THE TREATMENT OF SEXUAL IMPOTENCE IN THE MALE 905 hands and without reasoning or questioning do whatever I ordered. He was only too ready to accept the terms. Such weak characters need a superior will, and they at once feel better as soon as they know there is a stronger personality to guide them and to order their life. Unrestrained, unfettered liberty is not everybody's ideal. I examined him, and, although I had given him no treatment that morning, he left the office in a much better, more hopeful mood than when he came. The first two months the treatment was general -I told him he should forget that he had any sexual organs and consisted in the ordering of iron, nux vomica, syrup of hypophosphites, glycerophosphates, warm and cold baths, rectal enemata of cold water, plenty of meat, raw eggs in the morning, and other measures. He gained about ten pounds, his anemia disappeared, and he looked and felt brighter. I then proceeded with the local treatment. The posterior urethra was quite sensitive and so was the prostate gland. The urethra was treated with steel sounds, Kollmann's dilators, urethral psychrophores, instillations of hydrastine and of silver nitrate; the prostate gland was very gently massaged twice a week, followed once a week by faradization and once a week by hot and cold rectal applications. He was also given rectal suppositories consisting of ichthyol, antipyrin, and atropine, to be used each night on going to bed. After six months' treatment, he attempted intercourse, which, however, was not fully satisfactory. The erection was strong, but subsided quickly and was followed by a premature ejaculation. Treatment was continued off and on for another year; it was interrupted for three months during my annual vacation in Europe. At the end of this period, the man was perfectly well. He was an entirely different man both physically and mentally. Intercourse was perfect so far as erection, duration, and sensation were concerned. He married six months later, and is now living a happy married life. This case is not in any way unique. On the contrary, it is one of common, everyday occurrence, and well illustrates what can be done by persistent judicious treatment. Had this man fallen into improper hands or had he married before a complete cure had been effected, he would have had a life of misery to look forward to, misery for himself as well as for his wife; and, knowing his sensitive character and his tendency to pessimism and melancholia as well as I do, I feel quite certain that sooner or later he would have terminated that life of misery by his own hand. It was the good luck of the patient that he was well-to-do and could afford prolonged and expert treatment. But what are the poor-the workingmen, clerks, small business men, and the others to do, when they are afflicted with impotence? The hospitals will not receive them, and the treatment dealt out to such patients in the dispensaries is worse than useless. Case 2. Age, 28 years. Had masturbated from the age of 13 or 14; occasional intercourse from the age of 24. Weak sexuality in general. Lately began to notice diminishing potence; weak erections, premature ejaculation. Never had venereal disease. Examination disclosed very narrow prepuce; patient stated that he had not retracted it for years. Retraction, which was accomplished with considerable difficulty, disclosed an accumulation of smegma, of a foul, sickening odor, and several preputial calculi; several small ulcerations appeared on the superior surface of the glans. I instituted a thorough cleansing with soap and warm water, then with hydrogenperoxide solution; then touched the ulcerated spots with a 10-percent solution of silver nitrate. I ordered washing with hydrogen peroxide solution three times a day, then dusting with an antiseptic powder. In a week the balanoposthitis was completely healed. I ordered abstinence from intercourse for two months. In the meantime warm sitzbaths at night and cold baths in the morning were taken. No internal treatment of any kind was given. At the end of that period the man tried intercourse, and with perfectly satisfactory resultsin fact, more satisfactory from every point of view than ever before in his life. He has given up masturbation entirely and is living a normal sexual life. Case 3. Age 35. Single. Had ived a normal sexual life from the age of 22, having intercourse regularly once a week to once in four weeks. Never had any venereal disease. For the last year he noticed premature ejaculation and diminishing libido; felt well otherwise. Led a sedentary life. Investigation disclosed the fact that he had always suffered somewhat from constipation, but that the condition had become considerably worse during the past year, and he had also begun to develop hemorrhoids. The prostate gland was not enlarged, but somewhat painful to the touch, and slight pressure caused prostatic secretion