V THE EFFECT OF 7 • GENITAL IRRITATION IN THE Production of Nervous Disorders. * » By LANDON CARTER GRAY, M. D., OF BROOKLYN, LECTURER ON DISEASES OF THE NERVOUS SYSTEM, AND UPON THE ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM, LONG ISLAND COLLEGE HOS- PITAL ; VICE-PRESIDENT AMERICAN NEUROLOGICAL ASSOCIATION ; FIRST VICE-PRESIDENT NEW YORK NEUROLOGICAL SOCIETY | LATE VICE-PRESIDENT BROOKLYN ANATOMICAL AND SURGI- CAL SOCIETY ; MEMBER OF KINGS COUNTY MEDICAL SOCIETY, BROOKLYN PATHOLOGICAL SOCIETY, NEW YORK THERAPEUTICAL SOCIETY, NEW YORK MEDICO-LEGAL SOCIETY. REPRINTED FROM THE AN'NALS OF ANATOMY AND SURGERY, JAN. AND FEB,, 1882. BROOKLYN, N. Y. Unu>n»Akgus Steam Printing Establishment, Fulton and Front Sts. 1882. THE EFFECT OF GENITAL IRRITATION IN THE PRODUCTION OF NERVOUS DISORDERS.1 By LANDON CARTER GRAY, M. D., OF BROOKLYN, LECTURER ON DISEASES OF THE NERVOUS SYSTEM IN THE LONG ISLAND COLLEGE HOSPITAL. WE are apt to forget how easy it is to start a fashion in medicine. Let any one—if he be of eminence, so much the better—advance a new opinion, in support of which he shall cite cases that contain sufficient truth to give them an air of value at first sight, then let him make some earnest and confident assertions of opinion, he who deludes himself carrying, of course, infinitely more conviction than he who merely deludes others—and the thing is done. The journals, hungering for novelties, circulate the news. The profession itself, I am tempted to say almost in proportion as it is intelligent and studious, has a strong tendency to mistake novelty for progress. From hospitals and clinics come manifold seeming confirmations. It may even happen that the original writer is outdone, and lengths are easily reached that were far beyond his vision. A warning voice may here and there be raised, but it must be of authority to create more than an echo, and even then it may fail to effect its purpose. So the discovery advances on a royal road, swelling with the bulk of success at every step. It is diffi- cult to stay it. It is always difficult to dislodge an idea from 1 Read before the New York Neurological Society November i, 1881. Reprinted from the Annals of Anatomy and Surgery, Vol. v., Nos. I and 2, January and February, 1882. 2 LAN DON CARTER GRAY. the aggregate mind of a mass of men, especially of profes- sional men ; but when it has stolen in under the guise of science or art it is likely to be guarded with a particularly jealous care. Being in possession, it holds on with the ten- tacles of mental habit; many observations have been adduced in proof of it; the refutations come late and are few in num- ber as compared with the confirmations ; the confirmations have perhaps taken possession of a thousand minds, whilst the refutations may make an uncertain impression upon a hundred ; many who have publicly announced their belief keep secret the lack of faith that may come to them ; there are few who possess the habit of mind that would lead them to critically weigh the evidence, and fewer still who will trouble themselves to do this weighing. So Error, fleet-footed, speeds its way, while Truth comes tardily after, if it come at all. The history of the question of reflex paralysis is an illustra- tion of this course of events. And here let it be premised, before we plunge into the thick of our subject, that by reflex paralysis is meant one dependent upon irritation of some peripheral nerve, either of the internal or external tissues, which is attended by no structural alterations of the nervous centres visible to the microscope, and which is relieved by the removal of the irritation. This is, of course, a some- what arbitrary limitation of the term, although it is sanc- tioned, I believe, by the tacit unanimity of all the authors. Some of the older writers, whose works are curiosities to-day, have written passingly of cases of this kind, which they attributed to lesions of the sympathetic.1 But the really initial paper upon this subject was the celebrated one published by Mr. Stanley in 1833.2 He had collected 1 Thus Joseph Franck, Helmstedt, 1750, quotes Conrad Fabricius ; Whytt (observations on the Nature, Causes, and Cure of the Disorders which were commcnly called Nervous, Hypochondriac, Hysteric, etc., Edinb., 1767) has some remarks ; also, Prochaska: Institution physiologiae humanae, vols. i. and ii. Vienna, 1806. s Urinary Paraplegia. Medico. Chir. Transact., vol. xviii, 1833, p. 260. GbNlTAL IRklTA TION. 3 A number of instances in which disease of the kidneys or urethra had been accompanied or followed by paralysis and other grave nervous disorders, in some leading to a fatal issue. Marked lesions being found in the genito-urinary apparatus, and none being apparent to the naked eye in the spinal cord, he concluded that the nervous symptoms were of a reflex nature. His theory was probably based upon the writings of Marshall Hall, which had just been published with illustrative cases, upon the excito-motor or reflex functions of the cord. Mr. Stanley did not wait long for followers of distinction. Rayer, in France ; Henoch and Romberg in Germany ; Holland and Graves in Great Brit- ain ; then Notta, Leroy d’Etiolles, Esnault, Landry, Ma- cario ;—from these authors came a number of instances of paralysis seemingly caused by genito-urinary disease, in- testinal troubles, worms, even pleuritic and pulmonary affections.1 Comhaire brought physiological aid to the cause by his assertion that removal of a kidney from a dog caused paralysis on the same side.2 It was not until 1856, twenty-three years after the publication of Stanley’s paper, and after it had met with general professional accep- tation in the three most civilized countries of the world, that a capable, virile critic arose in the person of W. Gull, now Sir W. Gull, to call attention to the fact that Stanley’s 1 It is perhaps unnecessary, at the same time that it is exact, to give the precise references to these names : Rayer. Trait6 des Maladies des Reins, vol. iii. Henoch: quoted in Leyden, Klinik der Riickenmarks-krankheiten, II. Bd. iste Abth. S., 215. Romberg. Lehrbuch der Nervenkr. 1846. Dr. Calvert Holland. Edin. Med. and Surg. Journ. 1845. Vol. lxiii., p.325. Graves : Clin. Lectures on Pract. Med. Leroy d’Etiolles : Des Paralysies des Membres inferieurs. Paris. 1856. Esnault. Des Parapl6gies Symptomatiques de la metriteet du phlegmon uterin. Paris. 1857. 1 have not been able to obtain these two latter monographs. Macario : Union Aldd. 1859, p. 276. Notta : Archives de AUd. Nov., 1854, p. 556. 2 Sur l’exstirpation des reins. Paris. 1840. (I know of this work only by quotation.) 4 LAN DOM CARTER GRA V. cases were utterly worthless as proof of reflex paralysis. Mr. Gull wrote still more forcibly upon the subject again in 186f, in a paper which Dr. Weir Mitchell very properly designates as brilliant.1 In both these communications he pointed out, what it should seem might have been at least suspected half a century ago, that marked lesions of the cord might exist without being apparent to an eye unarmed with a microscope ; moreover, that, even according to Mr. Stanley’s own statements, several of the cases reported did present some evidence of gross disease of the cord or its membranes; and, finally, an instance is related in which gonorrhoea and syphilis were followed by paraplegia, termi- nating fatally, when the cord, macroscopically sound, was found to have undergone “a fatty degeneration” below the sixth dorsal vertebra. The tide of opinion now turned in the opposite direction—whether from the example set, or from the more extended study of nervous disease with the microscope, or from both causes combined, it would be diffi- cult to say after this lapse of time. Jaccoud followed in the same sceptical vein in France.3 Hasse and Valentiner raised their voices in protest in Germany,3 and Romberg formally abandoned the theory of reflex paralysis in the third edition of his work. Leroy d’Etiolles 4 extirpated the kidneys of dogs without the supervention of paralysis, thus flatly contradicting Comhaire. Kussmaul5 had the good fortune to make a post mortem examination of a man who became paraplegic during chronic cystitis, and in whom he 1W. Gull. Medico. Chir. Transac. 1856. Vol. xxxix., p. 195. Guy’s Hosp. Rep. 1861. 2 Jaccoud. Les Parapl6gies et l’ataxie des mouvements. Paris. 1864. P. 353- 3 The writings of these two gentlemen seem to be rather mythical, for, although they are alluded to by many, no one gives a reference, and I have been unable to lay hand upon their articles. 4 Op. cit. 6 Wiirz med. Zeitschrift, iv., p. 56, 63. (I know this only from the quota- ions in Leyden and Jaccoud.) Genital irritation. 5 found atheromatous degeneration of the hypogastric arteries and fatty transformation of most of the nerve tubules of both sciatics. Leyden reported two interesting cases of paralysis, seemingly caused by vesical disease, in one also accompanied by long-standing urethral strictures, and in whom the cord was intensely and extensively softened, there being also cerebral foci of disease; the myelitis, too, had begun at the points of exit and entrance of the vesical nerves. Weir Mitchell, in our own country, made clear, by a searching analysis of the various cases, that there was grave doubt as to whether the genito-urinary lesions in many of them were not the results or accompaniments of spinal disease, instead of being the causes.1 Notwithstand- ing this long array of proof in contravention of Mr. Stan- ley’s conclusions as to reflex paralysis from genito-urinary disease, M. Brown-Sequard steps forth, as late as 1873,2 as a champion of the old doctrine, cites all the old histories, and gives minute directions for the recognition of this par- ticular form of palsy. But this has been a mere episode in the march of science. Tiesler,3 Feinberg,4 and Klemm 5 have demonstrated, by experiments on dogs and rabbits, that neuritis of the sciatic nerve, induced artificially by caustics and irritants, can set up myelitis, and peri-pachy- meningitis, which is often extensive, in one instance reach- ing to the cerebrum; and at the present day all the leading writers on nervous diseases have almost entirely discarded the older views, some of them admitting rare exceptions, it is true, but exceptions which constitute an exceedingly 1 At. Y. Med. Journal. 