Neuroses of the Genito-Urinary System. 
L. BOLTON BANGS, M. D. A CONTRIBUTION 
TO 
THE STUDY OF NEUROSES 
OF 
The Genito-U rinary System. 
(Reprinted f rom the New York Medical Monthly} 
BY 
L. Bolton Bangs, M. D. 
Surgeon to the St. Luke's and Charity Hospitals. 
New York: 
DE LEEUW, OPPENHEIMER & MYERS, PRINTERS, 
108 and 110 DUANE STREET. 
1886. A CONTRIBUTION 
TO 
The Study of Neuroses of the Genito- 
urinary System. 
BY 
L. BOLTON BANGS, M. D., 
Surgeon to the St. Luke's and Charity Hospitals. 
MR. HILTON, in his book on " Rest and Pain," points 
out that the same nerve which supplies a mucous or 
serous membrane also supplies the muscular structures 
surrounding or allied to it. He explains spasmodic stricture of 
the urethra, retention of urine, and chordee during an attack of 
gonorrhoea, by the irritation of the latter " setting up an excito- 
motor action of the spinal cord." Dr. Otis's observations have 
been more extended. In his writings on " Reflex Irritations " 
he has shown that spasmodic conditions of the deeper urethra 
and various referred sensations may be caused by lesions in 
other parts of the same urethra ; and further, that these spasmodic 
conditions may be more or less permanent, simulating organic 
stricture. It is not difficult to understand these facts when the 
nerve supply (and its varied functions) of the genito-urinary 
system is borne in mind. The male urethra is not only a urinary 
organ, but a sexual one, and its nerves are in accordance with 
these different physiological necessities. As a number of confirm- 
atory clinical observations, which also find a ready explanation 
in the anatomy of the nervous system, have fallen under my 4 
notice, I have ventured to present some of them in this paper, 
trusting that they may be read with interest by others. 
A very common symptom of a subacute stage of urethritis, and 
of many chronic urethral conditions, is an itching of the pudenda. 
This itching varies greatly in intensity, and is sometimes insuffer- 
able, demanding some measure of relief. It seems to depend upon 
a condition of congestion of the mucous membrane, after the acute 
symptoms have subsided, and more especially of that of the bulb- 
ous or prostatic parts of the urethra. The intensity of the 
symptom no doubt varies with the degree of irritation or stimula- 
tion of the nerve ends in the mucous membrane, and with the neu- 
rotic state or tendencies of the individual. It is well known in 
the reflex-function of the spinal cord that stimuli appear to travel 
by " paths of different resistance." A slight stimulus follows the 
"most ready path to a certain motor root," while a stronger 
stimulus is " more widely diffused, affecting many nerve roots," 
and exciting greater action.* But why this peculiar sensation is 
excited in the skin is not clear. Unfortunately we know too 
little of the " paths of sensation." It may be that in these cases a 
sensation is reflected, and not a motion excited, because the func- 
tion of the nerves in the irritated mucous membrane is different 
from that of other parts of the urethra ; or, that only the nerves 
controlling nutrition are irritated, and hence reflect, so to speak, 
a nutritive symptom. Hebra used to say that pruritus meant 
" cutaneous capillary congestion," which is one of the first steps 
toward a change in nutrition. Whatever may be the explanation 
of the development of sensation in the skin, or elsewhere, the 
transmission of a motor influence is clearer. Dr. Otis has estab- 
lished without doubt the fact that an irritation, notably a stricture 
of large caliber, at the meatus or in the anterior penile urethra, 
will excite a reflex motor action in the more internal muscular 
structures, f The function of these muscles is to contract upon 
and expel the contents of the urethra. This is what they were 
made for, and is all they can do. In response to the anterior 
irritation they perform their function, and continue to do so till 
a "tonic spasm " is induced in them, which must be in proportion 
* See " Diseases of the Brain and Spinal Cord." By W. R. Gowers, M. D. 
t See Otis on " Genito-Urinary Diseases." Pp. 487 et seq. 5 
to the degree of irritation or to the susceptibility of the subject. 
