MOE TEP 1 RIC E R P T T PJi . Scliool of Eur sing IMPOTENCE AND STERILITY with Aberrations of the Sexual Function and SEX-GLAND IMPLANTATION By G. FRANK LYDSTON, M.D., D.C.L. Formerly Professor of the Surgical Diseases of the Genito-Urinary Organs and Syphilology in the Medical Department of the State University of Illinois, Member of the American Urological Association, Fellow of the American Medical Association, Member of the Society of Authors, London, England, etc. THE RIVERTON PRESS CHICAGO 1917 Copyright 1917 G. Frank Lydston, M.D. -709 TO THE MEMBERS OF THE AMERICAN UROLOGICAL ASSOCIATION AS A SLIGHT EXPRESSION OF APPRECIATION OF THE EARNEST AND CONSCIENTIOUS WORK OF THE GREATEST ASSOCIATION OF ITS KIND IN THE WORLD, W'HICH HAS ACHIEVED GREAT CREDIT FOR ITSELF AND HAS EMPHASIZED THE DIGNITY AND IMPORTANCE OF GENITO-URINARY SURGERY, THIS VOLUME IS RESPECTFULLY INSCRIBED BY THE AUTHOR FOREWORD MY belief that there is room for still another monograph on diseases and aberrations of the sex function is sufficient explanation for this volume. The advisa- bility of presenting in permanent form my hormone theory of aberrations of sex development and function and my re- searches and observations in the field of sex- gland implantation, will be sufficiently ob- vious to those laborers in the vineyard of science who have learned to their cost that the medical press alone cannot be relied upon to perpetuate, protect and give last- ing credit for original work. It is hoped that the legal profession may find in the chapters on Sterility, Sex Aberrations and Sterilization, material of forensic value. G. Frank Lydston 25 E. Washington St. Chicago CHAPTER I. Aberrant and Imperfect Differentiation of Sex. Hermaphroditism. The relation of physical deformities of congenital origin in- volving the sexual organs to abnormalities and imperfections of the sexual function is most important. The subjects of physically aberrant sexual differentiation are more numerous than is gener- ally believed ; fortunately, however, the majority of cases are either slightly marked or of but little practical importance as re- gards their physiologic and social status. Certain marked cases of physical aberr^ilion of sexual struc- ture always have been of vital importance to medical jurists. Her- maphroditism, so-called, has received considerable attention from authorities on medical jurisprudence. In England, where the law of primogeniture prevails, the male is relatively so important a factor in the body social that the legal traditions upon the sub- ject of hermaphroditism have been much more enduring and im- portant than elsewhere. As our knowledge of physiology and morphology has ad- vanced, however, the so-called hermaphrodite not only has decreased in frequency in all social systems, but is a much less important fac- tor in jurisprudence. The most important features of such cases at the present time are the questions of : 1. Impotence and sterility in both sexes. 2. Sexual perversion and inversion, or other psycho- pathies of a sexual type. That the evils resulting from aberrations of structure of tlic sexual organs produce mechanic and functional obstacles to pro- creation is not at all remarkable and is sufficient!}- well under- stood. The psychosexual aspect of the question is not, however, so fully and intelligently comprehended as it should be. The term — 7 — KAIPOTENCE AND STERILITY hermaphroditism has been apphed in a loose and unscientific fashion, the physical conformation of the subjects being accepted as the chief factor in diagnosis. Hermaphroditism literally implies a mingling of the physical and functional qualities of both sexes. The crucial test as now accepted is the existence of a more or less perfectly formed testicle and ovary in the same individual. Even from this stand-point, the existence of true hermaphroditism is open to serious question. If hermaphroditism be accepted as im- plying the performance of the male or female function at will, such a condition cannot possibly exist in view of the fact that the sexual function does not begin and end with the act of sexual congress, ])rocreation being necessary to its complete fulfillment. The so- called hermaphrodite is sterile — fortunately for society — and, so far as procreation is concerned, cannot functionate as either male or female. The author is of opinion that, while pseudoherma- phroditism is by no means rare, true hermaphroditism does not, and from biologic reasoning, cannot exist. Although in most cases of pseudohermaphroditism it is pos- sible to classify the subject as either male or female with greater or less ease, it must, nevertheless, be acknowledged that cases oc- casionally occur in which the differential diagnosis demands the highest degree of diagnostic skill. A case coming under the ob- servation successively of Guyon and Fournier pointedly illustrates this. These distinguished gentlemen rendered lengthy and dia- metrically-opposed opinions as to the sex of the subject. Cases occasionally occur in which a differential diagnosis is impossible until the age of puberty, when certain sexual attributes - — menstruation, the growth of beard, changing voice, etc., as the case may be — decide the question of sex. In very rare instances the sex cannot be decided during life. In some of the cases of alleged hermaphroditism the subject not only does not present what can justly be termed an admixture of male and female organs, but is ]:)ractically a neuter, being with- out desire or cajiacity to perform the functions of either sex. When, however, the subject of general and local malformation also is the subject of sexual perversion, observation of the case may in- dicate an apparent commingling of the functional capacity. A case coming under the author's observation aptly illustrates this. The subject was a mulatto cook to whose case the author's attention was — 8 — IlKRMArnRODlTlSM Aherrant p-yciKj>c"xvial (lifferciuialion with iiniierfect physical (hf- fcreiitiatif)]!. vScxual organs of normal form. Init undeveloped. called by .some of the lads of the neighborh(XJ(l. who came for relief from typic gonorrhea, which they claimed they had contracted from him. Investigation proved the truth of tlie hoys' story. This hy- pospadiac male had contracted the disease in the normal manner from a female and, subsequently, performing the passive role in the sexual act. had given the disease to the lads. IMPOTENXE AND STlvRlLlTY A case illustrating the difficulties of diagnosis in so-called her- maphroditism is re])orted by Dr. (}. ]v. Green : Cask. — A liousemaid. aged 24, had symptoms which seemed to point to retained menses. She was five feet seven inches in height, of dark complexion, and anemic in appearance, i^'or several years she had been in domestic service, and was well known to the doctor personally. On examination, the external genitals appeared to be those of a woman ; in keeping with this was the arrangement of the pubic hair, while there was in addition considerable mammary devel()])ment. There was an oval body, freely movable, in the right labium and a similar one in the left. On separating the labia a clitoris was found, rather larger than usual, llelow this was a small opening", wdiich apparently led to a narrow and contracted vagina. Subsequent examination, however, under ether, revealed a very different state of things. The "swell- ings" in the labia proved to be testes ; the labia w^ere formed by a splitting of the scrotum into two halves. At the I)ottom of the "split" the "clitoris" was clearly the ])enis. with its glans only developed, and without the corpus spongiosimi. Upon its tmder surface there was a groove which led backward to a urethral orifice, into wdiich a silver female catheter easily passed into the bladder. The sex of this "housemaid" was cvidenth', therefore, male, and the ([uestion arose what was to be done tmder the circumstances. The patient was anxious to continue being a woman, but the law does not allow a man to masquerade in woman's c!oth('s. Dr. (ireen determined that the difficulty would be met if he were to remove the testicles from the "labia." This was accordingly successftdK' done, and now. in his tmse.xed condition, the man has restmied his ordinary occtipation of that of a "housemaid." -Aberrant sextial differentiation may not involve any physical defects of the sexttal organs ; it may be ptirely ])svchic, and de- ])endent u])on im])erfection dilferentiation of sexttal affinity. 'J'hat there is an essential defect in the psvchosexital centers of the cere- bral cortex is probable; l)tU, if such defect exists, it is too occult for detection by an}- known method of research. Cases of psychic- ally defective sexttal diflerentiation ])resent themselves under three forms: 1. Cases with normal develo])ment of physical sexttal t}])e, both general and local. These constitttte the class of cases in which sexual ])erversion is least likely to be stispected. 2. Cases of normal general ])hysi(|tie, but defective or aberrant develo])ment of the genitals. 3. Cases in the male in which the genitals are im])erfecll}- develo])ed and the general ])h\-si(|tte effeminate. The same classification a])])lies to both male and female. The atuhor has. howe\-er, observed homosextialit\- oftcner among neti- ro])athic temales ot an tiltrafeminine t\-])e than in those of mas- — 10 — Ili-.R.MAPIIRODITISM culine anrilnuc'>. It is admitted that this probably is an excep- tional experience. Sextial affinitx' has been held to be a form of hun.^'er which, traced to its sotn'ce. is mereh' chemic — or at least, bio-chemic — affinitv. \i this be true, as the author believes it to be. imperfect differentiation of sexualitx' >honld be exi)ected to lead to rever- >ional ]ieculiarities manifested 1)}' >extial perversions of \-ariotis ['-(.■lul'ilK-nnaiiiirnditi-iii (;il)errain L;x-iiit> iscxual (litYc-rentiatii )n I, -liMwinLi- totes, which were rctaiiK-d within ilie jielvis. Suhject wa- a male. fornir^. This ])oint will be more ftill\- disctissed in the next chapter. The ])oint that the atithor desiro to make here is that pederasts. tn-nin_^s, — a term a])])Iied 1)\- Ca<])ar to individuals haviui.;- "the l)o('_\' of a man and the >otil ot a woman."" — and some other sextial ])erverts ( invert> e>])eciall_\ ) are closel}' akin to h\-pos])a(liacs and ei)ispadiacs — so-called herma])hro(liies. Psychic herma])hroditism or psettdoherma])hroditi, d — are embraced e|)is])adias and bv])osi)adias ;md rudimentary develo])ment or c'lbsence of uterus, ovary, testicle, and ])enis. Mucb of tlie rtibbisb that has l)een ])0])tilarl_\- acce])ted on the (|t:estion of herma])hro(litism has been jjromtili^ated b\' men about town and ])h_\sicians who are ii^norant of se.xual niorpholoi^x'. ( )n several occasions the atuhor has been invited by physicians to inspect a wonderftil herma])hro(lite, which, on examination. ])r()ved to be a male of by no means extraordinai-ily-defective tv])e. These cases on in\-esti,<4ation ])roved to be alUiclics of disrei)Utable houses in which the alleged femininit\- of the stibjecl was beinu' devoted to ])roht- able mercantile desii^ns. In one case — which -was claimed to be a male i)er\ert -the sttbject afterward confessed that his ])erversion was for rex'entie onl\-, his sextial a])])etitc beini;" o'ratilied only in the normrd manner. This was borne otU 1)\- the testimony of some ot hi> intimate associates. llKkMAPHRODITIS-M (ki}-, one of the older writers on medical jurisprudence, classi- fied cases of genital malformation as follows: — 1. Male individuals with .-uch unusual formations of the generative organs as in many respects to resemble tlie female. 1. F c male individuals with such unusual forma- tions of the same organs as to resemble the male. ,1, W'liere a mixture of the sexual organs of l)oth sexes is cxliibited without either being entire. It is obvious that there are certain acijttired con- ditions which wotild fall tinder the above classifi- cation, yet wottld not be trtte cases of aberrant sexual diflerentiation : ('. (j.. a ])rola])sed and hy- j)ertro])hied uterus has l)een mistaken for a ru- dimentar}- i)enis. and fe- males thus affected have been known to copttlate w i t li other females. An h\i)ertr()])hicd cli- toris ma\' be nn'staken for a rudimentary ])enis and ma\' ])erform the male ])art in co])ttlation. The im])ortance of cau- tion in deciding the sex in cases of genital mal- formation is a])tl_\' illtis- t rated l)y a celebrated case occtirring in Chi- Al)errant genito-exual differentiatinn ( hypo- spadiac). Alale txpe, ])sycliosexually ; general ])hy-i(|ue of female type. cago. In this ca>e socielx' was electrified the discoverv that IMPOTENCE AND STERILITY a supposed young lady who had been visiting about and sleeping with bona fide young lady friends was a boy. The first intima- tion of the truth was the development of a pronounced beard with a bass vocal accompaniment. The assertion that certain cases of sexual perve-rsion are akin to epispadias and hypospadias and the result of imperfect differ- entiation, may seem a trifle far-fetched, but the author nevertheless holds the o])inion that, even when the differentiation of sex is complete from a gross physical standpoint it still is possible that the receptive and generative centers of sexual sensibility may fail to become perfectly differentiated. The result, under such cir- cumstances, might be, on the one hand, sexual apathy, and, upon the other, an approximation to the male or female type according to the circumstances of the case. Such a failure of development and im])erfect differentiation of structure necessarily would be too occult for detection from physical character by any means of investigation at our command. It is, however, only too well recognized l)y its results and is often responsible for disgusting cases of sexual perversion that society is prone to attribute to moral de])ravity. This point, and the relation of reversion of type to sexual ])erversion, will be more fully discussed in the next chapter. That failure of differentiation and development is equally re- s])onsible for certain cases of sexual perversion and instances of hvpos])adias and e])is])adias is the ])rincipal ])oint to be remem- bered at this juncture. Cases of gross ])hysical aberration of genital structure are not difficult to account for, so far as the uiodits operandi of their forma- tion is concerned ; l)ut their cause is not so readily explicable. There evidently is an exhaustion of formative energy before the occurrence of com])lete fusion of the two lateral segments, of which tlie embryo is ])ractically com])ose(l. Defective genital forma- tion bears the same relation to th.is exhaustion of formative energy as do crania bifida. sp>ina bifida, etc. It is ol)vious that the degree of deformit}- (lei)en(ls entirely u])on the ])eriod at which develo])- mental ])rogrcssi()n ceases. vSo far as a])])earances go. one would naturally conclude that dilTerentiation does not cease at a very early ])eriod in the life-history of the fetus, else what is ordinarily acce])ted as true hei-niaphroditism would not only occur in reality. hut would be fre(|uent. -^ 14 - iii".i-;maimir()I)ITIs.m Geoflrov St. Jliliarc, one of the older writers, niapjjed out a verv elal)orate ])lan in explanation of liernia])hro(litism in a work cspecialK' devoted to that subject, lie divided the ,^-enerative a])- ])aratus into a series of ])ortions or segments, three in each lateral division. The n])])er set coni])rise(l the testes and ovaries : the middle the wonil). jjrostate. and seminal vesicles: the lower the i)enis. I '-cudDlie-niiaiilirodilisni ( alicrraiU .^cii it o sexual dilTcTtnliulion j , sli<)\\-iiit4- \nl\a. pscinliiN asiina, and absence of uterus. Sul)ject \\";i- a male. scrotum, clitoris, and vulva. Accordino" to him, therefore, there nu'ght occur any number of varieties of herma])hroditism, accord- ins2; to the combination of faulty structures. 'Phis scheme was de- fective because of the fact that, in spite of all appearances to the contrary, differentiation ])ractically never falls (|uite short of de- terminini^- one or the other sex. The simjdest ])lan for the explanation of i^enital deformities and anomalies is to remember that the fetus ])ractica]ly develops in two lateral segments and that any failure of union at the genital furrow will result in a greater or less degree of aberration of genital — 15 — I.M1'(JT1{XCI-: AM) STI{RTIJTY ccjufoniiation. The view that hyposj)adias and epispadias are tlie result of atresia and ru])ture of the fetal m-ethra apparently is un- tenable in view of the generally-defective ])hysique found in most cases of the kind. The relation of aberrations of genital formation to sterility and im])Otence is vcr}' important. Jmpotenxe does not exist in the female unless there be atresia or complete absence of the vagina. Almost any aberration of the structure of the ovary, tubes or uterus may, however, produce sterility. In the male impotence is more likely to result than sterility, as serious deformity may ])revent either erection or sufficient develo])ment of the organ to permit intromission. No matter how great the deformity, however, the in- dividual may be fruitful if circumstances be favorable, so long as the testicles ;u"e functionally ])erfect. llic author is of opinion llial pcn'crsion of llie qiiaHly or Icsscuiiuj of the qiiantitx of iJic sex Jioniionc formed in llie glands llial produced llic parental (jcnn cell or sperm cell — or hath — is tJie biologic foioidation of lH)tIi psycliic and pJiysical aberrations of sex differentiation. As to what causes the defective or vicious hormone sup])ly in the ])arent, this also nuist be theoretic. It pos- sibly is a defect in the su])rarenals or in the anterior lobe of the ])ituitary body with defective sex gland development. The author believes that an}- general or local condition which impairs the integrity of the bioplasm of the hormone-|)r()ducing cells in the sex glands may be res])onsible for ])hysio-sexual and psycho-sexual aberrations. Sexual excesses. s\])hilis — or other general infections — might reasonably be considered as ])ossible general causes. Physical or psychic maternal shock probably may bring about hormone disturbance and consequent maldeveloi)ment. This ma\- explain certain so-called "maternal impressions."" It certainly is true that vitiated blood is poor material for the elaboration of normal hormone by the sex glands and, without healthy and ])r()i)er hormone su])])ly, it is reasonable to suppose that the ovule and spermatozoa will lack the nutritive "])unch" necessar}- to com])lete and ])erfect deve]o])ment. If the author's 77'^7«.' be correct, sexual peri'ersion and iwi'ersion — 7eith or ccilh' out phxsicid al'crratiotis — are purely biocheinic in orii^i)!, and, if taken early, susceptil'le of cure by implantation of sc.v glands, thereby adding to the economy during the period of sex develop- — 16 - HERMAPHRODITISM meiif, a certain quantity of a nczv and better quality of sex-hormone. The author is convinced, moreover, that there is great advantage in the fact tJiat the added hormone usually is an alien strain. So logical does the foregoing seem to the author, that he believes that a certain proportion of cases of perversion and inversion, if treated prior to adult age, are hopeful cases for the procedure. What could be more logical than the treatment of masculinity in the female and of femininity in the male, by large and constant doses of sex hormone of the corresponding sex through the medium of implanted glands during the period of sex-development and differentiation? That the acquired type of aberrant physio-sexual differentiation frequently is susceptible of cure by implantation seems probable. Later on, the author will relate a case that is decidedly in point. (Case 6, Chapter XL) Licompatibility of the sex hormones due to biologically unfit mating may have much to do with teratologic sex aberrations. This is occult, it is true, but possibly is an important factor in eugenics. That a primary defect in the quantity and quality of the sex hormone is essentially the cause of certain aberrant types of phy- sio-sexual development — and incidentally of their attendant pschyo- sexual aberrations — is fairly conclusively proven by the facts that : 1st., Loss of the ovaries in previously normal young females is followed by the development of masculine secondary sex char- acteristics. 2nd., The same principle holds good in the loss of the testes in the male, secondary female sex characteristics developing. 3rd., Successful administration of the appropriate sex hormone is followed in greater or less degree by a return to the normal sec- ondary sex characteristics.* The author believes that the sex hormone aberration theory of sex maldevelopment is not incompatible with the theory of the influence of pituitary and adrenal cortex hormone on the primary development of the sexual organs. Normal sex hormone prob- ably is primarily essential to the. development of the ovum, the other hormones coming into play only after the embryonic develop- ment of the pituitary body and adrenals is completed, after which the endocrine nutritive cycle is established and the hormones work in harmony for the purposes of nutrition, differentiation and de- velopment. *As will be seen later, this has been proved by the author's work in sex gland implantation. — 17 — IMPOTENCE AND STERILITY Curiously enough, the sex hormone theory suggested by the author is not inharmonious with certain theories of the Neo-Darwin- ian school of biologists, notably Weismann's. According to the latter, the theory of germinal selection can be applied to the degen- eration of organs. The germ (or the chromatic matter in the nucleus of the germ) is com- posed of tiny particles called determinants, each of which has its cell, or group of cells, to form in the growing organism. These determinants them- selves feed and grow in the ovary and are subject to a kind of struggle for food. Some obtain more than their normal share of nourishment, and this leads to increased size or efficiency of the parts of the organism which they construct. But others obtain less than their normal quantity, and the parts of the organism which they build are of diminished strength. If we accept as the underlying determinant principle of nutri- tion 1. the parental individual sex hormone — modifying the ovule and si)ermatozoa — 2. the combined hormones in the fructified ovule — /. e., the ovum. 3. the maternal hormones furnished by the ovary and especially by the corpus luteum of pregnancy, the possible re- lation of perversions of the sex hormone to aberrations of sex de- velopment and differentiation would seem to have excellent biologic support. In determining the sex of alleged hermaphrodites the following points require consideration : — 1. The character of the voice. 2. The development of the mammae. 3. The growth or absence of beard. 4. The form of the shoulders, hips, and waist. 5. The ]:)reseiice or otherwise of the menses or vicarious dis- charges. 6. The character of sexual desire. In respect to this point the occasional co-existence of sexual perversion with genital de- formity should be given its due meed of consideration. Thus, in a case in which difficulty of diagnosis existed, a perverted sexual affinity for the same sex might mislead the physician. 7. The presence or absence of rudimentary (or perfect) testes or ovaries. 8. Tlie form of the sup])osed clitoris or ])enis, the method of attachment of its prepuce, and the absence or presence of per- foration in its glans. *•). The presence or absence of the hymen (rudimentary), — 18 — HYPOSPADIAS AND EPISPADIAS nymphae, labia majora, or bifid scrotum, as the case may be. In cases of doubt it is safest to regard the individual as a female until time and pubescence have settled the question. The cases of imperfect or aberrant sexual differentiation in- cluded under the head of sexual perversion obviously are more dif- ficult to study than those in which the aberration is of a purely physical character. This is especially true regarding sapphic love, or sexual affinity of female for female. That such cases are fre- quent is certain, but they are extremely difficult to trace. The confessional of the family physician doubtless might offer evidence of a clinical character, but he is very chary of airing the shortcom- ings of his patients in this particular direction. The existence of this abnormal sexuality can be explained only by aberrant psychosexual differentiation. In the case of the male, instances are so common that the subject is decidedly trite. It is not only charity, but a sense of justice and a desire to lessen the stigma upon human nature, that impels the author to include typic cases of sexual perversion under the head of aberrant sexual differentiation, and to attribute the condition to perverted or im- perfect evolutionary development, on the one hand, and a reversion of type, on the other. To understand such problems it is neces- sary to consider the sex life of the primordial cell and the prehuman ancestral hermaphroditic type of all animal life. Sex differentiation came relatively late in the operations of biogenic law. Until the male principle appeared there zvas no sex, but merely se.vually undifferen- tiated bioplasm 7vhich multiplied after its kind. CONGENITAL DEFORMITIES OF THE URETHRA. Hypospadias and Epispadias. These comprise practically all of the congenital deformities of the urethra, save the rare cases in which diverticula or duplicate channels exist. These conditions quite generally have been attrib- uted to a failure of development in intrauterine life. The embryo being practically laid down primarily in two longitudinal sections — which subsequently became fused together in a perfect anatomic entity — it is obvious that failure of fusion at any particular point may produce congenital deformity. The deformity necessarily varies in kind according to the location of developmental failure, — 19 — IMPOTENCE AND STERILITY and its degree is, of course, modified by the extent of such defect in fusion. It seems logical to infer that the deformities under con- sideration are the results of failure of fusion of the genital furrow. It is the normal fusion of this furrow which eventually dififeren- tiates the sexes. A failure of development results in an approxima- tion to the male or female according to the degree of perfection to which embryonic development has arrived at the time it is inter- fered with. The various forms of failure of differentiation have led in many instances to confusion in the determination of sex. The subjects of hypospadias and epispadias— especially the former — therefore, are very closely associated with so-called hermaphrodit- ism in its various phases. Failure of fusion of the scrotum, asso- ciated with cryptorchidism, rudimentary development of the penis, and hypospadias, represents the most frequent type of pseudo-her- maphroditism — the type that most often masquerades as true her- maphroditism. As will be seen later on, the subject of sexual per- version is very intimately blended with urethral deformities. Failure of embryonic development as the cause of urethral de- formities recently has been disputed. Thiersch, for example, and others have claimed that these deformities are due, not to imperfect embryonic development, but to atresia of the urethra, with subse- quent rupture behind the point of obstruction. Numerous argu- ments have been advanced in supi)ort of this view by various inves- tigators ; dilation of the ureter and pelvis of the kidney, such as is often found in hydronephrosis, and the presence of cicatricial tissue being the chief points. The author cannot accept the foregoing theory ; there are too many analogous conditions that almost necessarily must develop along the same lines as urethral deformities and which cannot be explained u])on a simple mechanic basis. The principal argu- ment against the theory is the general defective development as- sociated with urethral deformities, there being not only a failure of physical, but also of psychosexual differentiation in a large pro- portion of cases. It is not necessary to resort to a mechanic ex- ])lanation of the intimate association of congenital diseases of the kidney and ureter found coincidentaly with all urethral deformities. The same aberration and failure of embryonic development are sufficiently explanatory in both. ]I^•l'OS^AI)lAS. — In this condition the deficiency of development — 20 — SEX ML'TII.ATIOXS is situated alon,^' the Hoor of the urethra, and is associated witli a defective penile development proportionate to the degree of the hypospadias. The tn-ethra may open at any ])oint from the frcnwin prcpiitii to the ])erinenm ; the farther hack the opening, the greater the failure of physical ditl'erentiation of sex. In the majority of instances the deformit}' is >light. the urethra opening just behind or at the side of the frenum. Ca>es in which the opening is located posterior to the peno-scrotal angle are relativel}' rare. In the sinipler varietv there is. as a rule, no great inconvenience resulting froiu the conditi(jn. soiling of the clothing with urine and sterility being the principal features of annoyance. 'i'hese disagreeable results increase in degree ])r(i])orti()nate to the extent (jf the deformity. lu^isi'ADiAs. — l^pispadias is rarer than hypos])adias, is most often fotnid in the female, and generally is associated with exstrophy of the bladder. It sometimes is associated with congenital absence of the sym])hysis ptibis. and so often is coml)ined with ectopia I'csiccc that its consideration ])roperly falls inider the head of con- genital deformities of the bladder. There are some rare cases in which there is a simple epis])adias without exstrophy. The (operative management of urethral deformities does not come within the scope of this work. It is r)bvious. however, that in so far as a given deformity interferes with ])otency or fertility, operation is indicated. The author has had the good fortune to successfully o])erate on a ntimber of cases of this kind. .\c and tirethra. or to the tirethra alone, are occasional causes of impotence. Cases of nnuilation of the penis b\' jeaalous women are more fre([tient than generally is su])])osed. The aiuhor ha^ met with several cases of c()iu])lete amputation. Otiite recentlv also, a cac]f impotent. Impotence in the female usually implies eitlicr some deformity or disease that produces atresia of the vagina or some local inflammatory affection — acute or chronic — that — 99 — IMPOTENCE AND STERILITY gives rise to vaginismus ; /. e., pain and spasm dvn-ing attempts at copulation. In neurotic or hysteric subjects this condition may occur independently of local inflammation or atresia. Sterility practically implies incapacity for fecundation. Copula- tion and even orgasm may be perfect, yet fecundation cannot occur because of organic defect in one or both parties to the sexual act. These defects are several, and, broadly speaking, are of two kinds: (a) mechanic and (b) nutritive. In the first category are (1) condi- tions in which, although copulation is normal, and both ovule and sperm-cell are healthy, certain local conditions prevent them from meeting at the proper time; (2) the germ-cell and sperm-cell having met, their blending is prevented; or (3) the ovule having been fecundated, certain local conditions prevent the development of the ovum. In the second category are various more or less obscure condi- tions that affect the vitality of the ovule and the vitality and activity of the spermatozoa. Independently of constitutional weakness of either ovule or spermatozoon, or both, there probably is a lack of affinity between them in some cases that either prevents them from blending or, if blending occurs, makes the union unproductive. This lack of affinity heretofore has been regarded as "mysterious." The author believes that his application of the hormone theory in great measure solves the ])roblem. That certain vitiated conditions of ovule or spermatozoa may make the one deadly to the other is j)robable in the light of the hormone theory. The author's theory of hormone incompatibility reduces the problem of infertility to a purely bio-chemical basis in many other- wise inexplicable cases. This later will be fully exj^atiated upon. Suffice it to say here that this lack of affinity may be primary or secondary :* /. e., inherent to the cell determinants, or acquired by certain extraneous conditions, c. s^.: f Consanguinity J Individual incompatability ( Physical Inherent conditions '\ ,- ^ ^u ■{ v u- I'vxtreme youth ( Psychic Senililv I • III tlio matter of sex airmities in general, Goethe's iio\cl. "Eleetivo Airinities," will be recalled. — 100 — STKRTUTV AND IMPOTENCE-GENERAL CONSIDERATIONS Fear of consequences, notably of preg- nane}- or of contracting disease. Aversion for the sexual act Disgust for the partner in the act Painful conjugation (in the female) Anger Jealousy Psychic shock, before, during or soon after conjugation Acquired conditions a. Psychic b. Tox I Anemias and Cachexias Narcotics Alcohol Toxemia from disease In breeding domestic animals, notably fowls, the author has noted the greatest variation in fertility in crossing different strains, as well as a lack of uniformity in the resttlts shown in the progeny of different strains of the same pure-blooded variety. Prior to the discovery of internal secretions, the author was wont to explain stich phenomena by the inharmoniotis blending of some subtle bio-cheinical blood principle, by virtue of which the blood of certain strains when mingled "precipitated," so to s]^eak, various qualities — good or bad — • which do not appear when these strains are crossed with others of the same variety. Sports and type reversions perhaps may thus be explained. One of the experiences related by certain breeders of blooded stock, for which no logical explanation hitherto has been offered, is the apparent permanent "tainting" of the female — for breeding purposes — that has been claimed to result from a mongrel cross. Some extensive and careftil breeders are so convinced of this that they no longer tise for breeding purposes a thoroughbred female that ever has been impregnated by a mongrel, because of the alleged fact that, even when subsequently bred constantly to thoroitghbred males, a "throw back" of the progeny to the characteristics of the ill bred previous sire at any time may occtir. Instances have been reported of human females wdio have procreated children presenting the characteristics of the male parent of children born in a previous marriage. (".ranting that these incidents — in both the lower animals and human beings — are atithentic, may they not be explained by a — 101 — IMPOTENCE AND STERILITY more or less enduring effect of the combined sex hormones of the previous mating upon the ovary of the female? The theory of a psychic impression cause hardly would do in the case of the lower animals, and in the case of the human being would act, if at all, by modifying for a time the hormone production of the female sex glands. This would be more logical than the popular maternal impression theory. There are, to be sure, several possible sources of error in the alleged clinical observations — such as accidental new sources of undesirable paternity in the case of the lower animals, and both auto- and hetero-suggestion in the case of the human female. The author is free to say that he has had no opportunity of verifying the alleged facts involved in the foregoing, and that, in extensively breeding pure bred fowls where accidental contamina- tions have occurred, he never has observed such phenomena. An- other point worthy of consideration is the ever present possibility that the sire, or dam, or both, may have an inherited "cold" strain which crops out under the combined sex hormone influences of cer- tain matings, and results in what the author unconventionally has termed a "precipitation" of the objectionable ancestral character- istics. A moment's reflection will show that both male and female may be potentially fertile, although practically sterile. It also may be seen that, although sterile with one person of the opposite sex, either male or female may be fertile with others. Incompati- bility of otherwise normal hormones is the author's explanation of this. Sterility and impotence may or may not be combined. Thus, as a consequence of removal of the testes the male may be entirely shorn of sexual desire, and is necessarily at the same time made incapable of producing the germinal material necessary for fecundat- ing the ovule. On the other hand, the testes may be removed in some cases, and yet for a greater or less length of time the potency of the individual remains unimpaired. Stallions that are gelded late are likely to retain their sexual desire and power; if, however, castration be performed when they are young, they are rendered both impotent and sterile. It is nothing unusual for owners of stock to keep on hand a horse that has been gelded late in life, for the — 102 — STERILITY AND IMPOTENCE— GENERAL CONSIDERATIONS purpose of gratifying the marcs during the period of horsing. In horses of this kind emissions occur of a character somewhat re- sembhng normal semen, although spermatozoa are necessarily absent. The secretion emitted under such circumstances is furnished by the mucous glands of the urethra, the prostatic follicles, and Cowper's glands. The possibility of retention of the power of copulation after castration is so well recognized in the harems of the East that eunuchs from whom both testes and penis have been removed bring a much higher price in the market than those who have been merely castrated. Individuals who are absolutely incapable of emitting true semen may be perfectly potent. Such cases are an illustration of potency combined with sterility. The explanation of the continuance of mechanic sex capacity after castration or loss of the testes, probably is the fact of perfect development of the genito-spinal and cerebral sex centers and sym- pathic nerve supply, which continue to act for a greater or less length of time after loss of the secreting organs. Possible vicarious action of other hormones in the endocrine cycle is worthy of con- sideration. The author would suggest that there is a prostatic hor- mone which is more or less essential to sexual activity and which acts vicariously until such time as the prostate atrophies — as the normal prostate is likely to do — after castration. Much depends on the continuance of the sexual habit — disuse is detrimental — and on the psychic effect of loss of the testes. A very important source of error in the case of the oriental eunuch and castrated animals, and of human males who have lost the testes as a result of accident or disease, is that a certain amount of testicular tissue may escape removal or destruction, a very small amount being effective in perpetuating virility. A peculiar case has been related of an oriental chief eunuch, who proved to be the father of a number of infants presented to a certain polygamous patriarch by the ladies of the harem. It transpired that, when the eunuch was "castrated" as a young lad, the scrotum only was re- moved, the testes being temporarily retained — cryptorchidism — only to descend later, with embarrassing results. The person of the chief eunuch being sacred, he was exiled — in an iron box by sea. The box "accidentally" was lost overboard in a convenient gale. — 103 — IMPOTENCE AND STERILITY When cither animal or man is completely castrated prior to the completion of se.v development, im.potence invariably results. That sterility always follows castration in either sex at any age is self-evident. Sterility sometimes is due to disparity of development of the sexual organs in husband and wife. The author has met with several cases of such physio-sexual "misfits." Individuals in whom the testes are intact, the penis having been removed, necessarily are impotent, although vmder favorable circum- stances they hardly could be said to be sterile. They might be termed potentially fertile and dynamically sterile. If it were prac- ticable to bring the semen of such individuals in contact with the healthy ovule, fecundation would be as likely to occur as in indi- viduals possessing perfect virile power. The same holds true of men whose epididymes vasa deferentia, or ejaculatory ducts have been occluded by injury or disease. In time the testes may fail to elaborate fertile semen, but at first it certainly is formed. In- dividuals who from various causes are unable to secure or main- tain an erection, nevertheless may be capable of impregnating the female, for such persons are likely to have emissions and the ejacu- lated fluid may be capable of fecundating the ovule. It is not even necessary that the semen thus ejaculated should be thrown into the vagina, as has been shown in instances in which contact and emis- sions without penetration have been permitted by the female, with resulting pregnancy. It appears to be possible for pregnancy to occur when the semen is deposited only upon the external female genitals, although in some instances the recorded evidence is some- what dubious. Stivriuty in THE Male. Sterility in the male has been sadly neglected by the profession. When consulted with reference to unfruitfulness in married life, the medical man, as a matter of routine, usually attributes the difficulty to some inherent incapacity or acquired morbid condition of the female. It is probable that much of the effort that is directed to the cure of sterility in women is misapplied, the husband and not the wife being at fault. If the direct and remote results of gonorrheal infection in both male and female be given due consideration, the — 104 — STERILITY IN THE MALE responsibility of the male sex in the matter of sterility will at once be seen to be considerable. It has been stated by eminent gynecolo- gists — with reason and great moderation — that at least one-sixth of the cases of sterility that are brought to the attention of the physician, are due, not to difficulties in the female, but to morbid conditions in the male.* Etioloc.v. — Sterility in the male is due to: I. Some morbid condition that perverts the vitality of the seminal fluid and renders it incapable of fecundating the ovum. 2. Conditions obstructing the escape of the semen from the ejaculatory ducts. 3. Conditions preventing the proper deposition of the semen in the vagina. 4. De- fective development of the testes is likely to give rise to sterility on account of the functional inactivity of the imperfect organs. 5. Cryptorchidism. 6. Defective or perverted quality or insuffi- cient supply of sex hormone due to conditions 4 and 5 or to acquired local general conditions which disturb sex hormone pro- duction. .\ccording to Kehrer, the cause of childless marriages is to be sought much oftener on the side of the man than heretofore has been the custom. This statement is based upon investigations of the semen. Kehrer investigated ninctv-six cases : In 3.12 per cent, there existed inability to copulate; in all such cases tliere hail been prececHni;- masturbation. t Tlio men suffered from frequent pollutions, or the ejaculations were premature and the penis could not be in- serted into the vagina. In these cases Kehrer claims, impregnation may re- sult, if before the attempt at coitus a speculum be introduced into the vagina. In several cases conception was obtained by this maneuver. In 31.21 per cent, azoospermia — absence of sperm.atozoa — existed. In most of these cases gonorrhea, with unilateral or bilateral orchitis, had preceded. The author lays particular stress upon occlusion of the ejaculatory ducts through gonorrheal prostatitis. But azoospermia was also found where no disease of the sexual organs had occurred, and where nothing abnormal in the genital organs could be demonstrated. Oligospermia — deficient quantity of semen — was demonstrated in 11.45 per cent. Several times masturbation was con- fessed, or else gonorrhea with orchitis, or syphilis, had preceded. But. in addition. Kehrer thinks tliat the diseases of the female sexual apparatus that may cause sterility arc considered too lightly. *The g'ynecf)lojiic (-stimaU' above f|uritecl is, in the author's opinion, far .short of the marlv. ■^Considei'ing the pix-valence of masturlialion, tliis oli.sei'\ation is of no special valuf. — 105 — IMPOTENCE AND STERILITY Utero-vaginal catarrh under certain circumstances leads to sterility, and Kehrer also thinks that bacteria may exert a destructive influence upon the ovule. It is questionable whether these bacteria produce inflammation of the mucous membrane or only find in the latter suitable conditions for further development. Noeggerath found eight sterile marriages in a series of fourteen to be the fault of the male. Gross, in a table comprising one hundred and ninety- two cases, shows that the male was deficient in one out of every six. Sterility in the male may be due to any of the following condi- tions : (a) Non-secretion of semen — aspermia (defective or dis- eased testes). {h) The semen may not contain spermatozoa — azoospermia. (c) The spermatozoa may be few in number, motionless, or their movements ephemeral — oligospertma. This may be due to aberration of the male sex hormone. {d) Obstruction to the passage of active spermatozoa to the deep urethra and seminal vesicles. {e) Obstruction to the escape of semen from the meatus — as in stricture. (/) Escape of the semen at some point between the deep urethra and meatus, thus preventing its proper deposition in the vagina — as seen in hypospadias and extensive urethral fistula. The Australian aborigines had an ingenious custom of slitting the floor of the urethra Gown to the penoscrotal angle in a certain proportion of males, thus forming an artificial hypospadias, to prevent con- ception. {g) The vitiation of hormone production already men- tioned. Cryptorchids, in whom the testes are not only retained, but also are in an embryonal and imperfectly-developed condition, are usu- ally, if not invariably, sterile. This does not apply to monorchids. Cryptorchids are, however, often potent to a high degree. A cryptor- chid gonorrheic under the author's care is sexually extremely vigor- ous. Individuals from whom both testicles have been removed necessarily are sterile. When both organs have sustained serious injuries, sterility may result, either from destruction of the — 106 — JTi C. I- - . -, -'i 1^ o ^ STERILITY IN THE MALE ^ -^Uit. ,-, secreting structure of the organs or from traumatic occlusion of the efferent ducts. The semen may be secreted in proper quantity and of a healthy quality, yet it may be prevented in some manner from reaching the mouths of the ejaculatory ducts. This condition is more frequent than generally is supposed, it being difficult of detec- tion on account of the fact that impotence is not necessarily associated with it, the sexual orgasm being attended by the ejacula- tion of secretions from various portions of the sexual tract that collectively resemble semen, and which under normal circumstances form an important and considerable component part of that fluid. As already stated, the relation of gonorrhea or urethritis to sterility is a very important one. Epididymitis is attended by the exudation of inflammatory lymph in and about the epididymis. This may be speedily absorbed, or may become organized into connective tissue that subsequently contracts and completely obliter- ates the tubes of the epididymis — a condition which most effectu- ally prevents the escape of semen from the testis into the vas deferens. When consulted regarding matrimonial unfruitfulness the physician should carefully inquire of the husband as to a gonorrheal history, and especially as to the occurrence at some previous time of double epididymitis. The explanation of the apparent sterility of the wife may not be satisfactorily determined until after a microscopic examination of the semen of the husband has been made. A low grade of chronic inflammation of one or both epididymes may occur without sufficient pain or swelling to especially attract the patient's attention, hence examination may reveal thickened and indurated epididymes in the absence of a history of epididymitis. It should be remembered also, that the ejaculatory ducts, vasa dcferentia, or vesicles, may be infected, with resultant occlusion, without either history or objective symptoms of epididymal involve- ment. Inflammation — orchitis — and infection with subsequent atrophy of the testes proper may occur from various causes and produce sterility or impotence — or both. Orchitis secondary to parotiditis is a frequent cause. Any syste:mic infection may result similarly. Thus the author has met with a case in which one testicle was lost from trauma and the other some years later from — 107 — IMPOTENCE AND STERILITY some unknown infection. In another case, one testis was atrophied from infection secondary to vaccination, and the other from no apparent cause some time later. This and the preceding rare case are oddly suggestive of a similarity to the so-called sympathetic ophthalmia in which one eye is destroyed by one cause or another — notably by foreign bodies — and the remaining eye subsequently is lost without immediate exciting cause, after an interval, perhaps, of some months or even years. The author recently had under observation an operative case of his own in which unilateral orchitis with loss of the testicle followed a few weeks after supra-pubic section for removal of vesical carcinoma. The imminent danger of atrophy and loss of function of the testis from true orchitis, suggests the imperative duty of operative relief of tension in all cases, even of the traumatic variety. The old idea that a hematoma of the testis or cord should not be operated, is, in the author's opinion, responsible for numerous cases of testicle destruction. Injuries to the prostatic urethra incident to operations upon urethral stricture or stone in the bladder may produce occlusion of the mouths of the ejaculatory ducts and consequent sterility. Cauterization of the prostatic sinus may result in a similar condi- tion. A well-known French writer observed, regarding the use of the portc-causiique by Lallemand, that by its use many men had been unsexed, causing "more eunuchs than had all the harems of the east." It is to be remembered that sterility in the male may be attended by absolutely no symptoms that will lead to a satisfactory diagnosis without resort to the microscope. Both seminal ducts may be occluded, so that the semen cannot by any possibility pass through the ejaculatory ducts, yet, if the testes are well developed and firm and in a perfectly normal condition, sexual desire, power of erection and pleasurable sensations are normal. When these phenomena are normal, yet spermatozoa are not emitted, it usuallv is safe to infer that there is mechanic obstruction to the escape of semen from the testes, rather than a secretory ])erturbation, even though these organs and their ducts i)rescnt no evidences of disease. The gross uppenrancc of the fluid ejaculated during the sexual orgasm in a/()(">sperniia may be almost precisely similar in ap])ear- ance to normal semen, the absence of spermatozoa alone constituting — 108 — STERILITY IN THE MALE its principal clinical feature. As a rule, however, the fluid is thin and watery. Men who are suffering from pronounced stricture of the urethra are likely to be sterile, as a consequence of interference with ejacula- tion of the semen. In cases of stricture of long duration, sterility may persist for some time after the urethral obstruction has been removed. This is due to the fact that the obstruction to ejacu- lation has resulted in the semen being habitually forced back- ward into the bladder past the vent montanitm, or colUculus scmi- nalis, the function of which is to prevent such backward passage under ordinary pressure and to facilitate the extrusion of the sper- matic fluid from the urethra. It is said that there exists in Paris a certain class of prostitutes who prevent concej^tion by passing the index finger into the rectum of the male during intercourse, and pressing upon the membranous urethra just in front of the prostate at the moment of ejaculation. This ingenious and disgusting prac- tice causes the semen to be forced back into the male bladder by overcoming the resistance of the colUculus. If this performance be indulged in frequently, the function of this erectile structure may be permanently destroyed, the individual ever after ejaculating his semen into his own bladder. In most cases of pronounced stricture the semen is retained in the urethra until erection subsides, when it slowly dribbles away. In hypospadias and epispadias the deformity of the urethra may be such as to prevent the extrusion of the semen far enough into the vagina to accomplish impregnation. Individuals thus affected practically are sterile. A further and excellent illustration of potency conjoined with sterility is a case that the author elsewhere has described as illustra- tive of the effects of pathologic changes in the epididymis. A tuberculous testicle was removed from this patient, and in a few months chronic inflammation and induration occurred in the remain- ing organ. As a consequence, while the patient found that his sexual desire and power were very much stronger than prior to the opera- tion, he stated that after the appearance of disease in the remaining organ he no longer had emissions, the orgasm being apparently perfectly normal with the exception of the absence of seminal dis- charge. It sometimes is very difficult accurately to determine the causes of a lack of fecundating power in the semen. Thus, the sperma- — 109 — IMPOTENCE AND STERILITY tozoa may be absent from the seminal fluid in cases in which there is no history of inflammatory trouble with the testicle or other causes that would prevent its formation or discharge. In some instances, probably from constitutional depression or cachexia, the elaborated semen is perverted in quality and deficient in quantity, the vitalizing element being either absent entirely or of such degenerate constitution that it is incapable of impregnating the ovule. Spermatozoa may be present at one time, and absent at another in certain instances, according to the constitutional condition of the patient at the time. In one case of a professional man of the author's acquaintance, sterility had existed for a number of years ; the semen, being examined at various times, was found to contain no spermatozoa, yet they finally appeared in the seminal discharge and the patient succeeded in impregnating his wife. In connection with the subject of sterility the varying vitality of both ovule and spermatozoa must be taken into consideration. As is well known, there is no constant relation between the performance of the sexual act and the discharge of the ovule. It therefore is necessary, in order that impregnation may be facilitated, that both the male and the female elements be capable of retaining their vitality for a certain length of time. Obviously, if this were not the case, it would be necessary for copulation and ovulation to occur simultaneously. By a wise provision of nature, however, both ovule and spermatozoa retain their vitality for a considerable time. It has been claimed by some physiologists that their vitality is pre- served for a week or ten days, or even longer. If, during the persist- ence of this vitality, the male and female elements are brought in contact, impregnation is likely to occur. Anything that lessens the period during which the elements necessary to conception retain their vitality tends to produce sterility. In some females it is neces- sary for copulation to take place either just before or shortly after menstruation, in order that conception may occur. The mid-period necessarily is least favorable to conception, for at this time the ovule has reached its minimum degree of vitality, if, indeed, it has not already become disintegrated. Between this period and the next ovulation a sufficient time will have elapsed to impair, or perhaps destroy, the vitality of the spermatozoa. The sources of fallacy in taking this fact as a basis for precautions against pregnancy are the varying vitality of the ovule and spermatozoa and the fact that — 110 — STERILITY IX THE MALE ovulation probably is not necessarily coincident with menstruation. Indeed, ovulation probably may occur at the time of the sexual act as a result of extreme sexual excitement. These physiologic facts are worthy of consideration in the management of some cases of sterility. For example, if copulation be permitted only just before and after menstruation, the sexual energies of both parties to the act are conserved and made more active. The se^fual passion is stronger in the female at this time, and, if the male is abstinent at other times, he, too, is likely to be more passionate and vigorous. By taking this precaution the ovum and spermatozoa will be brought in contact at the time when the vitality of both is at its maximum. Leaving the question of impotence out of consideration, it is a well-known fact that sterile marriages occasionally are observed where both husband and wife are perfectly capable of procreation, yet for some peculiar reason the elements necessary for conception apparently have no affinity for each other, and this independently of the question of sexual passion. The truth of this assertion is shown by the fact that in many instances individuals who have been childless in a first marriage have married again, and have reared large families. The physiologic question involved under these cir- cumstances is well recognized by stock-breeders, who find, for example, that certain mares cannot be fecundated by a stallion that perhaps is distinguished by the multiplicity of his progeny, but are readily impregnated when covered by another and even inferior stallion. It is conceivable that varying states of vitality of the sperma- tozoa may result from morbid conditions affecting the general health. Perfection of elaboration of the various secretions of the body depends greatly on the condition of the individual. It is well known that the secretions of the salivary, mammary, and gastro-intestinal glands are greatly modified by mental emotions, and by various pathologic conditions affecting the system at large, and why may not this be equally true as regards the semen? It is probable that the condition of the emotional faculties at the time of copulation have much to do with fertility in the human subject. This is one of the possible explanations of the infrequency of conceptions in prostitutes, in whom, however, the results of infection usually sooner or later are an all-sufficient explanation. Abuse of the sexual apparatus, either through masturbation or — Ill — IMPOTENCE AND STERILITY sexual excess, next to inflammatory troubles of the testicle is prob- ably the most frequent cause of sterility. Prolonged overstimulation of the secreting structures of the testes finally results in exhaustion and relaxation of the organs, the semen being imperfectly elaborated, even though its quantity and consistency may be apparently the same. Again, the frequent shocks to the nervous system involved in the oft-recurring orgasm, in combination with the drain afforded by the excessive loss of seminal secretion, results in constitutional debility ; and this again, reacting upon the semen, devitalizes it. The important relation that the bodily condition bears to the number and constitution of the spermatozoids can hardly be overestimated. Other things being equal, the activity and potency of the spermatic cells is in direct proportion to the strength and vigor of the general system. The author's theory of the physiologic relation of the supply and constitution of the sex hormone to the procreative act, and therefore to both sterility and impotence, will receive special attention later on. Diagnosis. — The diagnosis of sterility in the male can be made only by examination of the ejaculated discharge. When the sper- matozoids are found to be absent, feeble, imperfectly formed, or few in number, the source of the infecundity of the individual is at once apparent. Defective hormone supply may in part explain such conditions. Careful physical examination of the testicles and sper- matic cords, with exploration of the urethra, may demonstrate the fact that the trouble is not defective elaboration of semen, but obstructive, the semen being prevented from escaping into or from the urethra. This is the only logical inference if the testes are firm and hard and of the proper size, the spermatic cords being also apparently healthy. Relative sterility, due to hormone perversion or incompatibility, with numerous and active spermatozoa, neces- sarily is too occult for detection. Prophylaxis of sterility in both sexes largely consists in careful treatment of gonorrhea and its complications. It is obvious that successful treatment in the male in a large measure protects both sexes from sterility. Competence and thoroughness on the part of the genito-urinary surgeon stands between the public and much sterility. Not the least of his functions is to prevent, if possible, uncured gonorrheics from marrying. The management of epididymitis is especially important in its bearing on possible sterility — 112 — PROPHYLAXIS OF STERILITY in the male. After critical observation and experience extending over a ])eriod of some nine years — following Hagner's work in epididymotomy in 1906 — the author has arrived at the conclusion that e])ididymitis invariably should be treated by radical operative measures. Although the surgery of acute inflammation of the epididymis is not new, the disease almost universally has been "mollycoddled." Physician and patient alike have failed to com- ])rehend the seriousness of the condition as regards its menace to the comfort, efficiency and especially the fertility of the affected individual. Following epididymitis in the large majority of cases t^e testis of the affected side is "put out of business." i. c, while still poten- tially fertile, it is dynamically sterile by virtue of permanent occlu- sion of the infected and inflamed epididymis or vas, or both. In that rare condition, simultaneously double epididymitis, or that frequent accident, an epididymitis subsequently occurring upon the opposite side. Sixty-five per cent, of the subjects are made sterile. Aside from the danger of sterility, recurrent epididymitis and reinfection of the posterior urethra from an infective focus remain- ing in the epididymis often are a source of serious crippling. Then, too. the probability of certain obscure cases of rheumatism being due to latent infection in the epididymis is worthy of consideration. It also will be noted that the analogy between pus tubes and the infected epididymis is by no means far fetched. In considering the surgical aspects of epididymitis the character of the infection is of no moment — excluding, of course, the tuber- cular form. Gonococcus, colon bacillus and staphylococcus are alike, so far as the surgical management of the inflamed epididymis is concerned. The benefits of epididymotomy are due to 1st. Relief of tension. 