Chapter III

DANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS.

A perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes. So, in the absence of this, we encounter a number of ill consequences, some local only; some affecting the well-being, and even the life, of the entire organism.

The parts being extremely vascular, and in very intimate relation with the central nervous system; we very naturally find that congenital phimosis, interfering with the normal growth of the glans penis, is prone to develop various reflex neurotic disorders or diseases; of which some have been minutely described by Dr. Sayre.[10] Thus forms of _paralysis_ may ensue; either confined to a single group of muscles, and simulating club-foot, or of a more general character. _Epilepsy_, _reflex cough_, _convulsions_, _choreic movements of the limbs_, are extreme examples; but a milder instance of the same causes in operation shows itself in young infants, as _nocturnal restlessness with defective nutrition_. _Hip-joint disease_ and _spinal caries_ may be simulated, and the mal-assimilation of food may eventually produce such gross deformities as _bowing of the legs_. Chronic _priapism_ is a not uncommon occurrence.

Obstruction to the free discharge of urine may produce symptoms of severe _vesical irritation_, occasionally supposed to indicate stone in the bladder. The straining efforts at micturition may cause _hernia_ or _prolapse of the rectum_; the _nocturnal incontinence_ of children is not unfrequently traceable to the same source. _Epistaxis_ has been described. Retention of urine in the folds of the elongated foreskin, together with the child's habit of pulling this, induce a condition of soreness which causes great smarting whenever micturition takes place, and induces the patient to defer that act as long as possible. Hence may in time result _dilatation of the bladder, cystic kidneys, and death_. Even _eczema_ of the abdominal wall has been thus produced; and has disappeared when the cause was removed, as in a case cited by Dr. Hayes Agnew (_Principles of Surgery_, 1881).

When the patient is allowed to reach adult life with the disability unrelieved, he becomes subject to attacks of _balanitis_; and the parts may ulcerate or even slough. In a case seen by the writer, where at the time no symptoms of inflammation were present, the retained deposits of smegma had ulcerated through the prepuce at various points--projecting from this exactly like chalk-stones from the fingers of a gouty person. In a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no fewer than 426 calculi, varying in size from a pin's head to a small bean, from this situation, in the person of a native of India, sixty years of age, who came under treatment for what appeared to be a large tumour at the end of the penis, the true nature of which was not detected until, on removing it, the knife grated against the contained calculi.' The defect constitutes a serious impediment to impregnation; in the event of an acquired local disorder, its presence seriously hinders diagnosis, and altogether precludes appropriate treatment. It has been supposed, and not without plausibility, to predispose to _epithelioma_. A case is given by Mr. Oliver Pemberton; and others have been reported. There can be no question that, under such circumstances, the presence of malignant disease about the glans would much longer remain undetected than in a normal state of the parts; and that the prospects of cure by operative removal would be proportionately lessened. Only comparatively mild examples of phimosis, in which the adhesions produced little or no constriction, and did not at all interfere with urination, could thus have been suffered to pass unrelieved until the subjects were far past maturity.

Phimosis, as an _acquired_ condition, is of frequent occurrence in an _acute_ form; as the result of inflammatory oedema of the prepuce in youths and adults. This, again, may be a consequence of simple balanitis, the result of want of cleanliness, combined with disordered general health and a catarrhal state of all the mucous membranes; in which event it usually yields to mild measures, such as the injection of warm fluids under the foreskin. In by far the greater number of instances it is produced by venereal infection; and imperatively needs prompt operation, usually in the guise of slitting up the structure on a director. In a _chronic_ form, slowly and gradually coming on, and very intractable to remedial measures, it is not seldom seen in old men of gouty habit; and of consequently unhealthy and irritable mucous membranes.

The pathology and treatment of ACQUIRED phimosis do not fall within the scope of the present work, but it is necessary to point out that these are essentially different from those of the congenital; and that the latter needs consideration upon principles totally diverse.

In the congenital we have to deal with tissues _perfectly healthy_, and with skin peculiarly elastic and distensile. In the factitious, all the parts are more or less altered by _disease_, acute or chronic; and as a sequel to the latter, or to repeated attacks of the former, _true contraction_ takes place; the prepuce often attaining a hard and gristly consistence, under which condition simple dilatation is difficult or impossible. The phenomenon is rarely, if ever, seen in association with congenital phimosis; barring gout or venereal taint in addition.

NOTE.--The infrequency of _cancerous disease_ attacking the penis,
renders it unsafe to dogmatise upon any supposed causal
relationship between that malady and the presence or absence of the
foreskin, and does not appear to warrant any stronger assertion on
this point than that which is recorded on the previous page.

FOOTNOTE:

[10] _Orthopædic Surgery_, p. 14. See also Hilton, _Rest and Pain_, p. 276.