It may here be remarked that, although always favorably impressed with the great benefits arising out of circumcision, nothing ever resulted in such a serious consideration of the subject as seeing a professional brother dying with a cancerous affection of the penis. The disease had originated in the mucous lining of the prepuce, and when seen in consultation with his attending physicians the gland had already disappeared and the inguinal glands were affected. The man was in the prime of life, and, aside from the local trouble, a specimen of perfect health and physique. He informed us that while a youth he had suffered from repeated attacks of herpes preputialis; that he had suggested circumcision more than once to his father, who also was a physician, but who, unfortunately for the son, could not see any merit in circumcision. To his eyes there was nothing that circumcision could do but what could be accomplished by washing and personal attention to cleanliness. When older, the prepuce gave him less trouble, and for a long time after his marriage it ceased to trouble him altogether. The idea of the necessity of circumcision did not occur to him again until the appearance of the cancerous disease; even then, not appreciating the danger, and looking upon the trouble as a simple transient result of some inflammatory action, he waited until the parts would be in a better state or condition of health before resorting to an operation,—that time never came.
Although to Roux, Wadd, and Hey the credit must be given for bringing the subject of cancer of this organ so prominently before the profession, the knowledge of the existence of the disease has long been a matter of record. Patissier, in the fortieth volume of the “Dict. des Sciences Médicales,” quotes from the third volume of the “Mémoires de l’Académie Royale de Chirurgie,” that in 1724 an officer, aged fifty, was attacked by a cancerous affection originating underneath the prepuce; at the time he consulted MM. Chicoineau and Sonlier the disease had existed for two years, the inguinal glands were implicated, and even the suspensory ligament was affected. These surgeons, nevertheless, determined upon an operation, and, after a long chapter of hæmorrhagic accidents, the patient finally made a recovery. Another case, quoted by Patissier, was operated upon by M. Ceyrac de la Coste, the patient a man of sixty, the disease originating, like the preceding case, underneath the prepuce.
Warren, in his “Surgical Observations on Tumors,” observes that cancer of the penis begins by a warty excrescence on the glans or prepuce. Walshe, in his work on the “Nature and Treatment of Cancer,” says: “The disease may commence in almost all parts of the organ, but the glans and prepuce are by far its most common primary seats. It may originate either from a warty excrescence or a pimple, or it may infiltrate the glans, or appear as a complication of venereal ulceration. Phimosis, either congenital or acquired, is an exceedingly common accompaniment, and it appears probable that the irritation occasioned by this condition of the parts may act as an exciting cause of the disease in persons predisposed to cancer. Circumcision is, therefore, an advisable prophylactic measure, where the constitutional taint is known to exist.”
CHAPTER XXI.
The Prepuce and Gangrene of the Penis.
Another accompaniment of that preputial appendage is gangrene of the penis, which, like carcinoma, starting in at the prepuce, may invade the pubes and scrotum. This disease is not so rare as to merit the little attention it has received from our text-books. M. Demarquay has collected the history of twenty-five cases; from him we learn that the prepuce is the most frequent seat of the start of the affection, from whence, according to Astruc, it rapidly spreads to the skin of the whole organ, and then attacks the corpora cavernosa; it may even extend as high as the umbilicus. This disease spares no age; it attacks young and old alike.
There is not a case recorded of this disease that particularized any other starting-point than the swelling, tension, active or passive congestion that takes place in the integument of the penis. By this it must not be understood that the initial disease or inflammatory action that produces the gangrene must necessarily have its seat in the integument, but that it is the integument of the penis (and especially that of the prepuce) in which, through the laxity of its tissues, passive congestion is favored that the gangrenous action begins. That this is the actual case there can be but little doubt about, as, even where the gangrene invades the body of the penis itself, even where the inflammatory action may have started from a violent urethritis, that condition of blood which favors gangrenous results will be found to have begun during its state of stasis, where it has parted with much of its watery element, as well as considerable of its vitality, while in its slow, tedious, and obstructed passage through the prepuce. Some of this dark, thickish blood, finding its way from the integumentary return circulation to that of the deeper structure, becomes there a mechanical as well as a pathological cause for that impediment to the free circulation of the parts, through its altered physiological condition. The deeper structures of the penis, besides their own blood-supply, carry back into the deeper or systemic circulation a large supply from the integumentary tissues, when in the latter, owing to the greater supply due to any inflammatory action, the blood-current is delayed and impeded in its lax and easily-dilatable tissues, and blood-changes occur favoring the gangrene in the deeper tissues, so that, whether the gangrene first takes place in the body of the penis or in the scrotum, it will be in the prepuce or adjoining integument that its real originating causes will be found.
Baron Boyer, in speaking of the inflammation of the penis, observes that the intensity of the swelling, great pain, and difficulty of urination that follow have led many to believe that the inflammation of the deeper structures really always formed a part of the disease. In otherwise healthy and vigorous subjects it does not, however, extend beyond the skin, as has been demonstrated where the resulting gangrene from excess of inflammatory action has ended in resolution, the deeper tissues not having been found to be injured. It is only where the tone of the general system is lowered, through disease, age, or other deteriorating conditions, that the whole organ is liable to become affected or to break down.
Boyer, in the tenth volume of his “Treatise on Surgical Affections,” gives several examples of this affection not due to age: one case was a person, simultaneously attacked by an adynamic fever and a blennorrhagia, who suffered from gangrene of the penis; the local and constitutional disturbance was not high, however, and the patient escaped with the simple loss of the prepuce.