2nd. Depletion. 3rd. Drainage. It is the author's opinion that the tension of the epididymal walls is accountable in a measure for permanent occlusion of the tubuli. The acute tension due to the thickening of the epididymis and more or less internal exudate, impairs the integrity of the tubular structures as well as occludes them. When closely pressed together the tubuli are more likely to become distorted, kinked and — 113 — IMPOTENCE AND STERILITY glued shut, than when there is no abnormal pressure from within and without the epididymis. Here, then, is the cue for prevention of a large number of cases of sterility in the male : Relieve tension in the epididymitis by multiple incisions or punctures of the dense zvalls of the affected part. Treatment. — The treatment of sterility in the male unfor- tunately is unsuccessful in a large proportion of cases. Chronic inflammatory conditions of the epididymis sometimes may be re- moved by measures that will be suggested later in the consideration of diseases of the testicle. Electricity is perhaps the most rehable remedy at our command for these conditions. Tonics, proper food, and attention to sexual hygiene occasionally may accomplish the desired result. It must be confessed that there are many cases in which, however faithfully we may seek for the cause of sterihty, it escapes observation, and the case consequently is absolutely in- curable. Some of the conditions that obstruct the passage of the semen from the urethra may be removed, stricture being the morbid state that is especially amenable to treatment. Obstructions in the vas sometimes are removable by resection followed by the author's method of anastomosis. When they are close to the epididymis and both vasa defer entia are involved, the vas may be anastomosed with the epididymis as suggested by Edward Martin. This operation as described by its originator is as follows : "The vas lies behind the spermatic artery, which sends its main branches forward to the inner side of the epididymis, anasto- mosing freely at this point with the artery of the vas. The epidid- ymis is approached from its outer side. A portion of the head is picked up in toothed forceps and excised. If the excision is made on the testicular side of the obstruction there will ooze from the wound semen which contains motile spermatozoa. The lumen of the vas is opened by a longitudinal cut one-quarter of an inch long. Into the wound of the epididymis the vas is implanted by means of four fine silver-wire sutures, carried on small face needles from the outer surface of the vas into its lumen ; thence from the cut surface of the opening made into the epididymis through its fibrous tunic. Because of the smallncss of the structures involved, the operation is tedious rather than difficult. Aside from the ordinary — 114 - - TREATMENT OF STERILITY IN THE MALE surgical instruments, there will be needed a sharp-pointed pair of scissors, a slender bistoury and a grooved director, such as are used by ophthalmologists." Lespinasse has ingeniously suggested the formation of an arti- ficial sac or reservoir for the semen in connection with the epidid- ymis in obseructive sterility in the male.* The semen is to be withdrawn by aspiration from the husband as required and injected into the uterus of the wife. Although not potentially sterile, hypospadiacs and subjects with urethral fistula may be dynamically sterile because the semen is not discharged so that it reaches the vicinity of the cervix. These cases may be curable by operation. Disproportionate size of the penis sometimes is a cause of sterility. This condition is hopeless. Arti- ficial fecundation is the only recourse. Sterility is sometimes due to syphilis which may produce chronic inflammation, although gross lesions are not perceptible. Sterility due to syphilis sometimes is curable by the ordinary therapevitic routine. Conformably with his views of the intimate relation of the proper formation of sex hormone to fertility, the author believes that his method of sex gland implantation may have a considerable range of usefulness in both sexes as a remedy for sterility. This subject later will be more fully discussed. Impotenck IX THE Male. In the majority of cases of impotence there apparently is a normal, or, at most, merely a debilitated and flaccid condition of the generative apparatus, yet the patient is unable to obtain an erection. The lack of power varies in degree from a condition in which there is absolutely no manifestation of the physiologic function of erection to cases in which the erection is partial, but insufficient for copulation. In some instances erection is perfect, but of a transitory character, ejaculation occurring prematurely. Care should be taken to dififerentiate the cases, else treatment is not likely to be successful. Clinically it will be found that cases of impotence may be divided into : — 1. Those in which virility is impaired by general constitutional • Trans. American Urological Assoc, 1914. — 115 — lmpotkncp: and sterility debility or exhaustion of nervous force — impairment of hormone supply being one element — the lack of sexual vigor being functional and secondary to the general disturbance. These cases may depend upon : a. sexual excess or masturbation, which produce both local and general debility, or /;. general diseases of an exhausting char- acter, c. Profound psychic impressions, d. Shock from trauma. They may or may not be associated with spermatorrhea, nocturnal emissions, etc. 2. Cases in which the lack of power is entirely due to adverse psychic impressions. 3. Those in which the patient is strong and vigorous, his testes secreting actively, and his vesicnlcc seminales being overdistended as a consequence of infrequent indulgence. In these cases premature ejaculation and a transitory character of erection are the principal features. 4. Those in which, as a consequence of masturbation or sexual excess, there is hyperesthesia of the floor of the prostatic urethra, or colliculitis. Imperfect secretion and premature ejaculation char- acterize these cases. 5. Cases in which there is some pathologic condition of the sexual apparatus that acts by distvu^bing innervation and producing mental depression, chiefly from the moral efifect of the condition. 6. Those in which deformity or acquired disease interferes with erection, completely or partially preventing it. 7. Those in which congenital malformations, injury, disease, or surgical operation have impaired or destroyed the structure of the sexual apparatus to an extent sufficient to prevent copulation. 8. Cases due to toxemia — from disease or from alcoholics or other drugs. Some of these conditions are amenable to treatment, while others, unfortunately, are beyond the reach of medical art. Impotence is divided for description into the false and true varieties. PsivUDO-iMPOTivNCK. — False impotence is the form that is most frequently seen, and usually is dependent upon causes of a purely mental or moral character, the sexual organs, so far as can be determined by examination, being perfectly healthy. Individuals suffering from this form of impotence usually are of a highly im- pressionable nervous temperament primarily, or have become so — 116 — IMPOTENCE IN THE MALE as a consequence of masturbation or sexual excesses. Some men who apparently are perfectly healthy find themselves unable to perform the act of copulation as a consequence of a lack of con- fidence due to a recollection of early indiscretions and an exaggerated estimate of their effects. Ignorance of sexual physiology often is the foundation for this form of im])otence. Failure to accomplish the act of sexual intercourse sometimes is due — paradoxic as it may seem — to extraordinary vigor and secretory activity of the sexual apparatus. Individuals who have masturbated but little, or perhaps not at all, and who never have attempted sexual inter- course until they have attained their majority, frequently are troubled in this manner. The author recalls several cases of this kind : — Cask. — A j-oung professional man 30 years of age, a fine healthy-ap- pearing subject as could be imagined. He had masturbated but little as a boy, and after attaining adult age became very fond of the society of women and acquired the reputation of being something of a i-ouc, yet he assured the author that he never had been able to accomplish the act of copulation, pre- mature ejaculation having attended every attempt — such attempts having been made at very infrequent intervals. He seemed to think that there was some organic disease, either of the sexual organs or "of the blood," that inhibited his sexual pcnvers. Examination showed that the sexual organs were perfectly healthy. On careful interrogation he said that he never had attempted intercourse twice consecutively, but had Iiecome thoroughly dis- gusted by his first failure on each occasion. It seemed that intercourse al- ways had been attempted under circumstances involving not only extreme sexual excitement, but more or less uneasiness as regards the possibility of detection. All possible means were tried to convince this patient that he was perfectly sound and sexually potent, but without result. He still enter- tains the opinion that he is impotent, and nothing but success in copulation, which certainly will be achieved if the act is ever attempted under proper circumstances, ever will convince him to the contrary. Overdistension of the seminal vesicles, in combination with overexcitement and consequent hyperesthesia of the prostatic sinus existing at the time of attempted copula- tion, is the explanation of tlie pseudo-impotence of this individual. Cask. — .\ similar case that came under our observation was much more tractable. This patient stated that he never had masturbated and never had attempted intercourse until past the age of 25. fie was of an exceedingly passionate temperament, and has found that he never had been able to ac- complish the act at a first or even a second attempt, but that if he attempted the act repeatedly with a person with whom he had the opportunity of as- sociating for several days at a time, he finally succeeded, and thereafter was in a perfectly normal condition. He finally happily married and has several — 117 — IMPOTENCE AND STERILITY children. The persistency of this individual is all that saved him from the same despairing frame of mind as that which exists in the previous case. The form of impotence born of excessive and uncontrolled desire has been familiar from time immemorial. Three centuries ago Montaigne dilated upon it in his philosophic essays as follows : — Neither is it in the height and greatest fury of the fit that we are in a condition ... to sally into courtship, the soul being at that time over- burthened and laboring with profound thoughts, and the body dejected and languishing with desire ; and hence it is that sometimes proceed those acci- dental impotencies that so unreasonably surprise the willing lover, and that frigidity which by the force of an immoderate ardor so unhappily seizes him in the very lap of fruition ; for all passions that suffer themselves to be relished and digested are but moderate. The surgeon not infrequently is called upon for relief for just such impotencies as Montaigne so clearly describes. That the remedy is better psychic control goes without saying. Continence as a cause of true impotence has been admitted by some writers. Howe relates two interesting cases that apparently were due to this cause : — Case 1. — In the winter of 1876 an undertaker of this city was ad- mitted to St. Francis Hospital, suffering from prolapse of the rectum. He was 45 years old and his general health was good. After recovering from the prolapse he informed me that he was impotent, and likewise was subject to nocturnal emissions. During the whole course of his life he had refrained from any gratification of his passions, and had never attempted sexual in- tercourse until within the past year. Twelve months previous to his ad- mission he had m.arried, and without expecting anything of the kind found himself impotent and unable to consummate the marriage. Every attempt at intromission failed, through weak erections and rapid emissions. He denied masturbation, and the condition of the genitals seemed to confirm his statement. From the age of 25 he had emissions once a fortnight and fre- quent erections, but the erections were feeble, and lasted only a few moments. Since his marriage the emissions had increased in frequency, and there seemed to be much relaxation and apparent elongation of the penis. The patient did not seem to be depressed by the fact of his impotence. He attributed it all to total abstinence, and hoped that, in the course of time, Nature would effect a cure. The author does not believe that continence per se ever causes true impotence. The cases in which it apparently does so usually are either masturbators or congenitally weak, or both. A few cases are recorded by Lallemand and others where rectal disease caused temporary impotence, but the patients were not con- — 118 — IMPOTENCE IN THE MALE tinent, and they recovered from the spermatorrhea and impotence when the prolapse was cured. In the patient whose history has just been given the prolapse of the rectum may have added to the genital weakness, but it probably was not the cause of it. Howe records a second interesting case of impotence from continence, unaccompanied by spermatorrhea : — Case 2. — The patient was 38 years old, and a broker by occupation. His general health was excellent, and he was constantly and actively em- ployed in a flourishing business. He commenced to masturbate a little when a boy of 12, and occasionally was guilty of the habit until he reached the age of 16, at which time he discontinued it altogether. At twenty he had intercourse in a natural way, and without any difficulty whatever. For six months subsequently he cohabited at intervals of two weeks, and never at any time indulged to excess. A period of eight years then elapsed without any opportunity for sexual congress. At the termination of that period he again attempted to renew his sexual relations with his former partner, but, to his great annoyance, failed. Though he subsequently made frequent trials, the result was the same. He finally gave up all hope, firmly believing that his impotence was beyond the reach of therapeutic agents. He attributed his loss of virility to continence, and not to any dissipation or bad habits in early life. A period of ten years elapsed, during which interval he tried sexual congress but once, and was unsuccessful. He had few emissions, and few erections. For twelve months previous to calling at my office he had had only three emissions, and no erections of any degree of permanence. He thought his desire for sexual pleasures had not diminished, but, the knowledge of his impotence being ever present, would prevent him from at- tempting it again. This mental state necessarily complicated his case, and added to the difficulty of a cure. On making an examination of his genital organs I found the penis and testicles somewhat smaller than natural. The left testicle was smaller than the right, and more than ordinarily sensitive to pressure. Otherwise the parts were unchanged. Knowing that the patient's habits were excellent, and that his general health was good, I made a favorable prognosis, and put him under treatment. He continued under treatment for three months, improving slowly. His erections were more fre- quent and natural, and his hopes of final recovery revived. He suddenly, without any notification, ceased his visits at the office. The summer follow- ing he consulted me for gonorrhea, and informed me that a few days after he had ceased calling he renewed his attempt at intercourse, and suc- ceeded, and had kept well in that respect ever since. The author has seen so many cases similar to those reported by Howe, that he feels warranted in the belief that prolonged continence in exceptional cases bears a definite etiologic relation to impotence. As already stated, however, he does not believe that continence alone ever causes true impotence. Oftentimes the impotence is — 119 — IMPOTENCE AND STERILITY purely psychic, resulting from the fear of non-success. The patient's confidence sometimes is shaken by the popular notion that prolonged continence necessarily results disastrously. In some cases the patient's statements regarding masturbation should be discounted. It is nothing unusual for patients to assert that they have practiced the vice "but a few times," etc., when, as a matter of fact, they not only have practiced it very frequently, but are not yet rid of the habit. In a general way, however, men who abstain from sexual intercourse up to thirty years of age often are impaired in their sexual power — pseudo-impotence — even though they have not masturbated. Disuse is detrimental to the vigor of all organs, and it is not surprising that a certain degree of inhibition of sexual activity should result in such cases. Where they have masturbated, especially if the habit has not been broken, impotence is common. When men of thirty or over deny both masturbation and normal sexual indul- gence, a primary lack of sexual activity may be suspected. On the other hand, sexual repression continued for years may seriously inhibit primarily active sexual impulses. It should be remembered, in considering the subject of pseudo- impotence, that the sexual passion varies in intensity in different individuals. Many persons are of frigid temperament and are likely to exhibit more or less sexual indifference. This usually is associated with a relative sluggishness of the sexual apparatus, which, however, is perfectly natural to the particular individual. Very slight mental disturbances at the time of attempted inter- course may result in temporary impotence. Anxiety or mental worry of any kind may cause it. Individuals who have labored mentally or physically to the extent of producing exhaustion are likely to experience temporary inhibition of sexual activity and desire. This physiologic phenomenon may be, as already has been suggested, taken advantage of in the treatment of sexual disorders. Emotional influences that are capable of making a powerful im- pression upon the nervous system especially tend to inhibit sexual desire, the more particularly as they tend to check the secretion of semen. The influences that tend to produce activity of secretion of the testes are chiefly emotional, and, conversely, diverse mental influences may check the secretion. Carter outlined this fact as follows : — The glands liable to emotional congestion are those which, by forming — 120 — IMPOTKNCR IN TFTE ^lALE their products in larger quantity, subserve to the gratification of the excited feeling. Thus, blood is directed to the mamma: by the maternal emotions, to the^ testes by the sexual and to the salivary glands by the influence of appetizing odors ; while in either case the sudden demand may produce an exsanguine condition of other organs, and may check some function which was being actively performed, as, for instance, the digestive. Lack of secretion has a mechanic bearing on sexual desire and impotence. When the secretions of the testes and seminal vesicles are abimdant, the vesicles become distended and directly and re- flexly excite desire by mere pressure. The individual whose vesicles quickly refill after emptying, soon experiences another erection with accompanying sexual desire. Activity of secretion, therefore, is an important factor in analyzing the causes and treatment of impotence. This explains the service sometimes rendered by pilocarpin. It must be remembered, however, that there is interaction between sexual passion and the distention of the seminal vesicles. While the vesicles become more or less rapidly distended even where no sexual desire exists, they fill under the influence of sexual passion with a rapidity that is in direct ratio to the degree and duration of the stimulation. It is obvious that exhausting diseases act in several ways, viz.: 1. by diminishing secretion, 2. by disturbing sexual innervation, 3. by diminution and perturbation of hormone forma- tion, 4. by toxemia, 5. by reducing general bodily vigor. The emotion of fright or the condition of mind produced by the fear of detection or of the results of copulation invariably will inhibit the sexual power. Disgust, indiiTerence, or antipathy for the party of the second part often has a similar efifect. The practical physician does not usually put much faith in the theory of affinity as existing between the sexes, but the author is of opinion that in many instances failure to consummate the marital act is due to a lack of harmony between the contracting parties. An apparent instance of this is the following: — Case. — A man 31 years of age, perfectly healthy, the sexual organs be- ing perfectly formed and apparently in a normal condition, came to the author for relief of impotence. He was a man of very highly-wrought nervous organization, and had never been anything of a roue. The only pos- sible exception that could be taken to his physical condition was the fact that he was somewhat inclined to corpulence. He stated that he had not experienced an erection for some months. During this time, however, he had been working very hard, and had not allowed his mind to dwell on sexual matters, and he himself was inclined to attribute the absence of erections to ~ 121 — IMPOTENCE AND STERILITY this fact. As he contemplated matrimony, however, he desired a course of treatment. On inquiry he stated that he had on several occasions failed in accomplishing intercourse, but that he had found that with certain females he was perfectly potent, while with others he was absolutely impotent. He was assured that there was no physical impediment to matrimony, and a course of local faradization was advised. He improved very rapidly, and in a few months the sexual function became so active that the bougie elec- trode could not be passed because the slightest contact with the urethra pro- duced vigorous erection. He stated that when he took a Turkish bath, as per advice, he was considerably embarrassed by the occurrence of erections so soon as the attendant attempted to rub him. Under these circumstances the author felt perfectly justified in advising matrimony. The result was unfortunately not what had been expected, for a year after marriage he had not yet succeeded in accomplishing intercourse. There was evidently in this casej some inhibitory cause of a mental character, as shown by the fact that after marriage he still had vigorous erections and nocturnal emis- sions with dreams. As soon as the idea of attempting intercourse entered his mind he found it absolutely impossible to secure an erection. The author finally succeeded in curing this case by the exercise of a little ingenuity. The wife was sent away for three months, the husband being meanwhile treated with electricity. On the day of the wife's home-coming the patient was provided with a rectal suppository containing a little belladonna, opium, and camphor. He was instructed to insert this on going to bed and was as- sured that the wonderful suppository never failed. The treatment was a brilliant success and there was no future trouble, the wife becoming preg- nant within a few weeks. A sensitive sexual organization is part of the price man has paid for civiHzation. The more refined the organization of the human rule, the more likely he is to suffer from impotence due to psychic impressions. Laying aside organic causes, the savage and the lower animals do not experience impotence. The human male who can perform the sexual act under any and all environmental conditions probably is an example of atavism, where — exceptionally — it does not prove neuro-psychic degeneracy. The commission of rape, in the author's opinion, is sure evidence of atavism. The male sex is not alone in paying the price of civilization. The female also has been sexually penalized for her upward progress from the social-primitive to the civilized type. Among the penalties are, frigidity in many, frequent sexual neuro-degeneracy — as evidenced by nymphomania — ■ relative or complete infertility, and an artificially created, so-called normal desire persisting during utero- gestation in a certain proportion of women. Repression of sexual desire, through religious and other social inhibitions, has had a very — 122 — IMPOTENCK TX THE MALE powerful influence on civilized woman. With many, sexual passion develops only in response to the demands of the male. It is probable that the sex habits of our pre-human ancestors, the female of which experienced sexual desire — the breeding instinct — only at certain stated periods, would have persisted in their human descendants if social environmental influences had not been brought to bear. It is probable that any sexual desire on the part of the female manifested at any time other than shortly before, during and after the menstrual period, has been acquired in response to the sex demands of the male. Certain it is, also, that nature never intended that the female of any species should either cohabit during pregnancy, or experience sexual desire at such a time. Once pregnancy has occurred, the function for which the sexual act was intended has been subserved so far as the female is concerned. Society's attitude towards the matrimonial cjuestion is based largely upon mawkish sentiment, ignorance of biologic law, and the impracticability of its application in every-day life. The average moralist, accepting marriage as a divine institution instead of what it really is — a conventionalized regulation of sex love via a civil, business and social contract — sees nothing in the problem save conformity or non-conformity to divine law. Quite naturally he cannot conceive of such a thing as divine error and consequently is dominated entirely by the "Tied you are, and tied you must stay" dogma. From this point of view there can be no such thing as marital mistakes to be rectified. In certain quarters, therefore, infallibility of matrimonial selection primarily is taken for granted and invariably demanded. It is noteworthy that marriage is the only human act in which anybody ever expects infallibility of judgment. Unfortunately, however, marriage in real life is a strictly human institution in which the contracting parties are not demigods, but fallible human beings, fundamentally jwssessed of certain animal traits which are a rather heavy handicap to the intellectual attributes that are distinctively human. ]\Iarriage necessarily is experimental. As a rule, neither of the contracting parties has any means of knowing the true character of the other. The young man who goes courting dons his best behavior with his best clothes. The young woman courted, not to be outdone at woman's own game, lays even greater stress upon externals. She puts on her prettiest — 123 — IMPOTENCE AND STERILITY gown and "company manners" and does her best to conceal, not only her physical defects, but her mental and moral flaws. Her mission in life is to catch a husband — honestly if she can, but to catch him. If either one is inexperienced, the game is an easy going one, and the end assured ; propinquity assists the fraud. Rarely is there a critical study of character on either side. When love dominates, the loved one is beyond criticism and there is no incentive to character study. After marriage both parties to the arrangement sooner or later become more critical. Marriage is a steady and intimate association which only compatibles can face without disaster. The rose tints of the pre-marital ideal become rather murky when incompatibility once becomes manifest. Compatibility involves several elements that only intimate association can discover. Broadly speaking, these may be either physical or psychic, the qualities that attract or repel being some- times blended so that it is difficult to determine where the one terminates and the other begins. Psychic impressions modify the physical and vice versa. The resulting complex, modified by the couple's imaginations, may or may not correspond to their pre- marital ideals. That such ideals should be so often shattered is not astonishing. Ideals based entirely upon externals, and the super- structure of which is built up from an imagination dominated by psycho-sexual erethism, are greatly handicapped in their contest with the psychic and physical realities of life. Under natural conditions, the physical is far more important than the psychic in the question of mating. Sex attraction is a purely animal attribute which, invest it as we may with a halo of sentiment and romance, is none the less a primitive biologic instinct that is common to all species. Civilization and its attendant refine- ments have added the psycho-sexual to the purely animal, but as yet the former by no means dominates matrimonial selection, nor would the best interests of the race be conserved by its domination. The unlike attracts and the like repels, here as elsewhere. If the large, powerful man usually selected a woman built upon similar lines, and the small man the small woman, we in time would have two races side by side — one of dwarfs and the other of giants. Should intellectual persons always gravitate together, procreation finally would cease and the race would run out, dying at the top, — 124 — IMPOTENCE IX THE MALE after passing through all the degrees of physical and mental degen- eration. As a n^.atter of fact, the natural tendency of human beings to select mates of opposite characteristics has been conservative, and has tended to maintain a certain racially healthful physical and mental average. It is true that the tendency to rise superior to the purely physical in matrimonial selection is increasing, pari passu with the progress of civilization and the increasing complexity of human life — but so is the business of the divorce courts, and so, also, is degeneracy. ]^Ien and women are growing more and more selfish and exacting. The family is coming to be less their concern, hence the qualifications of the given member of the opposite sex for parenthood are of diminishing importance. The demand for congenial companionship is greater and, as the test can be made only after marriage, mental incompatibility necessarily has become more prominent in matri- mony. The psychic element primarily is purely artificial, and there- fore less stable than the purely physical. The savage does not prate of incompatibility. With him the question is altogether a physical one. The physical element, however nnich modified by civilization, still being dominant in matrimony, the proportion of marital dis- harmonies is as yet relatively small, although it is steadily growing. Purely physical incompatibility probably is the exception, yet, as all physicians know, is more frequent than is generally supposed. It is not manifest in frigidity alone, for in many instances there is an instinctive repugnance to physical contact, yet there really is no frigidity, and psychic conditions apparently are ideal. Reduced to its biologic ultimate, sex attraction requires no more psychic explanation than does chemical affinity, and yet the fact remains that many human beings go through life without meeting their sex "complement." Some know what they have missed ; the majority, fortunately, do not. "Ignorance is bliss." The author is well aware that ideals of all kinds usually are assigned to the realm of spiritual things, and is willing to acknowl- edge that the hyperesthetic psycho-sexuality of civilized races has much to do with the construction of sex ideals, but he nevertheless is convinced that the question of physical affinity is to be given serious consideration. It is here that the author would take issitc with the purely spiritual conception of the ideal. The instance of childless couples who have been divorced and remarried, each — 125 — IMPOTENCE AND STERILITY taking the partner of the other, with resultant f ruitfulness, certainly has a biologic explanation that is well worth consideration. When a beautiful, refined, and intellectual woman, surrounded by every luxury, runs away with a coarse, unattractive stable-hand, the spiritual ideal is a dubious explanation. Where the physical conditions of married persons are absolutely harmonious, mental incompatibility is unusual. Where one or the other is a high-strung, neurotic individual, however, the psychic element is likely to be discordant. Should both be neurotic, com- patibility is almost impossible. Sentiment gradually is submerged until there is left a physical reality that contains no suggestion of the ideal. In most cases of marital infelicity, it is safe to say that the husband is at fault. There is a very cogent reason for this. He usually has in mind a physical standard based upon previous ex- periences. While the glamour of early married life lasts, he is satisfied with the situation. The inexperience of the wife primarily is a decided novelty. When, however, satiety arrives, as it usually does sooner or later, he recalls memories of past experiences in the light of which the physical charms of the wife begin to pale. He soon discovers [)hysical incompatibility, and resumes the pursuit of elusive past sexual impressions that his marriage temporarily inter- rupted. His relations with his wife perhaps began practically with legalized rape, that served to make permanent and incurable any qualities of frigidity which she primarily may have possessed. For her, the marital relation is only a painful and disgusting memory inspiring her with abhorrence. In many cases moral degeneracy on one or both sides is the cause of infelicity. The anti-social instincts of the degenerate are as manifest in the matrimonial relation as they are elsewhere. The undue familiarity usually existing between husband and wife is a feeder of psycho-sexual aberrations. Once the halo of sex mystery is dispelled, romance often fades completely. The author is firmly convinced that a less intimate association of husband and wife would be better for both health and morals. The less knowledge they have of each other's physiology, the better for sentiment. Privacy is an individual right, in or out of matrimony. Familiarity breeds satiety. Satiety is the parent of sexual discon- tent. The satiated, discontented man often browses in queer pastures — 126 - IMPOTENCE IN THE MALE in search of new thrills for his exhausted psycho-sexual centers Often he is unable to find them save in debasement that would astonish his intimates, but is not at all remarkable to the student of sex psychology. Granting that the foregoing premises are sound, they should go far in showing that, in many cases of impotence and sterility, the divorce court and a matrimonial "rearrangement" must be the final recourse. Every man and woman of experience and, above all, every physician, knows this, but nobody apparently has had the courage to openly state the facts. Meanwhile, the divorce mills grind merrily on and students of social questions continue to use only economic and moral explanations for certain biologic phenomena of matrimony, whilst physicians daily are asked to perform impossible therapeutic feats. That certain individuals of highly-sensitive nervous organization are impotent respecting some women, while with others they are perfectly potent, is a well-known fact. Individuals of this sort very often are convinced that they are impotent, by failure in experimenting with prostitutes for the purpose of determining whether or not they are justified in assuming the matrimonial state. The fact that they are impotent under such circumstances is highly complimentary to their moral tone. The environment that surrounds the average prostitute, in conjunction with the purely mercantile character of the transaction, is not likely to inspire with sexual passion an individual possessed of the average amount of decency and self-respect. It is not unusual for individuals to state that, excepting when under the influence of liquor, they are absolutely impotent with prostitutes. Considerable and forcible argument may be necessary to convince patients who have applied what they con- sider the crucial test of attempting intercourse with prostitutes, and have failed, that they are not impotent. Roubaud records a case which, although it has become so extensively quoted by writers upon the subject that it has been worn almost threadbare, is nevertheless very pertinent as applied to patients who are psychically impotent with some women, while perfectly potent with others : — Case. — M. X., son of a general of the First Empire, was brought up at his father's country-seat, which he did not leave until he was eighteen years of age, when he went to the military school. During his long period of iso- lation in the country he had been initiated, at the age of fourteen, into an — 127 — IMPOTENCE AND STERILITY experience of the pleasures of love, by a young lady, a friend of the family. This lady, then twenty-one years old, was a blonde ; wore her hair in the English style, that is to say, in corkscrew curls ; and in order to lessen the liability of detection in her amorous intrigue, she never had intercourse with her young lover except when clothed in her day attire, — that is to say, wear- ing gaiter-boots, corsets, and a silk gown. All these details I mention purposely, for they had great influence, not only over the degree of excitability of the genital function, but over its very existence in the case of M. X. The young lady was of strong passions, and, as it appeared, exhausted the strength of the young neophyte, and the severe regimen of the military school was no more than sufficient to restore to the genital organs the energy which had been seriously affected by too early and too frequent in- dulgence. But when, the period of his study having passed, he was sent to a gar- rison, and was disposed to enjoy the rights which nature had restored, he perceived that sexual desire was only provoked by certain women and with the concurrence of certain circumstances. Thus, a brunette did not produce in him the slightest emotion, and a woman in her night-dress was sufficient to extinguish and freeze every amorous transport. In order that he might experience the venereal desire, it was necessary that the woman should be blonde, should wear gaiter-boots, should be laced in a corset, wear a silk gown, and, in a word fulfill all the requirements of the lady who had first caused M. X. to experience the sexual orgasm. And this was not by reason of any sentimental love, the magic power of which lasts through a life-time. In his early sexual relations M. X. had only been actuated by animal desire. His heart had never been touched, and after twenty-five years, in consulting me for his singular infirmity, he declared that he had loved with his heart but one woman, and to her he had never been able to render homage, for, by a perverse coincidence, she was a brunette. His fortune, his name, his social position, made it the duty of M. X. to marry, but he had always resisted the solicitations of his family and friends, knowing that he would be incapable of availing himself of his marital rights, with a wife arrayed in the costume of the nuptial bed. Yet he was in good health, was of the sanguino-choleric temperament, was above the medium height, and was of so strong a constitution that for fifteen years he had been an officer in a regiment of heavy cavalry. Evidently his impotence was relative only, for, when the woman was blonde and when the other conditions specified existed, he accomplished the sexual act with all the ardor of a healthy man of amorous disposition. Roiibaiid finally cured this patient by suggestion, in conjunction with the use of alcoholic stimulants to the point of mild intoxication. The spell once broken, there was no further trouble. vSuch psycho-sexual inhibitions as the case related by Roubaud — 128 ~ 1.MPOTENCI-: IN THE MALE arc more frequent than is generally supposed. Prolonged sexual relations with an individual of a certain type not infrequently makes such a profound psychic impression that other types of women are unattractive. Especially is this true of men of tine nervous organ- ization who happen to consort with women of decided blonde or brunette type. Prolonged association with one type by no means rarely makes the other unattractive, sometimes even repellent. This, of course, is not always a matter merely of physique. Certain intellectual attributes in the woman may have much to do with the psycho-sexual impression she produces. Cases have been noted in which pseudo-impotence was relieved by the affected individual's picturing in his imagination the person of some woman other than the one with whom he was attempting to cohabit. In certain impressionable individuals impotence may result from a lack of affinity between the parties to the act, actual antipathy on the part of either being unnecessary to its causation, Goethe took advantage of this physiologic fact in his "Elective Affinities." In this tale is described the mutual enjoyment obtained by an estranged couple through the medium of their imaginations, each party to the act imagining the other to be the individual for whom an affinity was felt. Goethe carries the theory of affinity still further, and describes the child that was born as the fruit of this particular conjugal act as in no way resembling its parents, but presenting a strong resemblance to both individuals for whom the parents respectively felt an affinity, and who were present in imagi- nation at the time of conception. Hammond relates a Ccipe that is aptly illustrative of the manner in which certain mental conditions will produce temporary im- potence : — Case. — A married gentleman, who before entering into the matrimonial state, had been excessively given to sexual intercourse, but vi^ho had no rea- son to think that his powers were exhausted, or even materially weakened, found himself on his wedding-night and for some days thereafter absolutely incapable of consummating the marriage. His wife was a highly-educated, intelligent, refined, and beautiful woman ; he was devotedly attached to her, and on marrying at once and for all gave up the evil associations of his younger days. His passions were strong, but as soon as he attempted inter- course the desire he had previously entertained vanished at the thought that it was a profanation for a man like him to subject so beautiful and pure a woman to such an animal relation as sexual intercourse. "She is too good — 129 — HTPOTKNCE AND STERILITY for me," he would say to himself ; "I ought to have married a woman used to this sort of thing, or, better still, have remained single and gone on in the old way." This happened several times, and then, in disgust with him- self, he paid a visit to one of his former female associates, and soon satis- fied himself that his powers were as good as ever. Again he essayed the act with his wife, and again he met with disappointment. He had now been married a week, and the marriage was still uncon- summated. A case like this presented very little difficulty : I reminded him of the fact that in all probability, however pure and noble his wife might be, there was no profanation in sexual intercourse, chastely undertaken; that she had sexual organs which were intended for the performance of certain func- tion ; that these functions were all connected with the propagation of the human species ; that there was but one way that I knew of by which the species could be propagated ; that she had selected him as the man who was to put her in the way of fulfilling her office in the grand scheme of Nature, and that my advice to him was to lower his estimate of her angelic char- acter, and to look upon her in the not less worthy light of a woman to be treated as other women are treated under like circumstances. He left, promised to be less exalted in appreciation, but the next morning returned with the information that it was no use ; he had tried his best, his erections were strong and repeated, but as soon as he went further toward the object he had in view his desire became utterl}' extinguished. She was "too good, too delicate, for a mere animal like him ; he could not desecrate her beauti- ful body by any such vile act," etc. With the sensible co-operation of the wife, Hammond had no difficulty in curing this case by suggestion. Sexual perversion may cause impotence. It is obvious that individuals for whom the natural method of performance of the sexual act has no attraction are likely to fail should they attempt it. Impotence of a transitory character may be due to the psychic effect of satiety as well as to the debilitating influence of sexual excess. This is the form of impotence most freqttently seen in married men. Through resulting psychic perturbation, a lack of responsiveness on the part of the female is an occasional cause of pseudo-impotence in the male. This is especially likely to arise in married men and probably in the majority of instances is primarily their own fault. The proper ftmctioning of the sex glands, probably is more dependent on environmental conditions than are the secretions of any of the other important organs of the body. The functions of the digestive organs, salivary glands, liver and mammary glands are pertitrbed — through disturbances of the nervous and sympathetic — 130 — IMPOTENCE IN THE MALE centers — by such emotions as jealousy, worry, anger, disgust or fright. The perversion or suppression of the lacteal secretion through adverse — and their increased activity from favorable — psychic influences is especially suggestive. The disastrous effect upon the child produced by toxins developed in the mother's milk by fright, anger, jealousy and grief are familiar to every practi- tioner of experience. Even the cow — which certainly cannot be accused of a highly refined psycho-emotional organization — suffers from diminution or perversion — or both — of milk supply from disturbing influences. In this connection the important physiologic relation of the mammary glands and sexual organs is very sug- gestive. Why, then, should we expect the sexual organs, which are still more actively dominated by emotional influences via the sympathetic than are other organs, to be less sensitive to such impressions than they ? In direct ratio to the degree to which potency and fertility are determined by the proper performance of the function of the testis and ovary, and upon the innervation and vascular supply of erectile tissue, will be the evil effect of adverse psychic influences. The shrew, the termagant, the virago and the indifferent female will please take notice. With respect to the sexual act per sc, adverse psychic conditions are not so serious in their effects upon the female as upon the male, merely because they do not throw any mechanical obstacles in the way of coitus. The indifferent female can conceal her aversion to the sexual act. Not so the male, for with aversion or frigidity on his part comes the impossibility of its performance. The same may be said of such influences as fear, worry, etc. On the other hand, in the matter of fertility and sexual passion, adverse psychic in- fluences have an important bearing on the sexual function of the female. In searching for the causes of impotence and sterility in married life, the i)hysician should carefully seek for possible psycho-sexual disharmony of various kinds and degree. No method of treatment of impotence can succeed v/here pronounced marital disharmony exists and cannot be removed. To be sure, domestic quarrels may be followed by exaltation of sexual desire, but these instances are the exception — and besides, there really may be no sexual dis- — 131 -^ IMPOTENCE AND STERILITY harmony or aversion in such cases. Then, too, the easily aroused temper is Hkely to be associated with an ardent sex temperament, to the fire of which "making up" domestic quarrels merely adds fuel. When the wife ridicules her husband's sexual disability, ex- presses disgust or dissatisfaction with the sexual act, accuses the husband of infidelity as an explanation of his marital sexual ineffi- ciency, exhibits indifiference to the act, or complains of pain in coitus, relative impotence in the husband develops sooner or later and, so long as the adverse psychic conditions prevail, the condition is irremediable. The man or woman whose attitude is that of the man who, having caught the street car, ceases to "run after it," is on dangerous ground. Couples who, after marriage, take everything for granted and cease to exert themselves to perpetuate mutual sex attraction, always are on thin ice. The thinking physician, knowing the inside history of matri- monial mesalliances, is likely to be astonished, not at the frequency of marital-sexual disharmony, but that there is not even more of it. The author recalls a number of very interesting cases bearing on the problem of the relation of marital disharmony to impotence. One of the most typic was the following: Case : — A professional man, thirty-five years of age, had been gradually developing impotence for four or live years until now it was complete. He had been married for ten years and had had no extra-marital experiences. Beginning after a prolonged period of overwork and business worries, the trouble finally had impelled him to seek medical counsel. He showed no organic disease and physically was more powerful than the average man of his age. He stated that he had moderately vigorous erections but little desire, and that erection always failed him. He denied domestic infelicity, but in such wise that the author was suspicious that his denial savored more strongly of gallantry than truthfulness. After some months of treat- ment, without success, resection of the vena dorsalis penis was suggested and performed, with excellent results, so far as frequency and vigor of erections was concerned. He still, however, was impotent. Several months later tlie wife called upon the author and interrogated him regarding her husband's condition. The author found that the patient's failure to recover his potency was easily explained. The wife was an exacting, shrewish person and suspicious of her husband's fidelity. By her unfounded accusations, fault finding and ridicule — begun at the time the husband's virility was impaired by .sheer physical exhaustion — she finally succeeded in permanently inhibiting both liis power and desire. Tlie author bluntly stated the facts to both parties nnd did his l)cst to liarmonize their widely divergent psychic attitudes, but — 132 — IMPOTENCE IN THE MALE without result. A divorce was the sequence, about a year later. Two years subsequently, the patient married again and since has been perfectly normal. Certain phases of the matrimonial problem are of vital interest to the physician who is interested in problems involving the sexual function. Society bungles the matrimonial qtiestion, and if there ever is to be any progress, it necessarily will be largely through the educational efforts of the physician-sociologist. The author is of opinion that production of impotence by psychic influences is in a measure explicable by the hormone theory. Worry, aversion and other adverse sex psychic elements may, by disturbing the nutrition of the glands, pervert or inhibit sex hor- mone supply. Absolutely normal sexual relations demand certain favorable conditions. Love, with normal environment, and a normal ovary and testis, are great stimulants to the proper formation of the sex hormones. True Impotenck. — True impotence is rare in both male and female ; extremely so in the latter. The function of the male in the act of copulation is an active one, and erection of the sexual member is necessary ; w-hereas in the case of the female no preparation is necessary for the sexual act, her function being comparatively passive. The necessary element in the case of the male is a sufficient degree of firmness of erection to permit the introduction of the penis into the vagina, and any individual who is possessed of this amount of capacity cannot justly be said to be afflicted with true impotence. It is unnecessary to potency that the individual should experience either desire for, or pleasure in the performance of, the act of copu- lation. In certain conditions perfect erection and even ejaculation are possible, although the individual does not experience either desire or pleasure. Some of the diseases affecting the spinal medulla produce this phenomenon. In certain cases of aspermatism a similar state of affairs is noted. Severe priapism due to cantharidal poison- ing is not usually attended by sexual desire, and intercourse under such circumstances may be absolutely devoid of pleasure. The term impotence in the case of the male should be restricted to those cases in which there exists some actual physical impediment to the performance of the act of copulation. Such impediment may, however, be temporary or permanent. Etiology. — The causes of true impotence may be classified as (a) congenital; (b) acquired. — 133 — IMPOTENCE AND STERILITY (a) Congenital Causes. — 1. Marked hypospadias or epispa- dias. In some cases of the former the penis is curved or otherwise deformed. In the latter condition exstrophy of the bladder may co- exist. The author has met with one case of impotence due to a congenital lateral curvature of the penis. 2. Imperfect development of the penis and testes, the former being too small and too flaccid for copulation. Oftentimes the penis seems overlarge, yet the erectile tissue is not well developed, and erection is consequently imperfect. 3. Congenitally-excessive development of the penis (?). This form of impotence may be only a relative affair, the real cause being a disproportionate smallness of the vagina of the individual with whom intercourse is attempted. In the absence of tumors it is probable that the cases in which the penis is too large to permit of copulation are extremely rare, if, indeed, they ever occur. 4. Cryptorchidism or monorchidism, with imperfect develop- ment of the penis. 5. Excessive redundancy of the prepuce, with phimosis. 6. Congenital tumors of the organ. (b) Acquired Causes. — 1. Tumors of the penis, prepuce, or glans. 2. Inflammatory thickening of the prepuce, with phimosis, inci- dental to balanitis, gonorrhea, or chancroid. 3. Large venereal vegetations. 4. Excessive obesity. This cause is frequent, but is sometimes overcome by the ingenuity of the patient in reversing the relative positions of the male and female during copulation ; an expedient as old as the Decameron. Obesity also lessens desire. 5. Ankylosis of both hips may prevent copulation in the normal manner, although by appropriate posturing the act may be accomplished, at least by the male. 6. Tumors of the scrotum or testes, such as hydrocele, sarco- cele, hematocele, cancer, and elephantiasis. The two latter condi- tions may involve the penis. 7. Chancre or chancroid of the penis of sufficient size and irritability to interfere with copulation by the pain the act pro- duces. 8. Gonorrheal or simple urethritis. — 134 — IMPOTENCE IN THE :MALE 9. Acute or chronic chordee. 'J'he former condition occurs in gonorrhea ; the latter may resuh from frequent and severe attacks of ureth.ritis, or from stricture, and may occasionally arise as a consequence of urethrotomy. 10. Inflammation of the deep urethra, prostate, and seminal vesicles. 11. Circumscribed inflammation of the corpora cavernosa. In these cases calcareous plates sometimes form. 12. Cicatrices from wounds of the penis or urethra, interfer- ing with erection. 13. Removal of the penis and testes. If the operation be performed early in life removal of the latter only is necessary. 14. The habit of masturbation, spermatorrhea from whatever cause, nervous shock, and in some instances organic disease of the brain and spinal cord may produce a complete and permanent loss of power of erection by exhaustion or inhibition of the nervous stimulus to the parts. 