Chapter 22

THE PREPUCE, PHIMOSIS, AND CANCER.

In the _British Medical Journal_ of January 7, 1882, there is an interesting article by Jonathan Hutchinson on the "Pre-cancerous Stage of Cancer." In this article he states that, whereas, twenty years previously, his suggestion had been to treat all suspicious sores as being due to syphilis until a clearer diagnosis could be made out, he "had more recently often explained and enforced the doctrine of a pre-cancerous stage of cancer. According to this doctrine, in most cases of cancer, either of penis, lips, tongue, or skin, there is a stage--often a long one--during which a condition of chronic inflammation only is present, and upon this the cancerous process becomes ingrafted. Phimosis and the consequent balanitis lead to cancer of the penis.... A general acceptance of the belief that cancer usually has a pre-cancerous stage, and that this stage is the one in which operations ought to be performed, would save many hundreds of lives every year.... Instead of looking on whilst the fire smouldered, and waiting till it blazed up, we should stamp it out on the first suspicion.... What is a man the worse if you have cut away a warty sore from his lip; and, when all is done, a zealous pathologist demonstrates to you that the ulcer is not cancerous, need your conscience be troubled? You have operated in a pre-cancerous stage, and you have probably effected a permanent cure of what would soon have become an incurable disease. I do not wish to offer any apology for carelessness, but I have not in this matter any fear for it."

In view of the great frequency of the occurrence of cancer of the penis, and the facts pointed out by Roux, that, after the removal of the cancerous prepuce or a portion of the penis for cancer, in case of a recurrence the disease does not do so in the penis, but that it attacks the inguinal glands, showing conclusively that the prepuce is the inciting cause as well as the initial point of attack, the sentiments in the foregoing paragraph, taken from the words of Hutchinson, are worthy of our most careful consideration.

M. Roux, Surgeon to the Charité, during the second decade of the present century, first called the attention of the French profession to the intimate relation or dependence that cancer of the penis bears to phimosis. In England he was preceded in this field of surgical investigation by William Hey, whom Roux met in London in 1814. Hey had then operated by amputation of the penis on twelve cases of cancer, nine of whom had had phimosis at the time of the development of the cancer. Wadd at this time also published a work on the subject, but, although he noticed that phimosis was a cause of cancer, he did not fully grasp the subject as Hey and Roux had done, as he believed a cancerous diathesis a primary necessity, and did not then recognize that the primary cause was fully to be found in the prepuce itself.

Roux was probably the first to point out the peculiarly local character of penile cancer, as there is no locality wherein a timely operation is less apt to be followed by a recurrence. He records a number of cases where the prepuce alone was affected when first seen, but none wherein the glans was attacked and where the prepuce was exempt, giving ample evidence of the original starting-point of the disease.[94]

Erichsen also remarks on the little liability to recurrence of cancer of the penis after a timely operation; he divides the cancer to which the penis is subject to as being of two distinct kinds,--scirrhus and epithelioma. The latter variety commences as a tubercle in the prepuce, and, according to Erichsen, does not occur in the body of the penis except as a secondary infiltration or deposit.[95] Travers states that Jews who are circumcised are not subject to either form of cancer.[96]

Repeated attacks of herpes preputialis and some consequent point of induration are looked upon by Petit-Radel, Chauvin, and Bernard as frequent starting-points for the cancerous affection of the prepuce. The aged or persons of lax fibre being more subject to these inflammatory attacks, are also the most frequent victims of cancer in this situation. The celebrated Lallemand, in regard to the tendency to cancer induced by the presence of the prepuce, observes as follows:--

"Besides simple balanitis ... there also result various indurations, which are proportionate in their degree to the length or time and intensity with which the inciting inflammatory conditions have existed. I have repeatedly found the mucous lining of the prepuce thickened, hardened, ulcerated, and nodulated; at other times converted into a fibrous or even into cartilaginous tissue of excessive thickness; in others, still, in which it had assumed a scirrhous and cancerous nature. I have repeatedly operated on such cases, wherein the prolongation of the prepuce was the only recognized primary cause, the subjects being often countrymen of from fifty to sixty years of age, who had never known any women except their own, but who had, nevertheless, been long sufferers from balanitic attacks, accompanied by abundant acrid discharges, swellings of the prepuce, with more or less consequent excoriations and narrowing of the preputial orifice."[97]

