The Linacre Quarterly

Volume 26 | Number 1 Article 4

February 1959 The mpI ediment of Impotency and the Condition of Male Impotence: A Canonical-Medical Study: Medical Considerations Paul V. Harrington

Charles J.E. Kickham

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Recommended Citation Harrington, Paul V. and Kickham, Charles J.E. (1959) "The mpeI diment of Impotency and the Condition of Male Impotence: A Canonical-Medical Study: Medical Considerations," The Linacre Quarterly: Vol. 26 : No. 1 , Article 4. Available at: http://epublications.marquette.edu/lnq/vol26/iss1/4 in serious hemorrhage before one in contrast to the questio1 ,ble resorts to curettage. Had curettage morality of direct extraction. ·not' been performed during the ad­ m.1ss10.n prior , the present hos­ CONCLUSION The Impedimer of Impotency and . pitalization, t,,-. pregnancy might TI terine curettage for th_e at- have contintwct on to full term. ,_t of serious hemorrhage )n­ The Conditio' · Male Impotence This possibility is postulated on 'nt upon pregnancy prio to the fact that the patient went t• ttainment of fetal viabili , is A Can011. Medical Study through . an uneventful full-term lly licit only after the I tus pregnancy the yea_r before in spite h.:i ':ed or becomes detachec REV. PAUL V. HARRINGTON, JC. CHARLES J. E. K1cKHAM, M.D .. P.A.C.S. of her long history of chronic l pel­ '. 're is a high probability hat To_ present the proble s ,m,. ' , :, the matter of ma e impotence as related to vic inflammatory b disease. at 5t one of these conditio1 ; is the validity of marriage, t he c . onsiderations, as prepared y Rev. Paul V. J.C.L., were pubI ,s"j" 1 , August· and November 1958 issues :>f The There is possibly room Harrington, l for some fuF cd when hemorrhage i. so Linacre Quarterly. Th� me_dical ,_ EIS t forth by Dr Char es 1- E. K,ckham, debate as to whether or not r gra ua t f Holy c;oss College and Harvard ex­ se, ,. , that it constitutes an ir ne­ appears in this issue. Dr. K,cklwm er o traction of Medical School. He is sso e r f U o log at Tufts M edical Scho l and the fetus was actually dia l and serious threat to the life A ciat P: , Uo i° l o Departme 7,t- lfrlizabeth's Hospita , Bright n; justified when it is Surgeon,in_-Chief, f/ o was unexpectedly of L',e mother. In such cin: 1m­ Carney Hospital, Boston, an d ond'., ' -11e rci:/c�r H�spital at Norf lk, Mass. He is a discovered at the time of"examina­ sta nces it is unlikely that the f tus dip/ornate of the American Board of Urology. tion under ;mesthesia. Although is obtaining sufficient metal Jlic one might argue that the preg­ st,pport from the mother via the MEDICAL CONSIDERATIONS nancy appeared to be doomed placental circulation to sustain ife. emphasis on those features, per­ (there is no doubt AYING set forth the histori-­ that it was cer­ This justifies the assumption : is H taining to the sex apparatus, must tainly prejudiced cal evolution and present un­ by the "preceding dead or detached. be elicited. An evaluation of the curettage) it must derstanding of the impediment o� be admitted that Application of this criterion re­ person's attitude towards the oth r death of the impotency and the condition of � fetus was by no - supposes that the physician re, :,g­ sex is necessary. A careful physi­ means certain male impotency, it remains no v to at the time and .the nizes the distinction between d.i ect : _ cal examination should be carried placenta was· consider .this can·onical defimt1on s·ubsequently found abortion and licit removal c a out and an impression obtained as to have in the light of present-clay medical been firmly attached. In dead fetus. The theoretical i eal to the gonadal type involved. 1 ­ the absence of knowledge and determine what � severe enough of absolute certainty is not al"' ays spection of the genital organs will bleeding liable to be an immediate diseases, anomalies or abnormal­ attainable by all physicians. Th 're­ ities would or might constitute an reveal the existence of any anoma­ threat to the life of the mother it fore, a reasonable margin of ho est impotent condition. The possibil­ lies or gross defects. Palpation of would have been ethically more error in making judgments in , ev­ ities of cure or remedy of such a the scrotal contents is of impor­ prudent to use conservative hemo­ ere hemorrhagic emergencie� is condition will also be discussed· in tance as any abnormal findings static measures such as oxytocics tolerable as a realistic calcul.· ted an attempt to discover _ which may be of real significance. The and packing in this case. Then risk until greater precision beco•nes might be judged to be permanent. vas should be followed to the in­ even if indirect abortion occurred I possible in the diagnosis of fetal As mentioned previously, the an­ guinal canal and the size, consis­ it would have been a natural ·event death or detachment. tecedents of each condition can be tency and location of the testes determined by the fact of its con­ should be noted. The status of the genital nature or by the date of epididymis must likewise be re­ the surgery or accident which ac­ corded. The normalcy of the penis counts for it. must be confirmed. These relative­ ly simple procedures may provide _ The etiological background of a clue to the solution of the entire impotence may, in many instances, problem in an individual case. tax the diagnostic acumen of �he A complete neuropsychiatric most meticulous and painstakmg . investigator. A detailed present evaluation may, at times, be m­ and past history with - particular dicated. Neurogenic factors may 12 LINACRE QUARTERLY FEJIRUARY, I 959 . 