Elements of Surgery

by Robert Liston

There is danger in allowing the state of phymosis to exist long; it has been already observed, that this condition of the parts predisposes to ulceration, vegetations, and morbid secretions; but besides, experience has shown, that very many cases of cancer of the penis are attributable to phymosis, either congenital, or of long duration. In all cases, when the orifice of the prepuce is so tight as not to admit of exposure of the glans, the operation is expedient, the existing state of parts being very inconvenient; but it becomes a matter of absolute necessity, when there are extensive sores on the prepuce or glans, when there is much tumefaction or hardening of the parts, when urinary concretions lodge in the præputial cavity, or in the orifice of the urethra, when vegetations or warts form on the glans, and when the præputial orifice is so contracted as seriously to impede the flow of urine.

In paraphymosis there is a necessity for early interference, in order to save the organ; indeed active and decided measures are as imperiously called for here, as in the case of strangulated hernia: and it ought to be remembered that the organ is one of importance, and that its loss would render most people very miserable. To attempt relaxation by fomentations, and such like, is absolute folly; the stricture cannot yield to such remedies; and, from increase of swelling, strangulation will become more and more complete. Cold, too, is incapable of reducing the swelling; cold, or astringents, cannot possibly diminish the size of the vessels, whilst return of the blood in them is prevented by tight stricture; and so long as the stricture remains, the serous effusion cannot subside, but will increase. Besides, the application of cold may hasten the occurrence of gangrene, inasmuch as it tends to diminish the power of parts which are already in a weakly condition. The parts must be instantly replaced. With the fingers of the right hand, the surgeon grasps the glans, and by firm and continued pressure diminishes its volume, whilst with the left he endeavours, by steady pulling, to reflect the swollen prepuce over the glans, which he is at the same time pushing back, as well as lessening. By uniformity and perseverance in these manipulations, more than by any force, replacement will often be accomplished. He will be able to judge, from the duration of the disease, and from the appearance and feel of the parts, whether simple reduction, that is, without having recourse to the knife, be practicable or not. In some cases, particularly when gangrene is imminent, and when the ulceration is extensive, there is danger of materially injuring the glans, if attempts at reduction are injudiciously persevered in. When he is foiled in reduction, or deems the attempting of it imprudent, the stricture must be divided; and in this simple operation great errors are often committed from ignorance of the nature of the disease, and of the relative situation of the parts. It is necessary to divide only the edge of the prepuce, which, from being reflected, alone composes the stricture. The anterior and posterior swellings are to be separated as far as possible, and in the very bottom of the depression between them the stricture is exposed; a slight incision, a scratch, through this, either with the point of a bistoury, or with a lancet, is sufficient; the tight edge of the prepuce—the only part in fault—is divided, and then, by the process already detailed, reduction can be readily effected. After reduction, a minute notch in the extreme edge of the prepuce is the only deformity visible, except the swelling. But if, from ignorance of the true seat of the stricture, extensive incisions have been made, pretty much at random, the organ may be considerably disfigured—and that unnecessarily. By fomentations, rest, and low diet, the effusion will be dissipated in a very few days. Reduction is difficult when the contraction has continued for some time, and the tissues have become glued together by effused lymph.

Malignant ulcer, with induration of the surrounding parts, and contamination of the lymphatics, occurs occasionally on the glans penis, or on the lining membrane of the prepuce. As before observed, it is most frequently met with in those who have laboured under congenital phymosis; in that state of the organ, its extremity is apt to inflame, swell, and ulcerate, in consequence of accumulation and acrimony of the secretions from the membrane of the prepuce; indolent swellings form in the groin; and in one case, I recollect, these assumed a malignant action, a frightful ulcer formed, and the patient was destroyed, after division of the prepuce, and after the ulceration on it had been long healed, and the part had apparently become quite sound. Early removal of the diseased part, by incision wide of the indurated and altered structure surrounding the ulcer, is the only means of saving the patient, of preventing glandular inguinal tumour, ulceration of it, hemorrhage, hectic, and death. When the prepuce solely is involved, removal of this is sufficient, either entirely or in part, as circumstances may demand. When the glands and coverings, as also the body of the organ, are involved, amputation is to be performed, provided the lymphatics still appear unaffected. In this operation the integuments must be freely removed, otherwise the cut orifice of the urethra will be obstructed by their puckering and contraction during cicatrisation of the wound. With this view, the skin is drawn forwards and stretched by the left hand, and then with one sweep of a long knife a transverse incision is made at once through all the parts composing the organ. Two or three vessels by the side of the septum may require ligatures. The skin retracts considerably, leaving the cut surface free; the wound granulates, contracts, and cicatrises. It is advisable to cut the urethra a little longer than the body of the organ. If diminution in the canal of the urethra be threatened during the cicatrisation, it is to be obviated by the occasional use of a short conical bougie.

