CHAPTER XX.
The Prepuce, Phimosis, and Cancer.
In the British Medical Journal of January 7, 1882, there is an interesting article by Jonathan Hutchinson on the “Pre-cancerous Stage of Cancer.” In this article he states that, whereas, twenty years previously, his suggestion had been to treat all suspicious sores as being due to syphilis until a clearer diagnosis could be made out, he “had more recently often explained and enforced the doctrine of a pre-cancerous stage of cancer. According to this doctrine, in most cases of cancer, either of penis, lips, tongue, or skin, there is a stage—often a long one—during which a condition of chronic inflammation only is present, and upon this the cancerous process becomes ingrafted. Phimosis and the consequent balanitis lead to cancer of the penis.... A general acceptance of the belief that cancer usually has a pre-cancerous stage, and that this stage is the one in which operations ought to be performed, would save many hundreds of lives every year.... Instead of looking on whilst the fire smouldered, and waiting till it blazed up, we should stamp it out on the first suspicion.... What is a man the worse if you have cut away a warty sore from his lip; and, when all is done, a zealous pathologist demonstrates to you that the ulcer is not cancerous, need your conscience be troubled? You have operated in a pre-cancerous stage, and you have probably effected a permanent cure of what would soon have become an incurable disease. I do not wish to offer any apology for carelessness, but I have not in this matter any fear for it.”
In view of the great frequency of the occurrence of cancer of the penis, and the facts pointed out by Roux, that, after the removal of the cancerous prepuce or a portion of the penis for cancer, in case of a recurrence the disease does not do so in the penis, but that it attacks the inguinal glands, showing conclusively that the prepuce is the inciting cause as well as the initial point of attack, the sentiments in the foregoing paragraph, taken from the words of Hutchinson, are worthy of our most careful consideration.
M. Roux, Surgeon to the Charité, during the second decade of the present century, first called the attention of the French profession to the intimate relation or dependence that cancer of the penis bears to phimosis. In England he was preceded in this field of surgical investigation by William Hey, whom Roux met in London in 1814. Hey had then operated by amputation of the penis on twelve cases of cancer, nine of whom had had phimosis at the time of the development of the cancer. Wadd at this time also published a work on the subject, but, although he noticed that phimosis was a cause of cancer, he did not fully grasp the subject as Hey and Roux had done, as he believed a cancerous diathesis a primary necessity, and did not then recognize that the primary cause was fully to be found in the prepuce itself.
Roux was probably the first to point out the peculiarly local character of penile cancer, as there is no locality wherein a timely operation is less apt to be followed by a recurrence. He records a number of cases where the prepuce alone was affected when first seen, but none wherein the glans was attacked and where the prepuce was exempt, giving ample evidence of the original starting-point of the disease.[94]
Erichsen also remarks on the little liability to recurrence of cancer of the penis after a timely operation; he divides the cancer to which the penis is subject to as being of two distinct kinds,—scirrhus and epithelioma. The latter variety commences as a tubercle in the prepuce, and, according to Erichsen, does not occur in the body of the penis except as a secondary infiltration or deposit.[95] Travers states that Jews who are circumcised are not subject to either form of cancer.[96]
Repeated attacks of herpes preputialis and some consequent point of induration are looked upon by Petit-Radel, Chauvin, and Bernard as frequent starting-points for the cancerous affection of the prepuce. The aged or persons of lax fibre being more subject to these inflammatory attacks, are also the most frequent victims of cancer in this situation. The celebrated Lallemand, in regard to the tendency to cancer induced by the presence of the prepuce, observes as follows:—
“Besides simple balanitis ... there also result various indurations, which are proportionate in their degree to the length or time and intensity with which the inciting inflammatory conditions have existed. I have repeatedly found the mucous lining of the prepuce thickened, hardened, ulcerated, and nodulated; at other times converted into a fibrous or even into cartilaginous tissue of excessive thickness; in others, still, in which it had assumed a scirrhous and cancerous nature. I have repeatedly operated on such cases, wherein the prolongation of the prepuce was the only recognized primary cause, the subjects being often countrymen of from fifty to sixty years of age, who had never known any women except their own, but who had, nevertheless, been long sufferers from balanitic attacks, accompanied by abundant acrid discharges, swellings of the prepuce, with more or less consequent excoriations and narrowing of the preputial orifice.”[97]