From these visible and apparently easily understood conditions and results we are now to enter a broad field, wherein the prepuce seems to exercise a malign influence in the most distant and apparently unconnected manner; where, like some of the evil genii or sprites in the Arabian tales, it can reach from afar the object of its malignity, striking him down unawares in the most unaccountable manner; making him a victim to all manner of ills, sufferings, and tribulations; unfitting him for marriage or the cares of business; making him miserable and an object of continual scolding and punishment in childhood, through its worriments and nocturnal enuresis; later on, beginning to affect him with all kinds of physical distortions and ailments, nocturnal pollutions, and other conditions calculated to weaken him physically, mentally, and morally; to land him, perchance, in the jail, or even in a lunatic asylum. Man's whole life is subject to the capricious dispensations and whims of this Job's-comforts-dispensing enemy of man.

As strange as it may seem, this field of knowledge, this field of misery and suffering, disease and distortion, of physical and mental obliquity, presided over by this preputial Afrit of malignant disposition, was an unknown, undiscovered, and therefore unexplored region for some thousands of years, and it remained for an American to discover and describe this vast territorial acquisition, and to annex it to the domain of medicine, which, through its skill, could modify the influence of the evil genius that there presided and spare humanity much of the ills to which it had been subjected.

In this regard, Louis A. Sayre was to medicine what Columbus was to geography. Neither Strabo nor Herodotus had anything to say regarding what existed beyond the pillars of Hercules, and neither Hippocrates nor Galen had anything in regard to this preputial Merlin, which in their day, even, had its existence. Neither did Tissot nor Bienville, the two pioneers in the field of our knowledge regarding onanism and nymphomania, dream of the existence of this one cause of the diseases to which they gave so much time and study. It is only some twenty years since Louis A. Sayre read his paper, entitled "Partial Paralysis from Reflex Irritation Caused by Congenital Phimosis and Adherent Prepuce," before the American Medical Association. This was the starting-point from whence the profession entered into what had previously been a veritable "Darkest Africa."

When we read that only some fifty years before the times of Columbus Christian Europe had no lunatic asylum,—not that there was a lack of lunatics or that the existence of lunacy was entirely ignored, but that the then state of medicine and the general intelligence was not emancipated from the idea of demoniacs,—and we are told that the lunatics were in many instances hung, quartered and burned, hooted and chased about the streets, or chained in gloomy dungeons; until, as related by Lecky, a Spanish monk named Juan Gilaberto Joffe, filled with compassion at the sight of the maniacs who were hooted by crowds through the streets of Valencia, founded an asylum in that city. His movement in this direction called the attention of the Church and people to this class in a practical light, and from Spain a more enlightened idea in regard to this class swept onward throughout Europe. As observed, it seems strange to us of the present day that such ignorance in these matters should, or could, have so long existed. It seems impossible for us to conceive how these conditions of incoherent action and of mental derangements could have existed and their causes have not been fully appreciated; and yet we were not above, some twenty years ago only, subjecting children to punishment and scoldings for being addicted to nocturnal enuresis, or of accusing cases of nocturnal and involuntary emissions as being due to masturbation. The child was allowed then to grow up paralytic, or with a deformed limb, or continually punished to correct what was imagined to be a condition of willful carelessness, irritability, or willful moral perversion. Perversion, stupidity, and irritability of the mind or temper were not known to depend, in many instances, on preputial irritation; children were, accordingly, worried and punished for something over which they had no earthly control or the least volition. Humanity cannot, at present, sufficiently appreciate what Louis A. Sayre has done in its behalf. It is here that we realize the hidden wisdom of the Mosaic law and the truth of the assertion of the late Dr. Edward Clarke, that, "The instructors, the houses and schools of our country's daughters, would profit by reading the old Levitical law. The race has not yet outgrown the physiology of Moses."

These irritations from the preputial irritability are not always so slow moving as to span over either months or years in their fell work. Instances of their sudden action have been sufficiently recorded as to warrant them as being classed as causative agents in acute affections that instantly threaten life. In the London Lancet of May 16, 1846, there is a record of a very peculiar case reported to the London Medical Society by Dr. Golding Bird: "The case was that of a child seven or eight weeks old only, an out-patient of Guy's Hospital. The child had become almost lifeless immediately after nursing, and to all appearances looked as if under the influence of some narcotic. It had not, however, had anything of the kind given to it, nor had it sustained a fall, nor was the head so large as to lead to suspicion of congenital hydrocephalus. On inquiring if the child passed water, the answer led to an examination of the prepuce, which was found to be elongated, and had an aperture only of the size of a pin-hole, like a puncture in the intestines. The urine was dribbling out; it was evident that the child had never completely emptied its bladder. Mr. Hilton slit up the prepuce, and all the symptoms were immediately relieved and soon entirely removed." Dr. Bird referred to a case which he had related to the Society some years before, which was reported in the Lancet at the time, of a child who fell a victim to a malformation of this kind, and after death the bladder and ureter were found like those of a man who had long suffered from stricture. Mr. Hilton has seen many cases similar to the one mentioned by Dr. Bird. The greatest benefit resulted from slitting up the prepuce. In this case the benefit was very remarkable, a partial paralysis of the left side, under which the little patient labored, being quite removed in twenty-four hours.

In this case the difficulty was evidently both the result of mechanical pressure and reflex irritation. A somewhat similar case as to its results is given by Dr. Sayre, to whom the case was reported by Dr. A. R. Mott, Jr., of Randall's Island, in January of 1880: "John English, aged 46, native of England, widower, clerk; admitted to workhouse hospital. Patient had been at work for a week as a prisoner; on the 23d of December was noticed to be restless and uneasy, and finally, in the evening, he fell from his bunk in a fit. During the next forty-eight hours he had several convulsions, and during the intervals lay in a semi-comatose condition, showing no consciousness except to stir a limb when pinched. Pulse, 120; temperature, 1011/2 deg.; respiration, 18. Swallowed nothing, and passed faeces in bed. Continued in this condition until December 25th (temperature having fallen to 100 deg.), when a string was discovered passed twice around the penis behind corona and tied, the long prepuce serving to conceal it from observation. While not sufficiently tight to occlude the urethral canal, still a firm, indurated band remained after the string was cut, and did not disappear for four or five days.

"Within one hour after the removal of the string the man sat up and asked for milk, and from this time remained perfectly well (was under observation for three months). He declared that he remembered nothing that had taken place during the past three days; had never had fits, denied venereal diseases, was moderately addicted to drink, but had led a 'virtuous life since the death of his wife, two years before.'"

The following case in the practice of Dr. F. J. Wirthington, of Livermore, Pa., was also reported to Dr. Sayre: "When the child was born, he was considered the biggest and finest boy that had been born in the community for a long time, until, when he was about two and a-half years old, and being sick, a doctor was called in, who told them that their child was paralyzed, the paralysis being in his lower extremities, and who treated him with the usual nerve-tonic and with electricity. Notwithstanding all this, the boy went steadily down, and the paralysis continued until he was seen by Dr. Wirthington. The child was then unable to walk; on examination, the prepuce was found to be adherent almost all the way around the glans penis. Behind the corona was a solid cake of sebaceous matter. The case was promptly operated upon, and, although the previous attendant had not found any cause to account for the paralysis, a rapid recovery took place, the boy being able to walk even before the complete cicatrization of the wound, and was soon the picture of health."

Dr. T. F. Leech, of Attica, Fountain County, Ind., reports a case of a fourteen-month-old child, who had been the terror of all that part of the town for over six months, as he cried constantly. Except when asleep or nursed by his mother, he would lie perfectly still and squall, not showing any disposition to sit up; nor did he like to be raised up. He was very nervous, and would have times when his limbs would be rigid. This state of things grew worse, until the child was accidentally seen by Dr. Leech, who, on examination, found a contracted and adherent prepuce, the child being at the time in a high fever and suffering great nervous excitement. An operation by slitting and breaking up the adhesion afforded immediate relief; the spinal irritation, partial paralysis of the lower extremities, spasms during urination, and all trouble disappeared as if by magic.

Prof. J. H. Pooley, of Columbus, Ohio, reported the case of a fine, healthy boy who, up to three months before being seen professionally, had always been well and in perfect health. His condition was found by Professor Pooley to be one of localized chorea, manifesting itself in constant convulsive movements of the head. They were nodding or antero-posterior movements, alternating with lateral or shaking and twisting motions; these movements had become almost constant during the waking hours of the child. There was no distortion of the features nor any choreic movements of the extremities; indeed, the whole affection consisted in the nodding and shaking movements of the head referred to. These were almost incessant, sometimes slow and almost rhythmical, then for a minute or two rapid and irregular, seeming to fatigue the little fellow, and accompanied by a fretful, whimpering cry. The child had been subjected to a variety of treatment, but without any benefit or effect of any kind. Upon the most careful examination of the patient and his history, Professor Pooley could not discover anything that seemed to throw any light upon the case, except a condition of well-marked phimosis. Acting upon this, the Professor immediately circumcised the child, and from the very day of the operation the spasmodic action began to diminish, and in two weeks he was entirely well, without any other treatment of any kind.

