GENERAL SYSTEMIC DISEASES INDUCED BY THE PREPUCE.
Aside from all the local affections or reflex neuroses, either mental or
physical, that a prepuce may induce, there are an innumerable train of
diseases that may originate in this one cause that at first sight would
seem to have no connecting-link with any preputial condition.
It has already been suggested that the prepuce does not at all ages bear
the same analogous relation to man. In childhood, especially during our
earliest years, it is out of all proportion in size when compared to the
rest of the organ, or to any use it may have placed to its credit. Man
does not, then, certainly need that refinement of nervous sensitiveness
in the corona that is useful in after life in inducing the flow or
ejaculation of the seminal fluid; neither is there at that age much of a
corona to protect. In middle life, or what might be called the
procreative period of man, when the corona would seem to require all its
excitability or sensitiveness, seems to be the very season in life when
the glans is most apt to remain uncovered; so that nature and this
hypothetical idea of the use of the prepuce are evidently at variance.
So we go through childhood with this long funnel-shaped appendage into
manhood, when the increasing size of the body of the penis restores a
sort of equilibrium between the size and bulk of the organ and its
integumentary covering. At this period, as we have seen, although it
does not, from the equilibrium restored, and the more or less use to
which it is subjected, induce any great immediate or uncomplicated
troubles, it nevertheless endangers the existence of the penis through
the accidental course of some putrid or continued fever, or it subjects
man to the manifold dangers of venereal or tubercular infections.
In advanced age, owing to the diminution in size of the organ, the
prepuce resumes the proportionate bulky dimensions of childhood, and as
the organ recedes and becomes more and more diminutive, the prepuce
again, like in childhood, begins to tend to phimosis; the urine of the
aged is also more irritating and prone to decomposition or putrefaction,
and the constant state of moisture that the preputial canal of the aged
is necessarily kept in, either by frequent urination or the incomplete
emptying of the urethra that is peculiar to old age, and which results
in more or less dribbling, is a powerful factor in inducing the many
attacks of posthitis and balanitis, as well as those attacks of
excoriation and eczema which are so annoying to the aged. I have often
seen such cases happening to men past fifty, who, being widowers, and
never having had anything of the kind, as well as being in the most
complete ignorance of the nature of the disease, have, from delicacy and
fear that the disease might induce some suspicions as to their conduct
in the minds of those whose good opinions they value above all else,
gone on suffering untold miseries, especially if the urine were in the
least diabetic.
One such case that fell under my observation not only produced such
misery as to entail a loss of rest and of appetite, but even induced
such a disturbance of assimilation and nutrition that the resulting
hypochondriacal condition that developed from these enervating causes
ran the patient into a low condition, ending in complete prostration of
all vital powers and death, without the intervention of any other
disease. The subject was a timid, retiring man of about fifty-five
years, and this was the first and only time that the prepuce had ever
caused him any annoyance,--a circumstance which greatly preyed upon his
mind, as he could not disconnect it with the idea that it must be
suspected as venereal, although he had always led a most continent life
since the death of his wife. This is, of course, an extreme case; but as
it is a result beginning in a certain condition, be it an extreme,
erratic, or infrequent occurrence, it is, nevertheless, an example of
what may happen in advanced life, even where the prepuce has never
before been a source of the least disturbance or annoyance. Persons who,
with the increase of years, are also liable to an increase of adipose
tissue, are more subject to this dwindling down of the penis and
consequent elongation of the prepuce, with all the attendant annoyances,
than thin or spare people.
In this irritation that the prepuce is liable to cause, we have not only
to encounter the dangers that its thickenings or indurations may bring
on in their train, in the shape of cancer, gangrene, or hypertrophies,
but other and no less serious results are liable to follow a herpetic
attack, or in consequence of an attack of balanitis or posthitis. The
dysuria attending any of these conditions may be the initial move for
such a serious complication that life may be brought to a sudden end,
even in infancy, to say nothing of the ease with which life is taken off
in after years and in old age; with debilitated and imperfect kidney
action, it takes very little to hustle us off from life's foot-bridge.