13 be present whereby the reflex act early period of married life nay all the glands of internal secretion. is prevented by disturbances in 1,tanding of the physiologinl not have particular signific nee The anterior pituitary secretes the the higher centers, or. damage to mechanisms of erection and Ci-" ,_ especially in the sexually ine pe- gonadotrophic hormone \\ h i c h the neµromus, -ar mechanisms. as Jation and the associated n r•enced. The sex act general], at­ to stimulates the in , r�t,tial cells to a result of n, ' ..: lesions, may be anatomy is essential the p• · ! ,ns normalcy after a ce ain the production of androgen and evident. appreciation of the problem ,111 �unt of mutual adjustment has volved in male impotence. controls spermatogl'ncsis and regu­ t ·n place. These couples sh uld Organic factors, acquired or The so-called seminal tr, lates endocrine efficiency. be 1 cassured and advised � • a congenital. are commonly noted formed ·by the testis, epidic The scrotum exercises a thermo­ and. as previously stated, lack of co11 p�tent medical authority. An vas deferens, ampulla of ua., regulatory role. It has demonstrat­ continuity of the conducting chan­ im; nrrant aspect of prem, ure ejattdation is that in a def nite inal vesicle and ejaculatorv ed that sperm do not reach matur­ nels of. the seminal tract may re­ ity nu, •l,er of cases especially in the These organs are bilateral ,. in the higher temperatures of sult in an impotent condition ac­ normal individual. The flr<•· · 11c the inguinal canal and particularly intrc, nective type, its repet ion cording to the opinion of Cardinal gland has an accessory SC\ ,,,le. within the abdomen. may result in lack of confldl' ice, Gasparri and his. followers. The testis has a two-fold fumt1c,11. disc, .1ragement and frustr, ion Following the production of On the purely functional basis, The fundamental purpose is sper­ whith may terminate in an inti ,ct­ sperm in the testes, they and any loss of potency may be. _due to aiatogenesis-the production of ablr true psychic impotence. w .ich ancillary secretions are transported neurotic or psychoneurotic sources sperm which have their origin ll1 mav require intensive psychot ,er­ along the convoluted tubules of· with no gross pathologic changes the germinal cells of rhc semenifer­ apr the epididymis through the vas demonstrable in the structure of ous tubules. The s.:,.ond purpose deferens which dilates before the sex apparatus and no neuro­ ft should be recognized that the is the elaboration of an androgenic entering the prostate gland to form genic dysfunction or mechanical male is born with certain inhe, ent hormone by · the interstitial cells. the ampulla. At the base of the to impediment erection or ejacula­ sex endowments. In the weakly en­ The hormones exercise a control­ prostate it is joined by the duct of tion present, even · though there dowed, the sex factor may b, an ling power over the reproductive the seminal vesicle to form the may be minor and insignificant inconspicuous and unobtrusive ·le­ organs and promote male growth ejaculatory duct which traverses pathologic ch;rnges. Unconscious ment in his life and may n. :an and are required · for the normal the prostate and empties into the emotional disturbances, lack of little or nothing to him. He 1 1ay development and physiological ef­ urethra. Obviously, occlusion of confidence, sense of inferiority. not be aware of such deficiency ficiency of. the sex and accessory this seminal avenue at any point introspection, frustration, worry, until conjugal requirements rr 1ke sex apparatus. The development will prevent the testicular secre­ indifference and occasionally sex him realize his inadequacy. This of the secondary male characteris­ tion on the involved side from perversion may be encountered. may be manifested by entire lack tics is also dependent on these reaching the urethra in the ejacu­ Premature ·ejaculation is fre­ of libido or deficient erectile po,:er. hormones. Testicular inadequacy late and, when bilateral, the entire quently encountered when the He may not have the sligh est expresses itself in many·ways and secretion is eliminated. problem of impotence is presented. desire to have marital relations tnd in varying degrees. It may be ab­ In this group the reflex mechanism· thus lacks the most basic tnd solute as after castration, cir rela­ The seminal vesicles have a two­ is abnormally rapid and penil stim­ fundamental predisposition for the tive as in the involution of the fold function serving as a reservoir or storehouse for the sperm and ulation ends in too early ejacula­ normal functioning of the sex ap­ aged. It may be· failure of andro­ tion and· before intromission has paratus. These men are extremely genic function or a failure of sper­ also secreting a liquid which mod­ ifies and probably enriches its taken place. It is noted in the difficult to evaluate especiall) ·in matogenic function. It may be hypertonic person who is tense and excluding the psychic factor as primary in the testis itself· or sec­ stored contents. The prostate gland's only known role is the pro­ emotionally overactive and in the well as in pinpointing the individ­ ondary failure of the gonado­ of a secretion which, to­ hypotonic type who is disinterested ual who, for strictly selfish and trophic activity of the anterior duction gether with the secretions of the and apathetic. This may lead to ulterior motives, "protests his im­ pituitary gland. It must be em­ seminal vesicles and bulbo-urethral actual and complete impotence. potence too much." phasized that essential to the prop­ mix with the testiculat The prognosis in the hypertonic er function of the testicles is the glands, A knowledge o'f the anatomy component to form the ejaculate. is in most instances more favor­ integrity of the master gland, the and function of the organs in­ prostatic fluid forms the bulk . able. Premature ejaculation in th_e pituitary, which is the most im­ The volved in the sex act and an under- portant and dominant inember of of the ejaculate and dilutes the ex- 14 LINACRE QUARTERLY FEBRUARY, 1959 15 in serious hemorrhage before one in contrast to the questio1 ,ble resorts to curettage. Had curettage morality of direct extraction. ·not' been performed during the ad­ m.1ss10.n prior , the present hos­ CONCLUSION The Impedimer of Impotency and . pitalization, t,,-. pregnancy might TI terine curettage for th_e at- have contintwct on to full term. ,_t of serious hemorrhage )n­ The Conditio' · Male Impotence This possibility is postulated on 'nt upon pregnancy prio to the fact that the patient went t• ttainment of fetal viabili , is A Can011. Medical Study through . an uneventful full-term lly licit only after the I tus pregnancy the yea_r before in spite h.:i ':ed or becomes detachec REV. PAUL V. HARRINGTON, JC. CHARLES J. E. K1cKHAM, M.D .. P.A.C.S. of her long history of chronic l pel­ '. 