By the irritation that all these applications and accidents induce, warts and vegetations are the but too frequent results. These I have never seen in a circ.u.mcised individual, and their occurrence and frequency, as well as persistency, are directly proportionate with the degree of tightness, thickness, or redundancy of the prepuce and the irritability of the gland. As remarked by Lallemand, in reference to the victim of nocturnal enuresis becoming a future victim of nocturnal emissions, so it may be said of the person subject in early life to either warts, excoriations or vegetations on the p.e.n.i.s, that it is this cla.s.s that furnishes in after life the subjects for cancerous disease as well as furnishing the easiest victims for venereal infection. These warts, although easily removed, have a tendency to recurrence, especially as long as the moist bed that has once grown them there is still vegetating.

The prepuce is liable to indurations and hypertrophy. Of the first anomaly, the London _Lancet_ of 1846 has a record of two cases in which paraphimosis was induced in elderly subjects, and of one in which it induced phimosis. Since then a number of cases of thickening and induration have been reported. Hypertrophy may take place in any degree, varying from the mere leathery and overpendulous but un.o.bstructive prepuce to the case recorded by Vidal, in the fifth volume of his "Pathologie Externe et Medecine Operatoire," which happened in the practice of M. Rigal, de Gaillae. The hypertrophied prepuce was something enormous, and hung down to below the patient's knees; it was pear-shaped, with the base hanging downward; this base was as large as a man's head. This prepuce was successfully removed by M. Rigal, who presented the specimen before the Paris Surgical Society, who were then discussing a somewhat similar but not so extensive a case, presented by M. Lenoire. Vidal mentions having operated on a number of cases of this deformity of the prepuce in various degrees of growth.

As a rule, simple hypertrophic disease of the penile integument does not interfere with the s.e.xual functions of the male organ after its removal; it being susceptible of complete removal in exaggerated cases, even without touching the body of the organ. There are exceptions to this rule, however, when even this otherwise non-malignant disease may entail the loss of all the genitals. In the London _Lancet_ of July 11, 1846, at page 46, there is a record of a remarkable case of this nature reported by F. H. Brett, Esq., F.R.C.S. The case was that of a locksmith of forty years of age, who was naturally much phimosed. The p.e.n.i.s was enormously enlarged, as well as the s.c.r.o.t.u.m, which was more or less ulcerated and full of sinuses filled with a serous pus; some six months prior to the final operation, a part of the prepuce was removed to facilitate urination, but the whole ma.s.s had to be subsequently removed, including the whole of the skin of the p.e.n.i.s and the s.c.r.o.t.u.m, the t.e.s.t.i.c.l.es having been carefully dissected out and recovered with some skin flap.

In this case the disease was believed to have originated from a perineal fistula. The pathological investigation in the case, however, by Mr.

Quekett, who submitted the ma.s.s to a microscopical examination, confirmed Mr. Brett in his original opinion that the disease had the same pathological conditions as the similar disease found in India, where it originates from local inflammatory causes. In this case the preputial irritation was, in all probability, the precursor of the conditions that led to the perineal fistula, the patient having had a stricture for some twelve years. Mr. Brett states that the man had been abandoned by his wife on account of his previous s.e.xual disability, and on account, as well, of his having been incapacitated from following any vocation. After the operation all his functions were restored and his organs were sound.

Nelaton records a case reported by Wadd, in 1817, of an African negro so affected, whose p.e.n.i.s measured fourteen inches in length and twelve and a half inches in circ.u.mference; also the case reported by Gibert, of Hospital St. Louis, of a subject "with a p.e.n.i.s the size of a mule's."

Mr. Brett attributes the recovery of his case as being due in a great measure to the moral support given to the patient from the knowledge that his procreative organs were not interfered with, and on the same grounds he attributes the great fatality previously attending the operation to the fact that it previously had been the custom in many cases to make a clean general _taille a fleur de ventre_, sacrificing all the genital organs. In simple hypertrophy, he considers that the body of the p.e.n.i.s and the t.e.s.t.i.c.l.es will always be found to be in a normal condition; a careful dissection of the parts will invariably save not only the man's s.e.xual functions, but his moral stamina, which he sadly needs in such an emergency. In the discussion on this subject heretofore mentioned as taking place in the London Medical Society, Mr.

Pye, Mr. John A. Morgan, and others insisted on the necessity of retaining the t.e.s.t.i.c.l.es, whenever possible, in all these sweeping operations upon the genitals, they being actually necessary for the moral and physical support of man, Mr. Morgan observing that their removal would depress parts controlled by the sympathetic system.

