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 classic ride, hanging
on to the rear of the retreating and disheartened British, it harasses,
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, 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.