Dr. W. R. McMahon, of Huntington, Indiana, has reported three cases of epilepsy in children caused by congenital phimosis that were entirely relieved by an operation without any subsequent return of the difficulty. One of the cases was in a boy ten years old, with very firm preputial adhesions and a high grade of inflammation of the parts.

Dr. J. D. Griffith, of Kansas City, Mo., operated on a case of phimosis on a child nearly three years of age, who was afflicted with repeated attacks of convulsions and paralysis of the hips and lower extremities; the little fellow had as many as fifteen convulsions in a day; the patient was greatly troubled with painful urination and priapism. On examination at the operation, a firmly adherent prepuce and a large roll of caseous matter was found just back of the corona. A complete recovery followed the removal of these conditions.

The above cases are taken from the paper read before the Section of Diseases of Children at the International Medical Congress of 1887, by Dr. Sayre. It contains a number of additional cases of an analogous character to the above, reported to him by physicians in different parts of the country. They show the variety, extent, and far-reaching character of the diseases induced by any preputial irritation. Dr. G. L. Magruder, of Washington, D. C., in the same paper, has a record of twenty-five cases of various nervous disturbances which he had entirely relieved by circumcision or dilatation, without any medication whatever. Dr. Magruder, in concluding his report, in which he quotes the authority of Brown-Sequard, Charcot, and Leyden, as having noticed serious nervous disturbances resulting from reflex irritation due to affections of the genito-urinary organs, observes as follows:—

"From the foregoing, I think that we are justified in the conclusion that phimosis and adherent prepuce give rise to varied troubles of more or less gravity, manifesting themselves either in the muscular, osseous, or nervous systems; and that the removal of these abnormal conditions of the penis frequently affords marked relief, and, at times, perfect and permanent cure."

In the discussion that followed the reading of Dr. Sayre's paper, Dr. De Forest Willard, of Philadelphia, remarked that he had operated by simply stripping back the prepuce and that he did not circumcise, but that he looked upon the subsequent cleanliness of the parts as the greatest safeguard, not only as against reflex irritation, but also against masturbation. Retained filth and smegma are far more likely to call a boy's attention to his penis by their unrecognized irritative effects than washing can possibly do. His practice is in accordance with the belief that young children can be relieved by the simpler methods, such as dilatation; but he also observes that when a child has reached eight or ten years of age, and has never been able to expose the glans, contraction is almost certain to be present, and circumcision must be performed. In adults there is rarely any escape when the prepuce is tight.

Dr. I. N. Love, of St. Louis, said: "It has been my judgment and my practice for many years, in these reflex irritations, to pursue the radical course of circumcision. I believe thoroughly in the Mosaic law, not only from a moral but also from a sanitary stand-point. All genital irritation should be thoroughly removed. It is all very well to instruct the mother or the nurse to keep the parts within the prepuce clean, but they can not or will not do it. Complete and proper removal of the covering to the glans takes away all the cause of disturbance. Dr. Sayre takes a more pronounced position on this subject than the majority of those who have discussed his paper. An improper performance of a surgical procedure is no argument against the operation, but rather against the operator. For the reasons I have given, I am in favor of the radical application of the Mosaic rite of circumcision."

Dr. J. Lewis Smith, the president of the Section, believed in the evil results of the reflex irritation due to abnormality of the prepuce. In many instances the causative relation of the preputial disease to the symptoms which it produces is not so apparent as it may be in others, but after correct treatment of the prepuce they disappear. There was one result of phimosis which, he observed, neither Professor Sayre nor those who contributed to his paper noticed. The expulsive efforts accompanying urination sometimes cause prolapsus of the rectum, and frequently produce inguinal hernia. In a lecture before the Harveian Society (British Medical Journal, February 28, 1880), Edmund Owen, Surgeon to St. Mary's Hospital and to the Hospital for Sick Children, says: "Perhaps the commonest cause of hernia in childhood is a small preputial or urethral orifice, and next to that I would put the smegma-hiding or adherent prepuce." Arthur Kemp (London Lancet, July 27, 1878), Senior House-Surgeon to the Children's Hospital, says: "Phimosis is a common occurrence, and numerous ill effects can undoubtedly be attributed to it;" and he alludes to the observation of Mr. Bryant, as published in his book on the "Surgical Diseases of Children": "In fifty consecutive cases of congenital phimosis, thirty-one had hernia, five had double inguinal hernia, and many had umbilical hernia besides. In no one was the hernia congenital, its earliest occurrence being at three weeks. Circumcision was performed in these cases, and all were much benefited."[103]

During the session of the Ninth International Congress, where the above paper was read and remarks made, which appear in the third volume of its "Transactions," another paper was also presented by Dr. Saint-Germain, of Paris. The Doctor fully recognized the dangers from a narrow or adherent prepuce, but did not think that more than one case in three hundred really required circumcision; he believed in dilatation, as employed by Nelaton, with the exception that, whereas Nelaton employs three branches to his dilator, Saint-Germain preferred only a two-branch dilator.

Dr. Lewis, the president of the Section, related a number of cases where the use of uncleanly instruments had resulted disastrously. But, for that matter, the same objection can be offered against dilatation, as a filthy instrument is as liable to infect the patient as a knife. There is no earthly excuse why a knife that has been used on a case of diphtheritic croup should be used some hours afterward to circumcise a child. As to the operation of dilatation practiced by Dr. Holgate, it can really be said to answer the immediate demands, but how far its utility is efficient as to permanent results Dr. Holgate has not given the profession any information.[104]

One of the most interesting and instructive papers that it was ever the fortune of the writer to listen to, touching on the subject of reflex nervous diseases or neuroses due to preputial adhesions, was one prepared by Dr. M. F. Price, of Colton, California, and read at the semi-annual meeting of the Southern California Medical Society, at its Pasadena meeting in December, 1889. In the course of the paper he gives a considerable number of examples, of which some extracts are herewith given: One case was a boy aged seven, who for two years had had frequent attacks of palpitation of the heart; when seen by Dr. Price the little heart was laboring hard, beating at a furious rate (far beyond counting), with a loud blowing or splashing sound, and the pulse at the wrist a mere flutter. The breath was inspired in a series of jerks, the face flushed and somewhat swollen. The chest-wall was visibly moved at every thump of the heart. The doctor attended the child for a month without the little patient making any appreciable improvement. Some time during this period of observation the father happened to mention that the boy sometimes complained of his penis hurting him at the time of an erection. This led the doctor to examine the parts, when he found a long prepuce, with a mucous membrane adherent to the glans, about a line beyond the corona, the whole circumference of the organ. With the use of cocaine and a blunt instrument the adhesions were removed, with an immediate amelioration of all the reflex symptoms. The very next paroxysm was lighter and less exhausting; the improvement was continuous. The child soon went to school and had no further trouble; but, in the doctor's opinion, the two years' hard struggle have not been without its evil results on the constitution and organism of the child.

The next case was born November 2, 1888; a large, healthy boy at birth. By June of the following year the child was afflicted with what the mother called "jerky spells;" up to this time the boy seemed listless, did not care to sit up, and seemed from some cause to be in more or less pain, with his eyes turned to the left. The parents dreaded that the child, their only one, would turn out idiotic. The spasmodic spells alluded to were of a tetanic nature, the body being thrown backward; his head and eyes continued to be turned to the left, and nothing could attract the child's attention. The boy cried night and day, but he was in good flesh, had all the teeth he should have, bowels were regular, and the appetite good. Whatever the doctor did in the medical way seemed to be of no avail. One day, however, he thought of examining the prepuce, thinking, perhaps, that it might be contracted and that the convulsive movements might be reflexes from the parts. On examination the prepuce was found elongated and distended, with a very minute opening; this was dilated with difficulty, when the inner fold was found adhering almost the whole extent of the glans; the dilatation and breaking down of these adhesions was slowly persevered in, until sufficient dilatation was obtained and the glans was freed. From the very first operation the convulsions commenced to diminish, both in force and frequency, and a constant and rapid improvement of the child took place. Six months afterward the boy was perfectly normal, stood by himself, played with play-things, and was an interested member of the family circle.

