2. OF IMPOTENCE AND STERILITY.
1. IMPOTENCE.
Impotence, or the incapacity of sexual intercourse, and Sterility, or the inability of procreation, are subjects which frequently become questions in the Ecclesiastical Courts, as relating to the performance and dissolution of the marriage contract; and as medical evidence is generally required upon such occasions, the subjects necessarily present themselves for discussion in the present work.
Impotence may exist either in the male or female. Sterility is confined to the female, for if the male be proved capable of accomplishing the act of coition, no farther question can arise as to his virility.
Impotence may be Absolute or Relative, that is to say, the parties may be incapable of cohabiting with each other, and yet they may each accomplish the venereal congress, and enjoy a fruitful intercourse with others; it may also be functional or organic, and depend either upon physical or moral causes; and hence in some cases it may be temporary, in others permanent, and upon this point the evidence of the medical practitioner will be always very essential. It is therefore important that we should proceed to investigate the subject in its various relations to those different causes.
1. Organic Causes of Impotence.
IN MALES.
There was a period in the history of physiology, when the testicles were not considered essential to virility. Aristotle was led to such a conclusion from having observed that a bull was capable of impregnating the female after castration; a fact which depended upon the quantity of semen, retained in the vesiculæ seminales, conferring fertility upon a coitus which took place immediately after the operation. The true theory of the functions of the testicles having been thus abandoned, it was necessary to substitute some other explanation of their use, and the Naturalist of Stagira has accordingly asserted, that they merely serve as weights to hinder the spermatic vessels from being folded up; an hypothesis which, absurd as it is, has found advocates in the later schools; and in its support we shall find many experiments and cases related by Marchetti of Padua.[[287]] Sabbatier[[288]] observes, that subjects have been found who have only possessed one testicle, and what is more extraordinary, that there are others who although entirely destitute of these organs, have exhibited the other parts of generation in their natural state; in proof of which Cabrolio mentions the case of a soldier addicted to sexual pleasures, in whose body no testicles were found, although the vesiculæ seminales were distended with semen. Scurigio[[289]] and Lieutaud[[290]] refer to the same case; upon which Portal[[291]] very justly observes, that the soldier was doubtless furnished with testicles, but which, from their unnatural situation, probably escaped the notice of Cabrolio. The extraordinary situations in which the testicles may be found are fully detailed by Rinlaender;[[292]] their absence from the scrotum does not necessarily imply impotence; they are formed in the cavity of the abdomen, and until the sixth month, lie immediately below the kidneys on the fore part of the Psoæ muscles, after which period they gradually descend towards the abdominal ring, through which they generally pass into the scrotum before birth; but it occasionally happens that this descent, in regard to one or both testicles, does not take place until a late period, and in some instances they remain within the cavity of the abdomen during life;[[293]] in such a case, a question has arisen as to the virility or impotence of the individual so situated, and upon which medical opinion would seem to be still unsettled. Foderé states that such persons have even been remarkable for their vigour; for these organs, says he, appear to derive greater power of secretion from the warm bath in which they lie, than when they have descended into their natural situation. Mr. John Hunter has given a very different opinion, and one which appears to be more compatible with the sound doctrines of physiology; he believes that when both testicles remain through life in the belly, they are exceedingly imperfect, and incapable of performing the natural functions of these organs; and that it is such imperfection in structure which prevents the disposition for their descent taking place; an opinion in which Zacchias and Riolan entirely concur. Mr. Wilson[[294]] observes that he is acquainted with one case that confirms, and another that would to a certain degree refute this opinion; and this is probably the true state of the question; each case must rest upon its individual merits, and the practitioner, whose opinion is desired upon such an occasion, must carefully inquire into every moral and physical circumstance that can, collaterally, assist his judgment; such as the general appearance, soprano voice, and effeminate physiognomy, of the individual, “frustra enim ætas advenit, si testes defuerint; manebit enim etiam virili ætate fæminæ similis.”[[295]] But the absence of the testicles in the scrotum may depend upon other and less equivocal circumstances, they may have been removed by excision (Eunuchs), in which case there will be no difficulty in ascertaining the fact by the appearance of the cicatrix: or they may have been actually absorbed by an operation of Nature, after considerable inflammatory action. Mr. John Hunter[[296]] has given an account of three cases in which such a result occurred.
