These apparent digressions are not made either to be tedious or to weary the reader, nor without an object. They are made to show that, whereas syphilis is looked upon as such a deadly disease, and it may be said to be the sole cause of fear to the assiduous worshiper at the shrine of Venus Porcina, there is another still more fatal danger awaiting him, ambushed in the folds of the vaginal mucous membrane, or coming along silently out of the cervical canal,—like the legions of Cyrus stealing along the dry bed of the Euphrates into ancient Babylon, to fall unawares on the feasting Nebuchadnezzar on that fatal night. So, in like manner, the virus of tuberculosis, either extruding from a granular os or from its neighborhood, gradually moves down on the unsuspecting, uncircumcised, and easily inoculable-surfaced glans penis, to infect the system with a tubercular poison that has no such exceptions as those above noted, as at times are the followers of syphilis. It is not alone the individual himself that may be the sufferer from this poison, but his progeny for several generations may have to suffer for the infection thus received, just as much as they would were that infection to have been syphilitic. As before remarked, this has heretofore not sufficiently occupied the consideration of the profession, and, as it cannot certainly be denied that such a source of tubercular infection is both possible and probable, the subject is entitled to more serious and deliberate consideration than that which has heretofore been paid to it.

Tuberculosis certainly has these two channels of entrance: either through direct infection or through an evolutionary process resulting from syphilis. The appearance and vital statistics offered by the French War Office in regard to the Algierine provinces, the report of the United States Census, the opinion of Dr. Billings deduced from the census reports, the opinions of Hutchinson, Richardson, Bernheim, and many other observers, as well as the personal but unrecorded observations of many practitioners, all tend to bear testimony to the remarkable difference that exists between circumcised and uncircumcised races in regard to the ravages of consumption. Is circumcision a factor in this difference, or is it not? If it is, then circumcision should receive more attention than it has; if it is not, then we should not be idle in hunting up the cause of difference, for an ounce of prevention is certainly worth in this regard a whole pound of Koch's lymph as a curative agent.



CHAPTER XVII.

SOME REASONS FOR BEING CIRCUMCISED.

The surgical and medical history of circumcision is intimately connected with the remotest ages, this being, in fact, the earliest surgical procedure of which we have any record. From the same records we obtain hints as to two conditions for which circumcision probably was suggested, either as a preventive or as a remedy.

Jahn, in speaking of the people by whom the early Hebrews were surrounded, mentions their idolatrous practices, and that their peculiar forms of Pagan worship were accompanied by indulgence in fornication, lascivious songs, and unnatural lust. Others of their neighbors worshiped the "hairy he-goat," with which they also practiced all manner of abominations. Sodomy, or pederasty, seemed a sort of religious ceremony with some of these heathen nations; from a religion it necessarily became a social practice; this, in connection with the phallic practices and worship, necessitated frequent exposure of the male member. The evil results, to say nothing of the disgusting and demoralizing tendency of these practices of the Pagan, were evidently well known to the Jews. The contrast between the physique and health of the pastoral habits, out-of-door life and simple diet of the Jews, and the necessary opposite condition of health and physique due to luxury and to these practices among their neighbors, could not have escaped their attention. How much onanism had to do with the establishment of circumcision may well be conjectured. Again, the other hint is in reference to procreation, as some stress is laid to the connection between the conception of Sarah and the circumcision of Abraham. Here we have suggestions of a preventive to onanism, and a cure to male impotence when due to preputial interference.[79]

Strange as it may seem, these two important results, due to circumcision, seem to have been lost sight of for some thousands of years, as even the able works of the physicians of the latter part of the last century have nothing to say connecting onanism and circumcision. Neither the works of Tissot on male onanism nor the pioneer work of Bienville on nymphomania speak of the presence of the prepuce in the male, or of the nymphar or clitorian prepuce in the female, as being causative of, or their removal curative of, either masturbation, satyriasis, or nymphomania; moral, hygienic, and internal medication being by both these authors considered to be all that our science could offer or do to alleviate or cure this unfortunate class. It is only of late years that circumcision, in its true relations to onanism, has received full consideration. In regard to its being a cure of impotence, its recognition has been of longer duration.

It is related by Leonard, in his "Memoires,"—who, in his capacity of hair-dresser in ordinary to her Majesty, the unfortunate Marie-Antoinette, had ample opportunity for picking up all the domestic small talk of the royal family and their affairs,—that Louis XVI, in addition to all his troubles and the indignities which he suffered, besides finally being beheaded, was afflicted with a congenital phimosis which prevented the flow of semen from properly discharging itself. It appears that his Majesty was no little annoyed at not being able to procure an heir to his throne. His royal sister-in-law, the Countess d'Artois, had given birth to a prince, the Duke of Angouleme, who was the heir presumptive to the throne in case of the non-issue from Louis; another sister-in-law had been brought to bed with a royal princess, and here was the king himself without any prospective possibility of any heir. Like all kings, he was more or less unreasonable; so he blamed his first surgeon in ordinary for all these short-comings,—as if it were the duty of these court surgeons, among their many other tribulations, to furnish heirs to thrones. The surgeon finally informed his Majesty that if he wished to become a father it would be necessary for him to submit to the slight operation that was the subject of the church festival of the first day of January, namely, the Feast of the Circumcision. His most Christian Majesty entered a protest to this acknowledgment that there was anything in Judaism worth imitating. The surgeon insisted that the operation celebrated on the first of January would put him in a way to have the much-desired heir. The king finally waived all objections from any religious scruples, but could not be brought to look at the prospective operation with any sentiments of agreeable expectation.

The king finally became good-natured, and a touch of that plebeian jollity which at times made him quite agreeable spread over his features as he imagined the ludicrousness of the spectacle that would be presented by a king of France in the hands of these handlers of the scalpel, treating him like an African savage. He took some days to consider the matter. On the next day he informed M. Louis, his first surgeon in ordinary, that he had decided on submitting to the operation, and the day and hour were fixed. The royal circumcision, however, never took place, as it is most likely that in the privacy of his chamber his Majesty worked, like many a plebeian or man of low degree had done before him and has done since, to bring a refractory prepuce to terms. The king was somewhat of a mechanic, as his skill as a locksmith has passed into history; so that it is not unlikely that, with what little information he had on the subject, he managed to sufficiently dilate, by scarification and stretching, the preputial opening, as from the year 1778 the queen had three children.

Cases of attempted self-circumcision are not rarities, as people have some inexplicable idea that a self-inflicted cut is not as painful as one that is done by others. The writer well remembers being called to assist one of these domestic surgeons who had undertaken to circumcise himself with his wife's great scissors. The man had a very long but thin and narrow prepuce that had always been an annoyance to him. The writer had circumcised two of his children for the same malformation, and the father, seeing the benefit to these two, determined to share in the general benefit; but at the same time he arranged to do it all by himself, and give the family and the surgeon a sample of his courage and a simultaneous surprise party. Securing the scissors, he wended his way unperceived into the recesses of his wood-shed. The mental and physical anguish the poor man underwent, and what soliloquies he must have addressed to the rafters of the wood-shed while making up his mind and screwing up his physical courage for the last fell act with the scissors, can hardly be described, as, in all probability, they were of the most rambling and inconsistent order. At any rate, he must have reached a climax in time and grasped the fated prepuce with a revengeful glee, and, with all his powers concentrated in his good right hand, he must have closed the remorseless blades of the scissors on the unlucky prepuce. When the surgeon arrived at the scene of carnage, he was directed to the wood-shed, on the outskirts of which hovered the family, frantic with fear and apprehension; within, in the darkest corner, with wildly dilated eyes, and performing a fantastic pas seul, was a man with a huge pair of scissors dangling between his legs, warning all hands as they valued his life not to approach or lay a hand on him. He had shut the scissors down so that it clinched the thin prepuce, and there his courage and determination had forsaken him; he lost his presence of mind, and was not even able to take off the scissors; he had simply given one wild, blood-curdling yell—like the last winding notes from Roland's horn at Roncevalles—that had brought his family to the wood-shed-door, and they had then sent for a surgeon. New terrors here awaited the unlucky victim for self-circumcision. He dreaded lest the surgeon should accidentally have it enter his mind to finish the operation with the scissors, and in that case he would be helpless, as the surgeon would, undoubtedly, have a sure and tender hold of it. After executing a number of pas a deux on the Magilton step, while the surgeon endeavored to reassure him and gain his confidence, promising to remove the scissors without inflicting any further harm, he was finally allowed to approach, and, while the patient assumed a Taglioni attitude on one foot, the other leg being extended at right angles with the body and his hands clawing the air, the scissors was removed. The patient, through the aid of lead lotions and a week's rest, made a good recovery with a whole prepuce, chagrined at his failure, but happy to have escaped immediate pain.[80]

There is not much doubt but that the operation could have been suggested by its, at times, spontaneous performance, a case of which, by Cullerier, and some other additional cases have been mentioned in a former chapter. Cases occur at times, also, wherein the person having a previously normal and uninterfering prepuce has, through either herpetic inflammations or through impure connection, spurious gonorrhoea, or the use of some venereal-disease preventing-wash after connection, produced some irritation resulting in the abnormal thickening of the inner fold, or an interstitial deposit at the junction of the skin and mucous membrane, with consequent constriction, this deposit finally forming a hard, inelastic ring, which prevented a free exposure of the glans and interfered in sexual connection. In such cases,—like in stricture of the meatus,—any mechanical interference short of cutting with a knife only aggravates the existing difficulty, and it is not uncommon to have such cases apply for assistance after they have in vain tried to dilate the constricting preputial orifice. In the early writings of the Greeks, it is mentioned that among the Egyptians circumcision exempted them from a certain form of disease that affected the penis. Philon mentions particularly the immunity that the operation conferred against a species of affection which Michel Levy asserts to have been a gangrenous disease. So that, outside of any religious significance, there is no doubt that, in individual cases, circumcision has more than once been suggested, although it cannot be said that such individual cases would ever, or could, lead to its becoming a national or racial, much less a sectarian, rite.