're is a high probability hat To_ present the proble s ,m,. ' , :, the matter of ma e impotence as related to vic inflammatory b disease. at 5t one of these conditio1 ; is the validity of marriage, t he c . onsiderations, as prepared y Rev. Paul V. J.C.L., were pubI ,s"j" 1 , August· and November 1958 issues :>f The There is possibly room Harrington, l for some fuF cd when hemorrhage i. so Linacre Quarterly. Th� me_dical ,_ EIS t forth by Dr Char es 1- E. K,ckham, debate as to whether or not r gra ua t f Holy c;oss College and Harvard ex­ se, ,. , that it constitutes an ir ne­ appears in this issue. Dr. K,cklwm er o traction of Medical School. He is sso e r f U o log at Tufts M edical Scho l and the fetus was actually dia l and serious threat to the life A ciat P: , Uo i° l o Departme 7,t- lfrlizabeth's Hospita , Bright n; justified when it is Surgeon,in_-Chief, f/ o was unexpectedly of L',e mother. In such cin: 1m­ Carney Hospital, Boston, an d ond'., ' -11e rci:/c�r H�spital at Norf lk, Mass. He is a discovered at the time of"examina­ sta nces it is unlikely that the f tus dip/ornate of the American Board of Urology. tion under ;mesthesia. Although is obtaining sufficient metal Jlic one might argue that the preg­ st,pport from the mother via the MEDICAL CONSIDERATIONS nancy appeared to be doomed placental circulation to sustain ife. emphasis on those features, per­ (there is no doubt AYING set forth the histori-­ that it was cer­ This justifies the assumption : is H taining to the sex apparatus, must tainly prejudiced cal evolution and present un­ by the "preceding dead or detached. be elicited. An evaluation of the curettage) it must derstanding of the impediment o� be admitted that Application of this criterion re­ person's attitude towards the oth r death of the impotency and the condition of � fetus was by no - supposes that the physician re, :,g­ sex is necessary. A careful physi­ means certain male impotency, it remains no v to at the time and .the nizes the distinction between d.i ect : _ cal examination should be carried placenta was· consider .this can·onical defimt1on s·ubsequently found abortion and licit removal c a out and an impression obtained as to have in the light of present-clay medical been firmly attached. In dead fetus. The theoretical i eal to the gonadal type involved. 1 ­ the absence of knowledge and determine what � severe enough of absolute certainty is not al"' ays spection of the genital organs will bleeding liable to be an immediate diseases, anomalies or abnormal­ attainable by all physicians. Th 're­ ities would or might constitute an reveal the existence of any anoma­ threat to the life of the mother it fore, a reasonable margin of ho est impotent condition. The possibil­ lies or gross defects. Palpation of would have been ethically more error in making judgments in , ev­ ities of cure or remedy of such a the scrotal contents is of impor­ prudent to use conservative hemo­ ere hemorrhagic emergencie� is condition will also be discussed· in tance as any abnormal findings static measures such as oxytocics tolerable as a realistic calcul.· ted an attempt to discover _ which may be of real significance. The and packing in this case. Then risk until greater precision beco•nes might be judged to be permanent. vas should be followed to the in­ even if indirect abortion occurred I possible in the diagnosis of fetal As mentioned previously, the an­ guinal canal and the size, consis­ it would have been a natural ·event death or detachment. tecedents of each condition can be tency and location of the testes determined by the fact of its con­ should be noted. The status of the genital nature or by the date of epididymis must likewise be re­ the surgery or accident which ac­ corded. The normalcy of the penis counts for it. must be confirmed. These relative­ ly simple procedures may provide _ The etiological background of a clue to the solution of the entire impotence may, in many instances, problem in an individual case. tax the diagnostic acumen of �he A complete neuropsychiatric most meticulous and painstakmg . investigator. A detailed present evaluation may, at times, be m­ and past history with - particular dicated. Neurogenic factors may 12 LINACRE QUARTERLY FEJIRUARY, I 959 . 13 be present whereby the reflex act early period of married life nay all the glands of internal secretion. is prevented by disturbances in 1,tanding of the physiologinl not have particular signific nee The anterior pituitary secretes the the higher centers, or. damage to mechanisms of erection and Ci-" ,_ especially in the sexually ine pe- gonadotrophic hormone \\ h i c h the neµromus, -ar mechanisms. as Jation and the associated n r•enced. The sex act general], at­ to stimulates the in , r�t,tial cells to a result of n, ' ..: lesions, may be anatomy is essential the p• · ! ,ns normalcy after a ce ain the production of androgen and evident. appreciation of the problem ,111 �unt of mutual adjustment has volved in male impotence. controls spermatogl'ncsis and regu­ t ·n place. These couples sh uld Organic factors, acquired or The so-called seminal tr, lates endocrine efficiency. be 1 cassured and advised � • a congenital. are commonly noted formed ·by the testis, epidic The scrotum exercises a thermo­ and. as previously stated, lack of co11 p�tent medical authority. An vas deferens, ampulla of ua., regulatory role. It has demonstrat­ continuity of the conducting chan­ im; nrrant aspect of prem, ure ejattdation is that in a def nite inal vesicle and ejaculatorv ed that sperm do not reach matur­ nels of. the seminal tract may re­ ity nu, •l,er of cases especially in the These organs are bilateral ,. in the higher temperatures of sult in an impotent condition ac­ normal individual. The flr<•· · 11c the inguinal canal and particularly intrc, nective type, its repet ion cording to the opinion of Cardinal gland has an accessory SC\ ,,,le. within the abdomen. may result in lack of confldl' ice, Gasparri and his. followers. The testis has a two-fold fumt1c,11. disc, .1ragement and frustr, ion Following the production of On the purely functional basis, The fundamental purpose is sper­ whith may terminate in an inti ,ct­ sperm in the testes, they and any loss of potency may be. _due to aiatogenesis-the production of ablr true psychic impotence. w .ich ancillary secretions are transported neurotic or psychoneurotic sources sperm which have their origin ll1 mav require intensive psychot ,er­ along the convoluted tubules of· with no gross pathologic changes the germinal cells of rhc semenifer­ apr the epididymis through the vas demonstrable in the structure of ous tubules. The s.:,.ond purpose deferens which dilates before the sex apparatus and no neuro­ ft should be recognized that the is the elaboration of an androgenic entering the prostate gland to form genic dysfunction or mechanical male is born with certain inhe, ent hormone by · the interstitial cells. the ampulla. At the base of the to impediment erection or ejacula­ sex endowments. In the weakly en­ The hormones exercise a control­ prostate it is joined by the duct of tion present, even · though there dowed, the sex factor may b, an ling power over the reproductive the seminal vesicle to form the may be minor and insignificant inconspicuous and unobtrusive ·le­ organs and promote male