1866. Part second. * Lectures on Diag. and Treatment of the Principal Forms of Paralysis of the Lower Extremities. Phila. Lippincott & Co. 1873. 3 Ueber Neuritis. Konigsberg. 1869. # 4 Ueber Reflexlahmungen. Berlin -. Klin. Wochenschr. 1871, No. 41, and 1874, No. 44-46. 6 Ueber Neuritis Migrans. Strasburg. 1874. 6 La Arno at carter Or a v. meagre outcome of the claims that have been made in the past. In this country the question has assumed a different phase during the last decade, owing to the energy and wide- spread reputation of a New York physician. In the cases of which we have been speaking the alleged cause of the paralysis was in the kidneys, bladder, prostate, urethra, uterus, or intestines. Dr. Lewis A. Sayre, in two articles, one published in 1870, the other in 1875,1 has claimed that phymosis, adherent prepuce, and irritable clitoris, are fre- quent causes of paralysis in children, of retention of urine, and of many slighter nervous disorders. Dr. I. Baker Brown, of London, had before this set the medical world of England by the ears concerning the value of clitoridectomy for the relief of epilepsy, hysteria, catalepsy, etc., and had provoked a furious discussion, partly medical, partly ethical, that culminated in his trial before the Obstetrical Society of London, his expulsion therefrom, and his resignation from the London Medical Society—harsh measures, doubt- less, which could only have been taken in consequence of grave indiscretion on the part of the accused, or because of great intolerance on the part of his accusers.2 Mr. Thomas Bryant, in 1868, had narrated the histories of eight cases of urinary difficulties in childhood from elongated and adher- ent prepuce.3 In 1872 Barwell followed with the narrative of two cases of paralysis in children claimed to have been relieved by circumcision.4 Dr. Otis, of New York, has sup- plemented Dr. Sayre’s second paper with several interesting 1 Transact. Atner. Med. Assoc., vol. xxi, 1870, p. 205 ; and vol. xxvi, 1875, P 255- 2 Vide his work : On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females. London; Hartwicke. 1866. Also discussion on clitoridectomy through 1866 and 1867, in Lancet, as well as an account of his trial. 3 Congenital Phymosis, Med. Times and Gazette, May 10th, 1878. 4Lancet, 1872, p. 551, GENITAL IRRITATION. 7 histories of nervous irritations thought to have been caused by this genital lesion.1 The matter has attracted wide- spread attention, so much so that one would be thought to be lacking in precision did he not examine the genitals in all cases of slight nervous disturbance. Some enthusiasts have carried the matter so far as almost to look upon cir- cumcision as a panacea, and one well-meaning gentleman of my acquaintance, who had charge of a general clinic several years ago, made such slaughter among the innocents that the mothers of his section of the city ceased bringing their male children to him. Another gentleman even, as we shall learn later, believes that he has relieved cerebral softening by circumcision, as he was courageous enough to say, ten years before, that he had cured a general paralysis with in- sanity in the same manner. A matter that, to use Bacon’s familiar phrase, thus “comes home to our businesses and bosoms,” merits critical examination. In the first place, then, what evidence is there that genital irritation causes paralysis? For proof of this we must seek Sayre’s 2 and Barwell’s 3 cases. In Dr. Sayre’s first paper six cases are given: Case i. Boy, very white and delicate, aged 5 years, unable to walk without assistance, or to stand erect. Knees flexed at about angle of 450. When child’s attention was turned to something else, very little force could extend the legs nor- mally, but they returned to the flexed condition as soon as the hold was released. No irritation of the quadriceps could ex- tend them except slightly. Elongated, very tight and firmly adherent prepuce, meatus as inflamed as in a severe granular urethritis, and upon touching the urethral mouth an orgasm and slight convulsion were produced. Child frequently awoke in the night complaining of the pain in the penis, which was also evoked by the friction ot his clothing in riding. Circum- cision and adhesions loosened. In less than two weeks the 1 These can be found at the end of Dr. Sayre’s last article, cited above, * Op. Cit. s Op. Cit. 8 LAN DON CARTER GRAY. wound had healed. Improvement in the general health from the day of operation, and at the end of two weeks could ex- tend his limbs perfectly straight while lying on his back, and in five weeks could walk with limbs quite straight, being dis- charged as cured about a week after. The history is incomplete, as nothing is stated about the duration of the trouble, its onset, whether there was a return of the symptoms after discharge, and there is nothing to in- dicate that the patient was examined for organic nervous disease ; but so far as the history goes, it would certainly seem to be that of a delicate child