15. Temporary and symptomatic impotence sometimes is the result of constitutional diseases, such as fevers. Debilitating and prostrating acute or chronic disease, and neurasthenia from over- work or worry, may produce it. For several years the author's attention from time to time has been directed to a form of inipotentia coeundi which, so far as its etiology and pathology are concerned, hitherto has escaped observa- tion. Cavernositis chronica — -sclerosing inflammation of the cor- pora cavernosa — is sufficiently familiar to the genito-urinary surgeon, at least, but the dependence of the alTection on a general systemic condition apparently is not recognized. The patient, usu- ally above middle age, presents himself complaining of curvature of the penis during erection, which in effect is a chronic chordee. This often has progressed until coitus is impossible before the surgeon is consulted. Syphilis, alcohol, rheumatism and gout are the chief etiologic factors to which the condition is attributed. The possible causal relation of these etiologic factors to the local condition is logical enough, but it is not easy to explain why the pathologic process should localize itself in the erectile tissue of the penis, especially where the process is more or less diffuse. Where the condition is quite circumscribed, what the author has to say regard- ing a general arterial disturbance is not so pertinent. Old-time — 135 — IMPOTENCE AND STERILITY injury, perhaps long forgotten, and infections of various kinds, gonorrhea, especially, may have been the determining cause, espe- cially in the last mentioned class of cases. In the diffuse variety, and probably also in many cases of the circumscribed, the author is confident that something more than a local disease exists. In brief, whatever the primary etiologic factors, local and general, may be, the penile process is merely the local expression of general arterial disease. This in no wise lessens the importance of the etiologic factors usually assigned to chronic cavernositis for, as is well known, they bear a most important relation to the general condition. Experience has taught the author to look for evidences of general arterio- sclerosis in such cases. So often is it found that its existence may be suspected even when the accessible arteries are but little, if at all, involved. In gouty "high livers," who are not far advanced in life, incipient arteriosclerosis may exist, yet no cardiac or superficial changes be evident as yet. Errors in diagnosis by internists are frequent because of this fact. In "type" cases of the condition under consideration, cardio- vascular changes are found. Arciis senilis may be present. Time levels symptomatic distinctions between the man of forty-five or fifty years of age, in whom there is perhaps nothing but slight hyper-vascular tension ; and the man of sixty or above, with pipe- stem radials and temporals, cardiac changes and arciis senilis. The prognosis of cavernositis is in general unfavorable so far as disappearance of the deformity is concerned. The condition fortunately is painless and not dangerous to life. Occasional cases are met with, usually of the circumscribed variety, in which the sclerotic plaques disappear, whether despite or because of treat- ment, the author does not venture to say. Radium is promising but little that is definite can as yet be said about it. In the form asso- ciated with general arteriosclerosis thiosinamin sometimes seems to be useful. Certain local conditions occasionally are attended by symptom- atic impotence. Thus, inflammation of the testicles, varicocele, and tumors of the testes or scrotum, other than those that are capable of interfering mechanically with the act of copulation, may produce complete impotence. In some instances this is due to reflex inhibi- tion of the sexual power, while in others the condition is a purely — 136 — IMPOTENCE IN THE MALE mental one, resulting from the moral effect of the knowledge of the existence of pathologic conditions of the sexual apparatus. In varicocele, particularly, both elements in the causation of impotence deserve consideration. There is a lack of tone — in fact, a marked debility of the generative apparatus in many instances — and associated with this enervation there is profound mental disturbance, resulting from the consciousness that the sexual organs are not healthy. Syphilitic orchitis in a similar manner may produce impo- tence, and, as already seen, sterility. If this condition be not speed- ily relieved, permanent impotence and sterility may result as a consequence of changes in the secretory structure of the testes incidental to the pressure of the syphilitic neoplasm. Indulgence in alcohol may cause impotence. Various other drugs have been said to have a special action in producing impo- tence ; but a certain amount of skepticism is pardonable in this connection. It certainly must require large doses of the various sedative and alterative drugs to bring about this condition. Arsenic, antimony, lead, iodin, camphor, and hasheesh are among the drugs that are said to produce impotence. Iodin has been accredited with the power of producing atrophy of the testes. The author does not believe, however, that a single authentic case can be produced in which such atrophy is justly attributable to the use of this drug. One explanation for the popular idea that the potassium iodid is capable of producing atrophy of the testes is that certain cases of syphilitic orchitis have been insufficiently treated with the drug, or treated too late. Atrophy of the testicle has resulted, not from the drug, but from pressure-innutrition produced by syphilitic neoplasm that large and long-continued doses of iodid might have removed in time to save the testis. The carbonated waters taken in excess are said to produce impotence. The author regards this as a pleasing delusion on the part of "men about town." In general, the truth probably is that: 1st, narcotics may inhibit sexual power: 2d, any powerful drug which is given freely enough to injure the general health ma\- produce impotence. Vecki claims tliat a severe cold produces impotence by inhibiting olfaction. The author admits the clinical fact, but believes the tem- l)orary impotence to be due to the constitutional effect — toxemia — of the cold. It occurs where the naso-})harynx is not involved and tlie sense of smell is perfect. — 137 — IMPOTENCE AND STERILITY There probably is, however, some association between the olfactory and sexual function. That perfumes and personal odors may attract or repel is well known. Where olfactory impressions have a powerful influence over sexual desire, atavism probably is a sufficient explanation. In many cases of impotence it is impossible to attribute the condition to any particular cause. Since the advent of the X Ray, a special cause of impotence has been noted in the disastrous effect of the ray upon the structure and function of the testes. Careless operators have produced impotence in both their patients and themselves. A peculiar effect of the X Ray occasionally met with in persons exposed to its action frequently and for prolonged periods is profound anemia. This may be a factor in producing impotence, but the directly destructive atrophy-producing action of the ray upon the secretory cells of the sex glands is the logical explanation. Sterility may result without impotence. Similarly, the female may be sterilized by the X Ray. Obviously, the interstitial or hormone producing cells — cells of Leydig — share with the spermatic secretory epithehum the deleteri- ous results of the ray. This is an important factor in both the sterility and impotence that result. Proper screening of the sexual organs and filtering of the ray will prevent injury from the X Ray. If the action has not been too severe and prolonged and further exposure is avoided, the structure and function of the testes possibly may be restored to a greater or less degree. It has been asserted that radium will restore the integrity of gland tissue impaired by the X Ray. The method certainly is worth a trial. Sex gland im- plantation quite likely would be of service. TrKatmEnt. — The treatment of impotence may be divided into (a) moral, (b) medicinal and surgical. The latter may be subdivided into: (1) general, (2) local. The mainstay of treatment in false or nervous impotence con- sists of psychotherapy. In fact, there is no form of impotence in Vvhich a psychic element tliat requires correction cannot be found. The principal requirement is the restoration of the patient's self- confidence. The greatest delicacy and judgment are necessary in tlie management of these cases. The patient should feel that his physician sym])athizes with him in his apparent affliction. It will not do to laugh at his ailment, or to treat it lightly, even though — 138 — TREATMENT OF IMPOTENCE assured that his impotence is imaginary rather than real. The patient usually is comparatively strong and healthy, but has mastur- bated to a certain extent and has experienced nocturnal emissions with greater or less frequency. Morning erections often are strong and vigorous, and apparently perfectly normal. Sexual desire is felt and may be present in an exaggerated form. When such a ])atient attempts intercourse, erection either does not occur at all or takes place in a spiritless way that is not at all encouraging to his mind. When he reflects that he has masturbated, and that he has experienced an occasional nocturnal emission, with perhaps other little symptoms that coincide with the description of sperma- torrhea outlined in some quack treatise or other, he becomes com- pletely demoralized. So careful do these patients study quack literature, and so firmly convinced of their impotence do they be- come, that it often is absolutely impossible to gain their confidence or to benefit them in any way whatever. A symptom that greatly depresses the patient's mind is the escape of prostatic fluid and urethral mucus during prolonged and vigorous erection. An efifort shotdd be made to obtain the fullest confidence of such individuals, and they should be given instruction in the rudi- ments of sexual physiology. In the majority of cases they may be reasoned out of their perverted and pernicious notions regarding their physical condition. ]\Iany times we are compelled to be some- what disingenuous in our management of the case, for, the patient's confidence once gained, some comparatively trivial local or general measure may cure the case, providing the patient himself believes in the potency of the treatment. Above all, the patient should be assured that his sexual apparatus is in an exceptionally strong and healthy condition. Alarriage should be recommended where prac- ticable. Regarding this point, however, marriage should never be advised unless the occurrence of strong and vigorous erections ]:)rovcs copulation to be possible. Even under these circumstances, an occasional unfavorable result will ensue, because of persistent psychic inhibition of erectile power at the time copulation is essayed. In cases dependent itpon moral or mental causes pre- vailing when copulation is attempted, removal of the circtmi stances that produce mental depression is. of course, necessary. The ele- ments of sexual indifiference due to mental worry, nervous shock, — 139 — IMPOTENCE AND STERILITY fear and excessive passion may be amenable to correction. Disgust with the partner in the sexual act causes impotence which is irre- mediable when the unfavorable conditions are continued. It may prevail even when intercourse with a new partner is attempted. Sooner or later, however, the case usually recovers if a satisfactory sexual "rearrangement" is consummated. In those cases of married men in which lack of affinity is the principal cause of impotence, medical measures are likely to be un- successful, although some form of local stimulation of the sexual organs possibly may be efficacious. The divorce-court, however, is a better and more logical remedy if the circumstances imperatively demand a cure. In many instances of purely nervous impotence, irritability of the prostatic urethra exists. This may be removed in the majority of instances by the occasional passage of a cold steel sound. If the case be obstinate, astringent applications may be made by means of the cupped sound or deep urethral syringe. The prostate or seminal vesicles sometimes are congested or chronically inflamed. Massage of these parts relieves this condition. The psychrophor or cooling sound sometimes is serviceable. In cases of premature ejaculation success often may be at- tained by a second attempt at copulation. The patient should be advised to avoid excitement during intercourse. Very often he may succeed in delaying orgasm by thinking of something else beside sexual intercourse at the time of its performance. Patients who are apprehensive of failure should be advised to refrain from intercourse during the night, and to attempt it only in the early hours of the morning. It is well for newly married men affected with nervous impo- tence to confide in their wives and explain their temporary debility. The patient should be informed that, sooner or later, he will have a vigorous erection — as soon, at least, as the novelty of the situa- tion has worn off and his timidity has been allayed. He should be instructed to immediately take advantage of the situation, when an erection does occur, and ] perform the marital act. Measures of a general and hygienic character are requisite, especially in tlie management of cases in which actual structural disease does not exist. These general measures involve proper exercise, diet, baths, ])ropcr hours of sleep, temperance, or, better, — 140 — TREATMENT OF lAfPOTENCE tola! abstinence in the matter of alcoholics ar.d tobacco, and free- dom from care and worry so far as possible. Such measures apply also to the treatment of spermatorrhea, a condition with which impotence very often is associated. Cases in which impotence is due to an exhausted condition of the sexual apparatus and incidentally of the general nervous system, with in some instances impairment of nutrition, primarily require complete sexual rest. Occasional or so-called moderate indulgence is not to be thought of in these cases. Perfect conti- nence must be insisted upon for the time being, the length of time varying with the gravity of the case. It is unfortunate that the majority of patients, and particularly voluptuaries, are loath to accept such advice, believing, as they do, that by means of aphro- disiacs their virile powers should be restored without interfering with the indulgences that are responsible for their condition. Hammond's remarks upon this point certainly are judicious. He says : I have generally found that in those cases in which an erection suffi- cient for intromission does not take place, sexual repose for about a year is necessary. Again, the age of the patient and the length of time during which the condition has existed are factors to be considered in determining the question. In persons over forty, and in wliom the condition has lasted six months, no attempt should be made for even a longer period than a year. With every unsuccessful effort, even though no emission occurs, the nervous excitability is still further lessened, and the morale materially lowered. Generally in these extreme cases there is no difficulty in securing the requisite quiescence. The patient is fully aware of his inability, and is in no mood to undertake what he knows will result in failure. It sometimes happens, however, that masturbation, with the erection almost nil and the or- gasm imperfect, is practiced, when the individual finds that intercourse is impossible. It is in this respect that the requirement of rest must be strictly enjoined. Cases in which the principal trouble consists of premature ejaculation and feeble erection unquestionably require rest for a time ; but the patient is likely to disregard the instruction of his medical adviser because still retaining a certain degree of potency and able to copulate after a fashion — sufficiently well, at least, to make the indulgence pleasurable. In cases of this kind the patient should be informed that it is absolutely impossible to benefit his condition iniless he will consent to at least six months' continence. — 141 — IMPOTENCE AND vSTERIUTY The moral tone and mental condition of the patient deserve special consideration. The remarks that have been made in con- nection with the subject of masturbation and sexual excess are pertinent in these cases. Exercise, intellectual occupation, and avoidance of all sources of sexual stimulation must be insisted upon. Where practicable, the patient should be advised to take a change of scene ; in short, to cease associations that tend to excite his sexual passion. Traveling — and particularly a sea- voyage — is excellent for these cases. Cold shower-baths or plunge-baths are excellent adjuvants to the general treatment. Delicate patients should begin by a course of sponge-bathing. Cold sitz-baths or hot and cold water in alternation are useful. Whatever form of bath be selected, it should be followed by brisk rubbing with a towel or flesh-brush. Local douches with hot and cold water alternately are very stimulating to the parts. The Turkish bath taken in moderation and followed by the cold plunge constitutes one of the best of general tonics. The diet requires some attention. It should consist of an abundance of easily digestible and nutritious food, a preponderance of nitrogenous elements being essential. The various preparations of malt and codliver oil are excellent means of improving nutrition. An abundance of good rich milk and cream is demanded. Meats should be eaten rare and should contain considerable fat. A moderate amount of stimulants is often useful. Claret, port, sherry of good quality, or Dublin stout may be taken with the meals. The patient should be advised to sleep upon a hard mattress with light covering, this measure being particularly essential if nocturnal emissions are a feature of the case. Certain internal remedies are useful. Contrary to the general belief, however, not only are there no specifics for impotence — i. e., no drugs that can be depended upon to so stimulate the sexual apparatus as to immediately render copulation possible — but there is no drug known to science that can be relied upon for the restora- tion of the abused and maltreated procreative organs. All drugs and systems of treatment advertised are arrant humbugs and swindles. Treatment of impotence by mail is a delusion and a snare set for the credulous and ignorant by quacks. Nearly if not quite all of the aphrodisiac remedies that are likely to be useful in impotence, with the possible exception of cantharides, act rather — 142 — TREATMENT OF IMPOTENCE as general restorers of nervous energy than by a special predi- lection for, and stinnilation of, the sexual apparatus. Much of the reputation of various drugs depends upon the moral effect of their administration in cases of pseudo-impotence. Nearly all the cele- brated nostrums and quack remedies recommended as specifics for impotence have become celebrated through their influence upon the minds of the patients. An individual who is impotent because of lack of confidence in his virility, is likely to be relieved by a tritura- tion of milk-sugar, providing he has confidence in the efficacy of the placebo. If some alleged aphrodisiac be given, it is likely to acquire an undeserved reputation for efiicacy. The best remedy for a lack of tone in the generative apparatus probably is iron. The tincture of the chlorid may be given in doses of from 15 to 20 drops in water, three times daily, after meals. The pyrophosphate of iron perhaps is a more eligible preparation and equally effica- cious. It should be administered in doses of from 5 to 10 grains thrice daily. It may be advantageously combined with strychnia. The following is a favorite prescription of the author's: IJ Ferri pyrophos gr. v. Strychnine sulph gr. Voo Sodii arsenit gr. Voo M Ft. Caps. Sig. Three times a day after meals. Nux vomica, or its alkaloid, strychnia, has an excellent reputa- tion in the condition under consideration. Phosphid of zinc and nux vomica may be given in combination. The following is an excellent formula : IJ Zinci phosphidi gr. v. Ext. nucis vomicae gr. xx. M Ft. pil. No. xl. Sig. : One three times a day, after meals. Phosphorus is the most reliable remedy in these cases. It may be given in solution, as a tincture, in combination with zinc as in the formula just given, or in its pure state. A pill composed of '/^o grain of phosphorus and ^ / ^ grain of nux vomica is an excellent combination. The principal objection to the use of phosphorus is the offensive eructations and gastric disturbance it sometimes produces. The mineral acids — such as — 143 — IMPOTENCE AND STERILITY dilute phosphoric, muriatic, and nitric — are all of service. Hypo- dermic injections of strychnia often are useful, a single daily in- jection of ^/ei grain of the sulphate of strychnia being more effica- cious than much larger and more frequent doses taken per orem. Opium, the bromids, ergot, digitalis, gelsemium, and alcoholics all have their uses in nervous impotence. Cantharides exhibits a more marked and direct immediate action upon the generative apparatus than any other aphrodisiac. It should be given cautiously, however, for in large doses it may produce inflammation of the bladder and, coincidently, severe strangury. So severe are its effects in some cases that obstinate priapism and insatiable sexual desire may occur, perhaps with inflammation and sloughing of the penis and vesical mucosa. Deaths from the drug have been frequently observed. In impotence the tonic efi^ect of the drug should be aimed at. It may be given in from 10 to 15 drops three times daily. In occasional cases a gradual and cautious increase of the dose is warrantable. Thus, 10 to 15 drops three times a day may be given to commence with, the dose being increased 1 drop each day until slight strangury is produced, when it should be discontinued. If there has been no benefit to the impotence by this time, further administration of the drug is useless. Damiana is a much-vaunted remedy for im- potence that is useful to a certain degree as a tonic. The dose is 1 or 2 drams of the fluid extract three or four times daily. Both damiana and cantharides will be reverted to in a subsequent chapter. Ergot often is a valuable remedy in impotence, particularly in those cases in which there seems to be a lack of tone in the vascular supply of the penis. It may be given in doses of 10 to 20 drops, three or four times daily. Certain cases of impotence have been attributed to a lack of tone in the dorsal vein of the penis, this condition resulting in too rapid removal of the blood from the part during erection. Injections of ergotin in the course of the vein have been recommended for this condition. Ligation or resection of the vein may be of great service. According to Bartholow, jaborandi, or its alkaloid, pilocarpin, is an active aphrodisiac, being indicated in cases characterized by debility. He claims that it is more efficacious than any other agent. The dose should be 30 minims of the fluid extract, night and morning, or from ^/r, to ^/g — 144 — TREATMENT OF IMPOTENCE grain of the muriate of pilocarpin thrice daily. The author beheves that pilocarpin is of some vahie. It probably acts by increasing testicular, prostatic and seminal vesicle secretion. Cimicifuga also is recommended by the same authority, particularly in those cases of impotence accompanied by spermatorrhea of long standing, with excessive nervousness and anxiety and diminished sexual desire. In cases in which premature ejaculation from sexual hyperes- thesia and active secretion of semen are noied, regular intercourse, with moderate frequency, and the administration of such remedies as potassium bromid, chloral-hydrate, gelsemium, and ergot often will relieve the condition. Potassium bromid is the most popular sedative for sexual hyperesthesia or excessive desire, so often attended by partial impotence. Its efficacy has, however, been dis- puted by some authors. In explaining the sources of fallacy of those who disi)ute the anaphrodisiac effects of the bromids Bartho- low speaks as follows : 1. The physiologic eflfects of potassium bromid are not very decided, and are readily modified by any local disturbance. 2. Its therapeutic action is still more decidedly influenced by local morbid processes. 3. It is indicated where a sedative to the nervous system is required : c. g., in insomnia, too great reflex excitability, nervous and spasmodic affec- tions of the larynx and bronchi, sexual excitement, and irritable states of the sexual organs. 4. It will be effectual in the foregoing conditions, in proportion to the degree in which structural lesions are absent, or, in other words, in pro- portion to the degree in which these morbid states are functional rather than organic. 5. These conclusions, the result of observation and experiment, afford us a satisfactory solution of the cause of failure in the use of the bromid of potassium. Sexual excitement in mania is due, as shown by Schroeder von der Kolk, to structural alteration in the medulla oblongata, the center, ac- cording to this author, of the sexual impulse. The bromid of potassium can have no influence over these structural alterations, and hence cannot control manifestations of sexual excitement depending upon them. With increasing exj)erience in endoscopy, we have come to as- sign more and more importance to morbid conditions of the colliculus seminalis as the underlying cause of perturbations of the sexual function. Where the colliculus is inflamed, endoscopic application of nitrate of silver is essential. — 145 — IMPOTENCE AND STERILITY The local and general application of electricity in its various forms is very useful in impotence. It is especially useful in the form of the general faradic bath, the current being applied while the patient is in a tub of hot water. Its application should be fol- lowed by a cold shower- or sponge-bath, and the application of static electricity or the high frequency current to the spine, particu- larly over the lumbo-sacral region. It sometimes is beneficial to apply the latter form of electricity to the perineum, penis, and testes. Hammond claimed that he had succeeded by means of the static apparatus in restoring sensibility to the glans penis and adja- cent tissues when galvanism and faradism had failed. While in- clined to take some of this gentleman's clinical observations cum grano sails, the application of the static or high frequency current in this manner seems rational enough. The stimulating effect of static electricity upon the nervous system often is remarkable ; some patients say that it acts like a glass of champagne. The faradic current in moderate strength is a powerful stimu- lant to the sexual organs. The ordinary sponge electrodes may be used, the positive pole being applied to the lower part of the spine and the negative to the penis and testes. More benefit, how- ever, sometimes is to be derived by applying the negative electrode to the genitals and the positive to the inner aspect of the thighs. A wire brush electrode may be used instead of a sponge, this being attached to the negative pole and passed up and down the spinal column. The positive pole may be placed first upon the nucha and afterward upon the lower portion of the spine, the wire brush being passed over the genitals. More or less pain is caused if the current be at all strong, but considerable benefit will be derived from its use. The circulation and nutrition of the spinal medulla is greatly improved, and the vigor of the sexual nerves is necessarily in- creased. The application of the wire brush to the genitalia is es])ecially serviceable in cases of impotence that appear to depend chiefly upon anesthesia of the nervous su])ply of the glans penis. The galvanic current often is useful, either alone or in combination with the faradic current on alternate days. The high frequency current has proved very useful in the author's hands. It may be applied with a glass electrode directly to the ])rostatic urethra. __ 146 — TREATMENT OF IMPOTENCE One of the best stimulants for the sexual organs is the faradic current applied directly to the prostate. /\n insulated sound or bougie is attached to the negative ])ole of the faradic battery and passed down to the prostatic urethra. The positive electrode may be applied to the spine, thighs, hypogastrium, or genitals. It is best applied by means of a large flat sponge electrode to the lumbar region. The prostate may be faradized by a rectal electrode attached to the negative pole. The galvanic current may be used in a similar manner. In cases in which the trouble appears to depend chiefly upon h3'peresthesia of the prostatic sinus much benefit often may be derived from the application of the positive pole of the galvanic battery to the prostatic urethra. A local electric bath may be given by suspending the penis and testicles in a receptacle of warm water, the negative electrode being placed therein, and the positive held in the patient's hand. In applying electricity directly to the prostate care shovdd be taken to avoid too powerful currents and too long continuance of their application. Inflammation of the neck of the bladder, and even prostatitis, are possible sequences of carelessness in this regard. In the milder types of impotence the local aj)plication of elec- tricity by the insulated sound in combination with psychotherapy and the general measures that have been suggested rarely will fail to restore the vigor of the sexual apparatus, providing the patient is faithful in his treatment and devotes sufficient time to it. It is not well to make promises regarding the length of time necessary, and the patient should be told that the period necessary for treat- ment can be determined only by the progress of the case, some cases yielding in a short time, while others require a protracted course of treatment. Prostatic and vesicular massage are very frequently necessary in the treatment of impotence, especially in post-infective cases. It should be remembered that, to achieve permanency of result, it is necessary for the patient to continue treatment, and to abstain from sexual indulgence for son.ie little time after his capacity appar- ently has been restored. In cases of premature ejaculation and failure of erection due to extreme sensitiveness of the glans penis, circumcision usually is necessary, as most of these cases are afifected with redundancy and — 147 — IMPOTENCE AND STERILITY phimosis. The daily application of cold water to the glans is an excellent adjuvant to circumcision. The application of electricity by the galvanic brush or the high frequency current, is a very valu- able recourse. Daily applications of a solution of tannic acid in alcohol, or of aluminum acetate, are serviceable in allaying hyper- esthesia. The application of stimulating embrocations to the penis has been recommended for impotence. As a general rule, they are worse than useless. Sinapisms, however, as recommended by Roubaud, may be of temporary service in some instances, by tempo- rarily exciting erectile power and affording a permanent cure by the psychic efTect of the erection. The irritation produced by mustard is sufficient to reflexly excite an erection in the majority of instances.- Care should be taken not to prolong the application, lest serious inflammation result. Cases of impotence secondary to cerebral or spinal disease should not be subjected to much special treatment. All therapeutic efforts should be directed to the cure or improvement of the primary condition. As improvement of the condition of the brain and cord occurs, a corresponding improvement in sexual vigor is noted. Some remedies for impotence are injurious in cases de- pendent upon spinal disease. For example, spinal excitants, such as phosphorus and strychnia, should not be given in locomotor ataxia, as they are likely to aggravate the organic disease, and will in no way benefit the impotence. In some extreme cases of sexual hyperesthesia, the application of silver nitrate to the deep urethra by means of the deep urethral syringe is of benefit. As a temporary expedient and in psychic impotence, the applica- tion of very hot water to the penis and testes just prior to copulation often is efficacious. Most of the deformities of the sexual apparatus that produce impotence are not amenable to treatment. Diagonal section of the roof of the contracted urethra may benefit some cases of curvature of the penis. Epispadias, hypospadias, and certain tumors of the penis, scrotum, and testicles are amenable to treatment by the knife. The author has had some very interesting cases showing what sometimes can be done for impotence due to hypospadias. The following is of especial interest : Case. — A youth of seventeen with hypospadias and marked curvature of the penis. Erections deformed and intromission a physical impossibility. — 148 — i Soil TREATMENT OF IMPOTENCE sin^ Subject otherwise normal. The pseudo-meatus was located at about the middle of the penis — antero-posteriorly. Operation : 1st stage. The urethra (corpus spongiosum) was dis- sected away from the body of the penis and implanted posteriorly, the new location of the meatus being the penoscrotal angle. All connective tissue bands and fibrous contractures were divided and the penis straightened. After healing was complete, several months later, a new penile urethra was made from a flap taken from the scrotum. A practically perfect result was se- cured. The author assured the father of the boy that there was one espe- cially favorable element in the boy's condition, viz., that he could not con- tract gonorrhea, because of the fact that his entire penile urethra was com- posed of skin, which was not susceptible to gonococcal infection. To the astonishment of all parties concerned, the boy did contract a severe gonor- rhea within a year after the operation. Several years later he married and had a normal child. He still is sexually normal. Resection of the Vena Dorsalis Penis: Like all other surgical innovations, ligation and resection of the dorsal vein of the penis for the cure of impotence became a fad. The "commercial" surgeon hailed the new operation with delight, and the conservative and conscientious surgeon, who was ready to grasp at any straw which offered hope of relief for the most annoying class of cases that come under our observation, welcomed the operation as a friend in need. As is usual with new methods of treatment, the surgical fraternity speedily divided into two camps, viz. : those who pro- claimed from the house-tops the infallibility of the method, and those who proclaimed quite as vociferously its utter worthlessness. The gap between a certain prominent American surgeon, whose patients had a vigorous priapism, coming on before they left the operating table, and demanding ice-packs for its relief, and those who condemned the operation as worthless, was a wide one. There was, however, something so seductive about the reports of the surgeon with the priapism patients, especially in view of the fact that the procedure was extremely simple, requiring only a few minutes under local anesthesia, that one was loth to give ear to the adverse critics. Still more entrancing was the simpler "improved" operation of "subcutaneous ligation of the dorsal vein." The first point which the author's experience has settled to his own satisfaction is that the wide variation in results of the method obtained by different operators largely is explicable by a wide dif- ference of technique. As the object aimed at is purely mechanic — 149 — IMPOTENCE AND STERILITY and psychic, the average of results should be the same, provided the contemplated mechanic obstruction in the vein is accomplished by it. The operation is not so simple nor so easily performed as its more sanguine adherents have claimed. The rapid operation and the subcutaneous ligation consist in most cases of anything but liga- tion or resection of the vena dorsalis penis. The dorsal vein proper lies beneath the fascia propria — Buck's fascia — and cannot be accurately or safely ligated or resected with- out careful and painstaking dissection. Subcutaneous ligation of the vein is a conception of anatomic ignorance. Ligation of the super- ficial penile veins, however large and prominent they may be, and essential though it often is to a thorough operation, is not ligation of the vena dorsalis penis. Granting that this vessel can be ligated without an oi)en operation, it can be accomplished only by wounding or including in the loop of the ligature other important vascular and nerve structures. The relatively prompt effect of properly performed resection of the vena dorsalis penis in demonstrating dynamic sexual capacity, through purely mechanic circulatory agencies, necessarily must be a powerful factor in the result. Add to this the fact that the mechanic conditions secured by the operation practically are perma- nent in quite a proportion of cases, and we have excellent reasons for faith in the efficacy of the operation. Admitting, for the sake of argument, that its eiTect upon the circulation of the penis is merely transitory, this would not count against the operation in purely psychic cases, still less in those with a lesser degree of psychic aberration. The suggestion of dynamic capacity has done its work long before the effect of the operation disappears. If the argument that the effect of the operation is purely psychic, and that it consequently is not warrantable in the treatment of impotence, is permitted to liave much weight, the majority of j^atients would be discriminated against. Cases of impotence in which true organic ctiologic factors dominate are relatively infre- c[uent, and in many of those of an organic type, there are certain factors which minimize the importance of impotence per se — e. g., in certain cases of hypospadias, epispadias, etc. In presenting the claims of the operation to patients, a full and frank statement of i)()ssibilitics and ])robabilities of a successful — l.SO — TREATMENT OF IMPOTENCE result should be made, with due and thorough consideration of the individual merits of the given case. With the psychic element in mind, the patient should be encouraged as much as is consistent. A careful and exhaustive inquiry always should be made into the circumstances under which the erectile power is wanting, with especial reference to the psychic influences dominating at the time of failure. As to whether the results of the operation substantiate the claim that defective erection is due in a large proportion of instances to the too rapid emptying of the blood from the dorsal vein of the penis, the author is unable to say. This appears, however, to be a by no means inconsiderable factor in the etiology of impotence, and consequently in the results obtained by resection of the vena dorsalis penis. It must be remembered, however, that, in its mechanic re- sults, a sluggishness of arterial supply would in efifect be precisely the same as a too rapid return of the venous blood from the part. Defective arterial supply probably is a logical explanation of quite a proportion of cases of impotence, and consequently of the benefits derived from operation. From the author's experience his conclusions in brief are : 1. Resection of the vena dorsalis penis in the treatment of impotence is an operation requiring accurate anatomic knowledge. It cannot be done subctitaneously without serious injury to important parts or total failure of the operation. 2. The operation, while not essentially dangerous, is neither so simple nor so easily performed as some have claimed. 3. The ligation of the superficial penile veins often has been performed by those who claimed that they had ligated the dorsal vein proper. This operation upon the superficial veins often is essential to a complete operation, but when performed alone is futile. 4. The location of the dorsal vein is such that careful and jxiinstaking dissection is necessary for its ligation or resection. 0. The operation is beneficial in very many cases on strictly psychic grounds, but this does not militate against the advisability of its performance. The important thing for the patient is a restoration of function. 6. In some cases of impotence of organic origin the operation — 151 -- IMPOTENCE AND STERILITY is not to be thought of, but in quite a wide range of cases of the kind the operation is successful, firstly, because of its mechanic effect ; secondly, because of its psychic effect. 7. One of the most important elements in the cure of impo- tence by a properly performed resection of the vena dorsalis penis is the demonstration to the patient of dynamic sexual capacity through purely mechanic circulatory agencies. 8. Normal erection largely revolves around the maintenance of equilibrium between the efferent and the afferent blood flow in the erectible tissue. Inefficient intake, or excessive outflow, is equally detrimental to erection. Resection of the dorsal vein of the penis aids in restoration of the equilibrium. 9. The mechanic conditions secured by the operation are permanent in quite a large proportion of cases. 10. In cases of complete impotence which are not dependent upon irremediable local causes of functional disturbances of inner- vation, the operation apparently is successful in about 50 per cent of the cases, and beneficial in probably one-half of the remainder. 11. In by far the majority of cases of impotence that come under the observation of the surgeon, a trial of this operation is justifiable. The cases of impotence that are most trying to the physician are those met with in individuals at about middle age who have for many years indulged excessively in sexual intercourse. Patients of this sort consult the physician in the hope of receiving a remedy that will enable them to go on with their excesses, and, as a rule, they do not attribute their condition to its true cause. It is hard to convince such patients that they are paying for their early in- dulgence, and that they ought not to expect to perform the sexual act so often and so indiscriminately as when they were young. Such an opinion seldom satisfies them. The physician is consulted by many middle-aged rones who complain of real or imaginary sexual exhaustion, spermatorrhea, premature old age, etc., and these cases certainly are difficult to manage. If the patient cannot be made to understand the physiologic conditions involved in his case, and the importance of resting sexually in order that the organs involved may recuperate their exhausted vitality, very little success can be obtained by treatment. There is a vulgar notion among the laity to the effect that a man is capable of just so many acts of sexual indulgence — 152 — TREATMENT OF IMPOTENCE during his life-time, and that he may either distribute these acts at proper intervals throughout a great number of years or may per- form them within a few years early in life. There is much of truth in this, for it is a cardinal rule that overexcitement of any function will cause loss of power. The man that copulates with moderation is the one best fitted for procreation, because he is, from a sexual point of view, the most energetic. It is a well-known fact that the male population of the Orient become impotent at a very early age, earlier than any other race of men, on account of free indulgence of their sexual appetites. For that matter, among all nations men and women alike sufifer from premature old age when excessive sexual indulgence is conjoined with a life of indolence and ease. The man who indulges in sexual intercourse most frequently in his youth is the one w'ho is most likely to become impotent or sterile when he reaches middle age. It is said that quite a proportion of Oriental males become impotent at the age of from 30 to 40 years. ^Moderation in sexual intercourse is not only conducive to pro- longed virility, but to longevity. It is certain that many cases of neurasthenia in both male and female are due to sexual excess. The treatment of the class of cases under consideration depends for its sticcess mainly upon careful instruction of the patient in sexual physiology. The cause of his disability should be explained to him, and he should be assured that the only hope of restoration of virility and of its perpetuation lies in complete rest of the sexual function for a prolonged period, with moderate indulgence for the rest of his life, after his capacity has returned. In conjunction with these moral means for restoration, the remedies and local measures already recommended may be employed as the case demands. Care should be exercised in advising prolonged rest of the sexual function in old men. Obstinence sometimes is followed by permanent sexual disability. Where impotence depends upon one or more of the organic conditions enumerated in connection wuth etiology, the cause should be dealt with upon its surgical merits. Aspe;rmia. The term "aspermism," or aspermia, has been applied to some cases in which, although erections are normal and copulation is — 153 — ASPERMIA performed with facility, there is no ejaculation of semen. There may or may not be sexual desire. A peculiar feature of these cases is that the patient, although unable to have an emission during normal intercourse, invariably acknowledges the occurrence of voluptuous dreams attended by pleasurable sensations and emission of semen. On examination the urethra will be found to possess the usual amount of sensitiveness in all parts, excepting the prostatic sinus, where there apparently is complete anesthesia. The author has observed several cases in which aspermism was the f ovmdation of sterility. Two of these are of particular interest : Case 1. — A healthy man, 35 years of age, who had never had any ail- ment or injury, sought advice regarding failure of emission. The patient stated that he had been sexually normal until within a year, since which time he had found it impossible to have either orgasm or emission. Sexual desire still was normal and erection perfect, but no amount of duration of effort in copulation was sufficient to bring about an orgasm. Sexual intercourse never had been indulged in to any great extent, even before any abnormal- ity was noticeable. Erotic dreams and nocturnal emissions were quite troublesome. This case finally yielded to faradism of the prostatic urethra. The treatment was directed to the relief of the evident anesthesia of this part, which apparently was the cause of the aspermia. Another very interesting case recently came under the author's observation : Case 2. — A young man, 30 years of age, with the following history: He had masturbated for some years, beginning at the age of fifteen. For the last ten or twelve years he had had intercourse at frequent intervals, latterly two or three times weekly. He never had been able, either by masturbation or during sexual intercourse, to have an ejaculation of semen. The act, he said, was pleasurable, but absolutely unattended by anything like orgasm or seminal emission. On inquiry he stated that he had tired himself out in the attempt repeatedly, but without success. He was aware that it was not the fault of secretion, as he stated that he frequently after intercourse had lascivious dreams with copious emissions. On examination the sexual organs were found to be normal, with the exception tliat there was absolute anesthesia of the prostatic sinus, in which nothing was found on endoscopy. Sounds produced no sensation whatever, nor was a strong faradic current more successful. The patient in all other respects was perfectly normal — indeed, he was an exceptionally robust man. He stated that during strong sexual excitement there escaped from the meatus a small quantity of fluid, which, from his description, unquestionably was prostatic secretion. Sexual desire was marked, which made his condition particularly dis- tressing. He stated, however, that copulation was not entirely vmattended with gratification, else he would not have had intercourse so frequently. — 154 — IMPOTKXCE AND STKRILTTY Under prostatic massage and faradisni of the prostatic urethra, this case improved so that scanty emissions occurred during copu- lation, but he never fully recovered. Ultzmann related some very typic illustrations of aspermia. Roubaud advanced the theory that aspermia depends upon spasmodic contraction of the muscular fibers about the mouths of the ejaculatory ducts, preventing the escape of the semen into the prostatic sinus. This view hardly is in accordance with the phys- iology of the part. Keyes says, anent this point: Were there desire and pleasure, prostatic mucus would be secreted in excess and would be thrown out by ejaculation, while the semen proper would collect and distend the seminal vesicles and ducts below the ejaculatory orifices, and would escape and flow away from the meatus with the re- laxation of spasm brought about by the fatigue following prolonged sexual intercourse, but this is not the case ; the fault is evidently in the nerves. There is no pleasurable sensation, no call for secretion of prostatic mucus, nor for a supply of spermatic fluid. There is anesthesia of the prostatic sinus, and although the power of having an orgasm and ejaculation remains, as proved by dreams, yet there is some connecting link missing in the chain which transforms friction of the glans into pleasure at the prostate, and finally into secretion in the testicle. There probably is not only anesthesia of the floor of the prostatic urethra, but a lack of the special sensibility of the nerves of the glans penis that normally is acquired during erection. It is possible, too, that, although the nerves of the prostatic sinus are normally sensitive, the nerves of the glans fail to appreciate and transmit pleasurable sensations. The function of the latter nerves perhaps is inhibited by the consciousness of the patient of the lack of sensibility in the glans. During sleep inhibition does not occur, and the sub- conscious memory of normal copulation, of which the patient once was capable, is sufficient to impart a pleasurable sensation and re- flexly produce an orgasm. Defective secretion is, in the author's opinion, an important factor in some cases. Perturbation of hormone supply may be an element in these cases, ^^'ith increasing faith in the physiologic im- portance of the sex hormone, the author inclines to the belief that in many cases both of primary and secondary impotence, defective hormone is an important factor. In some cases, it alone may be the cause of the condition. Variation in sex hormone quality probably is the explanation of the wide variation in primary sexual capacity. — 155 — TREATMENT OF ASPERMIA TRKATiMEA'T. — The treatment of this condition generally is re- garded as very unsatisfactory. Roubaud reports a case in which blistering the perineum, with subsequent application of powdered morphin, produced a cure. He recommends antispasmodics, in ac- cordance with his theory of the pathology of the disease. Electricity in the form of the static and faradic currents applied to the spine and genitalia — -especially to the prostatic urethra — would appear to be the most rational form of treatment, and has been moderately successful in the author's hands. Faradism is to be recommended for both its moral and physical effects. A strong faradic current applied to the prostate sinus, daily if possible, thrice weekly at least — in combination with mildly irritant injections into the prostate from time to time, appears to be the rational indication. Prostatic massage also seems to be a logical measure. It seems to the author that in some of these cases there may exist at the time of copulation some peculiar inhibitory mental influ- ence that prevents culmination of the sexual act. Mental influences sometimes have this effect in perfectly healthy individuals. Once let the sexual act be naturally performed in these cases of aspermism and the "spell" is likely to be broken. When once the sexual act is co-ordinated with the mental elements necessary to the proper per- formance of the sexual function, not only will ejaculation occur, but the impression is likely to be a permanent one, the necessary sensibility being subsequently called forth in a normal manner on all proper occasions. The prognosis in these cases usually is not prom- ising. The question of matrimony is important in cases of aspermia. As the matter of sterility so far as the male is concerned is of rela- tively little importance, provided he be capable of performing the sexual act, the author can see no reason why the patient should not marry, particularly as marriage is likely to afford the mental condi- tion and the environment necessary to awaken the more or less dormant sexual sensibility. A frank statement of conditions of course should be made to the prospective wife. Roubaud's suggestion of the use of antispasmodics, on the theory of the dependence of the disease upon muscular contraction, seems a little fanciful. Inasmuch, however, as antispasmodics usu- — 156 — niPOTENXE AND STERILITY ally are sedative, success might be obtained by their administration through their effect upon the brain, and incidentally the production of mental calm where unfavorable circumstances of disquietude exist at the time of copulation. It generally is supposed that it is necessary for the semen to distend the prostatic sinus in order that orgasm may occur. This may be true of individuals who never have had an emission of semen, but that it is not true in general is shown by the fact that aspermics — /. c, individuals who expel no semen whatever — sometimes have an orgasm as keenly pleasurable as that of a healthy individual. Thus, in one of the author's cases in which he removed a tuberculous testicle, the remaining epididymis subse- quently became occluded from epididymitis and chronic thickening. There was, however, a restoration of i)reviously impaired power, the patient having intercourse regularly and experiencing the normal amount of pleasure therein. Never since the involvement of the remaining epididymis, however, has he had an emission, even of prostatic fluid. Duration of the Procrkativl; Power. The period of endurance of procreative vigor varies with the individual. It sometimes is preserved to very old age. It begins at puberty, growing more and more vigorous as time goes on, until maturity, when, if the subject has not indulged in vicious habits, the procreative power is at its height. It remains more or less station- ary until middle life, when a gradual decline is noticed. From this time on, under physiologic conditions, the activity of the procreative power gradually wanes along with that of all the other bodily func- tions. Fertility probably wanes faster than physical capacity. In normal women, physical capacity is coeval with life. Fer- tility begins with menstruation and ceases w'ith the menopause. The author recalls a very peculiar case occurring in the New York Charity Hospital showing that sexual congress may sometimes be carried on by the female under extreme difficulties : Case. — A woman, 20 years of age, with complete atresia vaginae, w-ho, strange to saj-, nevertheless led the life of a public prostitute. The external parts were perfectly developed, but there was no opening whatever corre- sponding to the normal situation of the vagina. The case differed, too, from — 157 — DURATION OF THE PROCREATIVE POWER ordinary atresia, inasmuch as there was no thickened fibrous cord between the bladder and rectum such as is ordinarily met with in occlusion of the vagina, and which represents the walls of the canal that have become fused together. When the index finger of each hand was introduced into the bladder and rectum respectively nothing could be felt between them but the walls of these viscera. Neither uterus nor ovaries could be detected. How this woman copulated is a mystery. There was no evidence of pederasty. Whatever the circumstances may have been, the woman certainly was not aware of her condition, but supposed that she had been performing the act of copulation like other women. The urethra was very commodious, and it is possible that it had been utilized as a sexual way. Such cases have been reported. It is safe to formulate the following cardinal principles for the laity, viz. : 1. Conservation of bodily vigor conserves procreative vigor. The better the care of the body, the better the likelihood of the procreative capacity being carried into the later years of life and the better the quality of children born. 2. Certain persons primarily are more virile than others. The standard must be individual. 3. Men of middle age or over, who expect as much of their procreative function as in early manhood, merely display their ignorance of physiology. 4. Men who have abused or excessively used their procreative function in youth and early manhood may expect to "pay the fiddler" at middle life. One cannot "eat his cake and have it." 5. The man who indulges to excess in alcoholics also may ex- pect to "pay the price" sooner or later. 6. Persons who have had deep-seated gonorrhea or severe syphilis may expect early waning or absolute destruction of the procreative power. 158 CHAPTER VIII. Sterility and Impotence in the Female. Fertilization. — For the purposes of this volume the process of fertihzation may be reduced to very simple terms. The condi- tions necessary are: 1st. 'J^he ])roduction of spermatozoa by the male and of an ovvile by the female. 2nd. The discharge of the one from the testis and of the other from the ovary. 3rd. The contact in the female sexual tract of a single spermatozoon with an ovule ; this probably usually occurs in the uterine end of the Fallopian tube. 4th. The chromosomes of both ovum and spermatozoon must be healthy. 5th. There must be no essential primary incompatibility of the ovule and the spermatozoon. 6th. The tubal and uterine mucosa must be normal, meaning that there must be no secretion of the membrane that is deleterious to the vitality of either ovum or spermatozoa, and no condition of the mucosa that will prevent lodgment and growth of the ovum. It is evident that there are numerous conditions which may : 1st. Impair the primary vitality of the ovule and spermatozoon. 2nd. Prevent the meeting of the two elements at the proper time and place. 3rd. Impair the fitness of the soil in which the two elements meet. It is obvious that nutritive perversion of the parental chromo- somes and obstacles to their meeting may occur in either party to the sexual act. Statistics show that about one in eight marriages are unpro- ductive. As already seen, a portion of the responsibility for sterility must be borne by the male. Most of it, however, justly or unjust- ly, — unjustly, of course, where the fault is due to gonorrhea con- tracted from the husband — falls upon the female. ETioiartholow remarks tipon this |)oint as follows: After every erection without ejaculation there is a mucous flow from the urethra. A mixture of this with the semen produces the so-called water\- semen. The same discharge is often ohserved after urination and defecation. It alarms the patient because he l)elieves that it is seminal. These are the cases to which AI. kallemand applies the term "diurnal pollution." If a proper examination of this fluid he made, it will be found not to contain si)ermatozoa. It is a thick, transparent albuminous fluid, alkaline in reaction. The presence of spermatozoa is essential to prove the existence of semen. Xo other test is applicable than the micrf)scopic. It cannot be denied that spermatozoa may be found in the lU'ine or mucous secretion from the urethra, if a nocturnal emission, or an emission produced by natural or utmatural means, has recently occurred ; l)ut these fluids should be examined, when this source of error may be eliminated. 'Jliis accords with the views of Flint, who long ago said: In most of these cases the fluid is either the liquor prostaticus or a secretion from the vesiculse seminales. The microscope affords the only mode of determining that the fluid is seminal. Were this mode of examination generally adopted, cases of spermatorrhea would be extremely rare. Ihassell. in one of the early editions of his work on the ttrine. says : Care must be taken not to confound the discharge of urethral gleet with seminal fluirl ; the distinction is easy, since the former is distinguished by the presence of infusoria. i)y the presence of scaly epithelium, and by the escape's being, in general, continuous. Sometimes the gleety discharge occurs only after sexual excitement and lasts but for a short time, when, of course, — 181 — I.MPOTHNCE AND STERILITY its character is more likely to be mistaken. The prostatic fluid also might be mistaken for semen ; in this the spermatozoa also would be absent, and, in addition, the microscope would reveal in it the presence of the prostatic cylinders, and perhaps, also, of the peculiar lamellated concretions of phos- phate of lime, which are found in the prostate in such numbers. Like the mucus from ordinary gleet, that from the prostate may also be continuous, but more frequently it appears only after violent efforts of defecation, when Spermuria. Last drop of urine exi)elled in a case of sperma- torrhea. a small quantity of matter may be expressed, forming only a drop or two, of a thick, stringy, and transparent fluid, which api)ears at the oriiice of the urethra. It is easy to mistake the discharge of chronic urethral cartarrh for semen. 