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."