Chapter 23

THE PREPUCE AND GANGRENE OF THE PENIS.

Another accompaniment of that preputial appendage is gangrene of the penis, which, like carcinoma, starting in at the prepuce, may invade the pubes and scrotum. This disease is not so rare as to merit the little attention it has received from our text-books. M. Demarquay has collected the history of twenty-five cases; from him we learn that the prepuce is the most frequent seat of the start of the affection, from whence, according to Astruc, it rapidly spreads to the skin of the whole organ, and then attacks the corpora cavernosa; it may even extend as high as the umbilicus. This disease spares no age; it attacks young and old alike.

There is not a case recorded of this disease that particularized any other starting-point than the swelling, tension, active or passive congestion that takes place in the integument of the penis. By this it must not be understood that the initial disease or inflammatory action that produces the gangrene must necessarily have its seat in the integument, but that it is the integument of the penis (and especially that of the prepuce) in which, through the laxity of its tissues, passive congestion is favored that the gangrenous action begins. That this is the actual case there can be but little doubt about, as, even where the gangrene invades the body of the penis itself, even where the inflammatory action may have started from a violent urethritis, that condition of blood which favors gangrenous results will be found to have begun during its state of stasis, where it has parted with much of its watery element, as well as considerable of its vitality, while in its slow, tedious, and obstructed passage through the prepuce. Some of this dark, thickish blood, finding its way from the integumentary return circulation to that of the deeper structure, becomes there a mechanical as well as a pathological cause for that impediment to the free circulation of the parts, through its altered physiological condition. The deeper structures of the penis, besides their own blood-supply, carry back into the deeper or systemic circulation a large supply from the integumentary tissues, when in the latter, owing to the greater supply due to any inflammatory action, the blood-current is delayed and impeded in its lax and easily-dilatable tissues, and blood-changes occur favoring the gangrene in the deeper tissues, so that, whether the gangrene first takes place in the body of the penis or in the scrotum, it will be in the prepuce or adjoining integument that its real originating causes will be found.

Baron Boyer, in speaking of the inflammation of the penis, observes that the intensity of the swelling, great pain, and difficulty of urination that follow have led many to believe that the inflammation of the deeper structures really always formed a part of the disease. In otherwise healthy and vigorous subjects it does not, however, extend beyond the skin, as has been demonstrated where the resulting gangrene from excess of inflammatory action has ended in resolution, the deeper tissues not having been found to be injured. It is only where the tone of the general system is lowered, through disease, age, or other deteriorating conditions, that the whole organ is liable to become affected or to break down.

Boyer, in the tenth volume of his "Treatise on Surgical Affections," gives several examples of this affection not due to age: one case was a person, simultaneously attacked by an adynamic fever and a blennorrhagia, who suffered from gangrene of the penis; the local and constitutional disturbance was not high, however, and the patient escaped with the simple loss of the prepuce.

Another case admitted to the Charité, aged thirty-six, was afflicted with a blennorrhagia, upon which an attack of low fever supervened. The penis inflamed, became engorged and livid, and soon gangrenous symptoms presented themselves, making rapid progress; at first the integument alone was affected, but later all the structures became implicated and the penis was completely destroyed, the sloughs detaching themselves in shreds, leaving a conical stump that healed but slowly.

One case, a young man of twenty, also at the Charité, was admitted with adynamic fever; a few days after admission the prepuce was observed to be somewhat inflamed; in spite of all treatment this progressed so rapidly that the purple discoloration presaged a gangrene, which was not slow in following; the focus seemed to be at the superior and back portion of the prepuce; an incision evacuated a quantity of purulent, serous fluid; the disease, however, extended up the organ as far as its middle before its actions ceased; the sloughs were then cast off, when it was found that part of the gland and a portion of the cavernous body had followed the integument in the general wreck, subjecting the patient to intolerable pain during micturition. After the recovery from the fever, the remaining portion of the gland and the mutilated parts of the cavernous body were amputated to remedy this condition; the patient subsequently admitted to have had a blennorrhagia at the time of his admission to the hospital.