growth ejaculatory duct which traverses pathologic ch;rnges. Unconscious ment in his life and may n. :an and are required · for the normal the prostate and empties into the emotional disturbances, lack of little or nothing to him. He 1 1ay development and physiological ef­ urethra. Obviously, occlusion of confidence, sense of inferiority. not be aware of such deficiency ficiency of. the sex and accessory this seminal avenue at any point introspection, frustration, worry, until conjugal requirements rr 1ke sex apparatus. The development will prevent the testicular secre­ indifference and occasionally sex him realize his inadequacy. This of the secondary male characteris­ tion on the involved side from perversion may be encountered. may be manifested by entire lack tics is also dependent on these reaching the urethra in the ejacu­ Premature ·ejaculation is fre­ of libido or deficient erectile po,:er. hormones. Testicular inadequacy late and, when bilateral, the entire quently encountered when the He may not have the sligh est expresses itself in many·ways and secretion is eliminated. problem of impotence is presented. desire to have marital relations tnd in varying degrees. It may be ab­ In this group the reflex mechanism· thus lacks the most basic tnd solute as after castration, cir rela­ The seminal vesicles have a two­ is abnormally rapid and penil stim­ fundamental predisposition for the tive as in the involution of the fold function serving as a reservoir or storehouse for the sperm and ulation ends in too early ejacula­ normal functioning of the sex ap­ aged. It may be· failure of andro­ tion and· before intromission has paratus. These men are extremely genic function or a failure of sper­ also secreting a liquid which mod­ ifies and probably enriches its taken place. It is noted in the difficult to evaluate especiall) ·in matogenic function. It may be hypertonic person who is tense and excluding the psychic factor as primary in the testis itself· or sec­ stored contents. The prostate gland's only known role is the pro­ emotionally overactive and in the well as in pinpointing the individ­ ondary failure of the gonado­ of a secretion which, to­ hypotonic type who is disinterested ual who, for strictly selfish and trophic activity of the anterior duction gether with the secretions of the and apathetic. This may lead to ulterior motives, "protests his im­ pituitary gland. It must be em­ seminal vesicles and bulbo-urethral actual and complete impotence. potence too much." phasized that essential to the prop­ mix with the testiculat The prognosis in the hypertonic er function of the testicles is the glands, A knowledge o'f the anatomy component to form the ejaculate. is in most instances more favor­ integrity of the master gland, the and function of the organs in­ prostatic fluid forms the bulk . able. Premature ejaculation in th_e pituitary, which is the most im­ The volved in the sex act and an under- portant and dominant inember of of the ejaculate and dilutes the ex- 14 LINACRE QUARTERLY FEBRUARY, 1959 15 atrophy of these parts, disease or pelled contents from the ejacula­ cause efferent impulses to �ave quantity of carrier fluid. Howt" ,· • . I trauma. Organic ,ources may be tory duct and probably separates the cord through sympathetic there is no conJl.rmatory test pc, ·ami congenital or acquired. Anomalies .and activates •he sperm. The ex­ ·dong the hypogastric plexw and at the present time, chemi, of the penis or u ·a are not m- pulsibn of th'o .- eminal fluid from ·· cite contraction of the sr )oth microscopic, which can det · frequently noted . cause of im- the vesicles and uas,along the ejac­ •scles of the seminal ves :les , · :esticular component. It GI potence. The forn · ulatory duct .i,1d from the prostate concluded, therefore, that ,re less com­ ; ··•tate and vas which e 1pty mon, but when en •. ntered, may depends on the constriction of the presence of sperm canr u contents through their ,so­ have great significanu. their smooth muscles as a reaction ci. d ducts into the post rior de monstrated in an ejaculat to stimulation of the· sympathetic urel ',ra. This is almost simu an­ presence ·of a testicular comr Congenital absence of the penis has been reported and is obvious­ hypogastric plexus. eou•.1y followed by active e. Jul­ cannot be proved. ly sion of the seminal fluid thr, ugh a catise of permanent impotence. Integrity of the parasympathetic There is much discussio1 .o Rudimentary development of the and sympathetic pathways to the the urethral canal as a resu of whether or ·not the sperm ;d contraction of the striated I: dbo organ has been observed net infre­ genitals and sex organs may be from the testes to the uretl· at quently in which the penis 1s so . caverr•osus and ischiocavern ,sus fundamental to the normal achieve­ the time of ejaculation. It 1 not small that it is entirely enveloped muscles-a parasympathetic el ect. ment of erection and ejaculation. known definitely, although 1l is in the redundant tis­ Sympathetic contraction of th, in­ . and concealed Erection is primarily a· parasym­ reasonable to assume that in the sues of the scrotum, pubis and per­ ternal sphincter takes place to >re­ pathetic action with a sympathetic brief period of ejaculation the ineum, making coitus impossible. vent regurgitation of the ejaci late side-effect. Ejaculation is primarily sperm could not tnvel the long A malformation which may be into the bladder. The higher en­ sympathetic in origin with para­ conduit of the epidic.;mis and vas amenable to surgical correction is ters are not essential to erec ion sympathetic assistance. T h e s e into the urethra. It has been dem­ transposition of the penis and and ejaculation but they may d as­ mechanisms are reflex from deJl.nite onstrated that the vesicles function scrotum. Thirty-three instances of tically modify these acts as psy hie levels in the spinal cord and are as a sperm reservoir and that. im­ reduplication of the penis have factors can readily stimulate OJ in­ supervised by control from the mediately prior to complete emis­ been reported and may be reme­ hibit them. higher centers of the brain. sion, the sperm fill the ejaculatory died surgically. The body of the ejacul 1te, dud. This explains the high con­ Urethral anomalies are a fre­ Erection ·re.suits from a reflex whether in the absence or presc 1ce centration of sperm in the initial quent cause of impotence. Stenosis psychic or tactile sensory phenom­ of sperm, is termed semen or portion of the semen. We have no of the external urethral meatus enon having its center in the para­ seminal fluid. The quantity of I uid