Case No. 3 was a repetition of Case No. 2, except that, with the experience of the latter case, the doctor wasted no time with medication, but proceeded at once to examine the prepuce, which was found to be very long, and with a pin-hole opening. The dilatation of this and the breaking up of the adhesions gave immediate relief. During the course of the paper he quoted the case related by Brown-Sequard, and recorded in the New York Medical Record, vol. xxxiv, p. 314, where he "related a very interesting case that presented all the rational signs of advanced cerebral disease, a case that he considered quite hopeless, that was relieved by an operation for phimosis and the treatment of an inflammatory condition of the glans penis." To use Brown-Sequard's own words, "So rapid was the recovery that within six weeks from the day of the operation he presented himself at my office perfectly well in every respect."

In the early part of this book, in speaking of female circumcision, it was mentioned that when the medical part of the volume should be reached some medical reasons for its necessity would be given. Dr. Price, in his paper, gives some information on this subject, which is of the greatest interest. In the course of the paper he says as follows: "Nor do I think these reflex neuroses from adherent prepuce wholly confined to the male sex. The preputium-clitoridis may be adherent and produce in the female similar reflexes. During the session of the American Medical Association, held in Chicago in 1874, I think, I attended one afternoon a clinical lecture by Dr. Sayre. A little girl, fourteen years of age, but about the size of a seven-year-old child, was brought in, who had never walked nor spoken, but with quite an intelligent countenance, who was in constant motion, and who presented very many nervous symptoms. Dr. Sayre examined her, and found the prepuce adherent the whole extent of the clitoris. He gave it as his opinion that here was the primary and sole cause of the symptoms, and that appropriate treatment shortly after birth would have prevented all the serious consequences so painfully apparent, and which was then too late to remedy.

"I once had occasion to pass a catheter into the bladder of a lady who presented an innumerable train of nervous symptoms, often bordering on insanity, but was unable to do so without exposing the parts. Although the meatus could be distinctly felt, the catheter would not enter. On exposure to view, an opening was seen in the clitoris, which was firmly bound down by preputial adhesions near the extremity of the organ. Entering the catheter at this point, it readily passed through the clitoris, then down through a passage under the mucous membrane to the natural site of the meatus, on into the urethra, and through into the bladder. In the light of recent experience, my opinion now is, that here was the cause of all the nervous symptoms in this case."

The relative disposition in regard to the irritability of the external sexual organs as existing in the female, when contrasted with the male, is, for some reason, not sufficiently considered or understood. The idea of masturbation or of irritation from the genitals ending in reflex neuroses is always, as a rule, associated with the male, and that it has not been more associated with the female has deprived her of the same benefit that the prosecution of the study in this regard has been to the male sex. Masturbation among the feeble-minded, which is so common, must, of necessity, have for its determining cause a foundation of morbid irritability of the sexual organs. This is well known to be so among the males, whose hands seem instinctively to be drawn to those parts. Dr. C. F. Taylor, of New York, in an article on the "Effect of Imperfect Hygiene of the Sexual Function," published in the American Journal of Obstetrics for January, 1882, gives us an account of his investigations in this regard, with the following results: "In an asylum for the feeble-minded of both sexes, it was found that the habit was about equal in the two sexes, there being only this difference: that the females began to masturbate one or two years earlier than the males, and that the habit, once established, was found to be more persistent than in the males. It was, further, ascertained that the habit came naturally, without the aid of precept or example to either sex."

It may well be a question as to whether the feeble-mindedness be not a reflex condition from this excessive morbid irritability of the sexual organs. There is not much doubt but that, if one of the cases reported by Dr. Price had not been circumcised, the expressionless, listless infant would have grown, in time, into a masturbating, feeble-minded, idiotic creature, as many others, so situated, have done before it. Now, would it have been logical to have laid the morbid irritability of its generative organs to its feeble-mindedness, when its feeble-mindedness was fully demonstrated to have been wholly dependent on the sexual irritation? From these premises we might take another step forward, and ask whether, under a proper hygienic prophylaxis,—which would involve a thorough inspection of the genitals of all children reported to be either physically or mentally deficient,—such a course would not greatly diminish the number of paralytics, feeble-minded, and generally deficient of both sexes? If the results in private practice are any criterion, it is safe to assert that a strict adherence to the Mosaic law for the males and to some of the African customs for the females would most assuredly relieve all these cases that might come under the caption of results of reflex neuroses. Twenty years ago this subject was, to the body of the profession, a terra incognita in regard to the male, and, as the female is similarly subject to the same morbid influence, it is to be hoped that in the present decade she will receive the same attention which the profession is now beginning to pay to the male sex.[105]

In the foregoing parts of this chapter, examples of reflex neuroses have been given to show the different effects that genital irritation will produce. The cases given were chosen for the diversity of variety of symptoms, and as cases representing the affection, without any other complication. Many more could have been added, but they are unnecessary. In the writer's practice there has been a number of cases in the adult that have exemplified that this form of ailment is by no means restricted to children, as has been shown in the case reported by Dr. Mott to Dr. Sayre, in regard to the middle-aged man with a string about his penis. One of these cases was that of a young man, six feet in stature, broad-shouldered, and well built. He applied for relief for a dyspepsia that affected his stomach and also his heart. The man had an apparently feeble and irritable heart; cold, clammy skin; disturbed digestion, and uneasy sleep; was constipated and flatulent. No treatment seemed to make any impression upon his case. At last he began to emaciate and look haggard. His mind was also becoming visibly weaker, was attacked by dizziness, and on several occasions he fell in a fit. With this condition he at last began to have frequent nocturnal emissions. On account of the latter his genital organs were examined, and the penis was found smaller than the average, with a long and narrow prepuce. The glans could easily be uncovered, but the tightness of the prepuce and its unyielding qualities made paraphimosis a possibility; so that the young man, having once or twice had considerable difficulty in returning the prepuce to its place, never attempted its retraction again. There were no adhesions, but the inner fold of the prepuce had been thickened by balanitis. Seeing the need of circumcision for the local benefit, the operation was suggested with a view of relieving the pressure on the glans, which was looked upon as the probable cause, in his broken-down condition, of the advent of the nocturnal emissions. He gladly submitted, and, to the surprise of both physician and patient, all his troubles disappeared, and he at once became a changed man. So impressed was he with the result, that, on his return to his home, he examined his younger brother, and, finding him with a like long, narrow prepuce, he immediately brought him in and had him circumcised, as a prophylactic against his being subjected to the risk of lost health as he himself had suffered.

Another case, a man of forty-five, also a farmer, was afflicted with dyspepsia, palpitation of the heart, general debility, constipation, constant headache, etc. He could not cut up an armful of wood without bringing on palpitations and gaseous eructations, or being upset for the day; and after having connection with his wife he generally had a terrific headache, lasting for two or three days;[106] he could stand no protracted mental effort, even such as is required to make an addition of a long line of figures, or the least business worry, without the supervening headache. All treatment against these conditions was useless; the colon was kept empty, the diet was changed; pepsin and bismuth, tonics, frictions, Turkish baths, and all hygienic observances and moral treatment were all of no avail. One day, on consulting the writer, he complained of a pruritus at the head of the penis. On examination it was found that he had a narrow, long prepuce, a congenitally-contracted meatus, and was then suffering with a slight balanitis. He was very careful to keep the parts clean, but, he informed me, that in spite of all precautions, these attacks would come on. The mucous covering of the inner fold of the prepuce and glans was so irritable that connection often brought it about. The glans was small and elongated, with the meatus red, and with lips oedematous and congested. To free him from this tormenter, circumcision was advised. The party could not, however, remain away from home for the time required for the operation; so that a compromise operation was performed,—one that would not keep him from business, and, at the same time, relieve the contracting pressure on the glans. This was by Clouquet's operation and bandaging back the prepuce over the penis, back of the corona,—an operation that, in my hands, has often filled all the desired purpose. The meatus was also incised. After the operation all of his troubles disappeared, as they had done in the preceding case, and he was soon a hearty and well man, able to chop wood, attend to business, and, in case of need, do family duty for a Turkish harem without recurrence of his old tormenting, dyspeptic palpitation or sick-headache.

