as the former affection, only the parts are in different relations
to each other. In phymosis the prepuce covers the glans, the tight
part is anterior to it; in paraphymosis the prepuce is reflected over
the glans, the tight part acts as a ligature round the penis behind
the glans, and such swelling speedily arises in consequence of the
constriction so as to prevent reduction. The glans and lining membrane
of the prepuce swell anteriorly to the stricture, the integuments of
the penis swell behind, and the stricture is depressed and concealed
between. The cellular tissue there is necessarily very loose, so
as to admit of free motion and change of relative position, and
consequently the engorgement is often very great. The infiltration
is at first serous, and the swelling is easily compressed; but, from
continuance of the inflammatory action, lymph is effused, and becomes
organised, and the turgescence is more solid and unyielding. When the
stricture is very tight, the patient cachectic and irregular in his
mode of life, and the case injudiciously or inertly treated, sloughing
takes place rapidly, or phagedenic ulceration occurs anterior to the
stricture. But in most cases the prepuce is not so tight as to cause
complete strangulation, yet obstructs the flow of blood sufficiently
to induce swelling of the included parts, breach of surface more
or less extensive, and an unhealthy appearance of the ulceration.
The ulceration is generally in the neighbourhood of the stricture,
at first limited and superficial, but increasing both in depth and
extent so long as the cause remains. The stricture is not situated
anteriorly to the swelling, as has been sometimes supposed, but near
its middle—where the tight orifice of the prepuce grasps the penis, and
causes a depression in the swelling. On separating the anterior and
posterior tumours, the stricture is readily exposed, though previously
effectually concealed.
In slight cases of phymosis, the orifice may be dilated by frequent
fomentation, and perseverance in withdrawing the prepuce as far
as possible. When ulceration or secretion of matter has occurred,
astringent injections, at first mild, and gradually strengthened,
should be frequently thrown into the præputial cavity. Suspension of
the penis should be enjoined, along with rest—of the whole body, as
well as of the affected organ in particular. When much inflammation
exists, antiphlogistic remedies must be put in force, followed by
fomentations. In bad cases, the prepuce must be divided in order to
expose the seat of morbid secretions, of ulceration, and vegetations.
The preferable situation for incision is close by the side of the
frænum, much less deformity ensuing than when the prepuce is divided
either laterally or in front. The flaps are at first loose and flabby,
but shrink as the œdematous swelling subsides. A straight director
is introduced within the præputial orifice—the groove pointing
downwards—and passed down to the reflection, close to the frænum; a
sharp-pointed curved bistoury is slid along the groove till it also
reaches the reflection; by raising the handle and pushing it forwards,
the integuments are transfixed there, and withdrawal of the knife by
a rapid sweep completes the incision. Care must be taken not to pass
the director into the urethra instead of into the præputial cavity. It
is very seldom that ligature is required to arrest bleeding. Should
the cellular tissue of the divided part not have been the seat of
solid effusion, the integument and the lining membrane of the prepuce
separate, leaving a large raw surface; and to prevent this a small
suture should be passed between the membrane and skin on each side
of the wound; these may be withdrawn on the second or third day, the
cellular tissue having then become consolidated, so as not to admit
of retraction. A warm bread poultice, or water dressing, is the best
application for the first few days; afterwards healing of the cut
surfaces may be promoted by the application of a gently stimulating
lotion. Should œdema of the prepuce remain, this may soon be effaced
by bandaging. By this operation sufficient space is obtained for
uncovering the glans, under any circumstances; and besides, to this
part of the organ is still preserved its natural investment, not in
the least curtailed either in size or in efficiency—the glans can be
uncovered and covered at will; whereas by any other mode of incision
the unseemly flaps always fall away, leaving the greater part of the
glans constantly uncovered, and placing the patient, if not in a worse,
at least in the same predicament, as if he had been subjected to
regular circumcision.
There is danger in allowing the state of phymosis to exist long; it has
been already observed, that this condition of the parts predisposes to
ulceration, vegetations, and morbid secretions; but besides, experience
has shown, that very many cases of cancer of the penis are attributable
to phymosis, either congenital, or of long duration. In all cases, when
the orifice of the prepuce is so tight as not to admit of exposure of
the glans, the operation is expedient, the existing state of parts
being very inconvenient; but it becomes a matter of absolute necessity,
when there are extensive sores on the prepuce or glans, when there is
much tumefaction or hardening of the parts, when urinary concretions
lodge in the præputial cavity, or in the orifice of the urethra, when
vegetations or warts form on the glans, and when the præputial orifice
is so contracted as seriously to impede the flow of urine.