CHAPTER XVIII.

THE PREPUCE AS AN OUTLAW, AND ITS EFFECTS ON THE GLANS.

Ricord has well termed this appendage to civilized man "a useless bit of flesh." Times were, however, when—man living in a wild state, and when in imitation of some of our near relatives with tails and hairy bodies; when he still found locomotion on all-fours handier than on his two feet; when in pursuit of either the juicy grasshopper or other small game, or of the female of his own species to gratify his lust, or in the frantic rush to escape the clutches, fangs, or claws of a pursuing enemy, he was obliged to fly and leap over thorny briars and bramble-bushes or hornets' nests, or plunge through swamps alive with blood-sucking insects and leeches—Ricord's definition would certainly have been inapplicable. In those days, but for the protecting double fold of the preputial envelope that protected it from the thorns and cutting grasses, the coarse bark of trees, or the stings and bites of insects, the glans penis of primitive man would have often looked like the head of the proverbially duel-disfigured German university student, or the Bacchus-worshiping nose of a jolly British Boniface. So that in those days, unless primitive man was intended to have an organ that resembled a battle-scarred Roman legionary, a prepuce was an absolute necessity.

With improvement in man's condition and his gradual evolution into a higher sphere, the assumption of the erect posture, and the great stride in civilization that originated the invention of the manufacture of the perineal band, which not only protected the glans in its thorny passage through life, but also acted like a protecting aegis to the scrotum and its contents, the prepuce became a superfluity; not only a superfluity, but, now that its natural office had been replaced by the perineal cloth, it actually began to be a nuisance, as its former free contact with the air had retained it in a state of vigorous and disease-resisting health which was now fast departing. As Montesquieu observes, in the causes that led to the decline and fall of the Roman Empire, those seasons of trials, tribulations, and struggle for existence are those of health and progress and healthy life, and the periods of luxury and idleness are those of degeneracy and decay. So with the prepuce, the luxury and idleness, voluptuousness and consequent feasting incident to its being supplanted in its original functions by the perineal cloth, which left it thenceforth unemployed, led it in the pathway of disease and death. This first innovation in civilization was to the prepuce the beginning of its decay and fall. Like Belshazzar in his great banquet-hall in ancient Babylon, the prepuce might have read the hand-writing on the wall, "Mene, Mene, Tekel, Upharsin," and foreseen the gory end that awaited it. Like to other human affairs, however, even in his fallen estate a kind word can be said for the prepuce. Puzey, of Liverpool, has found it of extreme value, and even unequaled by any other part of the body, for furnishing skin-grafts,[81] these grafts showing a vitality that is simply phenomenal, considering the laxity of its tissues and its seemingly adipose character. There is no doubt, however, that for skin-transplanting there is nothing superior to the plants offered by the prepuce of a boy, and where any large surface is to be covered this should undoubtedly be chosen, as offering the greatest and quickest success and the least chances of failure. This is really the only disadvantage that can be charged against circumcision, as in a strictly circumcised community they would be debarred from this great advantage. An uncircumcised individual could be procured, however, to supply the deficiency. It is related that in the latter part of 1890, a Knight Templar, in Cincinnati, required a great supply of grafts or skin-plants to cover a largely-denuded surface, and that the whole of his Commandery chivalrously and generously supplied the needed skin-plants in a body. A few healthy prepuces would have been more efficacious. In advising the use of the prepuce for these purposes it must not be overlooked that in case of a white man it would not do to use skin of any other color besides his own. We have no data to base any assertion as to the relative action of skin-grafts taken from Mongolians or Indians, but we have very reliable data in relation to the proliferating action of those of the negro,[82] which induces a growth of epidermis of its own kind; so that preputial grafts from the negro, combining the extra vitality and proliferation of the preputial tissue with the strong animal vitality of the negro, if applied to a white man, might not produce the most desirable cosmetic effects, especially if on one side of the countenance.

But, taken as a whole, when considered in its relation to onanism, nocturnal enuresis, preputial calculus, syphilis, cancer, and a lot of nervous and other ailments, or induced abnormal physical conditions, we can really conclude that the days of the prepuce are past and gone, that it has outlived its usefulness, and that those whom a religious or civil ordinance or custom happily makes them rid of it are people to be greatly envied. As Sancho Panza remarked, "God bless the man who invented sleep," so we may well join in blessing the inventor of circumcision, as an event that has saved some parts of the human family from much ill and suffering.

Phimosis is an ancient attendant on our inheritance of the prepuce, we being, in fact, born with it; this is the rule. There are, however, exceptions to this rule, which, singularly enough, are found to be hereditary. The writer has met with a number of such instances, and they have always been found to have been family traits. Within the past year, after attending a confinement, his attention was called to the child by the nurse, who thought that the child was deformed; the nurse, singularly enough, never having seen a natural-looking glans penis in all her life, was astonished at the size and appearance of the member. On examination, the organ showed a complete absence of prepuce. On inquiry, the father and another son, born more than twenty years previously,—this comprising every male member of the family,—were found to have been thus born, with the glans fully exposed. The family is now residing in San Diego, and is naturally one of more than superior physical health and intelligence. I saw another family similarly affected in the north of France, and of individual cases, without knowing the history of the rest of the family, I have seen a large number. As the prepuce can be observed in every stage of disappearance among mixed races, it would seem that in time it would disappear altogether. Its effectual absence in so many cases evidently belongs to some evolutionary process, and shows beyond question that nature does not insist on its presence either as a necessity or as an ornament.

The word or term "phimosis" is derived from two Greek roots, signifying "string" and "to tighten," or "to tie with a string." Galen, from its signification, accepted the word, and from him it has been transmitted through the different epochs of medicine down to our own times. In virtue of its etymological significance, it was formerly applied to any stenosis or closure of duct or aperture, but at present the term is used simply to denote that constriction that affects the prepuce, and which prevents the glans from being passed through the preputial orifice. Phimosis is said to be congenital or natural and acquired. The first of these is the common lot of all, as a rule, and with some it remains so throughout life. As babyhood advances in boyhood and boyhood into youth, the prepuce gradually becomes lax and distensible, and in proportion to the existence of these conditions it also loses in its length. Where, however, the distal end persists in its constricted condition it is drawn forward as the penis increases in bulk.

In many cases its tightness prevents the escape of the sebaceous matter that collects in the sulcus back of the corona, and the resulting irritation on the surface of the glans and the inner mucous fold of the prepuce ends in an inflammatory thickening of the latter, its inner surface becoming thick, undilatable, hard, and unyielding, all the natural elasticity that should be present having departed, with more or less inflammatory thickening and adhesions between the two layers of skin that form the prepuce. In this unyielding tube the glans is imprisoned and compressed, often suffering the tortures that the "maiden" of the dungeons of the Inquisition inflicted on the unhappy heretics. It becomes elongated, cyanosed, and hyperaesthetic; the meatus of the urethra is congested and hypertrophied, the corona is undeveloped and often absent, the glans having, on the whole, the long-nosed, conical appearance of the head of a field-mouse. There are hardly five per cent. of the uncircumcised but who suffer in some degree from this constricting result of the prepuce, to a greater or less extent.

On the other hand, the unconstricted glans penis assumes the shape and appearance that is seen in the circumcised. The head is shorter, the face flat and abrupt, and the meatus, instead of being at the end of a conical point, is situated on the smooth, rounded front of the glans, and does not differ in color from the covering of the glans itself. From the superior commissure of the meatus to the sulcus in the rear of the corona its topographical outline may be said to describe two opposite segments of a circle, as seen in the cuts representing the glans in its natural shape. The corona is prominent and well developed.

