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IMPOTENCE
1046 interest and knowledge at a high level." Thirdly, there is the continuing problem of handicapped children. The report makes it clear that the accommodation for epileptics, which has altered little for fifty years, needs to be extended; likewise the spastic child and the partially sighted receive close attention. Besides much else that is of interest and importance, the report discusses physical education, the school dental service, and hospital schools. It emphasises the value of good records of the child’s health at school. LAMBL’S EXCRESCENCES ON THE MITRAL VALVE ABNORMAL projections from the smooth surface of the cardiac valves are amongst the commonest manifestations of rheumatic or bacterial endocarditis. Attention was first drawn to similar lesions of less serious significance by Lambl,l who described small filiform processes on the ventricular surface of the aortic cusps. For many years these curious fibrous tags were thought to occur almost exclusively on the aortic valve, but in 1928 Grant, Wood, and Jones2 reported their presence on the mitral valve in 70% of 40 normal hearts. Magarey,3 who has lately published a detailed study of the so-called Lambl’s excrescences of the mitral valve, finds them remarkably common-they were present in 85% of 250 valves examined. The incidence rose from 0% in 22 cases under one year of age, to 100% in 75 cases over the age of 60. They may be single but usually are multiple, often exceeding twenty per valve. They vary in length up to 5-10 mm., and are filiform in shape but sometimes have a bulbous free extremity. Histo-
consist of a core of moderately cellular connective tissue covered by a single layer of endothelium. They are non-vascular but often contain deeply staining elastic fibres, which may be coiled in bizarre fashion. The pathogenesis of these processes, according to Magarey, is by organisation of fibrin deposits. Such deposits were observed by him in7% of the valves studied, and in several cases partial organisation had already taken place. Since the fibrin is usually deposited in plaque-like fashion, the formation of a filiform process would result from its partial detachment before organisaHe tion. Günzel4 offers an alternative explanation. that the constant and of the flexing extending suggests valve cusps lead to a surface-fraying of the subendothelial connective tissue. Three observations by Magarey tend to support Gunzel’s view. Firstly, the absence of blood-vessels from the excrescences does not support an origin from organised fibrin. Secondly, elastic fibres are usually absent from organised fibrin-as for example, in the fibrous adhesions resulting from fibrinous pericarditis. On the other hand, a well-defined zone of elastic tissue is present in the subendothelium on the auricular surface of the mitral valve and would readily account for the presence of elastic fibres in tags arising
logically they
Thirdly, the only easy explanation of the shapes assumed by the elastic fibres in the excrescences is that they result from sudden rupture of these fibres, such as would be expected through fraying by fraying.
bizarre coiled
from the surface. Whilst some filiform excrescences may arise by organisation of fibrin deposits, in most cases mechanical disruption would appear to be responsible ; and their more frequent presence on thickened, and presumably less flexible, cusps supports this view. Moreover, the quite common association of these bodies with fibrin deposits upon the affected valve-cusps may well be a result, rather than a cause, of their presence, since any unevenness of the endothelial lining of the vessels is known to predispose to fibrin and platelet deposition. The organisation of such deposits will lead to thickening of the valve with gradual submersion of the filiform processes, as was observed by Magarey 1. 2. 3. 4.
Lambl, D. F. Wien. med. Wschr. 1856, 6, 244. Grant, R. T., Wood, J. E. jun., Jones, T. D. Heart, 1928, 14, 247. Magarey, F. R. J. Path. Bact. 1949, 61, 203. Günzel, W. Beitr. path. Anat. 1933, 91, 305.
