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[REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, AUGUST, 1877.] NEW YORK: D. APPLETON AND COMPANY, 549 & 551 BROADWAY. 1877. PHIMOSIS : A REPORT FROM THE SURGICAL SECTION TO THE NEW YORK ACADEMY OE MEDICINE. Gentlemen : This paper is presented as a report from the Surgical Section of the Academy, in accordance with the requirement in the Constitution of the Academy. The re- porter would offer, as an excuse for the imperfect collation of authorities, the fact that he had not purposed to report until the autumn, but determined to do so at this time in response to a request from the President. Phimosis is differently defined by different writers. By some the term “ is applied to that condition of the penis in which it is impossible to retract the prepuce behind the glans.” Others restrict it to those cases in which the inability to retract the foreskin is due to narrowness of the preputial orifice. In the present report the former—more general— definition will be accepted, as the disorders arising from the condition seem to be essentially the same, whether the phi- mosis be due to narrowness of, or adhesion of, the prepuce. When necessary, the variety of phimosis intended will be especially specified. In the hope of eliciting discussion, the present report is submitted in the form of propositions. Proposition I.—In childhood phimosis is the rule, and may be considered as physiological. 4 The frequency of phimosis is a commonly-accepted fact ; nearly every writer upon genito-urinary diseases mentions it. Drs. Van Buren and Keyes say : “ With very young children, phimosis is so common that it may be considered normal. The foreskin of the child is developed out of all proportion to the rest of the penis, taking the member after puberty as a standard of comparison.” There is, however, no occa- sion for citing authorities. No one, whether giving especial thought to the subject or not, can have failed to observe how rarely the glans is seen uncovered in young children, even when the penis is in a state of erection. This inability to uncover the glans is frequently due to the length of the prepuce and to the narrowness of its orifice alone. I have satisfied myself of this, in some cases, by pass- ing, without obstruction, a probe beneath the foreskin quite to the sulcus behind the corona and in various directions. Observation too of some cases of so-called “ ballooning ” of the prepuce, shows that the collection of urine may be suffi- cient to separate the prepuce entirely from the glans, while the obstruction at the orifice may be considerable. Notably, I have observed this to be true in the cases of certain adoles- cents, where a narrow and somewhat tortuous outlet, admit- ting with difficulty an ordinary probe, rendered micturition slow and difficult. But, as a rule, I think it will be found that adhesions, in the sense of an agglutination of the two epithelial surfaces, exist in phimosis, and that, in most cases, they constitute the real difficulty to be overcome. Any one who has made or witnessed many circumcisions, or other operations upon the foreskin of children, must have observed the frequency of this agglutination, and that it is often so strong as to require considerable force for its breaking up. Prof. Job. Bokai (Jahrbucher fur Kinderheilkunde, Dec. 5, 1871), in a paper on “ Die zellige Verklebung (scheinbare Verwachsung) der Vorhaut mit der Eichei mit Knaben,” etc., gives the result of his investigations in this connection. He had noticed the frequency of troubles of micturition depend- ing upon phimosis and adhesions, and endeavored to ascertain how frequently the latter existed in children. Ilis conclusion is, that agglutination of the two mucous surfaces is, in general, 5 a physiological condition, which should be considered patho- logical only under certain circumstances. To justify this con- clusion, he gives the result of one hundred examinations of children, from birth to thirteen years of age. For conven- ience, he divides adhesions into three grades : 1. Adhesions extending from the corona glandis back- ward. 2. Adhesions beginning at the anterior part of the glans, and running backward. 3. Adhesions reaching from the point of the glans to the sulcus retro-glandaris. The adhesions varied in degree of firmness as well as in extent, the more extensive being sometimes so close as to cause bleeding when torn off. Now, of the one hundred children examined by Bokai, all above seven years of age—eight cases in all—were perfectly free from adhesions. Of the ninety-two cases under seven years of age, six were perfectly free. Altogether, then, 14 cases showed no adhesions. 24 “ “ the 1st grade of adhesion. 