The opponents of circumcision base much of their opposition to the fact that circumcision interferes with the natural condition of the parts. The question may well be asked, which of these two shaped glans is the natural product as nature intended it should be? It is a well-known fact that the most forlorn and mouse-headed, long-nosed glans penis will, within a week or two after its liberation from its fetters of preputial bands, assume its true shape. We may naturally inquire if nature made the glans of a certain shape, which seems to be the proper shape for copulative purposes, only to have the condition most effectually abolished by a constricting, unnatural band? How much the shape of this glans, from meatus to corona, may have to do with retaining the urethra to a healthy and normal calibre and condition has not been inquired into, but, as far as the writer has observed, a normal glans seems to have less abnormalities of the urethra, and in treating such cases he has always found that when the urethra of one of these normal-glans subjects was affected it was far easier to manage; on the other hand, secondary and even a tertiary recurrence to an operation is often the fate of a long, narrow, conical-pointed penis.

Phimosis is known to have been a cause of male impotence by its direct interference with the outward flow of the seminal fluid; but, although we have cases where impregnation has taken place by the aid of a warm spoon and a warm syringe, as in the case related in a former chapter, it must be admitted that the corona is not without some functional office in the act of procreation. Its shape indicates a valve action like that of the valve in a syringe-piston, and if we examine the two extremes of these conditions of glans—one devoid of corona, as many are, and the other with the corona in its most pronounced form, when in a state of erection—the difference, either in the appearance of the two organs or in the different philosophical action and results that must necessarily follow the use of these two differently shaped glans, will at once be apparent. Unfortunately—or, as many may consider it, most fortunate—the female organs are not always so shaped as to be in themselves wholly favorable to impregnation. The wearing of corsets, the habitual constipation of females, the relaxed and unnatural condition of the uterine ligaments and vagina in civilized women, all favor uterine displacement, with any or all forms of uterine ailments. To this we may add the effect of repeated miscarriages, application of astringent washes, irregular menstruation, etc., all of which conditions often result in an elongation of the neck, constriction of the cervical canal, with the external os placed on the depended point of the sharply pointed cervix, which is liable to point in any direction. Just imagine one of these conditioned females and one of the mouse-headed, corona-deficient, long-pointed glans males in the act of copulation! The conical penis finds its way in the reflected fold of the vagina, while the point of the uterus may be two or three inches in some other direction, making impregnation wholly impossible; besides, in the normal-shaped penis, the corona acting as a valve, behind which the circular muscular fibres of the vagina close themselves, tends to retain the seminal fluid in front, while the very shape of the organ assists in straightening out the vaginal canal and to bring the uterus in proper position. In the long, thin, narrow and pointed glans, devoid of corona, there is no mechanical means to retain the seminal discharge. Some years ago some one introduced the idea of postural copulation, to be tried in cases of sterility, and it has been found that impregnation would take place in some cases where it had formerly appeared impossible, this position having the effect of righting malpositions during the act, which were the cause of the sterility; but it stands to reason that, where the shape of the organ is such that it further favors malpositions, as well as where it offers no obstacle to the vagina immediately expressing or dropping out all the seminal fluid, impregnation is more difficult, and that, where the uterine deformity is coincident with this condition of penis to assist, it becomes well nigh impossible. Fodere mentions a penis about the size of a porcupine-quill on an adult male, and Hammond mentions one of the size of a lead-pencil in diameter and two inches in length. From total absence of the penis, either through disease or accident, to the diminutive organs mentioned by Fodere and Hammond, and on up to the full-sized and normal-shaped organ, we have every degree of sizes and shapes, and with these go every conceivable degree of ability or faculty for impregnation.

Aside from the foregoing considerations, there are others equally important. Although Greece was involved for years in war and ancient Troy was destroyed and all its inhabitants slaughtered because of the seduction of one woman; and Semiramis, through her beauty, got all her successive husbands in chancery; and poor, susceptible Samson, from firing Philistine vineyards and killing lions bare-handed, and the Philistines by the thousands with the jaw-bone of an ass, was reduced through Delilah to bitter repentance and turning Philistine mill-stones; and we know that the familiar infatuation of Antony for Cleopatra ruined Antony; and we are familiar with the well-known maxim of the French police-minister, that to catch a criminal it was but necessary to first locate the woman and the man would soon be found,—society has determined to ignore the influence of the animal passions as factors in our every-day life, or factors in the estrangements, coldness, and the bickerings that end in divorces. Not to shock the reader with detailed accounts as to what an important factor the shape of the penis may be in the domestic economy, I will refer the reader to Brantome's works.

Although the councils of the older church were not above giving these conditions their calm and deliberate consideration, which resulted in the foundation of the present physical considerations in relation to divorce laws, such studies or considerations are at present only touched upon gingerly and with apologies for doing so, as if the "study of man" was of any less importance to-day from what it was in the days of Moses, the elder church, or when Pope formulated his oft-quoted but little-followed maxim, that "the proper study of mankind is man." The present miscalled "delicacy of sentiment" is about as misplaced a condition of disastrous and misleading morality as was the out-of-place and untimely bravery of poor old Braddock when refusing Washington's advice at the Monongahela. The success and beauty of the Mosaic law is its squarely facing the conditions of actual life, and its absence from nonsense or nauseating sentimentality. Were our present churches to observe more of this plain talk, for which the good old Anglo-Saxon is as fully expressive and convincing as the old Hebrew, and deal less in rhetorical flourishes and figurative mean-nothings to tickle the ears of our modern Pharisees, mankind as well as womankind would be infinitely so much the better off, mentally, morally, and physically, and there would be less of the conflict between science and religion. Luther's dream of restoring religion to its primitive purity has come to but as poor realization at the hands of his so-called followers, which leads one to think that if the martyrs of the Reformation could come back and see the fruits of their martyrdom—suffered that pure religion might live—they would conclude that, for all the resulting good accomplished, they might as well have kept a whole skin and a whole set of bones.

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; in such cases impotency is liable to be as complete as in those cases of stricture wherein the seminal fluid is forced backward into the bladder. Having given this general view of the effects of phimosis as it may affect man in the shape of his organ, which may have a serious result in his domestic relations or in becoming a father, we will proceed to the consideration of diseases and conditions that phimosis encourages and to which it renders man more liable. In the consideration of these cases it must not be forgotten that the sexual relations are much more to man or woman than is generally acknowledged. The days for the establishment of the Utopian republic of Plato are not yet with us. That Platonic love does exist is true, as it has in the past and will in the future. Scipio, refusing to accept the beautiful betrothed bride of an enemy as a present, or Joseph leaving his coat-tail in the hands of the amorous bride of the eunuch Potiphar, with the suicide of Lucretia, in the past, are events which virtue and modern continence probably duplicate every day; but these are exceptions to the rule. Physicians daily see evidences of the most devoted Platonic affection in either sex, but they also see enough of the opposite side of the question to convince them that in the majority of cases the sexual relations are the bond of union, as well as the mainspring of love. As observed by Montesquieu, the bride of a first-class Turkish eunuch has but a sorry time, and a woman of the same calibre of mind as that possessed by the ordinary Circassian or Armenian bride cannot be in a much happier condition with a husband partly eunuchised by a constricted prepuce.



CHAPTER XIX.

IS THE PREPUCE A NATURAL PHYSIOLOGICAL APPENDAGE?

By many surgeons the idea of circumcision, unless connected with an immediate demand for interference,—such as a phimosis unmanageable by any other means, an induced phimosis from gonorrhoea or other irritation, syphilis in its initiatory sore, cancer or some such cause,—is looked upon as an unwarrantable operation, a procedure not only barbarous, painful, and dangerous, but one that directly interferes with the intentions of nature. The prepuce is by many looked upon as a physiological necessity to health and the enjoyment of life, which, if removed, is liable to induce masturbation, excessive venereal desire, and a train of other evils. The question then resolves itself, What is the real physiological status of this appendage, if it has any, and, if it is a physiological appendage, when does it merge into a pathological appendage? As by some it is held that the prepuce enjoys the same right to live and exist as the nose, ear, or a limb, which are only subject to amputation in case of a serious disease, they should be reminded that they are not taking into consideration that the nose and ear are calculated to warn us of danger, and that our legs are very useful; as even the great orator Demosthenes, by the timely and rapid use of his legs, was enabled to escape from a battle, where his oratory was of no avail against the illiterate javelins of the unscholarly Macedonians. If the prepuce only was endowed with an olfactory sense,—as, for instance, if a nervous filament from the first pair of nerves had been sent down alongside of the pneumogastric and then, by following the track of the mammary and epigastric arteries, had at last reached the prepuce, where the olfactory sense could have been turned on at will, like an incandescent lamp,—it might have been a very useful organ, as in that sense it could have scented danger from afar, if not from near, and enabled man to avoid any of the many dangers into which he unconsciously drops. But, seeing that the prepuce, to say nothing of being neither nose, eye, nor ear to warn one away from danger, or a leg to run away on after once in it, having not even the precautionary sensitiveness of a cat's moustachios, it cannot, in any way that we can see, be compared to any other useful part of the body.

All attempts to find reasons for its existence that are of real benefit to man have so far proved unsatisfactory, and, unlike the reasons for its removal, are, as a rule, founded on speculation. To further reason out the why and wherefore of its existence or of its summary surgical execution, we must consider its shifting positions as to the effects it produces, as well as to its conditions at different ages, sitting on its case like an impartial jury in the case of some unconvicted but diabolically-inclined criminal.

