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HAVE referred several times in previous chapters to coitus interruptus as a factor in the causation of pollutions, spermatorrhea, impotence, and sexual neurasthenia, with their varied and multitudinous symptoms. The subject, however, is so important that I consider it advisable to devote a special chapter to it. I do so because coitus interruptus is one of the most widespread forms of sexual abuse, and because it is, according to my experience, one of the most positively established causes of impotence and neurasthenia.

That some physicians have seen fit to deny the tremendously evil effects of this most unnatural form of sexual intercourse is surprising. It can only be explained by their ignorance, by their lack of experience. To me no fact in medicine is more firmly established than the evil influence of coitus interruptus on the physical and psychic condition of both the man and the woman. That there are some men who may go on practising coitus interruptus for years without material or ascertainable injury to their health is admitted. Exceptions are to be found everywhere.

I have known men who masturbated most excessively for years and then indulged in regular sexual orgies for years, who had several attacks of gonorrhea, who became infected with syphilis, and in spite of all this their sexual power remained unimpaired and they did not show a single neurasthenic symptom. But these are exceptions. When we discuss the effects of any mode of life, of any indulgence, of any habit, we have in view the generality of mankind. And on the generality of mankind, I repeat, coitus interruptus has a most pernicious, most blighting influence.

If we should examine carefully and tactfully into the history of the thousands and thousands of weak, anemic, irritable, languid, don't-care-if-I-live-or-not men and women, in a vast majority of cases we should find coitus interruptus to be the underlying

cause.

It is no use arguing abstractly and sophistically as to what difference it makes

whether the semen is deposited within the vagina or outside of it; the fact is, that withdrawal at the moment of highest excitation causes a terrible nervous shock to both the man and the woman, and the results are, as a rule, not long at making themselves felt. What Is the Proof?

It could perhaps be objected that we ourselves are falling into the post hoc, propter hoc fallacy, that because we see thousands of people who practise coitus interruptus become impotent and neurasthenic, it is no proof that it is the coitus interruptus that causes it. There might perhaps be other causes at work. But this objection falls to the ground when we state that the patients in these cases begin to improve and become well as soon as they abandon the practice of interrupted intercourse.

Several years ago I was struck by the fact that many people at the age of forty, fortyfive or forty-eight were in better health and in every respect better than when they were ten years younger. On investigation it almost invariably proved that the improvement in their health was due to the fact that, on account of the advance in age or menopause of their wives the danger of impregnation having become very slight or nil, they were enabled to give up coitus interruptus and perform sexual intercourse in the normal, natural manner.

I could give numerous instances demonstrating the positively injurious effect of coitus interruptus, but as they would be practically repetitions of each other the following case will suffice:

Cases Demonstrating the Effects Upon Man

Case One.-Masturbated as a boy, between fifteen and seventeen. Gave up the habit. Normal sexual relations from twenty-one to twenty-four. Became engaged at that age, married at twenty-five. Never had any venereal disease. Led a normal sexual life for the first three years, during which time his wife gave birth to two children.

After the second child, he began to practise coitus interruptus. A year or a year and

a half later began to notice weakened erections and premature ejaculations. At the same time began to suffer with "dyspepsia." He had severe heartburn, annoying abdominal distention after each meal, constipation. Legs felt hot and heavy, was unable to walk three blocks without getting tired and out of breath. Frequent attacks of cardiac palpitation. Very frequent urination in the day-time, but not at night, which, as we know, is one of the almost pathognomonic symptoms of sexual neurasthenia. But the most annoying and distressing symptoms were the change in his character, according to his wife's statement. From cheerful, he became gloomy, timid, and full of various anxieties. The change in his mood and character was ascribed to his stomach trouble, for which he went from doctor to doctor.

When he came to consult me, he had been suffering for five years. He came for treatment for his impotence, but had no idea that his gastrointestinal trouble had any relation to it. To me the history pointed unmistakably to coitus interruptus as the sole causa peccans. I gave him small doses of arbutin, and told him that no treatment would be of any avail unless he began to lead a normal vita sexualis. Otherwise his condition would be going from bad to worse.

My advice was followed, and in six months, without any other treatment, he was a well man. In six months more he was unrecognizable. He was as well as he ever had been. His wife's health, which had also been somewhat impaired, became normal, too.

A case like this is of more value than all kinds of abstract argumentation.