whose penis was in an unusually and painfully inflamed condition, who instinctively flexed his legs to relax the strain of the abdominal muscles and keep away the clothing from the inflamed part, and who would not walk because of the suffering thus entailed. Con- sidering his youth and the agony he must have endured, it is by no means remarkable that a week passed after the healing before he would venture to stretch his legs, and three before he would walk alone. Case 2. Boy, aet. 14, paralysis of lower extremities for about four months. Phymosis. Circumcision done. Symptoms en- tirely relieved. Nothing is said about the degree of the paralysis, or as to whether it might not have been due to organic changes or other causes that could have passed away in four months. Case 3. Boy, aged 15. Said to have had “nervousness and fainting fits,” as well as “weakness and neuralgia of the legs, which caused him to trip easily and fall.” Fits once or twice daily, slightest irritation of the penis produced painful erections. Phymosis. Up to six weeks after circumcision he had no return of the fits, but nothing is said as to the effect of the operation on the legs. History very incomplete ; no proof that paralysis was due to genital irritation; and if the “fits,” which are not de- scribed, were epileptic in their nature, it would be quite GENITAL IRRITATION. 9 probable that circumcision in the case would cause them to cease temporarily. The histories of three other children are given in a gen- eral way in this first article of Dr. Sayre's. Three little boys, aged respectively 7, 9, and 13 years.(cases 4, 5, and 6), were brought to him in the second stage of hip-joint disease. They were said to have been clumsy boys, and to have been “tumbling down all the time.” Phymosis was found in all three cases, and irritable penes. Circumcision, to use Dr. Sayre’s own words, “ at once quieted their nervous irrita- bility.” This is absolutely all the history given. We are not informed whether they were suffering from spastic- spinal paralysis, 'such as has been described by Erb 1 and Seguin,2 whether it is meant that their irritable penes were relieved or their habit of stumbling, or whether the improve- ment was permanent. Dr. Sayre gives the following cases in his second article: Case 7. Boy, 33/3 years old. “ Has frequently through the day what the mother terms ‘ spasms of ecstacy,’ in which he laughs immoderately, and his eyes are bright and glistening, but yet he apparently sees no object, and the penis is in a state of extreme erection.” Cannot see, although eyes have been examined and found sound. “Unable to stand; incapa- ble of voluntarily contracting any of his muscles when stand- ing, or rather when being held in the upright posture, as it was impossible for him to stand, but when lying on his back for some time can move his hands and can turn over; but when held upright his legs always spasmodically cross each other, hands close, wrists flex, elbows the same; in fact, all the adductor and flexor muscles act and produce a strange distortion: the mouth opens, and there is a vacant stare of idiocy with a curious laugh of half intelligence. The penis is in a state of almost constant erection, and greatly excited at the least irritation. The meatus is red and tender. Teeth nearly all destroyed by medicine, and is now nourished on a 1 Ueber das Vorkommen der “ spastischen spinallahmung” bei kleinen Kindern. Memorabilien, 1877. 12 Heft. 2 Arch, of Med., February, 1878, p. 80. 10 LANDON CARTER GRAY. bottle.” Phymosis, firmly adherent prepuce. Hr. Sayre cir- cumcised him on the spot ; and at the next visit the child shook hands with him, which he had never done before in his life. Considerable improvement is said to have followed, but not a cure, as about eight months afterward “ it could not hold its head up with the strength of the normal child, although it could sit down and get up and stand balancing itself without assistance; could speak several words, and had acquired the power of eating.” This was very evidently a well-marked case of spastic disease, from what cause cannot be determined from the meagre history; but there is no proof that it arose from the genital irritation, and it is undecided as to how much of the improvement was due to the circumcision, how much to the cessation of the vigorous dosing that had destroyed the teeth, and how much to the inherent tendency of the dis- ease itself. Case 8. Boy, aet. 2. Eight months before had slight fever for a fewT days, then paralysis of lower extremities, most marked in left leg. Both lower limbs weak, left the most so. Half an inch atrophy of left leg. Muscles respond to electricity. Congenital phymosis. Improvement at once, and about three weeks after is said to have gained perfect use of limbs. Elec- tricity was used daily soon after operation. This was probably a case of myelitis of one anterior cornu, which was probably in a convalescent stage, at which such cases can be improved by circumcision, as I shall endeavor to show in due time, and which was probably greatly aided by the electricity. Case 9. Female, aet. Delivered by forceps. Unable to keep the body erect ; could not roll over. Cannot stand ; ad- duction of both lower limbs, which cross one another. Ad- ductors and tendones Achillis tense. Clitoris is red ; touching it excites spasm of thighs. Clitoris removed. Some slight improvement two days after, but it could not have caused much elation, because the tendones Achillis were cut on the third day and the child placed in a wire cuirass ; next—how long after the history does not state—the adductors on either side GENITAL IRRITATION. 