The writer has resorted to circumcision in many cases to improve the temper and disposition of children, with the best of results, and in one case, in association with another physician, performed the operation on a lunatic, whose lunacy ran to women and girls, with whom he would fall desperately in love, without any encouragement or provocation, or even acquaintance; finally reaching spells of such incoherence of action and speech that confinement would be required. The peculiarity of his hallucinations called attention to the genital organs. This man had never masturbated, and was, when well, a compactly-built, active, and intelligent man. By occupation he was a contractor, and a man of more than usual executive ability besides. On examination it was found that he was a subject of congenital phimosis, never having been able to uncover the glans. He had been in the habit of washing out the preputial cavity by the aid of a flat-nozzled syringe. The prepuce was long, but not thick; nevertheless, it was inelastic and very firm. The examination seemed to have a good mental effect upon the man, as it made him quite rational for the moment. He entered into the idea that this condition had some connection with his derangement very intelligently, even suggesting many symptoms and attacks that he had suffered from childhood up as probably gradual-stepping processes through which his present condition had been reached. He cheerfully submitted to a thorough circumcision, which had the effect of ameliorating his condition. He was subsequently sent to an asylum, where, after a short time, he was discharged well. Some years afterward, conscious of feeling a return of the mental derangement, he voluntarily applied for admission to the same institution and remained until better.

This case is very instructive. The patient readily connected his mental trouble, by a retrospective view through a series of gradually-increasing troubles, that originated in the preputial condition, to the phimosed condition of that appendage, and he was certain that this prepuce had been at the bottom of all the physical and mental trouble he had experienced. The reflex nervous train of affections had undoubtedly produced some localized lesion in the brain-structure. The natural sound, healthy organism of that organ, and the bright, active nature of his mind, however, prevented a total wreckage of the mental faculties. It is safe to assume that, had he had the ordinary listless, unresisting mind, disposed to brood, and easily cast down, he would, from the first derangement, have become a hopeless and demented lunatic. The circumcision could not undo all the mischief that had been accomplished, some of which had certainly left a permanent taint, but the mildness of his future attacks and the better exercise of his volition were the undoubted results of the operation.



CHAPTER XXIV.

DYSURIA, ENURESIS, AND RETENTION OF URINE.

Any dissertation on circumcision and its many uses, either prophylactic or curative, would be incomplete without a reference to enuresis; another reason for making a somewhat full reference to the subject would be the undecided position that this morbid condition seems to occupy in medical literature, as well as the meagre and unsatisfactory treatment it has received by the majority of those who have mentioned it. It is anomalous, to say the least, to find, in general or special literature, enuresis mentioned as a diseased condition peculiar from babyhood to puberty; to find it fully described and to have it stated that it is a widely-prevalent distemper, affecting both sexes alike; to know that it is an annoying, intractable, persistent condition, wearing to the child in every sense, subjecting it to a demoralizing mortification as well as to unmerited scoldings, humiliations, and punishments, and that its habit, in badly-ventilated quarters, will breed other diseases,[107] as well as that its continued action tends to the development of onanism, with its long and widely-ramifying trains of physical and social ills; and to find works especially devoted to children's diseases silent on the subject. Knowing all these things, and also that Ultzmann, Lallemand, and others who have treated this affection, mention it as a children's disease, it is unaccountable to reason out why most of our text-books and treatises on children's diseases should be so remarkably and unreasonably silent. It certainly cannot be laid to its lacking in study material, as the author of "Quain's Dictionary of Medicine" says: "It is one relative to which much might be written without exhausting the subject, the pathology of which has wide and manifold relations.... There appears to be something analogous between this condition and that which determines in after life the seminal emissions under similar circumstances." Our American works are notably deficient in this regard; although Stewart, of New York, in his "Diseases of Children," published over fifty years ago, devotes a chapter to dysuria and one to retention of urine, treating the subject quite fully, even down to the description of preputial calculi; he, however, failed to notice that the irritation of preputial constriction or adhesions will produce both conditions, and, following many of the authors of the time, as has been done since, he adopted the urino-digestion theory of acid and irritating urine, due to faulty digestion, of Prout and Magendie, who looked to regulating the digestion of the child, or the mother who nursed it, as the only method of cure; the lithic-acid diathesis being, in their opinion, the main thing to be guarded from.

Other works that mention these conditions are equally on the wide sea of speculation, as they all, more or less, look upon the treatment that they advise as indefinite and unsatisfactory, showing an equal want of sound anchorage-grounds for their etiological reasonings. Dillnberger, of Vienna, in his hand-book of children's diseases, mentions enuresis, but has nothing better to offer for its relief than that advised by Bednar, who followed a systematically-timed period of awakening, gradually lengthened out, from the time of putting the child to bed. In addition, he advises internal medication, and, like Ultzmann, he recognizes the possibility of a local cause in little girls, in whom he advises the local application of nitrate of silver. Edward Ellis mentions dysuria, and a long prepuce is noticed among its numerous causes. The works that give the subject the most intelligent treatment (the word "intelligent" is here used advisedly, and is in reference to the results obtained) are those of West, of London, and Henoch, of Berlin. West, in his "Diseases of Children," says: "In the child, however, we sometimes find the symptoms produced by difficulty in making water owing to the length of the prepuce and the extreme narrowness of its orifice, which may even be scarcely large enough to admit the head of a pin. This congenital phimosis is, I may add, not an infrequent occasion of incontinence of urine in children, and is also an exciting cause of the habit of masturbation, owing to the discomfort and irritation which it constantly keeps up. In every case, therefore, where any difficulty attends the passing or the retention of the urine, or where the practice of masturbation is suspected, the penis ought to be examined, and circumcision performed if the preputial opening is too small. This little operation, too, ought never to be delayed, since, if put off, adhesions are very likely to form between the glans and the foreskin, which render the necessary surgical proceeding less easy and more severe."

In the "Lectures on Diseases of Children," Henoch, of Berlin, says: "I need scarcely add that an examination of the external genitals should never be omitted in any case of dysuria during childhood. You will not infrequently discover a phimosis which interferes more or less with the discharge of urine and retains portions of the latter behind the foreskin, where it may decompose and give rise to an inflammatory condition of the prepuce, with painful dysuria.... This is also true of the occasional adhesion of the labia minora in little girls, like the similar adhesion of the foreskin in boys. It is almost constant in the first period of life, but sometimes persists to the end of the first year; can usually be torn by the handle of the scalpel, and rarely requires an incision. In a few cases this adhesion appeared to me to be the cause of the dysuria, which disappeared after the separation of the labia from one another."

Henoch, however, does not seem to have grasped the full relation that the natural phimosis of young children bears to dysuria, as he here follows the prevailing opinion, that where by dint, push, hauling, and hard work the prepuce can be pushed back phimosis does not exist, as well as the general apathy to the fact that a prepuce can exert a very injurious influence by its pressure, even when not adherent and very retractable; such a prepuce is often attended by balanitis and posthitis, with an accompanying difficult, frequent, and painful urination. In a case which will be related farther on, in the discussion of the systemic effects of a long, contracted prepuce, as it induces diseased action by continuity of tissues, there is an account of a death of a two-year-old child which we can assume to have had its original starting-point in a condition of phimosis. Henoch, however, rather attributes the death in that case to what may well be considered the result of a cause, leaving the original cause more to appear as a final accessory condition.

My reasons for this view of the subject are simply owing to the fact that I do not believe that a child can long be afflicted with the ischuria phimosica of Sauvages without having the urinary organs beyond more or less seriously affected from the mere retention alone, irrespective of any reflex irritation from the pressure on the glans or of any from the irritation of the peripheral nerves; the dilatation of the adjacent cavities or channels and the deposit of calcareous matter being facilitated by the retention of urine and its naturally altered condition owing to that retention. So that dysuria in young children, beginning in a slightly phimosed condition, or in the irritability of the glans and meatus, due to its preputial covering, it is safe to assume, may produce a train of symptoms ending in permanently-injured health, or even death. The irritating urine of a slight access of fever may, by its passage over the irritable mucous lining of the prepuce, be the initial starting-point of a serious or fatally-ending disease. In all of these, it must be admitted, the presence of the prepuce is either actively or passively the cause of the most serious disease processes that may follow.