The gangrenous action may, in proportion to the low condition of the patient, be as proportionately rapid. Another case from Boyer, quoted from the works of Forestus, relates how the whole organ underwent such speedy disorganization that its liquefied remains were found in a poultice, which had been applied with a view of relieving the congestion,--a very dear price to pay for retaining the prepuce, that the exquisite sensitiveness of the tactile faculty for enjoyment, resident in the corona of the gland, might not be interfered with.

Gross does not mention this affection in his work on surgery, but Agnew devotes considerable space to its description, dividing the disease into two forms: the inflammatory, such as may follow venereal primary sores or operations on the penis, not excepting circumcision; and the obstructive variety, such as may follow embolism or any mechanical obstruction, either purposely or accidentally applied. Of the latter he gives a number of quoted instances; he only admits seeing one case, that of an aged man in the Pennsylvania Hospital, in whom the disease was caused by embolism of the dorsal artery.

J. Royes Bell, in the "International Encyclopædia of Surgery," pays more attention to it than any of our American authors; mentioning, among the causes which may give rise to it, the exanthemata, especially small-pox, and the poisoning by ergot of rye and erysipelas. Among the local causes lie mentions phimosis, paraphimosis, and balano-posthitis.

Bell quotes the case reported by Mr. Partridge, in the sixteenth volume of the "Transactions of the Pathological Society of London," wherein a sober man, aged forty, lost the whole of his penis up to the root, during the course of a typhus fever. Also the case reported by Mr. Gay, in the thirtieth volume of the same "Transactions," wherein a cabinet-maker, aged thirty-one, lost his penis through the probable results of rheumatic phlebitis, and due to the presence of a plug in the internal iliac vein. In the twelfth volume of the "Transactions" of the same society he finds the record of the case of a soldier who lost his penis through gangrene induced by syphilitic phagedena.

In the consideration of the subject of the prepuce as connected with penile gangrene, it must not be overlooked that the presence of a prepuce may be the inciting cause of some rheumatic affection (the writer has repeatedly seen such), just as such cases are often the result of stricture; as cases of rheumatism that have resisted all remedial means, but that have readily given way to the dilatation of a stricture, are by no means uncommon; not a mere muscular reflex rheumatic pain, but even when accompanied by a rheumatic blood condition. So that even in such a case as above reported as being due to rheumatic phlebitis, or the case reported in the fortieth volume of the "Dictionaire des Sciences Médicales" by Patissier, wherein a man lost penis and scrotum through gangrene, induced by urinous infiltration, may all in the origin be due, if not to the immediate, to the remote effects of the presence of the prepuce.

In the first volume of the _Journal of Venereal and Cutaneous Diseases_ the writer reported a case of the complete loss of penis in a young man as a result of phagedena due to syphilis. The man had had a long and pendulous prepuce; in his case, had circumcision been performed in early childhood, it would have lessened the chances of primary infection, and had it been performed after his infection, it would have removed one cause--if not the principal cause--of the ease with which the phagedenic action was inaugurated. The case already mentioned as an example of spontaneous and natural circumcision belongs to the gangrenous results following phimosis, ending with the loss of the prepuce. In Maclise's "Surgical Anatomy" several specimens of deformity are figured, showing the results of this mildest of the effects of a phagedenic action. The beginning of the interference in the return preputial circulation undoubtedly always takes place over the superior aspect of the corona, where the pressure of the glans is most sharply defined against the inner fold of the prepuce.

There are milder conditions, wherein the circulation of the prepuce is materially interfered with, both through the lax tissues of the parts and the peculiar anatomical construction and shape of the neighboring parts, wherein, without going as far as gangrenous breakdown, the person suffers considerably nevertheless, and is placed in danger of losing his penis; for, as observed by Patissier, whenever a person affected with a gonorrhoea is attacked by a putrid or any low-grade fever, he runs the greatest danger of losing his virile member through gangrene.

