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boy should be allowed to become one month old without a thorough examination of the genitals having been made. In many of these cases in girls, or even in women, adhesions, growths, or malformations are the source of the irritation and should receive immediate and radical attention."

Dr. C. N. Jones, of Brooklyn, in one of his osteotomy reports, states incidentally that all of the patients with bowlegs and knock-knees had preputial adhesions (a coincidence in signs of degeneration probably, and not relation of cause and effect).

Remondino, in his " History of Circumcision," says: "The idea of masturbation or of irritation of the genitals ending in reflex neuroses is always, as a rule, associated with the male, and that it has not been associated with the female has deprived her of the same benefit that the prosecution of the study in this regard has been to the male sex."

Dr. M. F. Price, in a paper read before the American Medical Association in 1874, incidentally refers to the case of a young girl, illy developed, who had neither walked nor talked, and who on examination by Dr. L. A. Sayre was found to have preputial adhesions with retained secretion. This, Dr. Sayre thought, accounted for the child's condition.

The above quotations include all that I could find upon the subject through the aid of the two great bibliographies, and yet there are thousands upon thousands of women in this country who are suffering from reflex neuroses that are directly and solely dependent upon preputial adhesions. It has now been determined that many of the school boys who are known to be bright and yet who cannot study have errors of refraction or heterophoria, and that they are repulsed by print without knowing why. The boy who finally becomes the expert baseball pitcher might become an Alexander von Humboldt if his eyes were only properly cared for. As a parallel we can now learn that the girl who becomes irritable, disagreeable, and hysterical may become charming, interesting, and possessed of all feminine graces when her prepuce is forcibly peeled away from the glans of the clitoris, and we have made a distinct step forward in civilization when this fact is generally appreciated by the profession. The importance of preputial adhesions in the female will be underes

timated by some observers and overestimated by others, just as is the case with heterophoria; but those of us who try to take a mean position will know that while some patients are strong enough to withstand one or both of these conditions for a lifetime, there are countless numbers who sink beneath the load that seats itself so insidiously that the patient herself does not realize what she is carrying until neurasthenia untunes the resisting power. The weighty Hibernian woman who pins her skirt up at the bottom at 6 o'clock in the morning, and who, besides doing a hard day's washing, gets three meals for the family, milks four goats, and drags the old man out of the house, is not disturbed much by preputial adhesions, decayed teeth, prolapse of the uterus, hernia, and a number of other complications that would send a fragile girl to the mad-house.

My attention was first attracted to the subject of preputial adhesions in women by a case of nymphomania in a young unmarried woman. The nymphomania had existed for about eight years, and the patient, who was a refined and educated woman, finally gave up in despair and confined herself to the house, not caring to meet people, and declaring that, as the best physicians had tried to help her, there was no use for further attempts. The uterus was low and anteflexed, and she had received all sorts of orthodox treatment directed toward the uterus. The case seemed to be one in which there was peripheral irritation somewhere, and, after a search along that line, I finally discovered that the patient's prepuce was firmly adherent to the glans clitoridis. The prepuce was stripped from the glans and the nymphomania disappeared at once. The uterus, after a little attention, remained in place as it never had done before, and the patient is now spirited and rosy, engaging in horseback riding, tennis, walking, and all of the pleasures of her companions. After this experience I examined and cared for a very large and miscellaneous lot of neurotic cases, giving attention to preputial adhesions, and it has certainly been a revelation to find what proportion of the cases are partially or wholly dependent upon chronic disturb ance of the clitoris. One of the striking cases was that of a young epileptic girl 12 years of age. I had previously sent her back to the family physician, informing him that as my