A case as occurring in Henoch's clinic, already mentioned or referred to
in a previous chapter, shows what a simple phimosis is capable of
inducing. In the history of the case the phimosis and the resulting
retention in the preputial cavity no doubt were the causes of the
calculus found there; and the succeeding calculi and abnormal condition
of the urinary organs, we can safely assume, were a subsequent creation
to that in the prepuce. The case is taken from Henoch's "Lectures on
Diseases of Children," Wood Library edition, page 256, and is as
follows:--
"A. L., aged two, admitted November 28, 1877. Quite well nourished, but
pale. Complete retention of urine for two days; slight redness and
marked oedema of penis, scrotum, and perineum. The foreskin cannot be
retracted, on account of phimosis. Abdomen distended, hard, and
sensitive, the dilated bladder extending a few fingers' breadth above
the symphysis. In order to introduce the catheter, it was first
necessary to operate upon the phimosis, during which a calculus, which
completely occluded the meatus, was removed. The catheter, when
introduced into the bladder, removed a quantity of cloudy urine. The
oedema, rapidly disappeared under applications of lead-wash, but on
November 29th vomiting and diarrhoea occurred during the night, with
rapid collapse; December 1st, death. Autopsy: In the bladder, a
sulphur-yellow stone, as large as a hen's egg, completely filling the
organ; similar calculi, from the size of a pea to that of a bean, in the
pelvis of the left kidney; right kidney normal."
In the above case, the oedema of the penis, scrotum, and perineum was as
much a result of the distension of the bladder by the retained urine
interfering with the return circulation from the oedematous parts as the
different appearances of diseased conditions were a result of the
primary phimosis; yet this case, if seen during its early infancy, when
probably the contraction of the preputial orifice was as yet not so
well marked, would have been pronounced one in which it would be
needless and barbarous to perform circumcision upon. We would most
assuredly have to wander aimlessly and unprofitably in the region of
speculation to build up the etiology of the above-related case and reach
the culmination there found, unless we accept the one that it was all,
from first to last, the result of the phimosis.
Jonah, pitched overboard at sea to appease the tempest and swallowed by
the whale, became convinced finally that he had better return to Nineveh
to preach reform; while Pharaoh would not let the children of Israel
depart even after Moses had so frightened him--as it is related in the
rabbinical traditions compiled by the Rev. T. Baring-Gould, M.A.--that
the royal bowels were completely relaxed at the sight of the snakes
turned loose about the royal throne,--a circumstance which nearly lost
him his claim to divinity, which was based on the fact that his bowels
moved only once a week, as in this case they not only moved out of time
and in the most unkingly manner, so that the noble king hid underneath
the throne, but before even Pharaoh could disengage himself from the
royal robes, which event could hardly have raised him in the estimation
of the gentlemen eunuchs of the bed-chamber. Those who unwound the mummy
of Pharaoh tell us that he had the appearance of a self-willed,
despotic, but intelligent, old gentleman; but the above rabbinical
relation, from Baring-Gould's "Legends of the Patriarchs and Prophets,"
seems to have had no convincing effect on Pharaoh; so we must not be
surprised if even a case like the one from Henoch's clinic would, with
many, carry no conviction.
In the second volume of Otis on "Genito-Urinary Diseases," of the
Birmingham edition, at page 380, there is an interesting account of a
physician who, in youth, was troubled with an annoying prepuce, which,
from frequent attacks of balanitis, had finally become more or less
adherent to the glans penis; up to the age of nineteen he had been
unable to completely uncover the glans. By six months of hard and
persistent labor he had finally broken up these adhesions. At the age of
twenty-two he married, and he then ruptured the frenum, which bled
profusely and left him sore for some days. Then for twenty-seven years
he had no further trouble, but at the end of that time he began to
experience what he believed were attacks of dumb ague, and the scrotum
began to swell and felt sore on firm pressure. Heavy, aching pains then
followed. This condition of things lasted for over five years, varied by
the appearance of carbuncles on the nose and elsewhere, to relieve the
monotony of the thing. From this time on, abscesses began to form in the
scrotum and into the integument of the penis, burrowing forward into the
prepuce, which was much swollen and painful. A gangrenous opening
effected itself in the dorsal surface, which relieved him somewhat. The
patient was finally examined by Dr. Otis, who found a badly strictured
urethra, the strictures beginning at the meatus, and at intervals
extended down as far as two and three-fourths inches. The case had no
venereal history, the patient never having had any disease or anything
of the kind. The strictures were plainly the result of the
balano-posthitic attacks as much as they were the cause of the
degeneration of the mucous membrane in the lower urethra, that allowed
of the infiltration of urine into the tissues, which caused all the
systemic disturbances, abscesses, misery, and agony of the patient,
depriving him of comfort, sleep, or ability for labor, and which sent
him here and there in search of health and relief.