Ultzmann, of Vienna, in his work on the "Neuroses of the Genito-Urinary Organs," gives the subject of enuresis considerable attention. It is not a work on diseases of children, but it, nevertheless, goes into the subject as if it were, and furnishes the profession with considerable information. He defines enuresis to be the passage of urine of a normal quality in a child who, with the exception of this involuntary urination, is healthy. In the first periods of life, a slight vesical or intestinal expulsive effort is sufficient to overcome the guarding sphincter muscles at their outlet; the child first obtains a voluntary control of the rectal sphincter; and, generally, with the second year it gains control of the vesical. Those who pass their second year without obtaining this control, but in whom the organs and urine are normal, may be said to be afflicted with enuresis. He divides enuresis into three varieties; that involuntary urination which takes place at night during sleep he terms the nocturnal; that which takes place while climbing, laughing, coughing, or in the course of any violent muscular exercise is the diurnal; and that wherein the involuntary evacuation takes place day and night alike he terms as the continued. This last is again subdivided into the continuous and periodical. As a cause, he cites anaemia, scrofula, rachitis; but adds that physical debility is not necessary for its presence, as well-developed, vigorous, puffy children are as liable to be affected as thin and scrawny ones; while not all scrofulous or rachitic children are so affected, only a small portion being enuretic. Sex has no influence on the liability that tends to being attacked, the proportion between the sexes being about equal. As to age, he finds the greatest proportion to be between three and ten years, but he has often treated those of either sex even at the age of fourteen and up to seventeen years. It is absolutely necessary to examine the external genitals and the urine of those affected by this disease, as phlegmasiae of the vagina, of the vestibule or urethra in girls, or the practice of onanism, or lithiasis, cystitis, or pyelitis may be the cause of the disease. Girls are apt to be found affected with polypoid excrescences at the meatus, which when removed will cause the enuresis to disappear.

From the above it will be observed that Ultzmann has paid much attention to these neuroses; but it will also be remarked that neither the balanitis, collection of infantile smegma, preputial adhesions nor irritations are taken into any account as possible factors of either dysuria or enuresis; he has followed more or less an electrical form of treatment for genito-urinary neuroses, the rectal rheophore being one of his favorite modes of treating enuresis; in his etiological views of these disturbances he has adhered more or less to the views of Trousseau, Bretonneau, and Dessault, who looked upon a debilitated or anomalous condition of the vesical neck as the cause of the majority of neuroses in that region.

It may be asked why these celebrated and observing physicians have neglected the preputial condition, if, as it is claimed, it is, in itself, so important and sure a factor of the derangements at the vesical neck? To answer this, or to explain any marked discrepancy that may occur in medicine between minds equally as acute and observing, it is but necessary to observe that there is, in medicine, to a certain extent, a like rule of inheritance, education, with fashion or custom of habit of thought and practice, as we find in religion. Canon Kingsley and Froude are equally as acute and discerning as the late Cardinal Newman, but that did not necessitate their following that prelate into the foremost ranks of the Catholic Church; and Pere Hyacynthe was equally as intelligent as Cardinal Newman, but that did not prevent him from leaving the fold into which the Cardinal had entered from out of the Reformed Church. Some are born Catholics or Protestants, and are so with vehemence; others are born in these religions, but are only lukewarm in their doctrinal observance; while others reason and jump the traces in either direction. The followers of the destructive theories of Bronssais could not see the errors of their ways, and neither could they be made to see the merits of a less interfering form of medical practice. Trousseau was himself at one time tainted with Bronssaisism, but, like Paul of Tarsus, he was made to see the error of his way, as he relates, through a case of gout that he nearly laid out in trying to lay out the disease antiphlogistically.

I do not assume that preputial irritation is at the bottom of all cases of dysuria or enuresis, any more than it would be rational to deny that cases of circumcision performed in some cases of diabetic enuresis have proved fatal as a result of the operative interference; but it is safe to assume that, in the great number of cases in whom some irritating conditions were found and removed, the enuresis or dysuria was due to such preputial irritation. It is also logical to assume, with West and Henoch, that the organ should in all cases be examined, and its condition rendered as harmless as possible. That the condition of preputial irritation has not been fully recognized by all parties as a cause of enuresis does not do away with the fact that it does exist, any more than the refusal of the prelates and doctors of Salamanca to listen to Columbus did away with the fact of the existence of the American continents.

A. L. Ranney, in his "Lectures on Nervous Diseases," pages 174, 175, speaks of enuresis in children as being a reflex cachexia, "excessive stimulation of the centripetal nerves connected with the so-called 'vesical centres' of the spinal cord,"—a condition which may be produced by either worms in the intestines or by preputial irritation. Ranney advises a careful exploration of the urethra and rectum in these cases, and the elimination of all local causes of the conditions.

Probably the most remarkable case of the immediate continuous effects resulting from phimosis is the one recorded by Vidal, in the fifth volume of the third edition of his "Surgery." This was a young man with a congenital phimosis, having but a very small aperture; on an operation to relieve the phimosis there was a gush of water, but this only fell at the feet of the patient, without being ejected at any distance; the urethra was found to have undergone precisely the same dilatation back of this preputial orifice that it usually undergoes back of a stricture; the whole urethra from the meatus backward was found to have exceeded the calibre of that of the vesical neck; the bladder was greatly dilated.



CHAPTER XXV.

GENERAL SYSTEMIC DISEASES INDUCED BY THE PREPUCE.

Aside from all the local affections or reflex neuroses, either mental or physical, that a prepuce may induce, there are an innumerable train of diseases that may originate in this one cause that at first sight would seem to have no connecting-link with any preputial condition.

It has already been suggested that the prepuce does not at all ages bear the same analogous relation to man. In childhood, especially during our earliest years, it is out of all proportion in size when compared to the rest of the organ, or to any use it may have placed to its credit. Man does not, then, certainly need that refinement of nervous sensitiveness in the corona that is useful in after life in inducing the flow or ejaculation of the seminal fluid; neither is there at that age much of a corona to protect. In middle life, or what might be called the procreative period of man, when the corona would seem to require all its excitability or sensitiveness, seems to be the very season in life when the glans is most apt to remain uncovered; so that nature and this hypothetical idea of the use of the prepuce are evidently at variance. So we go through childhood with this long funnel-shaped appendage into manhood, when the increasing size of the body of the penis restores a sort of equilibrium between the size and bulk of the organ and its integumentary covering. At this period, as we have seen, although it does not, from the equilibrium restored, and the more or less use to which it is subjected, induce any great immediate or uncomplicated troubles, it nevertheless endangers the existence of the penis through the accidental course of some putrid or continued fever, or it subjects man to the manifold dangers of venereal or tubercular infections.

In advanced age, owing to the diminution in size of the organ, the prepuce resumes the proportionate bulky dimensions of childhood, and as the organ recedes and becomes more and more diminutive, the prepuce again, like in childhood, begins to tend to phimosis; the urine of the aged is also more irritating and prone to decomposition or putrefaction, and the constant state of moisture that the preputial canal of the aged is necessarily kept in, either by frequent urination or the incomplete emptying of the urethra that is peculiar to old age, and which results in more or less dribbling, is a powerful factor in inducing the many attacks of posthitis and balanitis, as well as those attacks of excoriation and eczema which are so annoying to the aged. I have often seen such cases happening to men past fifty, who, being widowers, and never having had anything of the kind, as well as being in the most complete ignorance of the nature of the disease, have, from delicacy and fear that the disease might induce some suspicions as to their conduct in the minds of those whose good opinions they value above all else, gone on suffering untold miseries, especially if the urine were in the least diabetic.

One such case that fell under my observation not only produced such misery as to entail a loss of rest and of appetite, but even induced such a disturbance of assimilation and nutrition that the resulting hypochondriacal condition that developed from these enervating causes ran the patient into a low condition, ending in complete prostration of all vital powers and death, without the intervention of any other disease. The subject was a timid, retiring man of about fifty-five years, and this was the first and only time that the prepuce had ever caused him any annoyance,—a circumstance which greatly preyed upon his mind, as he could not disconnect it with the idea that it must be suspected as venereal, although he had always led a most continent life since the death of his wife. This is, of course, an extreme case; but as it is a result beginning in a certain condition, be it an extreme, erratic, or infrequent occurrence, it is, nevertheless, an example of what may happen in advanced life, even where the prepuce has never before been a source of the least disturbance or annoyance. Persons who, with the increase of years, are also liable to an increase of adipose tissue, are more subject to this dwindling down of the penis and consequent elongation of the prepuce, with all the attendant annoyances, than thin or spare people.

In this irritation that the prepuce is liable to cause, we have not only to encounter the dangers that its thickenings or indurations may bring on in their train, in the shape of cancer, gangrene, or hypertrophies, but other and no less serious results are liable to follow a herpetic attack, or in consequence of an attack of balanitis or posthitis. The dysuria attending any of these conditions may be the initial move for such a serious complication that life may be brought to a sudden end, even in infancy, to say nothing of the ease with which life is taken off in after years and in old age; with debilitated and imperfect kidney action, it takes very little to hustle us off from life's foot-bridge.

