Part 3

The penile and preputial layers of mucous or quasi-mucous membrane being firmly adherent, and growth of the glans penis proceeding apace, certain consequences necessarily follow.

The prepuce being (in extreme cases) tightly fixed to the margins of the urethral orifice, the meatus urinarius still retains the same calibre as when birth took place, and becomes far too small for the needs of the rapidly growing child. A difficulty in effectually voiding the bladder is experienced, and may eventually result in complete retention. The little patient tugs at the seat of unpleasant sensation; and this elongates the folds of skin at the extremity of the penis, normally somewhat redundant, and extremely distensile. The muscular force of the bladder being spent upon overcoming the obstruction at the narrow meatus, the urine trickles out feebly, and 'balloons' in the soft pouches beyond, which continuously retain a few drops. Hence great local irritation and excoriation.

It is not warrantable, however, to speak of contraction of the penile mucous membrane. No contraction takes place, except as a consequence of inflammatory attacks; and these, in the infant, are rarely sufficient to cause any material shrinking. The phenomenon is simply one of natural development under a rigid restraining envelope; and though eventually the aperture is found narrow enough, the 'contraction' is relative only. So also, in every male child there is more or less seeming redundancy of skin at the end of the penis;--for natural physiological reasons. The condition is apt, as first stated, to become factitiously enhanced under the pressure of urinary obstruction. But there is seldom or never a real superfluity of integument in this locality ab initio; in excess of what the subsequent needs of the full-developed organism may be reasonably supposed to warrant. It is requisite to lay some stress on these two points, as tending materially to influence our conceptions of the practice condemned in this pamphlet.

Although plainly not absolutely essential to the due increase in bulk of the penis, or to the subsequent performance of its functions, it is prima facie obvious that the prepuce must be intended to subserve some useful purpose. That, according to Dr. Willard (Keating's Cyclopædia), 'is to protect the head of the organ, during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm.' The latter half of this statement may fairly be questioned, as the prepuce is completely retracted during coition; and so no friction over 'the corona' can well take place under ordinary conditions. The first part, however, is unimpugnable; and to it may be added some consideration of the protection afforded during the first efforts at functional use.

Some measure of the degree in which the glans penis is shielded from external irritating agencies is afforded by the sensations of the adult for the first time deprived of this appendage; or in whom the latter is kept retracted for any length of time, contrary to preceding habit. Extreme discomfort, indeed considerable soreness and actual pain, are complained of; until tolerance becomes established, and until the delicate membrane has by exposure and friction become so hardened that the absence of its former covering is no longer noticed, a period occupying commonly several weeks.

In the case of young children, the unpleasant sensations involved must be relatively far greater; considering their physical helplessness and their more impressionable nervous system.

According, moreover, to the authority previously cited, early removal of the prepuce is apt to be followed by progressive sclerosis, with attendant evils of contracted meatus, balanitis, &c. And, failing this, 'the exposure of the tender skin to the friction of the clothing, &c. tends to keep up a state of abnormal excitement during the early years of life.'

It thus becomes apparent that, apart from any risks involved by operative procedures, ablation of the prepuce, whether in infant or in adult, is not a measure to be undertaken lightly, or without satisfactory evidence of positive necessity.

FOOTNOTE:

The fact that many adults, of not too sensitive organisation, gradually acquire a habit of retaining the foreskin partially or even entirely retracted, is of course not lost sight of. But this in no way affects the question of its sudden removal, or of the protection afforded by the structure in question to infants of tender years.

III

DANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS.

A perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes. So, in the absence of this, we encounter a number of ill consequences, some local only; some affecting the well-being, and even the life, of the entire organism.

The parts being extremely vascular, and in very intimate relation with the central nervous system; we very naturally find that congenital phimosis, interfering with the normal growth of the glans penis, is prone to develop various reflex neurotic disorders or diseases; of which some have been minutely described by Dr. Sayre. Thus forms of paralysis may ensue; either confined to a single group of muscles, and simulating club-foot, or of a more general character. Epilepsy, reflex cough, convulsions, choreic movements of the limbs, are extreme examples; but a milder instance of the same causes in operation shows itself in young infants, as nocturnal restlessness with defective nutrition. Hip-joint disease and spinal caries may be simulated, and the mal-assimilation of food may eventually produce such gross deformities as bowing of the legs. Chronic priapism is a not uncommon occurrence.

Obstruction to the free discharge of urine may produce symptoms of severe vesical irritation, occasionally supposed to indicate stone in the bladder. The straining efforts at micturition may cause hernia or prolapse of the rectum; the nocturnal incontinence of children is not unfrequently traceable to the same source. Epistaxis has been described. Retention of urine in the folds of the elongated foreskin, together with the child's habit of pulling this, induce a condition of soreness which causes great smarting whenever micturition takes place, and induces the patient to defer that act as long as possible. Hence may in time result dilatation of the bladder, cystic kidneys, and death. Even eczema of the abdominal wall has been thus produced; and has disappeared when the cause was removed, as in a case cited by Dr. Hayes Agnew (Principles of Surgery, 1881).