It does not appear that two testicles are essential to virility, although the Parliament of Paris in 1665 decreed that the matrimonial contract should not be deemed valid unless two testicles were evident; it is now generally admitted that persons with only one (Monorchides) are fully capable of procreation.
It has occurred to Dr. Baillie,[[297]] and other anatomists, to observe the testicles exceedingly small, “I have known,” says this distinguished pathologist, “one case in a person of middle age, where each of them was not larger than the extremity of the finger of an adult; this, as appeared from its history, arose from a fault in the original formation, and was attended with a total want of the natural propensities.” Mr. Wilson,[[298]] on the other hand, relates a case that would induce us to pause before we pronounced judgment on such an occasion: “I was,” says he, “some years ago consulted by a gentleman, on the point of marriage, respecting the propriety of his entering that state, as his penis and testicles very little exceeded in size those of a youth of eight years of age. He was then six and twenty, but never had felt the desire for sexual intercourse until he became acquainted with his intended wife; since that period, he had experienced repeated erections, attended with nocturnal emissions; he married, became the father of a family, and these parts which at six and twenty years of age were so much smaller than usual, at twenty-eight had increased nearly to the usual size of those of an adult man.”
The structure of the testicle may be defective; Mr. John Hunter has given a representation,[[299]] in his work on the Animal Œconomy, of a case in which the Epididymis, instead of passing to a Vas deferens, terminated in a cul-de-sac; with such a structure it is evident that the semen cannot be evacuated by the urethra, and that the individual must therefore be incurably impotent.
The structure of these organs may be so destroyed by a bruise, as to occasion impotence. This was formerly the mode adopted in the oriental courts for destroying masculine efficiency in the attendants of the Haram; and it is said that the Algerines, who are unwilling to castrate their horses, have recourse to this process, in order to render them incapable of procreation;[[300]] while it is well known that Park-keepers, who have the management of deer, annul the power of generating in bucks, by squeezing the testicles forcibly, and thus destroying their organization and secerning faculty.[[301]] Atrophy and wasting of the testicles may also result from local injury; Dr. Pihorel[[302]] relates an interesting case of this kind that occurred to an old soldier.
The body of the testicle is liable to many diseases, by which its structure becomes so changed, and its delicate organization so obliterated, that its secreting powers are entirely lost, such as schirrus, cancer, scrofula, &c. but we are to remember that such affections, if confined to one testicle, are not to be considered as affecting the virility of the party. M. Larry, Inspector General of the French Army, informs us that a disease which he calls Atrophy of the Testicles seized many of the troops in their return from Egypt; by which these organs became soft to the touch, and gradually diminished in size, without any pain; and it is well known that persons who are afflicted with Elephantiasis lose all sexual appetite, and that their genitals waste.
An organic fault similar to that which we have described, as relating to the Epididymis of the testicle, sometimes occurs in the Vesiculæ Seminales, where instead of entering the urethra, they terminate, after being joined by the Vasa Deferentia, in imperforated pouches, or cul-de-sacs, producing incurable impotence. In some cases the spermatic chord becomes varicose, and is followed by loss of power.
The most common malformation connected with the penis is the unnatural situation of the orifice of the urethra; sometimes it opens in the perinæum, occasionally on the dorsum of the penis, and frequently underneath. Mr. John Hunter was consulted by a person, who expressed great anxiety to have children, but whose urethra opened into the perineum, he therefore recommended him to inject by means of a syringe, previously warmed, the semen into the vagina, post coitum, and during the existence of the orgasmus venereus; the wife, it is said, became pregnant, and Sir E. Home observes, that no doubt was entertained by Mr. Hunter, or the husband, that the impregnation was entirely the effect of the experiment. It would appear that emissio seminis in vaginam is in some cases all that is required for impregnation, and therefore provided the orifice of the urethra be situated in a part of the penis that enters the vagina, any unusual deviation in its direction may not be material; nay farther, in some instances emissio sine penetratione has appeared sufficient;[[303]] many cases are recorded in which the hymen was entire at the time of delivery;[[304]] and Dr. Huxham[[305]] relates an instance of pregnancy, where from the preternatural formation of the female genital organs, it was impossible that the act of copulation should ever have been completed. A contracted state of the Prepuce, or Phymosis, may so interfere with the discharge of the seminal liquor, as to constitute a cause of impotence, (Dyspermatismus Præputialis, Culleni) an operation, however, will always in such cases remove the impediment.[[306]] By some authors the undue dimensions of the penis have been classed under the causes of impotence, but upon this point we would observe that the case already cited from Mr. Wilson, p. 201, clearly shews that exception ought not to be taken against mere diminutiveness[[307]] of structure; extraordinary dimensions in length and thickness may certainly prove a cause of relative impotence; there are besides certain enlargements in the neighbouring organs which may afford obstacles to the venereal congress, as remarkable obesity,[[308]] scrotal hernia, and hydrocele.