Case Two.-Man, married twelve years. Has four children. Has practised coitus interruptus for the last five years. Does hard intellectual work. Has himself felt that this method of intercourse was injuring him. Has become very nervous, urinates frequently, erections weak, ejaculations retarded. But his worst troubles are frequent night pollutions, and spermatorrhea defecationis. Has lost about twenty-five pounds from his normal weight. Lately has had attacks of vertigo, muscæ volitantes, feels a heavy band around the forehead, is afraid to go alone in a crowded street or theater (agoraphobia). Severe pain in back of neck, legs feel like lead, feet very cold, so that he must sleep with woolen stockings on. The urine is full of phosphates, also contains some shreds, which look like masturbation shreds.

He had been treated by a nerve specialist, but without any avail. I prescribed minute

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doses of cantharidin for the frequent urination, but told him that he need expect no relief until he gave up coitus interruptus absolutely. He did, and the improvement was immediate. In three months there was practically not a symptom left. The shreds in the urine, as well as the phosphates, disappeared without any local treatment.

Case Three.-A very remarkable case. The man came into my hands only two months ago. Family history excellent: himself always full of the "joy of life," through somewhat high-strung and "nervous." Married nine years. Has two children. The second labor was so difficult that it nearly cost his wife her life; she had some sepsis after the second child, and has never been perfectly well since. For the last five years coitus interruptus. For the last two years complete lack of libido, as if "he was not a man at all." Practises intercourse only once in five or six weeks, but the intercourse is not followed by any ejaculations; only later in the night, if he falls asleep, there is an abundant pollution. In the morning he feels extremely exhausted and depressed. He feels so "unhappy," that he would like to cry, go away and see nobody. To see or talk to people is torture to him.

The last year he has been suffering off and on with obstinate insomnia; for a month or two he will sleep well, then for a month or more he will suffer with the most obstinate insomnia, for which he has been taking increasing doses of veronal; following the veronal, he would feel more depressed than ever. The anxiety-neurosis is very pronounced. Wants to die, and is very much afraid to die. Imagines everybody knows what is the matter with him. Pulse generally about 80, but under the least excitement runs up to 100 to 108. Distention of the stomach after eating. Constipated.

Had never consulted a physician for his condition, as he felt ashamed. Investigation. revealed the fact, ascertainable in so many of these patients, that at first the attempt at withdrawal cost him a "superhuman" effort. He would have to gnash his teeth and strain every muscle in his body while doing it. Gradually it cost him less and less effort, but the ejaculation became also gradually retarded, until, as stated above, they ceased altogether. All this pointed unmistakably to coitus interruptus being the direct cause of his condition.

I laid out a course of hydrotherapeutic and general tonic treatment, forbade intercourse absolutely for six months. I saw the pa

tient yesterday. The improvement in his psychic condition is remarkable. He feels a "new man." For the first time in months he felt a stirring within him of his old libido, and he feels confident that he will get well. And so do I. Though the patient is not well yet, sufficient time not yet having elapsed for a final result, still I consider it worth while reporting, as showing what coitus interruptus may do even with an apparently perfectly healthy man.

Malefic Influence Upon Women

Case Four. Mrs. X., 32 years old, married eight years. Superb health before marriage. Coitus interruptus since the bridal night, as they thought they could not "afford" to have children. The first two or three years she did not seem to experience any ill effects. Gradually she began to lose desire for conjugal relations, and the lack of desire subsequently became a loathing. She would have severe pains in the ovarian region, pain in the neck, headache, would be depressed and irritated in the morning, with throat and mouth dry, and severe palpitation. She gradually developed insomnia, began to lose flesh, became quarrelsome, and cried hysterically at the slightest provocation. Lately she developed severe gastric symptomsburning in the stomach before and after eating and a permanent tachycardia. Pulse always 100. Legs tremble at slightest exertion or excitement. Well-defined anxietyneurosis, and talks of death and suicide.

Objectively nothing could be found, except the rapid pulse. Coitus at the present time only about once in two weeks, and always feels worse after. A talk with the husband elicits the information that he practised coitus interruptus with his wife. only, as he did not wish to have any children, but that during all these years he also had relations with other women in a perfectly natural way. His potency and general health are unimpaired, and it did not come to his mind that the coitus interruptus had in any way to do with his wife's having become a wreck.