11 were divided, and the legs kept abducted by two iron rods ; finally, electricity and a wheel-crutch are brought into play, although we are assured that “ the girl moves her limbs more readily, has more power over her body, and contraction at the knee daily lessening.” This was probably a case of meningeal haemorrhage, such as not infrequently occurs from forceps delivery, with secon- dary degeneration of the lateral columns of the cord. We can hardly be expected to regard the red clitoris as the cause. Case io. Retention of urine from paralysis of bladder, in man of 54 years. Phymosis. Catheterized on first day, again on second, and then circumcised. On third day passed his water voluntarily, and is said to have done so ever since, al- though there is nothing to show that Dr. S. ever saw him again, as he was a hotel patient. This case requires no comment. Case ii. Male, aet. Some lameness of right leg; trips and falls. Very slight pain on complete abduction and eversion oj the right thigh. Extension, adduction and flexion perfect ; penis large, extremely erected ; “ prepuce firmly adherent to the glans around urethral orifice, drawing it open when organ was erected.” Circumcision, and alleged cure in short time. The history is too incomplete to enable us to decide whether this lameness, which was apparently but slight, was due to pain in penis caused by certain muscular movements, as of abduction and outward rotation of the thigh, or whether the case was one of previous myelitis of the anterior horns, which had left this residue of paresis to be relieved by the circumcision, or whether the paresis was really caused by the genital irritation. Case 12. Case of asserted paralytic club-foot, about which Dr. Sayre was written. Phymosis, with adhesions. Circum- cision is said to have effected distinct improvement. Not enough of the case is told us to warrant any conclu- sions. 12 LAN DON CARTER GRAY. Case 13. Idiocy, spastic contraction of lower limbs. Clitoris very red and irritable, touch upon it causing spasm. No age given, or any other details whatsoever. Clitoris clipped and cauterized, and wire cuirass applied. Nutritious diet and tonics ordered. The history is certainly not precise enough to establish a new or decide a contraverted point. Case 14. Double varo-equinus, congenital, in child of 3 years. Mechanical treatment applied since child four months old. “ Feet were readily replaced in normal position by the hand, but immediately returned to their deformed posture when the support was removed. Phymosis. Circumcision. Two weeks after child »could stand flat upon his feet, with some inverson of left great toe. Although this does seem at first sight to have been a paralysis due to the phymosis, the removal of which seems to have cured it, yet in strict justice it must be borne in mind that it is not proven that it was not originally of or- ganic or other origin, nor that it was not due to the enforced rest of the prolonged mechanical treatment, and, moreover, no mention is made of the subsequent progress. In the appendix to his second article, Dr. Sayre adds these cases: Case 15. Male, 3§ years. Increasing feebleness of lower limbs for a year. “Could not stand without support, and even when supported his legs would bend in different direc- tions.” Phymosis, firm adhesions, which needed to be cut. Entirely well at the end of twelve days. This does certainly look like a paralysis from adherent prepuce, and 1 should believe it to be so if a full history did not contradict this scanty one. Case 16. Male, years. Became lame in left leg when one year old. Atrophy of left leg at time of examination. Child falls continually. Foot everted. Iron brace is worn on outside of leg. Phymosis. Circumcision. Five days after walks without a brace, does not fall down, and ran round the room for first time in two years. GENITAL IRRITATION. 