'I'his mistake does not often occtn', however, for the experienced man with past gonorrhea! trotihles ttstially does not attribnte his discliarge to any l)ut the real cattse. :V moment's re- flection is sufficient to show that there is al)tindant room for nn'stakes in the microsco])ic diagnosis of urethral discharges. 'I'he prostatic, nrethral, and Co\v])er's glands are prodigal in secretion, and slight stinnili or meclianic ])ressure often are snfficient to catise the secre- — 182 — SPERMATORRHEA - : tioii to appear at the meatus. Bladder-mucus or muco-pus, and phosphatic deposit in the urine, also are sources of error. It must be remembered, however, that in genuine spermatorrhea sexual excitement and mechanic pressure may cause true seminal discharge, which may at once appear at the meatus, or pass backward to appear later in the urine. W^henever true semen appears at the meatus without orgasm, the author believes that the function of the muscular urethra temporarily is inhibited, or overcome by prostatic pressure, or else orgasm occurs, but is too feeble to be perceptible to the patient's weakened sensorium. Symptomatic spermatorrhea in central nervous disease requires brief special consideration. As might be inferred from the fact that sexual excesses and masturbation bear an important etiologic rela- tion to locomotor ataxia, spermatorrhea is associated with that form of nervous disease more often than with any other. In passing, the author desires to express the opinion that, notwithstanding the fact that sexual abuses often are a very important factor in tabetic etiology, it is very doubtful if such influences alone ever cause tabes. Primary predisposition, — often involving heredity, — syphilis, alco- holism, and nervous overstrain, one or all, are likely to co-operate with faulty sexual hygiene, which becomes, therefore, merely a con- tributory cause, albeit an important one. The author believes, with most syphilographers. that tabes primarily always is due to syphilis — hereditary or acquired, usually the latter. Sexual phenomena in tabes usually develop in the early stage of the disease. Meryon, Trousseau, Duchenne, Topinard. and, later, Bartholow are a few of the prominent writers who have called atten- tion to these symptoms. Topinard speaks as follows : Four symptoms present themselves : spermatorrhea, satyriasis, anaphro- disia, and impotence. The first occurs among the most remote antecedents of the first period of tabes, throughout which it continues. The nocturnal pollutions, at first accompanied by erections and a sensation of pleasure, at last become passive. After the spermatorrhea, or without having been preceded by it, there occur, after some months or years, progressive diminu- tion of desire, difficulty in procuring satisfaction, and at last absolute im- potence. Topinard mentions a case of ataxia in which the patient for thirty years was tortured by priapism so obstinate as to yield only to large and increasing doses of opium. This is rare ; sexual atony is the rule. — 183 — IMPOTENCE AND STERILITY Among other neuropathic disorders in which spermatorrhea often occurs as a symptom may be mentioned neurasthenia from various causes ; tumors and other diseases of the pons, medulla, and especially of the cerebellum ; inflammation, tumors, and syphilis of the spinal cord ; epilepsy, certain phases of insanity, and diabetes mellitus. With reference to the diagnosis and relative importance of symptomatic spermatorrhea, Bartholow says : In all cases in which the involuntary loss is a symptom it is of little consequence from the therapeutic point of view : the centric lesion, of which it is a sign, is the point of importance to which our attention should be directed. That the spermatorrhea is a symptom merely should be easily deter- mined by reference to the accompanying lesions. There will be present evi- dences of degenerative changes in the great vessels, in the fundus oculi, in the organs of special sense, and in cerebro-spinal centers. As a rule, sper- matorrhea as a substantive affection occurs in the youtig, in men at the most vigorous period of life, and is a result of the abuse of the sexual organs. On the other hand, spermatorrhea as a symptom appears after the middle period of life, during the decline of sexual activity, and coincidently with symptoms indicating lesions of the cerebro-spinal apparatus. When sperma- torrhea is a symptom, the important centric lesions on which it depends soon manifest themselves by other and more characteristic signs, whereas when spermatorrhea is a disease the case remains in very much the same state for months or even years. Attention to these points hardly can fail to conduct the examination to a correct conclusion. Because of its relative frequency, pseudospermatorrhea, while really of slight pathologic importance, is of greater clinical moment than the genuine form. The psychic effects of spermatophobia are so numerous and varied, and so magnified by the imagination of its victims, that the ingenuity and breadth of mind of the physician often are sorely taxed in the management of such cases. While inexcusable, it is, in a way, hardly remarkable that most physicians are content with a laissec faire policy in dealing with spermatopho- biacs. Conscious that the patient is suffering with ailments which, from an organic standpoint, are maladies imaginaires, the medical man feels justified in "pooh-poohing" his patient's tale of woe which, baseless though it is, is yet sufficiently unutterable to the suiTcrer. The lack of an organic foundation renders the symptoms none the less prominent. Pseudo-impotency is often regarded as a fitting subject for jest on the ])hysician's ])art, but, to the patient, — 184 - SPERMATORRHEA the absence of erection, or the presence of other conditions that render successful copulation impossible, is terribly real. Each and every symptom, therefore, merits consideration — - as a beginning of suggestive therapy, if nothing more. The spermatophobiac invariably becomes extremely hypo- chondriac and practices introspection with a zeal that is worthy of a better cause. The slightest sensation of a subjective character, which, by persons of a normal psychic condition, would either be ignored or attributed to some rational cause, is attributed by the sufferer from pseudospermatorrhea to seminal losses. Should he perchance discover in addition to an occasional emission a little cloudiness of the urine, or a slight discharge at the meatus, during sexual excitement, after micturition or during a difficult stool, his worst fears are confirmed and he believes himself a victim of the worst imaginable type of spermatorrhea. Should he have any re- maining doubts as to the diagnosis they are dispelled by the first chance bit of quack literature that he peruses. And peruse quack literature he will, as the only possible source of enlightenment upon sexual matters. Reliable information — indeed, the simplest physio- logic truth — often is denied him because of the hide-bound condi- tion of an ultra-ethical and, if the truth were known, often essen- tially hypocritic profession. The author is aware that the foregoing statement has a decidedly radical flavor, but he has. nevertheless, no hesitancy in expressing the view that some phases of so-called medical ethics are positively sickening. The symptomatology constructed by spermatophobiacs is best appreciated by perusal of their correspondence. It is as historians of their own cases that these patients especially distinguish them- selves. All experienced neurologists and urologists will at once recognize the type shown in the following letter received by the author : My Dear Doctor: You will doubtless be surprised to receive a letter from me so soon after the consultation of yesterday; but, on reflection, I fear that I gave you a very meager account of a case which seems to me much more serious than you realize, judging from the advice j'ou gave me to "stop studying my symptoms and cultivate a spirit of indifference toward my numerous sensa- tions." I therefore take the liberty of writing my symptoms more in detail : — The state of my mind is, perhaps, more important than anything else. As I told you, I dread getting among people, no matter how congenial they — 18.T — IMPOTENCE AND STERILITY may be ; but I did not tell you the chief reason for my aversion to society. I am sure that my appearance betrays my condition, and many times I know from the queer way in which people look at me while talking with each other that they are discussing my ailment. Imagine my feelings, if you can. Of course, my confusion settles all possible doubt in their minds as to the correctness of their conclusions. I am positive, also, that the horrible odor of which I spoke to you really does come from the affected parts, and is so plain that he who runs may read. At the times when I detect the odor, the parts seem bathed in a cold, clammy sweat, though the skin does not feel wet. I have frequent spells of ringing in the ears, and sometimes snapping sounds with some pain that must be in my ear-drums. Just before meals I am dizzy, and this cames on just from hearing dinner announced. I notice that the spots before my eyes come only in daylight and are plainer on cloudy days. I am sure my hair is getting very thin and it seems very oily at times, and at such times the scalp is hot and tingling. Almost always, after meals, there is a full feeling in my stomach and bowels, and my breath seems like the odor of tobacco, though I do not use it. I get very much depressed at times and feel like suicide. I did not tell you this, but it is a fact. If I did not hope that medical science has some cure for my terrible disease I doubtless would make away with myself ere long. I wish that at my next visit to you you would examine mj' rectum. I am. sure there is something wrong there, for just before and after my bowels move I feel a peculiar crawling sensation that starts just at the opening of the bowel and passes along the stride into the testicles. I notice, too, that these organs — the testicles — are sometimes drawn up tightly and at other times hang quite low, the left one actually dragging at times. I have frequent palpitations, as I told you, but perhaps I did not tell you that at such times there is a strange tickling and fluttering feeling at my heart which has a tendency to cause a sense of suffocation. I think that I have given you the most important symptoms that have occurred to me as being necessary to give you besides those I told you of yesterday, but, if you do not mind, I will bring a full written list of all of them the next time I come, which will assist you a great deal in the treatment of the case. Very truly yours. This patient did indeed present a complete list of his symptoms. It covered eight pages of foolscap. TrivATment. — General Considerations. — In considering the therapeutics of spermatorrhea a knowledge of the relations of the involuntary seminal discharges to various organic and functional dis- turbances of the sexual organs or nervous system — or both — is of paramount importance. A knowledge of the pathologic conditions underlying seminal losses is especially valuable in assigning to sper- matorrhea its proper role — that of a symptom. Understanding the symptomatic character of involuntary seminal losses, the physician — 186 — TREATMENT OF SPERMATORRHEA is not likely to overrate the importance of certain very common cases in which the involuntary discharges constitute but little, if any, de- parture from the strictly physiologic. If, however, he labors under the erroneous impression that the disease-entity consists merely in involuntary discharges of semen, he is likely to be unnecessarily alarmed, and, what is worse, he is likely to seriously alarm his patient. In true spermatorrhea it is to be remembered that, while the disease essentially is a neurosis — - according to the author's view — there often are associated with the neurosis pathologic conditions of the genito-urinary system that demand attention. These pathologic changes may have arisen coincidently wnth the neurosis — being produced by the same causes — - or they may either precede or follow the neurosis — being due to causes absolutely independent of those producing the latter. No matter what relation pathologic changes in the genito-urinary system may bear to spermatorrhea, no form of treatment is likely to be successful that does not aim not only at the correction of the essential neuropathic condition, but also at the removal of co-existing local derangements. Thus, while, in the author's opinion, deep-seated gonorrheal infection does not often cause true spermatorrhea, it may co-exist with, and constitute a very important and obstinate factor in the perpetuation of that disease. An intelligent therapy of spermatorrhea necessarily must compre- hend proper treatment for the conditions produced by the deep in- fection, w^hatever such conditions may be. The majority of cases of pseudospermatorrhea are due to condi- tions that essentially, if not absolutely, are physiologic. This has come to be generally accepted by reputable physicians. Unfortu- nately, however, it too often has been taken for granted that the patient is quite as well balanced mentally, or should be quite as well balanced mentally, and should be quite as well versed in the princi- ples of physiology, as his medical adviser. When a youth, perhaps barely past puberty, immature of mental development, and unstable of nervous system — to say nothing of the melancholy and hypo- chondriasis produced by ungratified sexual desire and brooding over an imaginary spermatorrhea — presents himself to the average repu- table practioner, he is either laughed at for his ignorance or informed that his case is not worthy of serious consideration. He rarely is convinced, however, that his case is deserving of ridicule, still less — 187 — IMPOTENCE AND STERILITY that his symptoms are "trifles Hght as air." On the contrary, he becomes convinced that his case is either more serious or offensive than his physician cares to undertake, or else that the derision aroused by his tale of woe is merely a subterfuge to conceal medical ignorance. Should he chance to consult with a lay friend, more experienced than himself, he is informed that, from esthetic motives, ordinary physicians object to treating, or even studying, such im- portant and serious cases as his own. The quack, that court of last resort for the ignorant and incurable, is suggested and finally appealed to. The author has no hesitancy in asserting that the reputable pro- fession itself is largely responsible for the opulence and indisputable power of the quack. Would it not be better to employ the same psychic instability that is utilized by the quack for the purpose of alarming the patient and preying upon his fears, in an honest en- deavor to correct his psychopathic state? Therapeutic suggestion, honestly — which means scientifically — used will relieve most cases of pseudospermatorrhea, both psychically and physically, and keep them out of the hands of the vultures that find in such patients their most lucrative victims. The patient should be given to understand primarily that, while his case demands attention, it is by no means so serious as he supposes and readily will yield to treatment. He should be instructed in sexual physiology, but not expected to become an adept in one lesson. Such organic or functional disturbances as may have a bearing upon his symptoms demand careful attention. Oftentimes regulation of the diet, attention to the bowels, and the passage of the cold sound a few times will lessen the frequency of emissions which the practitioner pronounces off-hand, physiologic. If, in the meantime, the patient's confidence has been gained and proper psychic control attained, the result is likely to be all that could be desired. There are very few spermatophobiacs who do not demand careful attention, for, no matter how trivial the sexual de- rangement per se, the patient's psychic state is such as to make his ailments terribly real to him. The author takes this opportunity of saying that in his opinion the neglect of the profession to do its full duty in such cases is responsible for much suffering — both mental and physical. It is, of course, understood that there are occasional cases in which a perfectly healthy subject consults the — 188 — TREATMENT OF SPERMATORRHEA physician regarding infrequent emissions the significance of which the patient does not understand and whom it is perfectly safe to dis- miss with a few words of instruction in sexual physiolog>'. It is to be remembered, however, that the practitioner is not often con- sulted until the patient has developed a psychopathic state that demands the most judicious management. Prophylaxis. •^- Subservience to the rules of sexual hygiene is preventive of both pseudospermatorrhea and real spermatorrhea, save in exceptional instances where the seminal losses are symptom- atic of, or secondary to, debilitating general diseases or lesions of the nervous system. Even in the case of locomotor ataxia, however, it is to be remarked that proper sexual habits may be prophylactic, for it is probable that sexual excesses bear a very important etiologic relation to that disease. The various features of genito-urinary and sexual hygiene have received special attention in the chapters upon impotence, sterility, and masturbation. The cure of local organic disturbances of the sexual organs obviously is prophylactic of spermatorrhea. Special Treatment. — In considering the treatment of pseudo- spermatorrhea it is well to remember that in the form characterized by more or less frequent involuntary emissions the frequency of their occurrence is not the sole criterion of their importance. The im- portant point is the degree of tolerance of the emissions. Just as some individuals may copulate very frequently without apparent harm, certain plethoric subjects may apparently tolerate involuntary emissions that would produce most disastrous results in feebler subjects. It is to be remarked, however, that frequent emissions in themselves are usually a sign of disturbed innervation both of the sexual organs and general nervous system, or of some local source of reflex irritation. Before deciding the question of the necessity of treatment, even in apparently slight cases, it is wise to ascertain the condition of the sexual organs. The emissions may be a symp- tom of local disturbance of a congestive or inflammatory character that later on may cause serious trouble, but which may be readily relieved by proper early attention. By far the most important measure of general treatment in the class of subjects seeking advice in pseudospermatorrhea is physical training. With careful development of the muscular system will — 189 — niPOTENCP: AND STERILITY come improvement in nervous tone, both general and local. Exercise should, so far as possible, be taken in the open air, although field- sports should be aided by proper gymnastic training to secure general and symmetric muscular development. Exercises involving pressure or strain upon the perineum should be avoided, as a rule. Climbing, bicycling, and horseback-riding are especially pernicious. The cold bath or cold shower — very cautiously used at first — constitutes an auxiliary measure of great value. The baths should not be pro- longed — stimulation, not sedation or refrigeration, is desired — and should be followed by brisk toweling, or rubbing, either with the hands of an attendant or by means of a flesh-brush wielded by the patient himself. The functions of the kidney and bowel, and especially of the stomach, demand attention in all cases of sexual disturbance. Constipation and excesses or indiscretions in eating and drinking are particularly to be avoided. Sexual rest — both psychic and physical — • is indispensable, save in certain cases where matrimony is advisable, either primarily, or after a suitable course of treatment. It is not, as a rule, difficult to elicit a history of the usual cause of spermatorrhea — masturbation — in most cases. The patient's frankness, however, often has a limit. He alludes to the habit of masturbation in the past tense, and forgets to inform the physician that he has not yet discontinued the practice. If the inquiry be pressed closely, he usually lies outright. It has been the author's experience, however, that a large proportion of such patients event- ually can be induced to betray themselves. A popular method of deceiving the physician is to inform him that masturbation is per- formed unconsciously during sleep. This is a possible, but un- questionably rare, occurrence. A very valuable method of diminishing the frequency of seminal emissions is sleeping upon a hard and uncomfortable bed. Patients occasionally discover this for themselves. Several patients of the author's have derived excellent results from sleeping upon the floor. A hard mattress is often efifective. Physical discomfort and erotism are somewhat incompatible, and the patient whose bones and muscles are aching from a vain efi^ort to find comfortable and luxurious re- pose is not very likely to be disturbed by lascivious dreams. A few weeks of this practice will often break up the emission-habit. Light — 190 — TREAT.MEXT OF SPERMATORRHEA and relatively cool covering is advantageous. In a general way, the tendency to nocturnal emissions is directly proportionate to the lux- uriousness and warmth of the bed. Certain mechanic appliances have been used to break up the eiuission-habit. The most effective of these is the so-called "sperma- torrhea-ring." Although originally a quack device, this appliance often is successful. It consists of a double ring adapted to the cir- cumference of the penis when flaccid. The inner or elastic ring holds the appliance /';/ silu after it has been slipped upon the penis, while the outer ring, which is provided with moderately sharp me- tallic serrations, inflicts punishment u|)on the member whenever it chances to become erect. The ring is to be applied at night and, as a rule, if an erection occvu's the patient is immediately awakened — before an emission can take place. In some cases erection and emis- sion occur despite the appliance. In true spermatorrhea such de- vices are ineffective. A very ingenious device is a similar appliance connected with a small battery placed beneath the patient's pillow. An erection completes the circuit and causes a small alarm bell to ring, awakening the patient and thus forestalling emission. Any plan that will serve to interrupt the emission-habit is likely to be successful. It has been noted that the dorsal decubitus favors emissions, theoretically because in this position there is a determina- tion of blood to the genito-spinal center — relative hyperemia — with consequent heightening of reflex sensibility. In many cases the patient rarely, if ever, has an emission while lying upon his side. Under such circumstances a towel tied about the body in such a manner that the knot rests in the middle of the back, often serves to awaken the jmtient or make him so vmcom- fortable that he instinctively and unconsciously avoids the dorsal decubitus. In some cases the patient has emissions only while lying upon one or the other side. Changing to the opposite side is often effectual under such circumstances. In cases in which the patient fosters emissions by handling the genitals during sleep, the author has advised the patient to wear a pair of ordinary boxing-gloves at night. This simple device renders manual manipulation of the genitalia quite difficult. In all forms of spermatorrhea complicated by chronic conges- tion or inflammation of the prostate or — as is frequently the case — by chronic inflammation of the vesicidae scuiinalcs, the most impor- — 191 — IMPOTENCE AND STERILITY tant measure of treatment is massage, performed by the finger of the surgeon via the rectum. Instruments have been devised for the per- formance of prostatic and vesicular massage, but digital massage is the only safe, intelligent and reliable method. Considerable ex- perience is, moreover, necessary to the proper performance of the massage. The surgeon with short stubby fingers often merely wastes his time in attempting to perform this manipulation, which is in itself sufficiently simple. Aphrodisiac remedies, like those of an opposite character, are used far too recklessly in the impotence accompanying sperma- torrhea. This is natural enough, considering (1) that the profes- sion in general overrates the potency of this class of remedies, and (2) the imperative demand of the patient to be relieved of the sexual incapacity that often exists in pseudospermatorrhea and al- most always in true spermatorrhea. In the author's opinion there is no class of remedies so fallacious as the aphrodisiacs. Erections produced to meet emergencies by large doses of aphrodisiac drugs are pathologic, and inevitably fol- lowed by a reactionary depression which makes the patient's sexual powers more unreliable than ever, to say nothing of the local irri- tation produced by the action of such drugs upon the genito-urinary mucosa. In moderate doses, however, with a clear understanding of their tonic rather than their aphrodisiac properties, there are a number of drugs that have a markedly beneficial eflfect in all forms of sexual debility, whether characterized by spermatorrhea or not. Of these drugs, phosphorus is the most reliable, where tolerated by the stomach. It is best given in the pure state in pill form, but the dilute phosphoric acid, the phosphid of zinc, and the hypophosphites are quite serviceable. Nux vomica or strychnia and its preparations come next in order, and may be advantageously combined with phosphorus. Ergot also is useful as tending to restore muscular and vascular tone to the genital apparatus. It also tends to the correction of nervous hyperactivity of all kinds, and is too seldom employed with this object in view. The most overrated remedy for diseases uf the sexual apparatus is damiana. That this drug has a tonic effect in spermatorrhea and sexual debility in general is true, but as an aphrodisiac it is an arrant fraud. In general, it is inferior to strychnia. The drug should be — 192 — TREAT-MENT OF SPERMATORRHEA given in liberal doses — 2 to 5 grains of its solid or 1 to 2 drams of the fluid extract three or four times daily. Cantharides is the most popular of all remedies of the aphro- disiac class. It has been the basis of "love-philters" from time im- memorial. Its true worth, however, can be summicd up in very few words. As an aphrodisiac it is not only unreliable, but such results as may be obtained by large doses are pathologic, and therefore dangerous. Given in rational doses as a tonic, it is serviceable to a moderate degree. It seemingly has a general tonic effect, and in addition a somewhat stimulating action upon the nerves of sexual sensibility and the genito-spinal center. A marked degree of sexual stimulation never is to be obtained save by dangerously large doses. Nor is the drug always reliable in producing in rational doses even a mild degree of stimulation of the sexual apparatus. It has been claimed — and it must be confessed wnth some reason — that can- tharide acts locally only by virtue of its directly irritant action upon the genito-urinary mucosa z'ia the urine. If this be true, any stimu- lating effect upon the genito-spinal center must be produced reflexly. The possibility of the drug's acting by virtue of an irritant effect upon the mucous surfaces of the genito-urinary tract should impose additional caution in its administration where inflammatory or con- gestive conditions of the sexual organs exist. A dose of more than 20 minims of the tincture rarely should be exceeded, although by increasing one minim daily, as suggested in the preceding chapter, this dose sometimes may be exceeded. When malformations of the sexual organs exist they should be corrected by surgical measures so far as possible. Phimosis and meatal stenosis demand attention with especial frequency. The various other conditions already enumerated under the head of predisposing causes should be sought for, and if found should re- ceive appropriate surgical treatment. Disturbances located in the rectum and anus quite frequently are overlooked. These conditions are important sources of exaggeration of the genital reflexes, and require most careful consideration. \^aricocele, if large, always demands operation. Even in the milder forms the patient's psychopathic state is such that an opera- tion often is not only justifiable, but positively indicated. Such conditions as prostatorrhea from prostatic hyperemia or follicular prostatitis have received attention elsewhere in this vol- — 193 — IMPOTENCE AND STERILITY ume. Seminal discharges during a difficult stool should be ex- plained to the patient, and his constipation relieved. In many such cases the prostate is the seat of hyperemia or inflammation de- manding especial attention. Hypersecretion during erection and the appearance of spermatozoids in the urine after sexual intercourse or excitement should be explained to the patient upon a physio- logic basis. Anaphrodisiac measures constitute the most popular routine treatment for spermatorrhea. In the author's opinion, however, remedies of this class are much abused. In cases of what may be termed the sthenic type, characterized by a greater or less degree of constitutional vigor associated with marked sexual irritability, anaphrodisiac measures are a distinct advantage. The bromids in free doses, gelsemium, camphor and lupulin are types of this class of remedies. In many cases remedies directed to the alleviation of irritation of the mucous membrane are distinctly anaphrodisiac. Alkalies — the salts of lithia especially, if the subject be gouty, — and such remedies as pichi, buchu, ustilago maidis, triticum repens, and the balsams are of service under such circumstances. In a large proportion of cases of pseudospermatorrhea, and in a majority of, if not all, cases of true spermatorrhea, a tonic rather than a sedative line of therapy is demanded. The use of remedies of the aphrodisiac class as tonics already has been dwelt upon. Proper exercise and bathing for improving nervous tone have also received attention. Quinin, arsenic, manganese, and iron — the latter two especially if anemia exists — often are of distinct service. The fluid extract of salix nigra has seemed serviceable as a sexual tonic. It is well to remember that in the class of affections under con- sideration tonics should generally be combined with suitable mild laxatives. Constipation is nowhere more pernicious in its effects than in diseases involving the sexual function. One of the best ferruginous preparations is ferratin in tablet form. Pyrophosphate of iron, perhaps, is best of all. One of the most valuable tonics at our command is static electricity. The general tonic effect of the static current is not so generally appreciated by the profession as it deserves. That the moral effect of the spark is valuable in pseudo- si)(jrmatorrhea is obvious. The high frequency current is very useful. — 194 — TR7{,\TMI'.XT OF SPER^fATORRHKA A simple yet of ten effective tonic treatment is the free ingestion of raw eggs. The popular notion of the efficacy of eggs as an aphro- disiac is, of course, a fallacy, yet their effects as a tonic must be admitted and, moreover, they seem to have a special tonic effect upon the sexual apparatus. In several cases of very frequent noc- turnal emissions in sickly, delicate lads, the author has obtained ex- cellent results from the free use of raw eggs. \\'hether the beneficial ettcct of egg is to a certain extent due to the small amount of con- tained phosphorus is open to question ; its efficacy may well be attrib- uted simj:»ly to its highly nutritive properties. I*sychotherapy has a wide and im])ortant field of usefulness in the various forms of spermatorrhea. Suggestion necessarily enters into all methods of treatment to a certain degree. Cases occur, however, in which positive efforts in this special direction are war- rantable. The services of the specialist in })sychotherapy — or sug- gestion-therapy — sometimes may be enlisted to good advantage. Vibratory massage of the spine and genitalia sometimes appears to be of service in disorders of the sexual function. It acts both psychically and as a circulatory stimulant. The treatment of spermatorrhea secondary to organic cerebro- spinal disease necessarily resolves itself into the treatment of the primary nervous disorder. In many cases, however, appropriate local treatment is of distinct service in diminishing what is obviously not only a serious drain upon the patient's vitality, but also a source of most profound psychic depression. Cold sitz-baths and the prolonged local application of cold water to the genitalia — especially the testes — are of great value as a sexual sedative primarily, and more remotely in improving the tone of the sexual organs. Galvanism applied to the external surface of the genitals or, in selected cases, directly to the prostate via the rectal or deep urethral electrode, often is very serviceable. The faradic current, however, often acts better when the condition is largely psychopathic, because of the moral effect of the sound of the rheo- tome. Cold-water enemata often are of service, especially where congestive or inflammatory conditions of the seminal vesicles exist. The psychrophor of Winternitz — which consists essentially of a double-current metallic catheter — is a valuable adjunct to the treat- ment of cases characterized by urethro-prostatic hyperesthesia. The psychrophor is introduced into the bladder and a current of cold — 195 — IMPOTENCE AND STERILITY water — ice-water if necessary — made to pass through it for some minutes — the time varying with the degree of tolerance. This is to be repeated daily or every second day. In general, the urethral sound is the most useful instrument for the local treatment of all forms of spermatorrhea. If introduced cold and allowed to remain in the urethra for from five to ten min- utes it combines the effects of mild refrigeration with the blunting of nervous sensibility by its mechanic action. There is also an im- provement in the circulation of the prostate produced by the pres- sure of the instrument and the reactionary hyperemia incidental to its withdrawal. The milder forms of pseudospermatorrhea usually yield readily to the occasional use of the sound. In some cases the sound is painful, though the psychrophor is well tolerated. Sound- ing usually should be performed twice or thrice weekly. Direct medication of the prostatic urethra — and incidentally of the mouths of the ejaculatory ducts — is a very popular method of treatment of spermatorrhea. When judiciously and aseptically ap- plied, various astringents act well in these cases. The most useful astringents are silver nitrate, copper sulphate, tannin, thallin, pro- targol and ichthyol. These may be used in the form of suppository, ointment or solution. The most useful astringent is silver-nitrate solution in a strength of 2^ to 30 grains to the ounce. In the author's experience a relatively mild solution in considerable quan- tity is usually best. Where strong solutions are used, only a few drops should be injected. If the instillations are followed by prosta- tic massage, their beneficial effects are enhanced. Applications of strong solutions of silver nitrate to the colliculus sometimes give wonderful results. Vasostomy and the injection of silver salts into the seminal vesicles is sometimes of great service in spermatorrhea. The introduction of animal extracts into medicine was seized upon with avidity as a possible solution of all problems in the therapy of diseases involving the sexual function. The experiments of Brown-Sequard were used as a justification of all sorts of quackery, "regular" and otherwise. The "fake" solutions of spermin and its congeners, fathered by a noted neurologic specialist of this country, will be remembered in this connection. In view of the nitroglycerin upon w^iich such action as these preparations possessed depended, it is not surprising that their false pretensions were exposed. Legiti- mate solutions of spermin have been indorsed as of limited value. — 196 — TREATMENT OF SPERMATORRHEA The dessicated substance of the sex glands — testicle and ovary — of late have been very popular in the treatment of disorders of the sexual system, notably impotence in the male. The author's ex- perience with these preparations has not harmonized with that re- ported by a number of other surgeons who have extolled their action. The usefulness of the orchic preparation appears to be limited. Indeed, so far as the author is able to judge, its action in impotence is not noticeable unless the patient knows what he is tak- ing. The knowledge that he is taking testicle substance sometimes appeals very strongly to the patient's imagination. Its action in this regard is like that of the lamb's fries and Spanish fries diet of the man about town, who implicitly believes in their efficacy as a sexual stimulant. Inasmuch, however, as there is a more or less marked psychic element in all cases of impotence, the preparation under consideration has a prominent place in the therapy of that disease. Corpus luteiim substance, on the other hand, apparently is use- ful per se in the treatment of certain conditions in the female, and apparently is a much more potent preparation than any thus far made from the testicle substance. Pituitary substance and adrenal cortex substance both have been suggested for impotence. The author has employed these preparations in a limited number of cases, but, thus far, has had no reason to be enthusiastic about them. More reliable preparations of organic products eventually may greatly increase their usefulness. Fresh, vital hormone-carrying se- cretion can be successfully employed only through the author's method of sex gland implantation, which will be discussed in the next chapter. The author has experimented extensively with emulsions of various human organs, notably of the brain, testicle, spleen, pan- creas, liver and kidney, has shown that their use is practicable, and is encouraged to believe that future observations may show that they arc of distinct value in various conditions. Emulsions of the brain and testicle may prove of special value in certain conditions, such as sexual neurasthenia and impotence."' One of the most popular methods of treatment of spermator- *Vlde author's paper, "Experiments with Emulsions of Organs from the Dead Human Body, and Sex-glands of the Lower Animals." — American Medi- cine. 1914. — 197 — IMPOTENCE AND STERILITY rhea among surgeons of a past generation was cauterization of the prostatic urethra with pure silver nitrate via the porte-caustique of Lallemand, an instrument which the great Ricord said was "re- sponsible for more eunuchs than all the harems of the East." Cau- terization of the prostatic urethra is occasionally justifiable, but only in the hands of the expert, and never by any method other than z'ici the endoscope under illumination and ocular control. The caustic application should generally be limited to the colliculus seininalis, being- made with a view of lessening hyperesthesia and curing chronic inflammation of that structure. As formerly used, complete oblitera- tion of the mouths of the ejaculatory and prostatic ducts was a fre- quent result of the method. Sterility is a necessary consequence of such rough treatment. It is noteworthy that, while he carried his theory and practice to extremes, Lallemand builded wiser than he knew, as is shown by the stress laid by the modern urologist upon morbid conditions of the colliculus in the consideration of the pathology and treatment of sexual ailments. Marriage often is advised in spermatorrhea and its congeners. This "prescription" involves very serious responsibility. In some cases of pseudospermatorrhea the physician may safely advise mat- rimony, but he should use great care in determiining the patient's potency. Even psychic impotence may be a bar to marriage. In true spermatorrhea marriage never is justifiable. The author has commented elsewhere on the heinous practice of prescribing healthy and presumably innocent women in the treatment of masculine de- generates who cannot be other than wrecks of humanity. Often- times the game is not worth the candle, even though an apparent success be obtained. There is rarely an instance in which the woman ])rescribed does not get the worst of it. Such offerings upon the altar of Hymen — to say nothing of the still broader question of in- fection — are responsible for quite a proportion of the sum-total of human misery, lioth physic and j^sychic. Both the profession and the public may one day awake to a sense of their duties in this mat- ter, and the time may come when proposals of marriage, or, at least, n])plications for a licen'^e to marry, will be miorthodox unless accom- panied by a clean bill of health from a reputable physician. Half the misery of the human race comes from a lack of supervision at the marriage-license window. ^Tarriage is too easy, divorce too diffi- — 198 — TRKAT-MKXT OF SPERMATORRHEA cult, for the physical and moral welfare of mankind. Marriage should at least be as difficult to enter as it is to esca]De from. There are certain cases of spermatorrhea, pseudospermator- rhea, prostatorrhea and nocturnal pollutions in which the resulting physical, moral and psychic degeneracy demands the most radical measures. The author herewith records the opinion that in such cases vasectomy is justifiable. We have performed it in many in- stances, with the best results, and shall continue to perform it with perfect confidence in its harmony with the highest altruism in the relief of hvmian stiiTering. The technique of the operation of va- sectomy already has been discussed. The author would suggest that, before performing it, its results, so far as sterility is concerned, should be explained by the surgeon in the presence of witnesses. — 199 CHAPTER X. Sexual Neurasthenia. Sexual neurasthenia requires special consideration, even at the cost of repetition of much that already has been said. It implies ordinary neurasthenia with a sexual element, either psychic or phys- ical in character. Organic sexual disturbances hardly can exist with- out a strong incidental psychic element. A purely psychic sexual element in sexual neurasthenia is rare. There almost always is some functional derangement of the sexual apparatus, behind which lies a varying degree of organic disorder. The author's experience leads him to the conclusion that neu- rasthenia in the male is associated with prostatic hyperemia and hy- peresthesia, and with inflammation of the prostatic urethra, more often than with any other condition. Considering the abundant sensory and sympathetic nerve sup- ply of the prostate and its intimate relation to the sympathetic sys- tem in general, the frequency with which nervous symptoms develop in patients suffering from prostatic disease is not remarkable. Add to the purely organic factors the profound psychic impression made upon the patient by the knowledge of sexual disability, and we have a very satisfactory explanation of the frequency of "sexual neuras- thenia." It is the author's belief that the prostate secretes a hormone the perversion of which, conjoined with the absorption of infection toxins, often has much to do with the etiology of sexual neuras- thenia. Disturbed digestion, irregular bowel action, headache, depres- sion, lassitude, melancholy and brooding, hypochondriasis and intro- spection, unstable emotions and "hysteria" — for there is a condition in the male analogous to hysteria which we logically might call — 200 — SEXUAL NEURASTHENIA "prostateria" — are among the results of a sensitive, congested pros- tate and deep urethra.* It is the custom of the reputable profession to regard the sexual neurasthenics who are the prey of the quacks, as sufiEerers from purely imaginative ailments. As practically all of these subjects have been masturbators, many of them have indulged in sexual excesses, and not a few have had gonorrhea, the verdict of the profession is not sound as regards the quack's victim, however just it may be as to the quack himself. Reputable medical men are wont to wave the sexual neuras- thenic away with a bluff and hearty, "My good friend, forget it. There is nothing the matter with you." The patient seeks for some one who will sympathize with him, and goes to the quack. The quack doesn't diagnose the real condition, but, to the patient's cost, he does find a lot of things that do not exist, and all because the reputable physician flouted as imaginary, conditions which, to the patient's sensitive and morbid mood, always are terribly real. The layman who feels, however mistakenly, that the regular profession is both ignorant and unsympathetic, is fine material for the charlatan. It hardly is possible for one to indulge in either masturbation or sexual excess for any great length of time without producing dis- turbance of prostatic circulation and innervation. The physician is likely to advise such patients to stop their evil habits, but he ignores the sensitive prostate and hyperesthetic veru ynontaninn, which con- tinually are sending sexual stimuli to the psycho-sexual centers, where they are at once transformed into erotic ideas. These erotic pictures of the imagination reverse the nerve current, so to speak, and increase the prostatic irritation. The patient's sexual emotions are used as a shuttlecock by the seat of sexual sensibility in the prostate on the one hand, and the psycho-sexual centers on the other. More important still is the attendant sex-hormone perversion with its disastrous effects upon all the organic functions and upon cell metabolism. The result essentially is a toxemia, the effects of which, especially upon the nervous system, are most profound. Advising the patient to "keep his mind off the sexual organs," is a pseudo-Christian science prescription which usually works satis- factorily only when conjoined with the instillation of a little nitrate • The author dealt In extenso with the subject of Sexual Neurasthenia and the Prostate in the X. Y. Medical Record, Feb. 3, 1912. — 201 — lAirOTENCE AND STERILITY of silver solution into the prostatic urethra, supplemented by pros- tatic massage and the cold sound. Practically every masturbator who has practiced the habit for any length of time may be considered a neurasthenic with a more or less tender and swollen prostate. Experience shows that this condition underlies many of the cases of nocturnal emissions with which we meet. The analogy between the prostate and seminal vesicles and the uterus and tubes is nowhere better shown than by pathologic condi- tions of these organs. The infected subinvoluted uterus and tubes, with the surrounding pelvic infiltration, producing pressure symp- toms and neurasthenia, have their counterpart in the enlarged in- fected prostate, infected seminal vesicles, and periprostatic infiltra- tion, producing the same local disturbances and general nervous symptoms. The two conditions are alike also in the matter of the stubbornness and lasting quality of the infection. The management of sexual neurasthenia, while largely directed to the relief of local conditions, requires even more care and judg- ment than that of cases of neurasthenia in which there is no sexual element. Regulation of sleep, diet and work always is in order. Hydrotherapy, tonics, general massage, and static electricity, or the high frequency current, all have their uses, in conjunction with pros- tatic massage, instillation of silver and, in infected cases, irrigations. Urethral dilations and endoscopic applications of silver should sup- plement the other local treatment. We occasionally meet with cases in which, while the local con- ditions improve and the neurasthenia is more or less benefited, the patient remains unfit for the active duties of life and becomes a con- firmed hypochondriac. For cases such as these, complete change of scene and climate is required. A sea voyage sometimes accomplishes wonders. In a series of cases of the author's in which a sea voyage was practicable, the results were all that could be desired. In one case the patient's will was so unstable that it was necessary to keep someone with him constantly until the steamer started, lest he should fail in his determination to take the voyage. He was so emotional that, when his frequent fits of self-pity came over him, he would cry like a child. This meant much in a man like him, for he was an ex- soldier of tried mettle and courage. He first went to the Philippines, then to Japan. He returned perfectly well in five or six months and, — 202 — SEXUAL NEURASTHENIA as he expressed it, "snapping his fingers at the doctors." This case is typic of a number in the author's experience. vSexual neurasthenia associated with real or imaginary sper- matorrhea, obstinate jjrostatorrhea, or seminal emissions occurring frequently and resistant to treatment, sometimes is very difficult of management. In such cases benefit sometimes is obtained from tem- porary resection of the z'asa defcrentia. Aside from the moral ef- fect — which is profound — the relative rest secured for the sexual apparatus, and the lessened activity of the circulation of the prostate are extremely beneficial. As the attthor has shown in this work and elsewhere (Journal .V. M. A., July 21, 1906), and has demonstrated in liis own practice, subsequent anastomosis is perfectly practicable, b}- his method of "cotipling" the vas. Cases of sexual neurasthenia — with or without prostatic de- rangement — associated with impotence are the most trying of all. If unrelieved, these cases go from one doctor to another, and finally land in the arms of the quacks. ]\Iany of them are purely psychic at the beginning, but a few recurrences of their inability to copulate puts a large proportion of them into the permanent class. In such cases the nomenclature "psychic" is not at all comforting to the patient, which is not astonishing, inasmuch as potency really con- sists of ability to secure and sustain an erection. Our nomenclature has driven a host of patients to the quacks. The cause of impotence may be psychic, but the lack of erectile power per se is a purely me- chanic and obvious proposition. In many cases of impotence the failure of erectile power ob- viously is not due to general or local organic conditions. Once the accident of failure of erection has occurred, however, the patient's memory of the first time is sufficient to cause another and another, until failure is the rule of his sexual life. Even the removal of determinable organic etiologic conditions is likely to fail to cure sexual neurasthenia, once the habit of sexual failure has been es- tablished. Morbid prostatic conditions, involving especially the floor of the [jrostatic urethra, often underlie neurasthenia. In such cases pros- tatic massage, silver instillations, or endoscopic applications of silver to the colliciilns seiuhialis, often do excellent work. Xot infrequently all measures of treatment fail completely. If imjiotencc exists and th.e sexual disability is unrelieved, cure of the — 203 — IMPOTENCE AND STERILITY neurasthenia is impossible, hence any measure that holds out even a faint hope of relief should be adopted. As already noted, it has been the author's experience that a very respectable proportion of cases of sexual neurasthenia associated with impotence are rem- ediable by resection of the vena dorsalis penis. As to how far the psychic effect of the operation explains its benefits one need not argue in the face of mechanic effects, which constitute the only means of physically impressing the patient. If the patient notices an increase in the functional activity of the penis, he certainly is justified in having some psychic impressions from the operation, and, as these impressions run counter to those which have been a prominent feature of his sexual disability, the operation would seem logical enough. Even a small proportion of cures would justify the operation, and as the proportion really is encouraging, the procedure should be generally employed in suitable cases. In otherwise irremediable cases of sexual neurasthenia the author believes that treatment with sex-hormone via gland implanta- tion is a rational indication, where the method is practicable. The relation of the sex-hormone to sexual aberrations of the organs and functions, and to neurasthenia, already has been touched upon. The subject of gland implantation will be fully presented in the next chapter. 