Coitus interruptus forbidden absolutely, and a complete sexual rest for two months ordered for the wife. After that, resumption of normal intercourse. Also general tonic

treatment, massage and hydrotherapy. Improvement immediate, but it was ten months before the last symptoms, trembling of the legs, disappeared.

Case Five.-Miss A., school-teacher. Coitus interruptus for the last three years. Presents neurasthenic and hysterical symptoms. Anxiety-neurosis pronounced. Is always afraid something is going to happen, though she can not give any account what that something is or can be. This, however, I admit, is not a proper case to draw any conclusions from, because here the fear of impregnation, on account of her unmarried condition, was so great that in itself it was capable of causing all those symptoms.

She was advised to give up all sexual relations, which advice was followed, with decided improvement in all symptoms, both somatic and psychic. She soon married, her sexual life was normal and her health remained good.

Those who have not seen and therefore are skeptical about the very injurious effects of coitus interruptus are apt to raise an objection, to the effect that the cases I have recounted were probably not perfectly normal to begin with. That they were probably of a nervous temperament, that their parents were neurotic, that they had a hereditary taint, and so on.

I am not going to discuss this point very heatedly, because, as I have said elsewhere, I do not believe in a "perfectly normal" human being. Where is that mythical thing, a "perfectly normal," a "perfectly healthy" man or woman? The apparently perfect specimen sometimes contains deeply hidden a very dangerous moldy spot. And who can tell that some of our ancestors did not possess some physical or mental defect, which he transmitted to his grand-grandchildren, and become manifest in them?

This is all childish talk. We have to take humanity as it is. In discussing human nosology and pathology we do not deal with the exceptions at either end of the scale; we leave out the five percent at either end and take the middle ninety. Or say ten percent at either end and take the middle eighty. And on the middle ninety or eighty percent coitus interruptus produces the effect as described in this brief chapter.

HEODORE ROOSEVELT and myself

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have for many years been affected with an apparently incurable disease-a severe impediment in our silence. Just now the Colonel is a bit better. But I shall, perhaps, not recover entirely until I am assured that the practitioner has finally deserted the sloppy diagnostic methods and has combined with his bedside evidence proper laboratory data.

The great Austin Flint has ventured to inquire, "How is it possible to treat properly a disease until we determine its cause?" No, the laboratory is not all, not by any means. But it has proven its right to a place. Why peek at the tongue, tap at the shirt-buttons, massage the belly, look wise, and mix up a quarter's worth of medicine for each and every patient while your "dyspeptics" die of gall-bladder abscess, your "anemics" die of Bright's disease and your "cachetics" die of essential anemias?

In this article, my tenth on this subject, I have been forced to desert the field of diagnostics and to devote my attention to some delights of the sanitary water analyses. In the few instances which I have previously detailed, I have attempted to impress my readers with the practical value of this work.

There is need for the man in the field of accurate diagnosis. Every man can not be a specialist in analytical work, but he can apply some of the more simple tests. More than this, he can learn to interpret the results of his colleague's work when he finds this assistance necessary. When he understands the value and limitations of the work, then only will he come to his own. For, in conditions where this is necessary for the sake of himself and his patient, he will see to it that it is not omitted.

The Pollution of the Stream

And it came to pass that a great plague broke out among the inhabitants of Cran. This city was located at the mouth of the Siber and took her water from its currentpure, sparkling water of the northern glacier.

But Hygeia sent Mercury in haste to examine the sources of the stream. Searching well its banks, even in the icy zone, he saw no dead, no filth.

"Look to the air or the earth, Oh, Hygeia, for naught there is in the pure, white North to soil our beautiful river!"

"No men?"

"No dead men ""

"Ah?"

"Only one family-a shepherd, his wife, and their son; the young man sick unto death and needing assistance. That is all."

"Destroy! Destroy!" cried Hygeia, turning to the people. And the great plague was checked.

Yet I see men who have been graduated from our leading colleges during the past ten years search untiringly the banks of a stream for a dead cow or sincerely advise their patients that their typhoid fever doubtless came from the decomposing fish in the stream or from the manure pile in their neighbor's yard. "Smells awfully typhoid-like to me," they add, when explaining the miasm.

Great guns, what do you mean, doctor? That typhoid germs form spontaneously in the odors of cow dung or decomposing fish? And, yet, that is the idea a man evidently intended to convey in a talk before one of our leading medical societies a couple of years ago.