As before remarked, we are, as a rule, born with this appendage, just as much as we are with the appendix vermiformis, which rises up, like Banquo's ghost, whenever we eat tomatoes or any small-seeded fruit. 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 being a perfectly natural condition, and one consistent with health; at least, we imagine it is normal.

Phimosis in childhood is generally considered a physiological state, only to be taken as a pathological condition under certain circumstances. Preputial adhesions may, according to many observers, also be classed as physiological at an early period of life, as it is by them considered as congenital, and common enough to warrant its being classed as normal. As to the first, or phimosis, it undoubtedly is a physiological condition during infancy; but why, we do not know; and it is also a fact that from birth to puberty it remains so in fully over one-half of the cases. Out of 98 children, from one week to sixteen years of age, examined by Dr. Packard, the prepuce was entirely unretractable in 54, partly so in 3, and wholly so in 36; while in 1 it only half-covered the glans and in 4 the glans was wholly uncovered, 1 of these 4 being an infant only five weeks old.

Dr. Packard also gives the result of 172 examinations by himself, of from twelve to seventy-three years of age, and 106 examinations by Dr. Maury, a total of 278, in whom 100 had a long prepuce, 97 a partly-covered glans, and 81 (of whom 2 had been circumcised) in whom the glans was exposed.[83] As to adhesions, there is an unaccountable diversity of opinion as to their constancy as a natural condition, being frequent enough to class them as physiological occurrences. Dr. A. B. Arnold, of Baltimore, states that his experience in reference to preputial adhesions leads him to conclude that the frequency of its occurrence has been much overstated. In the number of children that he has circumcised, which exceeds 1000, he has met with it in less than four per cent. of the cases. He also mentions that in the adult the adhesions show greater firmness.[84]

On the other hand, Dr. Bernheim, of the Paris Israelitish Consistory, observes that, of over 3000 newborn whom he has examined, with but few exceptions he found the presence of preputial adhesions. He remarks, however, that in the majority these are detached or broken by the first attempt at erection.[85]

Bokai, out of 100 children, found 8 who were over seven years of age, who were perfectly free; while of the remaining 92 under that age 6 more showed no adhesions and 86 had various degrees of adhesions.[86]

Dr. Holgate, of the out-door department of Bellevue, considered that all phimosic cases have adhesions; while Dr. Moses, of New York, out of some fifty circumcisions performed at the eighth day, found only adhesions three times.[87]

These observations are, however, in perfect accord. If we connect the statement of Dr. Arnold, in regard to the increasing character of the firmness in the adhesions of the adult, with the statement of Dr. Bernheim, that the first erection is often sufficient to break up the existing adhesions in the infant, we must conclude that they are nothing more at first than a slight agglutination, which the slight manipulation required to properly locate the position of the glans, and to space out the prepuce preparatory to the operation of circumcision, must, in the majority of cases, be sufficient to liberate the prepuce from the glans; this is evident also from the statement of Dr. Moses, who only found six per cent. of the cases operated upon by him as being so affected.

The writer has been present at a large number of Hebrew circumcisions performed on the eighth day, and from that up to the sixth month (as in many communities they wait until a number of children are collected, so to speak, before sending for the mohel, who may reside at quite a distance), and in all of those witnessed he has never seen any complications from adhesions; but cases of adhesion have been often encountered from the second to the eighth year, and it has always been the case, as a rule, that the older the child the greater the firmness of the adhesion. In these cases the practice generally advised of using a probe is not practicable, as the person is more apt to wound the sound prepuce than to tear the adhesions; the practice most effectual is to hold the glans firmly but gently with the thumb and forefinger of the right hand, and then to draw the prepuce as firmly back with its fold held in the forefinger and thumb of the other. It is a more expeditious mode, and the least painful; by this method extensive adhesions can readily be broken up; vaselin and a piece of fine lint should then be interposed for a couple of days to prevent a re-adherence.

Another co-existing condition with phimosis, very often found, is a shortening of the frenum. Dr. Jansen, out of 3700 soldiers of the Belgian army, found 12.3 per cent. with this pathological condition and 2.5 per cent. with a narrow prepuce.[88]

Take the three conditions above enumerated,—phimosis, preputial adhesions, and short frenum,—all are but a departure from a normal, in a greater or less degree; and whether the resulting discomfort consists in mere mechanical impediment to urination, erection, or as a factor in nocturnal enuresis, dysuria, impotence, either through reflex action or interference with emission, malposition of the urethral orifice during copulation owing to any of these conditions, or in any of the nervous derangements that may accompany this condition, or in the more serious results, ending in positive deformity of body or limb, or in the warping of moral sentiments, or, even further, in inducing insanity, it cannot well be seen how the conditions that will certainly produce these results, in a more or less degree, can ever, in any logical sense, be considered a physiological condition.

There are certain conditions to life, up to the time of birth, which, unless they then cease at once to exist, immediately become from a physiological into very serious pathological conditions. These are well understood, and have their reasons for existing during our pre-natal existence; but the prepuce has no known function during uterine life or subsequently; and there being no valid reason for its existence, there are certainly no logical grounds for its being considered a physiological condition, especially when the serious results attending the most accentuated form of the above three conditions are considered, and as its necessity, in cases of its entire absence, has not yet been demonstrated.

It can well be said that about two-thirds of mankind are affected in a greater or less degree with these pathological conditions, causing them more or less annoyance. Of these, a certain percentage suffer a life of continued misery, as a direct or indirect result of these conditions.

As to the actual necessity of a prepuce existing, or as to what annoyances or diseases persons are subjected to who are born without it, there is a most singular and expressive silence in medical literature. It stands to reason that, if it is a necessity, some one person should have found it out long ago, and there should then be some evidence to present in relation thereto. There are cases reported in some of the older surgeries wherein an attempt has been made, in the absence of a prepuce, to restore or manufacture one by means of a plastic operation. Vidal describes such an operation,[89] but there is no reason given as to why the operation was undertaken; there is no record of any diseased condition which it was intended either to cure or to alleviate; so that we are left to infer that the person simply submitted to the operation from purely cosmetic reasons. The Hebrews of Palestine, after the Roman conquest, or those in Italy or Spain, attempted a like operation, but not from any reason of lessened health or to restore any lacking physiological action, their aim having simply been to hide their identity, for the purpose of escaping persecutions, exactions, or annoyances, either from their rulers or their fellow-citizens.

Dr. A. B. Arnold, in a paper on circumcision, read before the Academy of Medicine of Baltimore, argues that it is not difficult to divine the purposes of the prepuce, holding that it is necessary to protect the tactile sensibility of the glans, due to the presence of the Pacinian bodies which Schweigger Seidel discovered in the nerves, and that a better provision than the anatomy of the prepuce cannot be conceived for shielding the very vascular and sensitive structure of the glans from external sources of irritation and friction, that might rouse the sensibility of this organ, which, on physiological grounds, may cause early masturbation; further arguing that, the corona being undoubtedly the most excitable part of the glans, its denudation by circumcision leaves it more apt to be affected by chance titillations.[90] In this latter view of the case the preponderance of views is, however, in the opposite direction. J. Royes Bell states that, owing to the induration of the glans through the means of circumcision, masturbation and syphilis are less rife amongst the circumcised than amongst the uncircumcised.[91] M. Lallemand, whose experience in the treatment of seminal emissions is of the greatest value, looked upon circumcision as one of the means of curing those diseases, looking on the diminished irritability of the glans resulting from the operation as the curative element.[92] Dr. Cahen, in a "Dissertation sur la Circoncision," in 1816, before the Faculty of Medicine of Paris, called the attention to the diminished sensibility of the glans induced by circumcision. Dr. Vanier, of Havre, looks upon the prepuce as the most frequent cause of onanism. "If the prepuce is lax, its mobility produces an irritation to the highly irritable and sensitive nervous system of the child by the titillation in its movements on the glans; if too tight and constricted, then it compresses the glans, and by its irritation it leads the child to seize the organ."[93] So that in either case he looks upon the prepuce, through the sensitiveness it retains and induces in the glans, as the principle cause of masturbation. M. Debreyne, the Trappist monk and physician of La Trappe, who has paid considerable attention to medicine as applied to morality, practically makes the same observations. In children who have not yet the suggestions of sexual desire imparted by the presence of the spermatic fluid, the presence of the prepuce seems to anticipate those promptings. Circumcised boys may, in individual cases, either through precept or example, physical or mental imperfection, be found to practice onanism, but in general the practice can be asserted as being very rare among the children of circumcised races, showing the less irritability of the organs in the class; neither in infancy are they as liable to priapism during sleep as those that are uncircumcised.

Dr. Bernheim says that "the prepuce may be said in general to be an appendage to man, if not positively harmful in some cases, at least useless, requiring constant care, the neglect of which is liable to entail disease and suffering; the irritation it produces through the sebaceous secretion is a frequent cause of masturbation which nothing short of circumcision will remedy."