The caliber of the urethra is thus reduced, an obstacle is offered 
to the egress of urine and semen and to the ingress of instru- 
ments, i. e., a stricture of the urethra, giving all the symptoms of 
an organized stricture.* 
In order to get a clearer understanding of the paths for the 
transmission of either or both sensation and action, it may be well 
to review the anatomy of the nerves of this region. The internal 
pudic nerve supplies the muscles of the perinseum and deep ure- 
thra. It also supplies the penis, its skin, mucous membrane and 
erectile structure, and the branch known as the " dorsalis-penis " 
is especially accompanied by branches of the sympathetic nerve 
from the inferior hypogastric plexus. It will thus be seen that the 
same nerve which supplies the anterior part of the penis also sup- 
plies its deeper parts, notably its muscular tissues. Hence an irri- 
tation, for example at the meatus, is readily conveyed to the 
spinal cord, there to be converted into a motor impulse, and 
thence transmitted to the muscular structures of the penis. The 
impulse may also be transmitted to the base and neck of the blad- 
der, for the nerves which supply these parts of this viscus arise 
from the same roots (second, third and fourth sacral) from which 
■springs the internal pudic. Another interesting fact is that this 
nerve (internal pudic) supplies the integument in front of the anus, 
of the perinaeum, and of the back part of the scrotum ; while it 
communicates freely with the branches of another nerve (the small 
sciatic) which are distributed to the front and lateral surfaces of 
the scrotum. At this point notice another important fact. The 
same sacral roots (second, third, fourth, and sometimes the fifth) 
which give origin to the internal pudic and small sciatic nerves 
send branches to the prostatic plexus. The nerves of the latter 
are of large size, and are distributed to the prostate gland and 
vesiculae seminales. Here, then, is a direct communication be- 
tween the prostate gland, the urethra, and the integument of 
the perinaeum and pudenda. A direct channel for the transmis- 
sion of any influence, whether it be sensory or motor. 
The rectum and genito-urinary organs are also in immediate 
communication, not only from contiguity, but from associated 
* See Otis on " Genito-Urinary Diseases." Pp. 487 ft seq. 6 
nerve supply. The internal pudic supplies the mucous membrane 
of the lower part of the rectum and the external sphincter mus- 
cle of the anus. Thus an irritation in one may be reflected 
readily to the other. 
The following case is an illustration of the cause of the itching 
to which reference has been made, and of an aggravated form 
of it: * 
A gentleman, aged 28, acquired gonorrhoea, which progressed 
mildly for two weeks, when, after some indiscretion in exercise, 
his discharge suddenly ceased, and he was seized with the symp- 
toms, subjective and objective, of acute prostatitis. He had re- 
tention of urine and catheterism for six days. The acute symp- 
toms gradually subsided, and he seemed to be convalescing favor- 
ably, when a slight itching, which he had noticed during the day 
along the perinaeum, became by night more and more intense. 
The anus, the perinaeum, the scrotum and the penis itched intoler- 
ably. Sleep was impossible. He was almost frantic from the fre- 
quent calls to urinate and from the incessant scratching, which 
was imperative. When I saw him in the morning he was haggard 
and wretched. I could scarcely believe that this one symptom 
could have made such a change in his appearance. His pulse 
was 100, temperature only 99, and he had had no pain except the 
moderate pain at the end of each act of urination, to which he 
had then become somewhat accustomed. He was not constipated, 
and had no rectal disease. The intensity of the itching was al- 
ready subsiding, but he was speedily relieved by injecting into the 
rectum very hot water. After two injections, at an interval of two 
hours, he had no more of the symptom, and during his further 
progress no return of it. 