to appear at the meatus. I considered the entire condition due to his constipation. Treatment: An enema of warm water with soap-suds at night, followed by a rectal injection of 8 ounces of cold normal saline solution, retained in the rectum for ten minutes. In the morning a mild saline laxative, alternated with rhamnus purshiana, and aloin, strychnine and belladonna pills. Massage of the prostate gland once a week was done for four weeks. There was no treatment of the urethra. After six weeks' treatment, there was complete recovery. Case 4. Age 32. Married one year. An all-around athlete. Masturbated from the age of 15 to 18, when, being informed of the unjuriousness of the habit, he gave it up definitely. Had intercourse at the age of 20, and two years later contracted gonorrhea, which lasted eight months and was accompanied by prostatitis. Became engaged at the age of 28, from which time until his marriage-a period of three years -he abstained from intercourse. Immediately after marriage he found that the performance of the act was unsatisfactory, but, as his bride did not seem to be dissatisfied, he delayed attending to himself. Lately, however, he had noticed a distinct aversion on her part to his approaches and had also perceived that intercourse left her irritable and complaining of backache, headache, and so on. His complaint was lack of libido, premature ejaculation, sometimes even before intromission, a scalding feeling during the emission, and a sense of lassitude after the act. But, while the purely physical desire for the act was diminished, the mental desire remained as strong as ever; if anything, it was increased. Findings on examination: Posterior urethra exquisitely painful; prostate gland somewhat enlarged, boggy and painful; abundant secretion readily expressed. Testicles and epidydimis not enlarged, but tender to the touch. No gonococci, no shreds in the urine. Treatment consisted first of all in forbidding any attempt at sexual intercourse "until further notice." I gave him to understand that this was a conditio sine qua non, and told him that I would not take his case unless this condition was absolutely complied with. He agreed. I then gave him 1 milligram (1-64 grain) of atropine sulphate three times a day. This often relieves congestion of the posterior urethra and the neck of the bladder very markedly, a fact unfortunately not well known to the medical profession. A week later I began cautiously the passing of steel sounds; starting with No. 18 French, and increasing the size gradually until at the end of three months I was able to pass a No. 29 French easily. The sounds were passed twice a week. Besides, he had his prostate gland massaged and faradized once a week; once a week he had 3 minims of a 1: 100 silver-nitrate solution instilled into the posterior urethra, and once a week the solution of strychnine and hydrastine. At the end of three months' treatment he was advised to attempt intercourse. There was a very decided improvement in every respect, but it was not perfect. The ejaculation was still somewhat premature. I told him he would have to continue practically the same treatment for three months more, during which time he must abstain. He obeyed for two months, but at the end of that time he broke the injunction and had relations with his wife, which were highly satisfactory to both parties. He continued treatment for another month, and since that time he has been in perfect health. Fallacies About Neurasthenia By THOMAS G. ATKINSON, M. D., St. Louis, Missouri Professor of Nervous Diseases, American Medical College, St. Louis; Editor of "The Medical Brief' F OR some time past, there has been a growing suspicion abroad that neurasthenia is a fraud-worse than that, a myth stalking as a reality. As with the child and the story of Santa Claus, the nearer we approach it and the more we learn about it, the more apparent it becomes that it has no real existence. Or like the yokel who saw the giraffe for the first time, we are coming to say, "There ain't no such animal." Testimony upon testmony is coming in tending to show that we have allowed ourselves all these years to be fooled by an unembodied bogy. Not that there is no such condition as the one which we have called neurasthenia that is all too real for denial. But it is beginning to dawn upon our awakening intelligence that we have been investing it, in our minds, with an identity which it does not possess and mistaking the shadow for the substance. I am not quite prepared, yet, to deny point-blank the existence of neurasthenia "as she is taught," and get away with my denial. I think I could argue a pretty good case, but not altogether a complete one; and prejudices die hard. Some day I may attempt that larger task. For the present, I mean to waive the question of identity and to content myself with showing up a few of the fallacies in our concept and treatment of