In paraphymosis there is a necessity for early interference, in
order to save the organ; indeed active and decided measures are as
imperiously called for here, as in the case of strangulated hernia: and
it ought to be remembered that the organ is one of importance, and that
its loss would render most people very miserable. To attempt relaxation
by fomentations, and such like, is absolute folly; the stricture cannot
yield to such remedies; and, from increase of swelling, strangulation
will become more and more complete. Cold, too, is incapable of reducing
the swelling; cold, or astringents, cannot possibly diminish the size
of the vessels, whilst return of the blood in them is prevented by
tight stricture; and so long as the stricture remains, the serous
effusion cannot subside, but will increase. Besides, the application
of cold may hasten the occurrence of gangrene, inasmuch as it tends to
diminish the power of parts which are already in a weakly condition.
The parts must be instantly replaced. With the fingers of the right
hand, the surgeon grasps the glans, and by firm and continued pressure
diminishes its volume, whilst with the left he endeavours, by steady
pulling, to reflect the swollen prepuce over the glans, which he is
at the same time pushing back, as well as lessening. By uniformity
and perseverance in these manipulations, more than by any force,
replacement will often be accomplished. He will be able to judge,
from the duration of the disease, and from the appearance and feel of
the parts, whether simple reduction, that is, without having recourse
to the knife, be practicable or not. In some cases, particularly when
gangrene is imminent, and when the ulceration is extensive, there is
danger of materially injuring the glans, if attempts at reduction are
injudiciously persevered in. When he is foiled in reduction, or deems
the attempting of it imprudent, the stricture must be divided; and in
this simple operation great errors are often committed from ignorance
of the nature of the disease, and of the relative situation of the
parts. It is necessary to divide only the edge of the prepuce, which,
from being reflected, alone composes the stricture. The anterior
and posterior swellings are to be separated as far as possible, and
in the very bottom of the depression between them the stricture is
exposed; a slight incision, a scratch, through this, either with the
point of a bistoury, or with a lancet, is sufficient; the tight edge
of the prepuce—the only part in fault—is divided, and then, by the
process already detailed, reduction can be readily effected. After
reduction, a minute notch in the extreme edge of the prepuce is the
only deformity visible, except the swelling. But if, from ignorance of
the true seat of the stricture, extensive incisions have been made,
pretty much at random, the organ may be considerably disfigured—and
that unnecessarily. By fomentations, rest, and low diet, the effusion
will be dissipated in a very few days. Reduction is difficult when the
contraction has continued for some time, and the tissues have become
glued together by effused lymph.
Malignant ulcer, with induration of the surrounding parts, and
contamination of the lymphatics, occurs occasionally on the glans
penis, or on the lining membrane of the prepuce. As before observed, it
is most frequently met with in those who have laboured under congenital
phymosis; in that state of the organ, its extremity is apt to inflame,
swell, and ulcerate, in consequence of accumulation and acrimony of the
secretions from the membrane of the prepuce; indolent swellings form
in the groin; and in one case, I recollect, these assumed a malignant
action, a frightful ulcer formed, and the patient was destroyed, after
division of the prepuce, and after the ulceration on it had been
long healed, and the part had apparently become quite sound. Early
removal of the diseased part, by incision wide of the indurated and
altered structure surrounding the ulcer, is the only means of saving
the patient, of preventing glandular inguinal tumour, ulceration
of it, hemorrhage, hectic, and death. When the prepuce solely is
involved, removal of this is sufficient, either entirely or in part,
as circumstances may demand. When the glands and coverings, as also
the body of the organ, are involved, amputation is to be performed,
provided the lymphatics still appear unaffected. In this operation the
integuments must be freely removed, otherwise the cut orifice of the
urethra will be obstructed by their puckering and contraction during
cicatrisation of the wound. With this view, the skin is drawn forwards
and stretched by the left hand, and then with one sweep of a long knife
a transverse incision is made at once through all the parts composing
the organ. Two or three vessels by the side of the septum may require
ligatures. The skin retracts considerably, leaving the cut surface
free; the wound granulates, contracts, and cicatrises. It is advisable
to cut the urethra a little longer than the body of the organ. If
diminution in the canal of the urethra be threatened during the
cicatrisation, it is to be obviated by the occasional use of a short
conical bougie.
Imperfections about the orifice of the urethra are by no means
uncommon. Often there is a mere vestige of the orifice of the urethra
in the natural situation, the opening being situated half an inch or a
whole inch behind, and on the lower part—_Hypospadias_; in such cases
the prepuce is generally short.
