Impotence

IMPOTENCE (from the Latin in- negation and potentia - power, strength, ability), sexual impotence, a condition in which the act of copulation is either completely impossible or possible only to an incomplete extent. Impotence is spoken of when an adult male exhibits a persistent or temporary decrease in his previous individual sexual capacity. Here one should always take into account the fact that sexual potency is unequal in different individuals, and what is relative impotence for one may be quite normal for another. There are individuals who are able, without harm to their health, to perform a completely normal sexual act daily for a number of years, and sometimes several times a day. On the other hand, there are individuals who consider a sexual act no more than 1-2 times a week to be the norm for themselves. Climate, diet, and race are not without influence on sexual capacity. Eastern peoples and Semitic races are distinguished by heightened sexual capacity, while Eskimos possess sharply reduced sexual activity and capability. Meaty, fatty, and spicy foods, increasing the general excitation of the nervous system, contribute to an increase in sexual capacity. Intensified physical labor, weakening the entire organism, intensified mental activity, exhausting the nervous system, poor nutrition, and emotional distress can be causes of impotence. But the main cause of impotence is local changes both in the genital organs and in the central nervous system. A distinction should be made between temporary and permanent impotence. Furthermore, a distinction is made between the inability to fertilize, impotentia generandi, and the inability to copulate, impotentia coeundi. With the inability to fertilize, the sexual act as such is usually not impaired, but the individuals performing it remain sterile. A man incapable of performing the sexual act is usually also incapable of fertilization, but not vice versa: there are individuals who are able to perform a normal sexual act, but whose semen is unfit for fertilization. In order to fertilize the female egg, it is necessary that the semen contain normal, viable spermatozoa and that the latter be able to penetrate the uterus, i.e., that they possess sufficient motility. Consequently, all those diseases that are accompanied by a disturbance of the normal composition of the semen (aspermatism, azoospermia, necrospermia, asthenospermia) can be the cause of the inability to procreate (see Male Infertility). The absence of spermatozoa in the semen can be caused, among other things, by the absence of the testes as a result of prior castration. In these cases, patients, not being in control of fertilizing a woman, nevertheless do not lose the ability to perform the sexual act, provided only that the loss of the testes occurred in them after the onset of puberty. These observations prove that the main role in the physical ability to perform the sexual act and in the occurrence of erection is played not by the testes, but by the prostate gland. True, in such individuals a decrease in sexual desire (libido) is still observed. It should be emphasized here once more that chronic poisoning (work with lead, morphinism, alcoholism, and the like), prolonged chronic diseases of an exhausting character (cancer, syphilis) can cause a decline in the activity of the testes. In such individuals, the testes continue to produce spermatozoa, but are unable to produce viable ones. The elimination of harmful factors (poisoning) and an increase in the general tone of the organism usually lead to the restoration of the normal motility of spermatozoa. The inability to copulate is clinically subdivided into four main groups: organic impotence, paralytic impotence, impotence due to irritable weakness, and psychic impotence. It should be borne in mind that this classification is schematic. In everyday life, one usually observes both the transition of one form of impotence into another and a combination of various groups. Cases of impotence due to irritable weakness are most frequently encountered. - Organic sexual impotence is a condition in which the glands function normally, sexual desire and erection exist, but at the same time there are mechanical obstacles to the sexual act in the form of an abnormal structure and development of the genital organ or its surrounding parts, excessive obesity, a large hanging belly covering the genital organ even in a state of erection, large hernias, and tumors of the scrotum creating a mechanical obstacle to copulation. Changes in the size of the penis, both in the direction of its increase and especially in the direction of its decrease, can only in very rare cases be a factor making the sexual act difficult. There are racial differences in the size of the penis, but its size bears no relation whatsoever to sexual power. The treatment of this group of impotence is purely symptomatic. In paralytic impotence, neither erection nor ejaculation occurs, or if an erection does occur, it is with great difficulty and is weakened. Sexual desire at the same time is usually preserved, and the patient's condition is mentally very agonizing. In striving to achieve an erection and thus make the sexual act possible, patients resort themselves and force their partners to resort to all kinds of sexual contrivances and unnatural methods. In this way, they sometimes manage to achieve short-term physical excitation, a short-term erection, not always sufficient for the performance of a normal sexual act, but satisfying them in view of the impossibility of anything greater. For the occurrence of paralytic impotence, a disturbance in the activity of the sexual glands is necessary, and first of all of the prostate gland as an organ having a direct relation to the act of erection. Among the anomalies of the testes and their lesions causing impotence, mention must be made of their congenital complete underdevelopment, causing the absence of erections; acquired atrophy of the testes, however, has as its consequence a gradual weakening of sexual power until its complete disappearance only in the event that it is accompanied simultaneously by atrophy of the prostate. In the absence or atrophy of the testes as a result of a local disease, with a normally functioning prostate, the sexual act may be weakened, but usually does not disappear altogether. Dilatation of the veins of the spermatic cords can entail the weakening or even complete loss of sexual power. The therapy of cases of this group is purely symptomatic. The ability to perform the sexual act declines with the years significantly earlier than the production of spermatozoa is destroyed. Simultaneously with the decline in sexual capacity, sexual desire also decreases, as a result of which, as a rule, elderly individuals view the fading of erections quite coldly. Paralytic impotence thus is a physiological phenomenon in senile age and is of practical interest only when it is observed in individuals who are in the prime of their physical strength. Here two groups of patients should be distinguished: those who have never performed the sexual act, in whom paralytic impotence is a congenital phenomenon, and those in whom the sexual act at first occurred quite normally, but then erections began to weaken and disappeared completely - acquired paralytic impotence. The first group includes those individuals in whom the sexual glands are underdeveloped from birth or have atrophied as a result of some disease, most often inflammatory, in childhood. We have in such cases individuals with a disturbance of the functions of the organs of internal secretion - eunuchoids. They usually endure their sexual defects quite easily, since they have never experienced sexual desire. To the group of acquired impotence belong individuals in whom the function of the sexual glands, which had been normal for a certain period of time, began to weaken. These are individuals who not infrequently lived an excessive sexual life. They endure their affliction very hard and usually point themselves to sexual excesses, especially preceding mastography as the cause of their impotence. In the presence of paralytic impotence caused by acquired atrophy of the testes, the external appearance of the latter often does not change. The atrophied glandular tissue of the testis is replaced by connective tissue, which does not possess specific functions; the testis ceases to secrete, but the volume of the testis does not decrease. The small size of the testis does not yet indicate a drop in its functions. Large testes can function worse than small ones; thus, one cannot tie the complaints of patients to the external appearance and volume of the genital organs. Phenomena of paralytic impotence can also develop with complete health of the testes - on the basis of various diseases (most often of an inflammatory character) of the prostate gland. The frequency of its lesion during gonorrhea is the reason that a certain part of the cases of paralytic impotence is also a consequence of gonorrheal diseases. Frequently the main complaint of patients is disorders of sexual functions, rather than chronic gonorrhea. Finally, paralytic impotence can be caused by diseases of the central nervous system with complete health and normal function of the sexual glands. What is characteristic in this regard is the circumstance that sexual desire is usually expressed to a sufficient degree.