neurasthenia, which I have reasonable hope of making my reader see at least those of them who are not hopelessly committed to established ideas. Fallacious Theories About the Etiology The place to begin is at the beginning. Therefore, the first fallacy I shall speak of is one which pertains to the etiology of neurasthenia. It is popularly held and solemnly taught that the condition results from certain traumatic factors which we group under the name of "strain." I unhesitatingly pronounce this idea to be erroneous. I further unhesitatingly assert that no previously healthy person ever becomes a neurasthenic. I affirm that one can no more make a neurasthenic out of a healthy person than you can make a querulous weakling incompetent out of a naturally resolute level-headed man in business. As a rule, stresses only strengthen such a man. If you bear hard enough on him, however, you may break him; you may completely unnerve him-we have all seen that done; but turn him into a shiftless incompetent, never. So you may break down a healthy set of nerves; you may altogether demoralize them; you may have nervous prostration; but you will not have neurasthenia. The neurasthenic individual is born, not made. He is, from his mother's womb, a physical and mental unfit a shiftless potterer in nerves, just as some men are in business-and strain or stress does but show him up. A second fallacy relates to our concept of the nature and seat of the troubleour disease-picture. Neurasthenia is not an exhaustion of nerve function or a toxosis of nerve-tissues. So far as I know, the nerves of neurasthenic persons receive and respond to a stimulus as well as those of anyone else, nor has any histological difference ever been demonstrated in the nerve-t issue. With all due respect to my friends who have been teaching autotoxemia as a cause of neurasthenia, I do not take any stock in the doctrine, except in the sense of a vicious circle. Autotoxemia from retained waste products is primarily a result, not a cause, of neurasthenia, due to faulty innervation of metabolism and elimination. So with indigestion, insomnia, and all the train of other symptoms. To read into them a causal significance is, I am sure, putting the cart before the horse. The whole trouble is a misuse of nervous income. Now, the misuse of nervous income is not a matter of nervous tissue or of function any more than business success or failure is a matter of opportunity or money. Business "failures" have just the same opportunities and money as business "successes." The difference is in the way they utilize them and that is a matter of temperament or habit. So, then, neurasthenia is not a defect in nerve-tissue or in functionation, but a matter of nerve "habit," a subtle and intangible thing of heredity and mind. In short, it is not a condition of the nervous system in particular, but of the whole body-economy. Given a certain stewardship, represented by the entire bodymechanism, and the neurasthenic is inherently incapable of running it at a profit, just as the business failure, given a certain capital of money and opportunity, muddles and fritters it. The third, and last, fallacy of which I shall speak here is that of current treatment. It might be supposed that this grew naturally out of the two preceding fallacies; but such is not the case, for there is nothing even in the erroneous premises to which I have referred to justify the therapeutic fallacy that I am now about to expose. Some Therapeutic Fallacies There are two principles prevailing in the doctrine and practice of the treatment of neurasthenia, both equally irrational and fallacious; namely, that of direct nerve sedation and that of direct nerve stimulation, represented, respectively, by the use of bromides and of strychnine. How in the world either of these principles or either of these drugs can have gained currency, even on the prevalent idea of nerve exhaustion, passes my comprehension. If, as we are asked to believe, the nervetissue and its capacity are below par, poisoned by toxins, then, assuredly, it can not be rational therapy to depress and stultify them still further with a combina tion of two such toxic drugs as potassium and bromine. And if, on the other hand, the irritable symptoms of neurasthenia be the expression of a deficient nerve-system working against odds, then to whip it into still further frantic effort with strychnine is the worst kind of therapeutic folly. The truth is, the neurasthenic requires neither sedation nor stimulation at least not of a direct or forcible nature. The business ne'er-do-well is not helped either by petting or by putting money or opportunity in his hands. What he needs is a guardian, a manager to manage his affairs, so that he may be kept reasonably free from debt and muddle. So the nervous ne'er-do-well needs, not sedatives or stimulants, but a careful regulation of all his body-economies in