proper hygiene, occasional administrations of electricity, and a tonic consisting of coca, sandal and vanilla. A few months of such treatment fully restored him in every particular. His physician deemed his mental phenomena of an abnormal and perhaps dan- gerous character, hence he referred him to me. All his unpleas- ant symptoms passed away as he gradually improved, though such 7 a case neglected long enough undoubtedly might have ended in some permanent pathological lesion. Case 66-Impotency Due to Excessive Use of Tobacco.-Mr. G., aged 31, married, was referred to me as a case of impotency. I found him a hale man, well developed mentally and physically. His muscles were hard and elastic, and he was able to endure great physical strain. All of his organs were well developed- especially those of the genito-urinary system. After a thorough inquiry, I found that he was excessive in the use of tobacco, chew- ing and smoking to an alarming extent, and at times was in the habit of taking alcoholic liquors too freely, all of which I forbade. I ordered for him a moderate diet and pills of damiana and nux vomica; also the daily application of the Faradic stimulus to the cord and genito-urinary appendages. He was to abstain from all genital exercises. He continued under treatment for several months, with most excellent results. Tobacco and whisky are, in my opinion, frequent inhibitors of the sexual act. Case 92-Inertia of Uterus-A young married lady, aged 22, from a fright or shock, suffered abortion during her first pregnancy. After this her menses were scant and irregular, with failing health for several years. She did not become pregnant during this time. She and her husband were anxious for an heir, as an estate depended on the issue, aside from the natural desire of maternity. After a careful examination, I diagnosticated a neurasthenic con- dition with consequent inertia of the genito-urinary organs. I ordered generous diet and hygiene, gentle exercise, and adminis- tered fluid extracts of Damiana and Haw three or four times daily, commencing with small doses and gradually increasing. After a few months the menses became more regular and pronounced. With general improvement of health and spirits, at the end of the third month of treatment she became enciente, and went through a regular term with a happy delivery. Case 163-Impotency.-A gentleman of 36 years, of delicate frame, constantly complained of feeble digestion, irregular bowels and constipation. His complexion is sallow, he sleeps badly, his habits are sedentary, and he is given to literary affairs. Has been married several years without issue. His wife is buxom, pc A e and regular. Upon examination I found his organs rather small, 8 with the power of incomplete erection only. His semen under the glass exhibited but few evidences of life. I ordered a more active life, less study, regular hours and diet. Placed him on fluid ex- tracts of Damiana and Stylosanthus, and after six months careful management he was greatly restored. He reports his wife in a fair way to become a mother. In cases of impotence from masturbation, accompanied by sper- matorrhoea, we find morbid changes in the vesicular seminales* ejaculatory duts, bulbous portion of the urethra and prostate gland. Such cases frequently require surgical and special treatment; and in detecting and locating these lesions I have found nothing equal to photographing them by the sound in the galvanic connection* as introduced.