GENITO-URINARY AND VENEREAL AFFECTIONS IN THEIR MEDICO-LEGAL RELATIONS.

BY

F. R. STURGIS, M.D.

IN the article which has been assigned to me I propose to consider the affections of the genito-urinary organs in men and women in their bearing upon the marital relation, and the results which venereal diseases -and by these I mean gonorrhea and syphilis-have upon the bearers of the diseases as well as upon their offspring. To properly discuss the effects of these diseases in their medico-legal relations I propose to divide them into the following groups:

First. Impotence in the male.

Second. Impotence in the female.
Third. Sterility in the male.

Fourth. Sterility in the female.

Fifth. The effects of gonorrhea in its sexual relations; and

Sixth. The effects of syphilis upon the bearers of the disease and upon the children which may be born to them.

My portion of this article will be entirely confined to the medical side of these affections.

Impotence in the Male.-This affection is due to two causes, one physical, the other psychical, the first having its origin entirely in some physical malformation or physiological perversion, congenital or otherwise, and the other depending upon mental disturbances or impressions, whether originating from without or within the patient's mind. The physical causes are the ones which I shall first examine, and those of the penis are the foremost to invite attention.

Sometimes there is a congenital absence of the virile organ, while all the other parts are more or less perfect (entirely apart from any question of hermaphroditism), the man being in perfect health, with all the external symptoms of virility such as are apparent in the face and in the contour and shape of the body. The scrotum is present, with the testes in their normal place, but at the spot where the penis should be nothing is apparent. The urethra, in these conditions, usually opens behind the scrotum, in the perineum, as a small opening concealed by a fold of skin, sometimes seated behind a little excrescence, looking like a cockscomb, and communicates directly with the bladder, simulating somewhat the appearance of the female meatus. It will be noted that in this case there can be no question of hermaphroditism. There is no appearance

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or simulation of any of the female genitalia, the subject being, to all intents and purposes, a man, except that he has no penis.

Sometimes, however, the condition of things does not go quite so far as entire absence. In this case the malformation may be simply in the diminutive size of the penis, which varies from half an inch to two inches in length, and is capable of more or less complete erection, unless it be tightly bound to the scrotum. Under such circumstances the subject need not necessarily be impotent. He is capable of intromission within a certain distance, and, providing the ejaculation of the spermatic fluid be complete, the man may be the father of a family. Excessive smallness of the penis is not, therefore, a bar to the completion of the sexual act nor to the exercise of marital duties; but the condition is different in those cases known as a palmate penis-that is to say, where the penis is adherent to the anterior raphe of the scrotum and where it is then bound down, mechanically, during any attempts at erection. This condition of affairs is, however, easily remedied by freeing the penis, when the physiological functions of the organ are restored to their normal condition.

The opposite condition may also act as a bar to the sexual act, where the penis is inordinately large-and I do not mean enlarged from elephantiasis, but where the whole organ seems to be abnormally and equally developed, and where intromission into any ordinary vagina is impossible. Under these circumstances the man, although capable of complete erection and of the performance of the sexual act, is impotent from the disparity between his genitals and those of the average woman.

Another cause of masculine impotence is due to the fact that the penis is sometimes double for a greater or less extent of its length, each organ having its own urethra. These unite posteriorly into one canal and one penis, finding their termination in a single bladder, both organs from their point of bifurcation emitting two streams of equal size during micturition and being capable of double seminal emission. Under such circumstances it is possible that a man may have connection, as is noted in the case of a patient reported by Isidor Geoffroy St. Hilaire. This man, it is stated in the report, never engendered anything but twins. This last statement I do not claim to pass judgment upon, as it seems to me, unless two ova were deposited in the uterus at the same time for fecundation, that it would make little difference how many virile organs entered the woman at the same connection.

Another reason for the non-performance of the sexual act is due to a curious malformation which has been noted by many writers, viz., that at some portion of the penis a deposit occurs in the corpora cavernosa which prevents the complete distention of the organ. Sometimes this results from calcareous deposits, from inflammation (gonorrheal or simple), or from an injury done to the organ by "breaking a chordee," as it is called, and sometimes from syphilitic exudations. Where it results from gonorrhea or syphilis it is, as a rule, curable, but where it is caused by violence or injury done to the canal, or where it occurs idiopathically, little can be done by treatment, although some cases are reported to have recovered spontaneously. Under these circumstances the penis is turned either to one side or the other, or, as I have seen it in one instance, where the exudation was annular, one half of the penis remained entirely flaccid while the posterior half was erect. Intromission and sexual intercourse are usually impossible, although if the penis be merely twisted,

while erection is complete, coitus, with a little management, may be accomplished.