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. 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. These conditions are followed by the irritating affections incident to phimosis of our earlier life, with the modification that age has induced in making us subject to more serious and fatal ailments, both locally and generally.



CHAPTER XX.

THE PREPUCE, PHIMOSIS, AND CANCER.

In the British Medical Journal of January 7, 1882, there is an interesting article by Jonathan Hutchinson on the "Pre-cancerous Stage of Cancer." In this article he states that, whereas, twenty years previously, his suggestion had been to treat all suspicious sores as being due to syphilis until a clearer diagnosis could be made out, he "had more recently often explained and enforced the doctrine of a pre-cancerous stage of cancer. According to this doctrine, in most cases of cancer, either of penis, lips, tongue, or skin, there is a stage—often a long one—during which a condition of chronic inflammation only is present, and upon this the cancerous process becomes ingrafted. Phimosis and the consequent balanitis lead to cancer of the penis.... A general acceptance of the belief that cancer usually has a pre-cancerous stage, and that this stage is the one in which operations ought to be performed, would save many hundreds of lives every year.... Instead of looking on whilst the fire smouldered, and waiting till it blazed up, we should stamp it out on the first suspicion.... What is a man the worse if you have cut away a warty sore from his lip; and, when all is done, a zealous pathologist demonstrates to you that the ulcer is not cancerous, need your conscience be troubled? You have operated in a pre-cancerous stage, and you have probably effected a permanent cure of what would soon have become an incurable disease. I do not wish to offer any apology for carelessness, but I have not in this matter any fear for it."

In view of the great frequency of the occurrence of cancer of the penis, and the facts pointed out by Roux, that, after the removal of the cancerous prepuce or a portion of the penis for cancer, in case of a recurrence the disease does not do so in the penis, but that it attacks the inguinal glands, showing conclusively that the prepuce is the inciting cause as well as the initial point of attack, the sentiments in the foregoing paragraph, taken from the words of Hutchinson, are worthy of our most careful consideration.

M. Roux, Surgeon to the Charite, during the second decade of the present century, first called the attention of the French profession to the intimate relation or dependence that cancer of the penis bears to phimosis. In England he was preceded in this field of surgical investigation by William Hey, whom Roux met in London in 1814. 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.

Roux was probably the first to point out the peculiarly local character of penile cancer, as there is no locality wherein a timely operation is less apt to be followed by a recurrence. He records a number of cases where the prepuce alone was affected when first seen, but none wherein the glans was attacked and where the prepuce was exempt, giving ample evidence of the original starting-point of the disease.[94]

Erichsen also remarks on the little liability to recurrence of cancer of the penis after a timely operation; he divides the cancer to which the penis is subject to as being of two distinct kinds,—scirrhus and epithelioma. The latter variety commences as a tubercle in the prepuce, and, according to Erichsen, does not occur in the body of the penis except as a secondary infiltration or deposit.[95] Travers states that Jews who are circumcised are not subject to either form of cancer.[96]

Repeated attacks of herpes preputialis and some consequent point of induration are looked upon by Petit-Radel, Chauvin, and Bernard as frequent starting-points for the cancerous affection of the prepuce. The aged or persons of lax fibre being more subject to these inflammatory attacks, are also the most frequent victims of cancer in this situation. The celebrated Lallemand, in regard to the tendency to cancer induced by the presence of the prepuce, observes as follows:—

"Besides simple balanitis ... there also result various indurations, which are proportionate in their degree to the length or time and intensity with which the inciting inflammatory conditions have existed. I have repeatedly found the mucous lining of the prepuce thickened, hardened, ulcerated, and nodulated; at other times converted into a fibrous or even into cartilaginous tissue of excessive thickness; in others, still, in which it had assumed a scirrhous and cancerous nature. I have repeatedly operated on such cases, wherein the prolongation of the prepuce was the only recognized primary cause, the subjects being often countrymen of from fifty to sixty years of age, who had never known any women except their own, but who had, nevertheless, been long sufferers from balanitic attacks, accompanied by abundant acrid discharges, swellings of the prepuce, with more or less consequent excoriations and narrowing of the preputial orifice."[97]

Claparede sums up the inconveniences and dangers to which the possessor of a prepuce is liable to suffer from, as follows: "The retention of the sebaceous secretion is liable to alter its character, converting it into an acrid, irritating discharge, which induces more or less burning, smarting, itching, excoriations, and swelling, which, affecting the little glands situated about the corona and sulcus, induces them to secrete an altered and vicious secretion. 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; and cancer is apt to be the end of any of these conditions."[98]

J. Royes Bell, in Ashhurst's "International Encyclopaedia of Surgery," observes as follows: "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. A contusion or a urinary fistula may be the exciting cause. 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 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. Two kinds of epithelioma affect the penis,—the indurated and the vegetating, or cauliflower growth.... The nature of the disease, in either the prepuce or the glans, is masked by a phimosis.... The prognosis in these cases is much more hopeful than in epithelioma, in other situations.... Sir William Lawrence operated on a patient who was quite well years afterward, and Sir William Ferguson amputated the penis of a man of note in the political world, who lived many years after the operation, and died at an advanced age."

Agnew, of Philadelphia, describes an epithelioma of the prepuce occurring in persons past middle life, beginning as a tubercle, crack, or wart, for which he advises an early circumcision; he admits, however, to not having sufficient data to determine whether Jews and circumcised persons are exempt from carcinoma of the penis; but as its usual starting-point he evidently admits to be in the prepuce, circumcision must certainly be a preventive to its appearance. Gross gives substantially the same opinion as Agnew in this regard. Dr. John S. Billings, in his article on the "Vital Statistics of the Jews," in the January North American Review, of 1891, on the subject of cancer, observes as follows:—

"As regards cancer and malignant tumors, we find that the deaths from these causes among the Hebrews occur in about the same proportion to deaths from other diseases as they do in the average population. But as the ratio of deaths to population is less among the Jews, so the ratio of deaths from malignant diseases to population is also less. Among the living population the proportion found affected with cancer among the Jews was 6.48 per 1000, while of those reported sick by the United States census of 1880, for the general population, the proportion was 10.01 per 1000."

There are no convenient data as to the prevalence or percentage of cases of cancer among the Arabian or Mohammedan population of Asia and Africa, but the above comparison of 6.48 per 1000 among the Jews of the United States, against 10.01 per 1000 of the general population, shows that the circumcised race does, in the instance of cancer, certainly enjoy a certain amount of immunity, having in this regard not quite such an exemption as they enjoy from consumption, but still sufficient to assist in making them longer-lived and more able to enjoy life and die a less lingering and painful death.

It is surprising that, in view of the fact that carcinoma of the penis, starting with such frequency in the prepuce, should have left any doubt but that with the absence of this appendage there would follow less liability to cancer. Cullerier informs us that he had several times amputated the penis for cancerous diseases, but that he is unable to tell us whether the persons were affected with phimosis, remarking that on the last case he had observed the indurated remains of the prepuce; he had, however, recognized the necessity of freely exposing the gland in cases where, from continued irritation and inflammation, there was danger of cancer formation.

Nelaton describes two varieties of cancer that affect the penis,—that which attacks the integument and that which attacks the glans. The first of these varieties he observes as generally beginning as a hardened nodule in the prepuce, which becomes at once more or less thickened and indurated. He gives Lisfranc the credit of pointing out the fact, that, even in the most hopeless-looking case, the glans and body of the penis may be simply pushed back and compressed, but otherwise sound, and that before resorting to an amputation of the whole organ it is better to make a careful exploratory dissection in search of the penis, as it oftentimes happens that the prepuce and integument can be dissected off, leaving the organ intact. He also mentions that elephantiasis of the penile integument generally begins in the prepuce.

Baron Boyer believed that the vitiated preputial secretion allowed to remain beneath the prepuce was one of the causes of cancer of the penis, observing that it would be interesting to know whether cancer of the penis was a rarity among circumcised people, such as the Jews and Mohammedans.[99]

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. They are then seen by either the rural practitioner or the family physician, but before submitting to an operation they run the gauntlet of many physicians, and, when it comes to operating, they generally apply to some one of great skill and reputation. By this time there is little left of the organ, and, as a rule, the party is unable to tell where the disease originated, whether in the prepuce or glans, to them the swollen prepuce seeming to be the whole organ. Of late years, however, it has been pretty well established that it generally begins in the prepuce, and the great number of amputations of the penis on record for this disease does not lead one to believe that it is as rare a disease as was formerly believed. In Langenbeck's Archiv, Bd. xii, 1870, Dr. Zielewicz reports fifty cases of amputation of the penis by the galvano-cautery loop, mostly for carcinoma, one of the fifty being for gangrene and one other for a large papillary tumor. That one surgeon was able to report forty-eight cases of carcinoma or cancer that were treated by one special system of operating tells us plainly enough that the unfortunate possessor of a prepuce, no matter how normal or unobjectionable it may seem to be in the prime of man's existence, or however physiologically necessary it may be deemed, runs too many risks in holding on to his possessions.