13 How long had the limb been confined in the brace? And how can we determine how much relief came from the cir- cumcision and how much from removing the brace? Case 17. Reported to Dr. Sayre by letter from Dr. J. II. Adams, of Texas. It is simply the case of a gentleman of 27 who had had a large portion of the cutaneous surface of his penis behind the corona removed by some enterprising surgeon as a substitute for circumcision, in whom a dense cicatricial band formed at the site of the operation, who suffered great pain from it, and “whose locomotion,” very probably for this latter reason, “ became impaired.” Incision of the band re- lieved him. Case 18. Reported by letter from Dr. T. F. Leech, of Indi- ana. “ Paralysis of lower half of body; also spinal irritation” (?). Of this patient the doctor writes : “ Mr. John McGuire and wife, of our town, have but one child, a boy of fourteen months, who has been the terror of all this part of the town for six months, as he cries continually, except when asleep or nursed by his mother. He would lay perfectly quiet and squall !” This unpopular infant had phymosis and an adherent prepuce, as might have been expected ; and was circumcised, as was proper. Three days later he was said to have “ made marked improvement, and bids fair to make a rapid and complete recovery.” We are not told whether he made that recovery, and the history is too indefinite to permit of any deductions. Case 19. This seems to be rather a case of choreiform or chronic movements, said to have been relieved by circumcision, and is not germane to this part of my paper. Dr. Barwell reports two cases: 1 Case i. Boy, aet. 4. He had seemed ailing and fretful for a week before his mother noticed some impairment in his gait. At times becomes lost in thought, as it were, and has then a vacant stare. Phymosis, adherent prepuce. Circumcision. In a few days child is said to have walked as well as ever. There is nothing to indicate that the possibility of organic disease was considered. 1 Op. Cit. 14 LAN DON CARTER OR A V. Case 2. Girl, set. 5. Paresis of one leg of few months’ du- ration. Sometimes worse, sometimes better. Ascarides re- moved, and a vaginitis treated, and the child improved, but the leg was still atrophied three months after. Manifest to all men must be the objections to this history. To sum up, there have been twenty cases in all reported of alleged paralysis from genital irritation. In not one is the proof conclusive of this relation between cause and effect. In two cases there is some proof, but it is not sufficient (cases 14, 15). In two cases there was probably impaired locomotion from the pain of the irritated genitals (cases 1, 17). One patient had probably had meningeal haemorrhage during foetal life, and secondary degeneration of the lateral columns of the cord (case 9). Another was probably epilep- tic (case 3); another suffering from some spastic disease (case 7); still another from myelitis of one anterior cornu (case 8), and in twelve the histories were too indefinite to render any opinion justifiable (cases 2, 4, 5, 6, 10, 11, 12, 13, 18, and Barwell’s two cases). I have taken the trouble to address letters to Drs. S. Weir Mitchell, J. M. Da Costa, A. Jacobi, J. S. Jewell, Robert T. Edes, F. T. Miles, S. G. Webber, E. C. Spitzka, E. C. Se- guin, F. P. Kinnicutt, T. A. McBride, asking them if they had ever seen a case of paralysis from genital irritation, in which the proof of the facts was conclusive. They have all courteously answered me, and positively in the negative. Dr. Newton M. Shaffer has expressed the same opinion in a late article; and Dr. William A. Hammond has never seen a case resulting from preputial irritation. In view of the foregoing data and the acknowledged standing of these gentlemen as neurologists, the conviction is irresistible that genital irritation cannot cause paralysis, or does it very seldom. My personal experience, I may per- haps be permitted to say, is in accordance with that of my correspondents. GENITAL IRRITATION. 15 Yet there is good reason to believe that the operative procedures necessary to the relief of phymosis and adherent prepuce often cause considerable temporary improvement in cases of organic nervous disease, especially in the later periods. This is exemplified in cases 7, 8, 9, of Dr. Sayre’s papers, and in Harwell’s first case. Dr. C. Fayette Taylor tells of a boy about 2 years old, evidently a post-diptheritic paretic, who was circumcised by Dr. Fruitnight because of phymosis and adherent prepuce, and who derived great benefit from the operation.1 I have had four curious cases of this kind in my own practice. Case 1. Boy, about 3 years old, in whom a- diagnosis of tubercular meningitis was made. FI is prepuce was long, tight and firmly adherent. I was curious to learn what effect cir- cumcision would have upon him, and accordingly performed the operation. He at once began to sleep so much better, his irritable temper decreased so much, his appetite was so great- ly improved, he seemed so much more intelligent, that I should have doubted the correctness of my diagnosis had not the symptoms resumed their former intensity in the course of the second month, and had not an autopsy, some seven months afterward, displayed to me a tuberculous meningitis. Case 2. Boy 21/2 years old, who about a year previous had been confined to bed with slight fever for several days, then was paralysed in left leg, which shortly afterwards began to waste. Nocturnal incontinence. Drags left leg greatly in walking. Farado-contractility of the anterior tibial and calf muscles of this leg almost nil. The galvanic reaction was ascertained at the time, but no note was made of it, although I feel certain that it was the “ reaction of degeneration ” (Entartungsreac- tion). Diagnosis : Myelitis of one anterior cornu. Dong, tight and slightly adherent prepuce. After treatment with tonics, good diet, and electricity for four months without marked ef- fect, circumcision was done. The improvement in the general health and in the strength of the leg was marked, the drag- ging gait diminishing to a slight halt, and at this date, ten months after, the improvement has been maintained. 