Again, besides these pathological causes there may be complete torsion of the penis upon its axis during erection, as is noted in the case reported by Guerlain (Bulletin de la Société Anatomique, 1859, 2o serie, t. iv., p. 27), in which the penis, during erection, was completely rotated in such a manner that the dorsum of the penis became the under-surface, looking backward toward the scrotum, while the urethral aspect was turned uppermost and a little to the left.

Sometimes the corpora cavernosa present anomalies, either being atrophied or even going so far as to be completely absent. Such a

case is reported by Delbarier (Annales de la Médecine Belge, 1842, Mai, 5o Cahier, p. 10).

In most of the malformations considered above, it is apparent that the patient would be impotent from purely physical causes, without the mind exercising any influence as regards the sexual act. Another variety of physical deformity which sometimes acts as a bar to complete coitus is seen in cases of hypospadias. Epispadiacs, as a rule, are capable of copulating properly, notwithstanding that their sexual organs may not be perfectly normal, and the same is true, to a certain extent, among hypospadiacs. Provided that the hypospadias be in the anterior portion of the urethra, in such a position that during emission the semen can be ejaculated within the labia majora, coitus will be successful; but where the hypospadias is far back, say at the penoscrotal or behind the perineoscrotal angles, the emission which takes place of course does not reach the vagina, nor even probably the external vulvar lips in the female, and therefore becomes of no effect. Sometimes these cases are remediable, in others not; and of course when the latter condition obtains, the patient will have to be classed among those who are physically impotent.

Phimosis, particularly if congenital and adherent to the surface of the glaus penis, or where the orifice is exceedingly small, may sometimes be the cause of impotence in the male, by preventing the emission of the semen into the vagina, the entire charge being pocketed in the elongated and distended prepuce and only being evacuated by the manual interference of the patient. In the majority of instances, unless the adhesions are exceedingly firm and extensive, the evil may be remedied by circumcision.

Stricture of the urethra, when seated far back and when tight, oftentimes acts as a bar toward the completion of the sexual act, and I have seen cases in which the stricture was so tight that during the excitement and turgescence consequent upon the copulation the entire seminal discharge was forced backward into the bladder, but a few drops escaping per urethram during the act. The first micturition after the act showed the urine full of spermatozoa. The patients in these cases always complain of a great fullness in the perineum, sometimes accompanied with a momentary sensation of sharp pain, probably due to the enormous distention of the urethra at a point where the obstruction was present, and which was relieved as soon as the semen found its way backward.

Anomalies of the testicle are another cause of impotence, and in these instances they may be such as to lead to a condition of azoöspermatism in which healthy spermatozoa are not secreted. This is especially noticed in the case of monorchids in whom the testicle is retained in the abdo

men or at the inguinal ring. Where this occurs the patient is not only sterile, but he also is impotent: the erections are incomplete or evanescent, and whatever seminal discharge there is, ejaculation occurs so prematurely that frequently the patients have finished the sexual act before gaining entrance into the woman.

Sometimes the testes are found to be congenitally atrophied. In an interesting case given by Roubaud (Traité de l'Impuissance et de la Stérilité, p. 161), the patient, twenty years of age, showed a penis which, on erection, was about the size of a porcupine's quill and only two inches in length, and in whom the testes had only attained the size of a hazelnut; and these latter, upon contraction of the scrotum, would disappear entirely into the inguinal canals.

Atrophy may also result as a consequence of gonorrheal epididymitis, varicocele, and syphilitic orchitis, and in all three affections the atrophy is usually permanent and past cure.