The views set forth by Hutchinson in the beginning of this chapter are precisely those that are held by the writer, who would even go further, by advising all such as have, in their youth or since, suffered with balano-posthitis in any degree or form, or whose prepuce shows a tendency to elongation with age, to have the same removed at once; where the prepuce is not redundant, but only tight, a slight operation, such as slitting, will at once remove the possibility of any future danger, without keeping a man from his business a single day.

It may here be remarked that, although always favorably impressed with the great benefits arising out of circumcision, nothing ever resulted in such a serious consideration of the subject as seeing a professional brother dying with a cancerous affection of the penis. The disease had originated in the mucous lining of the prepuce, and when seen in consultation with his attending physicians the gland had already disappeared and the inguinal glands were affected. The man was in the prime of life, and, aside from the local trouble, a specimen of perfect health and physique. He informed us that while a youth he had suffered from repeated attacks of herpes preputialis; that he had suggested circumcision more than once to his father, who also was a physician, but who, unfortunately for the son, could not see any merit in circumcision. To his eyes there was nothing that circumcision could do but what could be accomplished by washing and personal attention to cleanliness. When older, the prepuce gave him less trouble, and for a long time after his marriage it ceased to trouble him altogether. The idea of the necessity of circumcision did not occur to him again until the appearance of the cancerous disease; even then, not appreciating the danger, and looking upon the trouble as a simple transient result of some inflammatory action, he waited until the parts would be in a better state or condition of health before resorting to an operation,—that time never came.

Although to Roux, Wadd, and Hey the credit must be given for bringing the subject of cancer of this organ so prominently before the profession, the knowledge of the existence of the disease has long been a matter of record. Patissier, in the fortieth volume of the "Dict. des Sciences Medicales," quotes from the third volume of the "Memoires de l'Academie Royale de Chirurgie," that in 1724 an officer, aged fifty, was attacked by a cancerous affection originating underneath the prepuce; at the time he consulted MM. Chicoineau and Sonlier the disease had existed for two years, the inguinal glands were implicated, and even the suspensory ligament was affected. These surgeons, nevertheless, determined upon an operation, and, after a long chapter of haemorrhagic accidents, the patient finally made a recovery. Another case, quoted by Patissier, was operated upon by M. Ceyrac de la Coste, the patient a man of sixty, the disease originating, like the preceding case, underneath the prepuce.

Warren, in his "Surgical Observations on Tumors," observes that cancer of the penis begins by a warty excrescence on the glans or prepuce. Walshe, in his work on the "Nature and Treatment of Cancer," says: "The disease may commence in almost all parts of the organ, but the glans and prepuce are by far its most common primary seats. It may originate either from a warty excrescence or a pimple, or it may infiltrate the glans, or appear as a complication of venereal ulceration. Phimosis, either congenital or acquired, is an exceedingly common accompaniment, and it appears probable that the irritation occasioned by this condition of the parts may act as an exciting cause of the disease in persons predisposed to cancer. Circumcision is, therefore, an advisable prophylactic measure, where the constitutional taint is known to exist."



CHAPTER XXI.

THE PREPUCE AND GANGRENE OF THE PENIS.

Another accompaniment of that preputial appendage is gangrene of the penis, which, like carcinoma, starting in at the prepuce, may invade the pubes and scrotum. This disease is not so rare as to merit the little attention it has received from our text-books. M. Demarquay has collected the history of twenty-five cases; from him we learn that the prepuce is the most frequent seat of the start of the affection, from whence, according to Astruc, it rapidly spreads to the skin of the whole organ, and then attacks the corpora cavernosa; it may even extend as high as the umbilicus. This disease spares no age; it attacks young and old alike.

There is not a case recorded of this disease that particularized any other starting-point than the swelling, tension, active or passive congestion that takes place in the integument of the penis. By this it must not be understood that the initial disease or inflammatory action that produces the gangrene must necessarily have its seat in the integument, but that it is the integument of the penis (and especially that of the prepuce) in which, through the laxity of its tissues, passive congestion is favored that the gangrenous action begins. That this is the actual case there can be but little doubt about, as, even where the gangrene invades the body of the penis itself, even where the inflammatory action may have started from a violent urethritis, that condition of blood which favors gangrenous results will be found to have begun during its state of stasis, where it has parted with much of its watery element, as well as considerable of its vitality, while in its slow, tedious, and obstructed passage through the prepuce. Some of this dark, thickish blood, finding its way from the integumentary return circulation to that of the deeper structure, becomes there a mechanical as well as a pathological cause for that impediment to the free circulation of the parts, through its altered physiological condition. The deeper structures of the penis, besides their own blood-supply, carry back into the deeper or systemic circulation a large supply from the integumentary tissues, when in the latter, owing to the greater supply due to any inflammatory action, the blood-current is delayed and impeded in its lax and easily-dilatable tissues, and blood-changes occur favoring the gangrene in the deeper tissues, so that, whether the gangrene first takes place in the body of the penis or in the scrotum, it will be in the prepuce or adjoining integument that its real originating causes will be found.

Baron Boyer, in speaking of the inflammation of the penis, observes that the intensity of the swelling, great pain, and difficulty of urination that follow have led many to believe that the inflammation of the deeper structures really always formed a part of the disease. In otherwise healthy and vigorous subjects it does not, however, extend beyond the skin, as has been demonstrated where the resulting gangrene from excess of inflammatory action has ended in resolution, the deeper tissues not having been found to be injured. It is only where the tone of the general system is lowered, through disease, age, or other deteriorating conditions, that the whole organ is liable to become affected or to break down.

Boyer, in the tenth volume of his "Treatise on Surgical Affections," gives several examples of this affection not due to age: one case was a person, simultaneously attacked by an adynamic fever and a blennorrhagia, who suffered from gangrene of the penis; the local and constitutional disturbance was not high, however, and the patient escaped with the simple loss of the prepuce.

Another case admitted to the Charite, aged thirty-six, was afflicted with a blennorrhagia, upon which an attack of low fever supervened. The penis inflamed, became engorged and livid, and soon gangrenous symptoms presented themselves, making rapid progress; at first the integument alone was affected, but later all the structures became implicated and the penis was completely destroyed, the sloughs detaching themselves in shreds, leaving a conical stump that healed but slowly.

One case, a young man of twenty, also at the Charite, was admitted with adynamic fever; a few days after admission the prepuce was observed to be somewhat inflamed; in spite of all treatment this progressed so rapidly that the purple discoloration presaged a gangrene, which was not slow in following; the focus seemed to be at the superior and back portion of the prepuce; an incision evacuated a quantity of purulent, serous fluid; the disease, however, extended up the organ as far as its middle before its actions ceased; the sloughs were then cast off, when it was found that part of the gland and a portion of the cavernous body had followed the integument in the general wreck, subjecting the patient to intolerable pain during micturition. After the recovery from the fever, the remaining portion of the gland and the mutilated parts of the cavernous body were amputated to remedy this condition; the patient subsequently admitted to have had a blennorrhagia at the time of his admission to the hospital.

The gangrenous action may, in proportion to the low condition of the patient, be as proportionately rapid. Another case from Boyer, quoted from the works of Forestus, relates how the whole organ underwent such speedy disorganization that its liquefied remains were found in a poultice, which had been applied with a view of relieving the congestion,—a very dear price to pay for retaining the prepuce, that the exquisite sensitiveness of the tactile faculty for enjoyment, resident in the corona of the gland, might not be interfered with.

Gross does not mention this affection in his work on surgery, but Agnew devotes considerable space to its description, dividing the disease into two forms: the inflammatory, such as may follow venereal primary sores or operations on the penis, not excepting circumcision; and the obstructive variety, such as may follow embolism or any mechanical obstruction, either purposely or accidentally applied. Of the latter he gives a number of quoted instances; he only admits seeing one case, that of an aged man in the Pennsylvania Hospital, in whom the disease was caused by embolism of the dorsal artery.

J. Royes Bell, in the "International Encyclopaedia of Surgery," pays more attention to it than any of our American authors; mentioning, among the causes which may give rise to it, the exanthemata, especially small-pox, and the poisoning by ergot of rye and erysipelas. Among the local causes lie mentions phimosis, paraphimosis, and balano-posthitis.

Bell quotes the case reported by Mr. Partridge, in the sixteenth volume of the "Transactions of the Pathological Society of London," wherein a sober man, aged forty, lost the whole of his penis up to the root, during the course of a typhus fever. Also the case reported by Mr. Gay, in the thirtieth volume of the same "Transactions," wherein a cabinet-maker, aged thirty-one, lost his penis through the probable results of rheumatic phlebitis, and due to the presence of a plug in the internal iliac vein. In the twelfth volume of the "Transactions" of the same society he finds the record of the case of a soldier who lost his penis through gangrene induced by syphilitic phagedena.