This observation was very valuable. It confirmed me in a 
view of the causation of other cases of pruritus of the anus and 
genitals which I had already acted upon. For example : A gen- 
tleman, aged 40, was kindly referred to me by a medical friend 
for treatment of some irritability of the sexual organs. He com- 
plained greatly of an itching of and about the anus (" pruritus 
ani "), which annoyed him during the day and disturbed his sleep 
* In the cases reported in this paper only the details which bear upon the subject are 
given. All others are purposely omitted. 7 
at night. For many months he had not had a night's rest except 
when using narcotics or sedative external applications. Of late 
both the sexual irritation and the itching had become aggravated. 
As he had been under the care of skilled dermatologists for the 
pruritus he now sought advice for the frequent erections, etc. 
There was no history of any venereal disease ; none of hemor- 
rhoids, except that he had occasionally passed a few drops of 
blood while straining at stool. He had no hemorrhoids on ex- 
amination. The skin of the anus and in its neighborhood was 
thickened and excoriated by the constant scratching. Inquiry 
developed the fact that the itching extended also along the peri- 
nseum and at times upon the back of the scrotum. No stricture 
of the urethra could be found. The prostatic urethra was very 
sensitive, and the introduction of the instrument gave him great 
pain. Although a man, apparently, of considerable resolution, he 
could hardly bear the pain, and described it as of a dull cutting 
character. In answer to close questioning he acknowledged that 
he had acquired the art of prolonging the act of sexual inter- 
course, and that he had practiced it too often. From this it was 
reasoned that the physiological congestion of the prostatic urethra 
had been renewed so often as to have now become pathological 
and chronic. He was advised to abstain from intercourse, to take 
abundant exercise in the open air, and to have the regular use of 
the steel sound. Reasoning also from the association of the 
nerve supply, that the pruritus was dependent upon the urethral 
congestion, he was directed to stop the narcotic lotions and salves 
in which he had so long slept enveloped, and to await the result. 
For a day or two (that day and the next) after the first use of 
the sound, urination was painful, and he passed a drop or two of 
blood at the end of each act. Then, in every way, he felt better. 
The effect upon the pruritus was very interesting. He was almost 
afraid to give up the lotions, but he slept the first night without 
them and with but slight itching. After that he had no itching 
whatever. He believed he was cured, and remembering the pain 
which the sound had caused him, was glad to believe so, and did 
not return for treatment, but maintained in great measure the hy- 
giene which had been ordered. Then he had a relapse ; but, as 
the symptom, when compared with the previous two years, was 8 
insignificant and did not now disturb his sleep, he put off report- 
ing. Finally he came in with the foregoing history. The sound 
was again used ; this time without pain, and the subsequent urina- 
tion was also painless and bloodless. His statement as to the 
time in which he had been entirely free from itching was indefi- 
nite, but the interval between the first and second use of the sound 
was about two months (May 25th, July 20th). The effect of the 
second introduction of the instrument was equally positive. The 
patient is now seen occasionally. At times he has some itching of 
the anus, but when he has any it is slight, and he feels it is depend- 
ent upon the degree of health in which he maintains his sexual 
organs. 
In some cases the symptom is found in a much more limited 
area, and the following may be studied as a type of those in which 
the itching is limited to the skin of the scrotum. The explana- 
tion of its limitation may be in the fact that the irritation of the 
mucous membrane is in lesser degree, but I can suggest no reason 
for the selection. Why the sensation should be transmitted to the 
scrotum and not to the anus or elsewhere is not clear. 
The subjects of it, however, complain quite as much as those 
with more extensive pruritus, and demand with equal earnestness 
measures of relief. 
S. L. J., aged 36.-This man complained only of an intense 
itching of the front and back of the scrotum. It disturbed him 
quite as much during the day as at night. The integument was 
thickened and pigmented as a result of the continued scratching. 
He looked to be and complained of being "fretful and worried." 
He gave no other symptom pointing to the sexual organs, but ex- 
amination revealed the presence of stricture of large calibre in 
the penile urethra, and also of an abnormally sensitive prostatic 
urethra. The latter in a married man, who might be supposed to 
be having what Keyes and Van Buren consider sexual hygiene, 
suggested further inquiry. Careful questioning developed that he 
had frequent intercourse, nearly every night; and that, in 
order to avoid progeny, he practiced withdrawal, or "conjugal 
onanism."* 
* These subjects do not readily yield the necessary confidence in regard to this matter. 