in several of his cases. The gradual thickening of the valves commonly associated with increasing age may therefore be due to a combination of wear-and-tear fraying with the organisation of fibrin, whose deposition is thus favoured. Changes of the same order take place in the arterial system, if, as Professor Duguid5 has suggested, the intimal thickening of atherosclerosis is traceable to thrombosis. IMPOTENCE PROBABLY less than 10% of cases of impotence are due to organic causes ; but these causes are nevertheless very numerous, as Dr. S. Leonard Simpson was able to show in opening a discussion by the Medical Society of London last Monday. One of the causes that is apt to be forgotten is diabetes, possibly because-as Dr. Simpson observed-diabetics seldom volunteer this symptom. In these patients, said Dr. W. G. Oakley, impotence may arise in two ways : first, when they come under treatment, and as soon as the diabetic state is stabilised the impotence disappears ; and secondly during the course of the disease even when stabilisation is complete. In the latter group libido is not lost, testicular biopsies are normal, and the sperms also are normal though the count may be slightly reduced ; yet the symptom proves intractable to treatment. The cause, Dr. Oakley thinks, may possibly be a neurovascular defect, or else endarteritis in the vessels concerned in erection (and Mr. S. M. Cohen later showed that peripheral vascular disease is an important cause of impotence) ; but Dr. Simpson believes that sometimes the origin may be functional. As to the undoubtedly functional cases, Dr. E. B. Strauss claimed that the commonest cause is anxiety, conscious or unconscious, primary or secondary. Dr. Strauss emphasised that sexual vigour is largely geneti" virile " physique is not cally determined ; and a necessarily accompanied by great sexual vigour. What he terms " psychosexual impotence " may arise in a number of different ways : (1) as honeymoon impotence, which derives from ignorance, nervousness, and weariness, and may persist through memory of initial ineptitude ; (2) from masturbation anxiety, where the man is the subject of symbolic castration ; (3) from as a sadomasochistic such perverse components impulse or homosexuality ; (4) from unresolved incestuousattachments (" not a Freudian whimsy ") ; (5) from unconscious fear of aggression ; (6) through psychosexual " immaturity (where the wife is commonly a nice woman who is loved and respected, and only a fast " woman is thought to have any interest in sexuality) ; (7) as relative impotence, where the man is unable to achieve coitus with one particular woman, usually his wife; (8) as " soldier’s impotence," where a brief courtship and honeymoon are followed by protracted separation in which the man may build up a fantasy picture of his wife, or come to prefer sociality to sexuality, or become sexually promiscuous and then prove impotent when tenderness is demanded ; (9) in association with a depressive syndrome ; (10) as an inability to ejaculate (usually associated with a narcissistic temperament ; (11) owing to fatigue ; and (12) owing to boredom, through rigid regard This list was supplemented by Dr. for convention. Henry Wilson, who suggested that sexual impotence is commonly one manifestation of a sense of general impotence in every field. The meeting touched little on the question of treatment_ This, according to Dr. Strauss, may be very easy or very difficult ; and he conceded that there is substance to the argument of Dr. A. P. Cawadias that a holistic and humanistic approach may prove as profitable as the Mr. Kenneth Walker urged that before analytical. treatment is started the wife should be seen. Often she and sometimes she is can throw light on the cause ; the cause. "
"
’’
"
5.
Duguid, J.
B.
Lancet, Nov. 19, p. 925.
consist of a core of moderately cellular connective tissue covered by a single layer of endothelium. They are non-vascular but often contain deeply staining elastic fibres, which may be coiled in bizarre fashion. The pathogenesis of these processes, according to Magarey, is by organisation of fibrin deposits. Such deposits were observed by him in7% of the valves studied, and in several cases partial organisation had already taken place. Since the fibrin is usually deposited in plaque-like fashion, the formation of a filiform process would result from its partial detachment before organisaHe tion. Günzel4 offers an alternative explanation. that the constant and of the flexing extending suggests valve cusps lead to a surface-fraying of the subendothelial connective tissue. Three observations by Magarey tend to support Gunzel’s view. Firstly, the absence of blood-vessels from the excrescences does not support an origin from organised fibrin. Secondly, elastic fibres are usually absent from organised fibrin-as for example, in the fibrous adhesions resulting from fibrinous pericarditis. On the other hand, a well-defined zone of elastic tissue is present in the subendothelium on the auricular surface of the mitral valve and would readily account for the presence of elastic fibres in tags arising
logically they
Thirdly, the only easy explanation of the shapes assumed by the elastic fibres in the excrescences is that they result from sudden rupture of these fibres, such as would be expected through fraying by fraying.
bizarre coiled
from the surface. Whilst some filiform excrescences may arise by organisation of fibrin deposits, in most cases mechanical disruption would appear to be responsible ; and their more frequent presence on thickened, and presumably less flexible, cusps supports this view. Moreover, the quite common association of these bodies with fibrin deposits upon the affected valve-cusps may well be a result, rather than a cause, of their presence, since any unevenness of the endothelial lining of the vessels is known to predispose to fibrin and platelet deposition. The organisation of such deposits will lead to thickening of the valve with gradual submersion of the filiform processes, as was observed by Magarey 1. 2. 3. 4.