It has been a question to what extent the penis might be mutilated, without the extinction of virility: repeated instances have occurred where the glans has been lost, and yet the individual has retained his faculty of procreation. Piazzoni[[309]] relates a case where both the corpora cavernosa were destroyed, but as the canal of the urethra was preserved, the person could perform the act of coition without difficulty. Franck[[310]] also states an instance in which so considerable a portion of the penis had been carried away by a musket shot, that when the wound healed, the organ remained curved, and yet it proved adequate to the performance of its functions.
A Paralysis affecting the muscles of the penis is not a disease of very rare occurrence; it may depend upon various injuries of the nervous system, and while it remains, it is unnecessary to say that the penis is incapable of performing those sexual functions for which it is constructed, constituting the Anaphrodisia Paralytica of Dr. Cullen. The continued erection of the penis (priapism) is sometimes the result of morbid irritation,[[311]] and occasions a temporary impotence, (the Dyspermatismus Hypertonicus of Cullen) in consequence of the urethra being so closely shut up by the vigour of the erection, that the powers which throw the semen from the vesiculæ seminales are unable to overcome it; gentle evacuations and a slender diet are the best remedies in such a case. Strictures in the urethra, or morbid affections of the prostate glands, may occasion a similar inconvenience, (Dyspermatismus Urethralis) and we perhaps ought to enumerate extreme costiveness under the same division of the subject.
IN FEMALES.
Adhesion of the Labia may take place in adult women from inflammation; in consequence of which the due secretion of mucus with which these parts are naturally clothed on their internal surface is prevented; or it may arise from the neglect of accidental excoriation. In children the labia frequently cohere in such a manner as to leave no vestige of a passage into the vagina, except at the anterior part for the discharge of urine; the disease, whenever it may occur, is easily and safely removed by the knife.[[312]] In some cases hard labour has given rise to preternatural union of the labia.[[313]]
In cases of ulceration, where due care has not been taken to prevent the surfaces from remaining in contact with each other, the opposite sides have adhered so as to obliterate the passage; Schirrous and steatomatous tumours,[[314]] and polypi may also occupy the cavity of the vagina: in certain cases these may be removed with safety,[[315]] in others some hazard[[316]] will attend the operation. There is sometimes a faulty organization of the vagina itself, it may be too short, and too narrow,[[317]] (Arctitudo.) Inversion or Prolapsus is perhaps one of its most common diseases;[[318]] in some rare instances the passage has been obliterated by the Clitoris, elongated and enlarged in such a manner as to equal the size of the penis, when it constitutes one of those many peculiarities which have been mistaken for an Hermaphrodite.
The membrane called the Hymen has been found of so strong and ligamentous a texture, that it cannot be ruptured, and consequently prevents venereal congress. Ambrose Paré relates the case of a young woman, whose hymen was as strong as parchment, which he was obliged to cut with the scissars, before coition could be effected; a more recent case is recorded in which the density of the membrane was so considerable as to require the application of a trocar.[[319]]
With respect to the incompatible locality of the vagina, a malformation which occasionally occurs, it is only necessary to allude;[[320]] the medical judgment upon it must be directed by the circumstances of each particular case.
Where irritability of the sexual organs exists to such a degree as to occasion insufferable pain at the moment of coition, it must be regarded as a source of impotence.[[321]] It may depend upon various causes; Dr. Cockburn[[322]] relates a case of this kind which depended upon internal piles, and which was cured by their removal. Mr. Anthony White[[323]] has published three very interesting cases, in which the pain which accompanied the attempt at coitus was so acute, that the women rarely escaped fainting; upon examination he discovered in each of them a small fistulous opening, leading into a sinus of at least two inches and a half in length; the disease was attributed in each instance to a local injury having some years previously occasioned an abscess in those parts; the painful state of the vagina was entirely and permanently cured by dividing the sinus.