Even where phimosis does not exist, but only the long, lax, and retractable prepuce, that is considered a perfectly physiological condition, the prepuce is liable to cause very distressing and complicating annoyances during the progress of other diseases. The writer has noticed that cases with a thick, leathery, and redundant prepuce, even when perfectly retractable, are more liable to require the use of the catheter during the course of a continued fever. Such a condition is also a very frequent accompaniment of prostatic obstruction. So often has this been noticed that its association with prostatic trouble or disease tends to the belief that the irritation produced by this condition of prepuce often lays the foundation for prostatic disease in not a few cases.[100] In elderly people, with the atrophied penis and elongating prepuce, the constant moisture from the urine on the inner fold and glans adds greatly to the irritation as well as to the discomfort of the patient.

A number of affections are accompanied by oedema, especially toward the latter stages of the disease; such, for instance, as the ending of cases of mitral insufficiency. In these, the distension of the prepuce and the resulting balano-posthitis is at times a source of great distress, and at times the resulting engorgement produces a retention of urine. It was after an attendance on one such case that required daily and frequent puncturings for its relief, but which, in spite of all care, finally became gangrenous, that a fellow practitioner cheerfully submitted to circumcision, to avoid the possibility of any such complication occurring to embitter his closing illness.[101]

The prepuce is the starting-point of many of the cases of penitis and retention of urine that often accompany attacks of gonorroea; especially can this result be anticipated where the prepuce is long, pendulous, and with its veins in a varicose condition. Why it should be so is self-evident. Anything that will add to the interference of the return circulation only exaggerates the tendency to penis engorgement; this increases the difficulty of urination, which, by the retention that results, in turn increases the constriction at the root of the penis, and adds to the already difficult return circulation. The bladder by its urine, and the penis by its blood, actually form, by their mutual pressures, an impassable dam at the root of the organ. That this is the true condition has been more than once verified from the instant relief given to the whole condition by the prompt employment of the supra-pubic puncture or aspiration, as catheterization in such cases is altogether out of the question, and should never be attempted or employed unless a soft catheter can be inserted.

A person laboring under a continued fever has his blood in a condition to favor sphacelus; with the slow-moving current of vitiated blood and its retention in such lax tissues as those of the prepuce, through the medium of the enlarged preputial veins, coupled with the lessened sensibilities of the bladder and his perhaps semi-conscious or unconscious condition, and an equally unconscious bladder, he is, to say the least of it,--if in possession of a prepuce,--also the unconscious possessor of a certain degree of percentage, no matter how small or fractional that may be, of recovering from his fever without his penis. Dr. W. W. McKay, of the U. S. Marine Hospital Service of San Diego, attended a case of typho-malarial fever in consultation with me, where, but for the persistent, intelligent, but delicate use of the catheter for nearly three weeks the penis would have become gangrenous. The subject was an uræmic, irritable, nervous, leathery-prepuced individual; the organ was unusually large, the skin of the penis thick, and it was only by keeping the bladder empty that prevented a state of engorgement that would have effectually interfered with further catheterization. As it was, the penis was often dank, livid, and discolored from the passive engorgement.

The writer saw a similar case with the late Dr. F. H. Milligan, of Minnesota. The congestion in this case was due to a gonorrhoeal inflammation involving the skin of the whole penis, retention having followed painful micturition, and the swelling of the penis following the retention; the prepuce was enormously distended, and the penis seemed in a state of erection as far as dimension and rigidity were concerned. The man, a steam-boat cook, informed us that it was fully twice as large as when rigidly erect in health. All efforts to reduce the swelling were unavailing; neither punctures, leeches, nor scarifications were of any avail; catheterization was impossible, but, after relieving the bladder by the supra-pubic aspiration, the patient experienced some relief. He, nevertheless, lost the whole skin of the penis, with that of the pubis and on the front of the scrotum. The man ran into a low form of fever, with uræmic symptoms; the stench was so great that it was almost impossible to remain in the same room with him; but he finally made a slow and very tedious recovery. In healing there was considerable downward curvature of the penis, which, however, did not prevent him from following his old, dissolute course of life.[102]