When the patient is allowed to reach adult life with the disability unrelieved, he becomes subject to attacks of balanitis; and the parts may ulcerate or even slough. In a case seen by the writer, where at the time no symptoms of inflammation were present, the retained deposits of smegma had ulcerated through the prepuce at various points--projecting from this exactly like chalk-stones from the fingers of a gouty person. In a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no fewer than 426 calculi, varying in size from a pin's head to a small bean, from this situation, in the person of a native of India, sixty years of age, who came under treatment for what appeared to be a large tumour at the end of the penis, the true nature of which was not detected until, on removing it, the knife grated against the contained calculi.' The defect constitutes a serious impediment to impregnation; in the event of an acquired local disorder, its presence seriously hinders diagnosis, and altogether precludes appropriate treatment. It has been supposed, and not without plausibility, to predispose to epithelioma. A case is given by Mr. Oliver Pemberton; and others have been reported. There can be no question that, under such circumstances, the presence of malignant disease about the glans would much longer remain undetected than in a normal state of the parts; and that the prospects of cure by operative removal would be proportionately lessened. Only comparatively mild examples of phimosis, in which the adhesions produced little or no constriction, and did not at all interfere with urination, could thus have been suffered to pass unrelieved until the subjects were far past maturity.

Phimosis, as an acquired condition, is of frequent occurrence in an acute form; as the result of inflammatory oedema of the prepuce in youths and adults. This, again, may be a consequence of simple balanitis, the result of want of cleanliness, combined with disordered general health and a catarrhal state of all the mucous membranes; in which event it usually yields to mild measures, such as the injection of warm fluids under the foreskin. In by far the greater number of instances it is produced by venereal infection; and imperatively needs prompt operation, usually in the guise of slitting up the structure on a director. In a chronic form, slowly and gradually coming on, and very intractable to remedial measures, it is not seldom seen in old men of gouty habit; and of consequently unhealthy and irritable mucous membranes.

The pathology and treatment of ACQUIRED phimosis do not fall within the scope of the present work, but it is necessary to point out that these are essentially different from those of the congenital; and that the latter needs consideration upon principles totally diverse.

In the congenital we have to deal with tissues perfectly healthy, and with skin peculiarly elastic and distensile. In the factitious, all the parts are more or less altered by disease, acute or chronic; and as a sequel to the latter, or to repeated attacks of the former, true contraction takes place; the prepuce often attaining a hard and gristly consistence, under which condition simple dilatation is difficult or impossible. The phenomenon is rarely, if ever, seen in association with congenital phimosis; barring gout or venereal taint in addition.

NOTE.--The infrequency of cancerous disease attacking the penis, renders it unsafe to dogmatise upon any supposed causal relationship between that malady and the presence or absence of the foreskin, and does not appear to warrant any stronger assertion on this point than that which is recorded on the previous page.

FOOTNOTE:

Orthopædic Surgery, p. 14. See also Hilton, Rest and Pain, p. 276.

CUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED ADVANTAGES.

From the preceding, the evils or dangers incurred by permitting a male child to reach adult life; or, in the event of pressing symptoms, to pass even a few weeks or months with this disability unrelieved; are sufficiently obvious. Although, as Dr. Willard (op. cit.) states, the adhesions between prepuce and glans can nearly always be broken down with sufficient readiness during the first few weeks after birth, there can be little doubt that, without conspicuous necessity, the medical practitioner will seldom care to 'make the baby cry,' and thus draw down upon himself vigorous maternal reproaches. It seems, moreover, hardly judicious to encourage any tampering by nurses or midwives, probably more or less ignorant and unskilled. We may take it for granted, therefore, that nothing will usually be done until the child is several months old; when some more energetic treatment will be requisite to remedy the condition in question. In milder cases no notice will probably be taken of the abnormality for at least several years, and its presence may be detected only by accident; the adhesions in such are trivial, and do not interfere with normal growth; hence are, as a rule, easily overcome.

Although less severe measures have been from time to time brought forward and advocated, the operation of circumcision is, to all intents and purposes, the only procedure in general use for remedying congenital phimosis; and as the latter is very common, so also is the performance of this ancient sacrificial rite among that large majority of the population who are otherwise in no way committed to it. There is a simplicity and thoroughness about the little amputation which may perhaps commend it to the surgical mind; and there are unquestionably certain superficial advantages of a hygienic nature about the patient's subsequent condition; though it may be doubted whether these are by any means so considerable as has been made to appear.

However this may be, it goes without saying that no other curative proceeding has so far met with any wide favour in the medical profession; and, if one may judge from their published opinions, the leading exponents of medical practice and opinion, in this country at least, are so pleased with circumcision and its results that they would willingly see the Mosaic Laws in this particular extended to the whole Christian population, whether affected by phimosis or not. Witness Mr. Jonathan Hutchinson:

It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of the removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare.--Archives of Surgery.

Arguments by this distinguished surgeon, in favour of extension of the custom as a matter of ordinary routine to every male Gentile, are to be found in the Medical Times and Gazette, December 1, 1855; together with a reference to previous utterances in an identical sense.