Far be it from me to argue that an elixir of horse manure or a decoction of dead rats is a pleasant or even a healthful drink; but when attempting to locate the source of typhoid fever, look for typhoid-fever patients. Don't expect elephants to come forth from the eggs of the goose (unless, forsooth, you are taking electric bitters at the time!).

Acknowledged that typhoid fever is ofttimes spread by flies, by milk, by dust and by contact, it is still spread at times by water even today as yesterday. The death of aviator Wilbur Wright, according to The New York Medical Journal, was "not only a national calamity but a national disgrace," speaking of typhoid fever as the cause of death and avoidable water contamination.

I recall having seen one ordinance ordering the installing of a filter for a water supply defeated at the last moment by a slicktongued lawyer representing the "citizens," on the argument that the subject might as well "be dropped before this community wastes considerable money and makes itself the laughing-stock of the state in an effort to filter water which is not running."

The Typhoid Bacillus Must Be Present

No matter whether a water is clear and sparkling in the light or whether it is a suspension of filth, the bacillus typhosus must be present to cause the disease. Comes, therefore, the usual question. Inquires the bacteriologist:

"Then you would advise me to examine the suspicioned water for evidences of contamination by human beings-human beings with typhoid fever?"

"I would."

"It follows that you would advise me to search for the typhoid bacillus?"

"Yes, it is worth the effort."

"What's that?" gasps the practitioner, "I must search for the typhoid bacillus before I can condemn the water?"

"No, indeed!"

"But I thought you said-
"I was answering the expert."

And there is the point. While the practitioner may often condemn a water by means of a few simple tests, yet the expert should not be content to stop at this point. But of these things I have written elsewhere and cannot now take the time of my readers. Judging from some of the letters I have received in the past, it makes a Ph. D. awfully mad to tell him to search for the typhoid bacillus. It certainly is a big job and you would be mad, too, if you were in his place. Still, if a man is prepared for the work, the compensation is great and the procedure often no more disheartening when negative results are obtained than when sputum of suspected incipient phthisis is searched for the elusive acid-proof germ.

I am not able to offer a wealth of curious cases in this paper. People usually do considerable talking about the advisability of a sanitary investigation of their well-waterbut, then, drinking boiled water is better than paying a laboratory fee, so that they assume that the water is bad and boil it (sometimes).

While I have examined a number of samples during the past few years, I have searched out a few more than those offered for analysis,

just for my own amusement and to keep my technic in working order. My observations in two of these are of some interest.

Testing the Well-Water

One member of a family was affected with typhoid fever and recovered. During the next ten years, three other members died with this disease. The chief clinical features in each of these cases were practically identical with those of the others. These patients died as a result of hemorrhages. Blame was laid on the well. At least one neighbor died as a result of this infection. Secretly this well was examined and acquitted. Here is how I reasoned it out: I found no typhoid germs ("Of course not," butts in the Ph. D.), the amounts of chlorine and ammonia were not increased, and the bowel bacilli, especially the colon bacillus, were absent. Therefore this well was not contaminated by human excreta from any privy and was doubtless a good well, its water being safe for drinking purposes.

Although not in a position to prove the fact, this person was certainly a typhoidcarrier, and that, through some careless habit-I know not what-these germs were distributed from the anus to the food of the other members of the family, is my belief.

Physicians who are likely to interest themselves, in the future, in matters of this sort may wonder how these samples from the well were obtained. I might venture that the collector of the water did not call at the house and ask for a drink, but he "happened" to boil the water in the radiator of his machine just in front of the house and so was forced to "borrow" a gallon or so, in order to cool off his motor. All of which shows the possibilities of the motor-car in questions of sanitation.

It is a great mistake to judge as to the purity of the water by the results of the chemical examination of a single sample. The ammonia-content of a certain water was high, but the bacteriological findings gave no indication that fecal contamination was occurring. Finally it was thought best to examine specimens from some other wells in that neighborhood. In all of these, the ammonia was excessive. A slough was located nearby and the source of the ammonia was traced to decaying vegetation in this.

Goiter and Drinking Water

The possible relations subsisting between endemic goiters and drinking water has not been finally proven. Once while working on a problem of this kind I received some rather unexpected assistance. At the time, I was