The question of hermaphroditism naturally presents itself in these cases of sexual perversion, but so far as their sexual aspects are concerned they need not concern the surgeon, for the simple reason that in nearly all instances the hermaphrodite may be classed as either male or female, and a careful examination should enable the surgeon to place the hermaphrodite as either a man or woman. The crucial tests in these cases are the presence or absence of the catamenia and the presence or absence of the sexual emissions; and where one or the other of these functions can be shown to exist the establishment of the patient's sex follows as a natural consequence. Some cases are spoken of as being neuters, in whom the sexual condition seems to be so evenly divided as to make it difficult of decision; but such cases are very rare indeed, and I am myself strongly disposed to doubt their existence. Occasionally, in the case of female hermaphrodites, the surgeon will be sometimes puzzled by being told that the catamenia have never appeared; but upon careful examination in these instances, where all other indications point toward the feminine sex of the patient, the monthly discharge of blood will be found to issue from some portion of the body outside of the sexual organ-in other words, they are cases of vicarious menstruation.

Besides the physical causes for impotence in the male just enumerated, the mental condition of the patient sometimes operates to prevent normal coitus. Those who have much to do with the treatment of sexual disorders in the male have been struck with the curious phases which this mental condition sometimes assumes. For example, some men who are perfectly well formed, vigorous, healthy, and capable, as has been shown by experience, of performing the sexual act, are rendered completely impotent unless the usual conditions to which they are accustomed are all fulfilled at the time of connection. One most curious instance of this mental condition is given by Roubaud (op. cit., p. 439 et seq.), in which the patient, when a boy of fourteen years of age, was seduced by a female friend older than himself, a member of his family. The girl herself was a pronounced blonde, wore ringlets, and inasmuch as the forbidden pleasure had to be done by stealth their amorous relations were accomplished when both were fully dressed. These relations lasted for some time, and the young man finally left home and went into the army. Upon trying subsequently to perform the sexual act, he found to his extreme astonishment that every woman was repugnant to him un

less she was a blonde, wore her hair in ringlets, and was fully dressed. Under these circumstances he could perform the sexual act with vigor and complete satisfaction, but for another kind of a woman, brunettes especially, and under any other conditions, as, for example, when undressed and in bed, he had such an aversion that he was practically impotent. Such was the force of imagination and of habit upon his sexual powers. Now the sequel is just as curious. With the perversity of human nature, he fell in love with a brunette, and it was this unfortunate condition of affairs that induced him to consult Roubaud, who gave him a potion which he told him to take, and bade him make an attempt at coitus with the brunette two hours after its ingestion, assuring him of success. The draft was taken, the man went to bed, and although no coitus was attempted at that time the patient had during the whole night a violent erection, with strong sexual desire. Apparently, from the history of the case, the reason why coitus was not attempted was from the fear that it would prove a failure. However, the next day he consulted M. Roubaud again and wished to know if he might use the draft a second time. Inasmuch as it contained a large dose of cantharides, M. Roubaud refused to give his permission, but substituted another one in which the amount of cantharides was very much reduced, and told the patient to take that. The man, having been convinced that he had at last obtained an agent which would at least overcome the physical results of his aversion to brunettes, took the second draft, and going to bed with the woman the second night accomplished his purpose and thus conquered his curious and seemingly irrational aversion to brunettes or to attempting the sexual act except when fully dressed.

This is an extreme instance of what mental impressions will do in causing perversion of the sexual functions; but not infrequently surgeons are consulted by patients who state that, while the sexual desire is strong up to the point of going to bed, the moment coitus is attempted the erection disappears and with it all possibility of intercourse. The same condition often ensues from the unreasonable fear that the attempted connection will end in failure. There is no physical reason for this dread: the patient is perfectly capable of performing the sexual act; and yet when he is with the woman he is perfectly useless as a bedfellow; and oftentimes the mere dread of failure, if failure has once occurred on attempting coitus, puts an end to all future attempts. There is often a physical cause for this mental disturbance, such, for instance, as hyperæsthesia of the deep portions of the urethra, slight and irritable urethral strictures, hemorrhoids, fissures of the anus and rectum, or a subacute inflammation of the neck of the bladder; and the well-informed surgeon will carefully search, in such cases, for any physical cause to account for the patient's sexual condition, and if such exists, by removing the physical cause cure the sexual disturbance.

Glycosuria is another of the causes which are mentioned as a possible source of impotence in the male, particularly in the latter stages, when all sexual desire and all sexual power seem to be either in abeyance or else completely lost, and in addition there also appears to be a diminution in the amount of the semen secreted.

Renal diseases, especially that condition of the kidneys known as atrophy, inflammation of the prostate, especially when associated with marked hypertrophy, and affections of the neck of the bladder, coexist