It would seem really as if a prepuce was a dangerous appendage at any
time, and life-insurance companies should class the wearer of a prepuce
under the head of hazardous risks, for a circumcised laborer in a
powder-mill or a circumcised brakeman or locomotive engineer runs
actually less risk than an uncircumcised tailor or watchmaker. They
recognize the danger that lurks in a stricture, but what a prepuce can
and does do, they entirely ignore. I have not had any opportunities for
comparison, but it would be interesting to know, from the statistics of
some of these companies, how much more the Hebrew is, as a
premium-payer, of value to the company than his uncircumcised brother.
Were they to offer some inducement, in the shape of lower rates, to the
circumcised, as they should do, they would not only benefit the
companies by insuring a longer number of years, on which the insured
would pay premiums, but they would be instrumental in decreasing the
death-rate and extending longevity.
I have seen so many cases of stricture whose origin could be traced to
balanitis that it can almost with confidence be assumed that, wherever
there is a long prepuce with a red and inflamed meatus in a child, that
unfortunate child will be a victim of fossal strictures when arrived to
manhood, and that, moreover, he will be a surer victim to the reflex
neuroses which so often accompany strictures, and which have been so
ably described by Otis, than the victim of uncomplicated strictures
acquired in the worship of Venus. There is no end to the misery that
these poor fellows have to suffer, besides the habitual hypochondriacal
condition into which the accompanying physical depression, throws them;
it unfits them for business, any undertaking, or even for social
enjoyment or entertainment; they keep themselves and their families in
continued hot water. These subjects are, also, more prone to gouty and
rheumatic affections, asthma, and other neuroses.
Among the many cases of nervous disorders simulating other diseases that
I have seen relieved were two Jewish lads with an imperfection of the
meatus. They were two brothers, and from the history of the cases, and
that given me by the mother of the lads in regard to the father, the
malformation must have been hereditary and congenital. It consisted of a
partial occlusion of the meatus by a false membrane, which divided the
meatus in two, horizontally, but which was closed at the posterior end
of the lower passage, which readily admitted a probe from the front as
far as the occlusion, about a third of an inch to the rear. The
restoration, or rather the making the anterior urethra and meatus to
their normal condition, relieved both boys of asthma, under which they
had labored for years.
The many cases simulating the general disturbances that accompany many
kidney disorders, that are simply the result, in their primary causes,
of preputial irritation and the disturbances to the kidney function due
to the same cause, have long induced me to look upon the prepuce as a
great and avoidable factor to some of the many forms of kidney diseases,
prostatic enlargements, vesical diseases, and many other diseases of the
urinary organs, which we know full well can result from strictures, as
the latter need not always act in a purely mechanical mode to do its
full extent of mischief.
One result of these preputial irritations not generally or particularly
mentioned in any of our text-books--a condition far-reaching as regards
its own results, and more annoying and serious than it appears at first
sight--usually begins with a reflex irritability of the anal sphincter
muscle, or a rectal irritation of the same order, which in time produces
such organic change that an hypertrophied and irritable, indurated,
unyielding muscle is the result. Agnew, of Philadelphia, describes the
condition, but does not mention this frequent cause under the name of
sphincterismus; once this is established, the train of resulting
pathological or diseased conditions that may follow are without
end.[108] This is no fancy sketch, nor will the student of the pedigree
and origin of diseases feel that the case is exaggerated or imaginative.
These are some of those cases that are always ailing, never well and
really never sick, but who are, nevertheless, gradually breaking down
and finally die of what is termed "a complication of diseases," before
living out half their term of life.
How this happens is simple enough--the straining required to produce an
evacuation is out of all proportion with the character of the discharge;
such patients often complain of being constipated when the evacuations
are semi-fluid; this straining is followed by a dilatation and
consequent loss of power of the rectum, which becomes pouched and its
mucous membrane thickened; the whole intestinal tract sympathizes and
digestion is interfered with, and the forcible expulsive efforts affect
all the abdominal and thoracic organs in a more or less degree, laying
the foundation for serious organic diseases. Now, this condition, which
may be said to be no more than one of obstinate constipation, is a far
more reaching condition and a far more injurious state than can be
imagined at a first glance. Constipation is not, as a rule, always
accompanied by the indigestion, either stomachic or intestinal, that
goes with this condition; the contents of the intestines in simple
constipation may simply lack fluidity without undergoing putrefactive
fermentation, but in this condition the undigested and retained
intestinal contents do undergo that change, resulting in the generation
of material whose re-absorption produces a toxic condition of the blood,
from whence begins a series of serious organic changes in the blood, and
from this in the organs.