The prognosis in these cases is poor, and treatment in the majority of cases yields no results. The same can be said for those cases of paralytic impotence caused by atrophy of the sexual glands. Transplantation of the sexual glands provides an improvement in function, but this improvement is temporary and its results are unstable. The prognosis is significantly better in paralytic impotence caused by inflammatory diseases of the prostate gland. Local treatment of the latter usually leads to the restoration of normal sexual activity. Impotence due to irritable weakness is characterized by the fact that the time interval elapsing between erection and ejaculation is very insignificant. Because of this, the semen is ejected prematurely, i.e., either immediately upon the introduction of the member into the woman's vagina or even before the start of the sexual act. In most cases, the tension of the genital organ is initially sufficiently strong at this time, but is quickly destroyed. In some cases, however, the erection is insufficient all the time, and ejaculation occurs with a flaccid organ, upon the slightest excitation of the patient caused by physical closeness to a woman. Normally, the duration of the sexual act is equal to 2-6 minutes, but a decrease in this time during long abstinence or during very strong sexual arousal should not be considered pathological. It is pathological only when it is constantly observed in a given person. The causes of this kind of impotence can be various. Here, both purely psychological moments and diseases of the spinal cord centers play a role, and for some diseases (e.g., for tabes), a cyclical course of the disease is characteristic in the form of a change of symptoms of irritation of the spinal cord centers of erection and ejaculation by paralytic phenomena. It is necessary to distinguish between primary damage to the spinal cord centers due to various organic diseases of the spinal cord or toxicosis and their reflex damage. The latter occurs due to irritation by inflammatory processes of the peripheral nerve endings embedded in the prostatic part of the urethra and in the seminal colliculus. The therapy of such cases should be directed either to the nervous system in case of its damage (the prognosis in this case depends on the nature of the disease of the nervous system) or to the local disease, and the treatment of such cases yields a good therapeutic effect. One of the etiological moments of irritable impotence is interrupted coitus (coitus interruptus). Thus, the term impotence is a collective one for a whole series of diseases of various organs, united by a single clinical symptom—a violation to one degree or another of the ability to perform the sexual act. This determines the impossibility of indicating a single universal method of prevention and therapy of impotence. Increasing physical strength, strengthening the nervous system, regulating sexual activity, abandoning all narcotics (tobacco, alcohol)—all this should contribute to the prevention of impotence. Acting in some cases on the psyche of the patient, local treatment of the genital organs in others, organ transplants, or general hygienic and dietetic measures with strict individualization of each case constitute the sum of therapeutic measures for impotence.

