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.[10] 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 œdema 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.