It is only by persistent questioning that the facts can be elicited. 9 
Here were two sources of irritation, each of which might be 
capable of exciting the symptoms of which he complained. He 
was advised to have internal urethrotomy performed ; but as it 
was inexpedient for him to leave his business, even for a few 
days, sounds were systematically used instead. He was directed 
to have natural intercourse at longer intervals. The effect upon 
the itching was so gratifying that up to the present time (a year 
from beginning the use of the sounds) he has put off having the 
stricture operated upon. Although, to a certain extent, he has 
changed his sexual habits, he cannot be said to be cured of the 
itching. It is at times troublesome, and then he comes to have 
the sound introduced. This always gives him so much relief 
that he is perfectly contented to go on as he is. He has gained 
largely in weight and in general appearance, and is less " nervous " 
and irritable ; but I believe that every source of irritation will yet 
have to be removed. 
I would not be thought to claim from the foregoing that all 
cases of itching of the anus or pudenda are due to irritations in 
the genito-urinary organs, but I trust that the explanation which 
is offered may serve to classify them still further, and thus simplify 
their treatment. 
Another sensation due to irritations in the genito-urinary or- 
gans, and which is transmitted to other regions, is pain of different 
kinds. It may be complained of in the back, in the thighs and 
legs, in the feet, and may even cause the subject of it to walk 
lame. It is worthy of notice, for not seldom has it been taken as a 
symptom of degeneration in the spinal cord. In acute or chronic 
prostatitis one of the characteristic symptoms is pain, often violent, 
referred to one or both thighs and legs ; a fact readily understood 
when it is remembered that the great and lesser sciatic nerves 
spring from the same sacral roots as the nerves which supply the 
prostate gland. The two following cases will serve to illustrate 
this, one in acute and the other in chronic prostatitis : 
S. L. H., aged 22.-Acquired gonorrhoea, which did well for 
about two weeks, when he had evidences of the extension of the 
inflammation to the deeper urethra. A week later he had a chill 
with rise of temperature, increased frequency of urination, and at 
the end of each act of urination he experienced a sharp darting 10 
pain down the back of each thigh and leg and into his heels. 
Examination by the rectum showed that the prostate gland was 
swollen to twice its normal size, tense and exquisitely tender. The 
pain in the legs increased in severity, and overshadowed all other 
symptoms. It was intermittent, recurring about every five min- 
utes, without any relation to the acts of urination, and was de- 
scribed as of a " lightning-like " character. The whole limb would 
start when the pain came. He dreaded it infinitely more than 
he did the pain of urination, and it was necessary to keep him 
constantly under the influence of morphia. This severe pain in 
the legs began on the first day of the disease, and by the fifth 
the patient no longer required morphia. On this day (the fifth) 
he had complete retention of urine, and the catheter was used till 
the twelfth day. The enlargement of the prostate was plainly 
perceptible by the rectum for a week longer. It was evident, 
therefore, that the amount of swelling did not determine the de- 
gree of pain, but that it was dependent upon the irritation of the 
nerves by the acuteness of the disease. This is interesting in re- 
lation to the next case, which, although of a chronic character, 
had, at times, exacerbations of an active kind. 