22 “ “ the 2d “ « 40 “ “ the 3d “ “ The younger the children, the more extensive, as a rule, were the adhesions, and vice versa ; the freedom of the pre- puce increased with the age. The adhesions occur, too, without reference to the shape of the prepuce or the narrowness of its outlet. Some time since Drs. Ilolgate and Bosley, Attending Phy- sicians to the Class of Children’s Diseases in the Out-Door Department of Bellevue Hospital, made (at the instance, I think, of Dr. J. Lewis Smith) a large number of examina- tions of children with reference to this same question. The investigation was prompted, as with Bokai, by the frequency of disorders of micturition in connection with phimosis. No statistical record of these examinations was made, but, in a conversation with me regarding them, Dr. Ilolgate stated that he considered phimosis in children to be normal, and estimated that it existed in eighty per cent, of the cases ex- amined. “ All cases of phimosis have adhesions.” “ The 6 narrow outlet is rare ” (meaning, I suppose, an outlet so nar- row as to entirely prevent retraction of the prepuce), “ occur- ring, perhaps, once in twenty or thirty cases.” Dr. M. J. Moses of this city, in answer to an inquiry from me, says, “Among infants who have been circumcised by me on the 8tli day, numbering, by rough estimate, say forty-five or fifty, I found adherent prepuce, I believe, three times .... The adhesion was directly to the corona of the glans.” The disparity between this proportion and that given by the gentlemen above quoted is due probably to different under- standing as to what constituted an adhesion, Dr. Moses only including firm adhesions, and throwing out ordinary agglu- tination. Proposition II.—Phimosis, by its unusual severity or persistence, may become pathological, and may give rise to disturbances both local and, remote. The local disorders include (a) those which are purely mechanical in their nature: such as interference with the proper development of the genitals; difficult or intermittent micturition, or even total retention of urine; and retention of secretions beneath the prepuce. (b) The direct results of the mechanical irritation, or mechanical obstruction : such as itching of the glans, pain, balanitis, and also, as a result of the strain ins requisite to void the urine, prolapsus recti or hernia. (c) Genito urinary symptoms not directly mechanical: such as incontinence of urine, vesical irritation or tenesmus, haema- turia, priapism, and, in adult life, erotic dreams, seminal emis- sions, painful and unsatisfactory coitus, etc. The remote phenomena are generally disorders of the ner- vous system', and among the disturbances of this kind that have been referred to phimosis as a cause are gastralgia, neu- ralgia, amblyopia, reflex paralysis, paresis, incoordination, etc. To speak of these various classes more in detail : Interference with the development of the organ caused by tight prepuce is not common, but cases of it have been referred to by writers. Disorders of micturition, however, dependent upon phi- mosis, are of very frequent occurrence—so frequent, indeed, as hardly to demand extended comment. The commonest 7 trouble is dysuria, in the forms of difficult expulsion of the urine and of interruption of the flow, the former being the more common. The difficulty sometimes reaches the degree of complete retention. The existence of dysuria is not won- derful, if the length and frequent narrowness of the prepuce, the position of the preputial orifice, the close application of the prepuce to the meatus urinarius, and the collections in or near the latter of secretions, be recollected as so many hin- derances that may present themselves to the flow of urine. Still further, dysuria is often seen to depend upon simple agglutinations between the epithelium of the glans and of the prepuce, even when there is no seeming obstruction. Cases to illustrate the various forms of obstructed micturition must present themselves to the recollection of every one present, and there is no need to discuss this group of disorders. Nearly as frequent are the troubles arising immediately from the irritation of retained urine or smegma. Itching is very common ; and so, too, are attacks of balanitis or balano- posthitis. I have seen cases in which the attacks of balanitis seemed to have produced inflammatory adhesions, in addition to the agglutinations previously existing, thus aggravating the subsequent condition of the parts. Of course, this itching ex- cites in the patient an unconquerable desire to pull at the pre- puce, or to rub or scratch the penis ; and hence, unfortunately, the vice of masturbation very frequently has its rise. The great difficulty experienced in voiding urine leads to prolapus recti, and to hernia, as the direct result of tlie neces- sary straining.1 Of the genito-urinary disturbances not directly mechanical, the most common, by far, are incontinence of urine and pria- pism. Less common are vesical irritations and hsematuria. If the phimosis persists to adult file, erotic dreams with the usual concomitant of seminal emissions, and painful or un- satisfactory coitus, are not rare; the latter due, in part at least, to purely mechanical causes. Incontinence of urine is so commonly dependent upon phimosis, that I have for years been in the habit of correcting 1 In a similar manner I have seen hernia produced in an elderly man suffering from enlargement of the prostate. 