2. Functional Causes of Impotence.
Repeated intoxication, and vicious indulgences, may so debilitate the constitution in general, and the organs of generation in particular, as to render the debauchee wholly incapable of venereal congress; such impotence however is not to be regarded as permanent; bark, steel, the cold-bath, and above all, a change of habits may restore the patient to the full possession of his powers. There is a peculiar species arising from debility which deserves some notice in this place; it depends upon a want of consent between the immediate and secondary organs of generation; thus the penis acts without the testicles, and becomes erected when there is no semen to be evacuated; while the testicles secrete too quickly, and an evacuation takes place without any erection of the penis. Under the consideration of constitutional causes, we must not omit to enumerate the occurrence of Epilepsy: there can be little doubt, but that in certain cases, the venereal orgasm has excited an attack of this disease, and prevented the consummation of the act; we are therefore bound to recognise it as an occasional cause of impotence, and Dr. Cullen has accordingly considered it as forming a distinct species, under the title of Dyspermatismus Epilepticus.
The operation of certain powerful narcotics may be likewise regarded as capable of producing impotence, and cases are recorded where impotence, so occasioned, has become permanent;[[324]] much credulity, however, has existed upon this subject; the anaphrodisiac powers of Camphor were long believed, and is one of the vulgar errors noticed by Sir Thomas Brown;[[325]] and Amurath the IVth published an edict which made smoking tobacco a capital offence: a measure which was founded on an opinion that it rendered the people infertile;[[326]] equally gratuitous are the different opinions which have been advanced respecting the aphrodisiac virtues of particular substances; one of which, from the extent to which it is believed, and the authority by which it is countenanced, deserves to be noticed on this occasion; we allude to the popular notion that a fish diet contributes to increase fecundity; and we are not a little surprised to see it sanctioned by such a writer as Montesquieu, who observes, that “the regimen of certain monks seems to be wholly repugnant to the intention of their founders.” The same belief is very generally entertained in fishing towns, in consequence of the great population of such places, but surely the fact admits of easy explanation upon that general principle in political economy, which no one will attempt to deny, that the number of marriages will be in proportion to the facility with which children can be supported.
A blow on the head may also deprive a man of his virility; a case of this kind is related by Hennen, in his Military Surgery, where a soldier became so affected in consequence of a fracture of the occipital bone, by the fragment of a shell.
3. Moral Causes of Impotence.
A temporary impotence from certain emotions of the mind is by no means so rare an occurrence as may be supposed; and in times of superstition was generally attributed to the influence of some magical incantation; an opinion which was even maintained by Zacchias, Teichmeyer, and Schurigio, but which it is hardly necessary to add, has been reprobated by Vogel, Cullen, and all modern authorities. Where this occurs it is often productive of the greatest distress of mind, and has not unfrequently led the unfortunate sufferer to the commission of suicide. Mr. Hunter[[327]] has treated this subject with his accustomed sagacity, and relates a successful mode of treatment; he prevailed on a person in this situation to promise on his honour to pass six nights in bed with a young woman without attempting to have any connection with her, whatever might be his power or inclination; he afterwards assured Mr. Hunter that his resolution had produced such a total alteration in the state of his mind, that the power of connection soon recurred, for instead of going to bed with the fear of inability, he went with fears that he should be possessed with so much desire, and so much power, as to become uneasy to him, which really happened; and having once broken the spell, his mind and powers went on together, and they never relapsed into their former state of imbecillity.
Disgust is also a frequent cause of temporary impotence “Morositas, Contemptus, Iræ, Tristitia, Corporis immundities ac fætor, venerem primario supprimunt.”[[328]] The imagination[[329]] is sometimes the cause of temporary impotence, with regard to particular females, as exemplified in the famous case of the Earl of Essex and Lady Frances Howard, in 1613, in which the marriage was declared void, because the Earl, on his own confession, was impotent with regard to his lady, (erga hanc) although he had no defect or impediment, and was able to copulate with other women.
We have thus related the principal causes of Impotence in the sexes; it would be as idle to dwell upon the absurdity of the opinions which attach any weight to astral influence, as it would to refute the idea, that suggested the custom so universally observed by the Scythians, and which is even followed at this day by the natives of some of the South sea islands, of cutting the veins behind the ears, in order to render the males impotent, and the females sterile.