A case as occurring in Henoch's clinic, already mentioned or referred to in a previous chapter, shows what a simple phimosis is capable of inducing. In the history of the case the phimosis and the resulting retention in the preputial cavity no doubt were the causes of the calculus found there; and the succeeding calculi and abnormal condition of the urinary organs, we can safely assume, were a subsequent creation to that in the prepuce. The case is taken from Henoch's "Lectures on Diseases of Children," Wood Library edition, page 256, and is as follows:—

"A. L., aged two, admitted November 28, 1877. Quite well nourished, but pale. Complete retention of urine for two days; slight redness and marked oedema of penis, scrotum, and perineum. The foreskin cannot be retracted, on account of phimosis. Abdomen distended, hard, and sensitive, the dilated bladder extending a few fingers' breadth above the symphysis. In order to introduce the catheter, it was first necessary to operate upon the phimosis, during which a calculus, which completely occluded the meatus, was removed. The catheter, when introduced into the bladder, removed a quantity of cloudy urine. The oedema, rapidly disappeared under applications of lead-wash, but on November 29th vomiting and diarrhoea occurred during the night, with rapid collapse; December 1st, death. Autopsy: In the bladder, a sulphur-yellow stone, as large as a hen's egg, completely filling the organ; similar calculi, from the size of a pea to that of a bean, in the pelvis of the left kidney; right kidney normal."

In the above case, the oedema of the penis, scrotum, and perineum was as much a result of the distension of the bladder by the retained urine interfering with the return circulation from the oedematous parts as the different appearances of diseased conditions were a result of the primary phimosis; yet this case, if seen during its early infancy, when probably the contraction of the preputial orifice was as yet not so well marked, would have been pronounced one in which it would be needless and barbarous to perform circumcision upon. We would most assuredly have to wander aimlessly and unprofitably in the region of speculation to build up the etiology of the above-related case and reach the culmination there found, unless we accept the one that it was all, from first to last, the result of the phimosis.

Jonah, pitched overboard at sea to appease the tempest and swallowed by the whale, became convinced finally that he had better return to Nineveh to preach reform; while Pharaoh would not let the children of Israel depart even after Moses had so frightened him—as it is related in the rabbinical traditions compiled by the Rev. T. Baring-Gould, M.A.—that the royal bowels were completely relaxed at the sight of the snakes turned loose about the royal throne,—a circumstance which nearly lost him his claim to divinity, which was based on the fact that his bowels moved only once a week, as in this case they not only moved out of time and in the most unkingly manner, so that the noble king hid underneath the throne, but before even Pharaoh could disengage himself from the royal robes, which event could hardly have raised him in the estimation of the gentlemen eunuchs of the bed-chamber. Those who unwound the mummy of Pharaoh tell us that he had the appearance of a self-willed, despotic, but intelligent, old gentleman; but the above rabbinical relation, from Baring-Gould's "Legends of the Patriarchs and Prophets," seems to have had no convincing effect on Pharaoh; so we must not be surprised if even a case like the one from Henoch's clinic would, with many, carry no conviction.

In the second volume of Otis on "Genito-Urinary Diseases," of the Birmingham edition, at page 380, there is an interesting account of a physician who, in youth, was troubled with an annoying prepuce, which, from frequent attacks of balanitis, had finally become more or less adherent to the glans penis; up to the age of nineteen he had been unable to completely uncover the glans. By six months of hard and persistent labor he had finally broken up these adhesions. At the age of twenty-two he married, and he then ruptured the frenum, which bled profusely and left him sore for some days. Then for twenty-seven years he had no further trouble, but at the end of that time he began to experience what he believed were attacks of dumb ague, and the scrotum began to swell and felt sore on firm pressure. Heavy, aching pains then followed. This condition of things lasted for over five years, varied by the appearance of carbuncles on the nose and elsewhere, to relieve the monotony of the thing. From this time on, abscesses began to form in the scrotum and into the integument of the penis, burrowing forward into the prepuce, which was much swollen and painful. A gangrenous opening effected itself in the dorsal surface, which relieved him somewhat. The patient was finally examined by Dr. Otis, who found a badly strictured urethra, the strictures beginning at the meatus, and at intervals extended down as far as two and three-fourths inches. The case had no venereal history, the patient never having had any disease or anything of the kind. The strictures were plainly the result of the balano-posthitic attacks as much as they were the cause of the degeneration of the mucous membrane in the lower urethra, that allowed of the infiltration of urine into the tissues, which caused all the systemic disturbances, abscesses, misery, and agony of the patient, depriving him of comfort, sleep, or ability for labor, and which sent him here and there in search of health and relief.

It would seem really as if a prepuce was a dangerous appendage at any time, and life-insurance companies should class the wearer of a prepuce under the head of hazardous risks, for a circumcised laborer in a powder-mill or a circumcised brakeman or locomotive engineer runs actually less risk than an uncircumcised tailor or watchmaker. They recognize the danger that lurks in a stricture, but what a prepuce can and does do, they entirely ignore. I have not had any opportunities for comparison, but it would be interesting to know, from the statistics of some of these companies, how much more the Hebrew is, as a premium-payer, of value to the company than his uncircumcised brother. Were they to offer some inducement, in the shape of lower rates, to the circumcised, as they should do, they would not only benefit the companies by insuring a longer number of years, on which the insured would pay premiums, but they would be instrumental in decreasing the death-rate and extending longevity.

I have seen so many cases of stricture whose origin could be traced to balanitis that it can almost with confidence be assumed that, wherever there is a long prepuce with a red and inflamed meatus in a child, that unfortunate child will be a victim of fossal strictures when arrived to manhood, and that, moreover, he will be a surer victim to the reflex neuroses which so often accompany strictures, and which have been so ably described by Otis, than the victim of uncomplicated strictures acquired in the worship of Venus. There is no end to the misery that these poor fellows have to suffer, besides the habitual hypochondriacal condition into which the accompanying physical depression, throws them; it unfits them for business, any undertaking, or even for social enjoyment or entertainment; they keep themselves and their families in continued hot water. These subjects are, also, more prone to gouty and rheumatic affections, asthma, and other neuroses.

Among the many cases of nervous disorders simulating other diseases that I have seen relieved were two Jewish lads with an imperfection of the meatus. They were two brothers, and from the history of the cases, and that given me by the mother of the lads in regard to the father, the malformation must have been hereditary and congenital. It consisted of a partial occlusion of the meatus by a false membrane, which divided the meatus in two, horizontally, but which was closed at the posterior end of the lower passage, which readily admitted a probe from the front as far as the occlusion, about a third of an inch to the rear. The restoration, or rather the making the anterior urethra and meatus to their normal condition, relieved both boys of asthma, under which they had labored for years.

The many cases simulating the general disturbances that accompany many kidney disorders, that are simply the result, in their primary causes, of preputial irritation and the disturbances to the kidney function due to the same cause, have long induced me to look upon the prepuce as a great and avoidable factor to some of the many forms of kidney diseases, prostatic enlargements, vesical diseases, and many other diseases of the urinary organs, which we know full well can result from strictures, as the latter need not always act in a purely mechanical mode to do its full extent of mischief.

One result of these preputial irritations not generally or particularly mentioned in any of our text-books—a condition far-reaching as regards its own results, and more annoying and serious than it appears at first sight—usually begins with a reflex irritability of the anal sphincter muscle, or a rectal irritation of the same order, which in time produces such organic change that an hypertrophied and irritable, indurated, unyielding muscle is the result. Agnew, of Philadelphia, describes the condition, but does not mention this frequent cause under the name of sphincterismus; once this is established, the train of resulting pathological or diseased conditions that may follow are without end.[108] This is no fancy sketch, nor will the student of the pedigree and origin of diseases feel that the case is exaggerated or imaginative. These are some of those cases that are always ailing, never well and really never sick, but who are, nevertheless, gradually breaking down and finally die of what is termed "a complication of diseases," before living out half their term of life.

How this happens is simple enough—the straining required to produce an evacuation is out of all proportion with the character of the discharge; such patients often complain of being constipated when the evacuations are semi-fluid; this straining is followed by a dilatation and consequent loss of power of the rectum, which becomes pouched and its mucous membrane thickened; the whole intestinal tract sympathizes and digestion is interfered with, and the forcible expulsive efforts affect all the abdominal and thoracic organs in a more or less degree, laying the foundation for serious organic diseases. Now, this condition, which may be said to be no more than one of obstinate constipation, is a far more reaching condition and a far more injurious state than can be imagined at a first glance. Constipation is not, as a rule, always accompanied by the indigestion, either stomachic or intestinal, that goes with this condition; the contents of the intestines in simple constipation may simply lack fluidity without undergoing putrefactive fermentation, but in this condition the undigested and retained intestinal contents do undergo that change, resulting in the generation of material whose re-absorption produces a toxic condition of the blood, from whence begins a series of serious organic changes in the blood, and from this in the organs.