8 the latter, if it exist, before trying other treatment, whenever [ have been consulted for incontinence of urine in boys. Priapism, too, is a very frequent and often a striking symptom. I have in mind cases in which it was the main reason why the child was brought to my notice by the mother, the accompany- ing dysuria not having been considered of sufficient import- ance. Vesical irritation is not rare. Ilsematuria is less fre- quently observed. Of the additional symptoms mentioned as obtaining in adult life, it hardly need be said that the phi- mosis, by its irritation of the glans, naturally increases the tendency to erotic symptoms. So, too, by the increased sen- sitiveness of the organ, and by the mechanical interference with intromission, coitus may be rendered both painful and difficult. I have seen a middle-aged married man, to whom coitus had become a matter of difficulty from adhesions (prob- ably due to a balanitis) of the prepuce to the posterior third or half of the glans, the anterior part being freely uncovered. When the intimate connection between disorders of the generative organs and those of the nervous system is recol- lected, we should naturally look to find the latter dependent upon a condition which, like phimosis, we have already seen to be the exciting cause of much local irritation. The earliest references to such a cause for nervous disar- rangements, that I have met with, are in Dr. Bumstead’s well- known work on “ Venereal Diseases.” These references are to articles in the Gazette des Hopitaux and Revue de Therapeu- tique Medico-Chirurgicale, by Fleury, Borelli, and Anagno- staxis, the neuroses specified being gastralgia, neuralgia, and amblyopia. I regret that I have been unable to find in this city files of these journals of so early a date (1850 and 1851), and that I can therefore give no further account of the cases there presented. Within a few years, however, several articles have ap- peared upon reflex irritations from the genital or genito-uri- nary organs. Dr. Sayre, at the meeting of the American Medi- cal Association in 1870, presented a paper upon “ Partial Paralysis from Reflex Irritation, caused by Congenital Phi- mosis and Adherent Prepuce.” In this paper are recited three cases. The first, occurring in a child five years of age, 9 was one of paresis of the extensor muscles of the thigh. The co- existence of phimosis with great irritation of the prepuce, pria- pism, and an orgastic condition, led Dr. Sayre to suspect that the paresis was dependent upon the local excitation. Circum- cision was accordingly done. The child’s general condition was at once relieved, and within a fortnight he recovered the power of walking without assistance. The second case was one of phimosis in a lad of fourteen, who also suffered from “ paralysis of his legs.” Circumcision relieved the symptoms, which had previously resisted the ordinary appropriate meth- ods of treatment. The third case was in a lad of fifteen. He presented for symptoms, neuralgia, weakness of the legs, and “falling fits,” “ because his legs would not hold him np.” He complained, moreover, of being “ troubled every night with painful erections and frequent emissions,” but denied mastur- bation. Circumcision was likewise followed in this case by immediate improvement ; the nocturnal disturbances ceased, or nearly, and the “fits” also. It is not quite evident whether the “fits” mentioned in this case were of a convulsive nature, or were some less violent expression of disturbed co- ordination. In addition, Dr. Sayre expresses his belief that the existence of phimosis, by its disturbance of the coordina- tion, may be an exciting cause of hip-disease, through the fre- quent falls to which the patient is subject. In the Hew York Medical Journal for October, 1871, Dr. M. J. Moses published an article on the “Value of Cir- cumcision as a Hygienic and Therapeutic Measure,” and in it relates a case of convulsion and “nervousness” relieved by circumcision. A second case of “absolute melancholia” was cured in the same way. In a paper read before this Academy, February 19, 1874, Dr. F. N. Otis related a large number of cases illustrating “ reflex irritations throughout the genito urinary tract, result- ing from contraction of the urethra at or near the meatus urinarius.” Preliminary to these he recited a case, treated by Dr. Brown-Sequard, in which an apparent cerebral ramollisse- ment was cured by circumcision. A second paper of Dr. Sayre’s (“ Transactions of the Ameri- can Medical Association,” 1875) presents some further cases. 10 The first was one of spasmodic contraction of the adductors and flexors of the upper and lower extremities, and a state of “ ec- stasy ” with priapism. The symptoms were quite violent, and appear to have been distinctly orgastic. It does not appear whether any form of masturbation was observed as exciting the “ ecstasy.” Quite firm adhesion of the prepuce to the glans existed, as well as a narrow orifice of the foreskin. The prepuce was split, and torn from the glans. Speedy ameliora- tion of symptoms followed the operation. The second case was one of paresis of the lower extremities, especially of the left leg, with‘atrophy. Improvement was rapid after circum- cision. The eighth case is interesting: A case of double varo-equinus, that had undergone considerable instrumental treatment, was materially relieved by circumcision; the ta- lipes being of a paralytic nature, and dependent, in Dr. Sayre’s opinion, upon a phimosis, which caused considerable local dis- turbance. Appended to the last-named paper are some cases cited by Dr. Otis from his own practice and that of other gen- tlemen. They illustrate retention of urine with partial pa- raplegia, incontinence with paraplegia, enuresis with hebetude, all relieved by removing the phimosis. Still further, Dr. James S. Green contributes to Dr. Sayre’s paper a striking case of “ hyperaesthesia of the skin over the whole body, very marked want of coordination of motion in the arms and hands, and great difficulty in walk- ing.” The case grew worse for three years in spite of treat- ment. Circumcision was followed by relief of the hyperaes- thesia within a few hours, “ and in forty-eight hours (he) had recovered entirely the use of his limbs.” The following history of a case, which I saw through the courtesy of Dr. Sayre, shows the most frequent variety of dis- turbance of locomotion associated with phimosis: Case I.