data on how long sperm may re­ may interfere with ejaculation but sympathetic Jl.bres of the 2nd, 3rd in each ejaculation varies am,mg main viably stored in the vesicles this condition is readily cured by and 4th sacral segments of the individuals and, in the same in­ and it is our present opinion with meatotomy and urethral dilatation. cord. The impulses are carried dividual, at various times. · 'he no scientific proof that in the exci­ Hypospadius, a congenital defect, along the internal pudenda) nerve average amount is approxima, ely · tation period, prior to ejaculation, in which the canal terminates on which effectdilatation of the penile 4 cc. In the normal individual, the r the sperm are carried to the uppe the under-side of the penis is a arteries and consequent engorge­ semen is composed of secrefrms seminal tract. It is well known that common congenital anomaly. Var­ ment of the corpora cavernosa and from the testes, probably the , pi­ men who eja.culate very infre­ ious gradations occur from an spongeosa. This is associated with didymi, the prostate gland and the quently may often have a normal opening on the glans just behi d compression of the penile dorsal bulbo-urethral glands. ( Cowpeis). � number of active sperm of regular normal site to one located m veins. which preclude venous re­ The urethral glands of Littre serve the morphology. In a physiologic dis­ the perineum. The anatomical va­ turn. Ejaculation. is basically a a role of lubrication. The amount, cussion in which ducts aridtubules rieties are classiJl.ed depending on complex reflex action from the which has its origin in the testis are involved, it is difficult to be the position of the orifice. The upper lumbar area of the spinal and epididymis, is extremely small dogmatic. glans or balanitic-type in which th� cord. Three separate mechanisms and has been estimated to be about urethral opening is on the under are involved. Afferent impulses one-twentieth of the total ejacula­ The sexual act may be rendered surface of the glans, at the site of arise chiefly in the sense organs of tion and this fraction would in­ mechanically impossible by a phy­ a rudimentary or absent frenum, the glans and are transmitted to clude the sperm. This is entirely sical condition resulting from a rarely presents symptoms other the cord a!ong the pudenda) nerve. conjectural. however. In addition lack of normal development of than those due to a tight meatus The summation of these stimuli to the sperm there may be a minute some portion of· the :sex system, 1959 17 16 LIN ACRE QUARTERLY REBRUARY, atrophy of these parts, disease or pelled contents from the ejacula­ cause efferent impulses to �ave quantity of carrier fluid. Howt" ,· • . I trauma. Organic ,ources may be tory duct and probably separates the cord through sympathetic there is no conJl.rmatory test pc, ·ami congenital or acquired. Anomalies .and activates •he sperm. The ex­ ·dong the hypogastric plexw and at the present time, chemi, of the penis or u ·a are not m- pulsibn of th'o .- eminal fluid from ·· cite contraction of the sr )oth microscopic, which can det · frequently noted . cause of im- the vesicles and uas,along the ejac­ •scles of the seminal ves :les , · :esticular component. It GI potence. The forn · ulatory duct .i,1d from the prostate concluded, therefore, that ,re less com­ ; ··•tate and vas which e 1pty mon, but when en •. ntered, may depends on the constriction of the presence of sperm canr u contents through their ,so­ have great significanu. their smooth muscles as a reaction ci. d ducts into the post rior de monstrated in an ejaculat to stimulation of the· sympathetic urel ',ra. This is almost simu an­ presence ·of a testicular comr Congenital absence of the penis has been reported and is obvious­ hypogastric plexus. eou•.1y followed by active e. Jul­ cannot be proved. ly sion of the seminal fluid thr, ugh a catise of permanent impotence. Integrity of the parasympathetic There is much discussio1 .o Rudimentary development of the and sympathetic pathways to the the urethral canal as a resu of whether or ·not the sperm ;d contraction of the striated I: dbo organ has been observed net infre­ genitals and sex organs may be from the testes to the uretl· at quently in which the penis 1s so . caverr•osus and ischiocavern ,sus fundamental to the normal achieve­ the time of ejaculation. It 1 not small that it is entirely enveloped muscles-a parasympathetic el ect. ment of erection and ejaculation. known definitely, although 1l is in the redundant tis­ Sympathetic contraction of th, in­ . and concealed Erection is primarily a· parasym­ reasonable to assume that in the sues of the scrotum, pubis and per­ ternal sphincter takes place to >re­ pathetic action with a sympathetic brief period of ejaculation the ineum, making coitus impossible. vent regurgitation of the ejaci late side-effect. Ejaculation is primarily sperm could not tnvel the long A malformation which may be into the bladder. The higher en­ sympathetic in origin with para­ conduit of the epidic.;mis and vas amenable to surgical correction is ters are not essential to erec ion sympathetic assistance. T h e s e into the urethra. It has been dem­ transposition of the penis and and ejaculation but they may d as­ mechanisms are reflex from deJl.nite onstrated that the vesicles function scrotum. Thirty-three instances of tically modify these acts as psy hie levels in the spinal cord and are as a sperm reservoir and that. im­ reduplication of the penis have factors can readily stimulate OJ in­ supervised by control from the mediately prior to complete emis­ been reported and may be reme­ hibit them. higher centers of the brain. sion, the sperm fill the ejaculatory died surgically. The body of the ejacul 1te, dud. This explains the high con­ Urethral anomalies are a fre­ Erection ·re.suits from a reflex whether in the absence or presc 1ce centration of sperm in the initial quent cause of impotence. Stenosis psychic or tactile sensory phenom­ of sperm, is termed semen or portion of the semen. We have no of the external urethral meatus enon having its center in the para­ seminal fluid. The quantity of I uid data on how long sperm may re­ may interfere with ejaculation but sympathetic Jl.bres of the 2nd, 3rd in each ejaculation varies am,mg main viably stored in the vesicles this condition is readily cured by and 4th sacral segments of the individuals and, in the same in­ and it is our present opinion with meatotomy and urethral dilatation. cord. The impulses are carried dividual, at various times. · 'he no scientific proof that in the exci­ Hypospadius, a congenital