R. Fronshtein.

Psychic impotence, sexual impotence of a man caused by psychic causes—ideas, emotions, etc. Psychic impotence is not an independent disease, but only a symptom of some neurosis (psychasthenia, nervous exhaustion, etc.). Passing states of psychic impotence can, however, also be observed in normal subjects if there are sufficiently strong inhibitory moments emanating from the cerebral cortex. Examples are cases of this kind well known to doctors in newlyweds, when agitation, fear, or awareness of some fault (for example, venereal disease in the past) temporarily paralyzes erection in nervous but otherwise healthy men. The psychological mechanism stands out especially clearly in those special cases which are called relative impotence, namely, when a subject turns out to be impotent with respect to one woman (not infrequently a wife), remaining potent with respect to other women, or when potency manifests itself only under special conditions, as for example in the case described by Orlovsky, where the patient, out of fear of alimony, retained potency only with respect to a woman who assured him that both her ovaries had been removed; attempts at intercourse with other women invariably ended in failure, since only the scar on the abdomen from laparotomy served as a conditional stimulus. Most often, psychic impotence is observed in neurotics of the psychasthenic type—indecisive, unsure of themselves, suspicious, and prone to autosuggestion. Fear of the first sexual act, overestimation of the woman (excessive idealization of the latter), obsessive memory of an accidental failure, prejudices about the fatal consequences of mastography—are firmly fixed in the consciousness of such patients and paralyze erection every time, as the approach of the responsible moment brings corresponding inhibitory ideas to the surface of consciousness. Such patients complain of a drop in normal erection precisely when approaching a woman, at the very moment of preparation for coitus. Depressed by constant failures, they go from doctor to doctor, from one advertised remedy to another in search of a cure, and the latter is pushed further and further away the more the patient's attention is focused on his illness. Before each attempt at a sexual act, he experiences severe self-doubt and fear of a new manifestation of his inadequacy, which has a paralyzing effect on the essentially reflex sexual act (erection). Thus, a vicious circle is obtained, in which a failed act causes psychological depression, and the latter paralyzes erection during a new attempt. Treatment. The psychological nature of this kind of impotence clearly indicates that psychotherapeutic intervention on the patient is the main method of treatment. Clarification to the patient of the psychological mechanism of his disorder, strengthening in the patient a sense of self-confidence and hope for a cure—often after the first psychotherapeutic conversations already give an improvement. More persistent are those cases when the patient has already managed to try various methods of ordinary special treatment (massage, bougienage, electrotherapy, etc.). A great deal of effort has to be spent by the psychotherapist to overcome the prejudices associated with the idea of masturbation as a harmfulness capable of causing severe disorders even many years after the cessation of masturbation. Psychotherapeutic intervention (suggestion, hypnosis, clarification, etc.) is usefully accompanied by general strengthening and distracting treatment (physical culture, travel). The treatment of the sexual apparatus itself should be carried out very cautiously and only in cases where special study has established symptoms requiring intervention (for example, atonic phenomena in the prostate in older men, causing a decrease in potency, which in turn acts depressingly on the psyche). Especially apart stands the psychoanalytic school of Freud, which seeks the roots of psychic impotence in the sexual experiences of early childhood, such as the psycho-sexual attitude of a boy to his mother, sister, etc., which attitude is fixed in the subconscious in the form of a complex, the psychological basis of which consists in the idealization of a woman, in her unconscious identification with the object of childhood attachment. In such cases, any attempt at a sexual act is inhibited as something forbidden. Only full awareness of this mechanism (by means of sometimes extremely prolonged psychoanalysis) gives a cure for sometimes stubborn cases of psychic impotence. Special expertise in impotence from a medico-legal point of view—see Expertise.

S. Tsetlin