CHAPTER XXIII.

REFLEX NEUROSES AND THE PREPUCE.

We have seen in the previous chapters what the immediate effects of the prepuce may lead to; we have followed its local effects in childhood to youth, thence into what it does in our prime, and we have seen how, when we are on the down grade, owing to the increase of years, then, like the minute-men of Concord, wakened up by Paul Revere's cla.s.sic ride, hanging on to the rear of the retreating and disheartened British, it hara.s.ses, worries, and downs a man here and there, striking down the man as if it had some undying, irremediable spite, which nothing but his misery and death could alleviate. Some authorities will argue that all that is required is cleanliness; that all men need do is to be like a true American, with the old Continental watchword of "eternal vigilance is the price of liberty" in continued active practice. A bowlful of some antiseptic wash and a small sponge should always be at hand, and he should be as industrious as if haltered in a tread-mill; he should make this a part of his toilet, and his daily and hourly care. This will, we are told, lessen his chances of becoming a victim to the many ills that lie in wait for him, all on account of the glory, honor, and comfort of wearing a prepuce, which is a perfectly physiological appendage.

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, ent.i.tled "Partial Paralysis from Reflex Irritation Caused by Congenital Phimosis and Adherent Prepuce,"

before the American Medical a.s.sociation. 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 emanc.i.p.ated 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 compa.s.sion 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 cla.s.s in a practical light, and from Spain a more enlightened idea in regard to this cla.s.s 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 a.s.sertion 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 cla.s.sed 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 pa.s.sed 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, 101; respiration, 18.

Swallowed nothing, and pa.s.sed faeces in bed. Continued in this condition until December 25th (temperature having fallen to 100), when a string was discovered pa.s.sed twice around the p.e.n.i.s behind corona and tied, the long prepuce serving to conceal it from observation. While not sufficiently tight to occlude the urethral ca.n.a.l, 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 p.e.n.i.s. 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 ch.o.r.ea, 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 ch.o.r.eic 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 circ.u.mcised 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 a.n.a.logous 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 circ.u.mcision 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 p.e.n.i.s 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 circ.u.mcise, 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 s.m.e.g.m.a are far more likely to call a boy's attention to his p.e.n.i.s 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 circ.u.mcision 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 circ.u.mcision. 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 p.r.o.nounced 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 circ.u.mcision."

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 r.e.c.t.u.m, 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 s.m.e.g.m.a-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.

Circ.u.mcision 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 circ.u.mcision; 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 circ.u.mcise 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 p.e.n.i.s 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 circ.u.mference 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 const.i.tution 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 appet.i.te 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 repet.i.tion 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. x.x.xiv, 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 p.e.n.i.s." 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 circ.u.mcision, 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 s.e.x. The preputium-c.l.i.toridis may be adherent and produce in the female similar reflexes. During the session of the American Medical a.s.sociation, 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 c.l.i.toris. 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 pa.s.s 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 c.l.i.toris, which was firmly bound down by preputial adhesions near the extremity of the organ.

Entering the catheter at this point, it readily pa.s.sed through the c.l.i.toris, then down through a pa.s.sage 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 s.e.xual 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, a.s.sociated with the male, and that it has not been more a.s.sociated with the female has deprived her of the same benefit that the prosecution of the study in this regard has been to the male s.e.x. Masturbation among the feeble-minded, which is so common, must, of necessity, have for its determining cause a foundation of morbid irritability of the s.e.xual 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 s.e.xual 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 s.e.xes, it was found that the habit was about equal in the two s.e.xes, there being only this difference: that the females began to m.a.s.t.u.r.b.a.t.e 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 s.e.x."

It may well be a question as to whether the feeble-mindedness be not a reflex condition from this excessive morbid irritability of the s.e.xual organs. There is not much doubt but that, if one of the cases reported by Dr. Price had not been circ.u.mcised, 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 s.e.xual 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 s.e.xes? If the results in private practice are any criterion, it is safe to a.s.sert that a strict adherence to the Mosaic law for the males and to some of the African customs for the females would most a.s.suredly 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 s.e.x.[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 p.e.n.i.s. 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 p.e.n.i.s 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 circ.u.mcision _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 circ.u.mcised, 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 bis.m.u.th, 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 p.e.n.i.s. 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, circ.u.mcision 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 p.e.n.i.s, 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 circ.u.mcision in many cases to improve the temper and disposition of children, with the best of results, and in one case, in a.s.sociation 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 m.a.s.t.u.r.b.a.t.ed, 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 circ.u.mcision, 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 inst.i.tution and remained until better.