defect, along the internal pudenda) nerve average amount is approxima, ely · tation period, prior to ejaculation, in which the canal terminates on which effectdilatation of the penile 4 cc. In the normal individual, the r the sperm are carried to the uppe the under-side of the penis is a arteries and consequent engorge­ semen is composed of secrefrms seminal tract. It is well known that common congenital anomaly. Var­ ment of the corpora cavernosa and from the testes, probably the , pi­ men who eja.culate very infre­ ious gradations occur from an spongeosa. This is associated with didymi, the prostate gland and the quently may often have a normal opening on the glans just behi d compression of the penile dorsal bulbo-urethral glands. ( Cowpeis). � number of active sperm of regular normal site to one located m veins. which preclude venous re­ The urethral glands of Littre serve the morphology. In a physiologic dis­ the perineum. The anatomical va­ turn. Ejaculation. is basically a a role of lubrication. The amount, cussion in which ducts aridtubules rieties are classiJl.ed depending on complex reflex action from the which has its origin in the testis are involved, it is difficult to be the position of the orifice. The upper lumbar area of the spinal and epididymis, is extremely small dogmatic. glans or balanitic-type in which th� cord. Three separate mechanisms and has been estimated to be about urethral opening is on the under are involved. Afferent impulses one-twentieth of the total ejacula­ The sexual act may be rendered surface of the glans, at the site of arise chiefly in the sense organs of tion and this fraction would in­ mechanically impossible by a phy­ a rudimentary or absent frenum, the glans and are transmitted to clude the sperm. This is entirely sical condition resulting from a rarely presents symptoms other the cord a!ong the pudenda) nerve. conjectural. however. In addition lack of normal development of than those due to a tight meatus The summation of these stimuli to the sperm there may be a minute some portion of· the :sex system, 1959 17 16 LIN ACRE QUARTERLY REBRUARY, and since the trajectory of ejacula­ more extreme grade is. in mos in­ young adult and when the ksion it descends dunng fetal life into tion .is rarely affected, there is no stances. associated with exstrc Jhy has extended beyond the qliln,. the scrotal sac where it should be question of impoten�y. The penile ,, r the bladder, a malforma ion complete amputation may b · , �­ found · at birth. Improper descent 'type_ has the ·ifke at any point 1nifested by absence of the an­ quired with consequent co11•, may occur whe, he gonad be­ between the ,. /,ms and the peno­ . ,,r bladder wall and the o er- and permanent impotence. comes directed i11tn �ome abnormal scrotal · junction arid its distance :i portion of the lower abd >m­ more localized process of ti, ch�nnel and may he found in the from the glan� will affect the fac­ wall. The posterior bla, der ease, partial removal may b. perineuo or may 11<' m front of the tor of potency. In the peno-scrotal ulature and t r i g o n e are ranted leaving a potentialh external oblique fascia. True un­ and perinea! type. the sex act is ,·d forward through the de ect tioning organ. In rare in� descended testis mav result from· seldom achieved because the penile iie on the level of or slig tly penile amputation may be its retention at som� point along deformity is so· extreme due to ;, · the abdominal surface In sary following severe traum, the pai:h of its normal descent and one or both testes may be retained severe chordee and the position of n ,lete exstrophy. there is t ital Elephantiasis of the u,·n ',k the urethral meatus is so situated er J'ddias, separation of the pt Jis. entirely within the abdominal cav­ due to local or systemic c , ,-,;, ity, in the inguinal canal, or in the that intro-vaginal emission be­ a udimentary b r o a d-stum 1ed dlay make coitus impossible but comes mechanically impossible. p us as a result of the epispa lial upper part of the scrotum. A dis­ may frequently be relieved b, adc­ tinction between true cryptorch­ These conditions may be amenable LL ·thra and frequently crypto, ch- . quate treatment of the primary to surgical correction and there­ 1sm. Impotence is always pre: ent ism and the high riding or retract­ disease. "Inflammatory lesions or ed testis should be made. In the fore impotency may not be per­ ,n the male and corrective n ..ceedingly can push or pull the retracted pede ejaculation, but if prop, rly · towards the correction of the rare. As far as the writers are able testis into the scrotum, but if it managed, before irreparable d, m­ chordee and .at a later period, vary­ to ·determine congenital absence has not set in the scrotal bed by age has taken place, it is no a ing from several months to years, of both testes has never been def· puberty. it should be considered factor in impotence. a urethroplasty is performed to initely demonstrated. The role of undescended. develop a nor rn a l func_tioning Plastic. ind uration of the pc nis malp osition in impotence is uncer­ When cryptorchism is observed urethral canal. These anomalies ( Pieroni' s disease) is an acquired tain although it is a well-recog­ beyond puberty, in the adolescent are a significant factor in the prob­ condition of unknown etiology in nized cause of sterility. In true and young adult, the testis or lem of male impotence and each which the presenting symptom is cryptorchism, the undescended testes are small and soft in con­ case must be individually evaluated curvature of the penis during erec­ testicle, unilateral or bilateral; lies sistency due to impaired blood sup­ in relation to its reversibility. Even tion. This condition may render outside the scrotum although it is ply and to the increased tempera­ if the condition cannot be remedied intromission impossible and excru­ in the path of normal descent. In ture of its resting area as com­ or cured by surgical intervention, ciatingly painful, and may cause spite of a certain amount of dog­ pared to the scrotum, and have hypospadias would not constitute impotence. It occurs most frequent­ matism in the literature. our fac­ undergone atrophy with probably an impotent condition, if vaginal ly in middle life and therefore in tual knowledge of the entity is permanent absence of spermato­ penetration and semination can be all probabiHty subsequent to mar­ limited, as attested by the differ­ genic function. The testis is also achieved by substituting, during riage, but. is found in all ages. It ence of opinion regarding the ulti­ exposed to trauma when in the in­ the