Phimosis

“ Secretions, urine and semen accumulate and decompose in a phimosed prepuce, cause irritation and lead to masturbation. All cases of phimosis should be operated upon in infancy, by complete or partial circumcision.
In women, the number of diseases which prevent conception is much greater than in man. The ovary may undergo cystic degeneration or become the seat of a tumor; but affections of the uterus and vagina cause more sterility than ovarian affections. This results chiefly from catarrh and inflammation which destroy the spermatozoa before they can reach the egg during its descent. ”

“ A perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes. So, in the absence of this, we encounter a number of ill consequences, some local only; some affecting the well-being, and even the life, of the entire organism.
The parts being extremely vascular, and in very intimate relation with the central nervous system; we very naturally find that congenital phimosis, interfering with the normal growth of the glans penis, is prone to develop various reflex neurotic disorders or diseases ”

“ The radical defect in congenital phimosis is thus the adhesion or imperfect separation of two muco-cutaneous surfaces, normally developed in close contact. As a rule, these are so slightly connected that a very slight degree of force is sufficient to part them; but in a considerable minority of instances the defect eventually becomes permanent; with the natural growth of the organ more difficulty is experienced in procuring retraction; and various disagreeable, or even dangerous, symptoms are prone then to make their appearance. ”

“ The last-named motive for circumcision, although, in the passage quoted at the beginning of this section, it has been stamped with the approval of the same high authority, needs but transient allusion. It is a priori probable that congenital phimosis prolonged into adult life renders the subject thereof somewhat more likely to develop local malignant disease than any one not so circumstanced ”

“ As in these no symptoms directing attention to the phimosis have previously existed for any length of time, it may be taken at once for granted that, however tight the so-called 'contraction' may seem on [Pg 52] inspection, the condition is present in only a minor degree; that under an anæsthetic the adhesions will yield to very slight force, and satisfactory retraction, with subsequent free mobility, be procured without the slightest difficulty. With adults, moreover, the avoidance of any need for confinement to bed, of even to the house, is an important consideration. ”

“ Hey had then operated by amputation of the penis on twelve cases of cancer, nine of whom had had phimosis at the time of the development of the cancer. Wadd at this time also published a work on the subject, but, although he noticed that phimosis was a cause of cancer, he did not fully grasp the subject as Hey and Roux had done, as he believed a cancerous diathesis a primary necessity, and did not then recognize that the primary cause was fully to be found in the prepuce itself. ”

“ Persons given to corpulency, with a long prepuce, are apt to become affected with phimosis in their latter years, as such persons are more subject to loss of their sexual vigor and power of erection than lean and spare people; in these, the gradual diminution of the size of the erectile tissues of the organ and its retraction allows of the reconstriction of the preputial opening, which, in the end, will not allow the prepuce to be drawn back over the gland. ”

“ In cases of pronounced phimosis the aperture in the prepuce may not be in a line with the meatus, and the resulting discharge of urine or the ejaculations of seminal fluid may from this cause be unable to find an egress. The fluid escaping from the urethra will, in case the opening is at the side or upper part of the prepuce, cause it to balloon out until a sufficient quantity is thrown out so as to distend, the opening as well as the prepuce, before it can find its way out ”

“ Henoch, however, does not seem to have grasped the full relation that the natural phimosis of young children bears to dysuria, as he here follows the prevailing opinion, that where by dint, push, hauling, and hard work the prepuce can be pushed back phimosis does not exist, as well as the general apathy to the fact that a prepuce can exert a very injurious influence by its pressure, even when not adherent and very retractable; such a prepuce is often attended by balanitis and posthitis, with an accompanying difficult, frequent, and painful urination. ”

“ One patient had developed a chronic herpetic affection by the constant use of an iodized ointment which he regarded as an infallible prophylactic. Many cases of phimosis result from the attending inflammation that follows on the liberal domestic application of nitrate of silver to an abrasion after connection, in the mistaken idea that the party labors under, that he is destroying some venereal virus.
By the irritation that all these applications and accidents induce, warts and vegetations are the but too frequent results. ”

“ You will not infrequently discover a phimosis which interferes more or less with the discharge of urine and retains portions of the latter behind the foreskin, where it may decompose and give rise to an inflammatory condition of the [278] prepuce, with painful dysuria.... This is also true of the occasional adhesion of the labia minora in little girls, like the similar adhesion of the foreskin in boys. It is almost constant in the first period of life, but sometimes persists to the end of the first year; can usually be torn by the handle of the scalpel, and rarely requires an incision. ”

“ Slitting, or the inferior or superior incision, he thought, left too much of the prepuce, which, wherever there is a tendency to phimosis, should be entirely removed, “with a view of preserving the health and cleanliness of the parts in after life.” In the phimosis that is acquired by old men, he found dilatation with a two-bladed instrument to be sufficient, provided the indurated circle was made to yield. For the circumcision of adults he has invented an adjustable shield, something like the Jewish spatula, with which he protects the glans. ”

“ In the child, however, we sometimes find the symptoms produced by difficulty in making water owing to the length of the prepuce and the extreme narrowness of its orifice, which may even be scarcely large enough to admit the head of a pin. This congenital phimosis is, I may add, not an infrequent occasion of incontinence of urine in children, and is also an exciting cause of the habit of masturbation, owing to the discomfort and irritation which it constantly keeps up. ”