such a fashion that his modest nervous income will be laid out to the best possible advantage and with the minimum of friction. Rational Conservation of Nervous Energy How shall this be done? There is no cut-and-dried method; no hard and fast rule. Each case is a law unto itself; and it is characteristic of these patients, as it is of all types of shiftless persons, that they do not exhibit their shiftlessness in the same direction two days running. For several days at a time, they often display a temporary efficiency in utilizing and managing one or two departments of their economy, and do finely in this direction; then, like the business incompetent, they give up the effort, renewing it in the same fitful way in other directions. Hence, the intelligent therapy of this condition demands periodic supervision, changing treatment from time to time as the shifting phases of the patient require, and always on certain principles which apply to the helping of all ne'er-do-wells. One of these principles is not to help them more than is absolutely necessary, but to let them help themselves as much as possible. Another is, that, when help is needed, it should be given in small, frequently repeated, judiciously placed doses rather than in large quantities. To the capable, energetic business man temporarily pressed, it is all right to give large sums of money and other heroic forms of aid. But for the constant potterer, such a course is manifestly worse than letting him alone. THE PHYSICIAN AND ETHICAL QUESTIONS Translated into actual therapeutic terms, then, what is the rational treatment of the neurasthenic? Briefly, to regulate, by whatever means seem most appropriate (preferably not drugs), whatever phase of his or her disordered, mismanaged bodyeconomy needs help at the time. It may possibly happen that, in carrying out this plan of treatment, the slight and temporary use of such drugs as strychnine and the bromides may be occasionally called for. They will far oftener seem called for. But their routine or cumulative administration, I reaffirm, is never called for in neurasthenia 909 The remedies which, here, are most frequently indicated are the gastrointestinal cleansers, the metabolic alteratives and eliminants, and the nerve-tissue nutrients, of which saline laxative, colchicine, and neuro-lecithin, respectively, may stand as typical samples; but others will, of course, suggest themselves. There are good and sufficient reasons, peculiar to the situation, why concentrated active principles are highly desirable. In a condition where minimal medication is indicated, it would hardly seem necessary to point out the unwisdom of administering drugs the remedial principles of which are complex and largely problematical. Single drug principles, in active, definite form, are alone amenable to such minimal control. The Physician and His Attitude Toward Religious and Ethical Questions By E. S. GOODHUE, M. D., Kailua, Hawaii Tis generally remarked, if not believed, that, as a class, physicians are materialistic, and personally indifferent to religious and spiritual betterment of mankind; that their study of the body and their emphasis upon its physical ills have made them disbelievers in God. Men have naturally inferred that the scientific spirit is incompatible with the religious spirit, and that where the one prevailed the other must inevitably disappear. I think that this impression, which with some has hardened into conviction, is a misconception due less to prejudice than to want of consideration of the subject. From the orthodox point of view, it is easy to consider a man or a class of men as materialists, atheists, infidels or disbelievers, when they are only reasonable doubters of dogma. In fact, the most of those who have been termed "infidels" by an unthinking world were not so, but men of such sincere religious convictions that they were unable to accept the artificial creed of their day. Such a man was Servetus, a Unitarian in all essentials. Darwin, by some even to this day called a "gross materialist," was nothing worse than a Unitarian, and his gentle, consistent life was evidence enough of the ethical adequacy of his beliefs. With men, as with children, calling "names" is pretty generally a matter of ignorance, unthinking prejudice or hostility. To a certain really good, old-fashioned Methodist minister I know, every one who doubts the Diety of Jesus, or the "inspiration" of the Bible, or that Jonah lived in the whale's belly, or that Moses received the commandments from God's hand is an infidel-and many other are of his way of thinking. This, then, is one of the reasons why medical men are looked upon as unchristian in their beliefs at least. It may be acknowledged at the outset that, as a class, their studies and habits of thought as well as their human contact with their fellow men have dispossessed them of whatever orthodox tenets they may |