L. F. H., aged 26.-This patient has a history of sexual irrita- 
tion from boyhood. Masturbation four times a week from 13 to 
15 ; then once in two weeks till 21 ; after that occasionally till 
present time. Gonorrhoea at 18. For the past four or five years 
erections have been imperfect, and intercourse almost impossible, 
although frequently attempted. Foi' the same period of time he 
has suffered from pains (not acute) in the penis at the peno- 
scrotal junction and in the rectum, especially after walking. He 
has also a peculiar feeling of retraction or " drawing back," 
which he locates somewhere in the deep urethra. But that which 
disturbs him chiefly is the fact that pain is now experienced down 
the back of the right thigh and in the calf of the right leg. At 
times this pain is of greater severity; then locomotion is interfered 
with, and he limps with this leg. Examination by the rectum 
shows that the prostate gland is irregularly enlarged and harder 
than normal. The enlargement seems to be more antero-poste- 
riorly than laterally, and is greatest on the right side. Gentle 
pressure on the lobes gives him an indescribable sensation in the 11 
rectum. The same pressure upon the median line of the organ 
causes a sensation of the ejaculation of semen, and at the same 
time a dull pain in the penis. While pressing here the examining 
finger feels a distinct spasm or twitch, limited to the immediate 
neighborhood of the prostate, and the patient exclaims, " That 
is the drawing-back feeling that I told you of." He has also 
strictures of large caliber in the penile urethra, and the prostatic 
urethra is abnormally sensitive. 
The patient was reassured in regard to his having " spinal dis- 
ease," and the relation between the chronically inflamed prostate 
and the pains in the legs was explained to him. The influence 
of the strictures upon the deeper structures was also shown to 
him, and he was advised to have internal urethrotomy as the first 
step in the treatment. This was accordingly done. The details 
of treatment are not necessary, but in brief it may be stated that 
applications of nitrate of silver were made to the prostatic 
urethra, absolute continence was enjoined, and abstinence from 
tobacco and alcohol advised. The intensity of the pains in the 
legs speedily diminished, and they entirely disappeared in two 
months. At the end of three months it is recorded : Prostate 
feels elastic and normal; no tumefaction of lobes : no pain, and 
no sense of ejaculation produced by pressure ; no spasm of levator 
ani (?) ; occasional pains in the penis and rectum persisted till 
his marriage (three months later), and for some time thereafter, 
but he had no difficulty with intercourse from the first. 
The following case, though not unique, has an element which 
I have not met in others, nor seen recorded, but as it bears upon 
the subject of transmitted sensations it may be read with interest: 
M. H. A., aged 26.-After repeated, prolonged and violent 
sexual intercourse, he had a sudden, sharp, darting pain in the 
left testicle. It was intermittent, and " flashed " upon him at any 
time-even at night-destroying his rest. Occasionally it radiated 
to the left lumbar region and to the left thigh. 7A? had noticed 
that unless he took care when sitting pressure somewhere upon the left 
leg caused this pain in the testicle. The pain has persisted (now 
two years to the time of taking this history), and there is no other 
symptom pointing to the sexual apparatus. 
When he came under my care he was in poor condition from 12 
disturbed sleep, and in constant apprehension of the pain. There 
was no enlargement or tenderness of the prostate gland. There 
was no swelling of the testicles, but the left epididymis was sensi- 
tive, and the patient winced while being gently examined. There 
was no stricture, but the whole urethra was very sensitive, and he 
complained especially when the sound entered its deeper parts. 
The interesting feature was that pressure over the left great sciatic 
nerve would produce the pain in the left testicle, but handling the 
latter did not cause pain in the leg. 
This patient has now been intermittently under my observa- 
tion for nearly three years. All that I can claim as the result of 
treatment is that the pain has been modified, is no longer felt in 
his thigh, and does not interfere with his general well-being. I 
doubt if anything short of marriage will permanently relieve him. 
He has had the benefit of varied counsel, but the measure which 
has done him the most good has been the systematic, persistent use 
of the steel sound. In regard to the latter, it may be as well to 
state that a haphazard, interrupted use did him no good. To be 
more minute, we together observed that if the sound was passed, 
and then an interval of a week or two was caused by a journey 
or by the exigencies of business, that he always had more pain. 
To use his own language, " The first use of the instrument seems 
to stir me up." He refused to have it done unless he was sure 
that he could return in three or four days, It was necessary to 
pass the sound at intervals of three or four days for two or three 
weeks at a time. Then relief would be had, and he would disap- 
pear for a time. 
127 East Thirty-fourth Street, New York.