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.