204 — CHAPTER XI. Sex Gland Implantation. Successful Auto-implantation of a Testis from a Subject Dead Twenty-four Hours — Other Successful Implanta- tions OF Testes and Ovaries from Dead Subjects — Ex- perimental Implantations in Various Conditions, and Cross Implantations of Testes and Ovaries Taken from Dead Subjects. Since long before the days of the oophorectomy craze — the darkest blot upon the history of the surgery of the last quarter of the nineteenth century — the attention of the profession has been more or less insistently directed to the possible relation of various de- rangements of the sex glands to certain morbid phenomena of a general or special character, notably affecting the nervous system. The interest aroused finally led to the widespread adoption of the Battey operation, which once was so disastrously fashionable as a remedy for "neuroses" in women. The period at which the author himself first began to suspect that in many cases we were on the wrong track, is fairly well fixed in his mind by two personal cases that occurred during the then prevalent epidemic of ovarian mutilation into which the masters of surgery had led us. These cases were respectively one that now probably would be termed dementia prascox, in a girl of twenty years, and another of "hystero-epilepsy" in a girl of eighteen. In the former the author set about removal of the ovaries to relieve the "reflex irritation" which, according to the then fallacious popu- lar theory, presumptively underlay the nerve and brain symptoms, and was astonished to find "atrophied" — or more probably, un- developed — ovaries and uterus. In the other case, operation was refused and, several years later, the author had the opportunity of making an autopsy, the young woman having died peacefully without — 205 — IMPOTENCE AND STERILITY surgical interference. "Atrophied" — undeveloped — ovaries and an undersized uterus again were found. Both subjects had menstru- ated, although tardily and irregularly from the beginning, but finally menstruation had entirely ceased. Even at that early period of the author's professional career, these cases suggested to his mind the possibility that an aberration of function of the ovary, rather than reflex irritation from diseased ovarian structure, bore an etiologic relation to some of the manifold nervous phenomena in women, for which bushels of ovaries were being sacrificed. In the light of recent researches in the field of internal secretions, it would seem that possibly the profession builded wiser than it knew in attributing to ovarian disease a host of nervous disorders in women. It was a great misfortune that we then had no knowledge of the internal secretions, and no blood researches to show us that the trouble often lay, so to speak, not in too much ovary, but in what was, in efi^ect, too little, the internal sex gland secretion being either insufficient in quantity or perverted in quality, from disease or congenital structural defect. It is remarkable that the nervous and other phenomena follow- ing castration in females who previously were normal in respect to the nervous system, did not make matters clearer to the profession, but possibly our attention was distracted and our reasoning powers were inhibited by the grave discussions with which we were regaled on the wisdom of "leaving the ovarian nerves intact" when we removed the ovaries. Even this point in technic was regarded as important chiefly because of the consideration of the influence of the ovarian tissue and the ovarian nerve upon menstruation, this function being regarded as the main factor in the preservation of a normal nervous system after extensive pelvic mutilations. Since the inception of the pelvic mutilation fad, the profession has had the opportunity of observing the nervous efifects of the Ramm-White operation of castration for enlarged prostate — now reposing so peacefully in the surgical dead lumber room by the side of the long defunct epidemic oi'jphorcctom\' mania, the ghost of which, unhappily, still perverts the minds of a few of the surgically obscure anrl, what is worse, inspires the malpractice of certain commercially depraved members of the j^irofession. ~- 206 -- SEX CLAXD IMPLANTATION It is noteworthy that Brown-Sequard's self experimentation with the extract of the testes of lambs really signified more than either he himself or the profession comprehended. Had we grasped the great principle involved, the much ridiculed "elixir of life" prob- ably would have been more of an epoch maker than a joke. Be- lieving that a most important principle was involved in Brown- Sequard's self experimentation, the author for many years has been especially interested in the problem of the normal equilibrium be- tween sexual activity and age, and that between general bodily vigor and sex gland structural and functional integrity. The most fascinating, although, perhaps, the least practical j)hase of the prob- lem, has been the ([uestion of the interrelation of senility and sex gland activity. The association of remarkable sex vigor with notable longevity is a matter of common observation, even among laymen, btit which is the propter and which the post? Do we age because the sex glands deteriorate or do they deteriorate because we age? As shown by his report of his experiments upon himself with the juices of sex glands of the lower animals, Brown-Sequard evidently had certain ideas of his own upon the subject. Is there merely a normal, very delicate equilibrium between age and sex gland activity, the mainte- nance of which determines whether or not the individual wnll live and preserve the vital functions, notably the sex powers, in active condition to the normal extreme age average ? Finally, while assum- ing as skeptical an attitude as we i)lease toward the possibility of the discovery of the "elixir of life," may we not — granting the accept- ance of the "ecpiilibrium" theory just suggested — logically search for a method of restoring or preserving that eqtiilibrium, thus pro- longing life to its rare, normal conclusion of extreme old age? 2^Iay we not even hope to go beyond the limit of what we now regard as "extreme"? Obviotisly, the collateral problems suggested are very numerous. At first sight the logical answer seems to be that sex gland activity is entirely dependent upon age and general nutrition, becom- ing impaired pari passu with advancing age, to be finally extin- guished by the degenerescence of senility. In the light of our present knowledge of the internal secretions, however, are we not justified in suspecting that rejuvenation of the supply of internal sex gland secretion may have a marked effect in retarding age, the disttirbance — 207 — IMPOTENCE AND STERILITY of equilibrium being in favor of the individual supplied with the gland elements necessary to the formation of young internal secre- tion ? Admitting the cogency of this theory, who could foretell how far longevity might be prolonged by successive supplies of young internal secretion? We, of course, must admit that anatomic and physiologic machinery is predestined to wear out, and whatever one may think of the future prospects of spiritual man, we must recog- nize his mortal limitations. Following the widely heralded alleged discovery of the "elixir of life" by Brown-Sequard, came a host of imitators. These were of two classes : First, ethical workers in therapeutic fields ; second, quacks who pretended to employ animal extracts. Among the latter was a distinguished American neurologist, since dead, who prosti- tuted to commercialism a once enviable reputation. His testine and cerebrine will be recalled by many of the older members of the pro- fession. Samples submitted to the author direct by the neurologist aforesaid proved to be merely solutions of glonoin. Since the publication of Brown-Sequard's experiments, and more particularly since the discovery of the internal secretions, the profession has been deluged with animal extracts of many kinds, manifold pretensions, and varying degrees of harmfulness and therapeutic efficiency. Naturally, much attention has been paid to sex gland extracts. These we will give scant courtesy. In the author's opinion, most of them, up to date, have been wrong in principle, toxic in action and, aside from their psychic effects, absolutely valueless, save as sordidly commercial propositions. Recently, however, some really scientific preparations have appeared and in some instances apparently have given brilliant results. One of the unfortunate features of organotherapy is the toxicity of animal extracts in general ; this with due deference to the brilliant results achieved by some of them. It is logical to assume, also, that the therapeutic potency of the best of them is not to be com- pared to that of the hormones produced in vivo and normally dis- charged into the circulation. Some of the various extracts of in- ternal secretory glands probably bear the same relation to the internal secretions that old-fashioned beef tea does to wholesome beef. The nutritive properties of the beef do not appear in the beef tea, but the toxic elements do. As to whether emulsions of fresh — 208 — SEX GLAND IMPLANTATION material will prove more satisfactory than "extracts" have done remains to be shown. The author is optimistic in this regard. Since the attention of the profession has been so pertinently directed to the internal secretions, the author has given considerable thought to the probable relation of sex gland secretory aberrations, first, to nutrition in general ; second, to brain and nerve integrity ; third, to sex power and activity ; fourth, to senile pathology and physiology. The impression that the well being of all animals hinged upon the integrity of the sex organs, and especially of the testis and ovary, prevailed in very ancient times. The mechanism by which the sexual apparatus operates was enveloped in mystery until we began to comprehend that the procreative function of the sex glands was not their only biologic mission. The phenomena which for centuries were known to take place after suppression of the secretion of the sexual glands by castration, and by the physiologic change incidental to the climacteric, were formerly supposed to be due to "reflex nervous action." It was noted that the sexes were much alike in this respect, and it has long been suspected that the male has a climacteric, analogous to that of the opposite sex, which occurs later in life than in the female, and is attended by varying peculiari- ties of nerve action. As this is likely to occur in the male long before fertility ceases — if, indeed, we accept such a climacteric at all, as the author is inclined to do — the only rational explanation in the light of modern research seems to be a diminution or change, or both, in the internal secretion of the sexual glands, with, of course, due appreciation of arterial changes, which themselves may be merely secondary. Still more logically will this theory explain the nervous phenomena of the menopause. In the latter part of the eighteenth century, Bordieu asserted that the nervous and other morbid phenomena which fol- lowed removal of the sex organs, and in diseased conditions affect- ing them, were due to either a deficiency or superfluity of the pro- creative glandular secretions. Bordieu, however, had no conception of internal secretions. Johannes Aliiller recognized certain "ductless" glands. He even designated the placenta as a ductless gland. These glands, he believed, modified the blood which circu- lated through them, and thereby gave what he called a "plastic influence" to the generative circulation. — 209 — niPOTENCE AND STERILITY The testicle long has been known to have a double function, but until recently none knew that both functions were secretory. That it acts as a duct gland has been accepted as long as its physiology has been known. In 1849, Berthold, of Gottingen, transplanted the testes of cocks to their abdominal cavities and showed that the masculine sex qualities were preserved, through, he averred, an effect upon the blood. Thus, without precise scientific knowledge, and with no accuracy of nomenclature, Berthold first proved the exist- ence and significance of what we now recognize as an internal secre- tion. Many years later, Forel asserted that "the implantation of a sex gland in any part of the body is sufficient to arrest the pro- duction of the special peculiarities of the eunuch," and he might nervous phenomena of the menopause. Since Berthold's day, and especially of recent years, consider- able experimental work has been done in sex gland implantation, some of which had in view merely transplantation per se and some the matter of internal secretion in mind. A number of the contribu- tions are worthy of special mention. Herlitzka, in 1899, re- ported successful experimental transplantations of testes of frogs into the peritoneal cavity of the same individual. Later, Meyns successfully transplanted portions of frog's testes into the dorsal lymph vessels. Hammond and Sutton reported a case of testicle transplantation. A testicle was removed from a subject who had just died of traumatic hemorrhage, due to a rupture of the liver, and placed in sterile salt solution in cold storage. A sarcomatous testicle was removed from a patient, twenty-nine and a half hours later, and the testis from the dead body systematically anastomosed upon the cord stump. Healing was perfect. One month later, only a small nodule remained on the end of the cord. Some time later this was observed to have enlarged a little, whether or not from return of the sarcoma has not yet appeared. The object of the trans- plantation was a purely psychic effect, and no observations regarding sex hormone therapy were made. This case obviously was a severe test of implantation on account of the possible, or even probable, malignant involvement of the cord and the anastomosis. Foa, after extensive experiments on animals, concluded that testicle grafts fail, merely because of the impracticability of reestablishing, by any technic then known, blood and nerve supply. — 2in — SEX GLAND IMPLANTATION Guthrie, however, found that a testicle removed from a fowl and planted in the shoulder of the same bird, was growing, had considerably enlarged, and had acquired a liberal blood supply after four months. He also concludes from his experiments that "ovarian tissue" from fowls engrafted into fowls may develop and preserve its functional powers to a high degree." Cevolotto found that, after forty-five days, small pieces of testicle tissue implanted under the skin of rabbits showed changes which proved that the highly dilTerentiated cells of such tissues tend to retrograde to ordinary connective tissue cells. He notes an increase of Sertoli cells as an evidence of degenerescence of the gland tissue proper. In this far, Cevolotto is pessimistic regarding the success of sex gland trans- plantation. Lode, follov/ing Berthold, believed he had proved by experi- ment that testes of fowls transplanted beneath the skin retain their vitality and functional activity, continuing to secrete semen. He also concludes that, in fowls at least, a special secretory nerve supply for the testes does not exist. Foges, from his experi- ments on fowls, concluded that, while the semen producing power of transplanted testes was preserved, their influence on the secondary sex characteristics was not. This latter observation does not accord with the results of certain recent experiments on fowls by the author, although, as to the end results, it is too early to arrive at definite conclusions. In human beings the author has proved the reverse to be true. The gross results of caponizing fowls are familiar, even to the laity. In a series of recent experiments on fowls, the author made some interesting observations of the effects of glands from non- related birds, implanted in the capon. The nutritive stimulant effect was remarkable. Ribbert holds that he has shown by animal experimenta- tion tlie feasibility of transplantation of various living tissues, the terminal results not being vmiform for different tissues, and resorp- tion finally taking place in all tissues save the epithelial structures of the skin and conjunctiva. Guthrie reports an experiment in which removal of the ovaries resulted in the developnient of secondary male character- istics, the subject when grown being spurred, plumaged like the male, ])Ugnacious to cocks, and treading hens as would a cock. The author — 211 — IMPOTENCE AND STERILITY has observed a number of supposedly normal hens — never experi- mented upon — which were spurred, given to crowing, pugnacious to strange cocks, and who would assume charge of the flock of hens and tread them systematically, as soon as the cock was removed from the run. Despite their "inversion" symptoms, these hens were good layers and their progeny was normal. Such hens are familiar to most breeders of domestic fowl.* Claude Bernard, in 1855, called attention to the glycosuric function of the liver as dependent on a special internal secretory action under control of the nervous system. Brown- Sequard, in 1869, first expressed the idea that all glands, whether with or with- out ducts, supplied to the blood a substance a deficiency of which produced pathologic disturbances. It was not, however, till the publication of his celebrated experiments on himself that attention was given to the question of internal secretions. In 1889, at the age of seventy-two years, he injected himself with testicular extract from the lower animals. According to his reports, he experienced a marked improvement in mental activity, physical strength, and bowel action, and an increased appetite. Poehl states that "injections of spermine have been given to enfeebled old men who had lost appetite and sleep, and produced improvement lasting for months. From the instances given, I have selected that of an old lady of ninety-five years, afflicted with severe sclerosis of the arteries, with no appetite, a bad digestion, and consti- pation. This patient had complained for several years of sacral pains, and, moreover, was nearly quite deaf and suffered from * Apropos of plumage as a criterion of secondary sex characteristics in fowls, thie author takes the opportunity of observing that it is not so impor- tant as might be supposed. The hencock, or "hennie," is familiar to all game fowl fanciers. The plumage of the male practically is the same as that of the female. These fowls are vicious fighters, some strains are heavy weights, and all are excellent layers and breeders. The hencock often crops out either as a sport or a throwback (atavism). An observation of my own may be of interest. For ten years the author had bred a certain strain of brilliant colored, rich plumaged, black red game bantams. The originator of the strain had bred them for twenty-five years. Neither of us ever had made an out- cross, but carefully preserved the type by inbreeding and lino breeding. De- siring to increase the vigor of the stock by a change of environment, the author placed some of these bantams — a full brother and several sisters — in the hands of a very careful country breeder. In the second year thereafter, four fine specimens of hencock appeared in the progeny. These the author succeeded in perpetuating fairly well by careful selection — a difficult task because the female hennie could not be distinguished from her "regulation" .'sisters. 212 SEX GLAND IMPLANTATION periodical attacks of malarial fever. The injections of spermine, given for a period of fifteen months, restored the old lady to such an extent that she recovered her power of hearing and felt the sacral pains only slightly and after a long walk. Her general condi- tion was highly satisfactory." Brown-Sequard's self experimentation is generally recognized as the pioneer work in organotherapy. The suggestion of the old humoral pathology, fathered by Bichat, and of the once derided alleged vagaries of Hahnemann, which lingers about the physiology and pathology of the internal secretions and vaccinoserotherapy, is striking, and should appeal to the modesty of modern science. It shows how close the great thinkers of past generations came to the solution of problems which a better knowledge of chemistry, biolog>', and bacteriology would have made clear. Bayliss and Starling proposed the name hormone, meaning to awake or excite, for the substances contained in those internal secretions that affect the functions of other organs. It appears that continuous doses of some hormones are necessary to maintain physiologic activity at par. Presumptive evidence of this is shown by the physiologic hypertrophy of the remaining gland when one of a pair is removed or destroyed. In the case of duct glands, this, of course, bears upon the ordinary secretory function, as well as upon that of internal secretion. That the internal secretions are therapeutically powerful is shown by the brilliant results obtained from the administration of thyroid extract and implanted thyroid fragments in cretinism and allied conditions due to pathologic disturbances or removal of the thyroid, and by the more recent observations on pituitrin and other extracts. That the preservation of a very small portion of thyroid tissue in thyroidectomy will prevent serious after-results has been abundantly proved. This latter observation is also true, although perhaps in less measure, of the ovary and testis. Paschoud also has published some remarkable results from thyroid grafting. That even the smallest possible fragment of even approximately normal ovary should be preserved in pelvic operations, ought to be regarded as axiomatic. That the same conservatism should be ex- hibited toward the male has not yet dawned upon the majority of surgeons. When a testis is condemned to removal in testicular tuberculosis, and it is possible to save a small fragment of gland — 213 — TMPOTKNCE AND STKKILITY substance, this should l)e done. Rarely, however, when the testis is extensively involved and there is suppuration, is it wise to leave fragments of the organ in the scrotal sac on account of the almost inevitable secondary tissue infection. If, however, the fragment be implanted in another and easily accessible situation, suppuration may be avoided and the gland tissue is likely to be preserved. If tuber- cular infection should occur, it is easily accessible to treatment.* According to Bicdl, the hormones do not provoke the formation of antibodies. It would appear, then, that any increased resistance to infections that may result from them when used therapeutically would, of necessity, be indirectly produced through such stimulating or tonic effect as they might have upon the organism in general. The question of whether resistance to infection can be dissociated from the formation of antibodies is, of course, not under consideration here. Schiefterdecker's hypothesis of the physiologic action of the specific internal secretions is very interesting, in that he advances a direct nervous intervention as a substitute for the old theory of reflex action. He says : "Internal secretion determines the effect which the products of metabolism, excreted by the nerve cells during the simple processes of nutrition, will exercise upon other nerve cells or upon the cells of the end organs, such activity being called 'trophic' It also determines the effect which the jjroducts of metabolism ex- creted in the course of specific activity will produce, and this effect is known as 'irritation' or 'stimulus.' " We will not argue the point of whether "irritation" and physiologic "stimulus" are the same. The distinction seems too obvious — clinically, if not biologically. The wonders of even the generative sex gland function are almost incomprehensible to all but the scientist, who has come to accept them as a matter of course. At birth the ovaries contain something like seventy thousand ovules, only 360 of which mature and discharge during a normal menstrual life of about thirty years. The real meaning of this is staggering. The intrinsic capacity of development into a new being under favorable conditions may be assumed to be theoretically possessed by each and every one of * Dr. John F. Golden, of Chicago, in a recent conversation informed the author that, having in mind the author's work, and the conservation of the patient's nutrition, he had auto-implanted in the abdominal wall a fragment of testis from a case of testicular tuberculosis with apparently the best of results. - 214 — SEX GLAND LMPLAXTATTOX these ovules, and we surely must grant creative potentialities to the 360 ovules which mature and are discharged from the ovary. Every one of these mature ovules, fertilized and transplanted to a favorable soil, would develop into a new being. And the fertilized ovum seems indifferent to its feeding ground, whether peritoneum, Fallo- pian tube, or endometrium. The embryo could come to maturity on each of them, were the i)urely mechanic conditions favorable. Living blood — if it is not alien — with the complex biochemical products that it contains, alone is necessary. The local source of the blood matters but little. The kinetic energy of the spermatozoon is remarkable, and the movements thereby rendered possible are very active. It can tra- verse its own length in one second, an inch in seven and a half minutes, and the distance from the ostium vagiucC to the cervix in about three and a half hours. The zoosperm is indifferent to somatic death until long after its occurrence. Living sperm cells are found in the vagina eight days after coitus, and have been found in the Fallopian tubes three and a half weeks afterward. Three days after the execution of a murderer, living spermatozoa were found in the testes. In the female bat they live for months, and in the queen bee for three years. They have been kept alive for three days in a culture oven. The marvelous nutritional and formative potentialities of the generative secretional products of the sex glands are proved by the results of the combination of the spcrmatozoid and the ovule. The combination of a cell measuring only \'-,,„ inch in length with another cell measuring V12.-, of an inch in diameter [produces a germ which requires only a proper environment for its development into a new being. Comprehension of this wonderful biologic fact alone should be sufficient to enable us to a])preciate the possibilities of sex gland secretion in therapeutics. Both the spermatozoid and the ovule seemingly must depend inevitably upon the internal secretor}- function of the glands which jjroduced them for the remarkable results following their combina- tion. The internal secretory function of the testis and ovary possibly may in no wise be dependent upon the generative glandular mechan- ism but it is hardly conceivable that either spermatozoa or ovules of normal constitution can be formed independently of the local and general nutritional stimulus produced by the hormone. — 215 — IMPOTENCE AND STERILITY What is it that imparts the formative energy to spermatozoid and ovule if it is not the internal secretion acting through the medium of the blood, or directly upon the procreative glandular tissue — or both? The vmion of sperm cell and ovule merely serves to make dynamic the potential cell energy of each. The combination surely develops a powerful nutritional stimulus. It is by no means im- probable that the quality of progeny depends on the quantity and quality of the internal secretion, both before conception in both sexes and after conception in the female. Why may we not hope to im- prove heredity, or even determine sex, by the employment of internal secretion through the medium of sex gland implantation or other methods of administration? What may we not accomplish thera- peutically with the vital energy of glandular organs which produce such powerful biologic elements as the ovule and spermatozoon and in such large quantity throughout life, if only we can make that energy do our bidding, as seemingly we can? Wliile the double secretory function of the generative glands has for some years been conceded, the existence of specially differ- entiated histologic secretory elements in these important glands has not been so generally accepted. Certain investigators, notably Nuss- baum, have held that the generative elements of the glands produce the hormone. Others, again, have contended that there is a double set of secretory elements, one of which elaborates the internal secretion and the other the generative secretion proper. The problem appears much simpler in the case of the ovary than in that of the testis. Prenant, Born, and Fraenkel showed that the corpus luteum is epithelial in structure and possesses an internal secretory function that is independent of the generative function of the gland. Bouin held that he had demonstrated that the testis contained, not only the obviously important seminiferous tubules, but also other morpho- logically differentiated elements of great biological importance from a secretory view-point. Nussbaum, after a series of experiments on frogs, concludes that the influence of the testes on sexual desire and function is biochemical and acts, not only with the glands normally attached, but also when the testes are isolated by cutting off their nerve attachments. Lespinasse, before the genito-urinary section of the American Medical Association in June, 1913, reported a case of impotence — 216 — SEX GLAND IMPLANTATION cured by "slices" of testis, one mm. in thickness, taken from a living subject and immediately transferred to the scrotum and rectus muscle of a subject who had been castrated. On the fourth day desire and power of erection returned, and had persisted for two years when the patient was last seen. The same author reports a second case of impotence treated by implantation in the scrotal sac of a portion of testis from a living body. Lespinasse's interesting experiments in the already familiar field of transplantation of frag- ments of sex glands from the living to the living, bore no reference to the broad general subject of hormone therapy — save as regards virility — or of transplantation of sex glands from dead subjects. He notes, however, the probable preservation of the interstitial in- ternal secreting tissue as the explanation of his results.* Loisel showed by experiment that the testes and ovaries of both warm and cold blooded animals contained toxic substances which produced serious symptoms and even death, when injected into frogs and rabbits. This, however, merely proves the existence of toxic materials in extracts made from the generative glands, and, so far as it goes, in general explains the frequent disappointments and occa- sional harm of therapeutically using extracts from these tissues. In the author's opinion, Loisel's observations have no bearing on the action of the physiologic internal secretions of a successfully im- planted sex gland. That the mere passage of the spermatozoa is not necessary to secondary sex characteristics has been amply proved by experi- mental, accidental and pathologic-mechanic sterilization, i. e., steril- ization which does not destroy the spermatozoa-producing func- tion of the testis, but merely prevents their exit from the gland. Obviously, however, and without questioning the fact that there is a double secretory function of the testis, this alone does not prove that the spermatic secretory tissue proper is not wholly or partially responsible for secondary sex characteristics, for spermatic secretion and resorption still continue after mechanic sterilization. Still less does it prove, when taken alone, that the internal secretion is not elaborated and eliminated with the semen by the tubiili seminifcri, * The implantation of slices of testis practically is a repetition of Leo Loeb's culture of tissues within the living body, reported In Johns Hopkins Hospital Bulletin, 1898, and Proceedings of the Society of Experimental Biology and Medicine, viii, 1911, and Anatomical Record, viii, 1912. — 217 — IMPOTENCE AND STERILITY or that the tubuh are not necessary to perfect sex development. Neither does absence or nonformation of spermatozoids mean that the remaininj^ elements of the semen are physiologically worthless. It has been shown that a very small amount of testicular or ovarian tissue is sufficient to preserve the secondary sex characteristics. This also does not prove the relative unimportance in this regard of the true generative tissue.* In brief, histologic secretory differentiation having positively been demonstrated — and disregarding the spermatozoids — we still cannot by it alone exclude the secretory function of the true genera- tive gland tissue from what we will term the sex cycle. The histologic structure on which internal testicular secretion depends was termed by Leydig, "between cells." Four years later, Kolliker described them. In 1903 they were termed by Bouin and Ancel, in an ex- haustive treatise, glande interstiticlle du testicide. These cells are situated in the interstitial tissue between the tubuli seminiferi and are of mesodermic origin. Hanes says that the Sertoli and sperma- togenic cells play no part in the internal secretion, the Sertoli cells supplying fat to the sperm cells, the internal secretion, in all proba- bility being supplied by the cells of Leydig. The physiologic characteristics of these cells, and experimental work on animals by various investigators, suggest the possibility that, even where the spermatic tubules are "strangled out" of implanted testicular structure by subsequent destruction and replacement of generative glandular tissue by true connective tissue, the internal secretory function of the implanted gland tissue — and hence such therapeutic efficacy as it may possess — possibly may continue in- definitely. The author's experiments show that the cells of Leydig actually proliferate, so that the remnants of successfully implanted glands contain relatively more interstitial cells than does the normal gland. The facts that, first, the semen is not perfectly elaborated and the spermatozoa consequently are not perfectly formed imtil the seminal elements are acted upon by the epididymis ; second, that destruction or removal of the epididymis does not affect the secon- * The relative unimportance of the spermatogenic cella in the formation of secondary ."^cx character.'? is suggested by the author's experiments. The semi- niferous elements atrophy after implantation, yet there is a marked action of tlie remaining elements of the gland upon the secondary sex characters. (Note Cases 1 and 6, Chapter XIII. — 218 -- SKX CLAXO niPI.AXTATlOX (lary sex characlcristics, and. ihird. that secondary sex characteristics manifest themselves before either spermatozoa are formed or ovules matured, in a measure j^rove that the latter are not dependent upon the generative elements, but upon some special property of the glandular tissue of the sex glands. ]\Ioll says: "If it be assumed that the testicles can secrete substances upon the influence of which the development of the secondary sexual characters depends, it is obvious that these substances have nothing to do with the sperma- tozoa, inasmuch as the testicles exert the influence under considera- tion at an age at which the formation of spermatozoa has not yet begun. The substances that act in this way must be of a dififerent kind." ]vlarshall and Hammond, in experiments on sheep, conclude that castration checks horn growth (a secondary sex characteristic). Unilateral castration inhibits, but does not check horn growth. Re- moval of the testes without removal of the epididymes checks horn growth. The authors accept the hormone theory of development of secondary sex characteristics. They believe, however, that the role of the epididymis in hormone production is of little or no importance. This is not in harmony with the observations of veterinarians, who have held that preservation of the secondary sex characteristics and of potency after castration is due to failure to include the epididymes in the exsection. Cryptorchidism is, of course, another and a satis- factory explanation in some cases of inexpert castration. The author has seen a supposed gelding repeatedly cover mares. This animal was said to have retained his sexual power because he was "castrated late." The author's observations tend to show that the epididymis plays at least a minor role in hormone production. It has been shown that the X ray destroys the spermatozoa producing function of the testis without afifecting the secondary sex characteristics. The further observation that the X ray primarily destroys the spermatic glandular tissue, but does not affect the inter- stitial tissue, is held to show conclusively that the latter is the source of the all important internal secretion. A few tubuli escape the action of the ray, and regeneration of the testis has been shown to occur. The question arises, however, as to whether inhibition of the ])roduction of the delicate spermatic cells — spermatozoids — — 219 — IMPOTENCE AND STERILITY necessarily means that the generative gland tissue proper really is destroyed. Does not the so-called "regeneration" mean a restoration of function? The author does not believe that a regeneration of killed tubuli seminiferi is possible. We may profitably note what occurs in the orchitis of parotiditis, and reflect on how easily the gland is destroyed. It also should be noted, however, that when one testis is atrophied by parotiditic infection and the remaining organ subsequently is lost, the secondary sex characteristics are preserved. This the author has observed in one case. It is quite as pertinent to the subject in hand as are the results of X ray experiments and acci- dents. Prolonged and repeated exposure to the ray will, of course, destroy the entire structure of the gland and produce effects similar to complete castration. Summarizing all that is known regarding the internal secretory tissue of the testis, Biedl says : "We are led to the inevitable conclu- sion that the hormone which gives to the organism its male char- acteristics is elaborated in the cells of Leydig, in the interstitial tissue. Despite their mesodermal origin, these cells are able actively to pro- duce certain specific substances and to transfer these substances to the blood stream. Such being the case, we are justified in describing them as an 'interstitial gland.' " As already hinted, the author is not quite sure that Biedl's conclusion is "inevitable." It is by no means impossible that the procreative elements of the testis themselves have a double secreting action, the internal secretion being elaborated by the true secretory glandular tissue, and mainly taken up and distributed by the blood vessels of the organ, the excess escaping with the spermatozoa.* Consistently with this hypothesis, the internal secretion probably is constant, while the spermatozoa producing function is easily in- * In reference to this point, Waldstein and Ekler's experiments (Der Nachweis resorbirten Spermas im weiblichen Organismus; abstract in Deutsche medizinische W^ochenschrift, October 9, 1913) are very interesting. They found that within two and one half to sixteen hours after coitus, the blood of the human female contained a ferment which peptonized the albumin of testicular extract. Comparing this with Fauser's observations in dementia praecox, we are justified in suspecting that the internal secretion of the testis is in part eliminated by the semen. The marlted improvement so often noted in the nutrition of sterilized — not castrated — males, and resulting from con- tinence, thus may be scientlflcally explained. It is possible, however, that there is a change in the ovarian hormone itself, under the stimulus of coitus. The author believes that the sense of well being experienced after normal coitus by both sexes probably is due to a large dose of hormone entering the circulation on the one hand from the testis and on the other from the ovary. — 220 — SEX GLAND [MPI.ANTATION hibited or destroyed, and the spermatozoa doubtless are more or less intermittently produced, varying with sex stimuli and demand. In brief, the author is not inclined to the belief that the destruction of the spermatozcja producing function necessarily means complete destruction of the true generative gland tissue. Biedl further says : "It is highly probable that, by the agency of its secretory products, this gland is responsible for the develop- ment of the male sexual gland from the differential genital tract. That it has a determining influence on the normal development and maturity of the generative portion of the sexual gland, the formation of the secondary genital organs, and the existence and persistence of those morphological and biological characteristics which are the ])roperty of the male sex, is undoubted." The immediately foregoing positive assertion of Biedl's being accepted as in the main true, how can we reject as improbable the view that a successful testicular implantation should, other things being eqvial, increase virility — either by the direct action of its internal secretion upon the generative gland tissue, or (a) by enter- ing the blood, im]:)roving general nutrition, and (b) returning to and acting as a stimulant, tonic, and nutrient reconstructive upon the generative gland cells? If the internal secretory tissue is the self elaborated "meat" upon which the generative tissue jiroper of the testis '"feeds," aged and weakened glands should profit even by an increased supply alone; this, granting that an oversupply is im- practicable — as probably it is. In connection herewith, it is note- worthy that advancing age and castration alike tend to the pro- duction of obesity. It should be noted also that obesity, even in relatively young subjects, is likely to be attended by comparative inactivity of sexuality.* From the viewpoint of its internal secretory function, the ovary is very similar to the testicle. The correlation of the physiologic function of the Graafian follicles and of the corpus luteum has long been well known. The function of the stromal gland cells, however, * Apropos of the nutritive .stimulant action of tlie hormone, one of the authoi-'s own experiments is interesting. Implantation of testes from a year old cock upon a nonrelated capon of the same age resulted in an improvement in carriag'e, increased glossiness of plumage, a better apjiearance of the face, comb, and wattles, increased liveliness, and a disposition to combativeness, with a sliglit development of sex activity, wliich last phenomenon was of short duration. — 221 — IMPOTKNCE AND STERIIJTY has attracted attention only in recent years, Regaud and Policard being the first to suggest that these glandular cells might be secre- tory. Bouin, in 1902, described these cells as glandes inter stitielles de I'ovaire. Biedl says, "that the secondary female sex characteristics, especially those of the genital tract, are dependent upon the inter- stitial cells of the ovary is at present not proved." He further directs attention to the fact that the X ray destroys the Graafian follicles alone. The interstitial tissue is not only preserved, but it hyper- trophies. While the observations thus far made upon the ovary and its secretions are not as conclusive as in the case of the male gland, Biedl states, "that the tissue which performs the function of external secretion is also the site of production of the ovarian nonsexual hormone, which exercises an alterative influence upon a large num- ber of tissues and functions, is suggested by analogy with the male sexual gland." This is distinctly contradictory to Biedl's attitude regarding the testis, and his reasoning by analogy seems obscure. In any event, differences of opinion as to the precise histophysiologic source of the internal secretion of either the ovary or the testis have little bearing upon the experimental or therapeutic value of implantation of the sex gland tissues in their totality. The real, probable, or possible results of implantation of the ovary depend — so far as the properties of the gland per se are concerned — upon, first, the existence, effects, and continued pro- duction of an internal secretion ; second, the existence, effects and continued production of the ordinary generative sexual secretion ; third, successful implantation of a normal gland, in whole or in part, with its structure entire; fourth, the duration of the life of the im- planted gland.* Granting that the Graafian follicle, the corpus luteum, and the ovarian interstitial tissue are equally important, or that only one of these tissues really is important from the internal secretory stand- ♦ Stich, Deutsche medizinische Wochensclirift, September 25, 1913, in a r6sum6 of the present status of organ transplanting, sums up the subject of ovarian transplantation by stating that it occasionally succeeds in animals which are blood kin. Stich altogether ignores testicular transplantation, apparently as a subject on which no data are available. — 222 — SEX GLAND IMPLAXTATIOX point, llie procedures and results should be the same, unless it is held that a complexity of origin impairs the effects of the gland secretion, which obviously it cannot. The first work of any importance in ovarian transplantation from the living was done by Robert T. Morris, of Xew York. From Leo Loeb's pioneer experiments in cultivating tissues in vivo and /;; vitro, some years prior to Carrel's recent remarkable experiments, the author had suspected that niore or less successful grafting of the human testis from one living subject to another was possible. Aside from the recorded experiments on animals, this was suggested by observation of the effects of division of the spermatic cord, exclusive of the vas deferens, in a large number of varicocele operations, and experimental severance of the cord, including the vas, in numerous hernia operations on old men in a certain public institution. In these cases the author closed the hernial opening over the "tucked up" proximal end of the cord, and sutured the distal end of the cord across the ring. In respect to division of the cord, the procedure w^as similar to the operation for hernia later suggested by Bloodgood. Early in his surgical experience the author found in operating for varicocele that, unless infection occurred, complete division of the cord was not followed by atrophy of the testis, even when the operation involved complete extrusion of the gland via the operation incision. Apparently the circulation of the cord could not be restored at the point of junction of the ends of the divided portion before the testis died of innutrition, if the salvation of the gland depended upon the spermatic artery and the artery of the vas. The vascular supply of the t\inica vaginalis alone apparently being of no magnitude, the notion obtruded itself upon the author that possibly comparatively little blood was really necessary to the life of the testis, and, further, that the juices of the surrounding tissues might be sufficient to preserve the life of the organ or at least a portion of it. Reasoning by analogy, the implantations of ovarian tissue subsequently performed by various operators, in which gland tissue from the living was replanted in the living, seemed quite conclusive evidence of the possibility of successful testicle grafts under similar conditions. With the publication of Carrel's remarkable experiments, and ha\ing in mind not only nimierous experiments with tissue from the — 223 -- IMPOTENCE AND STERILITY living published in the literature and recent developments in the study of internal secretions, but certain preconceived ideas of his own, the author became convinced that implantation upon living- sub- jects of sex glands from the dead body was both practicable and likely to be therapeutically successful. He felt, also, that if success- ful, the procedure possibly might open up avenues of medical and surgical therapy which would be somewhat staggering, even to those of us who are not easy to astonish.* As long ago as 1913, the author from time to time endeavored to secure opportunities for experimentation with material from the dead body in sex gland implantation in both sexes. That the diffi- culty of obtaining proper material was great, should be obvious to any one who knows the prevailing sentiment in America against using the dead for scientific purposes — especially the recently dead. These difficulties were greatly enhanced by the fact that it seemed desirable to secure glands from special subjects, of a certain age, dead of violence, in fresh condition, and as certainly free from syphilis as it was practicable to determine. The Wassermann test might, or might not be practicable. Having secured the proper cadaveric material for experimentation, it still remained to secure a living subject who would permit the experiment. With the triple object of experimental sex gland implantation, to determine whether it was practicable, for the purpose of studying the action of the sex hormone and of testing the pro- cedure in the treatment of dementia prjecox, the author at- tempted to secure a favorable subject afflicted with this disease, and endeavored to enlist the cooperation of several medical friends whose opportunities for securing material were better than his, but without success. The double problem of securing human sex glands under proper conditions and of having a complaisant sub- ject ready and waiting for the experiment seemed insoluble, until the l)lan of combining surgeon and subject suggested itself and the author resolved to perform the experiment upon his own person. January 16, 1914, there were placed at the author's disposal two supposedly appropriate male subjects from which to select the material necessary for gland implantation. One of these was re- * Carrel liimself concluded from his observations that gland.s could not be successfully transplanted .save where donor and recipient were kin. — 224 — SEX GLAND IMPLANTATION jected. The other, a suicide by gunshot, and a relatively inferior but apparently healthy subject, eighteen years of age, was selected. The subject had been dead seventeen hours, having lain at the under- taker's under the ordinary conditions and temperature since shortly after death. The weather at the time was very mild. In the author's haste to secure the necessary material, the appliances necessary to secure blood for the Wassermann test were forgotten, hence it was necessary to rely upon such history of the subject as was obtainable and a careful examination of the body, especially of the genitals, including incision and macroscopic examination of the lymphatics. The danger of syphilis obviously could not be entirely eliminated, but was not sufficient to weigh heavily in the balance of opportunity to secure the long sought material. Both testes were removed as aseptically as practicable, the in- struments and gloves being sterile, and iodine being freely employed in lieu of the customary scrubbing. The testes immediately were placed in a jar of sterile normal salt solution. Casi; 1. .iutoi)!iplatitatipii of the testis: subject fifty-six years nf age. Seven hours after securing the necessary material, and twenty-four hours after the death of the subject from which it was removed, the author im- planted in his own scrotal sac one of the experimental testes. The operation was performed in his office, with the assistance of his former associate. Dr. Carl Aliche!, whose hjyaUy and intelligent co-operation throughout our experiments cannot be too highly commended. The conditions, so far as asepsis was concerned, obviouslj- were not those of an up-to-date operating room, with the usual corps of nurses, but were as satisfactory as was possible under the circumstances. Technic : Local anesthesia was employed — a ten per cent, solution of novocaine in one per cent, urea and quinine hydrochloride. Of this about a dram and a half was injected. The anesthesia was satisfactory so far as the skin was concerned, but by no means so as regards the deeper tissues, merely because especial care was taken not to puncture the veins of the cord and also to avoid infiltration of the tissues about the cord at the site selected for the implantation. The author made an incision two inches in length, in the mid-scrotal region, about an inch external to the right of the scrotal rhaphe, and dissected down to the cord. The awkward position nccc--sary to the work and the dis- tance of the field from the operator's eye were such that the tunica vaginalis inadvertently was cut. The escape of vaginal fluid and the appearance of the testicle at the bottom of the wound gave the first intimation of the accident. The opening in the tnnical vaginalis was closed with fine catgut and the operation ])rocccde(l with. SEX GLAND IMPLANTATION The author next made beneath the deep fascia a pocket about two inches in depth, at the bottom of which was the cord. Into this pocket, directly upon the cord, was implanted the testis, already prepared by removal of the epididymis and decortication to the extent of about half its surface. The fascia was closed with a pursestring suture of fine catgut, following which, bismuth subiodide and the usual gauze dressing were applied and a suspensory was adjusted. Postoperative course : Probably because of undue movement, the ex- igencies of practice at the time making it impracticable to rest physically, there was a little superficial hemorrhage, forming a small clot immediately beneath the skin incision. Saprophytic infection occurred, with considerable edema of the penis and scrotum, extending well up toward the inguinal ring. On the fourth day the author opened the superficial portion of the wound, drained, and aseptized it. There was not then nor subsequently any pus infection during the progress of healing. There was a little over 1° F. rise in temperature, lasting four or five days. There was considerable pain, following undue motion, on the eighth day after the operation, and a small quantity of seminiferous tubules pro- truded from the wound, the pursestring fascial suture evidently having given way. Although there was no rise in temperature and, as already stated, no pus infection, the author now concluded that the experiment was a failure, and decided to remove what apparently was a somewhat dangerous foreign body. He therefore requested Dr. Michel to remove the implanted gland, and as there was a little resistance when traction was made on the protruding gland tissue at the bottom of the skin (i. e., the extrafascial wound), the attempt was made to remove it entire by forcible traction. The resistance to traction and the pain attending this procedure demonstrated pretty con- clusively that it would have been wiser to let the gland remain. The gland splitting longitudinally, onlj' half of it, and, strange to say. the more solid portion, covered by the tunica albuginea, came away. This, on examination, showed well formed and abundant vascular adhesions, which apparently conclusively showed that the implantation was a success. We therefore decided to leave the decorticated remaining half of the gland /;( situ. At the time of the implantation the semi-decorticated gland was so soft and so readily became extruded, that it was with difficulty retained in the implantation cavity while the pursestring suture was being inserted and tied. Had this circumstance been remembered, the mere fact that a moderate amount of traction, or even slight pressure, was not sufficient to dislodge the implanted tissue from its bed and extrude it, would have suggested the wisdom of allowing the gland to remain. After the removal of the portion of gland there was some increase in the local inflammatory symptoms, due to simple trauma. This, however, subsided within forty-eight hours. Immediately following the removal of the gland tissue, there was a moderate discharge of a mucosanious looking secretion, which continued in gradually diminishing quantity for five weeks, at which time the sinus was completely healed. The tardiness of healing in — 226 — S1<:X CI.ANJ) IMPLANTATION a noninfected wound is worthy of note, suggesting the characteristic of fistulae of glands in other regions, notably the parotid. Numerous microscopic examinations by Dr. Michel of the fluid from ihe fistula showed blood corpuscles, leucocytes, and immature spermatozoids, such as normally are found in the testis prior to their complete elaboration in the epididymis. There was no evidence of pus infection, the fluid being free from pus cocci. After the extraction of the portion of the gland, there was no further appearance of seminiferous tubuli in the w'ound, neither was there any debris nor broken down gland tissue in the secretion from the "fistula." After the inflammation in the surrounding tissues had completely subsided, a distinctly circumscribed, ovoid, insensitive body adherent to the spermatic cord could be distinctly felt. This mass measured approximately 4.5 by 3 cm. by 2 cm., and was evidently composed of the remaining portion of the testicular gland structure, with a certain amount of new connective tissue investment. The size of the mass gradually decreased. June 1, 1914, it was a smooth, fairly movable, ovoid, insensitive, circumscribed, typically glandular body, about the size of a small almond, still loosely attached to the spermatic cord. August 1, 1914, the mass was nearly round, about the size of a hazel nut and, strange to say, slightly sensitive. It had not diminished much, if any, in size for several weeks, although still further shrinkage was expected. It was noted that the tumor varied considerably in size at different times. This was very suggestive of actual function. The "nodule" gradually decreased in size until, at the end of eighteen months, it could barely be felt. That during this time the mass was composed largely of proliferated active hormone-producing cells the author is firmly convinced. Apparent Local Results of the Experimental Auto- Implantation. That the imi)lanted mass was for many months composed of living, functioning testicular tissue is, to the author's mind, not an open question. Dead tissue of such loose structure and soft consist- ence as are the tubuli seminiferl, devoid of the normal fibrous enve- lopment — the tunica albuginca — and connected by an open wound with the surface of the skin, could not los^ically be expected to re- main i)i situ, much less to become encysted by connective tissue, but would have broken down and come away, either in mass or as debris. Nor would the sinus have healed so long as necrotic tissue was present at its tissue terminus. If the mass was purely inflammatory, it should not have become circumscribed, freely movable on its cord attachment, and relatively lasting, but should have disappeared pari passu with the absorption of exudate in the surrounding inflamma- tory area. The persistence of the tissue mass at the site of im- — 227 — IMPOTENCK AND STERILITY plantation, together with the continuance of the apparent physiologic results, appear to be conclusive, an opinion which was held by all who noted the progress of the case. As to whether the implanted tissue eventually would be entirely destroyed and replaced by connective tissue, the author ventured the opinion that it would not, holding that, if the implanted tissue finally disappeared, the temporary nature of the implantation result logic- all)- might be explained by faulty technic, embracing too free decorti- cation, which, as elsewhere stated, in future can be avoided. He further believed that the testis and ovary, if not completely decorti- cated, would be more likely to endure permanently after implanta- tion, even though considerable atrophy occurred, in this respect probably difTering from the thyroid and other glandular tissues. Since the original experiment it has become evident that, in most cases, complete atrophy of the implanted tissue eventually oc- curs, the time at which it occurs being variable, but in all cases being delayed sufficiently to secure the benefits of the sex hormone for a prolonged period. Experience has shown, also, that decortication really does hasten atrophy. If trophic nerve supply is essential to structural integrity, then more or less atrophy of implanted gland tissue should be expected, whatever technic is employed, unless it is conceded that regeneration of such nerve supply may occur. The author believes that he has proved that apparently com- plete destruction of the generative portion of gland tissue does not nullify the physiologic efifects of the implantation. With hardly perceptible tumor, the Leydig cells apparently still remain and func- tion, producing the all important hormone. They seemingly pro- liferate and may increase, in amount and activity, the production of internal secretion. On the other hand, they might eventually be so changed by blood, tissue, and trophic influences as to become inert, as regards their internal secretory activity, some time before the mass entirely disappears. In brief, whether or not there is eventually apparent disappear- ance of the gland tissue after a successful implantation, the method theoretically should be therapeutically useful and its benefits perma- nent : First, because the interstitial gland tissue may remain and function, producing hormone ; second, because the hormone may — 228 — SEX GLAND IMPLANTATION have (lone its work of regeneration, the conditions for which we operated having- been so profoundly modified by nutritional changes that they do not recur, with consequently no indication for continu- ing the remedy. Although complete atrophy should be the fate of implanted alien testes and ovaries, irrespective of whether the entire gland or pieces are used, and suf^cient benefit has not resulted, we still may have recourse to successive imi)lantations of fragments of glands, repeating the "treatment" as often as may seem necessary.* vSu(;r.KSTioNs for Improvivmknts in Tixiinic. The difticulties under wdiich the author labored in his auto- exj)eriment require no fvu^ther comment. That not only the sex gland implantation, but also the technic of the process necessarily was experimental is self-evident. In his subsequent work the procedure was modified by either leaving intact all the tunica propria of the testis, or decorticating from two to four narrow, longi- tudinal surfaces, about two or three mm. in breadth, run- ning the entire length of the gland. These narrow bands of decortication are an extra, but probably unnecessary, provision for nutrition by the tissue juices of the implantation bed during the formation of vascular adhesions and new blood supply. Vascular adhesions naturally may be expected to form at the points of de- cortication. The limited area of decortication will not subsequently permit of an invasion of connective tissue from the surrounding structures sufBcient to endanger the delicate glandular elements of the implanted organ. The portion of the tunica albuginea still re- maining affords ample protection for the gland tissues beneath it, * Fre.sh triturations of gland tissue even may be u.sed in tlie form of an emulsion, injecting tlie fluid almost anywhere beneath the skin. Excepting implantation, this would seem to be the most rational method of administer- ing liormone. The danger of tlie phenomena eliaracteristic of anaphylaxis naturally suggests itself in connection with successive implantations and testicular emulsion treatment. Tlie author has implanted the testes of cocks repeatedly in the same subject, and even in female fowls without evil results. Implanta- tion in fowls is a .severe test of protein dosing. If the testis of the human being were as large in proportion to the body as that of a lusty cock, the gland would weigh several pounds; this aside from the relatively greater activity of the glands of the fowl. The author also has experimented upon guinea pigs, upon himself and upon a number of otlier human subjects with large doses of Iiuman brain emulsion, given beneath the skin and intra- musru!arl.\', witliout injui'\'. . 