In the consideration of the subject of the prepuce as connected with penile gangrene, it must not be overlooked that the presence of a prepuce may be the inciting cause of some rheumatic affection (the writer has repeatedly seen such), just as such cases are often the result of stricture; as cases of rheumatism that have resisted all remedial means, but that have readily given way to the dilatation of a stricture, are by no means uncommon; not a mere muscular reflex rheumatic pain, but even when accompanied by a rheumatic blood condition. So that even in such a case as above reported as being due to rheumatic phlebitis, or the case reported in the fortieth volume of the "Dictionaire des Sciences Medicales" by Patissier, wherein a man lost penis and scrotum through gangrene, induced by urinous infiltration, may all in the origin be due, if not to the immediate, to the remote effects of the presence of the prepuce.

In the first volume of the Journal of Venereal and Cutaneous Diseases the writer reported a case of the complete loss of penis in a young man as a result of phagedena due to syphilis. The man had had a long and pendulous prepuce; in his case, had circumcision been performed in early childhood, it would have lessened the chances of primary infection, and had it been performed after his infection, it would have removed one cause—if not the principal cause—of the ease with which the phagedenic action was inaugurated. The case already mentioned as an example of spontaneous and natural circumcision belongs to the gangrenous results following phimosis, ending with the loss of the prepuce. In Maclise's "Surgical Anatomy" several specimens of deformity are figured, showing the results of this mildest of the effects of a phagedenic action. The beginning of the interference in the return preputial circulation undoubtedly always takes place over the superior aspect of the corona, where the pressure of the glans is most sharply defined against the inner fold of the prepuce.

There are milder conditions, wherein the circulation of the prepuce is materially interfered with, both through the lax tissues of the parts and the peculiar anatomical construction and shape of the neighboring parts, wherein, without going as far as gangrenous breakdown, the person suffers considerably nevertheless, and is placed in danger of losing his penis; for, as observed by Patissier, whenever a person affected with a gonorrhoea is attacked by a putrid or any low-grade fever, he runs the greatest danger of losing his virile member through gangrene.

Even where phimosis does not exist, but only the long, lax, and retractable prepuce, that is considered a perfectly physiological condition, the prepuce is liable to cause very distressing and complicating annoyances during the progress of other diseases. The writer has noticed that cases with a thick, leathery, and redundant prepuce, even when perfectly retractable, are more liable to require the use of the catheter during the course of a continued fever. Such a condition is also a very frequent accompaniment of prostatic obstruction. So often has this been noticed that its association with prostatic trouble or disease tends to the belief that the irritation produced by this condition of prepuce often lays the foundation for prostatic disease in not a few cases.[100] In elderly people, with the atrophied penis and elongating prepuce, the constant moisture from the urine on the inner fold and glans adds greatly to the irritation as well as to the discomfort of the patient.

A number of affections are accompanied by oedema, especially toward the latter stages of the disease; such, for instance, as the ending of cases of mitral insufficiency. In these, the distension of the prepuce and the resulting balano-posthitis is at times a source of great distress, and at times the resulting engorgement produces a retention of urine. It was after an attendance on one such case that required daily and frequent puncturings for its relief, but which, in spite of all care, finally became gangrenous, that a fellow practitioner cheerfully submitted to circumcision, to avoid the possibility of any such complication occurring to embitter his closing illness.[101]

The prepuce is the starting-point of many of the cases of penitis and retention of urine that often accompany attacks of gonorroea; especially can this result be anticipated where the prepuce is long, pendulous, and with its veins in a varicose condition. Why it should be so is self-evident. Anything that will add to the interference of the return circulation only exaggerates the tendency to penis engorgement; this increases the difficulty of urination, which, by the retention that results, in turn increases the constriction at the root of the penis, and adds to the already difficult return circulation. The bladder by its urine, and the penis by its blood, actually form, by their mutual pressures, an impassable dam at the root of the organ. That this is the true condition has been more than once verified from the instant relief given to the whole condition by the prompt employment of the supra-pubic puncture or aspiration, as catheterization in such cases is altogether out of the question, and should never be attempted or employed unless a soft catheter can be inserted.

A person laboring under a continued fever has his blood in a condition to favor sphacelus; with the slow-moving current of vitiated blood and its retention in such lax tissues as those of the prepuce, through the medium of the enlarged preputial veins, coupled with the lessened sensibilities of the bladder and his perhaps semi-conscious or unconscious condition, and an equally unconscious bladder, he is, to say the least of it,—if in possession of a prepuce,—also the unconscious possessor of a certain degree of percentage, no matter how small or fractional that may be, of recovering from his fever without his penis. Dr. W. W. McKay, of the U. S. Marine Hospital Service of San Diego, attended a case of typho-malarial fever in consultation with me, where, but for the persistent, intelligent, but delicate use of the catheter for nearly three weeks the penis would have become gangrenous. The subject was an uraemic, irritable, nervous, leathery-prepuced individual; the organ was unusually large, the skin of the penis thick, and it was only by keeping the bladder empty that prevented a state of engorgement that would have effectually interfered with further catheterization. As it was, the penis was often dank, livid, and discolored from the passive engorgement.

The writer saw a similar case with the late Dr. F. H. Milligan, of Minnesota. The congestion in this case was due to a gonorrhoeal inflammation involving the skin of the whole penis, retention having followed painful micturition, and the swelling of the penis following the retention; the prepuce was enormously distended, and the penis seemed in a state of erection as far as dimension and rigidity were concerned. The man, a steam-boat cook, informed us that it was fully twice as large as when rigidly erect in health. All efforts to reduce the swelling were unavailing; neither punctures, leeches, nor scarifications were of any avail; catheterization was impossible, but, after relieving the bladder by the supra-pubic aspiration, the patient experienced some relief. He, nevertheless, lost the whole skin of the penis, with that of the pubis and on the front of the scrotum. The man ran into a low form of fever, with uraemic symptoms; the stench was so great that it was almost impossible to remain in the same room with him; but he finally made a slow and very tedious recovery. In healing there was considerable downward curvature of the penis, which, however, did not prevent him from following his old, dissolute course of life.[102]

A calm, unprejudiced consideration of the subject of the liability of the uncircumcised races dwelling in the temperate and semi-tropical countries to cancer, gangrene, and elephantiasis might well lead one to ask: Why are we afflicted with a prepuce? We can understand how a man may become gouty, and become a subject in the end for a gangrene of the extremities; or how senile gangrene may, through a series of pathological processes and blood changes, with the aid of age, finally be reached; or how, by a like course of diseased processes, we reach the apoplectic stage. These conditions, however, can be put off, or partly, if not wholly avoided, by a proper course of life, and, at the worst, it is only after the fires of our youth and prime have completely burned out, that these conditions are liable to claim us as their lawful victim. Not so, however, with some of these conditions that may end in penile gangrene; that are liable to pounce upon us unawares, like an Apache in an Arizona canyon; or as the hired mercenaries of old Canon Fulbert did upon poor Abelard in his study, and, without further ado or ceremony emasculate man as effectually as the most exacting Turk could demand, with a veritable taille a fleur de ventre operation.

Nature has her own ways of protecting what there is of any utility; there is a law of the survival of the fittest that we all appreciate. If, then, this penile appendage is of any utility, why is it that, unlike the rest of the body, it falls such an easy victim to gangrene? The procreative function seems to be, in a sense, one of the main cares of nature in its relation to the animal as well as the vegetable kingdom; but here is a useless bit of skin, adipose tissue, mucous membrane, and some connective tissue, that on the least provocation is liable to go off into a gangrene and drag one of the main generative, or even all the procreative, apparatus into the general wreck. Nature certainly never intended anything of the kind. To be generous, and not libel nature, we must conclude that the prepuce is a near relative to the fast-disappearing climbing-muscle; very useful in our primitive, arboreal days, when we needed such a muscle to reach our perch for the night, and a prepuce or something of the kind, in default of a breech-cloth, to protect the glans penis from being scratched by the briars or thorny and rough bark of the trees in our ascent. The prepuce was well enough in our primitive and arboreal days,—ages and ages ahead of our cave and lake dwellings,—when the notch in a tree and its rough bark formed our couch; but in these days of plush-cushioned pews and opera-seats, cosy office-chairs, car-seats, and upholstered furniture or polished-oak seats, it serves no intelligent purpose.

Emasculation has never been looked upon with favor by its victim, and it would be but natural to suppose that man would take every precaution against the accidental occurrence of such an undesired condition. The writer well remembers that, in his "Tom Sawyer" days on the banks of the upper Mississippi, in the happy days of the crack rafting crews, before the introduction of the towage steamer, when the river towns were more or less terrorized by wild gangs of these men, some of whom were always fighting and quarreling and drinking when not at work. In the lot there was one man with a great reputation at a rough-and-tumble fight. His main hold was that he generally tried to emasculate his adversary by destroying the physiological condition of the testicle. The man was not a large or powerful man, nor was he a great boxer or wrestler, but this reputation made him feared by all the bullies on the river. The report that not a few who had tackled him had subsequently been of no value, either as fornicators or fecundators, or had to be castrated on account of the resulting testicular degeneration, seemed in no way to encourage any one to wish to meet him in a personal encounter. It would seem as if the desire to avoid such an accident—provided persons knew the dangers that lurk in a prepuce—would induce many to submit to circumcision. That many more do not do so can only be attributed to the general human wish to escape a less present evil for a greater unknown one, being evidently deterred by the prospective pain that must be suffered immediately.