Imperfections about the orifice of the urethra are by no means uncommon. Often there is a mere vestige of the orifice of the urethra in the natural situation, the opening being situated half an inch or a whole inch behind, and on the lower part—Hypospadias; in such cases the prepuce is generally short.

Sometimes the urethra is deficient to a great extent, terminating immediately before the scrotum, or even behind it. A child had passed no water thirty hours after its birth. The bladder was distended. The genital organs were imperfect; the urethra was wanting, and the penis was diminutive and abnormal. A small trocar was passed from the vestige of the orifice onwards, in the proper course, guided by the finger in the rectum. The urethra seemed to have terminated at the bulb; the canula reached this, and was retained for twenty-four hours. Afterwards the urine passed readily through the canal, partly natural, but principally artificial, and the power of retaining it became perfect.

In adults the hypospadias is inconvenient; the orifice is often contracted, and the whole parts are irritable; and the ejaculation of the seminal fluid is unsatisfactory to the parties concerned. The deficiency may be repaired in some measure, when there is abundance of skin to spare, but no rules can be laid down for such irregular operations.

Imperfection of the urethra anteriorly, on the dorsum, is rare—Epispadias. The following is rather a remarkable instance:—The man was aged 26, robust and healthy. The whole extent of the urethra anterior to the pubes was exposed superiorly, there being a wide fissure through the corpora cavernosa and glans. The penis was retracted considerably, so that the posterior part of the fissure lay beneath the symphysis pubis. The numerous lacunæ of the urethra were beautifully distinct, and the mucous membrane was seen covered by their secretion. When the patient made water, the urine, after emerging from beneath the pubes, divided into numerous small streams, some of which spread over the side of the penis, while others passed along the exposed urethra. The callous margins of the fissure, formed by the corpora cavernosa and glans, were carefully pared, and, a catheter having been introduced, the raw surfaces were retained in apposition by suture. The wound healed perfectly, almost entirely by the first intention; and the organ both looked well and proved efficient. The malformation was congenital, and was considered by the patient as analogous to harelip; but the story related to account for it in consequence of an impression made in his mother’s imagination, was not very plausible.

The disease of the external parts of the male genital organs, commonly called Chimney-sweeper’s Cancer, is one of a formidable and intractable nature, but fortunately not very often met with. The scrotum is the part usually attacked. A wart forms, generally at the lower part, assumes an irritable appearance, and quickly degenerates into open ulceration of a malignant character. The ulcer extends rapidly, consuming the neighbouring integument, and involving the testicle and other subjacent parts in induration and enlargement. The induration extends along the spermatic chord, and the lymphatics participate in the diseased action at an early period. The discharge from the sore is acrid, sanious, and possessed of much fetor; sometimes fungi protrude, but more commonly the surface is excavated and smooth. Not unfrequently the skin surrounding the ulcer is studded, to a considerable extent, with numerous clusters of warts, of an unhealthy and angry aspect. A very aggravated specimen of the disease is here represented. The general health is soon undermined, and the disease advances from bad to worse with the usual certainty and rapidity of malignant action. It seldom occurs till after the age of thirty or

forty; and though most frequent in chimney-sweeps, is not peculiar to them. No treatment can be expected to arrest its progress at an advanced stage; the only opportunity of saving the patient is at the commencement of the disease, when the affected part is small, and before the lymphatics have become involved. Local application and internal remedies are not to be trusted to; in the early stage the parts may be excised. An incision is made wide around the wart or ulcer, and the included parts are dissected away to a considerable depth. When the testicle has become affected, the chance of success is much diminished; but still, if the inguinal glands appear sound, and the chord tolerably free, castration is to be performed as the last, though desperate, means of eradicating the disease.