attempted relations, a position may be considered irreversible in mate fate of the involved gonad. guinal area. The interstitial cells different from that usually and spite of various surgical and medi­ the optimum time for initiating a n d their androgenic hormone normally taken. cal measures which have been ad­ therapy and the type of treatment elaboration may not be significant­ In epispadias, the urethral open­ vocated and employed for its re­ to be pursued. ly affected but when the condition ing is on the dorsum of the penis. lief. The human testis is normally is bilateral and especially of the It is not commonly observed. The Malignant disease of the penis found high on the posterior ab­ intra-abdominal variety, there may glans type is of no import. The is not infrequently observed in the dominal wall from which position be loss of potency because of 18 19 LINACRE QUARTERLY FEBRUARY, 1959 diminished androgenic production. so,nc investigators limit it to ,ve hormonal function to the j,' r.t however, we must again emp hasize Ei:igbei:g observed that men with v··;us. It should be emphas ed that the individual cannot ev, I'· the necessity for proof of its value bilateral undescended testes, treat­ t1 as the position of the imr is- rience or sustain a normal e1 ,1 in the specific caE"' i,..volved. ·ed or ontreateci , xcreted only one­ l testis becomes farther a ay and thus cannot penetrate half of the nurmaJ. amounts of the scrotum, the percent ge under both the classical arw In cases of bi] · ,I orchiectomy ·testicular fun androgen and lound the urinary )erative success likewise !e­ ern theories, the person i� no , · "1 remains. If surgery were pe1' )rmed prior to gonadotropins high. This can well s. considered impotent and marriage the person is considered explain the lack of libido and the condition is to be judged 1 summary, the individua in to be canonically impotent under impotence noted in a certain per­ ent, the ·impediment of im a cent and adult life with in- the terms of the Gasi.arri opinion centage of such men. It has been is thought to be present. our personal experience that the t, .:! bilateral undescended es- because there can be no testicular male beyond puberty with bilateral th 1s sterile in practically all in- If, durfog. a pre-marital r, component in the ejaculate. The intra-abdominal testes is in most st s because all spermatog nic examfoation, it is found d, lie spermatogenic and hormonal func­ instances impotent and exhibits hi .on has ceased. This is e, Je- individual suffers from b, .. :·al tions of the testes are thus elimin­ systemic stigma of gonadal defic­ e, true of the intra-abdom ,al undescended ·testicles at le .. -t of ated. The secondary male sex iency, although this same conclu­ 91 • f). Permanent impotence ,ill -the intra-abdominal variety and characteristics will gradually dis­ sion cannot be made oI · the in­ al,o be frequently encounterec in if, on questioning. the patient ad­ appear· along with the natural guinal group in spite of the asso­ such cases. A low urinary 17 k, :o­ mits that he has never experienced libido so that the accomplishment ciated atrophy and loss of sperma­ steriod assay and a high gona lo­ an erection or at le 'st has not ex­ of the sex act becomes impossible togenesis. trophin liter associated with f til­ perienced one for m extended unless something is done to retain ure of normal sex attributes to There is considerable difference period of time, and if no remedy is these by androgen therapy. As manifest themselves are particu ir­ known for this condition, it would mentioned above. in the recently of opinion regarding the optimum ly poor prognostic signs. age for instituting treatment of the appear that such a person should orchiectized, androgenic function undescended testis, but it is gen-· Since the spermatogenic ft 1c­ be prevented f r o m contracting may be sustained by testosterone erally accept�d that surgery must tiun of the testes concerns only he marriage because the impotency therapy and there may be no be carried out before puberty. A fertility or sterility of the indi, id­ would be thought certain and thus change in the sex characteristics cogent argument against too early uaL and not his potency, the t ,ta! the excepting clause.s of Canon and urges and the individual may surgery is that irreparable damage lack of sperm production vill 1068, Section 2. which refer to be capable of normal erection and to the .circulation and function of never cause an impotent condit.0n. doubtful cases, could not be in­ ejaculation. Such a person is to the delicate gonads may result. However, if a condition of bilat ral voked. be thought potent at least in the undescended testicles prevents ny understanding of the modern opin­ Individuals _who present them­ The efficacy of synthetic andro­ testicular component from appt ar­ ion because he is capable of erec­ selves for treatment in adolescent gen administration must be care­ ing in the ejaculate, then, u, cler tion and insemination, even though or adult life should be regarded fully appraised. In many instances the Gasparri opinion, the per ,on the semen lacks any testicular com­ as neglected cases. Gross and the effects may be dramatic. As a will be impotent even if he is ,·ble ponent. Jewett, in reporting a series of result of scientific and clinical in­ to experience a normal erect•on. 1222 cases, recommend that sur­ vestigations its.value is bejng more There are many victims of bi­ and if the condition cannot effec­ gery be deferred, if possible, un­ and more recognized. Th!s aspect lateral orchiectomy who do not tively be treated and is to be c-)n­ til the age of nine to eleven years will be discussed in greater detail react favorably to the testosterone sidered permanent, any marri;,ge, except in the presence of a trouble­ in relation to the castrate and program and, in the light of pres­ intended by the man, is to be rro­ some hernia when it may be done hypergonad individuals. It can be ent knowledge, there is no ade­ hibited and any union, alre,1dy at any time in infancy or early stated that, in the cryptorchid with quate explanation. It has been as­ childhood. It has been substan­ contracted by him, is to be de­ sumed by some investigators that clared invalid. androgen deficiency, the adminis­ tiated that the otherwise normal tration of the proper hormone may the reason is psychic and that the but undescended testis and the Further. if the case of bil;iit'ral result in ability to carry out the individual subconsciously refuses testis in normal position keep pace undescended testicles has resulted sex act in the previously