Chapter 27

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 toxæmia, 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 toxæmia,--that toxæmia 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-toxæmia into that produced by the normal products of tissue-interchange, abnormally retained in the body, giving rise to uræmia, toxæmia 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 ammoniæmia. (_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 toxæmia; 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 toxæmia; 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 uræmic 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 hæmorrhoids 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 hæmorrhoids 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 toxæmia, the ammoniæmia 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 ammoniæmia due to infection, or toxæmia from the urinary tract, or uræmic toxæmia 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 "Traité des Dégénérescences Phisiques," ably discusses the degenerative and morbific influences and results of toxæmia, as well as he clearly defines their sources. The connection between toxæmia and mental affections has already been shown, and Prof. Hobart A. Hare, in his instructive and interesting prize essay on "La Pathogénie et la Thérapeutique de l'Épilepsie (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."