—March 16, 1877.—Laurence Nelson McKee, .aged seventeen and a half months. (Colored.) The child was brought to Dr. L. II. Sayre because of his inability to walk. The mother gave the following history: The child never had walked ; had made few efforts to do so. She thought the left side seemed to he paralyzed ; when she “ walked him along” his left lower extremity dragged. The left hand was constantly clinched, and could be opened with difficulty. He has had no difficulty in micturition no incontinence of urine. The mother has noticed, however, a tendency 11 ■on the child’s part to play with his privates, and also that the penis was frequently erect, perhaps half the time. The child has phimosis; aperture of prepuce very small. Prepuce split up by Dr. L. H. Sayre, and found to be adherent up to the meatus. It was worked off from the glans by means of a scalpel-handle. A considerable collection of smegma was re- moved. The frenum was also cut. 21 st.—Mother reports that the night after the operation she observed the child to attempt to stand ah>ne. Within the five days that have elapsed the mother states that he has improved in his speech. The left hand is opened more readily, the rigidity of the fingers is gone, and he begins to use the hand freely, whicli he never did before the operation. The drag- ging of the foot is much better, and that member is put out nearly as free- ly as is the other. A month later I saw the child. The mother reports him as still improv- ing in his gait. Dr. Green lias sent me the notes of several cases besides the one above cijed. Some of these are particularly interest- ing, on account of the long duration of the symptoms, the age of the patients, as well as the results of treatment. Here fol- low some of the more striking cases : Case II.—T. S. II., agerl forty-two years. Has always been troubled with pains in head, back, and limbs. Since 1858 has been subject to slight epi- leptic convulsions. Has b'jen losing his memory gradually. Is constantly in a state of nervous irritability; despondent, and has a suicidal tendency. Has been troubled with spermatorrhoea. I found the prepuce adherent and contracted. A probe passed into preputial orifice only to the depth of three-eighths of an inch. Operation of circumcision performed. Six weeks after operation reports himself as follows: “lam a new man; no head- ache ; no spasms ; memory improved; am calm, and my judgment in busi- ness was never so clear. In fact, I do not remember I was ever so well.” Case III.—C. S., aged thirty-three years. Literary gentleman. Has suffered for ten years with spermatorihoea. Headache, fugitive pains in the back and limbs, with acute hypersesthesia of the skin, and gradual loss of power in his right leg. He was morose, despondent. Testicles sensi- tive. Spasm of the sphincter V'sicas; frequent retention of urine. Pre- puce adherent. Circumcision performed. Two months after ope. ationhe writes : “ All my symptoms are relieved to my entire satisfaction.” Case IV.—J. C., aged thirty years. Machinist. Has been losing his sight for two years, so that it is difficult for him to pursue his business. He is despondent, abstracted, and at times, when hurried to answer a question, troubled with aphasia. Has had his eyes examined in New York. His difficulty pronounced to be atrophy of the optic nerves. Examined penis; found in a constant state of semi-erection. The pre- 12 puce coul any event directed to repeat it daily. One instance he men- 15 tioneel of recurrence twice of the enuresis, owing to the ag- glutinations having been allowed to reestablish themselves. In such a case circumcision will probably make a complete cure. If the prepuce be redundant, the circumcision is the pref- erable operation ; if not, splitting of the prepuce, if necessary, may be done to assist its retraction. In adolescents, or in children, wdiere the prepuce has been the seat of much in- flammatory process, the knife will be generally needed in one method or the other. Dr. Sayre urges, as does Dr. Green in his comment upon the cases above cited, the necessity of circumcision, and of doing it thoroughly, watching carefully for constricting bands of mucous membrane, and nicking them if they exist, divid- ing also the frenum if it be short, etc. [In the discussion upon the foregoing paper, Dr. F. N. Otis cited certain cases of spermatorrhoea and mental disor- der depending upon an unusually long prepuce, although no phimosis existed. The symptoms disappeared upon ablation of the foreskin. Dr. Otis was inclined to attribute the dis- turbances to the constant “ poulticing,” so to speak, of the glans by this redundant prepuce.] MEDICAL WORKS PUBLISHED BY D. APPLETON & CO. 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