Sometimes the urethra is deficient to a great extent, terminating
immediately before the scrotum, or even behind it. A child had passed
no water thirty hours after its birth. The bladder was distended. The
genital organs were imperfect; the urethra was wanting, and the penis
was diminutive and abnormal. A small trocar was passed from the vestige
of the orifice onwards, in the proper course, guided by the finger in
the rectum. The urethra seemed to have terminated at the bulb; the
canula reached this, and was retained for twenty-four hours. Afterwards
the urine passed readily through the canal, partly natural, but
principally artificial, and the power of retaining it became perfect.
In adults the hypospadias is inconvenient; the orifice is often
contracted, and the whole parts are irritable; and the ejaculation
of the seminal fluid is unsatisfactory to the parties concerned. The
deficiency may be repaired in some measure, when there is abundance
of skin to spare, but no rules can be laid down for such irregular
operations.
Imperfection of the urethra anteriorly, on the dorsum, is
rare—_Epispadias_. The following is rather a remarkable instance:—The
man was aged 26, robust and healthy. The whole extent of the urethra
anterior to the pubes was exposed superiorly, there being a wide
fissure through the corpora cavernosa and glans. The penis was
retracted considerably, so that the posterior part of the fissure
lay beneath the symphysis pubis. The numerous lacunæ of the urethra
were beautifully distinct, and the mucous membrane was seen covered
by their secretion. When the patient made water, the urine, after
emerging from beneath the pubes, divided into numerous small streams,
some of which spread over the side of the penis, while others passed
along the exposed urethra. The callous margins of the fissure, formed
by the corpora cavernosa and glans, were carefully pared, and, a
catheter having been introduced, the raw surfaces were retained in
apposition by suture. The wound healed perfectly, almost entirely by the
first intention; and the organ both looked well and proved efficient.
The malformation was congenital, and was considered by the patient
as analogous to harelip; but the story related to account for it in
consequence of an impression made in his mother’s imagination, was not
very plausible.
The disease of the external parts of the male genital organs,
commonly called _Chimney-sweeper’s Cancer_, is one of a formidable
and intractable nature, but fortunately not very often met with. The
scrotum is the part usually attacked. A wart forms, generally at the
lower part, assumes an irritable appearance, and quickly degenerates
into open ulceration of a malignant character. The ulcer extends
rapidly, consuming the neighbouring integument, and involving the
testicle and other subjacent parts in induration and enlargement.
The induration extends along the spermatic chord, and the lymphatics
participate in the diseased action at an early period. The discharge
from the sore is acrid, sanious, and possessed of much fetor; sometimes
fungi protrude, but more commonly the surface is excavated and smooth.
Not unfrequently the skin surrounding the ulcer is studded, to a
considerable extent, with numerous clusters of warts, of an unhealthy
and angry aspect. A very aggravated specimen of the disease is here
represented. The general health is soon undermined, and the disease
advances from bad to worse with the usual certainty and rapidity of
malignant action. It seldom occurs till after the age of thirty or
forty; and though most frequent in chimney-sweeps, is not peculiar
to them. No treatment can be expected to arrest its progress at an
advanced stage; the only opportunity of saving the patient is at the
commencement of the disease, when the affected part is small, and
before the lymphatics have become involved. Local application and
internal remedies are not to be trusted to; in the early stage the
parts may be excised. An incision is made wide around the wart or
ulcer, and the included parts are dissected away to a considerable
depth. When the testicle has become affected, the chance of success is
much diminished; but still, if the inguinal glands appear sound, and
the chord tolerably free, castration is to be performed as the last,
though desperate, means of eradicating the disease.
By _Hydrocele_ is meant a tumour caused by accumulation of fluid either
in the chord or within the cavity of the tunica vaginalis testis. It
has been divided into diffused and encysted. By the former term is
understood effusion and accumulation of serum in the cellular tissue,
the cells gradually dilating to accommodate the increasing fluid, and
ultimately becoming converted into vesicles of large size: the parts
around are thickened and condensed. This affection is very rarely a
local one, but almost uniformly combined with and forming a part of
anasarca arising from constitutional causes. When the swelling proves
troublesome, it may be diminished by drawing off the fluid through one
or several punctures; in the chronic form of the disease free incision
is attended with risk, and is besides unnecessary.
[Illustration]
The scrotum is sometimes distended rapidly by effusion of serum often
of a putrescent and acrid nature. This affection supervenes upon
ulcers or sinuses in the groin, perineum, or neighbourhood of the anus,
in patients out of health. It occurs also occasionally as a consequence
of injury of the genital organs, or interferes with bad strictures,
without any disease of these parts, and without the least cause for
the suspicion of urine having escaped into the cellular tissue. This,
together with the skin, is destroyed, and the testicles exposed. The
only chance of saving the tissues consists in early and free incision
of the most dependent part of the swelling, generally the inferior and
posterior. Some cases and remarks on this subject will be found in the
_Medico-Chirurgical Transactions_, vol. xxii., p. 288.