There is a question that should interest man above that of the simple loss of penis. It appears that there is a powerful moral effect that follows this loss, as might, in the majority, be anticipated. According to the experience of Civiale, many who have lost the penis, through amputation for disease or through disease itself, end in suicide. He mentions particularly a patient at the Charite who had lost his penis, who, finding no other means to take himself off, saved up sufficient opium, from that given him to calm his pains, to take all at one dose and commit suicide. In the London Lancet for March 27, 1886, there is reported a discussion on this subject, to which the reader is referred, as it fully covers the moral and physical effects of castration and penis amputation for disease. M. Roux, who amputated the penis of a brother of Buffon, in 1810, reported that, in that case, M. Buffon lost none of his customary gayety.



CHAPTER XXII.

THE PREPUCE, CALCULI, AND OTHER ANNOYANCES.

From an article published in the New York Medical Times of March, 1872, from the pen of Dr. J. G. Kerr, of Canton, China, we learn that phimosis is not an uncommon occurrence among the Chinese. As has been demonstrated by C. H. Mastin, of Mobile, climate is a great factor of calculus. ("Transactions International Medical Congress" of 1876, page 609.) That of China seems a most favorable climate in this regard; so that, between the prevalence of phimosis among the Chinese and the calculus-producing tendency of the climate, China may be said to be the classic land of preputial calculi, as England is that of the gout, or the United States that of delirium tremens. From Dr. Kerr we learn that the occurrence of these concretions were, as a rule, multiple, and that in two cases that fell under his observation the number of stones from each individual exceeded one hundred. In one case there were forty, and in three cases there were between twenty and thirty. These were of different sizes and weight, some being an inch and five-eighths in diameter, and from that size down to where one hundred and sixteen taken from one individual case only weighed one ounce. The tendency to calculous disease in that climate may well be imagined, when the same observer relates a case of urinary infiltration into the skin on the under side of the penis that gave rise to the formation of a collection of calculi in that locality, four of which were the size of pigeons' eggs; and another case in which a urinary fistula induced the formation of a calculus in the groin, near the scrotum, the calculus weighing two and a half drachms and measuring one and a half inches by three-quarters of an inch in diameter.

Claparede mentions a case in the practice of M. Dumeril, in which the stone extracted from the prepuce weighed two hundred and twenty-five grammes, or about eight ounces. Civiale speaks of a young man of twenty with phimosis, who, after practicing sexual connection for the first time, experienced pain and a purulent discharge, from whom, on examination, he removed five stones as large as prunes. The patient had felt them in their position, but had imagined the condition to be a natural one.

E. L. Keyes gives their composition as being of calcified smegma, urate of ammonium, triple and earthy phosphates and mucus, and as symptoms and results: pain, purulent discharges, interference with urination and the sexual act, involuntary emission, ulceration of the preputial cavity, and impotence.

Enoch mentions a child of two years in the Charite, who, being operated upon for phimosis, was found to have a preputial calculus occluding the urethral meatus. At the autopsy a calculus as large as an egg was found in the bladder.

The presence of these formations, although not necessarily dangerous in themselves, may, by their effects and in the irritation they induce, be the means of producing serious mischief. The only preventive or remedy for this condition is circumcision.

Acquired phimosis has been mentioned as a result of inflammatory lotion, such as is connected with balano-posthitis; it sometimes happens that, the act of coitus being done forcibly, especially with public women, who are apt to use very astringent and constricting washes, the prepuce becomes injured, with the result of producing a phimosis. One man will produce the same results through the means of some vaunted wash or dip which is supposed to act as a prophylactic to any venereal infection. 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. These I have never seen in a circumcised individual, and their occurrence and frequency, as well as persistency, are directly proportionate with the degree of tightness, thickness, or redundancy of the prepuce and the irritability of the gland. As remarked by Lallemand, in reference to the victim of nocturnal enuresis becoming a future victim of nocturnal emissions, so it may be said of the person subject in early life to either warts, excoriations or vegetations on the penis, that it is this class that furnishes in after life the subjects for cancerous disease as well as furnishing the easiest victims for venereal infection. These warts, although easily removed, have a tendency to recurrence, especially as long as the moist bed that has once grown them there is still vegetating.

The prepuce is liable to indurations and hypertrophy. Of the first anomaly, the London Lancet of 1846 has a record of two cases in which paraphimosis was induced in elderly subjects, and of one in which it induced phimosis. Since then a number of cases of thickening and induration have been reported. Hypertrophy may take place in any degree, varying from the mere leathery and overpendulous but unobstructive prepuce to the case recorded by Vidal, in the fifth volume of his "Pathologie Externe et Medecine Operatoire," which happened in the practice of M. Rigal, de Gaillae. The hypertrophied prepuce was something enormous, and hung down to below the patient's knees; it was pear-shaped, with the base hanging downward; this base was as large as a man's head. This prepuce was successfully removed by M. Rigal, who presented the specimen before the Paris Surgical Society, who were then discussing a somewhat similar but not so extensive a case, presented by M. Lenoire. Vidal mentions having operated on a number of cases of this deformity of the prepuce in various degrees of growth.

As a rule, simple hypertrophic disease of the penile integument does not interfere with the sexual functions of the male organ after its removal; it being susceptible of complete removal in exaggerated cases, even without touching the body of the organ. There are exceptions to this rule, however, when even this otherwise non-malignant disease may entail the loss of all the genitals. In the London Lancet of July 11, 1846, at page 46, there is a record of a remarkable case of this nature reported by F. H. Brett, Esq., F.R.C.S. The case was that of a locksmith of forty years of age, who was naturally much phimosed. The penis was enormously enlarged, as well as the scrotum, which was more or less ulcerated and full of sinuses filled with a serous pus; some six months prior to the final operation, a part of the prepuce was removed to facilitate urination, but the whole mass had to be subsequently removed, including the whole of the skin of the penis and the scrotum, the testicles having been carefully dissected out and recovered with some skin flap.

In this case the disease was believed to have originated from a perineal fistula. The pathological investigation in the case, however, by Mr. Quekett, who submitted the mass to a microscopical examination, confirmed Mr. Brett in his original opinion that the disease had the same pathological conditions as the similar disease found in India, where it originates from local inflammatory causes. In this case the preputial irritation was, in all probability, the precursor of the conditions that led to the perineal fistula, the patient having had a stricture for some twelve years. Mr. Brett states that the man had been abandoned by his wife on account of his previous sexual disability, and on account, as well, of his having been incapacitated from following any vocation. After the operation all his functions were restored and his organs were sound.

Nelaton records a case reported by Wadd, in 1817, of an African negro so affected, whose penis measured fourteen inches in length and twelve and a half inches in circumference; also the case reported by Gibert, of Hospital St. Louis, of a subject "with a penis the size of a mule's."

Mr. Brett attributes the recovery of his case as being due in a great measure to the moral support given to the patient from the knowledge that his procreative organs were not interfered with, and on the same grounds he attributes the great fatality previously attending the operation to the fact that it previously had been the custom in many cases to make a clean general taille a fleur de ventre, sacrificing all the genital organs. In simple hypertrophy, he considers that the body of the penis and the testicles will always be found to be in a normal condition; a careful dissection of the parts will invariably save not only the man's sexual functions, but his moral stamina, which he sadly needs in such an emergency. In the discussion on this subject heretofore mentioned as taking place in the London Medical Society, Mr. Pye, Mr. John A. Morgan, and others insisted on the necessity of retaining the testicles, whenever possible, in all these sweeping operations upon the genitals, they being actually necessary for the moral and physical support of man, Mr. Morgan observing that their removal would depress parts controlled by the sympathetic system.



CHAPTER XXIII.

REFLEX NEUROSES AND THE PREPUCE.

We have seen in the previous chapters what the immediate effects of the prepuce may lead to; we have followed its local effects in childhood to youth, thence into what it does in our prime, and we have seen how, when we are on the down grade, owing to the increase of years, then, like the minute-men of Concord, wakened up by Paul Revere's classic ride, hanging on to the rear of the retreating and disheartened British, it harasses, worries, and downs a man here and there, striking down the man as if it had some undying, irremediable spite, which nothing but his misery and death could alleviate. Some authorities will argue that all that is required is cleanliness; that all men need do is to be like a true American, with the old Continental watchword of "eternal vigilance is the price of liberty" in continued active practice. A bowlful of some antiseptic wash and a small sponge should always be at hand, and he should be as industrious as if haltered in a tread-mill; he should make this a part of his toilet, and his daily and hourly care. This will, we are told, lessen his chances of becoming a victim to the many ills that lie in wait for him, all on account of the glory, honor, and comfort of wearing a prepuce, which is a perfectly physiological appendage.