229 IMPOTENCE AND STERILITY and probably soon regenerates and covers such portions of the de- corticated area as are not occupied by new blood vessels. Under favorable conditions, local anesthesia is sufficient for implantation operations. In the insane, general anesthesia is likely to be required, and the author thus far has employed it. Asepsis should be most rigid both in securing the glands and their implanta- tion. The author now removes them from the dead body without permitting his hands to come in contact with them. The glands should be removed from the body as soon as possible after death. The slightest degree of decomposition will insure failure. Obvi- ously, haste in removing the glands is not so urgently necessary in cold as in warm weather, nor is it so necessary immediately to implant the glands. The glands should be placed in sterile normal salt solution, or, preferably, in Ringer's solution, immediately on removal from the body, and under favorable conditions implanted within twenty-four hours. As Carrel has shown, tissues may be kept frozen for several weeks and still retain their vitality. This fact perhaps in future can be taken advantage of in preserving sex glands for implantation. In one of the author's cases the ovary was kept in a refrigerator for a week. In a series of cases which followed it, refrigeration was employed for from two to five days, but the results were not en- couraging. An aseptically prepared gland, when frozen, can undergo no change save a certain degree of "autolysis" which will prevent its functioning. Even complete autolysis would not make dangerous the implantation of an aseptic gland. The autolyzed tissue would be likely to be merely appropriated as nutriment by the living tissues of the implantation bed. It is worthy of note in connection here- with that the author's former associate, Dr. Carl Michel, has ex- perimentally demonstrated that gland tissue kept at a temperature of C)7° C. for about twelve hours, loses its functional activities — "functional autolysis." This, he states, is due to relative overfunc- tioning in the absence of nutriment. Other forms of autolysis he terms: (a) ]'j]iysical ; (b) putrefactive. The loss of activity of the gland in "functional" autolysis is ])robably due, Tiot so nmch to a lack of nutriment as to biochemic products of the gland tissue itself, these products (both internal — 230 — SEX GLAND IMPLANTATION and external secretion) being inhibitory to the vitaHty of the tissues which produce them. This involves a familiar principle in biolog}% particularly in pathogenic germ biology. Excreted into and modified by the blood after implantation, before autolysis has occurred, the gland products (secretion) re- turning to the gland, are stimulant to its function and nutritive to its cells. Dr. Alichel suggested that tissues designed for implantation should be kept in Ringer's solution at a temperature not below o"^ C, and not longer than two weeks, the object being merely to inhibit the biochemic function of the cell enzymes without destroying either them or the cells that produce the ferment. Dr. IMichel probably is correct in his conclusions, although he has overlooked a most important point in his reasoning, viz., freez- ing possibly may destroy the delicate cells of Leydig and the ovarian interstitial cells of Bouin, without necessarily destroying the rest of the gland. Thus it is not improbable that glands which have been frozen may sometimes apparently survive implantation and yet not function, especially from the internal secretory standpoint. The aim of implantation is not to insert what inevitably must become a functionless mass of connective tissue and useless generative gland cells into the body of the recipient. The author originally was inclined to believe that the epididymis should be removed, where the object is merely gland implantation for experimental or for therapeutic purposes to secure the benefits of internal secretion. He said, in his first paper : "\\'hile the epididymis probably produces hormone, it is here of no particular service, and by its mere bulk and the mechanic irritation it produces, greatly enhances the danger of failure of the implantation. Again, the removal of the epididymis afifords a surface favorable to ad- hesion and nutrition, without extensive decortication and exposure of the delicate tubiili seminiferi." Subsequent experience showed that in many instances it is better to preserve the epididymis. The results of anastomosis of the implanted testicle thus far have not been very encouraging. Very little work, however, has been done in this direction on the human stibject, and it seems to be a legitimate field for experimentation. Anastomosis of testes — 231 — T^rPOTENCK AND ST]<;RIMTV from closely related subjects — especially from the living to the liv- ing — at least is hopeful, despite the great difficulties attending anas- tomosis of the spermatic vessels. When, for any reason, it is desirable to attempt to preserve the generative sex function of the implanted gland, the epididymis and a portion of the vas should be preserved for anastomosis, a pro- cedure which, mechanically at least, is perfectly feasible — and suc- cessful in simple anastomosis of the duct in the living subject — by the method devised by the author, described in a previous chapter. 'I'his method of anastomosis can be applied without disturbing the cord or testis of the recipient of the implanted gland, further than to expose and divide the vas deferens for anastomosis, as shown by several experimental cases of the author's. The obstacles to anastomosis of the small vessels of the cord appear at present to be insuperable. That more or less successful anastomosis of a testicle immediately after its removal from the living body is practicable in a certain proportion of cases, is prob- able. The importance of this is easy of comprehension. There are countries where there are no legal obstacles to persons disposing of portions of their bodies as they see fit. Possibly our own laws may one day be amended so as to enable us safely to use gland material from the living that is voluntarily submitted to us by its possessor. Meanwhile, if, as is possible, anastomosis of testes taken from dead bodies ever should prove to be even moderately successful, some wonderful work is likely to be accomplished.* That the chances of failure of implantation are greater where anastomosis is performed goes without the saying, as experiments have not been encouraging and relatively free incision and exposure of the site of operation is necessary, and more tissue of a lesser degree of vitality is implanted than where our object is merely to secure the benefits of internal secretion. If, however, the gland it- self should survive, the anastomosis is not likely to fail. Here again arises the question whether Carrel's results in kidney transplanta- tion in the lower animals are equally important as bearing upon sex * It should be remembered that "considerable atrophy" of the testis may occur, without either the generative or the hormone producing function of the gland remnant being necessarily destroyed. — 232 — SEX GLAND IMPLANTATION gland transplantation in human beings.* Obviously, rest in bed for some days should be enjoined in implantations, and for a more pro- longed ])eriod when anastomosis is performed. The site selected for implantation is an important considera- tion, and should be decided on the merits of the individual case. It may be that the sex glands will finally be shown to be quite as suc- cessfully implanted in one part of the body as another, but at present writing the author ventures to suggest that there are ])oints of elec- tion. In the male, the site should preferably be the neighborhood of the testis and spermatic cord. The tunica vaginalis will invest the implanted gland on one side, and thereby give it in part a natural covering. The gland tissue probably will adhere to the tunica vag- inalis more readily than to the other tissues, and there will be very little connective tissue at the point of adhesion, svibsequently by its contraction to menace the integrity of the implanted gland. Future experience may show the advisability of folding and stitch- ing the tunica over the gland. This possibl}^ would be wise where only a portion of testis is implanted. The author would suggest, also, that where only a portion of the gland — this also applies to the ovary — is implanted, the cut edges of the tunica albuginca should be sutured together to protect the delicate gland tissue from connective tissue invasion. Whether or not there is a special "selective" trophic or blood nutritive element in the environment afforded the implanted tissue by the proximity of its bed to the testicle, is an open c[uestion. Future experience may change our view, but at present it seems doubtful if it would be wise to implant the gland into the cavity of the tunica vaginalis. The resulting mechanic irritation, conjoined * The author feels that he cannot too often insist that failure in trans- plantation of an excretory organ has little Vjearing on that of a double secre- tory organ like the testicle or ovary. Carrel seems to believe that the results of his experiments should estop organ transplantation altogether, judging by his recent paper before the American Surgical Association. He apparently loses sight of the hormone therapy angle of organ transplantation. It is to be regretted that he did not discuss this, more especially as lie knew of the author's own experiments, several weeks before. To have mentioned these experiments perhaps would have been only fair to the general scientific bear- ings of organ transplantation. The author further insists that, while the preservation of the generative function of tlie transplanted ovary is not to be expected — save possibly in testicle anastomosis under the most favorable conditions — and that of the testis possibly not at all, sex gland Implantation still offers great therapeutic possibilities. As to the local possibilities, note in this connection the remarkable results obtained in several of the author's cases. — 233 — IMPOTENCE AND STERILITY with trauma of the sac, might produce so much exudation and swelHng as to cause severe pain and even endanger the recipient's own testicle. Hydrocele probably would result, although this pos- sibly might be avoided by cutting "windows" in the sac, for drain- age. Aseptic extravaginal implantation in no way endangers the subject's testicle. The second best implantation site doubtless is the pelvic pro- peritoneal space, as later will be suggested for the ovary. As third choice of location the author would suggest the mons veneris, the pubis being shaved and the incision made transversely just below the upper margin of the pubic hair. The length of in- cision, of course, will vary with the amount of fat, an incision one inch in length being ample in spare subjects. By the downward insertion and opening of a pair of forceps or blunt scissors, a pocket may by dry dissection easily be made for the gland. This pocket should extend dowaiward to just above the pubic symphysis. In this location, after the hair again has covered the part, neither the scar nor the small tumor which will result — if the implantation is successful — will cause comment by others. The cavity of Retzius also is safe and accessible. The gland should be implanted high up, or well over to one side to insure peritoneal contact. The axilla appears to be another eligible location, the incision being made well away from the centre of the axilla and the bottom of the pocket made to correspond with about the centre. One important difference between male and female here must be noted. The former normally is dominated by the psychic in- fluence of a testis that can be seen and felt. He always is conscious of its presence. The reverse is true of the female and the ovary. The psychic benefit of the consciousness of a demonstrable testis, especially in the scrotum, must not be forgotten in the case of the male. It will be by no means a negligible quantity in external ovarian implantations in the female. As to what extent exposure to traumatism may militate against the success of implantations in exposed sites is a matter for future determination. It is, however, worthy of consideration. In ovarian implantation of glands from the dead subject, which is quite as practicable as similar testicular implantation, and for which the necessary glands of proper quality are much easier to — 234 — SEX GLAND IMPLANTATION secure, the order of choice of sites for operation at present writing appears to be as follows : 1. The properitoneal space. 2. The cul-de-sac of Douglas (extraperitoneally). 3. The labiiim majiis, the incision being made high up and the part "pocketed" downward, as in the case of the scrotum. 4. Beneath the mammary gland. 3. The pubic region, as in testicular implantation in the male, better, perhaps, the cavity of Retzius, where observation of the im- planted tissue is not desired. 6. The rectus muscle. The peritoneum forms the normal environment for the ovary, and if half or n:!ore of the surface of the iniplanted organ is made to rest iK-rmaneritly on the peritoneum — which by adhesion in suc- cessful cases will form a protective and nutritive investment for the gland — the chances for success will be greatly increased. An eligible point is the ilioinguinal region, well out toward the anterior superior spine of the ilium. After exposure of the peri- toneum, a pocket should be made anteriorly to it, downward into the pelvis. The cul-de-sac of Douglas is an available and logical site for implantation. A small vaginal incision should be made posterior to the uterus, the peritoneum being carefully pushed up with the finger, thus making a pocket for the reception of the implantation gland. The labium majus is a particularly eligible site, because of the proximity of the canal of Nuck, which is a peritoneal derivative and the analogue of the tunica vaginalis in the male. The author will reiterate that a point in favor of "exposed" sites of implantation in some cases is the psychic efifect of objective evidences of success on the mind of the patient, which sometimes is so desirable. Incidentally, the surgeon can more easily determine whether or not the implantation is successful. The methods of Tuffier an.d of Martin of implantation within the pelvis and rectus muscle of ovarian tissue from living donors, is a procedure entirely different from that under discussion. Het- erointraperitoneal implantation within the pelvis is unnecessary and has an clement of danger. For experimental jnn-poses especially, it — 235 — IMPOTENCE AND STERILITY is usually best to implant the gland in a part accessible to observa- tion, and from which, if desired, it can be subsequently removed. To imitate the natural environment as closely as possible, the author would suggest the experiment of partially wrapping the testis in a graft from the tunica vaginalis or peritoneum, and the ovary in "appendage" peritoneum, whenever the implantation site is more or less remote from the normal ovarian or testicular environment ; in brief, where the environment would otherwise be alien, or possibly even hostile, it possibly can be made temporarily akin, or at least friendly. Should the membranous lining of the implantation pocket ])e absorbed, as is probable, it will have served its purpose of a matrix for the growth of a thin protective layer of connective tissue. A similar technic might be advisable in thyroid implantations. It is probable that implantation in the normal habitat of the thyroid is more logical than elsewhere. Where the tissue has no capsule, or the capsule is insufficient, fascia may be used as a protective "cap- sule." Theoretically, a piece of peritoneum should be ideal. Ordinary connective tissue is a deadly foe of glandular, brain, and nerve tissue, as shown by its effects in cirrhosis of the liver, interstitial nephritis, and various diseases of the cerebrospinal axis. So far as possible, therefore, we should protect the implanted gland from invasion by it. It is well to remember that the environment of the ovary is such that it should be removed from the dead body relatively earlier than the testicle. The close proximity of the bowel is favorable to early decomposition of pelvic fluids. In implantation in either sex, care should be taken : First, to make as limited an incision as is compatible with the insertion of the gland. As the gland is soft, and the skin and fascia elastic, a very small incision will suffice. Second, to insure that the dissec- tion of the pocket shall be as dry as practicable and to traumatize the tissues as little as possible. Third, to avoid injuring the delicate gland tissue during its preparation and implantation. It should not be regarded as dead insensitive tissue that may be recklessly mauled, but as living tissue to be carefully handled. Fourth, to use the finest chromic gut — or better, perhaps, iodinized gut — and insert no more sutures than are actually necessary to a perfect closure. The purse- string suture for the fascia is ideal. Fifth, at all times to avoid rough mani]nilation of the implanted gland during healing, and -- 236 - SEX GLAXD IMPLANTATION especially to manipulate it as infrequently and as gently as possible, while adhesions and vascular supply are forming. The problem of the quantity of gland necessary for implanta- tion is a most important one. If the major premises herein out- lined — or suggested — are correct, this problem practically involves the question of the proper dose of internal sex gland secretion in various conditions and in individual cases. In his first paper the author said: "If a fair average of successes should prove to be practicable, an entire testicle body is preferable. In general, how- ever, probably one-half of a testis is sufficient to give definite physi- ologic results, and is surer to be preserved than a whole gland. In the case of the ovary, however, the author is inclined to believe it better to implant an entire ovary, even though a small portion of the gland is seemingly sufficient to preserve the secondar)- sex character- istics and often even to prevent the nervous wreckage incidental to oophorectomy." Further experience has led to the conclusion that, in the case of the testis the quantity of gland implanted may be varied according to the material used, small glands being implanted entire. If the implantation is successful, the dose of internal secretion, however large or small it mav be, ])robably is continuous as long as any of the implanted tissue remains. It is for this reason that a relativel}- small portion of implanted sex gland tissue is likely to be efficacious. Even though implantation should prove successful, definite results probably should not be hoped for before six or eight weeks after the implantation, at which time complete estab- lishment of circulation in the gland — if it survives — may reasonably be expected.* In general, it is probable that such results as may occur will be noted earlier in testis than in ovary implantation, and in the case of the testis, earlier where the gland has been decorti- cated, although complete decortication possibly endangers permanent success. The establishment of a sufficient vascular supply is essen- tial, not only to the life of the gland, but to the necessary supply of materials from the blood for the elaboration of internal secretion, and to the entrance of the latter into the blood. * In the author's experimental and therapeutic work, marked results have occurred much earlier. The initial dose of hormone shows effects for the first twenty-four to thirty-six hours. The secondary or systematic constitu- tional effects beg-in within ten days to tlirce weeks. Xew blood vessels are found by the eighth day. — 237 — IMPOTENCE AND STERILITY Rationale oi^ Skx Gland Implantation. The story of sex gland internal secretion therapy can be simply told. Tlie hormone is a cell stimulant, nutrient, and regenerator. The application of the principle is, of physiologic necessity, far reaching. It may in a measure serve to reconcile Bichat's humoral pathology and the cellular pathology of Virchow and prove them to be equally logical, but only half truths. .V more highly developed neuropathology probably will be the connecting link between them. The germ, however, will not grow less important in etiology, but, as time goes on, undoubtedly will be aggrandized as a causal factor of disease. In brief, the micro-organism will be more clearly under- stood as merely the agency through which most ])athologic machin- ery is set in motion. Should implantation ever become an established therapeutic procedure, as it seems logical to predict that it will be, it doubtless will be found that the required dose of internal sex gland secretion will be p;overned by: 1. The age and general bodily vigor of the recipient of the gland. 2. The age and presumed general and sexual vigor of the dead subject from which the gland was taken. 3. The disease and the stage of disease for the cure of which implantation is (lone. The quantity of tissue implanted. The cause of death of the donor is of vital importance. The safest subject is one dead of violence. Subsequent experience may show the safety of using glands removed from subjects dead of various diseases, notably nephritis and disease of the heart. Let us hope for this, as selection restricted to subjects dead of violence greatly limits the possible supply of eligible material. Subjects dead of infectious diseases, or affected by malignant disease, whether or not it is the cause of death, and those of a known cancerous heredity especially, are to be avoided. Aside from their dangerous charac- ter, testes removed from subjects dead of general infection undergo softening and decomposition with astonishing rapidity. In general, subjects dead of either acute or chronic infectious disease are not promising sources of sex gland supply, for two reasons: 1. The possible danger to the recipient ; 2. the lack of vitality of and the rapidity with which at;tolysis occurs in the glands from the donor. It should be borne in mind, however, that the conditions in which gland im])]antation is indicated oftcii arc such that even con- — 238 -- SEX GT^AX]) IMPLAXTATIOX siderable risk might be justified. On the average, the dangers of infection cannot equal in gravity those of the formidable surgical operations that we daily perform, and implantation per se is not dangerous to life. Perfectly normal and entire testes and ovaries are not absolutely essential. Fragments of normal portions of gland tissue taken from sex organs may be utilized, where neither the subject nor the gland is affected by malignant disease, tuberculosis, acute or chronic infection — purulent or other. When the recipient of the gland is known to be syphilitic, syphilis in the donor may be disregarded. It possibly may even add to the value of the gland. The uninfected glands of patients dead of tuberculosis are likely to be especially valuable, if the applicability of the method to the treatment of tuberculosis should be proved. Theoretically, tuber- culosis should be found to be an inviting field for sex gland therapy. The only theory of treatment of the disease that has stood the test of time is that of nutrition, first, last, and all the time. The in- ference regarding the indications for sex gland implantation is obvious. In any general bacterial infection of chronic type there is systemic reaction of ordinary glandular, internal, and lymphatic secretion. The lymphatics, in the attempt to filter the toxic sub- stances and the internal secretory glands, stimulated to hyperactivity, act in combination with the other defensive factors to overcome the infection. vSex glands taken from an individual who has developed a relative immunity to the infection by means of his natural physi- ologic resistance, and thereby decreased the relative virulence of the infecting organism, theoretically should possess, ccrteris paribus, special therapeutic potency. Transplanted to an individual suffering from the same disease, the hormone of such glands should increase cell resistance and stimulate to greater activity the physiologic nutri- tive-defensive cycle, thereby aiding in overcoming the infection. In treating experimentally tuberculosis by sex gland implanta- tion, we therefore may use glands taken from subjects dead of that disease. There probably is little or no danger of local infection if the glands are macroscopically sound. The ovary, especially, should be safe, for it rarely is affected by tuberculosis, and even in the testis primary tuberculosis is rare. The hormone from the internal secretion of the implanted gland might be less in quantity and in- — 239 — IMPOTENCE AND STERILITY ferior in quality to one from a normal subject, yet potent enough to restore the balance of nutritive defense against the tubercle bacillus. The excessive sexual activity noted in many victims of tuber- culosis is here worthy of consideration. Is there a relative excess of gland activity with excess hormone thrown out as a defense, with coincidental sexual excitation, or is the tubercle toxin itself a psychosexual stimulant ? The author would suggest that the Fauser- Abderhalden test might show some interesting results in this field. In cases of complete castration in either sex, a double implanta- tion is likely to secure the best results. Obviously, even admitting that a single gland is therapeutically sufficient, double implantation gives one hundred per cent, better chances of success. In impotence and sterility in the male, it would seem rational to implant an entire gland, not only from the viewpoint of the dose of internal secretion, but also becavise of the more profound psychic effect thereby at- tained. A successful anastomosis possibly might restore the procre- ative glandular secretory function. In certain cases of sterility in the female, where the secondary sex characteristics are not marked, or the general vitality is low and there are no mechanic pelvic im- pediments from malformation or disease, a large dose of ovarian internal secretion possibly may stimulate the recipient's ovaries and induce fertility. This also applies to certain males in whom sper- matozoa are formed, but in whom they are small in number and feeble in vitality. The age of the subject from which the sex glands are taken for implantation is of great importance. Subjects from about the age of puberty to twenty-five, or perhaps even thirty years of age, are best, as at this time sex gland function is very active. The younger the subject — below eighteen or twenty year.s— the less the danger of encountering syphilis, and the more active the propensity for growth after implantation. Obviously, the danger of syphilis is relatively less at a given age in the female than in the male. Glands from subjects much younger than pubescents eventually may be found to be of especial value in meeting particular indications, more especially as pubescence is not really necessary for the production of hormone. The author's best results have been from glands of subjects at about the age of puberty. Again, we possibly may secure good results from the implan- _ 240 — SEX GLAXD IXfPLAXTATTOX tation of glands taken from subjects of relatively advanced age. Testes from donors of even the recipient's own age at least may prove effective. Advanced age is associated, not only with a senile quality of internal secretion, but also with a relatively deficient quantity. The successful implantation of a single generative gland logically would increase the supply of internal secretion by one- third, with proportionate benefit to the recipient. The foregoing remarks apply especially to the male, in whom the procreative period — and probably also the internal sex gland secretory period — lasts much longer than in the female. In dementia praecox and allied conditions, a healthy gland taken from a subject at any age below middle life possibly may be effective, if, indeed, sex gland implan- tation should hereafter prove to be effective at all in such cases. Racial distinctions possibly need not be drawn in procuring implantation material, unless anastomosis is proposed. Theoretical- ly, sex gland activity is likely to be greater in certain donors than in others, merely because of racial qualities. There is even a serious question, also, as to whether the tissue and blood elements of the recipient of the anastomosed gland would not eventually overcome any racial potentialities that might exist in the implanted gland. This the author found experimentally to be true of skin epithelium in cross grafting skin in negro and white, in 1880, a result verified by other experimenters. Tuffier asserts that transplantation of the ovary from white to black and vice versa fails of success. The author's experience in this regard is limited to a single case. On March 18, 1914, he im- planted in the axilla of a white woman aged sixty-seven years, afflicted with senile dementia, an ovary from a mulatto woman of forty years, dead eight hours of disease of the heart. Although greatly shrunken, the implanted gland apparently was still living three months later. Presumably, while the local results might be of briefer duration than in homotransplantation, we still would obtain adequate hormone results. That the W'assermann test should be employed where practic- able goes without the saying. It must be remembered, however, that no more than a single test can be made on a dead body, and the test alone cannot be relied upon to eliminate the danger of infection. If it is shown later that freezing of the sex glands does not seriously — 241 — IMPOTENCE AND STERILITY impair the chances of success in implantation, there will be no necessity for urgent haste in implanting the gland, the work can be done with deliberation and a Wassermann test always will be practicable. The danger of syphilis is minirnized by the probability that Treponema pallidum lives but a few hours after the death of the host. Freezing probably kills the protozoon within an hour or two. If, therefore, frozen, or even refrigerated, glands should be shown to be satisfactory for implantation, the danger of syphilis would be practically nil. That refrigerated glands are available the author's work has conclusively demonstrated. In passing, the author would suggest that, from the hormone therapy standpoint, it would be interesting to study the results of cross implantation of the sex glands of male and female. The ex- periment, at least, is practicable. The author reports herewith (Case VI), a case in which he implanted a testicle in a senile female dement.* As to any essential difference between the male and female sex gland hormones in their influence on sex development, the author has this to say : The primary sex characteristics are probably laid down in the initial combination of the male and female gen- erative gland secretions — i. c, ovule and spermatozoon — and are inevitable phenomena in embryologic development. The hormone, apparently, merely determines by its activities the secondary sex characteristics. Once these have developed, it may be a matter of indifference whether the body cells, even those of the sex glands themselves, are fed with male or female hormone. Accepting this hypothesis, the ovarian hormone should be therapeutically effective in the advilt male, and vice versa. Possibly the male hormone is more powerful and likely to be more effective than even the ovarian, in the sex gland therapy of the adult female. The persistence of typic sex characteristics, sexual power and desire in animals castrated late, after the internal secretion has done its work — e. g., geldings — is here again worthy of note. * Since this foregoing experiment was made the author's attention has been called to Steinach's unsuccessful experiments of ovarian implantation in castrated male animals. Steinach makes no comments on the hormone therapy usages of such experiments. (Jahrbuch 6 flir sexuelle Zwlschen- stufen, January, 1914.) — 242 — SEX GLAND IMPLANTATION Apparent Physiologic Effects of Testicular Gland Implantation. With due regard to the difficulty .of excluding the psychic ele- ment in therapeutic experiments, particularly as regards subjective phenomena, whether the experiments are of the auto variety or the hetero variety, the author will present the apparent results of his own auto-experimentation. Apropos of the possible "psychic" element in his observations, several facts should be remembered : First, the experiment primarily w'as designed merely to decide the question of the feasibility of successful implantation of sex glands from a dead subject ; second, the local discomfort, a certain degree of ap- prehension, and the inconvenience resulting from the operation were such as tended, during the early postoperative period, to offset un- due optimism based upon subjective sensations ; third, the apparent results were such as are logically compatible with our knowledge of internal secretions, particularly of the sex glands ; fourth, the im- plantation per se practically was a success, even though the gland proper from biologic handicaps did not pern:anently endure; fifth, subsequent observations of numerous cases have verified the con- clusions to which the auto-experiment led, so far as the effects of the sex hormone on nutrition are concerned. The phenomena here recorded were, so to speak, "by results." Originally presented for what they were worth, more comprehensive observations of subsequent work have more than confirmed them. The transient exhilaration usually experienced from cocaine did not follow the use of the mixture of novocaine, quinine, and urea hydrochloride. Despite considerable pain and some natural apprehension as to local results, there began at the end of twenty- four hours a marked exhilaration and buoyancy of spirits, lasting for about twenty-four hours, at which time considerable swelling of the operation field and adjacent parts had developed. Possibly the stimulation experienced was merely delayed action of the local anesthesia. Later experience, however, apparently has shown that it was due to the absorption of secretions from the semidecorticated gland, which absorption temporarily ceased synchronously with the development of inflammatory exudate about the implanted tissue, or because of temporary exhaustion of the supply, the gland not having — 243 - IMPOTENCE AND STERILITY as yet begun to function. This is termed by the author the "initial dose" of hormone. On the seventh day after the operation the author again be- came conscious of stimulation and buoyancy so marked that he took an undue amount of exercise, also attending the theatre in the evening. It was on the day following that increase of local dis- comfort led to an attempt to remove the implanted gland. Follow- ing the traumatism incidental to removing half the gland, the sense of stimulation disappeared, to return on or about the tenth day, suggesting that the second period of stimulation was synchronous with the beginning of the establishment of vascular adhesions and consecjucnt functioning of the gland, with absor])tion of internal secretion, i. c., what may be termed the "secondary or physiologic dose" of hormone. This was checked by the traumatic reaction in- duced in the implantation bed, but recurred as soon as this began to subside, and was marked for several weeks, being gradually re- placed by what might be termed a normal consciousness of unusual physical and mental vigor. While the sense of stimulation was at its height, ability to en- dure physical and mental labor with much less than the usual amount of rest and sleep was noted. This gradually lessened, pari passu with shrinkage of the implanted tissue, but both physical and mental efficiency still remained far greater than before the implantation. Blood pressure seems to have been greatly modified. As recorded by different observers on two varieties of instrument it gradually fell from 140 — systolic — to an average of 125, at which it persisted for some months. At present writing it is 125. The foregoing record is presented without comment, save to remark that the reduced blood pressure has been associated with con tinuation of increased mental and physical vigor, and was taken irj each instance when the author was working under "a full head of steam." There was a distinctly perceptible change in the bloodvessels. A moderately varicosed condition of the veins of the legs and arms markedly improved. The temporal arteries, which had been de- cidedly and disquietingly prominent, became indubitably smaller, and their walls softer. Pari passu with shrinkage of the implanted tis- sue and diminution of hormone dose, the vessels have become more — 244 — SEX GLAXl) IMPI.AXTATIOX ]}rumincnt. but by no means so prominent as before tbe experi- ment. There has been no change for some months past. .\. decided change in the heart action has been noted in a cer- tain direction. For some years frequent attacks of cardiac irrita- bihty — probably due to overindulgence in smoking, combined with mental overwork and the worry incidental to the exigencies of practice — had been experienced. Often palpitation on retiring prevented sleep for several hours. This symptom entirely disap- peared and has not recurred, save as rarely induced by digestive disturbance or colds. While the dose of internal secretion was at its height, a very ])eculiar symptom was noted: Glasses which had been comfortably worn for some years seemed to be a "misfit." Little attention was paid to this, however, there being no suspicion that the ocular dis- turbance bore any relation to the results of the experiment. As the sanie interesting phenomenon occurred in the case of ovarian transplantation shortly to be presented, the author concluded to record it here. The explanation of the symptom would seem to be a stimulatifjn of the muscles of accommodation. The condition is still slightl}- noticeable. A test of accommodation by Dr. J. E. Colburn, ]\Iay 14, 1914, showed it to be practically the same as at his last examination, nearly four years before. There had been, if anything, a slight increase in the range of accommodation. There was an increase of ten poitnds in weight within about eight weeks. This may or may not have l)een significant. There was an improvement in the circulation of the skin, so marked as to excite comment by persons who had no knowledge of the experiment. Incidentally, resistance to cold appeared to be increased. The hemoglobin record which had ranged from ninety to ninety-five for some years, since the implantation has been 100 plus. As no test had been made for some time prior to the experi- ment, this deserves no special em]:)hasis, yet it might not be amiss to call attention to Case \'ir. The efi'ect of the implantation on the sexual function was merely what might have been expected from local irritation of the genitalia in any normal individual at the same period of life. As to what might result in cases of impaired sex function, no deduc- tions could be drawn from this particular experiment, save that — 245 - - IMPOTENCE AND STERILITY the psychic effect of reflex stimulation and the increase of tone should be markedly beneficial. Case III is more to the point. As to what might result from a dose of internal secretion larger than that afforded by the portion of gland finally remaining in situ, in a person whose mental faculties are not under stress and preoccupation, a definite opinion would be premature, but a decidedly stimulating or perhaps permanently tonic effect should logically be expected, judging by the report of other cases of testic- ular implantation shortly to be recorded, and judging by our knowl- edge of the relation of general well-being to sex vigor, and the marked improvement in physical and mental efficiency resulting from a moderate dose in my own experimental case. Supplemented — where indicated by the mechanic vascular con- ditions — by resection of the vena dorsalis penis, as modified by the author, successful sex gland transplantation should not often fail to relieve impotence where the sexual organs are properly developed and serious brain or cord disease does not exist. Brown-Sequard noted a pronounced stimulation of the func- tion of the bowel following the self-administration of his animal extract. As a victim of a rather constipated habit the author re- grets that his own experiment was not attended by a similar result. The author had been annoyed for fifteen years or more by marked keratosis of the soles of the feet, which, combined with an eczementous condition of the flexures of the toes, gave much discomfort. Nothing seemed to benefit the condition. The idea of curing it eventually was abandoned, the occasional application of palliative ointments being the final recourse. About four weeks after the implantation experiment, the skin of the feet had become normal, with an unusually healthy color. By February 27, 1914, the skin was as soft and flexible as that of a young person. No remedial applications of any kind had been made for several months. Possibly it may be contended that the improvement in the condition described was nothing but a coincidence, but it cer- tainly must be admitted that it is not incompatible with the probable effects on nutrition of internal sex gland secretion. (Note also Case VII.) Cranting for the sake of argument that the change in the skin really was due to the internal secretion of the implanted gland — and this the author believes to have been the true explana- — 246 — SEX GLAND IMPLANTATION tion — what may we not expect from the action of internal secre- tion on the blood vessels? At present writing, Aug. 1st, 1917, the keratosis has not re- turned, and the skin is still normal, save at the borders of the soles, W'here in certain limited areas it is dry and slightly eczematous. From the author's experience in his own case he is inclined to believe that psoriasis and kindred diseases are due to perver- sion of internal secretion. The results of sex gland implantation in Case VII have led to the firm conviction that this theory of their etiology is well grounded. As to the possibility of the cure of certain chronic diseases of the skin, the general principle is self- evident and no comment is necessary. Carrel and Guthrie assert that transplanted exogenous glands can function only temporarily. The kidneys of the cat, trans- planted in the same individual, survived. When transplanted from one living individual to another, they excreted urine for three weeks, at the end of which time they ceased secreting and the animal died. This has little bearing on the exogenous transplanta- tion — at least for therapeutic purposes — of the sex glands in the human being. (See author's Case VI.) The sex gland, by virtue of its internal and external secretory structures, is a more highly specialized organ than the kidney. It is also a doubly functioned organ. The kidney is distinctly an excretory organ, while the testis and the ovary are not, in the true sense of the word. The true generative secretion in either sex is not thrown out for elimination as useless or toxic matter, but, on the contrary, its physiologic function does not begin until after the discharge and organic union of the secretions of the two sexes. The organs which produce the generative secretion are more active, more highly organized, and more energetic than the kidney. So highly specialized are their functions that no other organ can act vicariously for them, as can the skin and bowel for the kidney. When the generative secretion ceases or is prevented from escaping from the sex glands, the organs still function importantly — producing hormone.* Again, as already stated, even though the implanted gland finally should perish, its work of general cell regeneration has • E. Illlmann, Annal.s of Surgery, August, 1914, reports a case of func- tionally successful anastomotic transplantation of the kidney from one dog to another. — 247 — IMPOTENCE AND STERILITY been to a greater or less extent accomplished, with beneficial results which may be permanent. Then, too, apparent atrophy does not necessarily mean that the interstitial cells (Leydig) are destroyed. Considerable diminution in bulk even may occur from various causes without the generative function itself being destroyed. That the conditions are different in the two varieties of gland is shown by comparing the results of Carrel's and Guthrie's lower animal kidney transplantation experiments with the author's own autolmman and heterohuman sex gland implantations. Theory aside, the experiments related in this volume have conclusively proved that, as regards formation of new blood supply and sur- vival of the hormone producing cells and internal secretion therapy, transplantation of sex glands, even from the dead body, is both practicable and successful. As to Carrel's belief that practically the only hope of success in gland transplantation in general is in a close blood relationship of donor and recipient, the author believes that, while such relation- ship is highly desirable, he has proved that it is not essential to either sex gland hormone therapy via implantation, or to prolonged survival of the essential elements of the gland. The author has further confirmed this view by experiments on fowls. It is note- worthy that Carrel and Guthrie's conclusions from their experi- ments on the kidney of the cat, if accepted as final in their bearing upon gland implantation in general, would reduce to a minimum the practicalit}^ of Carrel's own discovery of the persistence of tissue vitality after somatic death, so far as its application to the hormone treatment of disease is concerned. Apropos of implantation of testis from distinctly alien sources Guthrie* reports a case of transplantation of a testis of a guinea fowl to the shoulder of an ordinary domestic cock. The implanted tissue disappeared. In passing, it might be interesting to Dr. Guthrie, if he has not already made the observation, that it is possible to crossbreed the guinea fowl and the .-Vmerican game fowl, hence they are not as alien to each other as might be supposed. The author saw, a little over a year ago, a bird — apparently a male — so bred on the farm of Mr. H. B. Gleezen, the well-known game fowl breeder, of George- town, Mass. Journal of lOxpciiniciital McHlicinc, xii, 1!H0. — 248 ~ SEX GLAND IMPLANTATION -^ -^'^-rsi^ The exogenous transplantations of ovaries from the Hving to the living in sheep and guinea-pigs, reported by Voronoff and Castle, support Carrel and Guthrie's conclusions, but there still remain the questions: 1. Whether diiterent results may not occur in human beings ; 2. the possible therapeutic value of implantations of human sex glands, with or without permanent life and function of the cells of Leydig, even though generative gland tissue atrophy inevitably should occur. Case II. Successful implantation of ovary from a subject twenty-three hours after death. Mrs. J., aged fifty-nine years, suffered from the nerve wreckage incidental to a pelvic operation performed fifteen years ago, and also from hepatic and gouty disturbances. The uterus and appendages were removed. A "piece of the ovary" was said to have been preserved. The author explained to this woman the objects and e.xperimental nature of ovarian implantation, and she was brave enough to submit to the operation. Too much praise cannot be bestowed on her for co-operating in the experi- ment. The implantation was performed Alarch 3, 1914. Ovaries, were taken from an apparently healthy girl of sixteen years, a virgo intacta, dead twelve hours of skull fracture. The operation was performed eleven hours after the removal of the ovaries from the subject, and twenty-three hours after death, Dr. Michel assisting. One ovary, the left, was implanted in the left labium majus, this location being selected because of the obesity of the patient, and our desire to study the local results of the implantation. There was no marked tissue reaction, only slight tenderness, very little pain, and no rise of temperature, the wound healing by primary union. The patient was up and about on the fifth day, reporting at the office on the ninth day. She might have been up sooner but for a persisting vaginal prolapse and vesicocele since the operation of many years ago, which required self-inserted tampons to permit locomotion. May 14, 1914, the implantation appeared to have been successful, the ovary was still in situ, and of course, "living." The case was examined by several physicians, who found that the ovary still was plainly' perceptible. It is obvious that Mrs. J.'s case was a severe test of implanta- tion. After fifteen years of neuro]:»athy and loss of sex function, with other disturbances alien to the latter, a great deal was not to be expected of the method. A com])lete failure of therapeutic results would not have disproved the efficacy of implantation in general. (The same may justly be said of Experiments IV and V.) Apparent results in Case II. Making due allowance for psychic effects, the author will present the report of the patient and her family. Briefly, this is as follows : There was a marked exhilaration for the first few days, interrupted one morning by what the patient termed a "slight nervous chill." — 249 — IMPOTENCE AND STERILITY Oil the seventh da^' she complained that her glasses seemed to be no longer effective, and that she could not see with them to read or crochet. She then asserted, and appeared to demonstrate, an unwonted flexibility and comfort of action of her knees which, she said, had been "stiff and lame for several years." Her "hot flashes" disappeared. She no longer experienced an almost constant sense of exhaustion, and arose refreshed in the morning, whereas she stated, she formerly arose as tired as when she went to bed. She stated that she apparently needed less sleep. She was formerly annoyed by som- nolence on inappropriate occasions. This disappeared. Having in mind the "initial dose" of hormone, the author is inclined to credit the patient's state- ments as to early effects. Blood pressure was not changed ten days after the operation. After the first ten days, the patient gradually lost the primary effects. March 24th, however, she reported great increase in physical endurance, stating that she could climb three flights of stairs without discomfort or cardiac disturbance. Formerly she was compelled to aid herself by holding on to the baluster. She reported again, great increase in endurance, with improvement in the digestive functions and complete disappearance of the joint stiffness and of a feeling of numbness and coldness in the limbs asso- ciated with uncertainty of locomotion which had troubled her for some years. Blood pressure still was unchanged, registering 150, the same as before the implantation. Complete relief of constipation of many years' standing was also reported. Four weeks after the implantation, there was a marked change in blood pressure, which Dr. Michel reported to have after- ward ranged from 125 to 130 (systolic). On April 27th, it was 125. May 14th, it was 125. Two different instruments were used in making the record. Dr. Harry S. Gradle, who had been making a study of Mrs. J.'s accom- modation, reported that it had improved remarkably while the patient was under his observation — a period of four weeks. The patient made a severe test of her physical condition during her spring housecleaning, and experienced only the normal degree of fatigue. She stated also that an obstinate, frequently recurring bilateral sciatica of over thirty years' standing had entirely disappeared. About July 1st, she had a moderate transient, unilateral recurrence, following mental disquiet. Au- gust 1, 1914, the improvement in the subject's condition still endured. The implanted ovary, although diminished in size, still could be distinctly felt. Blood pressure, vSeptember 10th, was 128. The condition of the 1)owe]s was not so good as at previous report, although still better than before the im- plantation. I'ollowing a severe nervous shock, the patient recently was in a very unsatisfactory condition. Later she improved, but now is said to be in bad health, although much better than before the implantation. Both she and her family were so gratified by the results of the implantation that they are anxious to have another performed. Case III. A man, aged fifty-eight years, commercial traveler, who, for a period of five years had been under the author's care from time to time for partial atonic impotence, consented to submit to testicular implantation. — 250 ^- SF.X Gl.AXD nrPI.AXTATIOX There was no local disease or abnormality. Somewhat less than half of a testis was implanted, the material used being obtained from the body of a man, aged thirty years, ten hours after death produced by contact with a live wire. The implantation was performed thirty-six hours after the death of the donor. The recipient was somewhat neurasthenic, as naturally was to have been expected, but was apparenth' in excellent health and well pre- served for a man of his years. The implantation was performed, March 14, 1914, Dr. Michel assisting. The portion of gland was partially decorticated and implanted in the left side of the scrotum, in contact with the cord, immediately posterior to the testis of the recipient, the technic being essentially the same as that employed in my autoexperiment. There was only moderate reaction after the implanta- tion. This had subsided by the twelfth day, at which time a moderately firm, circumscribed, movable mass of glandular outline could be felt at the site of the implantation. During the process of healing the patient expressed himself as conscious of a remarkable stimulation of sexual activity. Accord- ing to his account of the subjective symptoms, this began almost immediately — four or five days — after the implantation and continued during the progress of healing. Obviously the psychic element must be considered in connection herewith, as there was very little inflammatory reaction and the patient was not at all apprehensive of accidents. Nocturnal erections began on the second night after the operation and recurred regularly while he was under my observation. On the fourteenth day the patient left the city. A letter received from him, June 15th, was worthy of note merely as bearing upon his condition at that time. Quoting this letter, the points of interest are : ". . . The erections at night have continued regularly. They have rarely occurred before during the past four or five years. The erections are not quite as strong as in my younger days, nor so long continued, but the sexual act is natural again and is not followed by great exhaustion as was formerly the case. . . . The lump where the piece of gland was planted has shrunk somewhat, but 1 feel sure that the gland is alive and hearty. ... I am still feeling fine and much more vigorous than I have felt for years." The evident improvement in this patient's sexual function cannot reasonably be entirely explained by the psychic effect of the implantation. Nocturnal erections dissociated from erotic dreams do not occur from purely psychic impressions. As to the influence of local irritation, this might explain the sexual stimulation occurring immediately after the operation, but naturally it would have subsided later. On July 20th, this patient presented himself for examination. The implanted mass of gland tissue was still perceptible and about the size and shape of a good sized almond. He asserted that the improvement in sexual vigor still persisted. No observations were made of the physiologic effects of the implantation in this case, save to note the blood pressure — which was 165 (systolic), and has thus far had undergone no change — and to examine the semen microscopically, which was normal, July 20th. January 15, 1915, the patient again reported. The implanted nodule — 251 — iaipoti<:nce and steiiility had almost disappeared, but was still perceptible on careful palpation. Im- provement had been maintained and the patient was very enthusiastic. December 29, 1916, the patient reported himself as still doing well, and very much pleased with the results of the implantation. In a recent letter he claims to be still satisfied with results. Febrtiary 21, 1914, the aitthor's attention was called to a masterly paper by Dr. Bayard Holmes, of Chicago, "The Non- mental Character of Dementia Praecox." It was interesting to note that Fauser's experiments in the diagnosis of dementia prsecox and allied conditions, which experiments had not previously been brought to the author's attention, were complementary to the theory on which he had been working, in endeavoring practically to administer internal sex secretion in various conditions. Follow- ing Abderlialden's theory of "dysfunction," Fauser found that the Abzvelirfenneut or defensive ferment in the blood of patients with dementia prsecox reduced the antigenlike material made respectively from the testicle or ovary, according to the sex of the patient. He finally established his test as a reliable diagnostic procedure. Sum- ming up his studies of the Abderhalden test and its application to the insanities, Holmes says : 1. The evidence accumulated taken with many other factors indicates that dementia prsecox is a condition or disease in which the secretions of the genital glands are greatly perverted. 2. As a part of this disturbance of the balance of the internal secre- tions, many other glands are coincidentally disturbed. 3. This "dysfunction" of the genital glands may be and is likely to be due to various peripheral infections, such as are found to produce dysfunc- tion of the thyroid. 4. The Abderhalden reaction promises a method of diagnosis which can be applied early, in pedagogic and penal, if not judicial laboratories. 5. The psychogenetic theory of dementia ought to stand aside and give way to research into physical conditions and etiological factors and methods of prevention and cure. 6. Every institution that makes any pretense to psychiatry, even every reformatory for juvenile offenders, male or female, should have a laboratory fitted out for the defensive ferments reaction. Adding to the list of causes of dysfunction imperfect or aber- rant sex gland development, leading to dementia prcecox and allied conditions, the etiologic picture is complete. I>i the light of Fauser's observations, the conclusion is obvious that the logical indication in dementia prcccox is the administration — 252 — SI-.X CI.AXl) IMIM.AXTATIOX of mtcnial sccrctiuii. or a comhiinitioii of secretions, hi iiitf'hnita- lioii of sc.v (jhmds -wc iuvvc llic iitosi Uxjical mclhod for the odniiiiis- tralioii of probably the iiiosi iniporlaiit of all the iiilenial seereti(>)is ill llie field of psychiatry. If the essence of the etioloi^y of denientia ])r;ecox reaUy is a (l_\'sfiniction of the sex ,<^'!an(ls. then tlie in(hcations are esiieciahy clear and lo<4icaL It must l)e remenihered. however, tliat. ahhou.yh. it is c(jnceded that the indications for sex gland implantation seem to l)e especially clear in dementia prjecox. h\' the time the diagnosis is made, considerable organic netn^on change mav have occttrred. with a restilting permanent aberration of function. Cnlike other lirgans. compen>ator\- actifjn of ])rain cells ])robal)l\' will not (jccur and conserve its mental functions. A moderate im])airment of the structure of the hepatic or of the renal cells mav not be manifested by any ap])arent change in the health of the subject. In the case of the kidney, vicarioits acti(jn of other eliminative areas may in- definitely keep tlie subject in apparently good health. The slightest impairment of the delicate, highly specialized brain netiron strticture almost inevitabl}- will l)e followed by a greater or less degree of luental deterioration. The hebe])hrenic tyjje of dementia pr^ecox jjrobably is the mrjst ])romising one for honuone thera])}'. While diseases of the nervous system in general seeiu to be a ])romising field for sex gland secretion theraj)}", early administration is tirgentlv necessarx' to give b(jth the ])atient and the remed\' a fair chance. Kegeneration of strtictttrall}' damaged, delicate neuron, nerve hl)re, and ganglion cell is rather more tlian can fairh' be ex])ected of an}' remedv. fn the earl\- stages of kjcomotor ataxia and ])arcsis, im])lantation seems to be worthy of trial. The disastrotis effects of the spirochete are largely due to the cell toxemia it produces, and to the pressure of vasctilar cell intiltraticjn. The resttlting damage is of a ntttri- tional ty])e. and the indications seem to be clear enough. Chronic inel)riet_\' offers considerable inducement for sex gland therapy. The innutrition and nerve instabilit)' which cause the cell to "cr}'" for alcohol. (|uite likeh' can ])e met Ijv the hormone of the sex gland secretion, administered in one form or another, preferably, l)erha])S, b\- im])lantation. C.iven a reiuedy which really stinnilates the nutriticni of nerve -~ 2??> — I.Ml'OTKNCI-: AND STl-RfUTY tissue, and the ])()ssibilitic's of scr\icc in tlicra])}- arc boundless. There are few chronic ch'seases in \\hicli the nervous s\'steni is not more or less involved, with resultant trophic, sensorw or motor pertttrbation. Apropos of the ])ossible benefit of internal sex gland secretion in arterial conditions in which sy])hilis is the primary etiologic factor, the analogy between senile and sy])hilitic vascular changes is suggestive. In enlarged prostate, benetit possibly might occur from sex gland implantation through. 