1 Annals of Anatomy and Surgery, Vol. iv., No. 1, July, 1881, pp. 4 and 48. 16 LAN DON CARTER GRA V. Casf, 3. Male, 23 years old. Fine, rhythmical tremor, on excitement and voluntary movement only. Diplopia about three to four months ago. Tremor confined to upper and lower extremities, not in the head or neck. Tendon-reflex normal. Worker in a brass factory for seven years, where he is surrounded by a fine dust of brass filings. On excitement his voice fails him. Diagnosis : Tremor, of disseminated sclerosis type, from brass poisoning. Phymosis and adherent prepuce. After six weeks’ treatment by the iodide of potash and the wearing of a wire respirator, the tremor greatly im- proved, but was still perceptible. He was then circumcised, and from that day forwards for upwards of two months, when I lost sight of him, he had no return of the tremor. Case 4. Male, aged 14. Is subject to attacks which com- mence by extension of right extremities, to which succeeds a tremor of them, and, when this has lasted for quite an inter- val, there ensues a tremor of the whole body. About half the time there would be a loss of consciousness, when the muscu- lar movements would be more severe, and would be followed by deep sleep. At times, after one of the conscious spells in the night, patient wrould cry for a long time, although, as he says, “ I knew I was crying, but I had to cry on, as I could not stop.” He would frequently walk about his room after an attack in a somnambulistic state. These fits would come as often as ten to fifteen times daily. Diagnosis.—Epilepsy, of the Hughlings-Jackson type. This condition had begun in 1874. On October 9th, 1874, I circumcised him because of phymosis and adherent prepuce. At first the fits were only slightly decreased in number, though not so severe; but in about ten days they ceased, none appearing from October 27th to December \6th, 60 days, when they slowly reappeared, one to three coming every three or four days, until they resumed their former severity and frequency by the middle of January. The bromides have a curious effect on this patient, which it is proper to speak of in this connection. They make him much worse, at times almost maniacal, after prostrating him physically to an alarming extent; but after they have been stopped he is always free from any of his nervous symptoms for a period varying from one to two months and a half. Where a genital irritation is removed by operation, we GENITAL IRRITATION. 17 have several factors at work that may be potent in effecting improvement. The patient usually obtains rest, as has been suggested by Dr. Shaffer, but this is usually short, in my own cases not extending over twenty-four or forty-eight hours, and is, therefore, obviously inadequate. An irritant is removed from an exquisitely sensitive organ, one so sen- sitive that the deepest stages of ether and chloroform nar- cosis must be reached before anaesthesia of it is produced. The profound impression upon the nervous system of ether- ization or chloroformization must be considered ; those who have seen, as I have, an inveterate and unmanageable tic douloureux greatly relieved for two or three days by alco- holic intoxication, and other like phenomena, will not ques- tion this. Conjointly with this cause, inseparable from it as most of the operations are done, is the impression upon the nervous centres of the cutting or tearing or cauterizing of the operation itself. The more unstable, the more impres- sionable the nervous system be, whether from actual dis- ease or from heredity, the more active will these three last factors be, particularly the latter two. I have seen a con- firmed epileptic, having convulsions every day or two, of strong kleptomaniac tendencies, go for six weeks without a fit and not steal, after having had a depressed cicatrix re- moved from the scalp, the bone being sound beneath this cicatrix and no nerve being implicated in it. Our therapeu- tics takes too little account, in my opinion, of these impres- sions. Your nerve centre cannot itself be directly reached except by great violence. It usually lies deeply encased in bony cavities, and its only means of communication with the outer world is through nerve fibres. Precisely as the out- spread panorama of a landscape passes to the cortical cells along the optic nerve; precisely as the music of an opera reaches the cerebrum upon the auditory nerve ; precisely as the fragrance of flowers steals inward through the olfactory 18 I ANDON CAR TER GRA V. nerve ; so, in the same manner, do the differences in barom- etric and thermometric pressure, and cutaneous and visceral impressions of any kind make themselves known to the cen- tral ganglia by way of the sensory spinal and cerebral nerves. For