“ J. Lewis Smith, the president of the Section, believed in the evil results of the reflex irritation due to abnormality of the prepuce. In many instances the causative relation of the preputial disease to the symptoms which it produces is not so apparent as it may be in others, but after correct treatment of the prepuce they disappear. There was one result of phimosis which, he observed, neither Professor Sayre nor those who contributed to his paper noticed. The expulsive efforts accompanying urination sometimes cause prolapsus of the rectum, and frequently produce inguinal hernia. ”

“ Through middle life, unless the prepuce be the subject of some vicious conformation, little inconvenience may result from its presence, except it be from the dangers to infections already pointed out during this period of life; an ordinarily movable and retractable prepuce will not acquire the condition of phimosis, unless it be through disease or accident; but with our entrance into old age, or after having passed our vigorous prime, the torment of the days of our infancy and childhood come to harass us again. ”

“ This prepuce is then long, and the penis is found at the end of an undilatable canal, which is formed by the constricted prepuce; at this early stage of our existence it is often additionally bound down to the glans by a greater or less number of adhesions. We are then in what many term a state of physiological phimosis, that [219] being a perfectly natural condition, and one consistent with health; at least, we imagine it is normal. ”

“ A second form of masturbation occurs in very young children from accidental irritation; in boys from phimosis; in girls from itching due to worms (oxyuris) about the anus and vulva. Innocent as regards its cause, this form of onanism may become dangerous by habit. Attention should therefore be paid to phimosis and worms, and the former treated by circumcision and the latter by the usual remedies. ”

“ It is easy to perceive why or how Agnew, Gross, Cullerier, and many of those who have written on the subject, have failed to appreciate the existence of the prepuce as an exciting cause, or as being, in the majority of instances, the part primarily attacked. The nodule, excoriation, or abrasion that develops into a cancer generally produces more or less local disturbance; in many it produces a phimosis that is only relieved by the ulcerative process that exposes the gland, which may by that time itself be attacked or even destroyed. ”

“ 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. ”

“ Phimosis, or narrowness of the opening of the prepuce is nearly always of embryonic origin. It prevents the glans penis from becoming exposed, at least during erection. It is a very common condition and very disagreeable. If the prepuce is forcibly drawn back behind the glans penis before erection, as is often the case in masturbation, the penis is gripped by the prepuce so that it cannot sometimes be drawn forward and inflammation with oedema results ”

“ In _concealed chancres_ with phimosis, the sac of the prepuce should be slit up along the dorsum to admit of the ointment being applied. If phagedaena occurs, the prepuce must be slit open along the dorsum, or if sloughing, cut away, and the patient should have frequent sitz baths of weak sublimate lotion. When the chancre is within the meatus, iodoform bougies are inserted into the urethra, and the urine should be rendered bland by drinking large quantities of fluid. ”

“ With a phimosis the parts are not kept clean, but the gland is macerated and rendered tender and excoriated by retained secretions, and the irritation causes an epithelioma [230] to grow in those predisposed to the disease, as is found to be the case when the tongue is irritated by a broken tooth, or the scrotum by the presence of soot in its folds. Syphilis has no direct influence in inducing the disease, but a syphilitic chap or ulcer may be the starting-point of an epithelioma. ”

“ In a case which will be related farther on, in the discussion of the systemic effects of a long, contracted prepuce, as it induces diseased action by continuity of tissues, there is an account of a death of a two-year-old child which we can assume to have had its original starting-point in a condition of phimosis. ”

“ Carcinoma attacking the genital organs usually assumes the form of epithelioma; the other kinds are rarely met with. Epithelioma may invade the prepuce, or the whole penis, or any part of it. The most common age for it is fifty years or over. In the great majority of cases there has existed a congenital or acquired phimosis. ”

“ 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 operation is now complete; but in the adult it will be well to introduce a few interrupted sutures.
The prepuce has sometimes been slit up longitudinally on a director. Although well suited to cases of adventitious phimosis in the adult, the method is in no way adapted to the congenital form, [Pg 28] and has never found general favour with the medical profession. It has no advantages over circumcision; although retaining the prepuce, it still leaves the glans largely uncovered ”

“ In this manner a simple elongation of the prepuce will produce an inflammation of the surface of the glans (balanitis) , or that of the prepuce itself (posthitis) , or the two conjoined (balano-posthitis) , complicated possibly with phimosis. By an extension to the mucous membrane of the urethra of the same condition of the inflammatory process, we have blennorrhagia; blennorrhagia is liable to be followed by inguinal swellings or tenderness, orchitis, stricture, and prostatic disease; the formation of preputial calculus, from retention of the urine in the prepuce ”

“ They appear as pustules, which are rapidly converted into small, acutely inflamed ulcers with sharply cut, irregular margins, which bleed easily and yield an abundant yellow purulent discharge. They are devoid of the induration of syphilis, are painful, and nearly always multiple, reproducing themselves in successive crops by auto-inoculation. Soft sores are often complicated by phimosis and balanitis, and they frequently lead to infection of the glands in the groin. ”