Lambl, D. F. Wien. med. Wschr. 1856, 6, 244. Grant, R. T., Wood, J. E. jun., Jones, T. D. Heart, 1928, 14, 247. Magarey, F. R. J. Path. Bact. 1949, 61, 203. Günzel, W. Beitr. path. Anat. 1933, 91, 305.
in several of his cases. The gradual thickening of the valves commonly associated with increasing age may therefore be due to a combination of wear-and-tear fraying with the organisation of fibrin, whose deposition is thus favoured. Changes of the same order take place in the arterial system, if, as Professor Duguid5 has suggested, the intimal thickening of atherosclerosis is traceable to thrombosis. IMPOTENCE PROBABLY less than 10% of cases of impotence are due to organic causes ; but these causes are nevertheless very numerous, as Dr. S. Leonard Simpson was able to show in opening a discussion by the Medical Society of London last Monday. One of the causes that is apt to be forgotten is diabetes, possibly because-as Dr. Simpson observed-diabetics seldom volunteer this symptom. In these patients, said Dr. W. G. Oakley, impotence may arise in two ways : first, when they come under treatment, and as soon as the diabetic state is stabilised the impotence disappears ; and secondly during the course of the disease even when stabilisation is complete. In the latter group libido is not lost, testicular biopsies are normal, and the sperms also are normal though the count may be slightly reduced ; yet the symptom proves intractable to treatment. The cause, Dr. Oakley thinks, may possibly be a neurovascular defect, or else endarteritis in the vessels concerned in erection (and Mr. S. M. Cohen later showed that peripheral vascular disease is an important cause of impotence) ; but Dr. Simpson believes that sometimes the origin may be functional. As to the undoubtedly functional cases, Dr. E. B. Strauss claimed that the commonest cause is anxiety, conscious or unconscious, primary or secondary. Dr. Strauss emphasised that sexual vigour is largely geneti" virile " physique is not cally determined ; and a necessarily accompanied by great sexual vigour. What he terms " psychosexual impotence " may arise in a number of different ways : (1) as honeymoon impotence, which derives from ignorance, nervousness, and weariness, and may persist through memory of initial ineptitude ; (2) from masturbation anxiety, where the man is the subject of symbolic castration ; (3) from as a sadomasochistic such perverse components impulse or homosexuality ; (4) from unresolved incestuousattachments (" not a Freudian whimsy ") ; (5) from unconscious fear of aggression ; (6) through psychosexual " immaturity (where the wife is commonly a nice woman who is loved and respected, and only a fast " woman is thought to have any interest in sexuality) ; (7) as relative impotence, where the man is unable to achieve coitus with one particular woman, usually his wife; (8) as " soldier’s impotence," where a brief courtship and honeymoon are followed by protracted separation in which the man may build up a fantasy picture of his wife, or come to prefer sociality to sexuality, or become sexually promiscuous and then prove impotent when tenderness is demanded ; (9) in association with a depressive syndrome ; (10) as an inability to ejaculate (usually associated with a narcissistic temperament ; (11) owing to fatigue ; and (12) owing to boredom, through rigid regard This list was supplemented by Dr. for convention. Henry Wilson, who suggested that sexual impotence is commonly one manifestation of a sense of general impotence in every field. The meeting touched little on the question of treatment_ This, according to Dr. Strauss, may be very easy or very difficult ; and he conceded that there is substance to the argument of Dr. A. P. Cawadias that a holistic and humanistic approach may prove as profitable as the Mr. Kenneth Walker urged that before analytical. treatment is started the wife should be seen. Often she and sometimes she is can throw light on the cause ; the cause. "
"
’’
"
5.
Duguid, J.
B.
Lancet, Nov. 19, p. 925.