1, relief of the senile etiologic element through improved nutrition ; 2, antagonism to the bacterial infection element — gonococcic or colon — which is such an important etio- logic factor in ])rostatism ; 3. resolution of the adventitious (in- flammatory) tissue, more or less of which is found in the enlarged prostate. In dementia priecox the etiologic possibility of syphilis should be seriously considered before resorting to implantation. Here the Wassermann test is of great service. Syphilis unquestionably is res])onsible for some cases of dementia ])r;ecox, or at least of a certain ])roportion of cases which fall symptomatically under that nomenclature. The author ((ualifies merely becaitse the Fauser- Abderhalden test mav force the adoption of a new nomenclature. In a case of alleged dementia praecox in a boy of twenty years, seen about five years ago, in consultation with a most competent alienist, the aitthor diagnosed syj^hilis. The Wassermann test proved negative. No history of .sy])hilis had been recorded. During a fairly lucid interval, the patient finally related an escapade of intoxi- cation and ex])osure to infection, a ])romptlv and mistakenly cauter- ized ])enile sore of brief duration ap])earing later. Careful ins])ection showed a fairly ty])ic adeno])ath}' and a s])arse, fading maculo- ])a])ular sy])hilide. The ])atient recovered under s])eciiic medication and now is a])parently ])erfcctly well. As a ])resumptive verification of the diagnosis, a retinal or choroidal hemorrhage occurred, un- doubtedly because of neglect of treatment, some nK)nths ago. de- stroying the vision of tlie affected e\e. It ma\' be remarked that s\'])hilis in the reci])ient ought not to be regarded as a contraindication for inii)lantation. The disease may act as other infective diseases ap])arentl\' do, by a toxic influ- — 254 — SEX GLAXI) IMPLAXTATIOX cnce on the internal secretory function of the sex glands. Anti- syi)hilitic treatment is indicated, but the impression made by the infection upon the sex glands luay be such that treatment is ineffect- ive. Here gland implantation is worthy of trial. v^enile cataract and its associated conditions in their incipiency are an attractive tield for experimental work with sex gland hormone via implantation. v^hould sex gland implantation prove even moderately effective in checking or im])ro\-ing the conditions incidental to at least a moderate proportion of cases of senility, arteriosclerosis undoubtedly will be considered amenable to treatment. As to incipient senile dementia, the inference is obvious, and the author believes this to be a very ])romising held. Possibly certain types of ])rostatovesical disease and chronic rheumatoid affections of the joints also may ])rove amenable to treatment. The thought occurs to the atithor that the sex gland hormone possibl}' nu'ght increase the resistance of the brain cells to toxins and improve their nutrition sufhcientl}' to correct the ttnderlying neuropath}' of epilepsy. X^eurasthenia. in the author's opinion, more often is a pttrely sexual phenomenon than generallv is sttspected. It seeminglv is due to causes which, directly or indirectly, affect the production or composition of sex gland hormone. Long continued emotions of all kinds, especially sex emotion, ]:)rodtice it. \\'orry, cerebral over- strain, sexual desire without gratification — sometimes even sexual life withotit desire — sexual excess, frecjuent child bearing — or no children at all, after the proper age — irritation of the sexual appa- rattis, innutrition from any cause, all are disastrotts. ])robably through vitiating the quality or lessening the quantity of the hornu.ine wliich. in the sex gland nutriti\'e cycle, is necessary to the structure and functioning of both the internal secretory and genera- ti\-e secretory gland cells themselves. Chronic infectious diseases, such as s_\])hilis. may be assumed to act upon hormone ])roduction in tw(j ways, \\/..: 1. Worry, ])r()(lucing nutritive depression and ])erverte(l chemism ; 2. intoxication — inhibition :ui(l ]ierversion of t unction f)f the internal secretor\- ai)])aratus. The result is ]m-o- loiuul neurasthenia. Tlie exhaustion ])roduced b\- anv disease is merely neurasthenia. ])robabl}' ])ro(luced 1)\ internal secretorx' dis- I.MPOTKNCK AND STERILITY turbancc affecting the production of hormone, the natural rejuvc- nator of nerve energy. Possibly so called ])hysical exhaustion is due to the same cause, and not altogether to "fatigue" toxins. ]\Iay we not believe that all the vital functions really are mani- festations of hormone activity, acting upon neuron, ganglion, and nerve fibre? Other hormones are essential, but is it too much to say that the sex hormone is most important of all ; in brief, the most potent link of the endocrine cvcle ? It is probable that a hormone complementary to the testicular hormone is produced by the prostate. The markedly beneficial results of prostatic massage in sexual neurasthenia might be ex- ])lained by. first, reflex stimulation of sex gland activity; second, liberation and aljsori)tion of sex hormone by mechanical pressure ; lliird, the stimulant and tonic eff'ect of the hormone on the nervous s\'stem. The administration of sex gland hormone via implantation pos- sibly may prove serviceable in malignant disease. It certainly is worth trial. The germ theory of the etiology of carcinoma has not seemed to the author well grounded, indeed, he is of o])inion that the nearer we come U) a ])erfect knowledge of the internal secretions, the nearer we shall be to the true etiology and rational therapeutics of carcinoma. In an}' event, wh;itever the aljuormal impulse may be, the result is ])erverted cell growth, and we may at least regard hopefully any remedial measure that ])roniises improvement in cell nutrition. To ])ut tlie author's view of the etiology of malignant disease concretely, he believes that there is more than a chronologic coinci- dence in the association of sarcoma with childhood and youth, and of carcinoma with later life. A disturbance of cell nutritive equi- librium from perverted cpiantity or ([ualitv — or ])()th — of internal secretion — probably of the sex gland, the thyroid ])erhaps ])laying an im])ortant ])art — in mv o])inion underlies both varieties of malignant disease. The sex gland hormone theoretically should restore this ecpiilibrium, making in effect the cells of the sarcoma older and stronger and those of the true carcinomata younger and stronger. In the light of the foregoing view of malignant disease, the theory of C'olmheim is csi)eciallv a])t in its ai)])lication to ma- lignant disease of earlv life, and to sarcoma and the other varieties of carcinoma at any age. - 2.i6 - SEX GI.AXD IMIT.AXTATIOX 'Jlic association of cancer witli the ai)])roach or occurrence cjf the nieno])ause. and witli advancin.i^" age in the male, is sui^gestivc of change in the sex ghuid hormone as the cliief underlying factor, I^pithelioma of the skin, especially, may be compared to psoriasis, in that a defect of nutrition due to ])erversi(jn of internal secretion and localized by special factors of irritation is a reasonable underlying cause. 'i'he role of micro-organisms in carcinoma ma\- eventually I)rove to be merelv that of a special determining factor of perverted cell growth through the irritation ])roduced. and ncj more "specific" than traumatism, which so often a])pears to be the ])oint of de-- ])artttre for malignant disease. 'rh_\-roid extract has been stated to have cured psoriasis. This is not stir])rising. The thvroid and sex gland hormones seemingly are complementar}-. Thxroid defect ])ossibly may be the more im- portant factor in malignant diseases of early life. Diseases dtie to defective (jtiantity and (juality of either, or of both hormones. ])erhaps ma}' be cured by either, bttt possibly may reqtiire a c()m1)ination of both. The one thing needful in thyroid implantation may be a simultaneous sex gland implantation. It is the author's firm conviction that the administration of sex gland hor- mone l)y implantatinn — with or without thyroid hormone, as events ma\- ])ro\"e — is well wortln- of trial in malignant disease. As to whether beneficial results will follow organotherai)y. this naturally will be determined bv factors independent of the etiology of the disease. Cask 1\'. Dementia praccox, catatonic type. Woman atied twenty-six \'ears. family histdry unknown. dvn"ation of disease ])robably more than six years ; \\'a>sermann negative. Operation. March 8, 1914. Site of implanta- tion, deep within tlie ])elvis in the properitoneal space on the right side. Incision about 1.2.T inch long, just internal to and slightly below the anterior superior spine of the ilium. Alaterial used, portion of an ovar\- removed from woman of twenty- four years during a tumor operation, and refrigerated for thirty liours. It should be noted that a gland removed from a living sul)ject and refrigerated is e(iuivalent to one removed from a dead stibject at a corresijonding ])eriod after death — prior to beginning decomposition — save where the donor died oi an infectious or an exhausting disease. The wound healed Ity pirimary imion. Xo rise of temperature. The case was examinetl on ]\[arch 22. 1914, The implantation appeared to be success lul. The mental status was unchanged. At the second examination. May 11. l'U4, the im])lanted gland appareiuly was still /); .'situ. There had TAJPOTENCl-: AND STJ^RILITY been no iniprovenieiit in the menial or i)hysical status. The author examined the case. July 26, 1914. The implantation /ry- sc probably was a success, although on account of its position the gland could not be palpated. The mental status still was absolutely unchanged. ]\ven granting the potency of the method, under favorable conditions, a negative result should not be surprising in such unpromising cases as 1 \' and \', or in such as subseciuently were experimented upon. C.\SK v. Poiiciitia praccox. (jirl, aged seventeen years. Duration of disease, about three years Pro])ably a masturbatory habit. No family history. Wassermann negative. Operation, March 8, 1914. Site of im- plantation, right labium majus. Alaterial used, the com])anion to the ovary implanted in Case II. This had been merely refrigerated, but not frozen, for a week in normal salt solution. A Graafian follicle had just ruptured at the time of death of donor, and the corjjus luteum was beginning to form. Examination, Alarch 22, 1914, showed that this implantation probably was a success. There had been a slight rise of temperature, owing probably to coincidental incision of redundant labia and slight resultant infection. The wound healed by ])rimary iniion, but a small, apparently superficial al)scess formed near the implantation site bed. This was opened and drained. The o\'ary still was ;';; situ. .May 11. 1914, the oxary still was in situ. There seemed to be a slight im])ro\ement in both the physical and mental status. .■\t the last examination, July 26, 1914, the im])lanted gland tissue was barely discernible on ])alpation. The mental condition was found to he remarkabl\' improved. There a])peared also to be considerable improvement in the patient's jjhysical condition. ySo marked was the improvement in this case, that a reasonable number of such apparent results justly could be regarded as ])ro]):d)ly confirmatory of the theory upon wliich the implantation was based. Front what is known today of the internal testicular secretion and of the influence of the ovarian internal secretions it])on secondary sex characteristics and the functions of the nervous sys- tem, especial!}- in the light of Fattser's hlood dia<>iiostic ohservations, the internal secretion of the ovary seems to he logically indicated, not onlv in earlv cases of dementia pra'cox and allied conditions in the female, htit es])ecially in certain severe cases of hysteria, the nerve wreckage that often follows com])lete sttrgical removal of the o\aries, in severe and ohstinate cases of neurasthenia, and the netiro])athy of the nieno])atise. Will such henelicial efTects as nia\- he secttred hy a more or less continuous dose of internal secretion incidental to sttccesstul sex gland implantation I)e ])ennanent, /'. <'., will the result he mcrel\- temporary stimulation rather than what ma_\- he termed "regenera- tion ?'" ^- 258 — Sl'.X CI.WI) I.MI'I.AXTATIOX ()l)viousl\", niaU'rial from the li\iii.L:' sul)ic'Cl with iniiiie(hatc' transference from donor to reci])ient is tlie mo>t (lesiral)le method when availal)le — as it rarel_\- is, the effects, liowever, will be no better. C'asi- \'I. This, in a sense, is tlie most reniarkahle ui all oui" inii)lania- tion cases. Woman, ni^vd sixty years, senile dement. At tlie time of the im- I'ii^. 1. — Slio\\'ing jjostei'ior l)or(ler of imphmted testis, with site of removal of epididymis, (A) and extensive vascular areas. (Case VI.) j)lantation she apparently was in good healtli, save as to her mental condition. Wassermann ne.gative. With thi' douhle ohiect of the p(^ssi1)le l)eneticial etTecl of the male se.x hormone in senile dementia in the female, and deter- miniiiL;' whether sex tilands coiiUl ])e successfully transplanted for therapeutic purposes from the one sex to the other in the human hein.ii'. we made a cross implantation in this case, Alarch 18, 1914. in this case the possihle effects in tieneral of the te>ticidar hormone on the secondary female sex characteristics coidd he ahsolutely iiiiiored. The gland emi)loyed was the right testis of an apparently health) man, .aged thirty years, dead from contact with a live wire The donor had ])een dead ten hours when tlie testis was removed. The gland had hcen refrigerated for four days. — 2.S9 — lAll'OTl'.NCI': AX I) STl'.RIT/ITY Till' gland wa:- carefully prciiarcd l)y rcniuxing the epididymis and slight- ly denuding the tuhuli hy excising four longitudinal strips of tunica albiii^inca about three mm. in width, extending lor the whole length of the gland. The entire gland was used. A transverse incision about 1.25 inch in length was made, about four inches above the symphysis pubis, down to the aponeurosis of the recti. The wound was pocketed downward for approximately two inches, and the testis implanted at the bottom of the pocket. The fascial opening was closed with a ])ursestring suture of tine catgut, the skin wound with a catgut continuous suture, and the line of closure settled with collodion and gauze. Healing was prompt, aseptic, and afebrile. Considerable swelling Fig. 2. — Anterior border of im]>l;inted testis, showing multiple vascular areas. (Case VI.) develoi)ed at the site of the implantation and the patient complained of slight tenderness on light pressure. The skin was somewhat reddened after a few days, and the implantation seemed likely to be a failure — as had been exi)ectcd. ]\luch to the author's gratification, however, su])puration did not occur, and the case did far better, so far as the size of the mass which survived was concerned, than any other of our early testicle im- ])lantations. Alarch 28, 1914, the im])lanted gland could be distinctly outlined on ])alpation and was fairly movable. There was no longer any tenderness at the site of im])lantati()n. May 11, 1914, the surrounding exudate seemed to have disapj)eared and the gland was circumscribed, freeh- movable, and appi'ared to be as large as when imi)lanted. July 2(>, 1914, the mass seemed considerably,' smaller on ])alpation ; it was moderate]}' consistent to the feel, — 260 — Si:X C.l.WI) IMIM.AXTATIOX I'i'k'. ,1. — l.arcral view en' implant cd testis with minicrdus \-ascular areas. ( (."asc W.) still I'rcely iiKA'ahle, and inscnsilix e. 'i'licrc had liccn no change in the physical or mental status. ]'*or ])urposcs of stnd.w tlie in.iplanted testis in the foregoing cross implantation was removed inider novocaine. July 17. 1914. The measure- ments of the excised mass were 4 cm. in length, 3 cm. in lireadth. and iimm. in thickness at its thickest ])art. The gland proper was surrounded hy a pseudocapsule of connective tissue and fat. The tunica alhuf/iiica clcarl}' showed, liere and there, and contained numerous small blood vessels. A'ascu- lar attachments to the surrounding tissues were distinct, evidentlj' at the points of denudation of the fitiiica albiKjinca. The ])oint of severance of the epidicK^mis was flattened and showed a broad area of vascular adhesion. 4. Lateral \ iew of im]}!anted te.-^tis with mimcrous va-cular areas. (Case \'l. ) ^ 261 — njPOTHXCE AND STERILITY Fig. 5. — Longitudinal section of implanted testis. (Case VI.) The mass weighed 9.5 grams. The proper capsule of the gland, the tunica albui/iiica, and the connective tissue of the mediastinum showed beautifully. The substance of the mass, within the tunica albuijinca, was of a yellowish color, and to the naked eye, distinctly fatty. Tlie macroscopic and microscopic findings are shown in the drawings ( I'igs. 1 to 12). Needless to saj^ the author was astonished to find living tnlnili scminifcri and ducts in addition to a more than normally rich vascular sui)ply and a surprising abundance of interstitial cells. I'Vom the results in this case the author concluded that im])lanted human sex glands from either sex may survive in the tissues of the opposite sex, there being no greater tendenc\- to necrosis, and perhaps less rapidity of degeneration than in homosexual transplantations. It is a striking fact that, before removal, the bulk and outline of the timior and the conditions later shown in the s])ecimen were more strongly indicative of a successful im- plantation than were the conditions in our early homosexual experiments in I'ig. 0. -Transverse sectidu of im])]an(e(l testis. (Case YI.) — 262 — Sl-.X GLAND TMPr.ANTATIOX '\ii. 7. — 151(>()(1 vessels, connective tissne, and fat in periphery- tunica alhntiinea — of iini)lante(l testis. (Case VI.) b'i>^. 8. — X'unierous new blood vessels, fat, and connective tissue in and l)eneath the tunica alhu.uinca of implanted testis. (Case VI.) — 263 1.\1P()TKXC1<: AND STKRTIJTY citlicr tlie male or the female.* Xo phj-.siologic observations were made in this case. As already noted, no mental nor phj'sical improvement followed the imi)lantation of the testis, but as the subject suffered a fracture of the neck of the femur about ninety days after the imi)lantation, it would be difficult to determine whether or not the testicle hormone was of any value. C.\SK VII. Man, aged fifty-three j'cars, musician, consulted the author Tune 10, 1914. Always a hard drinker and a gourmand; no history of syphilis; Wassermann negative; history of two tappings for ascites, six I'ig. 9. — Showing area of proI)al)l\- dead, and another of distinctly vitalized tubuli seminiferi with an abundance of living inter- stitial cells in implanted testis. The vitality (jf the glandular tissue and the ([uantity of interstitial cells increases from the center toward the periphery' of the implanted gland. (Case VI.) years before. A diagnosis of cirrhosis of the liver was made at that time. When the ]iatient was first seen, his alxlomen was enormously distended with fluid. Jaundice had appeared a few da\-s previously and had become (|uite ])ronounced. No pain was complained of, nor was there any historj' of ])re\'ious ])ain. On the scalp, backs of the arms and forearms, the elbow^s. the front of the right leg, the buttocks, and the lumbar region, were large ])atclH's of severe, typic jjsoriasi^. from which the patient h;id suft'ereel for many years. 'I'he p:itclu's on the arms were (piite symmetric, each measuring about 15 cm. long and 9 cm. wide. Those on the leg, six in number, averaged * Tn exiKM-inu'nts on fowl.';, the most dofmitc* ro.'jult tlie author thus far lias olitaiiH'd was from an imi)Uintat ion of a testis of a yoimj? cockerel upon a jinllct foui' months f)lcalii and hiittock^ were of \-ariuus and moderate .-^ixes. A patch oi" psoria^i.^ nu-asurinu 7 cm. hy 9 cm. existed on the abflumen. in\'ulvin,u a small portion oi the skin co\ering an umbilical hernia. 'JA\m ])atches on the lumliar re.s^ion mea-nrerl re-pecti\el_\' ahont 6 and 8 cm. The subject was \-ery weak and markedly- incommoded b\' the enormous bulk of his abdomen. His appetite had been excellent imtil a few days before, since when it had rapidly failed. June 14th. the author remo\ ed nearly ~ix gallons of dark bile-stained transudate fr(jm the abdi,)mina] ca\ity. affording tlie patient great relief. I'ig. Id.- Section near peripberw al-o showing gradual increase of vitality- of gland tissue from the center toward the peri- jiliery iif implanted tt'-ti-. (Large am^'unt >■( interstitial ti-sue. ) ( Ca-e \' 1. ) The liver was now found to be greatl\' enlarged and indurated, showing plainly through the collapsed abdominal wall. The gall bladder was greatly distendefl and its walls thickened and hard. In the left iliohypochondriac region was a hard, oblong mass extending downward from the under surface of the li\'er for alxnit four inches. I'rom its location this ttuiior might have been either renal or (jmental. It couUl not be defmitely determined that it was attached to the liver. Several hard, irregular masses were noted at the left (jf the median line in the umbilical region. There was a good sized umbilical hernia, e\'iflently now containing oidy fluid, which freely flowed back and forth under pressure. This had been unsuccessfulh' operated upon some }'ears ago. The indue contained bile in large amount and a small (piantity of all)iuuin. but no casts. The patient's heart was very weak — 265 ~- iMPoTicxci-: AX I) sti-:kility following the operation and strvclmine was i;iven hypodermically for sev- eral days. l{nconraged by the observations wliieh already had been made oi the ai)parent effects of the sex hormone ni)on nutrition, and especially upon that of the skin, and with a clear understanding on the ])art of the patient of the experimental nature of the i)rocedurc, the author resolved to make a testicle implantation in this case. On June 19th, we planted in the patient's right scrotal sac a testicle, with the epididymis excised, removed from an ajjparently healthy sul)ject about twent^'-one years of age, dead about thirty hours before from contact witli a live wire. Ice had been packed around Fig. 11. — Free and attached interstitial cells with contiguous tul)uli seminiferi in inii)lanted lesti:-. (Case A'l.) the testes for jierliaps four hours. The operation was done ten hours after the renio\al of the testis from the dead subject, /. ('., forty hours after death of the donor. The local postoperative course was vmeventful for two weeks. The wound apparently healed by ])rimar3' union and there was very little swelling about the site of the imjjlantation. Until the fourteenth da\- the implantation jwr sc seemed to have been successful. On the third day after the implantation improvement was noted in the skin erui)tion. l!y the eighth day after operation, the lesions were so im- ])roved that they scarceh' could be recognized as i)soriasis. The skin of the leit arm was nearly normal. The i)atches upon the back and scalp had entirely disappeared. The jaundice had improved, the blood i)ressure, which was low on account of the patient's debilitated condition, had increased, the pulse was ])erce])til)ly stronger. ai)i)etite greatly increased, the hemoglobin, Avhich was a])proximately sixty per cent., was now seventy ])er cent., and — 266 — SEX GLAXD l.M PLANT ATIOX there was a distinct iniprovemeiit in color of llie skin, aside from the lessen- ing of the jaundice. A considerahle reaccumuhition of fluid already had occurred. The white cor])U- over 21. ()()(). falling rapidly after the third day to about what it was originally. The ol)vious explanation of the ra]>id rise and fall in the white cell count was an ephemeral reaction to a foreign body. There wa- at no time any noticeable effect on the sexual function, which had been in abcwancc for several \'ears. ]''i,g. 12. — Section from area of peri])hery of implanted testis, cor- responding with site of the epididymis, showing vein contain- ing blood and vasa effereiitia. (Case \'l.) There were no areas of softening or of fatty degeneration in the interior of the gland. The Sertoli cells could not be distinguished. The blood and skin conditions continued to improve and the patient grew stronger — de.-])ite an cxten.^ive reaccumulation of fluid in the peritoneal cavit\- — until the fourteenth day. The ])ercentage of hemoglobin had rapidly increased to 90. anrl llie red corpuscles, which showed 2.27?S)i)i) at the time of the im])lantation. liad increased liy the tenth day to .^6()().l)()(). varying from day to day. but at no time falling ])elow 4. 001). 000 before the close of the ca-~e. The --ill.- of ibe p:-oria>i- on ihc left ai'ui and buttock> now had become jiracticallv normal, and that on the right arm and leg nearly >o. The patient a^-ertei[ that hi^ teetli. whicli bad liei-n so tender :'.nosiu"e to ins|ieclion tbex' pro\ed to ])v merely thickened and liarden.'d |)ortions of omentum. The spleen and i>anci'eas were i.'irrliosed. The kidnt'vs slinwed niarltitia1 nephritis. 'I'he author does not recall i'\HT having met with a case with such e\tensi\e alcoholic pathology. There --- 2()H ~- SJ'.X CJ.AXI) IMiM.AXTATIOX \sri> 111) c\iiiil()t^ic cxaminatinn oi the li\er sliowcd tyi)ic cirrho-ii-;. The iniplaiiled testis was carelessl_\- j)reser\'e(I. and wlien >uhniitted for hi>tul(),L;ic >tiid\- \va> fmiiid ti:i l)e so decmnposed as to l)e wortldess for stud_\'. 'Idle lore.yoiny case was a se\ere test of sex .yland implantation and tlie apparent results upon the hlood and >kin were correspondint;ly noteworthy. A- a i)rohal)le index to the i)hysiolo,L;ic effei'ts (.)f the sex hormone, the ehaiiKes iii the ])soriatic skin were phenomenal. That the subject received the heiietit of hoth the initial and the >econdary ])!iy that tlu' testicle elaborated hormone until the >crotal infection occurred. ;> period of two weeks. That any remedy what-oe\er could ett'ect such niarkefl changes in the C(.indition ot the blood and >kin in so unpromising a ca>e as the fore.uoin.e. is remarkable. Xo treat- ment (jlher than ini]dantation, •^a\■e attention to the bowels, was i>'iven. The changes hardly could have been ^jjontaneous in a ca>e in which there existed no natural tendency to improvement. The survival of the im])lanted testis for so loiiK a periocl in a subject in which the nutrition of the tissues of the donor was so impaired is in itself ])henomenal. The a])parent improvement in the biliar\' obstruction, aiul the diminution in size of the li\'er and omental masses arc merely ncjted as clinical phenomena, with no suggestion of any pirobable relation to them of the sex hormone. 'Jdiey obviously are susceptible of other explanations, which harflly can be true of the skin and blood phenomena. 'J'lie action and interaction of the ini])]antc'(l \-oun,2; "-land and its senile, or even niiddle-a_n'ed environnient, are worthy of seriotts cemsidcration. 'I'o what extent an a^q'ed environnient of nerve inflti- ence and tissue juices eventually will alter the l)iochcniisiu of the iiu])lanted ,^-land intist remain an o])en f[ttesti(Mi. Stihse(|ttent experi- ence has seemed tfj show that, while the inland atro])hies perha])s a little faster than in }-oun.y"er soil, its life is iirolont^ed sttfficientlv to >ecure marked action of the hormone- That the imjjjanted inland wi'! henetit more or less 1)\- the im- ])roved fjualit}' of the hlood ])rodttced h}' its own internal secretion seem> lo.q-ical eiuni.^'h. To what extent anrl for how lon,^^ a time is ])rol)leniatic. The inte,<4rit\- of tlie ^'land ti>~~tie and the qualitv and ([tiantity (.f its ])ro(hict ol)\-i()U>]\' are laro'eK' dominated 1)\' the elements on which it fecfls. Imidanted \oun,i^- ^land tisstie ])ossil)ly may not lon^' remain \'otm,<^' when fed on]\- 1)\" the l)]ood of more mattire, and c-^ijecialh' of -^cnile life. l'"ac]i ^ex inland is a lahoratory : the ^'land cells are the worker>. These workers select from the hlood ihe materials for the elahoraiion of hoth the iniernal and procreative 269 lAFPOTENCE AND STERILITY secretions. C])()n the (|uality and quantity of these materials depend the quahty and (juantity of the finished product. '^I'he end result of implantation, therefore, possibly may be merely the elaboration and absor]:)tion into the blood of a larger quantity of internal testicular or ovarian secretion than the reci])i- ent's own glands are capable of ])roducing, this secretion eventually becoming of the same ([uality as the subject's own secretion, in this event the benehts derived from iiuplantation w'ould be only such as would result from a constant dose of a larger quantity of internal secretion, of a ])otency identical with that produced by the reci])ient's own glands. If it should i)rove to be true that a gland im])lanted in an elderly subject becomes greatly moditied by its new environment — which modification should not be astonish- ing, for "the cell is what it eats" — then the same consideration would even more forcibly a])ply to a gland taken from an elderly donor and implanted in a younger recipient. The nutrition of an old, but still functioning gland probably is more likely to be im- proved by young blood than a young gland is to be deteriorated by old blood. This suggests more leeway in procuring material. It eventtially may be shown that there are s]:)ecial indications for the selection of a gland from a donor of relatively advanced age as best ada])ted to the condition in hand. Mow far the trophic influence of the relatively aged nerve supply of the implantation site may affect the permanence of im- plantation results would Ije difficult of conjecture. It is hardl}' ])nssible that a comnuinitv of nerve supply, sensory or tro])hic. or both, could l)e estaljlished l)etween the im])lanted gland and the investing" tissues.'" If. however, we ever succeed in greatly im- peding the wheel of time in its remorseless grind upon human life — and the author is willing to confess optimism — it is most likel}- to be through the agenc\- of internal secretion thera])y, via gland implantation. As to what glands, or combinations of glands, will ])rove most efficacious, the futtux alone can show. The sex * The ri-siilts nf ini pbi lUa t ii jii in several of oui- cases ai'e iiiteresUns- and iin]iorlaiit in their relaliims (ci the elTin-ts of fatal eleclrieal shock on cell vitalits' in general, and possihlN nia\ lia\e a lu'arinL; upon the ]>ossiliilit>- of resuscitation aflei- siiiipesed death Ironi the electric current. The author belie\-es tliat ctdl \'italit\- \aries with the dosai^e ol' and duration of e.\|iosure to the current. l)(iul>tless in snnie eases the seX .ulands would not l),' suitable inateiial for ini- phuit.'i lion. — 270 — SI-'.X ("J.AXI) lAirr.AXTATIOX gland secretion seems to l)e the most important of all the internal secretions so lar as its ]»ossihle ettects in increasing etViciencN' and lon<4"e\-it_\- are concerned. Indeed, it may be a ])o\\erftil stinnilant to the activit\' of all the (jther hormone ])r()dticing orgatis. In any event, senilit_\- and its control are merely a matter of ntitrition. If a complementar}- hormone shotild he fotmd to be necessary to the ftill ])h}siologic action ot the sex gland hormone, it mav ])rove to be the thyroid, ])itttitar_\'. pineal gland, or the sitprarenal — or several of these in combination. 'Jdie thyroid swelling incidental to menstrtiation and sexttal excitation so freqtienth' manifested in cases of hyjjerthyroidism certainly is ([tiite sttggestive. 'J'he pro- fotmd nntriti\-e ettects of thyroid internal secretion are familiar enongh. Possibly the ettects oi the sex hormone (tn the thyroid i-^ in a --ense "inhibitory."' rather than com])lementary. the th\-roid running riot, so to speak, with restilting hyperth\'roidism when the intittence of the sex hormone is removed. Granting this hypothesis, (iraves' disease wottld be an indication for sex gland implantation. \\". Blair Hell says, in reference to correlation of the internal secre- tions in regard t(j their genital fttnctions : ^^'hen the reproductive functions cease and the ovaries atrophy at the menopause, tlie harmony between general and genital metabolism is tem- porarily deranged, and various disturbances may ensue. The basis of treat- ment is the administration of the necessar}- secretions. Some patients react to tluToid extract. S(jme t(j pituitary, others, again. Xo coml)inations. so great are the indi\'idual \ariatiiins. Strictl\" speaking, the o\'ary is concerned onh' in the temporary function of reproduction, and. by its hormones, of bending the metabolism of the body t(; its purpose. As accessory to these functions the ovar\- has been supposed to be responsible for the beauty of the vessel by means of which its ends are io be attained. I)Ut toda>" one is beginning to w(.)nder how far the ovary does influence secondary sex characteristics, and whether full secondary- characteristics can be ol)tained by the influence of the ovary alone. There is evidence that hyi)erplasia of the suprarenal cortex can upset an\' influence that the female genital glanrl ma\" possess, and can i)roduce in a female some of the secondary characteristics of the male. Any influence the ovar}- has over general metabolism is, then, related to and dependent on its primary reproductive function. It probably does not influence metabolism except in so far as this special function is concerned. Removal of the ovaries may produce temporary disturbance, but this does not in\'alidate the view mentioned. The rest of the ductless gland system is related to the genital functions in various ways. The thyroid, pituitary, and suprarenals influence the — 271 — ].MPf)TliXC]<: AND STJ^RIMTY development and subsequently preserve the integrity and activity of the genitalia. Others — the thymus and possibly the pineal — appear to prevent sexual precocity. All the ductless glands control metabolism in response to the necessities of the genital functions. In addition they adapt the whole organism to the possibility of the situation, and regulate the secondary characteristics, both ])hysical and psjxhical, to suit the needs of the individual. Once, however, the reproductive organs are removed or undergo atrophy, the l)rimary genital functions of the rest of the ductless glands cease, and the rearrangement of the metabolism that follows produces what are known as s3'mptoms of the menopause. Contrariwise, insufficiency of the thyroid or suprarenals causes the cessation of the genital fimctions with atrophy of the uterus. The ])()ssil)ility of sex ^'land ini])lant;iti()n increasing lons^'evitv reqitlres special consideration: A sticcessftil implantation niay not api)reciably alter the strtictnre of the recii)ient's tissues and organs, although the effect on the skin and blood ])resstire of the expei"i- ment outlined in this volume naturally is suggestive. The viscera in general, and es])ecially the heart, l)lood vessels, and the nerve and brain tissttes, may remain essentially the same, yet, even grant- ing this, further senile changes should be retarded if, as seems ])robable. the internal secretions of the generative organs eventually are })roved ])rofoundly to affect nutrition. In l)rief, we may hope to retard senility even if we cannot "citrc" it. The ((uestion at once sttggests itself, .Might not the stimttlating effect of the secretion defeat its own ends by exposing to overstrain organs — notabl}- the heart — alreadx' senile? Possibly, even prob- ably, it wotild do so, unless the increased efiiciency was conserva- tively em])loyed. I^ven if an increased capacity for long stistained and considerable nntscttlar effort and increase in res]:>iratory ca]!acity should result, no one who is otit of training shotild expect great tolerance of severe stress on heart, wind, and limb. It has occttrred to the attthor that sex gland implantation is likely to give the most satisfactorx' resttlts when employed at or abotit middle life, with the view of retarding senility and preserving efiiciency, or increasing it. if it is below ])ar. The normal man of forty xears. possibl}'. might at least retaitt the vigor of forty years until more adxanced age. The man i)ast middle age with impaired efficienc)' would be likel\- to hax'e liis (.'fficiencN- restored. Sttccessive im])lantations, ot cotu'se, might ])r()ve to be necessarw We have shown that ini])lantation of the re])r()dtictive glands is especially — ni — S1-:X CJ.AXl) IMIM.AXTATIOX effective in yonny' sul)jects with (lefecti\e i)h\sical sextial and psychosexnal de\el()])nient. and in stil)iects who have l)een trau- niatically deprived ot the i;enerati\e glands — recentlv in voung subjects, or at any time in sul)jects ])ast the age of pnbertv. In connection lierewith it is well W remember that the eti'ect shoitld be more marked in young subjects in whom the chief secondary sex characteristics never have been normally develojjed, than in older subjects. ('.ranting that the method ])roves valuable in mental conditions, stich as dementia ])r;ecox. the degree of benefit and ])ermanence of results of sex gland imi)lantation will de])en(l tt])on: 1. 'J'he age of the ])atient. 2. The s])ecihcitv and acti\-itv of sitch infective cause as mav be determined. 3. The ditration of the disease and the amount of secondary degenerative changes. 4. 'J'he degree to which perversions and defects of other in- ternal secretory glands enter into the etiology. 5. 'Jdie dose and activity of hormone. 'J'he ])robable efficiency of sex gland trans])lantation in sextial perverts and inverts, in whom the normal ])sychic or physical, or both, sex characteristics are poorl}- developed, at once suggests itself. Paresis seems to be a suitable lield for exi)erimentation with sex gland im])lantation. and the author already has operated in tw(j cases, in which, however, local failure ])revented aity possible therapeutic results. The third case is tcjo recent to permit tis to draw conclusions. S\philis in the donor ma}' here be disregarded. It is an interesting qtiestion whether many of the mental vagaries and moral perversions that so often develo]) after middle age are not due to a lessening or ])erversion, or both, of internal sex gland secretion. \\'e are wont to attrilntte these conditions to strtictural arterial changes, but the justice of this is doubtful. Future ex- ])erience with sex gland im])lantati()n seems to me likely to change our \iews in this regard. Indeed, even where arterial changes are proved, a defective sttpplv or vitiated (|ualit\- of hormone some- times mav be the \-er\- essence of the etiologw The mental al)erra- tions which so fre([tientlv follow castration in either sex are sug- gestive in this connection. — 273 — IMPOTENCE AND STERILITY Tlic possible detrimental action of the secretions of the im- planted gland n]X)n the functions of the recipient's own glands has in a way been decided by Aletchnikoff's experiments. In 1898, he produced "serums" from both human and lower animal semen. He killed the spermatozoa in the serums l)y heat. When injected intra- venously, these serums destroyed the s])ermatozoa through the medium of a cytotoxemia. 'J'his toxemia was temporary, the sperma- tozoa finally acquiring immunity. Since the ex])eriments herein reported, examination of the seminal secretion in several cases showed the secretion to l)e normal in each instance. In one experi- mental case the wife of the subject conceived a few months after the implantation. Obviously, if destruction of S])ermatozoa resulted from im- ])lantation because of toxicity of a large dose of alien secretions, the evil could be only temporary, unless the anatomic and physio- logic machinery of their elaboration was destroyed, and this would involve, first, impairment of testicular structure in the recipient ; second, aberration of nervous su])ply ; third, i)erverted blood consti- tution or, fourth, a combination of two or more of these conditions. In the author's first paper in 1914 he said : "Should sex gland implantation prove to be as great an advan- tage in therai)eutics as the author is inclined to believe, we soon will relegate certain gland extracts to the dead lumber room and use only the physiologic living extracts, administering them continu- ally via implanted gland tissue. And who shall say how far the ])rinciple may be ap])]ied if tissues from dead l)odies can often be successfully used? vSex glands, thyroid, liver, pancreas, brain, s|)leen, kidney — it is impossible to say where vito-organotherapy will end, for it is by no means certain that all tissues have not a selective action on the blood, or a s])ecial biochemic action, the fresh ])roducts of which are of therapeutic value. In brief, each tissue l)OSsibly manufactures its own sj^ecial amnnmition — antibodies — with which to combat disease, and even if growth of the implanted tissues should not occur, it is ])ossible that a sufficient dose could l)e given and a stifficiently prolonged action secured, to accomplish valuable results.* * In pas.sing-, it is worthy of comment as a medical curiosity tliat tlie muc'li derided ('al)anis, in tlie latter part of the eighteenth century, asserted that tlie brain was a seci'etory organ, "secreting thoughts just as tlie stomacli secretes bile." — 274 — SEX GLAXD LMPr.AXTATIOX ■"In the li.Li'lit of AlxIcrlialdenV wonderful work, it mav evciit- uallv be shown that. 1)_\- a special, selective, trophic action, every hiyiih" s])ecialize(l tissue and ort^an of the body, whether glandular or not. elaljorates an internal nutritive metabolic prodtict — "secre- tion" — of its own. The atuhor wotild suggest especially the ad- visabilit}- of ex])eriniental subcutaneous administration of emulsions of fresh human brain tissue in certain derangements of the brain and nervous system. s])lenic tissue in certain anemias, heart tisstte in cardiac disease, thyroid in h}'poth}'roidism. kidney tissue in renal diseases, hmg in pulmonary disease, liver and pancreas in diabetes and of sex glands in various conditions." The author since has experimented in this manner (in 1914) with emulsions of renal tissue from a recently dead human body, on the guinea-pig. and en one human suljject. Xo harm resulted, save a transitory orchitis in the gtiinea-])ig. As already stated, he also has experimented extensivelv with htiman brain emulsion. Possibly the hormone of the internal secretion of glands, or certain metabolic ])ro(hicts. elaborated by certain other tissties. is taken up by the blood, returns to the tisstte. and stimulates its ordi- nary vital functions. This "secretion-ntttrition-c\'cle" — if we may be so bold as to coin a term — perha|)S ma\' be necessary to the normal life of the tisstte itself. How far one internal secretion may su])plement another, is a fascinating tield for s])eculation that already has received attention in this volume. The author is especially inclined to believe that, in certain cases, the sex gland secretion may be a powerful adjtivant to thyroid or other hormone therapy, especially where simultaneotis implantation of sex glands is ])erformed. As for extracts of glands (jf the lower animals, their field oi usefulness probably always will l)e liiuited. while as for implantation of such alien tissues, failure naturallv should be expected. A priori it would seem as illogical as was the old method of transfusion of blood from the lower animals — }et such implantations ])ossibl}' ma_\' have a certain range of thera])eutic usefulness. Since his fir>t series of experiments were made and the greater ])an ()\ this clia])ter was written, the author's attention has been called to some \'ery interesting ol)ser\-ations which, so far as the\' ,l:o, sc-r\e to strengthen the ])osition herein recorded regarding the \alue of sex gland trans])lantation hormone therapy. — 275 — IMPOTENCE AND STERILITY Leopold-Lcvi reports a case of rheumatism and ])Soriasis, asso- ciated witli liv])o thyroidism. siiccessfullv treated with tlivroid ex- tract. Ill another case of ])soriasis excellent results followed the administration of "testicular ])()wders." (larre. of IJonn, has expressed himself enthusiasticallv rei;ard- inj^- the pros])ects of thyroid im])lantation. He savs : Traiis])laiitati<)n of the thyroid will rc\'olutioni/.c the work of the social worker within a few years. Crime, idiocy, the lack of develoi)ment in children, det^eneracy will he lessened through the knowledge of this reniark- ahle organ which is jirst dawning upon ns. To the tln'roid ha\e heen traced thousands u])on thousands of cases of stunted growth, o\ mental imdevelopment. of idiocy, and sucii defects. An tmdeveloped thjToid means an undevelo])ed child. Let us take the case of father and son. The father has a normal thyroid, and the son's is undeveloped, hence he is making no progress, mentalh' or phj-sically. We can remove one-third or even two-thirds of tlie father's gland without injuring him in the least, and hy transplanting this to the son can soon hring him to ])ositive normal development. 'rransi)lantation of thyroid from the dead to the livinj;- tmder ])r()per conditions ])rol)ahly is qtiite as i)racticable as transplantation from tlie livint^" to the liviui^, unless, as Carrel has stated and Garre seems to believe, and in a measiu'e contrary to the aitthor's experi- ence with the testicle, donor and recipient al)solutelv must he closelv related. Handler states that he has used ovarian extract with success in dysmenorrhea, the disturbances of the climacteric, atrophy of the tttertis, and amenorrhea. As he tisitally combines iron with the ovarian extract, comment is unnecessaiw. Dubois and Roulet assert that intravenous injections of prosta- tic extract produce a fall of blood ])ressttre. with an associated increase of brain vohtme and a lessening;' of renal tisstie volume. Iscovesco notes the eti'ects of a "li])oid" extracted from the testis and ovarv. Clinical trial of this li])oid in the daily dose ot 0.02 ,<;'ram (one-third of a grain) for thirtv da\s in eleven jjatients stilTcrini^- from hypochondria, or neurasthenia with sexual weak- ness, and in ei^ht a^ed men. restilted in increased _i;cneral \i,^'()r. a better mental attitude, and im])roved ca])acit\- for work. In foiu' of the eis^L; old men the blood ])rc'ssure was lowered. \ esical tenesmus, due to ])roslatic h\])ertro])b\-, in three of the cases, — 276 — SI'.X (U.AXI) IMIM.AXTATIOX disai)i)eared c()ni])letc'ly and |)cniiancntly after an injection of 0.1() i^Tani (two and a half grains) of the li(|uid. Xo toxic eftccts were noted from tlie larj^e doses, either in these ])atients or in the animals. The author la\s stress on the er}-throcytic ])ro])erties of the lipoid and extols it in the treatment of severe anemia, notahly chlorosis, and in severe c(jn(litions of inntitrition. In additicjn to the implantations alread}' recorded herein, the author. ])rior to the c()m])letion of his hrst ])ai)er ( Aut^itst 1, \^)]4). had |)erf(jrmed o])erations in hoth sexes, itsing material that had heen refrigerated from three to seven days. The cases com- ])rised two females and ei_^ht luales. suffering" from various condi- tions, three senile dements, two cases of dementia ])r;ec()x. two of epilepsy, and three of genera! paresis. In two suhjects a douhle im- ])]antation was made. In one an anastomosis of the vas was ])er- formed. In one case, a male, a cross im])lantation was made. None of the suhjects was promising, and as all were institutional cases, a discriminating selection was not ])racticahle. Full}' ai)])reciating this, as well as otlier unfavorahle environmental conditions which :i.re inse])aral)le from ex])erimental work in large ])ul)lic institutions, and while hoping for l)enehcial thera])entic results, the attthor feared that in all the cases the ])rincii)al result would likely he the ac([uire- ment of a hetter knowledge of the limitations of sex gland implanta- tions per se. and he was onlv too glad to avail himself of such material and conditions as were ohtainahle. The resttlt in the ma- jority of the o]jerati(jns can be \'er\- l)riet]\- recorded : 'Jdie im])lantations failed in all of the males and in one of the teiriales, with var_\ing degrees of local infection and temperatin-e. The environmental conditions, the had condition of the subjects. and the ditiiculty of ])re\enting mentalK' deranged suhjects from handling the im])lantation sites, probal)]}- had much to do with the failures, hut the autlior is (lis])osed to charge them cliiellv to the material used. Different restilts ])Ossihl_\- might have been obtained it the implanted glands had been ])reserve(l b\- com])lete freezing. This, however, remains for sttbsec[uent solution. The results ])rob- abl_\- could not fairly be ascribed to the heterologous source of the glands. In ])art of this series of cases the local conditions were favorable for some davs.* Xoto h-lter in X. Y. Medical .Tournal, >[ar. 2:;, 3 914. — 277 — IMPOTENCE AND STERILITY The case of anastomosis in an old man of seventy-five years, a senile dement, was rather interesting. The implantation womid healed, the case was afebrile and looked very promising for about ten days, when the gland and the surrounding inflammatory area began to break down and slowly soften. On the fourteenth day we opened up the ])urulent collection and removed the tunica olbii- giiiea, which was all that remained of the implanted testis.'''' The gland had been refrigerated only four days, and as the companion organ was still m situ, July 26, 1914, in a female dement subject (Case VI) in whom it was implanted on the same day the anasto- mosis was performed, the material probably was not at fault. Anas- tomosis necessarily is a severe test of implantation, even under the most favorable conditions. The donor of the testis was a man of thirty years, dead ten hours from contact with a live wire. In one of the males a double scrotal implantation was per- formed, using on one side an ovary taken from a nuilatto woman dead eight hours of disease of the heart. 'I'he testis was from a subject dead twelve hours of a skull fracture received two days previously. The material had been refrigerated three days. The infection evidently was due to the implanted testicle, spreading to the opposite side for when the organs were removed from the in- fected area on the fifth day, the ovary still was normal and adhesions already were noticeable on its surface. The other ovary taken from the mulatto was cystic. '^^Phe pathologic tissue was excised and a small ovary reconstructed from the apparently normal glandular remnant, enveloped in an ad- herent fragment of broad ligament, and im])lanted, March 18, 1914, in the axilla of a female senile dement, sixty-seven years of age. The wound healed aseptically without any rise in temperature. !May 11, 1914, the gland a])parentl_v still was in situ. On July 26, 1914, a small movable body, a little larger than a good sized pea, still could l)e felt at the site of the implantation. As there was very little gland tissue from which to reconstruct an ovary, and the donor was of a race alien to the reci])ient, the a])i)arent local result of the foregoing experiment is at least noteworthy. There has been no change in the ])atient's ])hysical or mental condition. * .Xnlc hdW tliis (lilTcrcd t'l-oni the condition of llic iniplaiited testis on removal in C^ase VI I. — 278 — SJ-:x cr.Axi) lmpi.axtatiox Xo studies oi the i)li\ sioloi^ic eti'ects of the implantations were made in any of the im])lantati()n institutional cases, for reasons which should be obvious to those familiar with the unfavorable environments aflorded by lari^e hospitals for the insane, where even the most intelli,i(ent, progressive, and enthusiastic staff physicians are handicapped by (j\-er\vork and scanty resources in the matter of laboratory and instrumental ecpiipment. All of the implantations performed were understood bv the relatives (jf the subjects to be experimental, and were done with their full knowledge and consent. 279 — CHAPTER XII. Further Experimental and Therapeutic Work in Sex Gland Implantation. Wiv now will consider more in detail certain features of the researches recorded in the ])receding- chapter and record additional observations which will serve to make the work more comprehensive and com])lete, and it is hoped, even more convincing. The illustra- tions speak for themselves. The photomicrographs are confirmatory of the evidence afforded by the illustrative drawings already pre- sented. Certain experiments upon fowls already have been mentioned, without presentation in detail. A number of experiments were made. Fully comprehending the improbability of securing marked results from testicular im])lantations upon adult subjects castrated prior to the full develo])ment of secondary sex characteristics, and having in mind merely the possible effects of the sex hormone upon nutrition, the author made the following experiment : I. Subject, a Buff \V\-audotte capon, eighteen months old, caponized at the age of four months. Weight, nine pounds. Male plumage distinct.* The almost complete absence of comb and wattles, the pallor of the face, spiritless air, massive development, clumsiness, lack of gloss of plumage, relatively inferior length and bulk of cock feathers, limited appetite, sluggish movements, lack of spurs, and asexuality of the subject were very char- acteristic. April 28, 1914, the left testicle of a normal cock of the "butcher shop" mongrel variety, was implanted in the left side of the pelvis — extraperitoneally — of the cai)(>n. The wound healed prompth'. P>egiiniing about one week after the imi)lantation, the subject "braced up" considerabh'. The plumage ])ecame more glossy, the carriage of the fowl was more like that of the normal male, and the appetite and color were * It i.s neccHSATY io defer caiioiiizinK \in1il the male plumage is fairly wf'll shown and the testes ar(; siiniciontl.\- lai\i;o to be coiripai-atix-ely easily foinid. 'riiis accounts foi- the iircscnci' iil' the |iluinaK(; I'ai-tor of the seeoiidai-\- si'.v cli.'iract crs hi llu' i,-a]ioii. — 280 - SI'.X CI.AXl) IMIM.AXTATIOX greatly iiiiprdvod. I'.y the end (jf tlic second week the iinprovenient in condition \va,-> marked in e\ ery way. and nianiiudatidn of the \ent showed a (Hstinct sexnal rellex Nvith characteristic respond? on the pari of the sub- ject, le~- iinl_\- in deuree tiian in the nnrnial fnwl. The iinjir' i\ en;ent nut mdy did ma continue, Imt deterioratii ^:i occurred ahhouyli at the enfl of three weeks after the implantation the conchtion still was better than prior to the experiment. The sexual reflex had almost en- tirely disappeared. Afeanwhile several hcteroiniplantations of inlands from noiirelated donors were done upon normal fowls, with recovery of the sub- jects, but. as sh(_>wn b\' sul)se(iuent dissection. withoiU success of an\' of the imi)lantations per sc. IT. The left testicle of a small mon.yrel cock, one year old, was re- mo\ed and replaced b_\- the left testicle of a recently killed Black Minorca cock, one year old. There was considerable hemorrhas4e. but the bird ap- parently reco\"ered from the inuuerliate cttects of the operation.* Death oc- curred on the second day. apparently from enteritis with profuse diarrhea. Wound normal. X^o autojjsy. III. A testis from a lar.ye Ihiti' Rock, tifteen months old — the largest testicle. l)y the wa\'. that we e\er ha\e -een in a fnwlt — wa^ implanted ex- traperiiiineally in tlie left side of the abdi)men, ju-t abo\e the groin, of a female Ijiitt Wyandotte, fi\e >ears old. Deatli occurred, probably from en- teritis, on the third day. Wound normal. Xo autops\". In the carl}- ])eri()d of Iti.s work the author did a dotthle hetero- iin])laiitati(jii ti])on a _\ear-ol(l iiKjni^-rel cock, which wa.'^ reported to have (hed six da_\s later from exhattstioii and diarrhea. -\.s this Ijird had Ijceii ke])t ttnder ver_\' tiiisaiiitar\- conchtions and had heen half starved and otherwise al)ttse(h and the operation had heen severe, no signiticaiice had l)een ascril)ed to its death. Xow. how- ever, after the restths obtained in Kx])erinients II and III. we began to consider the toxic ])Ossibilities of ini])lantation. and were perti- nently reminded of the ])henomena of anaph\laxis. said to result occasional!}- from various serttms. and which, frankly, the author had not believed to be dtte to ])rotein. btit to some other sertim content ])r()dticing toxemia. Acute se])sis. dotibtless. practicallv * Till' aullif)!- has nut \'<'t siu-cetM'u-d in iK-n'tM-t iiiK a satisfacl(>r\' tcH-liiiic !'nr i-a.strat iii.u' adnlt hirils. The ribs ar'> tli-ni. the testes too .soft to endure ima-h iiianiiMilaliiin. and tlie \-oss- of tlie inland in fowls. — 2S1 -- IMPOTENCE AND STERILITY could be disregarded in our experiments, as fowls tolerate opera- tions well, where severe hemorrhage can be avoided. When properly performed, caponizing in young fowls does not show over one per cent, of deaths, and this from shock and hemorrhage, or hemorrhage alone. To determine the following i)oints : 1, The effect of successive implantations on the same subject ; 2, the effect of implantation of the male sex gland upon the female ; 3, the effect of large doses of gland tissue upon the female ; 4, the effect of alien protein from the fowl's testicle U]K)n a higher animal ; the following experiments next were made : IV. Alay 21, 1914, the companion testis of tiie one used in Experiment 111, was implanted in the right side of the pelvis — extraperitoneally — of the came capon used in Ivxperiment I. The Ijird seemed indisposed for forty- eight hours after the implantation. He then rapidly recovered. May 29th, the color, general carriage, lustre and carriage of plumage, spirit, activity and ai)petite all were more than ever like the normal characteristics, although hy no means up to standard. The sexual reflex reappeared in slight degree. August 24th, a slight further improvement was noticeahle in the various ])oints mentioned, save as to the sexual refle.x, which had disappeared. The hird was much more active than ever and showed signs of combativeness, fighting a little with strange males — who ver\' ])romptly attacked him. This latter point is imjjortant, inasmuch as normal males at once recognize the capon as in no sense a rival and rarely annoy hiiu. The subject, as before, showed no disjjosition to approach the female sexually. About the middle of November, 1914, the capon was found fighting quite savagely with another bird through the lattice of his coop, and sev- eral times was heard to crow distinctly. The subject still showed no disi)osi- tion to approach the female sexually. Shortly after this the bird was accident- ally killed. That a marked degree of physiokjgic regeneration occurred in this case is evident. So far as it goes, the experiment also tends to show the safety of successive implantations. Obviously the dose was much larger than in httman implantations. Reimplantation in the human subject, if done at all. would be performed only after a considerable interval, and considering this ])()int and the resttlts of the experiment on the capon may be regarded as safe. A note- worthy ])oint is the continuance and slowness of the ])rocess of regeneration. That there should have been in the ca])on any awakening whatever of dormant sex characteristics is remarkable. '^I'here is a vast difference between implantation upon (a) a . 282 v^l'.X CI. AM) IMLM.AXTATIOX \()un,L;' male lliat has recently ]k\-\] castraled or one that has heen castrated after full maturity, and ( h ) a male that has heen castrated earlv and has arrived at full maturity. The difference lies in the fact that in the one instance the secondary sex characteristics may continue to s^row or are already develo])ed, while in the other the secondary sex characteristics never have develo])e(l and regenera- tion is very difficult of accomplishment. ( )nce ])S}chosexuality has developed mid impressed the animal durins^' the ])eriod of growth. Imr. 1. — Capon used in e\]K'rimc'nts T and T\'. the results of its intiucnce remain, oven though sex power and de- sire completely disap])ear. IJoth sex power and desire may, how- ever, remain for a variahle ])eriod after complete castration in adults. \Micre they remain in young animals, the explanation usuall}' is an incom])lete operation. 'I'he author recalls an instan.ce of a gelding that was castrated late, who served mares as normally as could any stallion, llere. the o])eration ma\- or ma\- not havi: heen com])lete. A])ro])os of this point, the high valuation set in the ( )rient upon eunuchs who have suffered complete ahlation of the genitalia is readily understood. — 283 — J.MI'()TENCr<: AND STl'.UII.lTY Fis^'. 2. — Normal full brother of cai)on shown in I'ig. 1. It is ])i-()bal)le ihal. in the experiment: on the ca])on, verv little of the implanted tissue surx'ixed, }-el: it nnist have been snlhcient at least to set the regenerative ])rocess in motion. The a])])lication '*'%ll TL'^'» Fi-r. ;■!.- Section of iit.iinil |,Mi~ ..t c, l,i,l iuui iiionlli- (.1,1, >li.i\viri^- cli.-inicli'i-isl ii'ally ^rcat iil>iiii(hiiic(' .,f i,MHMlixc yl.iiMl h-Mii- llihiih ^. iiniiif. n'l. A, l.'iillcil up cylinder-like- - scjmcnl iif (li Ik il( pi i iIi.im ,i 1 inM-lni(nl, (..iic^i ilin^;- li. the \ iscci\il laxcr of the III,,;,;, ,-,i,i!,ii,h.