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 a.s.sume 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 circ.u.mcision 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 circ.u.mcision 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 p.u.b.erty; to find it fully described and to have it stated that it is a widely-prevalent distemper, affecting both s.e.xes 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 a.n.a.logous between this condition and that which determines in after life the seminal emissions under similar circ.u.mstances." 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 pa.s.sing or the retention of the urine, or where the practice of masturbation is suspected, the p.e.n.i.s ought to be examined, and circ.u.mcision 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 l.a.b.i.a 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 l.a.b.i.a 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 a.s.sume 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 a.s.sume, 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 pa.s.sage 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 pa.s.sively 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 pa.s.sage 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 pa.s.s 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. s.e.x has no influence on the liability that tends to being attacked, the proportion between the s.e.xes 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 s.e.x 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 v.a.g.i.n.a, of the vestibule or urethra in girls, or the practice of onanism, or lithiasis, cyst.i.tis, 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 s.m.e.g.m.a, 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 rheoph.o.r.e 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 a.s.sume 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 circ.u.mcision performed in some cases of diabetic enuresis have proved fatal as a result of the operative interference; but it is safe to a.s.sume 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 a.s.sume, 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 r.e.c.t.u.m 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 a.n.a.logous 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 e.j.a.c.u.l.a.t.i.o.n 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 p.e.n.i.s 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 p.e.n.i.s 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 p.r.o.ne to decomposition or putrefaction, and the constant state of moisture that the preputial ca.n.a.l 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 appet.i.te, but even induced such a disturbance of a.s.similation 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 circ.u.mstance 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 p.e.n.i.s 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 a.s.sume, 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 p.e.n.i.s, s.c.r.o.t.u.m, 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 quant.i.ty 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 p.e.n.i.s, s.c.r.o.t.u.m, 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 p.r.o.nounced one in which it would be needless and barbarous to perform circ.u.mcision upon. We would most a.s.suredly 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 circ.u.mstance 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 n.o.ble 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 p.e.n.i.s; 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 s.c.r.o.t.u.m 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 s.c.r.o.t.u.m and into the integument of the p.e.n.i.s, 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 cla.s.s the wearer of a prepuce under the head of hazardous risks, for a circ.u.mcised laborer in a powder-mill or a circ.u.mcised brakeman or locomotive engineer runs actually less risk than an uncirc.u.mcised 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 uncirc.u.mcised brother.

Were they to offer some inducement, in the shape of lower rates, to the circ.u.mcised, 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 a.s.sumed 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 p.r.o.ne 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 pa.s.sage, 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 a.n.a.l 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 r.e.c.t.u.m, 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 ca.n.a.l, 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 const.i.tution, 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 cla.s.ses 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 a.s.similation 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 princ.i.p.al divisions:--

(_a_) The carbohydrates, fats, or alb.u.minous 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 ca.n.a.l 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 a.s.suming 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.)