Note 103 — Chapter XXIII · Reflex Neuroses and the Prepuce.

In looking over the literature of reflex neuroses and more direct injurious results, I find that George Macilwain, in a work on “Surgical Observations on the More Important Diseases of the Mucous Canals of the Body,” published in London in 1830, calls special attention to the case of a man aged thirty-eight, admitted to the Finsbury Dispensary, and who was in the care of Mr. Hancock. The patient was suffering from excruciating pain in different joints, the pain being so great that he was confined to his bed and unable to stand on his feet. He was unable to rest at nights, and neither rheumatic nor any other apparently suitable treatment was of any service. Rigors were soon added to his other troubles, and during their continuance the pain in his joints was greatly aggravated. He was referred to Mr. Macilwain for treatment, who promptly relieved him by the removal of a urethral stricture, which had quietly been the cause of all the disturbance. It is particularly interesting that even at that early day the reflex neuroses and complications that may arise from the irritability of the genito-urinary organs were so well understood. How well Dr. Macilwain appreciated the nicety of these relations can be seen from his remarks in connection with the above case, in which he says: “It may be observed that the severity of the symptoms is not always commensurate either with the duration of the disease or the degree of stricture, and that, although the progressive development of them varies considerably in rapidity, in different individuals, it is, nevertheless, in the latter stages, always more rapid.” Macilwain also graphically describes the insidious approach of these genito-urinary troubles. In speaking of stricture he says: “Although minute inquiry generally informs us that the stricture has been of some standing, and in some instances has existed for years, yet it may happen that it is only a few months or a year since the patient’s attention has been directed to the disease. This is very intelligible; for, in conformity with what we observe in other parts of the body, the bladder has a power of accommodating itself to a change of circumstances. Its strength, for a long time, may increase so correctly in proportion to the increase of the obstacle which opposes the ejection of its contents that a very considerable period elapses before the difficulty in making water becomes cognizable to the patient, or it occasions an annoyance so trifling as scarcely to excite his attention. This increase of strength in the bladder frequently renders the formation of stricture so insidious that the urethra at the affected part is very narrow before the individual is aware of the existence of any contraction whatever; the bladder, however, at length becomes unable to empty itself, and the abdominal muscles and diaphragm powerfully act as coadjutors, so that each effort to make water is accompanied by a straining which is very distressing, and the complete evacuation of the bladder is often not accomplished even by these combined forces. The straining which accompanies stricture, and which seems necessary to evacuate the bladder, although it be occasionally exceedingly annoying to the patient at the time, is more important with reference to the results which are its consequence. I am firmly of opinion that there are a great number of patients laboring under hernia which has been produced by no other cause. I must confess that I had seen a great number of instances of stricture in ruptured patients before I drew any inference from the observation of their co-existence.” The foregoing observations of Macilwain, made in 1830, are here reproduced for their clearness of expression and explanation, as well as to show what injuries can be produced on the young child afflicted with phimosis. We are, as surgeons, familiar with the anatomical and pathological changes there are undergone by the bladder and its lining membrane, as well as in the ureters and kidneys, in many cases of stricture, as well as of the great amount of prostatic irritability and enlargement that is due to the same cause. How similarly these results can be and are actually produced by phimosis is undeniably expressed by the post-mortem appearances in the poor infant described by Golding Bird to the London Medical Society, and mentioned in the London Lancet of May 16, 1846. The bladder and ureter were like those of a man who had long suffered from stricture. From the remarks of Dr. J. Lewis Smith, that phimosis may be productive of inguinal hernia and prolapsus of the rectum, and the observations of Edmund Owens and Arthur Kemp, both high authorities on children’s diseases, being both connected with children’s hospitals, as well as the remarks of Mr. Bryant in his “Surgical Diseases of Children,” who all concur in looking upon phimosis as a great factor in hernia, Bryant having observed thirty-one in fifty consecutive cases of phimosis, we are certainly warranted in assuming that phimosis is not only a mere local timely inconvenience that will disappear with the approach of puberty, but a condition which, in the more easily affected organism of the child,—lacking, as it does, that resistance that comes with our prime,—is productive of serious harm; as even the first few years of life, even a few months of infant life, with a phimosis, are sufficient to so change the structures of parts that the poor child will grow into a man with an impaired kidney or sacculated ureter. The strain required to induce a prolapsus of the bowel or a rupture into the inguinal canal is exerted as much on the bladder, ureter, and kidney as on the other localities. Physicians who have taken the pains to observe must have noticed, more than once, how the child afflicted with a phimosis has not only at times to wait for the stream of urine to appear, there seemingly being some obstruction to its starting, but how often such a case is afflicted with a stammering, halting urination. A child thus started out into life, with a defective kidney or kidneys, is sadly handicapped in his usefulness, comfort, or in properly competing in the race of life. No parent would for a moment think of starting his son in life by giving him a business that is heavily mortgaged at the start, but many a parent unconsciously launches the unsuspecting child into a life of such ill health—resulting from a simple narrow prepuce—beside which a heavy mortgage or a heavy yearly tribute would be but a mere trifle. I have seen such men, who in after life, broken-down and perfectly physical wrecks, would gladly have given all their wealth and been willing to have some genii set them down in the middle of the Sahara, shirtless and pennyless, provided they had their health. To say nothing of the trifling loss of the prepuce, these parties would gladly have had a foot or a leg go with the prepuce if necessary, and have their health.