< :uhI the l,i,ii,;, iill.ii ,,i in ,i ot tcMi- ot lii-hci- aniinaN. H. M.-nle-^lis, /. r.. pen'toiMMJ folil lit i-piili>il)k;. h'i.^s. 1 and 2 show the more imiiortant (hlTerences in the aj)- l)earance of the- head of the caponizecl and of the nncapcjnized fowl Tile hirds are ftill hrotliers of {hv >ame a,^e. \'. An exceptionally lar.iic te-tis iri>ni a nicin.urel cock, one year old. and a small te.-ti> I'roni a White l,e,L;liorn cockerel, fotn" months old, were implanted in the ri,L;ht >ide of the pclvi> -extraperitoneally — of a lhor(.)UL;h- hrcd ki.iilu i'.rahma pullet. I'oiir nioiithi old. At the same time the com- panion testis of the younii ke.Lihorn was implanted in the pullet"s left hreast. That the dose (.)f .yland ti^^ne was :,'normons is ohvioiis. Healin.y was ])ronipt and the -uliject was continuously normal. Sev- em\-tive day.- after im])lantation. the jiullet wa> killed. Autop-y : liody ex- ceptionally ]dunip and well iiouri.-lied. Or.uans normal. Xo vestiiic of the uland implanted in the hreast. Tho-e imi)lantcd in tlie pelvis were livinti". and plainly reco.nnizalde as teste-. \'a>cular supply macroscopically abundant. \ essels oi attachment between the two int])lanted .ylands macroscopicall\' \isible. The lar.yer .uland was a lirm Ijuticular body about 2 cm. lont^'. 15 mm. wide and 1 cm. thick. W'ei.Liht, ,1.05 .yram. The smaller testis was especially \ascular in it> en\ironmem- and its "testicular" conformation especially plain. It nic.'i-iu'ed a])pr' iximatel} 1 cm. in leui^th. f) nnn. in width, and 5 mm. in thickne--. beinLi abont two-thirds its normal size. \\\-i,L;ht. 0.6 gram. The niicr^-copic characters of the iniplaiUed organ- are shown in Figs. 1()_ H, 12. 1.1 and 14. — 285 — l.MPOTKNCIC AND STP'.KIT.ITY Kij?- ■">. .S lulMilc (. iiil;' IMlil. -hnwiii; iiuiiiliite of implantation, the autiior is in doubt as to whether or not some nii>take in tlie identity of the snhject was made. .\s far a.s ])()iiits 1, 2. and o are concerned, the results of the fore.i,''! lin.L;' e.\i;eriinents seem (jtiile conchtsive. In the case of the hen tised in h'xperiinetu 111, old a,^"e prohahl)' had intich to do with the result. The ])ossil)iHt_\- that a lari^'e do>e of hornione from a rela- ti\-elv \-ounn' ,^"land ma_\' have heen the disastrous factor is frcelv admitted, hut. I'-rantint'' this, no such result cottld occin- from the 7. 'I'l ;ii]~vcr>i- Mctinii <.f ('ijiiliilviiiis nf a vdhh^- r .\l:i--;(- nf ci.aLi-iilatrd -ciiicii are seen within llic ti.lnili "Ui. !ia\-iiii;- ihc Imiaii '.f the tulmli clrar. sli.iwiiii;- tralK-cul;c ami tubuli. line lit tliemall dose restiltin,!^- from im])]antation in the htiiuan suh- ject. The other fatalities ])rohal)l\- were due to coincidental cattses. with due re_qarfl to the possibility of individual predisposition and the remote effects of shock. Iv\])eriment \'. as shown h}- the luicroscopic appearances of the removed .glands nearly three months after implantation, and by sul)se(|uent histolo,^ic sttidw demonstrated also the success of the implantation per sc. confirming- the results obtained in otir ])revious experiments on the human subject ( I'i.^'s. 15. 16. 17. and 18). That .^uch remarkable results should accrue from implantations of male IMPOTKNCE ANJ3 STERILITY Fiy. 8. — Iiiterslitii\l (iii(citiil)iilar) connective ti^isiie of ein'didyniis of a \'Oung ram. Compare willi l'"it;>. '.), M, 17 anil JS. glands upon the female is not so astonishin,^- as it may seem at first sight. The l)lood of the female is excellent ])abuluni for every tissue in the body, as witness the development of the fetus ui utero. * ^r^ ^ ri^f. fi. Seclion of (lie body of tl^tl^ of .1 \onni; i.im V. Tnteistitial (inlei'tuliidar) eoiniectivo tis- hy no means all that could he desired. I'rimary union occurred, hut on the fourth day sl(.)usj:hin,y; of the su])erricial tissues of the ahdomen het^an, and hy the seventh da\- nearh' the entire ahflominal wall was denuded down to the muscular aixMieurosis, nccessitatinti' the killinj^ of the animal. I{\-en after niakin,*.^' elite allowance for greater facilitv of in- fection, the fore^t^oini^- result was in striking" contrast to that obtained in fowls. In a large miniher of fowl implantations we have seen I'il.^-. tiK -Section of (csti^ of n fnc-l seeretini;' tissue is li\iny. Compare with Ki^'s. 11. \-l. I I and 1(1. but two cases of infection. These were i)itrel}- local and chronic, consisting of a had smelling fnngtts-like growth with slight snp])ttra- tion, and no deterioration of general health. It is \\-orthy of conimeiit that the relative degree of traitmatism in im])lanting adult testes in fowls — es])ecially voting ones — is immensely greater than that involved in im])lantations in the higher animals. In lowls the im])lanted gland is so large that it presses considerably on the tissues of the implantation bed, and even on the — 289 — IMPOTENCE AND STERILITY viscera. Fowls, moreover, are relatively insensitive to injuries. As to the "alien species ])rotein" factor in the foregoing experiment, \vc confess that we were somewhat in douht. Since, however, his recent extensive experiments wuth organic emulsions,* the author has felt reassured on this point. In a numher of ex])eriments in "exchange" transplantations in both unrelated and related young cockerels, we apparently have met with hut one success in ])reserving the secondary sex characteristics, although, in every instance, thev developed much better than they Fiy. n. —-Section of testis of cock one year old, implanted in an unrelated pullet four months old, and removed at the end of seventy-five days. (Kxperiment y .) A-15, Subcortical area showini;;' completely organized connective tissue, mainly of the interstitial variety, but coiitaininf>- ordinary fil)roeoimect ive tissue in small amount. An abundance of new vessels tilled with normal lilood nia\- \n- seen. ]? shows the actively regenerating, but not yet l)ermaiiently organized interstitial tis-lic inldsUtial tclN in testis ..t imi.1; imij year old, iuiplaiitrd ni".n a ,\..iin:;- iini-clatcil li-inalc ami imioxcil at tlic end uf s(\ i-nty-five days (I-^xpiTi- inciit \'.) Tile iiornial h]'n„\ c^inli-iit ..f the niiincr.iiis \i--i'Is is jdaiidy socii. Tlicff ap- ]iaiTml\- is \i\y litllo fil.ix;c"iiiii It i\c' ii~s!;(^ -iiid tliis i~ --iiiuitid cliicMy ill the viciiiily of llic vessels. ( Minj.are with I'ii;-. s. !i, lo_ 17 -md Is. Im\'. l::.--.Sei'li'.ii ,,f testis ,,f ewcl; one ,\-ear "Id, iniplaiiteil ^n an uiifelated pullet f.Mif uiomli: "Id. and iciii"\cd at the end "f se\iiitydi\ e da.\ s ( l-'.xpiaanient \'.) A. Oi'iliiiaf.\' e"n neeti\-e tissue. (-"iTesp. .ndi nn' t" the hK-alicm nf the pefiteiieal tesiieulai- investiueiu . ]5 SuheMi'tieal la.vff nl aliiualant ].\- iii-e.lifei-at int;- iiil ei'-t i I ial ( intef-tiiliular) C(.iiiieel i ve tissue with a -iiiali aninunt "f the erdiiiary vaiiet.x-. ( '. I'i'niianenil.\- iiru'anized iiitei'stil ial lis ■sue, with a moderate aiiiounl e^f onlinaiy hlu'oeeniie't i\e tissue, riehly supplied with new Mood \essels eontainint,' lainnal hhiod. — 291 — TMPOTENCK AND STERTTJTY [•■i^-. II. Scctidii of K-ti- til. Ill (o(l^. (iiic \(,ir iiM, iiiiiiliiihd tni v, m nl y I'nc ilnys in :iii iiiircl.'iti'ii piillcl. tiMii iiiDiillis old ( i:\|i( I iim 111 \ ). s|i,,\\iiii; |m i iii.iiu iil ly ori^iiiiizcd intcr- sliliiil (iiilcrliiliiil.il) loniKiliM li^viii. ,111 .iliiiiid.iiil supiih ,,t luw Mc.od \csscls coiitniii- iii.i;' iioMiial lilond, .iiid nil, iK i oils l.ii^c. (hiph -.Iniiid, loimd .md o\oid bodies const it lit iiiK dcyciicnitol. hut. -nil Iniiit;, lilmli -(iimiiliii Fiy. i:i. Sri-lioii of tcslis iviiiovcd fvoni iiiiili of lliii'l.\- yc;ii-s, .lend icii liouis fmiii iM)iit:ict "■illi .1 li\c wire. Chiiiil M'fi-iyvviilcil foul' diiys in .111 ordiiiiiry ice liox iiiid iiiiphinled ill tile :il)doiiiiii;il \\;ill ii|Miii llie a 1 loiicii losi s of llii> riulil recliis in llic liypof^asl rie rciiioii of an iinrclalcd female senile dcliielil. a^'cl sixly yiar-. Claiel rciiioxcd afler four iiionllis and nine days. A, Tiinird iil Inn.i 11, a . -li. iw iiii;' clia raeterisl ic lilivoeoniiect i vc tissue and Idood \-cs-cls (1m, 111 (,1,1 and 11, \v). I!. Sol ,c, ,rl i< .1 1 siraliiiii of pr, ,li fciatcil iiitcrst il ial ( intiTliiliulai-) li"iie. c, ,nl a in inn' an aiiiinilancc ,,f new l.lo,„l \cssels. Here and tlierc in tlie nia>s ,,f inter-liiial I i-siie nr,. seen llie ,larK. ili-l,,ii(d ,,iilliiii's .,f liiliiili sr 1,1 iiil I'lri . which have l„ ,,f lissiu- is ' pl^i iiil.\ disccrniMe. 292 S1-:X CI. AND IMI'F.AXTATIOX reci])icnt nialurcd with s^reat rai)idity — compared with uthcr males of the same strain — as to color, weight, comb and wattles, plumage, carriage and what is termed \)y fanciers the "talking \'oice." which within two weeks was transformed from the "peep" of the _\-onng fowl into the lK)arse notes of the adult. 'J'he l.)ird became more si)irited and combative. The testes of the Brahma were imi)lanted in the normal position in the Leghorn, who siihse- qnentl\' showed all the usual characteristics of the capon. The etfecls of the implantation on the Brahma graduall\' disap])eared. and lie now — seven months after the removal of the testes — resembles a capon ca-traled rather late. ni;irkedly conforming witli uncastrated males in Hi,', ic,. -S((ii.iii t 1(^11- til 111 111 111 IT tliiu\ \tii^ ill 1 1 liii li HI- innii ciiiitact willi ;i li\e wire, inipl.iiiii I 11)1 II III iiniiluiil ti in ili ( 1 mil niiuii iti 1 t iiv iUi\-s. Itciiioveil finir iii'iiilli- ami mill iln- ithi iiii| I iiit it i ii \ Iikhh nlhin/ ii a -hnwiim- uriliiiary tilirn- C'liiiiul i\i' ti--iu iml I 1 I il \i — 1 N I) siiiiiiiiiit ( ii 11 II ti I i-t ( interstitial (iiitcrtiil)iilar ) tissue. iil)Maifi]\ -li w iiu ili-tmli il aitlim- t l.-iliti / Ijiil v in inlfrri . with abmiiluiit siip|il\- lit l)Ii 1 \i— I- ( Siiiiiiiil luliiili till - lilt i\ ( iHllii liiiiii lit which has ilis- aiipeai'iil— plaiiih ii iiliil iml iiiiiiiivt ik ihli In ihi- ]iiiiiiiilii ilea tlii> tiihuli look the stain in vrvy n iliiiti ili_iii Imi i|I1i|i i- will it will K li-ti\eil, as iliil the iitiiiiie>- ti'jiialily livini;- liii,u;i <,lhii,in,.- ul' impfiu' iti.t;- tin" Ia\ iliK i|uali!ics ami li-iiilitx i I' xaiiuus sliaiiis li.\- scX ,t;laii(l implaiita tiniis 11 pull nn rill a I hii-ijs a I diici' svt,t;i;i.>st s il self and max' jirox-e of i lit crest to IjrtM.Hleps. — 293 — IMPOTENCE AND STERILITY IX. May 15, 1914, we removed the testes of two White Orpington cockerels — half brothers — three months old, and implanted the testes of one subject upon the other, in the normal site of the testes, leaving one bird caponized for a control. December 11, 1914, the implantation subject was examined and found to be a splendidly developed, normal male, with all the secondary sex characteristics perfect. He is active, very pugnacious and per- forms his sexual function just as would any normal male fowl. The capon- ized subject showed fairly well developed secondary sex characters and while more active than is usual with capons, presented a marked contrast with the implanted subject. The histologic study of sections of the implanted fowls' testes removed 17. — Section of another aii'a of same testis from which Fig. IC was tal and C. It will Ije seen that this histologic feature is ])r()minent in all similar sections — from both fowl and human being — exhibited herewith. This ])articular phenomenon is ex])lical)le by the greater circulatory activity and consequent better nutrition at the points mentioned. .\t the ])eriphery, notably adjacent to the pia viaicr testis, or tunica vascit- losa, conditions especially favor tissue regeneration. A certain amount of ordinary connective tissue is found in the im])lanted glands, a])parently derived — as shown in Figs. 8, 10. 11, 12, 14, and 15 — not from the tunica propria of the gland, but from the septa of the gland, of which the corpus lii(jlinioriaiiuin is the most iin])ortant, and ])robably also from the walls of the blood A'cssels ( b'igs. 9 and ]2j. Hy far the greater ])art of the new tissue is com])()sed of ])ro- liferated characteristic interstitial ( intertubular j cells. What is going on in the mass of degenerated tubuli in the in- terior of the gland, and its hnal result, is well shown in Figs. 14, 15, and 16. The richness oi the new blood sup])ly of the implanted gland is well shown in l^'g. 11, and in the next folkjwing of the series (12). Fig. 12 also demonstrates conclusivel)' that the regenerated tissue is not composed of (ordinary libroconnective tissue — save in small * N. Y. :M('(]. Jour., Mar. lil, April 4, .July n, 1911. — 295 — IMl'OTluVCIi AND ST]\RTLITY anu)unl — but of what ma}' l)c inferred to be tbe cbaracteristic inter- stitial cells. This tissue ])]ain]y is present in the implanted glands in far greater amount than in the normal gland. This perha])s is the most im])ortant ])oint. The character of the regenerated tissue is witnessed by Figs. 12 and 17. The ([uestion of whether or not the degenerated tubuli of the testis may retain their vitality after they are functionally dead from destruction of their gland epithelium, would seem to be answered, not only by their retaining their form sufficiently to be recognizable after a long period of time, but also by the manner in Fig. ]S.- Section of testis iiuiilniited in the sii]>r;iinil)ic i-e^-ion of a wonuin sixty years of age, and renio\e(l at tli(> < nd of four iiioiitlis and nine days. A-l!. ()l)Solete but still living tiihiili sciiiiiiiffri. (', Interstitial (inteiluliular) cell i)ioliferation. which they stain. (See especialK'. Fig. 17.) Fig. 14 is a ])ertinent illustration. The remnants of the tubuli took the stain so well that they had the appearance of small ])lums. The surface of these dark bodies showed the characteristic granular ai)])earance that we have observed in the degenerated, though distincth' recognizable tubuli found in im])lanted human testes. It is hardly probable that tis- sues so delicate as are the liihiili sciiiiiiifcri, woidd endure, if dead, and show as ])lainl\- as thev do in b'ig. 17 (see also Figs. 14 and 16) at the end of seventx -live days after implantation in an alien bed. To believe this, one must underrate the "digestive" or "assimilative" - 296 — SI'.X (;i,.\.\l) IM I'LAXTATIOX cap.'icit}- of the iioniial tissues ot' the ini])l;intati()ii 1)C(1, and over- rate tlie resistance of those tissues to which show even more satistactoriK' the chanj^es occurring in im])lanted luunan glands. The im])lanted and removed gland herein submitted to histologic study, is the one alreadv recorded of a testicle im])lante(l up(jn a woman of sixt_\' _\ears and removed over fom- months later.* The illustration ( iMg. 16), comprising an area of the same sec- tion of the im])lanted testis — a little larger than that shown in Fig. 1 .^ — heautifull)- shows the various strata from the ])eri])hery to the centre of the gland. It shows with es])ecial distinctness the ottt- lines of the obsolete liihiili sciitiiilfcri, which have been replaced by the interstitial coimective tissue. The foregoing illustration wc)uld seem to show ])retty con- clusix'el}- that, while the tiihiili sciiiiiiifcri of im])lante(l glands un- doubtedl}- Icjse their ftinction, coincidentallv with the death of their secretor_\- ei)ithelium — which ])robablv inevitably occurs in imi)lan- tations such as the attthor"s — the mass ])ro])er of the Itibular struc- ture — /. ('., the basement membrane and its i)r()toi)lasmic content — may survive for a prolonged ])eriod. Whether or not anastomosis — prfn-iding a successful technic ever is elaborated — will ])reserve, or, if it be not \\holl_\- destroyed, regenerate the generative gland epithe- lium, is ver_\- doubtful, although, ])erha])s, not imiiossible. The resemblance of the structtu'c shown in b'ig. 18 to that shown in Fig. 8 is interesting, more especialK' as the latter shows a section trom the e])idied. l)ut a good ])ortion of the i)eripher\- a])])arentl\' still was lix'ing. The fate of tlu' gland implanted in the scrotum will l)e ])resented later, it I)eing ♦ *,, 9'-W^ m # '■—I t... %> ^NP •■#■ -C^ ^ mm Ki-. :.'(!.- ,S(cih.ii of imiicu ;ill)U.i;iiira of iin| ihiiilni tcsIN fioin lUmnv dead of narcotic ]ioisoiiiiif;, rciiKjvcd oil Ihc iiiiitli (la,\ after iiiiphiiilaUon. 'J'lic section shown is frt)ni the inferior surface of (he iiiiiiea, /, ,.. in Ihe zone of I'oniael with llie hiiiicii r si'clion shows an alanidanee of proliahly reucnei'al int;' or reiieiierateil connective tissue ci'lls of a iiceuliar type anil a inoderale niniiher of leucoc\tc>-. The nuclei in tlic specimen scenieiiarently new blood vessels eon- tainina- normal blood. 15. area ot )ieeuli.ii- eelj^. iinbaldy derived from the interstitial Cintertiibnlar) tissue. 'Phis seetion shows ilie ordinarx^ eiiaraeteristics of the connective tissue of tlie liitiirii iiiiiprl ii of file teslis. with numerous leueocytes. new environment to begin. Reflecting on Leo J^oeb's ex])eriments in cultivating tissue cells, both /;; 7'n'o and /';; I'iiro, and the en- durance of life in frozen cells, it should not be surprising that a healtln-. sterile gland, bathed in nourishing blood and tissue juices at the normal tem])erature of the bo(l\-, should survive and eveiUual- ly lorm a new \-ascular supjtlw The somewhat e.\traordinar\- a])pearance of the immediately lorcgoing section ( I'ig. 21 ) — which strongly resembles a neoplasiuic growth — ptjssibl}' ma\- be explained as follows; In the author's — 300 — f) SF.X r.T.AXI) T.Xrrr.AXTATTON tcclmic of implantation small areas of the liiiiica alhi((/inca arc ex- pected. At the ])oint shown in the illustration, the area of the exscction did not in\-olve (pn'tc the entire thicl-;ness of the tunica throughout, hut at one point was left an extrcmcK' small aperttu"e throus.j"h which the rapidl}' ])roli ferating- interstitial cells extruded. The area ma_\", of course, re])resent a se\ered 1)li)od vessel, througli which the cells are extruding- from heneath. We have noted in other sections an invasion of the cortex hy interstitial cells at jjoints of denudation. In presenting tlie various st'ctions illustrative of the histology f im|)lanted testes, the author is not unmindful of ])()ssil)le sources of error, which suhse(pientl\- ma\- he corrected either h\' himself or other investigators. At ])resent writing, however, the results seem to he conclusive. The ])eculiar t}'pe of connective tis- sue shown in the \-arious sections nmst either he the interstitial cell of r.ex'dig— or a derixative of it — or there exists in the testis a delinite t_\])e of tissue hitherto undescrihed. It is hardly i)ossil)le that the tissue demonstrated herewith could have been overlooked ])\- the man\- com])etent histologists who have studied the normal tissue regeneration in the testis are four: 1. The true secretor_\- The leucocxte theorv of connective tissue generation of Cohnheim and MetchnikolT ha\ing heen abandoned, the i)()ssil)le sources of tissue regeneration in the testis are four: 1. The true secretory e])ithelium: 2, the Sertoli cells; 3, the ordinary lihroconnective tis- sue of the gland se])ta and the tunica alhuginea : 4, the interstitial connective tissue or "between cells"" of Leydig'. The e])ithelial cells max he ruled out, ofThand. The v'^ertoli cells are, in our oi)inion, of even less importance. The_\' lie within the tubuli and have a purely lutritixe function, concerning the true secretory epitheliimi, and die when the latter dies. The ordinary flbroconnective tissue ])lays but a minor part. The microsco])ic sections ])resente(l in this volume ])lainl}- show the strata of the histologic elements and emphasize the dilTt'rence in the structure of the various strata. The interstitial cells ff)un(l in the normal ram's testicle and those shown in the section from an implante(l lowTs testis are (|uite >imilar throughout. It is not to be expected that the cells in regenerated implanted glands alwa_\s will apjjcar the same. That icctions of implanted glands or, for that matter, of normal glands, — 301 — TMPOTl^NCl': AND STJ-.RTIJTY will show the "idealized" classic confoniiatioii and arrangement shown in certain works on histology also is not to he expected. The cells are thicker than normal and more or less altered in form and grouping", hy contraction of the mass and resulting pressure, l)oth hy their own organization and a certain amount of ordinary iihro- connective tissue. Like all other connective tissue, the interstitial tissue of the testis "consolidates and contracts," hut it holds its own in respect of vitality, and a very small nodule of the im])lanted-tissue-end- result. prol)a1)ly contains as many, jjossihly more, of the Le_\dig cells than does the entire organ at the time of implantation. That these cells arc as active, or their hormone i)roduct as ahundant and physi- ologically as ])otential, as are the internal secretory cells under normal gland conditions, is open to question. I'ossihly the relative increase in the quantity of the highly s])ecialized cells in the im- ])lanted gland, with a consequent relatively greater amotuit of hor- mone produced, mav comj^ensate for a dilTercnce in the quality of hormone production. That the implanted cells are therapeutically effective is no longer an open {[uestion in the author's mind. The chief ])rol)lem now is: Will the imjilanted gland in elderly subjects eventually functionally succumh to the recipient's tissue influence and ])ro(luce a (piantitv and (|uality of hormone normal to his or her age? Possihl)-; we have, however, two factors to consider: 1. The rejuvenation of the entire hod}- hy the alien hormone, a rejuvenation in the beneht of which the implanted tissue itself participates. 2. h'ven granting that the ([uality and ((uantity of the honuone l)roduce(l hy the implanted tissue eventualh' is not comparahle to that produced hy a similar number of cells under normal conditions, the sum total of hormone ])ro(luction of the implanted tissue and the subject's own glands necessaril\- is grep.ter than normal to the subject's ;ige. It is prol)a])le that a gland from an older donor, implanted on a \oung subject, ma\- be rejuxeiiated b\- the im])lantation. In gen- eral, such im])laiUati()ns ai'c more logical than the imi)l;mtation ot' \ei'y maluix- glands upon older I'ei-ipients. In all ol Iii.x implantation woi'k the author has been in)])ressed with the tact that the liiiiiai (ilhiKjinea and the gland tissues just — 3()J — Sl-'.X Cl.AXI) IMI'I.AXTATIOX l)enc';illi il sliduld l)c tlu' iiio>l \alu;il)lc of the U'--ticii!;n" tissues wIutc ])artial iiii])lantati()iis arc (loiu'. iikt(.'1\ l)t.'c-au>c l)ftti,'r iKiurished and llicrcforf inostK' lil' was satisfactory. 'J'he contraction of this in- fection. acc(jrding to his mother, "preyed upon his mind a good deal and may ha\e had something to d(j with his mental condition." Something over three years before the author first saw the patient, mental s\'m])toms began to l)e noticeable. Dr. Archibald Church was con- sulted. September 13. 1914. His report in brief was as follows: "The case impresses me as Ijeing the initial phase of a dementia pr;eco.\. I anticipate that he will develop a phase of activity, perhaps with a good fleal of excitement and boisterous conduct, or he may become more and more stupid and catatonic. At any rate it will be some time before he is better and Ids ultimate ])r(.>si)ects are extremely bad." Soon after the case was brought t(j : "The hemogb^bin was 80 per cent, the whites 12,400. the reds 4.800,000. the polymorphonuclear neiUrophiles 57 ])er cent, small lymplKxwtes 30 per cent, large lymphocytes 8 per cent, transitionals 1 per cetit. and eosinophiles 4 per cent. Th.e form and character of the red corpuscles were normal and no ])arasites were to be observed. Tlie serum of this blood was centrifugated for two and a half hours and 1..T c. c. of the strum was placed in each of six dialyzers, in whicli was also ])laced one gram of the following: Hmnan organ albinnins prepared according to the method of .Miderlialden ;uid each tested iree from ninhydrin * 'i'lii.s ca.se \v:(.-; r.-jKirOMl in tli... X. Y. Medical ,1(H1|-iim1. Ai.ril :;. T.O ."i. - - 30.3 — ]:\I1'()T1',.\C1<: AND STJ'.RIIJTY rcduciii.^ i.-k-nR'iit> lirl'ore hciiig used, nanicK- against cci"c'1)ral cortex, pancreas, tlijroicl, ovary, testicle, and one control. The\- were incnbated in Hrlennieyer flasks each containing- 20 c. c. of sterile water for a period of sixteen hours at a temperature of 90° to 100° V. At the end of that time they were each tested against the ninhydrin solution and boiled for one minute. Every tube proved negative, being perfectly clear at the end of a half hour. The blood serum in this case does not give any of the reactions of de- mentia ])r;ec()x. Neither does the blood picture of the microscopical exam- ination correspond with the blood ])icture in cases of deiuentia prsecox. Al- though 1 made no considerable examination, the ocular reflexes and the mental picture did not suggest to me even the possibility of an embryonic case of that disease. I do not hesitate to state that this is not a case of de- mentia prjecox." Dr. lloliiK's' re])ort, taken in cointection with Dr. Clnnxli's diagnosis and the anthor's own. which corroborates that of Dr. Chtirch. is wortliy of seriotts reflection. That the subject was in- sane is l)e_\()n(l the ])ossil)ility of doubt. With (hie deference to Dr. lioliues" ()])ini()n, that the case must be classed as dementia pr;ecox is olniotts. The prevailins^' nomenclature of psychoses is faulty, it is true, and, in the case of dementia pnecox, absurd, in a \\a_\', the term havino- only a syiuiJtomatic-chronoloL^ic basis, with no definite pathologic foundation, btit at jjresent it is the best noiuenclature available. it is ])()ssible that the Abderlialden test and heiuologic observations eventually may enable us to resolve dementia prjecox into several distinct path- ologic t\])es. one of which responds ])ositively to the .Vbderhalden test, while the others do not. This would facilitate a more scientific nomenclature and classification. It of course is ])ossil)le that our conchision regarditig the head injury in the case is incorrect, if so, this nattirall}- luight ex])lain the negative Abderlialden. Even granting, h()\ve\-er. that the head injury was an exciting etiologic factor, the same nomenclatttre wottld confront tis. The evidences of mental deterioration in the case in ])oint are distinct, and of a character which lead me to classify the psychosis as hebephrenia of the ])aranoid ty])e. J lallucinations have been a doiuinant feat tire. X'oices whis])ering adverse comments and in- sidts were (lail\- com])lained of. Lack of energy, and the com])laint that he was too weak to work, were salient ])()ints. 'J'he most prominent feature of tlie c.ase was the ])alienl's notion that he was a great architect and btiilder. I lis ])articular obsession was that -- 3(14 -- SI-:X (U.Wl) IMri.AXTATlOX he was ill the eniplox' of tlie city (it Cliicai^o, his s])ecial l)usiness Ix-ini^' tlie rein()(lelhii,<4- of e\-er_\- lar^e l)iiil(h'n,!4" witliin tlie loo]). lie S])ent nianv lioiirs eacli (hi\- in writiiii,^ "s])ecitications" for such rcniodeliiiL;'. 'I'lie following; are ^ani])Ies of liis hicuhration> : Fiir. ■2'2. — Ti-sii^ fi'ciin a lin(l\- diiid icii liom'- ivoiw cncaiiic [•ni^niiini;', iiiii>lant(.'i n< 'iri.u'iiial 1. Tlie Afallcrs Buildinji- was built as large in City as neither Building contribute to Herbert at all. l-'ino stones un Mailers Building has stones rep- resenting the ends of eartb. (Jne on each side of door as two poles or ends of earth. Have building largest in world and fme stones as Equator higher up as students dont know. Have lights sbowing these stones. — 305 — I.MPOTKN'CJ-: AXi:) STJvRILlTY 2. The Hub stuie built before Alar shall Field & Company Building. Both sell men's suits. Buildings has no opposition on Account of neither seeing each other. Mostly for two hotels or Theatres. Blackstone and LaSalle Hotel, leaving both tops off both hotels and they will be eighteen or Blackstone Theatre and Majestic Theatre, Blackstone takes one off of Ma- jestic leaving Eighteen. 4 Building and 4 stories make same as largest Printer Building. Both see Monadnock Bldg. 3. The LaSalle Hotel built after ]\IcCormick Bldg only a Hotel. Built same distance from Railroad and McCormick Bldg. and not hurting T. C. R. R. Have large smoke stack running up side of Hotel for no interruption of I. C. smoke stacks. Built also on account of Taft. Same height as Mc- Cormick. Top of Seats are higher in LaSalle Hotel on accounts of foreign countries and Washington and also Quaker City Church. People must not think they are Queen and Kings Seats here on that account. Little like Blackstone on Top of Build, onlj' larger and different altogether. 4. The Franklin I'ldg. is the building supposed to be finest printers building in city to honor Bctijaiiiiii I'ranL'lin the same man discovered tele- phony. Same can be used as business building as close to Heisen Bldg. as Heisen Bldg. built for high telegraphy today, bringing telephony and tele- graph together on account of printing paper being very precious, and two fastest ways of protecting same. Offices to be used as same making Frank- lin Bldg. lunest in city. ()cto1:)er 3, 1914, by reqttest of the ])titient's mother and with complete nnderstancHng on her part of the experimental nattire of the procedtire, the atithor implanted two testes upon the patient, one in the suprapubic region and the other in the left side of the scrotum. The resuk of the suprapuljic implantation ah-eady has been rehited. In passing, it may be stated that faitUy technic i)robably was respon- sible for the loss of this testicle. The gland was very large and firm and the implantation bed was hardly ample enottgh, the resulting pressure being disastrous, liven as matters were, a considerable portion of the gland was living, adherent, and, had it not been re- moved, possibly would have survived for some months. The scrotal implantation was ])erfectly successful. Fig. 22 shows the condition at the end of the sixth week ( .\ ). December 16, 1914, there had been no diminution in the size of the im])lantation mass that could not ])e ex])1aincd ])y resolution of the defensive exu- date sttrrotinding it. Begimiing abotit one week after the implantation, considerable im])rovement in the i)atient's mental condition was noticeable. His "architectural" writing became a little more coherent, and he would not write luiless urged to do so. He was encotu'aged to correspond — 306 ^ vSEX GLAXn T^[^^ were discussed at length his ex]ires- sions still were unsoimd. althoitgh not so markedly as former!}-. There was a change in the as])ect of the case in that there now was a tendenc}' to melancholv and. as a s])ecial source of worr\-. an imagi- nar} detect of eyesight, which had been careful!}- tested and ])ro- nounced normal ])\- Dr. I larr\- (".radle. There also was a new delu- sion, lie attributed the ■"luni])"" in his ^crotum to a large marble which he had swallowed when a bii\. November 3. ]*'14. Dr. I\ali)h Webster re])orterehe:ided the entire shiiation and knew the reason for his ])s\chic condition, althou.nh he said that it was at limes unhearahle. On Consultation with the patient I recalled to him (nir experience with oxarian .uraftin.n. After I had jjuhlished the desci'i])tion of o\arian .uraftin.u" in 189.T and had introduced the idea, a lar.ue mimhjr of authors soon fur- nished data of their own hearing ui)on the suhject. There was a tiX't"-'''''' conclusion alons^ lines which hiolo.uists mi.iiht ha\e anticipated, lo the effect that the tissues of (.)ne indix idual are amaL;oiiistic to the tissues of another mdixidual. Therefore, helernpla^tic t>rafts of aii\ >'irt are comnioiil}- ali- sorhed pronii)tly hy the ho>t. The de.uree oi antau-onism hetween individuals varies greatly, and occasionally we ma\' lind two people (or other aniiuals ) which receive each other's tissues with good grace, if a l:)it of levity luay he pardoned. The ])atient was willing to take the chances of ohlaining benefit from a grafted testicle, and entered the Post-Graduate Hospital, l'"el)ruary 4. 1914. The first ]>atienl who otTered opportunity for furnishing the graft had un- descended testicle and hernia: he agreed to allow me to use a pari of his testicle for grafting" purposes. This i)atienl. a \oung man Iweiily-six years of age. responded so strongly. ho\ve\er. to the \'on Pircjuet test for tuher- culosis thai 1 preferred nol to luakc use of his tissues. The next case was one of a man fifty-six \ears of age with a \er_\' large hernia, who made no re-pi)n~e to the \ on ['ir(|uet te-t fur luherculi i -i> nor to the \\':i.-serniann test for sxphilis and who ga\c a record of good general health. .\ wedge of tissue was taken from the testicle of this patient and placed in nonual saline solution uiuil W. -\. S. could he anesthetized and ])repare(l. The segment oi testicle was cut intu four slices with a sharp razor, these slices a\eraging ahout three nun. in thickness, and in length approximately that of the testicle from which ihcy had heen removed. One of these seg- luents was engrafted in the right scrotum, another one was placed beneath the fascial sheath of the right rectus abdominis, and the third segment i)laced beneatli the sheath of the left rectus alxlominis. .A W'ier's celluloid testicle was placed in the left side of the scrotum for the purpose of g"i\ing to the sympathetic lu^rves the impression of a natural mass in that \icinil_\-. The wounds healed b_\- primary- union, and in fort\-eight hours from the tim.c when the grafting was done, the ])atient slated that he was distincll\' con- scious of the effect en" the internal secretion which he was absorl)ing" from the grafts. In fact, at thai time occurred the lirsl distention of the corpora ca\erno-a and corpus sixHigiosuiu thai had not occurred in ten \ears. - - 309 -- IMl'OTJ'.KXI-: AND STERTFJTY Tlic su1)se(|iicnl liislorx- of this case showed considerable tem- porary ini])rovenient. v^iich l)enelil as was derived disapi)eared after a few months, as nn'i^ht have been expected from the fact that the "wedge" of testicle mnst have been small and the testicle from which it was taleins liercwitli l)i-i'ef rc'])orls of six additional cases of successful im])]antations. lie will at this time say hut little ftu'ther than he alreadv has said re,<4"ardin,<4' the physioloy-ic and therapetttic effect of sex i^iand ini])lantation. wStifticc it to state that not onlv have ])reviotis ohservations heen veritled. httt there also have been noted certain a])parent results which still further contirni the aiuhor's belief that in the sex ^iand JKjrmone we have the most ]io\verftd cell stinudant. nutrient and re.^'enerattjr at ])resent available to medical science. At ])resent writin<^ the additional evidence is stich that the facts seemin,i^i_\- are estaiilisliecl on a reasonabl)' firm basis, free from sus])ici()n of coincidence or intercurrent factors. -Vote in this connection the cases of double te-^ticttlar imi)lantations herein reported. These case> a])])arentl_\- are conclusi\-e. I'nder pro]jer conditi(jns failure shotdd Ijc rare and the resttlts are nnt likely to be disappointing. Case 1. — This is by far the most re- iiiarkai)ie of the author's series of im- plantations, and to his mind is as con- chisive eviflence of the value of the work as a single case possibly eould be. It is especially" weighty evidence when considered in connection with the ap- jjarent results of our other implantation work. A man. a.yed 29. sustained an injury td his testes while ])layini;- football, twelve years before he consulted the author, in July. 1915. His ri.yht testicle was enormously swollen ( projjahly he- matocele) an.d very painful. When the swelling subsided, the gland had en- tirely disa])])eared. The remaining testicle atrophied to a model ate de- gree. \'irility was unimpaired, and the liatient married three year- later. < )iie Kiii-. 1. I)i.ul,l(. iiiiiilaiitati'Mn of ti'-tcs from .1 lio.lv ill a <::>-(• of .loiil>lc oiiiiii.leto .nn.,,li eliild was horr. of the union. ] A 1 POTENXE AND STJ'.R 1 1 <1T Y About two months prior to our examination the patient, without pre- cc15. the author iiuplanted on this ])atient both testes taken from a boy of 14, dead of a crushing injury. The subject was just approach- nig puberty, and not well developed. The testes were removed si.x hours after death, and kei)t on ice in sterile salt solution until the operation, thirty-nine liours after the death of the donor. The implantation was made in the scrotal sac on each side, at the normal site of the testes. The glands were im])laiUed eiUire. the epididymes not being removed. Healing was ])rompt ; there was only 1 degree of transient febrile reaction, and very slight inflanuuatory swelling about the im])lanted glands, h'ive days after the imi)lantation circumcision was ]ierformed. The i)atient returned home in two weeks. X'igorous and painful erections occurred after the eighth day. and recpiired an ice l)ag. Successful coitus was ])racticed three weeks after dismissal froiu the hospital. Seven months after o])eration, the patient reijorted that he was i)erfectly normal, was taking active gymnastic exercise, and bad lost nearly 20 ixiunds of his tlabby fat. l'',rections vigorous and more fre(|uent than in the average normal subject of similar age. The p;itii'nl laid t'special stress on his mental ;uid physical fitness for business, 'idle imiilanted testes had atrophied only moderatel.w and were of relatively fair size and fairly normal consistency. The epididymes were i)lainly dis- tinguishable. .As Dr. William T. lU'lfield, who courteousl\' exaiuined the case and (pu'>tioned the patient, remarked. "The testes, while small, are as well (lcvc1o|)ed and ai)i)arently as normal as in many iierfectly virile men who come nndci' our obser\ation." -^ - 312 - S1-:X r.I.AXI) IMIT.AXTATIOX III i)assint; I \vi>h t" state tint, fur a while after the ini]>lantatii)n. the liatieiit experienced iKirmal oruasni witliDttt eniissidii. He stated trostate. and the seminal vesicles. In hrief. it prohal)ly is Composed of all the n-nal normal elements of the normal semen, save the H'-ticular secretion, of wliit'h tlie spermatozoa are the important element. I-'or some \\eel<< after tlie implantation the jiatient complained of "fritihtfid nervoii>nes>." .\s h? descrihed. them, his s_\'m]>toms were not unlike tlm-e iimduced 1)_\- sirychnine and similar spinal excitants. 'Idie "nerv(jus" symptom^ I'mally disappeared.. 'Idie author attrihuted them to the unwdnted do-e of hormone i uKjre than twehe \ears a,L;<). despite the suhsequcnt im])air- ment of develo])ment of masculine secondary characteristics. It would seem that: 1. A relati\ely lar.ye dose of hormone is necessar_\- to perfect de\'elopment of secondary sex characteristics. 2. A \ery small dosaiic is .suflicicnt to preser\e \irility. ,i. Onct.' \-irilit\' is estahlished. an extremeK" small dosa.ye. of sex hormone will i)reser\e the psycho-sexual and ])h_\"sio- sextial sex characteristics that are so essential to potency. it has heen ohstT\ed that indi\iduals possessed of exceedin.ylx' rudimentar\- testes often are \irile. Ind.-ed. it has heen oiu" ex])erience that such ])ersons sometimes are jjuvscssed of more than the avera.ye de.L;ree of virility. We recall several cases oi cr_\|>tochidism comiiiL; under our ohser\ation in which there was a normal de.uree of virility with complete sterility. It will he interesiin.Li- to note the further pro.^ress of the case relative t" alriipjiy of the imjilanted .ulands. -- 3)3 I.MPOTKNCE AND STERILITY As already noted, the glands after two years still are in fair eondition and hai'e not appreeiahl\ atrophied during the past year. Possil)ly the preserx ation of the epididymis lias something lo do with this. As to how h)ng the therapeutic results will endure, one cannot predict. Prohahly permanently, or at least long after the last vestige of implanted gland tissue has disappeared. The author is confident that, as long as even a small portion of the implanted tissue remains, its favorahle effects will endure. I^ven though an occasional repetition of the implantation should prove neces- sary to maintain the ])atient's normal sex standard, the result still would he remarkable and the scientific status of the method sustained. Case 2, — This case was purely ex- perimental, and no exhaustive report will be made at this time. The subject was a healthy professional man, aged 58, who submitted himself to the ex- periment from purely scientific motives. The companion testis of that used in Case ,3 was employed. The implanta- tion was made in the left scrotal sac. The local result of the implantation was what we now feel justified in call- ing "typic," save that the subject got about on his feet after twenty-fotir- hotu's, which resulted in considerable swelling and tenderness of the oper- ated region. Wdien the patient keeps to liis l)ed, the reaction is very slight, compared to the tissue "insult." 2. — K.\])cvinic'iit;il iniplantation of a •single testis from a dead body. In this case there was a rise of temperature of 1 degree, which subsided in twenty- four hours. Seven months after the implantation a nodule about the size of a good-sized grape was still perceptible. Fourteen months later, the nodule was the size of a large pea. Certain oddities of apparent physiologic effects were noted in this case, which, if sustained by future observation, will be reported. Ca.sh 3. — A man, aged sixty, ai)parently normal in every respect, sub- mitted to imi)lantation, with a view of increasing ])hysical vigor and endurance in general, and sexual vigor in particular. The necessary material was secured from an apparently healthy lad of seventeen years of age, dead twelve hours of crushing injury to the head. Death had occurred about four hours after the injm-y. The operation was performed shortly after that in Case 2. — 314 — Si:\ C.I.WI) IMI'I.AXTATIOX The lc>R-> were icirii^cratcd tor about forty-cis^ht iiours. A single gland. ! the right, was eniplovL-d. The epididymis was reniuved, and numerous areas of the Cortex denuded. The implantation was made in the right scrotal sac. The implantation was perfectly- successful. Tliere was practically no febrile reaction, and very little swelling at the site of th.e imi)lantation. Xo opportunity has ])resented itself for a review of this case, but a little over seven months after the implantation the patient wrote that lij was satisfied with results, and that there still was "([uite a lump" at the site of the im])lantation. Twenty-two months after the implantation, the patient wrote that his "physical, sexual and mental vigor" still were greatly improved, and 1 i K m * 'dm. M f I SI, II i|,I:int;lt .lia.l 1. 1 t a mIv. that his blood pressure — which was 1.^0 at the time of the implantatioii — was Li5. Cask 4. Double testicular implantation. Subject aged sixty-nine. Xo organic disease. Complained of shortness of breath on comi)arativcl\' slight exertion and of "im-teadiness" of lower limbs. Sexual power still fair, but "failing" as usually might be expected in a man of his age. lirielly. as the patient and his friends expressed it. he had begun to show his age. His n,irmall\- ruddy complexion had ])aled considerably, lilood pressure. K"^0 — -ystolic. I)ige-li\e function normal, despite a ten;lency to o\er-cating. W'islies to submit to implantation for its prolsable effect of increased elticiency juid ini]>ro\ cment of -exual jiower. Double :~crotal implantation ( )ctober 27. 1''16. Alaterial taken from healthy lad. fourteen years of age. dead about ten hours from crushing injury of the head. Material refrigerated twelve hours, l-.pididymes not remo\'ed and testes im])Ianted intact without decorti- cation. \'erv slight local reaction and no temperature. Patient up and about on the eighth day. Improvement in color was noticeable on the third day. and \\as connnented on by the author's assistants and the i)atient's friends. Six months after the implantation, well detfned nodules, insensitive and ireely movable, marked the sites of implantation. Atrophy had been rather more rapid than in the average case. Init both the epididymes and the bodies of the testes were plainly to be felt, the entire mass on each side being about the size of a small almond. The patient's appearance was that of a man ten year- younger than his ,-ige. his face -liowing .a healthfid rucMiness. b'.fticiency had markedly increased, and the "insecurity" of the lower liml)s had entire!) disaijpearefl. The su])erticial \eins of the lower extremities, which were Considerably enlarged and varico-e. had improved to ;i marked degree. The sexual pcjwer had markedly increased. The patient expressed himself as 315 lAipoTi^xci-: AND sti<:rii2o — I^IPOTENCE AND STERILITY Belot, popular presentation of sexual perversion 51 ]>ernard, glycosuria function of the liver 212 Berthold, transplantation of testes 210 Biedl— — effect of X-ray on Graafian follicles 222 — formation of antibodies by hormones 214 — interstitial cells of ovary 222 — • relation of hormone to secondary sex characters 219-220 Blood pressure, effect of sex gland implantation upon 244 Boarding schools, dangers of 51 Bordieu, views of glandular secretion 209 Bouin, interstitial cells of ovary 222 Bouin & Ancel, interstitial cells of testicle 218 Brown-Sequard, self-experimentation of 207-212 Cantharides, aphrodisiac action of 193 Capon, implantation of testis in 280-282 Caput gallinaginis, irritability of, in spermatorrhea 173 Carrel & Guthrie, observations on transplanted glands 247 Cavernositis, as a cause of impotency 136 Celebrities, dangerous examples of 28 Cell changes in implanted testes 301 Cevelotto, implantation of testicle tissue in rabbits 211 Circulation, effect of sex gland implantation upon 245 Circumcision 88 — as a remedy for genital irritation 89 — for nervous diseases 89 — • proper method of 89 Cirrhosis of liver, case of sex gland implantation in 264 Clevenger, sexual perversion, theory of 38 Climacteric, in the male 209 Clitoris, hypertrophy of 13 Coitus — — interrupted, evils of 84 — necessitj' of, pernicious ideas regarding 85 — proper frequency of 80 — unphysiologic forms of 84 ColUculus seminalis — — cauterization of 198 — relation of, to impotence 145 Compatibility in marriage 124 Complementary hormone 271 Conception, fear of, as a cause of sterility 170 Congenital deformities of urethra 19 Connective tissue, protection of implanted tissue from 236 Conservation of testicle tissue 214 — 324 — INDEX CenUinence — — as a cause of impotence 118 — in the young, beneficial effect of 79 — practibility of 86 Corpus luteum, structure of 216 Cross breeding, effect of, on fertility 161 Cross implantation of sex glands 242, 259, 278 Cryptorchidism, sterility in 106 Dallinger, essay on cannibalism in copulation 38 Dam i ana — — as an aphrodisiac 157 — properties of 192 Deformities of sexual organs, acquired 22 Dementia precox, sex gland implantation in 257, 303 Determination of sex 18 Diet, relation of, to sexual instinct 87 Diseases of the sexual function and instinct 25 — general considerations of 25 Drugs — — production of impotency by 137 — treatment of impotency by 142, 143, 144 Dubois & Boulet, effect of prostate extract 276 Duration of procreative power 157 D_vsmenorrhea, ovarian extract in 276 Early sexual indulgence, effects of 29 Electricity, treatment of impotency by 145 Emotions, effects of, on sex glands 130 Emulsions of organs, as a therapeutic resource 197 Environment, relation of, to sexuality 27 Epididymis, role of, in hormone production 295 Epididymitis, relation of, to sterility 107 Epididymostomy, treatment of sterility by 114 Epididymotomy, as a prophylactic of sterility 113 Epileptic attack, resemblance of orgasm to 67 Epilepsy, relation of, to masturbation 76 Epispadias 19 Erection — — physiology of 97 — reflex apparatus of 98 Erotomania 56 Exercise, beneficial effects of on the sexual system ^ Exhausting diseases, production of impotence by 121 Exhibitionists 48 Experimental implantation of human sex glands 225, 277 — 325 — LAIPOTENCE AND STERILITY Familiarity, undue, as a cause of marital infelicity 126 Fauser, observations of dementia prsecox 252 Female children, masturbation in 64 — relative frequency of masturbation in 64 Fertilization, process of 159 Flint, vicvv-s of spermatorrhea 181 Foa, observation on testicle grafts 210 Foreign bodies, use of, by masturbators 47 — case of 48 Formative energy of spermotozoa and ovule 216 Fowls, experiments in implantation of sex glands in 280 Fraenkel, structure of corpus luteum 216 Freezing, effect of, on gland tissue 230 Frigidity 161 — relation of, to sterility 162 furor iitcrinns 56 Garre, thyroid implantation 276 General health, relation of, to vitality of spermatozoa 111 Genital irritation, relation of, to masturbation 62 Genital malformations 12 Germinal selection 18 Goethe, elective affinities, theory of 129 Gonorrhea, relation of, to sterility 107 Guthrie, experiments in ovarian grafting 211 GuJ^ classification of genital malformations 13 Gymnastics, special forms of, relation of to masturbation 66 Flammond — — psychic impotency, case of 129 — remarks on the treatment of impotency 141 Hammond and Sutton, case of unsuccessful testicle implanta- tion 210 Hassel. views of spermatorrhea 181 Heredity, relation of, to sexual perversion 47 Hermaphroditism 7 — case illustrating difficulty of diagnosis 10 — definition of 8 — forms of 13 • — ignorance regarding 12 — occasional difficulty of diagnosis 8 Hcteroijlastic grafting of testicle 308 Hippocrates, description of spermatorrhea 171 Holmes, observations on dementia prsecox 252 Hormone, complementary to sex gland 271 IIorsc-l)ack riding, effect of in spermatorrhea 175 — 326 — INDEX Howe, impotence clue to continence, case of 119 lluniicr, relation of to sexual affinity 39 Hypospadias 19, 21 — impotence, produced by 148 Idleness, relation of, to sexual vice 86 Ignorance of sexual physiology, relation of to sexuality 29 Implantation of testis, technique of 231 Impotence — — general considerations of 97 — in the female 159 — in the male 115 — etiology of 116 — symptomatic, from fevers 135 — treatment of 138 — true form, etiology of 133 — varieties of 117 Infertility — — biochemic explanation of 100 — hormone incompatability in 100 Injuries of the prostatic urethra — — relation of. to sterility 108 — relation of. to impotence 108 Insanit_v, as a result of masturbation IZ, 76 Intimacies among children, dangers of 63 Iscovesco. lipoid extracted from ovary and testis 276 "Jack the Clipper psychopaths 46 Kehrer. causes of childless marriages 105 Krafft-Ebing — — remarks on sadism 39 — inverted sexuality, case of, in the female 43 — inverted sexualitj', case of, in the male 43 Lallemand. description of masturbators 71 — seminal losses 175 Leopold-Levi. treatment of psoriasis by thyroid extract 276 Leydig, "between cells" of testicle 218 Libidinousness. excessive 55 Lipoid, extracted from ovary and testis 276 Literature, pernicious, effect of, on sexuality 29 Local results of sex gland implantation 236 Lode, observations of testicle transplantation 211 Loisel, toxic extracts from sex glands 217 — 327 — IMPOTENCE AND STERILITY Longevitj' — — eflfect of sex hormone upon 272 — relation of sex vigor to 207 Male climacteric 209 Marital infelicity, responsibility of husband in 126 Marital relation, mismanagement of, by husband 163 Marriage — — as a remedy for masturbation 91 — as a remedy for sexual disturbances 198 Marshall and Hammond, experiments in controlling sex charac- teristics of sheep 219 Masochism 48 Massage, prostatic, treatment of impotence by 48 Masturbation 61 — among animals 61 — as a cause of insanitj' IZ — ethology of 62 — frequency of 62 — in 3^oung children 62 • — prognosis in 90 — relation of genital irritation to 62 — results of 71 Material eligible for sex gland implantation 138 Mental disquiet, production of pseudo-impotency by 121 Metchnikoff — experiments with semen 274 Michel, functional autolysis 231 AIoll, substances controlling secondary sex characteristics 219 Monogamy, artificial nature of man 26 Mons veneris, as a site for sex gland implantation 234 Moral degeneracy, relation of, to marital infelicity 126 Morris, heteroplastic grafting of testicle 308 Mutilation of sexual organs 21, 22 Miiller, views of ductless glands 209 Necrophilism 48 Neurasthenia, sexual 200 — treatment of, by sex gland implantation 255 Normal persons, sterility in 111 Novelty, relation of, to sexual desire 56 — relation of sex hormone to 58 Nussbaum, origin of sex hormone 216 Nymphomania 52, 56 — etiology of 58 — treatment of 59 — hormone therapy in 60 — 328 — INDEX Nymphomaniacs, fondness of, for gynecologic manipulations 57 Obesity, effect of, on sexuality 221 Olfaction, relation of, to sexual desire 39, 137 Orchitis, relation of, to sterility 107 Orgasm — — accidents produced by 68 — in the female 68 — resemblance of, to epileptic attack 68 Ovarian implantation 222 — case of 249 — sites for 235 Ovarian, irritation, relation of. to sexual perversion 46 Ovary — — diseased, conception in presence of 165 — effects of implantation of 222 — internal secretion of 222 — secretory cells of 222 Ovule— — vitality of, in relation to sterility 110, 159 — conditions impairing" vitalit}' of 161 Paschoud, thyroid grafting 213 Passion in women, psychic inhibition of 164 Perineal strain, dangers of 67 Peyer, definition of spermatorrhea 174 Phimosis, as a factor in masturbation 63 Phthisis, relation of, to masturbation 76 Physical training — — • benefits of, in sexual disturbances 86 — in spermatorrhea 172, 179 Physiologic effects of sex gland implantation 243 Pilocarpin, administration of, in impotence 121, 136 Plumage, in fowls, as a criterion of secondary sex character- istics (foot note) 212 Poehl, injections of spermine 212 Polygamous nature of man 27 Pornography 48 Porte caustiqiie 198 — sterility produced by 108 Potency — — following castration, explanation of 103 — after castration, with sterility 104 Precocious sexuality 23 — etiology of 24 Prenant, structure of corpus lutcuin 216 — 329 — IMPOTENCE AND STERILITY Preservation of sex gland tissue for implantation 230 Profession, responsibility of. for sexual ignorance 30, 31 Properitoneal space, as a site for sex gland implantation 234 Prostate — — hormone of 200 — irritation of, in relation of, to libidinousness 55 Prostatic urethra, applications to, in spermatorrhea 196 Prostatitis, sexual phenomena in 183 Pseudo-hermaphroditism 7, 8, 10-13, 15, 20 Pseudo-impotence 116 Pseudo-spermatorrhea 172, 177 Psoriasis, sex gland implantation in, case of 264 Psychic impotency, causes of 127, 129, 132 Psycho-sexual failure of differentiation 14 Psycho-therapy- — — treatment of impotence by 138 — treatment of spermatorrhea by 50 Quantity of sex gland tissue for implantation 237 Racial-cross sex gland implantation, cases of 241, 277, 278 Ramm-White operation 206 Rationale of sex gland implantation 238 Rectum, disease of, as a cause of impotence 118 Regaud & Policard. secretory cells of ovary 222 Religious psychology, relation of, to masturbation 75 Repression of sexual desire in women, cause of 122 Resection of vasa dcfcrcntia 92 Resection of vena dorsaUs penis in treatment of impotence 149 Reynolds, sexual perversion, peculiar case of 47 Ribbert, transplantation of tissue 211 Roubaud, psychic impotency, typic case of 127 Sadism 39 — cases of 47 Satyriasis 52 — associated with sexual perversion, case of 54 — typic cases of 53 — ■ etiology of 53 — in elderly men 54 Schiefferdeckcr, physiologic action of internal secretions 214 Secondary sex characteristics — — substances controlling 219 — preservation of, after castration 219 — 330 — INDEX Secretion — — lack of, in impotence 121 — treatment of, by pilocarpin 121-144 Semen — — normal, microscopic appearance of 178 — microscopic appearance of, in sperniuria 182 — perversion of, relation of. to sterilitj- 110 Seminal losses 175 — etiology of 176 — treatment of 186 Sensitive sexual organization, relation of, to impotence 122 Sex deformities 7-10, 12-23 Sex, determination of 18, 19 Sex gland implantation 205, 245 — cases of 249, 250, 257, 258, 259, 264, 111, 278. 303, 311, 314, 315, 316, 317 — effect of senile environment upon 269 — technic of 225 Sex hormone— — relation of, to aberrant sex differentiation 16 — incompatability of, as a cause of sex aberrations 17 Sex mutilation, ph^-siology of 22 Sexual abuse, as a cause of sterility 111 Sexual desire, repression of 123 Sexual erethism 55 Sexual excess 78 — impairment of semen by '^2 — injury to sexual function produced by 83 — local and general results of 82 — perversion of internal secretion by 79-83 — treatment of 84 Sexual excitement v.-ithout gratification, results of 175 Sexual function and instinct — — diseases of 25 — purpose of 25 Sexual irritability in tubercular subjects S3 Sexual neurasthenia 200 Sexual passion, variation of intensity of 120 Sexual perversion and inversion 31 — as a cause of impotence 130 — atavism in 35 — classification of 2)1) — etiology of 34 — heredit}- in 36 — psycho-therapy in 49 — scriptural history of 34 — 331 — IMPOTENCE AND STERILITY Sexual perversion and inversion — — sterilization for 51 — treatment of 50 — typic cases of 40, 43 Sexual precocity, relation of, to masturbation 23 Sexual sensibility, seat of 68 Site for sex gland implantation 233 Spermatorrhea 170 — as a complication of nervous disease 177, 183, 184 — definition of 171 — etiology of 173-179 — hypochondriasis in 185 — neglect of, by physicians 170 — pseudo 177 — symptomatic 183 — symptoms of 179 — treatment of 186 — varieties of 177 Spermatozoon, kinetic energy of 215 — vitality of, in relation to sterility 110 Spermuria 182 Spitzka, sexual perversion, theory of 39 Sprague, peculiar case of 45 Sterility — — general considerations of 97 — in the female 159 — etiology of 159 — treatment of 167 — in the male 104 — etiology of 105 — treatment of 114 Sterilization 92 — treatment of spermatorrhea by 51 Stich, transplantation of ovary (foot note) 222 Stricture of the urethra, sterility from 109 St. Hilliare, theory of hermaphroditism 15 Suggestion therap3% as a remedy for sexual irregularities 90 Syphilis — — as a cause of impotence and sterility 137 — of brain, simulating dementia prgecox, case of 254 Tabes, spermatorrhea in 183 Tardieu, sexual perversion, case of 44 Thiersch, theory of virethal deformities 20 Thompson, sexual indulgence, as a cause of prostatitis 174 — sexual phenomena in prostatitis 183 Topinard, sexual symptoms of tabes 183 — 2,2,2 — INDEX Tuffier and Martin, method of ovarian implantation 235 Tumors of brain, relation of, to satyriasis 54 Tunica vaginalis, advantages of sex gland implantation in vicinity of 233 Uncleanliness, relation to masturbation 64 Undue familiarity in marital relation 164 Urquhart, heredity in sexual perversion, case of 47 Unphysiologic coitus 84 Urethra, congenital deformities of 19 Urethral catarrh, relation of, to pseudo-spermatorrhea 182 Urethral defects, etiology of 19, 20 — Thiersh's theory of 20 Urnings 11 Vasa deferentia, anastomosis of 94 Vasectomy 92 — indications for 93 — technic of 94 Vecki, impotence from disturbance of olfaction 137 Vena dorsalis penis, resection of, for impotence 149 Vesiculae seminales, hyperesthesia of, in spermatorrhea 174 Waldstein and Ekler, experiments on female blood after coitus (foot note) 220 Wassermann test, in sex gland implantation 241 Weissman, theory of germinal selection 18 Wharton, sexual perversion, case of 46 Wilde, Oscar, case of 49 X-raj- — — as a cause of impotence and sterility 138 — efifect of, on function of testis 138 — on graafian follicles 219 Young females, predilection of elderly men for 55 — Z22> — IMPOTENCE AND STERILITY ■with Aberrations of the Sexual Function and SEX-GLAND IMPLANTATION by G. FRANK LYDSTON, M. D., D. C. L. Price $4.00 Sold by Subscription Only. Send postage prepaid on receipt of subscription price. THE RIVERTON PRESS. 25 E. Washington st.. CHICAGO UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. 315 L 005 128 101 2 linSlSSSlI ^^^'°^'^^ L'^'^^R'^ 'FACILITY AA 000 145 935 3