PREPUTIAL ADHESIONS IN CHILDREN, WITH CASES. BY JOSEPH B. COOKE, M.D., ATTENDING PHYSICIAN TO THE NORTHWESTERN DISPENSARY, DEPARTMENT OF DISEASES OF CHILDREN; ASSISTANT ATTENDING PHYSICIAN TO THE OUT-DOOR DEPARTMENT OF ST. MARY'S FREB HOSPITAL FOR CHILDREN, NEW YORK CITY. EROM THE MEDICAL NEWS, July 8, 1893. [Reprinted from The Medical News, July 8, 1893.] PREPUTIAL ADHESIONS IN CHILDREN, WITH CASES. By JOSEPH B. CO£KE, M D., ATTENDING PHYSICIAN TO THE NORTHWESTERN DISPENSARY, DEPART- MENT OF DISEASES OF CHILDREN; ASSISTANT ATTENDING PHYSICIAN TO THE OUT-DOOR DEPARTMENT OF ST. mary's free hospital for children, NEW YORK CITY. The bearing of preputial adhesions in children on the causation of various reflex disturbances has been recognized and mentioned by writers for many years, but there seems to be a general tendency on the part of physicians to either greatly over-estimate the importance of the subject, or, mqre commonly, to lose sight of its significance entirely. In December, 1892,1 began a systematic examina- tion of the genitals of all children coming under my observation with histories of disorders that might possibly be of reflex origin, including all of those indefinite symptoms so often ascribed to the pres- ence of intestinal worms, together with every other morbid condition for which I did not at once see an adequate and evident cause. The results of this investigation were not in the least degree startling; nor did I expect them to be so. Some of the cases examined had no adhesions whatever of the kind in question. Many of those that did present such adhesions were not benefited 2 in any way by the removal of the condition; but, on the other hand, a sufficiently large number of children were so completely and so promptly re- lieved of their trouble that I am convinced that such an examination should never be neglected in any instance in which the prepuce might be thought to occasion reflex irritation. The cases that have been selected as illustrations will serve to show the varieties of symptoms that may be due to the existence of preputial adhesions. I have not attempted to compile any statistical tables, but it may be safely said that almost every child, male or female, will be found to present some adhesions-possibly very slight ones-between the prepuce and the glans of the penis or of the clitoris, as the case may be. The time necessary to inspect the genitals and break up any adhesions that may be found is of so short duration that the comparatively small proportion of cures resulting from the pro- cedure should deter no one from trying the experi- ment. Two or three minutes spent in this way may save a child many weeks of medication and discom- fort, and its parents a considerable amount of anx- iety and worry, to say nothing of the credit that will accrue to the physician if.he be successful: Case I.-Priscilla , a colored child, eight and a quarter years of age, was seen at the North- western Dispensary, December 30, 1892. There was a history of pain in the right leg and groin for one day, causing her to limp. There had been in- continence of urine for two years, steadily growing worse. The urine was voided every hour by day, and often at night. The desire to urinate would 3 arise suddenly, and without warning, and was suffi- cient to awaken the child from sleep. She never "wet the bed," in the ordinary acceptation of the phrase. She had exhibited choreic motions for two years, and was a "nervous" child, easily fright- ened. She often had "nightmare," and ground her teeth, and talked and moaned in her sleep every night. The prepuce was completely adherent to and entirely covered the glans clitoridis.1 Retrac- tion was attempted under cocaine on December 31st, but was given up on account of pain. Chloroform was administered,2 and retraction was effected. No smegma was found between prepuce and glans. On January 1st the child's condition was unchanged. The prepuce was cleansed and dusted with iodo- form. There was slight purulency of the denuded surfaces, due, probably, to a previously existing vaginitis. On January 2d, the condition was yet unchanged. On January 4th the child went to school Urina- tion was less frequent, and sleep was perfectly quiet. The child's father thought her general health better; he said that she was more lively, and less irritable. On January 6th the child urinated less frequently, and with less distress than formerly. The pain in the leg and groin had entirely disappeared. The chorea had ceased entirely. There were no more "nightmare," and the like. Sleep was perfectly quiet. This child has now been under my observation for nearly five months, and there has been no return 1 This condition is said to rarely occur in females of the negro race. Vide Morris, Amer. Journ. Obstet., Dec., 1892. 2 General anesthesia was employed at the special request of the parents of the child. Vide the writer's article referring to this case, in The Medical News, April 8, 1893. 4 of her symptoms. She has received no medicinal treatment of any sort. Case II.-Madge , a white child, ten years of age, was seen at the Northwestern Dispensary, on December 30, 1892. She gave a history of in- continence of urine for several years. The urine was not voided much oftener than normal, but micturition was sudden and without warning, oc- curring often in the street, and sometimes at night. She had 11 wet the bed " regularly up to four years of age, but seldom thereafter. She had presented choreic motions of increasing intensity for several years. She ground her teeth at night, and had "nightmare" constantly. She had been treated for " worms " two years pre- viously. No worms, however, appeared in the stools. For over a year and a half there had been pain in the leg and groin, mostly at night, interfering with rest. There was often merely a desire to stretch the leg. Asthma and dyspnea occurred on the slightest ex- ertion for over two years. There was pain over the chest, stomach, and liver. The lungs and heart were normal. The child was slightly anemic, but its general condition wras fair. The bowels moved once daily. There was slight edema of the lower eyelids that might have been due to anemia. The child had had measles, but the edema had been present previously. There was no history of scar- latina or of diphtheria. The prepuce was tightly adherent to and almost entirely covered the glans clitoridis. It was retracted under cocaine. There was no smegma. The surface was dusted with europhen. A teaspoonful of mistura rhei et sodae, after meals, was prescribed. On January 2 the urine had a specific gravity of 1010, was of acid reaction, light-yellow color, clear, and contained no albumin. The prepuce was cleaned and dusted with iodoform. 