To the practical physician these changes are evident and their cause
just as plain, and it is just here where the laity lack the proper
education, and where they should understand that the intelligent
physician generalizes the disease and only individualizes the patient;
and it is this ignorance on the part of the laity that gives to
empiricism and quackery that advantage over them, as they look upon all
disease as a distinct individual ailment, that should have an equally
distinct and individual therapeutic agent to cope singly with. The laity
know very little of these things, and in their happy ignorance care
still less for the finer definitions of or of the clinical importance of
toxaemia, or the processes of abnormal conditions that lead up to such a
state, or the results that may follow when that condition is once
reached. To them, dyspepsia is an indigestion ascribable to the stomach,
and a sick-headache is ascribed to something wrong about the stomach or
liver.
The laity have never been called upon to answer the questioning of the
late Prof. Robley Dunglison: "What do you mean, sir, by biliousness? Do
you mean, sir, that the liver does not secrete or manufacture a
sufficiency of bile, or not enough? Do you mean that the bile-material
is left in the blood, or too much poured in? Do you mean that there is
an excess in the alimentary canal, and a deficiency elsewhere? Please,
sir, explain what you really mean by the term 'bilious!'" The Professor
had a way about him that at least made one stop and seriously inquire,
before adopting any random notion in regard to medicine. It is to be
regretted that, in the humdrum tread-mill work of many physicians, they
even have to drop into the commonplace way of treating dyspepsias and
such ailments without any further inquiry. A farmer knows better than to
drive a dishing wheel, or with merely having a nail clinched in the
loose shoe of a valuable horse; but he is fully satisfied to do so in a
metaphorical sense, as regards his own constitution, and the mere hint
from his physician that he had better lay up for repairs, or that there
is something wrong about him that will require investigation, and that
there is an ulterior cause to his feeling tired, headachy, or dyspeptic,
or an allusion that there is something systemic, as a cause, to his
momentary attacks of disordered vision or amaurosis, will generally make
him look on the doctor with mistrust.
The merchant, banker, and mechanic are not up to Professor von Jaksch's
ideas of toxaemia,--that toxaemia may be exogenous or endogenous, or that
the latter is further subdivided into three more varieties,--and, what
is worse, he cares still less. The above three classes of humanity, when
sick, simply would want to know if Professor von Jaksch was good on
dyspepsia, the measles, or typhoid fever. They care very little that he
divides endogenous or auto-toxaemia into that produced by the normal
products of tissue-interchange, abnormally retained in the body, giving
rise to uraemia, toxaemia from acute intestinal obstruction, etc., the
above being the first division. The second depends on the outcome of
pathological processes, which change the normal course of assimilation
of food and tissue-interchange; so that, instead of non-toxic, toxic
matter is formed. The second group he names noso-toxicoses, which he
subdivides into two principal divisions:--
(_a_) The carbohydrates, fats, or albuminous matter, which may be
decomposed abnormally and give rise to toxic products, _e.g._, diabetic
intoxication, coma carcinomatosum.
(_b_) A _contagium vivum_ enters the body through the skin, or the
respiratory or digestive tract, and develops toxic agents in the tissues
on which it feeds, as in infectious diseases.
In the third group the toxic substance results from pathological
non-toxic products, which again produce a toxic agent, only under
certain conditions. This group he calls auto-toxicoses, and includes in
it poisonous substances, resulting from decomposition of the urine in
the bladder, under certain pathological conditions, and giving rise to
the condition called ammoniaemia. (_Medical News_ of January 7, 1891;
from _Wiener klinische Wochenschrift_ of December 25, 1890.)
As observed above, unfortunately the patients know nothing, nor can they
be made to understand these conditions, that are only reached through
labyrinthic pathological processes, and, what is still worse, this way
of looking at disease is incompatible with the idea of specific-disease
treatment, which to them looks more practicable and quick, and which is
also more to their liking. They cannot see any sense in such reasoning,
which to them is something eminently impracticable; neither can they see
a reasonable being in the doctor who practices on such, as they call
them, _theories_.