Claparède sums up the inconveniences and dangers to which the possessor of a prepuce is liable to suffer from, as follows: "The retention of the sebaceous secretion is liable to alter its character, converting it into an acrid, irritating discharge, which induces more or less burning, smarting, itching, excoriations, and swelling, which, affecting the little glands situated about the corona and sulcus, induces them to secrete an altered and vicious secretion. In this manner a simple elongation of the prepuce will produce an inflammation of the surface of the glans (balanitis), or that of the prepuce itself (posthitis), or the two conjoined (balano-posthitis), complicated possibly with phimosis. By an extension to the mucous membrane of the urethra of the same condition of the inflammatory process, we have blennorrhagia; blennorrhagia is liable to be followed by inguinal swellings or tenderness, orchitis, stricture, and prostatic disease; the formation of preputial calculus, from retention of the urine in the prepuce; and cancer is apt to be the end of any of these conditions."[98]

J. Royes Bell, in Ashhurst's "International Encyclopædia of Surgery," observes as follows: "Carcinoma attacking the genital organs usually assumes the form of epithelioma; the other kinds are rarely met with. Epithelioma may invade the prepuce, or the whole penis, or any part of it. The most common age for it is fifty years or over. In the great majority of cases there has existed a congenital or acquired phimosis. A contusion or a urinary fistula may be the exciting cause. With a phimosis the parts are not kept clean, but the gland is macerated and rendered tender and excoriated by retained secretions, and the irritation causes an epithelioma to grow in those predisposed to the disease, as is found to be the case when the tongue is irritated by a broken tooth, or the scrotum by the presence of soot in its folds. Syphilis has no direct influence in inducing the disease, but a syphilitic chap or ulcer may be the starting-point of an epithelioma. Two kinds of epithelioma affect the penis,--the indurated and the vegetating, or cauliflower growth.... The nature of the disease, in either the prepuce or the glans, is masked by a phimosis.... The prognosis in these cases is much more hopeful than in epithelioma, in other situations.... Sir William Lawrence operated on a patient who was quite well years afterward, and Sir William Ferguson amputated the penis of a man of note in the political world, who lived many years after the operation, and died at an advanced age."

Agnew, of Philadelphia, describes an epithelioma of the prepuce occurring in persons past middle life, beginning as a tubercle, crack, or wart, for which he advises an early circumcision; he admits, however, to not having sufficient data to determine whether Jews and circumcised persons are exempt from carcinoma of the penis; but as its usual starting-point he evidently admits to be in the prepuce, circumcision must certainly be a preventive to its appearance. Gross gives substantially the same opinion as Agnew in this regard. Dr. John S. Billings, in his article on the "Vital Statistics of the Jews," in the January _North American Review_, of 1891, on the subject of cancer, observes as follows:--

"As regards cancer and malignant tumors, we find that the deaths from these causes among the Hebrews occur in about the same proportion to deaths from other diseases as they do in the average population. But as the ratio of deaths to population is less among the Jews, so the ratio of deaths from malignant diseases to population is also less. Among the living population the proportion found affected with cancer among the Jews was 6.48 per 1000, while of those reported sick by the United States census of 1880, for the general population, the proportion was 10.01 per 1000."

There are no convenient data as to the prevalence or percentage of cases of cancer among the Arabian or Mohammedan population of Asia and Africa, but the above comparison of 6.48 per 1000 among the Jews of the United States, against 10.01 per 1000 of the general population, shows that the circumcised race does, in the instance of cancer, certainly enjoy a certain amount of immunity, having in this regard not quite such an exemption as they enjoy from consumption, but still sufficient to assist in making them longer-lived and more able to enjoy life and die a less lingering and painful death.

It is surprising that, in view of the fact that carcinoma of the penis, starting with such frequency in the prepuce, should have left any doubt but that with the absence of this appendage there would follow less liability to cancer. Cullerier informs us that he had several times amputated the penis for cancerous diseases, but that he is unable to tell us whether the persons were affected with phimosis, remarking that on the last case he had observed the indurated remains of the prepuce; he had, however, recognized the necessity of freely exposing the gland in cases where, from continued irritation and inflammation, there was danger of cancer formation.

Nelaton describes two varieties of cancer that affect the penis,--that which attacks the integument and that which attacks the glans. The first of these varieties he observes as generally beginning as a hardened nodule in the prepuce, which becomes at once more or less thickened and indurated. He gives Lisfranc the credit of pointing out the fact, that, even in the most hopeless-looking case, the glans and body of the penis may be simply pushed back and compressed, but otherwise sound, and that before resorting to an amputation of the whole organ it is better to make a careful exploratory dissection in search of the penis, as it oftentimes happens that the prepuce and integument can be dissected off, leaving the organ intact. He also mentions that elephantiasis of the penile integument generally begins in the prepuce.