what other reason do we slap or dash water upon a new-born babe who fails to make the usual respiratory move- ments? It is well known to physiologists that a frog can be killed by a smart blow upon the belly. When a man be- comes livid, pulseless and dazed from a bullet-wound, before haemorrhage has had time to do its work, it is the nervous centres that are shocked by the peripheral violence. When gun-shot wounds induce disturbance in distant nerves, as has been shown in the celebrated circulars of Drs. Mitchell, Morehouse, and Keen, they act through the medium of the central ganglia. This impression upon nervous centres is a factor, and an important one, throughout the whole ex- tended range of the complex phenomena of life. It is in- separable from the action of all drugs, whether they be brought in contact with the alimentary canal, with the skin, or with the subcutaneous tissue. Who has estimated its relative performance in the effects obtained from cathartics, from cholagogues, from irritants, from sedatives, from stimu- lants, from tonics, from electricity? Who has told us what part it plays in change of locality, not merely from one cli- mate to another different one, but from one neighboring town to another, or even in the removal from one story of a house to another, such as occasionally gives relief to asth- matics ? Wherever there be nerves of sensation, there we must have it; and, in neglecting it as we have done, we fail to make use of a rich and well-worked mine of material lying ready to our hand. The fact that operations upon the genital organs will, for the time being, ameliorate the symptoms of organic lesions GENITAL IRRITATION. 19 should make us cautious in accepting the conclusions to which we would otherwise be naturally led by the cases of Mr. Bryant and Dr. Otis. Although we must omit one in- stance narrated by Dr. Otis of a patient of M. Brown-S6- quard, who was cured of symptoms of cerebral softening by circumcision, yet, undoubtedly the proof submitted by him and Mr. Bryant is unimpeachable in demonstrating that the removal of a phymosis, adherent prepuce, irritable cli- toris, and urethral strictures will often relieve urinary in- continence, retention, intermittent and painful micturition, priapism, and a host of unclassifiable nervous symptoms, more especially in children. But, as these cases do not seem to have been thoroughly examined for organic nervous disease or other causes, and, furthermore, as their histories after the operation do not usually extend over a month or two, the data are wanting upon which any man can judici- ally formulate an opinion that they might not have been cases of organic nervous or other disease, improved for a time by cessation of genital irritation.1 Notwithstanding that Mr. Bryant would seem in his cases to have carefully excluded the possibility of stone or disease of the bladder, there is no evidence that Dr. Otis has considered these causes, and of both Mr. Bryant and Dr. Otis we may ask whether their patients had highly acid urine, or nephritis, or spastic disease, or meningeal troubles, especially the tu- berculous, or spondylitis, or organic disease of any kind, or were of a neurotic heredity. To illustrate the facility with which even an alert observer can be misled in regard to deductions of this nature, I may perhaps be pardoned for the recital of the following case of Dr. S. Weir Mitchell, at 1 Dr. E. C. Spitzka writes me that he has seen the prepuce in some way anomalous in eight cases of infantile spinal paralysis, and in all cases of paralysis from spinal disease in male children, and makes the interesting suggestion that it maybe only one effect of the generally defective develop- ment. 20 LANDON CARTER GRA V. the same time expressing my regret that the length of this paper forbids me giving the details in full.1 L. P., male, aet. 6, a strong, healthy-looking child, whose father had had syphilitic accidents. No trouble in teething. Had had malarial fever, yielding to quinine. Was not quite well from this date, though no special disease apparent ; was indisposed to action, lacked appetite, and woke often with a cry. A little later complained of stomachic pain, and two days after passed a large ascaris lumbricoides. Was given a vermifuge. On evening of same day fell down, had slight facial spasm, and became unconscious. On being roused after two hours of semi-coma, slight plosis of left eyelid and partial motor paralysis of both legs were observed. Salines and vermifuge again ordered, causing expulsion of four worms and much slimy mucus ; and thereupon he began to move legs freely and could stand with slight aid. During the next month he passed several worms, and at the end of this time was as well as usual, except a slight limp and slight ptosis. Dr. Mitchell at this time deemed it to be a case of palsy from worms. Remained improved for six months, when he had a series of convulsions without apparent cause, ending in a much more complete paraplegia. Former vermifuge treat merit had now no effect in expelling any more worms, “yet a persistent purga- tive course so far improi