5 The urinary symptoms were slightly worse, pro- bably as a result of the additional irritation set up by the freshly denuded surfaces of the prepuce and glans. On January 4th the child was better as to sleep, pain in the leg, and urinary trouble. On January 6th there had been no urinary trouble whatever since January 2d. The child was able to retain its urine, even when the desire to urinate had existed for some time. There had been no chorea or nightmare since January 1st, and no pain in the leg or groin since January 2d. There had been no dyspnea or asthma since January 2d, except on severe exertion. There was no more pain over the chest, stomach, or liver. The bowels moved twice daily. The rhubarb and soda mixture was withdrawn. This child received no medication beyond the rhubarb and soda mixture mentioned. I have seen her at intervals of one or two weeks for several months. None of her troubles has reappeared. Case III.-James , a white child, seven years and ten months old, through his mother, applied for admission to St. Mary's Hospital, January 2, 1893. The mother believed the child to be ill with rheu- matism. I visited his home to examine him for admission, and found him in bed. There was a history of severe pain in left foot, beginning a week before at about 5 p.m. The pain had extended up the leg to the hip by 9 p.m. of the same day, and was very severe during the night. The pain was intermittent and lancinating in character. There was no history or evidence of injury or local disease. On the following day the function of the leg was lost. The part could be moved only with great pain, and walking was impossible. On examina- tion it was found that the pain was slight by day, 6 provided the leg was not moved, but it became very severe by night, causing loss of sleep. The child cried out with pain during the night, and talked, moaned, and ground his teeth in sleep. He had been constipated several days ago, but the bowels were now regular. There had never been any urinary disorder. The leg had been wrapped in cotton-batting, and a turpentine liniment had been applied by the direction of a physician. The slight- est manipulation caused great suffering. There were no signs of inflammation in any part of the leg. The pain was now chiefly confined to the left leg. The orifice of the prepuce was small, but the glans could be easily exposed. There was a very slight adhesion on the left side (the left leg was affected), near the frenum. This was readily broken up. All dressings (cotton-batting, etc.,) were removed from the leg, and no medicine was given. The child was not admitted to the hospital, but was told to get up and dress himself as soon as he felt so inclined. On January 4th the boy was up, and had no pain whatever. He could move the limb in every direction, and could walk, kick, and hop with the leg. On January 6th he was up and dressed. There was absolutely no pain or interference with the function of the leg. Six weeks later there had been no return of the symptoms. Many more cases of this kind could easily be cited, but these are enough to emphasize the point in question. I have selected three instances, oc- curring within four days of each other, merely to show how little difficulty I met with in collecting data. None of these children had ever come under my notice before. As stated in the introduction to this paper, a large number of those children in whom adhesions were found were not benefited in 7 any appreciable way by the removal of the condi- tion, but no harm was done in breaking up the adhesions and placing the parts more nearly in their normal relations. The technique of the procedure, if so important a term may be used, is too simple to require more than the briefest mention. Boys with actual congenital phimosis should, of course, be circumcised, but in cases in which the orifice of the prepuce is of sufficient size to permit free exposure of half of the glans, the adhesions may, as a rule, be broken up by mere traction on the parts with the thumbs and fingers. If this is not enough, a blunt probe passed under the prepuce, and swept around the glans, will complete the separation. Care must be taken to fully expose the corona, back of which considerable smegma will often be found. The frenum should also be care- fully inspected, for, as shown in Case III, a very slight adhesion may be the cause of severe symp- toms. The parts should then be thoroughly cleansed with warm boric-acid solution, dusted with some antiseptic powder, and anointed with vaselin or a bland ointment. The penis should be inspected, and the prepuce fully retracted daily for three or four days, or until the mucous membrane has healed, in order to pre- vent the parts from growing together again. If the symptoms are actually due to the adhesions, they will probably be increased somewhat for the first day or two, owing to the additional irritation. If the symptoms return after two weeks or more, the parts should again be examined for fresh adhesions. 8 In girls the prepuce may be seized with a thumb forceps, and a probe will readily separate it from the glans clitoridis. The precautions and after-treat- ment already described are then to be carried out. As a rule, the pain is very slight, and if an anes- thetic is at at all needed, cocaine is all that is neces- sary. I do not think general anesthesia is to be recommended for so trifling a matter, as there is always an element of danger in its use. The idea of carefully investigating this subject in children was suggested to me by the very interesting paper by Dr. Morris, in the American Journal of Obstetrics /in which he describes the condition as it exists in young women. 1 Op. cit. 34i West Fifty-Sixth Street. The Medical News. Established in 1843. A WEEKL Y MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7 50 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.