practice was confined to surgery I could not accept the patient. Little did I think at that time that the case was purely a surgical one; but later, when the child was again sent for, it was found that she had a tightly adhering prepuce and that she was a persistent masturbator. The patient was not taking any medicine and was having three and four attacks of grand mal weekly. Preputial adhesions were separated and the epileptic attacks stopped immediately. At the end of a month she had another attack, and then four more in rapid succession. On examination the prepuce was found to be as firmly adherent as it was at first. It was again separated, and the patient has had no more attacks to date-two weeks elapsed. This is not one of the cases in which "any operation" will temporarily stop the attacks, because the operation is too slight to deserve the dignity of the name. This patient has no epileptic attacks when the prepuce is free, and she has the attacks when it is adherent to the glans clitoridis. After separation of preputial adhesions there is a marked tendency for them to recur, and women whose hopes are raised by disappearance of the old irritation and a subsidence of reflexes are often very much depressed by the return of all symptoms. This can be avoided if the prepuce is stuffed with bichloride ganze at intervals of two or three days, until the appearance of normal smegma shows that the mucous surfaces have developed sufficiently to care for themselves. The method of separating adhering prepuces consists in first washing the vulva with bichloride of mercury solution. A couple of drops of cocaine solution are then thrown into the glans clitoridis through a hypodermic needle, and four or five drops more are thrown anywhere into the prepuce. If one margin of the prepuce is then seized with fixation forceps, the thumb nail will easily complete the work of clearing the glans. Raw surfaces are then sprinkled with aristol and the prepuce packed with a little ball of gauze.

Finally, allow me to say that I have found numbers of women, with all sorts of reflex neuroses, in whom the glans clitoridis was fully developed and free from any important adhesions; so we can readily perceive that, influential as preputial adhesions are, they form only one factor in the great group of peripheral irritators.

SUMMARY.

1. The prepuce and the glans clitoridis are bound together by adhesions, partly or completely, in about eighty per cent of all Aryan American women.

2. Preputial adhesions are rare among negresses, and seem to occur in only a few of the individuals possessing a large admixture of white blood.

3. Highly developed domesticated animals do not present examples of the degeneration, so far as the author's observation has gone.

4. When preputial adhesions are extensive the glans clitoridis and the imprisoned mucous glands remain undeveloped, but they may develop later when the physician has separated adhesions.

5. The failure of the embryonic genital eminence to properly develop the prepuce and glans clitoridis for perfect cleavage undoubtedly means that Nature is trying to abolish the clitoris as civilization advances.

6. The degenerative process represented by preputial adhesions is characteristic of the civilized type of homo sapiens, in which we find decaying teeth, early falling hair, and imperfect corneas and eye muscles.

7. Preputial adhesions which involve small portions of the glans clitoridis are of interest simply as anatomical curiosi ties.

8. Preputial adhesions involving a large part or the whole of the glans clitoridis may cause profound disturbance, and they are among the most pronounced of the peripheral irritators. They cause desire for masturbation which leads to neurasthenia, and they are responsible for grave reflex neu

roses.

9. Preputial adhesions probably form the most common single factor in invalidism in young women.

The clitoris is a little electric button which, pressed by adhesions, rings up the whole nervous system.

133 WEST 34TH STREET.

TUBAL PREGNANCY.

BY

JOSEPH PRICE, M.D.,

Preston Retreat, Philadelphia, Pa.

(With plate and two illustrations.)

THE study of ectopic pregnancy from a strictly operative standpoint has led me to designate this contribution by the title "Tubal Pregnancy." I do so for the reason that in all cases met by me, both in my own and in the work of others, I have in no instance met a case in which the gestation has not been primarily tubal. In one instance, in which the question of original ovarian pregnancy was strongly indicated, and so stated at the time the case was reported, I have reason to believe my inferences were incorrect, as no traces of ovarian structure were found in the sac. This, of course, decides the question, if microscopic examination amounts to anything. This latter variety of ectopic gestation must be conceded as possible; though, as it is not discovered at all in these days of frequent operation by the numerous investigators in the field, it must be regarded rather as a possibility than as a probability. As to the causes of aberrant gestation, we are to consider them both as anatomical and moral. They may have their origin in anatomical loss of structure or in perversion of function, such as absent ciliary motion in the epithelium; or in absolute disease of the tube; or, as I have had more than once called to my attention, in the fright of illegitimate conception. A salpingitis from any cause may predispose to the accident, so that it is not necessary to limit its causation in this respect to gonorrheal salpingitis

alone.

There are no reliable statistics as to the frequency of tubal pregnancy. Such data as we have at present depend entirely upon the more or less unreliable observation of the past and have very little value. Indeed, it is a question whether such

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