The practical physician, however, sees in Professor von Jaksch's
summary the turning-point of many a poor fellow's career,--from one of
comparative health into one of organic disintegration, decay, and
dissolution,--all the required processes starting visibly from the very
smallest of beginnings; any obstruction in the urinary tract or
intestinal canal being sufficient to start any of the conditions which
end in toxaemia; and, from a careful observation running over several
years, I do not think that I am assuming too much in saying that a
balanitis is often the tiny match that lights the train that later
explodes in an apoplectic attack or sudden heart-failure due to toxaemia;
the organic and vascular systems being gradually undermined until,
unannounced and unawares, the ground gives way and the final catastrophe
occurs,--unfortunately, an occurrence or ending looked upon as
unavoidable by the friends of the victim. They cannot see any danger;
the idea that diseases have the road paved, not only for an easy
entrance but an easy conquest, by the action of these toxic agents on
the tissues, is something that they cannot grasp. These blood changes or
blood conditions are things too intricate, and the physician who
understands them is, to them, a visionary and unpractical man. These
conditions are, however, neither new nor unknown, and there is really no
excuse for the ignorance exhibited in these matters by the general
public, as it is through the blood that this mischief takes place. They
can reason in their impotent way, that they should drench themselves
with "blood tonics" and all manner of nauseous compounds to "purify"
their blood, but the simple, scientific truth is something beyond their
understanding, as well as something that they steel themselves against.
Sir Lionel Beale, in observing the immense importance he attaches to
blood composition and blood change in diseases of various organs, truly
remarks that "blood change is the starting-point, and may be looked upon
as the cause, of what follows," the other factor being the "'tendency'
or inherent weakness or developmental defect of the organ which is the
subject of attack;" to which he adds that he feels convinced that, if
only the blood could be kept right, thousands of serious cases of
illness would not occur; while the persistence of a healthy state of the
blood is the explanation of the fact that many get through a long life
without a single attack of illness, although they may have several weak
organs; and that an altered state of the blood, a departure from the
normal physiological condition, often explains the first step in many
forms of acute or chronic disease. Sir Lionel has been a pioneer in the
field of thought that looks for the cause of the disease, which, however
remote it may be, should not be overlooked as a really primary
affection. His extensive labor in the microscopic field has fully
convinced him that many of the pathological changes in the different
organs are due to what might be called some intercellular substance that
is deposited from the blood. (Beale: "Urinary and Renal Disorders.")
Toxic elements in the blood affect the kidneys in a greater or less
degree, and there produce changes at first unnoticed,--at least, as long
as the kidney can perform its function,--but the day arrives when, as
described by Fothergill, blood depuration is imperfect, and we get many
diseases which are distinctly uraemic in character, and ending in any of
the so-called kidney diseases, Bright's disease being one of the most
common. As observed by Fothergill, however, the kidney is not the
starting-point, the new departure only taking place when the structural
change on the kidney has reached that point that it is no longer equal
to its function--the "renal inadequacy" of Sir Andrew Clarke. (J. Milner
Fothergill, in the _Satellite_, February, 1889.)
During the Bradshawe lecture, Dr. William Carter made the following
remarks: "According to Bonchard, one-fifth of the total toxicity of
normal urines is due to the poisonous products re-absorbed into the
blood from the intestines, and resulting from putrefactive changes which
the residue of the food undergoes there." In the course of the lecture,
Dr. Carter fully explains that one of the benefits derived from milk
diet in Bright's disease is the small residuum deficient in toxic
properties, and lays great stress on the employment of intestinal
disinfectants or antiseptics that exercise their influence throughout
the whole tract, suggesting naphthalin as peculiarly efficacious,
thereby cutting off one source of blood contamination at its source.
Although these are recent developments in medicine, Bonchard mentions
that in the practice of M. Tapret cases treated on this principle did
well. (Braithwaite's _Retrospect_, January, 1889.)
Persons laboring under this toxic condition of the blood, with a
consequent deterioration in the texture and the physiological function
of the vital organs, are of that class that easily succumb to injuries
or serious sickness, and of that class to whom a surgical operation of
even medium magnitude is equal to a death-warrant.
