CHAPTER XXII.
The Prepuce, Calculi, and Other Annoyances.
From an article published in the New York Medical Times of March, 1872, from the pen of Dr. J. G. Kerr, of Canton, China, we learn that phimosis is not an uncommon occurrence among the Chinese. As has been demonstrated by C. H. Mastin, of Mobile, climate is a great factor of calculus. (“Transactions International Medical Congress” of 1876, page 609.) That of China seems a most favorable climate in this regard; so that, between the prevalence of phimosis among the Chinese and the calculus-producing tendency of the climate, China may be said to be the classic land of preputial calculi, as England is that of the gout, or the United States that of delirium tremens. From Dr. Kerr we learn that the occurrence of these concretions were, as a rule, multiple, and that in two cases that fell under his observation the number of stones from each individual exceeded one hundred. In one case there were forty, and in three cases there were between twenty and thirty. These were of different sizes and weight, some being an inch and five-eighths in diameter, and from that size down to where one hundred and sixteen taken from one individual case only weighed one ounce. The tendency to calculous disease in that climate may well be imagined, when the same observer relates a case of urinary infiltration into the skin on the under side of the penis that gave rise to the formation of a collection of calculi in that locality, four of which were the size of pigeons’ eggs; and another case in which a urinary fistula induced the formation of a calculus in the groin, near the scrotum, the calculus weighing two and a half drachms and measuring one and a half inches by three-quarters of an inch in diameter.
Claparède mentions a case in the practice of M. Dumèril, in which the stone extracted from the prepuce weighed two hundred and twenty-five grammes, or about eight ounces. Civiale speaks of a young man of twenty with phimosis, who, after practicing sexual connection for the first time, experienced pain and a purulent discharge, from whom, on examination, he removed five stones as large as prunes. The patient had felt them in their position, but had imagined the condition to be a natural one.
E. L. Keyes gives their composition as being of calcified smegma, urate of ammonium, triple and earthy phosphates and mucus, and as symptoms and results: pain, purulent discharges, interference with urination and the sexual act, involuntary emission, ulceration of the preputial cavity, and impotence.
Enoch mentions a child of two years in the Charité, who, being operated upon for phimosis, was found to have a preputial calculus occluding the urethral meatus. At the autopsy a calculus as large as an egg was found in the bladder.
The presence of these formations, although not necessarily dangerous in themselves, may, by their effects and in the irritation they induce, be the means of producing serious mischief. The only preventive or remedy for this condition is circumcision.
Acquired phimosis has been mentioned as a result of inflammatory lotion, such as is connected with balano-posthitis; it sometimes happens that, the act of coitus being done forcibly, especially with public women, who are apt to use very astringent and constricting washes, the prepuce becomes injured, with the result of producing a phimosis. One man will produce the same results through the means of some vaunted wash or dip which is supposed to act as a prophylactic to any venereal infection. One patient had developed a chronic herpetic affection by the constant use of an iodized ointment which he regarded as an infallible prophylactic. Many cases of phimosis result from the attending inflammation that follows on the liberal domestic application of nitrate of silver to an abrasion after connection, in the mistaken idea that the party labors under, that he is destroying some venereal virus.
By the irritation that all these applications and accidents induce, warts and vegetations are the but too frequent results. These I have never seen in a circumcised individual, and their occurrence and frequency, as well as persistency, are directly proportionate with the degree of tightness, thickness, or redundancy of the prepuce and the irritability of the gland. As remarked by Lallemand, in reference to the victim of nocturnal enuresis becoming a future victim of nocturnal emissions, so it may be said of the person subject in early life to either warts, excoriations or vegetations on the penis, that it is this class that furnishes in after life the subjects for cancerous disease as well as furnishing the easiest victims for venereal infection. These warts, although easily removed, have a tendency to recurrence, especially as long as the moist bed that has once grown them there is still vegetating.
The prepuce is liable to indurations and hypertrophy. Of the first anomaly, the London Lancet of 1846 has a record of two cases in which paraphimosis was induced in elderly subjects, and of one in which it induced phimosis. Since then a number of cases of thickening and induration have been reported. Hypertrophy may take place in any degree, varying from the mere leathery and overpendulous but unobstructive prepuce to the case recorded by Vidal, in the fifth volume of his “Pathologie Externe et Médecine Operatoire,” which happened in the practice of M. Rigal, de Gaillae. The hypertrophied prepuce was something enormous, and hung down to below the patient’s knees; it was pear-shaped, with the base hanging downward; this base was as large as a man’s head. This prepuce was successfully removed by M. Rigal, who presented the specimen before the Paris Surgical Society, who were then discussing a somewhat similar but not so extensive a case, presented by M. Lenoire. Vidal mentions having operated on a number of cases of this deformity of the prepuce in various degrees of growth.
As a rule, simple hypertrophic disease of the penile integument does not interfere with the sexual functions of the male organ after its removal; it being susceptible of complete removal in exaggerated cases, even without touching the body of the organ. There are exceptions to this rule, however, when even this otherwise non-malignant disease may entail the loss of all the genitals. In the London Lancet of July 11, 1846, at page 46, there is a record of a remarkable case of this nature reported by F. H. Brett, Esq., F.R.C.S. The case was that of a locksmith of forty years of age, who was naturally much phimosed. The penis was enormously enlarged, as well as the scrotum, which was more or less ulcerated and full of sinuses filled with a serous pus; some six months prior to the final operation, a part of the prepuce was removed to facilitate urination, but the whole mass had to be subsequently removed, including the whole of the skin of the penis and the scrotum, the testicles having been carefully dissected out and recovered with some skin flap.