To the practical physician these changes are evident and their cause just as plain, and it is just here where the laity lack the proper education, and where they should understand that the intelligent physician generalizes the disease and only individualizes the patient; and it is this ignorance on the part of the laity that gives to empiricism and quackery that advantage over them, as they look upon all disease as a distinct individual ailment, that should have an equally distinct and individual therapeutic agent to cope singly with. The laity know very little of these things, and in their happy ignorance care still less for the finer definitions of or of the clinical importance of toxaemia, or the processes of abnormal conditions that lead up to such a state, or the results that may follow when that condition is once reached. To them, dyspepsia is an indigestion ascribable to the stomach, and a sick-headache is ascribed to something wrong about the stomach or liver.

The laity have never been called upon to answer the questioning of the late Prof. Robley Dunglison: "What do you mean, sir, by biliousness? Do you mean, sir, that the liver does not secrete or manufacture a sufficiency of bile, or not enough? Do you mean that the bile-material is left in the blood, or too much poured in? Do you mean that there is an excess in the alimentary canal, and a deficiency elsewhere? Please, sir, explain what you really mean by the term 'bilious!'" The Professor had a way about him that at least made one stop and seriously inquire, before adopting any random notion in regard to medicine. It is to be regretted that, in the humdrum tread-mill work of many physicians, they even have to drop into the commonplace way of treating dyspepsias and such ailments without any further inquiry. A farmer knows better than to drive a dishing wheel, or with merely having a nail clinched in the loose shoe of a valuable horse; but he is fully satisfied to do so in a metaphorical sense, as regards his own constitution, and the mere hint from his physician that he had better lay up for repairs, or that there is something wrong about him that will require investigation, and that there is an ulterior cause to his feeling tired, headachy, or dyspeptic, or an allusion that there is something systemic, as a cause, to his momentary attacks of disordered vision or amaurosis, will generally make him look on the doctor with mistrust.

The merchant, banker, and mechanic are not up to Professor von Jaksch's ideas of toxaemia,—that toxaemia may be exogenous or endogenous, or that the latter is further subdivided into three more varieties,—and, what is worse, he cares still less. The above three classes of humanity, when sick, simply would want to know if Professor von Jaksch was good on dyspepsia, the measles, or typhoid fever. They care very little that he divides endogenous or auto-toxaemia into that produced by the normal products of tissue-interchange, abnormally retained in the body, giving rise to uraemia, toxaemia from acute intestinal obstruction, etc., the above being the first division. The second depends on the outcome of pathological processes, which change the normal course of assimilation of food and tissue-interchange; so that, instead of non-toxic, toxic matter is formed. The second group he names noso-toxicoses, which he subdivides into two principal divisions:—

(a) The carbohydrates, fats, or albuminous matter, which may be decomposed abnormally and give rise to toxic products, e.g., diabetic intoxication, coma carcinomatosum.

(b) A contagium vivum enters the body through the skin, or the respiratory or digestive tract, and develops toxic agents in the tissues on which it feeds, as in infectious diseases.

In the third group the toxic substance results from pathological non-toxic products, which again produce a toxic agent, only under certain conditions. This group he calls auto-toxicoses, and includes in it poisonous substances, resulting from decomposition of the urine in the bladder, under certain pathological conditions, and giving rise to the condition called ammoniaemia. (Medical News of January 7, 1891; from Wiener klinische Wochenschrift of December 25, 1890.)

As observed above, unfortunately the patients know nothing, nor can they be made to understand these conditions, that are only reached through labyrinthic pathological processes, and, what is still worse, this way of looking at disease is incompatible with the idea of specific-disease treatment, which to them looks more practicable and quick, and which is also more to their liking. They cannot see any sense in such reasoning, which to them is something eminently impracticable; neither can they see a reasonable being in the doctor who practices on such, as they call them, theories.

The practical physician, however, sees in Professor von Jaksch's summary the turning-point of many a poor fellow's career,—from one of comparative health into one of organic disintegration, decay, and dissolution,—all the required processes starting visibly from the very smallest of beginnings; any obstruction in the urinary tract or intestinal canal being sufficient to start any of the conditions which end in toxaemia; and, from a careful observation running over several years, I do not think that I am assuming too much in saying that a balanitis is often the tiny match that lights the train that later explodes in an apoplectic attack or sudden heart-failure due to toxaemia; the organic and vascular systems being gradually undermined until, unannounced and unawares, the ground gives way and the final catastrophe occurs,—unfortunately, an occurrence or ending looked upon as unavoidable by the friends of the victim. They cannot see any danger; the idea that diseases have the road paved, not only for an easy entrance but an easy conquest, by the action of these toxic agents on the tissues, is something that they cannot grasp. These blood changes or blood conditions are things too intricate, and the physician who understands them is, to them, a visionary and unpractical man. These conditions are, however, neither new nor unknown, and there is really no excuse for the ignorance exhibited in these matters by the general public, as it is through the blood that this mischief takes place. They can reason in their impotent way, that they should drench themselves with "blood tonics" and all manner of nauseous compounds to "purify" their blood, but the simple, scientific truth is something beyond their understanding, as well as something that they steel themselves against.

Sir Lionel Beale, in observing the immense importance he attaches to blood composition and blood change in diseases of various organs, truly remarks that "blood change is the starting-point, and may be looked upon as the cause, of what follows," the other factor being the "'tendency' or inherent weakness or developmental defect of the organ which is the subject of attack;" to which he adds that he feels convinced that, if only the blood could be kept right, thousands of serious cases of illness would not occur; while the persistence of a healthy state of the blood is the explanation of the fact that many get through a long life without a single attack of illness, although they may have several weak organs; and that an altered state of the blood, a departure from the normal physiological condition, often explains the first step in many forms of acute or chronic disease. Sir Lionel has been a pioneer in the field of thought that looks for the cause of the disease, which, however remote it may be, should not be overlooked as a really primary affection. His extensive labor in the microscopic field has fully convinced him that many of the pathological changes in the different organs are due to what might be called some intercellular substance that is deposited from the blood. (Beale: "Urinary and Renal Disorders.")

Toxic elements in the blood affect the kidneys in a greater or less degree, and there produce changes at first unnoticed,—at least, as long as the kidney can perform its function,—but the day arrives when, as described by Fothergill, blood depuration is imperfect, and we get many diseases which are distinctly uraemic in character, and ending in any of the so-called kidney diseases, Bright's disease being one of the most common. As observed by Fothergill, however, the kidney is not the starting-point, the new departure only taking place when the structural change on the kidney has reached that point that it is no longer equal to its function—the "renal inadequacy" of Sir Andrew Clarke. (J. Milner Fothergill, in the Satellite, February, 1889.)

During the Bradshawe lecture, Dr. William Carter made the following remarks: "According to Bonchard, one-fifth of the total toxicity of normal urines is due to the poisonous products re-absorbed into the blood from the intestines, and resulting from putrefactive changes which the residue of the food undergoes there." In the course of the lecture, Dr. Carter fully explains that one of the benefits derived from milk diet in Bright's disease is the small residuum deficient in toxic properties, and lays great stress on the employment of intestinal disinfectants or antiseptics that exercise their influence throughout the whole tract, suggesting naphthalin as peculiarly efficacious, thereby cutting off one source of blood contamination at its source. Although these are recent developments in medicine, Bonchard mentions that in the practice of M. Tapret cases treated on this principle did well. (Braithwaite's Retrospect, January, 1889.)

Persons laboring under this toxic condition of the blood, with a consequent deterioration in the texture and the physiological function of the vital organs, are of that class that easily succumb to injuries or serious sickness, and of that class to whom a surgical operation of even medium magnitude is equal to a death-warrant.

The above conditions are an almost constant attendant on that condition of the sphincter described by Agnew as sphincterismus, which also is productive of haemorrhoids and fissure, and often of fistula. That sphincterismus is caused in many cases by preputial irritation is as evident as that the same affection, or haemorrhoids or any other rectal or anal affection, will, in its turn, produce vesical and urethral reflex actions, and primarily functional and secondarily organic changes in those parts. Besides, the great number of cases wherein the gradual and progressive march of each pathological event could be traced with accuracy has convinced me of the true cause of the difficulty being the result of reflex irritation.

Delafield, in his "Studies in Pathological Anatomy," gives, as the first form of pneumonia, that from heart disease; in the days of Broussais this would have sounded absurd, but, to-day, some forms of heart disease are known to be the regular sequences of some particular form of kidney disease, just as some form of pneumonia attends an affected heart and that some forms of pneumonia degenerate into phthisis. When the blood change is an established fact, it is only a question as to which is the weak organ, and the organism of the individual will decide whether it will be a simple sick-headache or the beginning of a pneumonia ending in phthisis.