The above conditions are an almost constant attendant on that condition
of the sphincter described by Agnew as sphincterismus, which also is
productive of haemorrhoids and fissure, and often of fistula. That
sphincterismus is caused in many cases by preputial irritation is as
evident as that the same affection, or haemorrhoids or any other rectal
or anal affection, will, in its turn, produce vesical and urethral
reflex actions, and primarily functional and secondarily organic changes
in those parts. Besides, the great number of cases wherein the gradual
and progressive march of each pathological event could be traced with
accuracy has convinced me of the true cause of the difficulty being the
result of reflex irritation.
Delafield, in his "Studies in Pathological Anatomy," gives, as the first
form of pneumonia, that from heart disease; in the days of Broussais
this would have sounded absurd, but, to-day, some forms of heart disease
are known to be the regular sequences of some particular form of kidney
disease, just as some form of pneumonia attends an affected heart and
that some forms of pneumonia degenerate into phthisis. When the blood
change is an established fact, it is only a question as to which is the
weak organ, and the organism of the individual will decide whether it
will be a simple sick-headache or the beginning of a pneumonia ending in
phthisis.
I have purposely dwelt on this part of this subject, owing to the recent
origin and publication of many of the views connected with it; also on
account of the greater ease of making the subject plain by fully
discussing each step of the process; and if the views of Sir Lionel will
be recalled, that a toxic element in the blood is the starting-point,
and that an irritable or weakened organ invites destruction,--the
induction of serious and fatal kidney disorder by the transmitted
irritability and consequent injury to the kidney produced by preputial
irritation in the first instance, and the supplemental blood-poisoning
by intestinal absorption of septic matter, which soon brings about Sir
Andrew Clarke's "inadequacy of kidney,"--all will be readily understood.
When this point is reached, a too hearty meal, exposure to variable
weather, or a little extra care or anxiety, are sufficient, as
determining causes, to bring life into danger.
As pointed out, many cases of Bright's disease or other renal difficulty
have their origin in this distant but visible source, and, although
malarial poisoning and a great number of other causes will produce the
same particular organic changes and diseases, this condition must be
admitted as one of the frequent causes. The influence of the
genito-urinary tract on the rest of the economy, and the importance of
the sympathy it excites, or how quickly, by its being irritated, some
apparently dormant pathological condition will be awakened to life and
activity, is not sufficiently appreciated. As observed by Hutchinson, a
patient who has once been the subject of intermittent fever is more
prone, on catheterization, to have a urethral chill and fever than one
who had never had the fever. (Hutchinson: "Pedigree of Diseases.")
Ralfe observes, in his "Kidney Diseases," that long-standing disease of
the genito-urinary passages must be reckoned as among the chief
etiological factors of chronic interstitial nephritis (page 227). The
condition of the kidneys in cases of strictures of long standing is
known not to be a reliable one, and any incentive to dysuria or to
retention, no matter how slight, is apt to lead, eventually--and that
even in very young subjects--to that toxic condition mentioned in a
former part of this chapter as one of von Jaksch's subdivisions of
toxaemia, the ammoniaemia of Frerichs; this condition being the fatal
ending of the case of the two-year-old child mentioned by Henoch, who
died after the relief of a retention due to phimosis and calculi
resulting from the phimotic occlusion. Having seen so many cases wherein
the conditions described in this chapter were so apparently--whether
from ammoniaemia due to infection, or toxaemia from the urinary tract, or
uraemic toxaemia from the intestinal tract--all due to some preputial
interference or irritation, I cannot help but feel that in these
conditions--which, singularly, are not so prevalent with the Hebrews as
with Christians--we have one factor in the cause of the shorter and more
precarious vitality of the latter.
Morel, in his "Traite des Degenerescences Phisiques," ably discusses the
degenerative and morbific influences and results of toxaemia, as well as
he clearly defines their sources. The connection between toxaemia and
mental affections has already been shown, and Prof. Hobart A. Hare, in
his instructive and interesting prize essay on "La Pathogenie et la
Therapeutique de l'Epilepsie (Bruxelles, 1890)", mentions that
convulsive disorders resulting from the presence of some toxic substance
are of frequent occurrence. How much this may enter as a partial factor
into many of the cases of epilepsy which are classed in the order of
"reflex" may well challenge our consideration. Hare lays great stress on
the necessity of circumcision wherever there is an indication of
preputial local irritation. "If practicable, circumcision should be
performed; it is an operation with but small risk or danger, and easy of
performance. In such circumstances it is always permissible to
circumcise, were it for no other end than an acknowledged attempt to
reach a cure."