impotent to accept or become reconciled to in their development from birth to in a complete loss of hormonal male. In the subject of impotence his unusual situation. It is very the pre-p�bertal years, although function or has so reduced the as an impediment to · marriage. probable, however, that the un- 20 LINACRE QUARTERLY FEBRUARY, 1959 21 k_nown X is generally the factor di\ idual must be established. · as· is true in many patients' failure If an individual has underg ne to respond to therapeusis in medi­ ,;late ral orchiectomy prior t a cal entities. i 'Titles an,! Abstracts · emplated marriage and d ,es Current Liter ure: If testosten 'le properly admin­ �spend to therapy then ti- ·re ist.ered and md.,1tained without in­ 1 ·rtainty that he is permanc it- The purpose o/ •artment in THE LJNAC>- OllARTERLY is to make available by ,ting such current artic ·..... ,1_-. arc· thought terruption over a reasonable period (, 1otent under both opmi< 'IS, to be of particular > the Catholic physician /,y 1·irtuc of their of time does not produce benefi­ a ,, is to be forbidden to ma ry. moral. religious, or •,hie implications. It is no: ':mired to the cial results, the individual who has H medical literature ., ,f necessity, this source is tire· most fruitful. ver. if doubt exists as to When abstracts a1 11 are intended to reflect the content of tlie undergone bilateral orchiectomy is \1·J ,er or not the testoster ne original article. P.,, ,I editorial comment may follou• the abstract to be considered permanently im­ w, effective, he is to be allo, ed if. considered dcsir 1 ,itributi<;:ms from readers are invited. potent under both opinions since, to rry but the marriage co tld on the one hand, he cannot expe­ cm vably be declared null . nd IGslc:adden, W. S.: Physician, ,· I rhc Gibbons, W. J. (S.J.): Antifertility drugs world's hidden crisis, Am. /. ,!.,r1 , • 1)5: and morality, America, 98: 346-348, 14 rience erection and, on the other vo1( ,ta later time when it is c ·ar 211-215, February, 1958. December, 1957. hand, he cannot deposit a semen th, rhe hormone therapy has 10t Writing principally as a demo.,: 11,hcr, Gibbons, W. J. (S.J.) and Burch, T. K.: that has been produced in the be, ,1 beneficial and the patient c m­ the author advocates birth-contro, "· ,he Physiologic control of fertility; process answer to · "the world's hidden cri"' .. testicle. Obviously. this presumes t1r, �s to be unable to perform he · and morality, Am. Eccl. Rev., 138: overpopulation. He rcncludcs, "Super­ 246-277, April, 1958. that the condition was antecedent. SC. LlCt. stition, taboos, and , ,1iou;; and tradi­ tional fixations are le • too powerful In the above two articles the moral Interpretation of the efficacy of Hypogonadism-diminished or implications of anti-fertility drugs are to be overcome quickh ·nw best pres­ fully and authoritatively discussed. testosterone medication is in many ab�ence of gonadal function-i; an ent hope lies in educating the nuddle instances difficult. The status of important factor in male impote1 ce. class group . · .. to the tr�1h that o, er­ Zilboorg, G.: Psychiatry's moral sphere, population threatens national st, 11•·1ty America, the individual prior to therapy It is at times mistaken for sin pie 99: 308-309, 7 June, 1958. and prosperity." In this brief but scholarly paper the must be determined. Have the ef-. obesity, but, on the other h,, id, author reviews the Church's attitude to­ fects of orchiectomy been manifest undergrowth malnutri· on Moynihan, J. F. (S.J.): Catholics 1nd wards modern psychiatry, particular!y as a n d neurosis, Spiritual Life, 3: 2-17-256. by changes fo· the secondary sex have been erroneously diagno :ed expressed in the discourses of the late December, 1957. Pope Pius XII. physical signs? Have the normal as hypogonadism because of 1s­ Father Moynihan discusses neuroses sex concupiscences been affected? sociated depression of ge11 tal within the frame-work of Catholicism. Lifschutz, J. E.: Hysterical stigmatization, and states " . . . in the long nm. the Am./. P,ychiat., 114:-527-531, Decem­ If deteriorative changes have been growth. True hypogonadism is confronting of anxiety, which is the ccre ber, 1957. demon'strated prior to the institu­ constantly related to defective I or­ of neurosis, depends on what the indi­ The writer summarizes the history of tion of the hormonal replacement monal mechanisms involving the vidual regards as of value to himself and stigmatization from the time of St. Fran­ to his existence. In other words, there is cis of Assisi to the present, including the program and there is a return to­ pituitary. the testes, or both In a relationship between neurosis and ,one's case of Theresa Neumann, and adds an wards normalcy the prognosis is their severest expression these dis­ system of values, one's philosophy and instance of non ..reli gious stigmatization. optimistic. An increase in the urin­ turbances result in eunuchoidism theology of life. For whatever may haw He leans toward "the classical psycho­ in the past been alleged to be the chief dynamic interpretation of hysterical stig· ary 17 ketosteriods and a normal with complete failure of sperma­ factor contributing to the development of mata by Fenichel and Ferenczi" in which gonadotrophic liter is also a sig­ togenesis and endocrine produc­ neurosis, there is· a growing consensus they ar�. viewed as hysterical "material- nificant guide. Precise questioning ere among current psychiatrists that today izattons. tion, while, in the less se, it is basically an anxiety over the mean­ of the involved male as to his libido instances, the defects may invplve ing of life." Craig, R. D.: Sexual sterilization, Am. /. and sex abilities must be carried only one category of testicular Obstel. and Gynec,, 74: 328-340, Aug· ust, 1957. out and the credence of the in- function. Pincus, G., Rocle, J., Garcia, C-R., Rice­ Wray, E., Paniagua, M., and Rodri­ This article represents "a survey of guez, Iris: Fertility control with oral the pertinent literature on s�xual steril­ medication, Am. /. Ob,tet, and Gynec., ization for the past 25 years. . Emphasis (To be concluded next issue) 75: 1333-1346, June, 1958. is on the physical, psychiatric. and legal "Enovid" ( norethynodrel ai:id ethynyl aspects. Ethical factors are not discussed. tStradiol 3-methyl ether) was shown to be effective oral contraceptive, pregnancy Fabing, H. 0.: Epilepsy and the law, occurring in none of 265 Puerto Rican Med. Clin. N. A., 361-373, March, women who adhered to the prescribed 1958. regimen. The writer reviews epilepsy from the FEBRUARY, 1959 22 LINACRE QUARTERLY 23