II NATURE OF CONGENITAL PHIMOSIS—PHYSIOLOGICAL IMPORTANCE OF THE PREPUCE.
The word 'phimosis' (φἱμὁω, I bind) signifies that condition of the penis in which the prepuce cannot be retracted beyond the corona glandis; and which may be either congenital or factitious.
The latter is a pathological phenomenon, the product of injury or of disease. To apply the term 'abnormal' to the former is, however, hardly permissible, except when the difficulties in retraction are permanent and extreme; when they cannot be overcome by judicious perseverance, and by careful manipulation in the early weeks of infant life. A certain amount of adhesion between the two contiguous surfaces of mucous membrane is almost constantly present at birth, as a continuation of the normal intra-uterine agglutination (Keating's Cyclopædia of the Diseases of Children, 1890, vol. iii.; article by Dr. De Forest Willard).
The radical defect in congenital phimosis is thus the adhesion or imperfect separation of two muco-cutaneous surfaces, normally developed in close contact. As a rule, these are so slightly connected that a very slight degree of force is sufficient to part them; but in a considerable minority of instances the defect eventually becomes permanent; with the natural growth of the organ more difficulty is experienced in procuring retraction; and various disagreeable, or even dangerous, symptoms are prone then to make their appearance.
The complaint, however, is simply one of degree. If the adhesions at the margin of the urethral meatus are so tight that they fail to be quickly separated by the stream of urine directed against them—the force of which necessarily varies in different infants—considerable impediment to micturition results; and, perhaps usefully, serves to direct early attention to the state of the parts. In rare cases, no opening at all into the urethra has been discoverable; and complete retention has necessarily ensued. Very often, however, nothing of this sort happens for several weeks, months, or even years; and the existence, or rather persistence, of the disability may not be noticed at all until adolescence of adult life. The majority of instances lie between these extremes; not seldom unpleasant symptoms begin to be observed when the boy is a few months old; but there is a wide range of variation.
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.[9]
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.