2. STERILITY.
Sterility occurs more frequently in the female, than impotence does in the male sex.
Its causes may be distinguished into those that arise from imperfect structure, and into those that entirely depend upon a morbid performance of certain functions.
1. Organic Causes.
Absence of the uterus. We have before alluded to this occasional defect; it has sometimes occurred, where the vagina has been wholly impervious.[[330]] Columbus dissected a woman who had always complained of great pain in coitu, in whom he found the vagina very short, and no uterus at its termination. In Hufeland’s German Journal[[331]] for May 1819, a case is related of a total deficiency of the uterus, which was discovered by Professor Stein during an operation undertaken to remedy a supposed contraction; in this paper the author quotes several analogous cases from the writings of Engel, Schmuker, and Theden.
Imperforated uterus. The os uteri, says Dr. Baillie, has been found to be so contracted as to have its passage in a great measure obliterated; and it has even been known to be closed up by the growth of an adventitious membrane. The os tincæ may be also shut up, either originally, or by cicatrix, in consequence of suppuration, laceration, ulceration, or the like, when the case may be considered as incurable, unless the menstrual discharge force a passage by its pressure, or the introduction of a trochar is able to afford an opening[[332]]. Original conformations of this kind seldom admit of any cure, for besides the impervious state of the os tincæ it not unfrequently occurs that the uterus itself appears as a solid body, without any cavity in its centre.[[333]] Morgagni states that he was consulted by a barren woman, whose vagina was only a third part of the usual length, and that its termination felt firm and fleshy, in which case he advised a dissolution of the marriage. Marchetti, on the contrary, has given a case where the vagina ran downwards beyond the internal orifice of the uterus, and terminated in a kind of cul de sac.
Polypus in utero. This may be sometimes removed by exsection; a valuable paper upon this subject by M. Deguise is to be found in the Nouveau Journal de Medicine, entitled “Observations des Polypes Uterines,” in which the author relates many successful cases, and controverts the common opinion, that after the operation for an uterine polypus, the organ is incapable of being impregnated.
Ovaria, absence of, or diseased condition of. There is a specimen in Dr. Hunter’s museum, in which one ovarium is wanting; other instances have been recorded in which no vestige of an ovarium could be observed on either side.[[334]]. The case of this kind published by Mr. Pears in the Philosophical Transactions for 1805, we have before described: to this may be added another instance from the writings of Morgagni. Instances of diseased ovaria are very common, and may arise from a variety of causes: the Fallopian tubes may also, in consequence of peritoneal inflammation, become obliterated, and lose the power of conveying the ovum from the ovarium to the uterus; they may besides be originally defective in structure; Dr. Baillie has seen them, without any aperture, or fimbriated extremity, terminate in a cul-de-sac. Morgagni noticed these tubes in some courtesans having been entirely obliterated by the thickening of their parietes; an evident consequence of the habitual orgasm in which they had been kept by too frequent excitement. Richerand on dissecting a subject at La Charité that had been sterile, found the fringed margins, or expanded extremities of the tubes, adhering to the lateral and superior parts of the pelvis, so that it had been impossible for them to perform the motions necessary for fecundation.
2. Functional Causes.
These are constitutional debility, leucorrhœa, or an excess, or deficiency of the menstrual discharge. Observation has fully established the fact, that women who do not menstruate cannot conceive; this discharge appears to be essentially necessary for the due and healthy state of the uterus, and Dr. Denman[[335]] has also observed that in cases of painful menstruation, a membranous substance is often discharged, and that no woman, in the habit of forming such a membrane has been known to conceive, although, he adds, that as it is not uninterruptedly formed at each period of menstruation, the capability of conceiving may exist at any interval of freedom from its formation.
Women who are very corpulent are often barren, for their corpulence either exists as a mark of weakness of the system, or it depends upon a want of activity in the ovaria; thus spayed, or castrated animals generally become fat.
A state of exhaustion of the uterine system, occasioned by frequent and promiscuous intercourse with the other sex, is also a very common cause of barrenness in women, and hence few prostitutes conceive.
In some cases the uterine system is capable of being acted on by the semen of one individual, but not by that of another, for many instances are on record where persons have lived in wedlock without offspring, and being, after divorce, re-married, have each had families.