Encysted hydrocele of the chord occurs in children more frequently than
in adults. The fluid is thin and clear, and contained in a distinct
cyst, of a smooth, shining, serous appearance internally; this cyst
may be either an unobliterated portion of the congenital spermatic
process, or composed of thickened and condensed cellular tissue,
strengthened exteriorly by the expansion of the cremaster muscle. The
tumour is seldom large, usually of an oval form, and situated nearly
midway between the testicle and groin; causing no pain, but proving
inconvenient simply from its bulk and situation; fluctuating, and
sometimes partially diaphanous; evidently circumscribed, the chord both
above and below being natural to both sight and touch; not altered by
change of posture or by muscular exertion. Sometimes it encroaches both
on the groin and on the testicle, but even then attentive manipulation
readily distinguishes it from swellings connected with these parts.
Discharge of the fluid by means of a small trocar and canula, not
only dissipates the swelling, but often effects a permanent cure,
particularly in young persons—the cyst either ceasing to exercise a
secretory function, or becoming obliterated. If reaccumulation take
place, the treatment is to be conducted on the same principles as in
hydrocele of the vaginal coat.
Hydrocele of the tunica vaginalis is exceedingly common, particularly
amongst labouring people, and occurs apparently with equal frequency at
all ages. It is a gradual accumulation within the tunica vaginalis of
a fluid partaking more or less of the serous character, furnished by
the exhalants of that membrane,—but whether from excessive secretion
or deficient absorption, it is difficult to determine. It is probable
that the accumulation is the result of excited action in the part, for
its origin is most frequently attributable to external injury—blows or
bruises, followed by rapid swelling, which, after a time, subsides,
leaving perhaps some enlargement of the testicle, or of the more
superficial tissues, and succeeded by the gradual appearance of the
disease in question. Sometimes it is attributed to powerful and
habitual muscular exertion, as in blowing wind instruments, lifting
heavy weights, &c.; and perhaps the impediment to the venous return,
so produced, may be the cause of the effusion. The accumulation, as
already stated, is gradual, and consequently the formation of the
swelling is proportionally slow. It commences at the lower part of
the scrotum, and by degrees ascends, at first globular, afterwards
of a pyriform shape; after it has attained a considerable size, the
testicle cannot be felt in its usual situation, for it is now placed
not at the bottom of the bag but towards its middle and posterior
aspect, and if the tumour be tense it can scarcely be felt at all.
The raphe is displaced to the opposite side, the usual puckering of
the scrotum has disappeared, and the tumour feels light in proportion
to its size. On manipulation it is found yielding and elastic, and
in all ordinary cases a distinct fluctuation is communicated to the
fingers during alternate pressure. And by using the hand as a shade,
the rays of light are made to permeate the swelling, rendering it
more or less transparent according to the thickness and density of
the covering, and the hue of the contained fluid. It is seldom that
the distention of the vaginal coat is to such an extent as to reach
the groin, consequently the spermatic chord is felt to be free, as
also the inguinal aperture; and even when the swelling does reach so
high, the upper part is the least tense, permitting displacement of
the fluid and distinct perception of the chord. The patient complains
of a sense of dragging and weight in the parts, and of uneasiness and
inconvenience during exertion, but seldom of pain. When large, the
tumour is necessarily covered by borrowed integument, often so as
almost entirely to conceal the penis. In many cases the testicle is
increased in size and indurated, and sometimes this enlargement forms
a considerable part of the swelling. Occasionally the spermatic veins
are varicose; and this has been, by some, considered one of the causes
of the disease. Hydrocele is occasionally complicated by the presence
of hernia, when a careful examination must be instituted in order to
understand the exact share each disease has in the production of the
swelling. In cases of very slow increase, and in persons of advanced
age, the vaginal coat and its investments are not unfrequently much
thickened, so as to obscure the sense of fluctuation, and destroy the
transparency of the tumour. Sometimes deposit of earthy matter takes
place between the layers of the membrane, rendering it hard, rigid,
and in a measure osseous; in such cases cholesterine has been found in
the contained fluid; sometimes the cavity is intersected by membranous
filaments, delicate and reticulated; sometimes complete septa subdivide
it into several compartments. The fluid is generally thin, albuminous,
and of a straw colour; in some cases paler, and coagulating on cooling,
being gelatinous; in others of a dark colour, probably from admixture
of blood.
The treatment is either palliative or radical. The former consists
in evacuating the fluid from time to time, according as the feelings
of the patient demand it; in children this simple tapping is often
successful in preventing return of the disease. But here the disease
often enough disappears under the use of a stimulating lotion, as a
strong solution of the muriate of ammonia.