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.