I have purposely dwelt on this part of this subject, owing to the recent origin and publication of many of the views connected with it; also on account of the greater ease of making the subject plain by fully discussing each step of the process; and if the views of Sir Lionel will be recalled, that a toxic element in the blood is the starting-point, and that an irritable or weakened organ invites destruction,—the induction of serious and fatal kidney disorder by the transmitted irritability and consequent injury to the kidney produced by preputial irritation in the first instance, and the supplemental blood-poisoning by intestinal absorption of septic matter, which soon brings about Sir Andrew Clarke's "inadequacy of kidney,"—all will be readily understood. When this point is reached, a too hearty meal, exposure to variable weather, or a little extra care or anxiety, are sufficient, as determining causes, to bring life into danger.

As pointed out, many cases of Bright's disease or other renal difficulty have their origin in this distant but visible source, and, although malarial poisoning and a great number of other causes will produce the same particular organic changes and diseases, this condition must be admitted as one of the frequent causes. The influence of the genito-urinary tract on the rest of the economy, and the importance of the sympathy it excites, or how quickly, by its being irritated, some apparently dormant pathological condition will be awakened to life and activity, is not sufficiently appreciated. As observed by Hutchinson, a patient who has once been the subject of intermittent fever is more prone, on catheterization, to have a urethral chill and fever than one who had never had the fever. (Hutchinson: "Pedigree of Diseases.")

Ralfe observes, in his "Kidney Diseases," that long-standing disease of the genito-urinary passages must be reckoned as among the chief etiological factors of chronic interstitial nephritis (page 227). The condition of the kidneys in cases of strictures of long standing is known not to be a reliable one, and any incentive to dysuria or to retention, no matter how slight, is apt to lead, eventually—and that even in very young subjects—to that toxic condition mentioned in a former part of this chapter as one of von Jaksch's subdivisions of toxaemia, the ammoniaemia of Frerichs; this condition being the fatal ending of the case of the two-year-old child mentioned by Henoch, who died after the relief of a retention due to phimosis and calculi resulting from the phimotic occlusion. Having seen so many cases wherein the conditions described in this chapter were so apparently—whether from ammoniaemia due to infection, or toxaemia from the urinary tract, or uraemic toxaemia from the intestinal tract—all due to some preputial interference or irritation, I cannot help but feel that in these conditions—which, singularly, are not so prevalent with the Hebrews as with Christians—we have one factor in the cause of the shorter and more precarious vitality of the latter.

Morel, in his "Traite des Degenerescences Phisiques," ably discusses the degenerative and morbific influences and results of toxaemia, as well as he clearly defines their sources. The connection between toxaemia and mental affections has already been shown, and Prof. Hobart A. Hare, in his instructive and interesting prize essay on "La Pathogenie et la Therapeutique de l'Epilepsie (Bruxelles, 1890)", mentions that convulsive disorders resulting from the presence of some toxic substance are of frequent occurrence. How much this may enter as a partial factor into many of the cases of epilepsy which are classed in the order of "reflex" may well challenge our consideration. Hare lays great stress on the necessity of circumcision wherever there is an indication of preputial local irritation. "If practicable, circumcision should be performed; it is an operation with but small risk or danger, and easy of performance. In such circumstances it is always permissible to circumcise, were it for no other end than an acknowledged attempt to reach a cure."



CHAPTER XXVI.

SURGICAL OPERATIONS PERFORMED ON THE PREPUCE.

In operative interference there is one point which should not be lost sight of, this being that the length and bulk of the prepuce in a great measure depends on the constriction at its orifice; if the orifice is small, the prepuce tight and inelastic, every erection, by putting the penis-integument on the stretch, adds to its bulk,—nature naturally trying to make up the deficiency,—the two points of resistance being where the glans pushes it ahead, having the constricting orifice for a hold or purchase, and the skin at the pubes, which is called upon to furnish the extra tissue for the time being needed during erection, which should be supplied by the prepuce—this being the only office which I have been able to assign to this otherwise useless but very mischievous appendage. In cases where preputial irritation produces more or less priapism, the continued stretching of this integument causes a marked increase in its growth, which is mostly added forward. It was on this principle or its recognition, that Celsus devised his operations, and on which the persecuted Jews undertook to recover their glans by manufacturing a prepuce; and, although the trial was not reported as being very successful, I do not doubt but that, if the skin could have been drawn sufficiently over so as to constrict it anteriorly so as to give the glans a purchase, as in the case of phimosis with an inelastic prepuce, the operation could be more of a success; all that is required is the continued extension and the prepuce might be made to rival in length the labia majorae of the females of some African tribes, or the pendulous buttocks of the Hottentot Venus.

I have employed the knowledge of this elasticity and source of supply of the penis-integument, on more than one occasion, in recovering the denuded organ with skin. A number of cases are on record where, owing to the want of that artistic and mechanical knowledge without which no surgeon is perfect, the operator has drawn forward the skin too tight in circumcising, after which, owing to the natural elasticity of the skin, the integument has retracted, leaving the penis like a skinned eel or sausage. This accident is even liable to occur where the skin has not been tightly drawn, but where subsequent erections have torn through the sutures, and where the natural retraction of the skin has laid the organ bare for some distance. I have seen a number so recorded, but do not remember seeing any remedy suggested, it seemingly being accepted that the recovery must take place by gradual granulation,—a necessarily very slow process, owing to the constant interference by—the always present in such cases—unavoidable erections.

Several years ago I advised circumcision to a gentleman owing to a contracted condition of the muscles of one hip and thigh, which was threatening to render him a deformed cripple; he had a congenital phimosis and a very irritable glans penis. The operation was performed in a proper manner by a surgical friend, but this friend, unfortunately, was a great believer in antiseptic and wet dressings. A few days after the operation he called upon me to ask me to go and see the patient, as they were both in a pickle, the patient being exceedingly angry, being in constant misery, and the penis so denuded by the giving way of the sutures—owing to the erections—that it looked to the patient as if he never could have a whole penis again, and the doctor saw no way out of the difficulty; the penis was, in reality, a dilapidated and sorrowful-looking appendage, and anything else but a thing of beauty or pride; it was raw, angry-looking, and bleeding at every move; the first wink of sleep was followed by an attempt at erection that raised the patient as effectually as an Indian would in scalping him; so that, taken altogether, the penis, anxious countenance, and the flexed position of the whole body to relieve the tension on the organ, the man looked about as battered, cast down, and sorrowful as Don Quixote did in the garret of the old Spanish inn, with his plastered ribs and demolished lantern-jaw.

Luckily, the patient was seen before the retracted portion of the penile integument had had a chance to condense and indurate. The bed was slopping wet with the drenchings of carbolized water that the penis had undergone, the man's clothing was necessarily damp, and the whole bedding and clothes were steamy,—all of which greatly added to his discomfort and tendency to erections. The man was washed, placed in a new, clean, and dry bed, and his clothing changed. The organ was then forced backward until the preputial frill or edge was approximated to the cut end of the penis-skin, where it was made fast by an uninterrupted suture around the whole of the circumference. A short catheter, about three inches in length,—the catheter being as full size as the urethra would comfortably hold, and of the best and thickest of the red, stiff variety,—was introduced into the urethra. This protruded about half an inch beyond the meatus. A stiff, square piece of card-board was pierced and slipped over this, and then adhesive rubber straps were brought from the integument to this little platform, the first being from the median line of the scrotum, lifting the sac forward and upward. The pubes were shaved and the next four straps started from the root of the penis, each strap being split at the glans-end so as to encircle the protruding end of the catheter. By these means the skin was brought back and firmly supported over the penis, toward the glans; and, in case of any erection, the act would only assist in drawing the covering farther over the penis as the pasteboard platform and adhesive straps formed the distal end of an artificial phimosis. The catheter allowed of free urination, and the scrotum was further held up in position by a flat suspensory bandage passed underneath the scrotum and fastened over the abdomen near each hip. The penis wound was then dressed with a very little benzoated oxide-of-zinc ointment passed between the adhesive straps; a bridge-support placed over the hips to support the bed-clothes, and all was finished, and full doses of bromide of sodium and chloral were ordered at bed-time. When the dressings were removed, five days afterward, all was healed, the sutures removed, and the suspensory alone replaced. The patient had not been troubled with any more erections or annoyances of any kind. These are the points which often do more or less mischief: wet dressings are uncomfortable and favor erections, while the effect of the weight and action of the scrotum in drawing backward on the integument should not be overlooked; in addition, it should not be overlooked that we have it in our power to produce, so to speak, an artificial phimotic action, which has the same traction on the penis-integument that the natural phimosis induces.