A calm, unprejudiced consideration of the subject of the liability of the uncircumcised races dwelling in the temperate and semi-tropical countries to cancer, gangrene, and elephantiasis might well lead one to ask: Why are we afflicted with a prepuce? We can understand how a man may become gouty, and become a subject in the end for a gangrene of the extremities; or how senile gangrene may, through a series of pathological processes and blood changes, with the aid of age, finally be reached; or how, by a like course of diseased processes, we reach the apoplectic stage. These conditions, however, can be put off, or partly, if not wholly avoided, by a proper course of life, and, at the worst, it is only after the fires of our youth and prime have completely burned out, that these conditions are liable to claim us as their lawful victim. Not so, however, with some of these conditions that may end in penile gangrene; that are liable to pounce upon us unawares, like an Apache in an Arizona cañon; or as the hired mercenaries of old Canon Fulbert did upon poor Abelard in his study, and, without further ado or ceremony emasculate man as effectually as the most exacting Turk could demand, with a veritable _taillè à fleur de ventre_ operation.

Nature has her own ways of protecting what there is of any utility; there is a law of the survival of the fittest that we all appreciate. If, then, this penile appendage is of any utility, why is it that, unlike the rest of the body, it falls such an easy victim to gangrene? The procreative function seems to be, in a sense, one of the main cares of nature in its relation to the animal as well as the vegetable kingdom; but here is a useless bit of skin, adipose tissue, mucous membrane, and some connective tissue, that on the least provocation is liable to go off into a gangrene and drag one of the main generative, or even all the procreative, apparatus into the general wreck. Nature certainly never intended anything of the kind. To be generous, and not libel nature, we must conclude that the prepuce is a near relative to the fast-disappearing climbing-muscle; very useful in our primitive, arboreal days, when we needed such a muscle to reach our perch for the night, and a prepuce or something of the kind, in default of a breech-cloth, to protect the glans penis from being scratched by the briars or thorny and rough bark of the trees in our ascent. The prepuce was well enough in our primitive and arboreal days,--ages and ages ahead of our cave and lake dwellings,--when the notch in a tree and its rough bark formed our couch; but in these days of plush-cushioned pews and opera-seats, cosy office-chairs, car-seats, and upholstered furniture or polished-oak seats, it serves no intelligent purpose.

Emasculation has never been looked upon with favor by its victim, and it would be but natural to suppose that man would take every precaution against the accidental occurrence of such an undesired condition. The writer well remembers that, in his "Tom Sawyer" days on the banks of the upper Mississippi, in the happy days of the crack rafting crews, before the introduction of the towage steamer, when the river towns were more or less terrorized by wild gangs of these men, some of whom were always fighting and quarreling and drinking when not at work. In the lot there was one man with a great reputation at a rough-and-tumble fight. His main hold was that he generally tried to emasculate his adversary by destroying the physiological condition of the testicle. The man was not a large or powerful man, nor was he a great boxer or wrestler, but this reputation made him feared by all the bullies on the river. The report that not a few who had tackled him had subsequently been of no value, either as fornicators or fecundators, or had to be castrated on account of the resulting testicular degeneration, seemed in no way to encourage any one to wish to meet him in a personal encounter. It would seem as if the desire to avoid such an accident--provided persons knew the dangers that lurk in a prepuce--would induce many to submit to circumcision. That many more do not do so can only be attributed to the general human wish to escape a less present evil for a greater unknown one, being evidently deterred by the prospective pain that must be suffered immediately.

There is a question that should interest man above that of the simple loss of penis. It appears that there is a powerful moral effect that follows this loss, as might, in the majority, be anticipated. According to the experience of Civiale, many who have lost the penis, through amputation for disease or through disease itself, end in suicide. He mentions particularly a patient at the Charité who had lost his penis, who, finding no other means to take himself off, saved up sufficient opium, from that given him to calm his pains, to take all at one dose and commit suicide. In the London _Lancet_ for March 27, 1886, there is reported a discussion on this subject, to which the reader is referred, as it fully covers the moral and physical effects of castration and penis amputation for disease. M. Roux, who amputated the penis of a brother of Buffon, in 1810, reported that, in that case, M. Buffon lost none of his customary gayety.