A number of affections are accompanied by œdema, especially toward the latter stages of the disease; such, for instance, as the ending of cases of mitral insufficiency. In these, the distension of the prepuce and the resulting balano-posthitis is at times a source of great distress, and at times the resulting engorgement produces a retention of urine. It was after an attendance on one such case that required daily and frequent puncturings for its relief, but which, in spite of all care, finally became gangrenous, that a fellow practitioner cheerfully submitted to circumcision, to avoid the possibility of any such complication occurring to embitter his closing illness.[101]
The prepuce is the starting-point of many of the cases of penitis and retention of urine that often accompany attacks of gonorrœa; especially can this result be anticipated where the prepuce is long, pendulous, and with its veins in a varicose condition. Why it should be so is self-evident. Anything that will add to the interference of the return circulation only exaggerates the tendency to penis engorgement; this increases the difficulty of urination, which, by the retention that results, in turn increases the constriction at the root of the penis, and adds to the already difficult return circulation. The bladder by its urine, and the penis by its blood, actually form, by their mutual pressures, an impassable dam at the root of the organ. That this is the true condition has been more than once verified from the instant relief given to the whole condition by the prompt employment of the supra-pubic puncture or aspiration, as catheterization in such cases is altogether out of the question, and should never be attempted or employed unless a soft catheter can be inserted.
A person laboring under a continued fever has his blood in a condition to favor sphacelus; with the slow-moving current of vitiated blood and its retention in such lax tissues as those of the prepuce, through the medium of the enlarged preputial veins, coupled with the lessened sensibilities of the bladder and his perhaps semi-conscious or unconscious condition, and an equally unconscious bladder, he is, to say the least of it,—if in possession of a prepuce,—also the unconscious possessor of a certain degree of percentage, no matter how small or fractional that may be, of recovering from his fever without his penis. Dr. W. W. McKay, of the U. S. Marine Hospital Service of San Diego, attended a case of typho-malarial fever in consultation with me, where, but for the persistent, intelligent, but delicate use of the catheter for nearly three weeks the penis would have become gangrenous. The subject was an uræmic, irritable, nervous, leathery-prepuced individual; the organ was unusually large, the skin of the penis thick, and it was only by keeping the bladder empty that prevented a state of engorgement that would have effectually interfered with further catheterization. As it was, the penis was often dank, livid, and discolored from the passive engorgement.
The writer saw a similar case with the late Dr. F. H. Milligan, of Minnesota. The congestion in this case was due to a gonorrhœal inflammation involving the skin of the whole penis, retention having followed painful micturition, and the swelling of the penis following the retention; the prepuce was enormously distended, and the penis seemed in a state of erection as far as dimension and rigidity were concerned. The man, a steam-boat cook, informed us that it was fully twice as large as when rigidly erect in health. All efforts to reduce the swelling were unavailing; neither punctures, leeches, nor scarifications were of any avail; catheterization was impossible, but, after relieving the bladder by the supra-pubic aspiration, the patient experienced some relief. He, nevertheless, lost the whole skin of the penis, with that of the pubis and on the front of the scrotum. The man ran into a low form of fever, with uræmic symptoms; the stench was so great that it was almost impossible to remain in the same room with him; but he finally made a slow and very tedious recovery. In healing there was considerable downward curvature of the penis, which, however, did not prevent him from following his old, dissolute course of life.[102]
A calm, unprejudiced consideration of the subject of the liability of the uncircumcised races dwelling in the temperate and semi-tropical countries to cancer, gangrene, and elephantiasis might well lead one to ask: Why are we afflicted with a prepuce? We can understand how a man may become gouty, and become a subject in the end for a gangrene of the extremities; or how senile gangrene may, through a series of pathological processes and blood changes, with the aid of age, finally be reached; or how, by a like course of diseased processes, we reach the apoplectic stage. These conditions, however, can be put off, or partly, if not wholly avoided, by a proper course of life, and, at the worst, it is only after the fires of our youth and prime have completely burned out, that these conditions are liable to claim us as their lawful victim. Not so, however, with some of these conditions that may end in penile gangrene; that are liable to pounce upon us unawares, like an Apache in an Arizona cañon; or as the hired mercenaries of old Canon Fulbert did upon poor Abelard in his study, and, without further ado or ceremony emasculate man as effectually as the most exacting Turk could demand, with a veritable taillè à fleur de ventre operation.
Nature has her own ways of protecting what there is of any utility; there is a law of the survival of the fittest that we all appreciate. If, then, this penile appendage is of any utility, why is it that, unlike the rest of the body, it falls such an easy victim to gangrene? The procreative function seems to be, in a sense, one of the main cares of nature in its relation to the animal as well as the vegetable kingdom; but here is a useless bit of skin, adipose tissue, mucous membrane, and some connective tissue, that on the least provocation is liable to go off into a gangrene and drag one of the main generative, or even all the procreative, apparatus into the general wreck. Nature certainly never intended anything of the kind. To be generous, and not libel nature, we must conclude that the prepuce is a near relative to the fast-disappearing climbing-muscle; very useful in our primitive, arboreal days, when we needed such a muscle to reach our perch for the night, and a prepuce or something of the kind, in default of a breech-cloth, to protect the glans penis from being scratched by the briars or thorny and rough bark of the trees in our ascent. The prepuce was well enough in our primitive and arboreal days,—ages and ages ahead of our cave and lake dwellings,—when the notch in a tree and its rough bark formed our couch; but in these days of plush-cushioned pews and opera-seats, cosy office-chairs, car-seats, and upholstered furniture or polished-oak seats, it serves no intelligent purpose.
Emasculation has never been looked upon with favor by its victim, and it would be but natural to suppose that man would take every precaution against the accidental occurrence of such an undesired condition. The writer well remembers that, in his “Tom Sawyer” days on the banks of the upper Mississippi, in the happy days of the crack rafting crews, before the introduction of the towage steamer, when the river towns were more or less terrorized by wild gangs of these men, some of whom were always fighting and quarreling and drinking when not at work. In the lot there was one man with a great reputation at a rough-and-tumble fight. His main hold was that he generally tried to emasculate his adversary by destroying the physiological condition of the testicle. The man was not a large or powerful man, nor was he a great boxer or wrestler, but this reputation made him feared by all the bullies on the river. The report that not a few who had tackled him had subsequently been of no value, either as fornicators or fecundators, or had to be castrated on account of the resulting testicular degeneration, seemed in no way to encourage any one to wish to meet him in a personal encounter. It would seem as if the desire to avoid such an accident—provided persons knew the dangers that lurk in a prepuce—would induce many to submit to circumcision. That many more do not do so can only be attributed to the general human wish to escape a less present evil for a greater unknown one, being evidently deterred by the prospective pain that must be suffered immediately.
There is a question that should interest man above that of the simple loss of penis. It appears that there is a powerful moral effect that follows this loss, as might, in the majority, be anticipated. According to the experience of Civiale, many who have lost the penis, through amputation for disease or through disease itself, end in suicide. He mentions particularly a patient at the Charité who had lost his penis, who, finding no other means to take himself off, saved up sufficient opium, from that given him to calm his pains, to take all at one dose and commit suicide. In the London Lancet for March 27, 1886, there is reported a discussion on this subject, to which the reader is referred, as it fully covers the moral and physical effects of castration and penis amputation for disease. M. Roux, who amputated the penis of a brother of Buffon, in 1810, reported that, in that case, M. Buffon lost none of his customary gayety.