Baron Boyer believed that the vitiated preputial secretion allowed to remain beneath the prepuce was one of the causes of cancer of the penis, observing that it would be interesting to know whether cancer of the penis was a rarity among circumcised people, such as the Jews and Mohammedans.[99]

It is easy to perceive why or how Agnew, Gross, Cullerier, and many of those who have written on the subject, have failed to appreciate the existence of the prepuce as an exciting cause, or as being, in the majority of instances, the part primarily attacked. The nodule, excoriation, or abrasion that develops into a cancer generally produces more or less local disturbance; in many it produces a phimosis that is only relieved by the ulcerative process that exposes the gland, which may by that time itself be attacked or even destroyed. They are then seen by either the rural practitioner or the family physician, but before submitting to an operation they run the gauntlet of many physicians, and, when it comes to operating, they generally apply to some one of great skill and reputation. By this time there is little left of the organ, and, as a rule, the party is unable to tell where the disease originated, whether in the prepuce or glans, to them the swollen prepuce seeming to be the whole organ. Of late years, however, it has been pretty well established that it generally begins in the prepuce, and the great number of amputations of the penis on record for this disease does not lead one to believe that it is as rare a disease as was formerly believed. In Langenbeck's _Archiv_, Bd. xii, 1870, Dr. Zielewicz reports fifty cases of amputation of the penis by the galvano-cautery loop, mostly for carcinoma, one of the fifty being for gangrene and one other for a large papillary tumor. That one surgeon was able to report forty-eight cases of carcinoma or cancer that were treated by one special system of operating tells us plainly enough that the unfortunate possessor of a prepuce, no matter how normal or unobjectionable it may seem to be in the prime of man's existence, or however physiologically necessary it may be deemed, runs too many risks in holding on to his possessions.

The views set forth by Hutchinson in the beginning of this chapter are precisely those that are held by the writer, who would even go further, by advising all such as have, in their youth or since, suffered with balano-posthitis in any degree or form, or whose prepuce shows a tendency to elongation with age, to have the same removed at once; where the prepuce is not redundant, but only tight, a slight operation, such as slitting, will at once remove the possibility of any future danger, without keeping a man from his business a single day.

It may here be remarked that, although always favorably impressed with the great benefits arising out of circumcision, nothing ever resulted in such a serious consideration of the subject as seeing a professional brother dying with a cancerous affection of the penis. The disease had originated in the mucous lining of the prepuce, and when seen in consultation with his attending physicians the gland had already disappeared and the inguinal glands were affected. The man was in the prime of life, and, aside from the local trouble, a specimen of perfect health and physique. He informed us that while a youth he had suffered from repeated attacks of herpes preputialis; that he had suggested circumcision more than once to his father, who also was a physician, but who, unfortunately for the son, could not see any merit in circumcision. To his eyes there was nothing that circumcision could do but what could be accomplished by washing and personal attention to cleanliness. When older, the prepuce gave him less trouble, and for a long time after his marriage it ceased to trouble him altogether. The idea of the necessity of circumcision did not occur to him again until the appearance of the cancerous disease; even then, not appreciating the danger, and looking upon the trouble as a simple transient result of some inflammatory action, he waited until the parts would be in a better state or condition of health before resorting to an operation,--that time never came.

Although to Roux, Wadd, and Hey the credit must be given for bringing the subject of cancer of this organ so prominently before the profession, the knowledge of the existence of the disease has long been a matter of record. Patissier, in the fortieth volume of the "Dict. des Sciences Médicales," quotes from the third volume of the "Mémoires de l'Académie Royale de Chirurgie," that in 1724 an officer, aged fifty, was attacked by a cancerous affection originating underneath the prepuce; at the time he consulted MM. Chicoineau and Sonlier the disease had existed for two years, the inguinal glands were implicated, and even the suspensory ligament was affected. These surgeons, nevertheless, determined upon an operation, and, after a long chapter of hæmorrhagic accidents, the patient finally made a recovery. Another case, quoted by Patissier, was operated upon by M. Ceyrac de la Coste, the patient a man of sixty, the disease originating, like the preceding case, underneath the prepuce.

Warren, in his "Surgical Observations on Tumors," observes that cancer of the penis begins by a warty excrescence on the glans or prepuce. Walshe, in his work on the "Nature and Treatment of Cancer," says: "The disease may commence in almost all parts of the organ, but the glans and prepuce are by far its most common primary seats. It may originate either from a warty excrescence or a pimple, or it may infiltrate the glans, or appear as a complication of venereal ulceration. Phimosis, either congenital or acquired, is an exceedingly common accompaniment, and it appears probable that the irritation occasioned by this condition of the parts may act as an exciting cause of the disease in persons predisposed to cancer. Circumcision is, therefore, an advisable prophylactic measure, where the constitutional taint is known to exist."