PHYMOSIS IN CHILDREN 
J. T. FREELAND, M. D., BEDFORD, IND. 
This is a very common affection and one to which little attention 
is generally paid although it is commonly productive of serious 
diseases both functional and organic. 
1 have been able to find but little literature on the subject. 
Several noted specialists have referred to it in cases where it has 
caused diseases which came within their special domain. 
I n a large clinical experience as assistant, then subsequently as 
house surgeon in the Hospital for Ruptured and Crippled, New 
York, T had an excellent opportunity for observing the results of 
phymosis, and since leaving the hospital I find that preputial 
troubles are proportionally common in private practice. 
There are two classes of diseases caused by phymosis : 
First, the reflex. 
The glans penis is abundantly supplied with sensitive nerves 
from tin* dorsal branch of the pudic, which is a branch of the 
sacral plexus, and from this plexus radiate nerves whose branches 
cover a large area through which reflex disturbances may be dis- 
tributed. 
Second, a class of diseases caused by faulty nutrition of the 
parts involved. 
By long continued irritation of the glans a spinal irritation is 
set up through the medium of the sacral plexus. It is well 
known what effect spinal irritation has on the trophic nerves, so 
the result is that the nutrition of parts, which in childhood is very 
active, is now interfered with, and the result may be delayed de- 
velopment or even necrosis of bone and tissue. 
Let us consider how great the local irritation may be in a given 
case of a child six years old. 2 
Indiana State Medical Society. 
The prepuce is so tightly contracted that the meatus can not be 
exposed. After circumcising or dilating the preputial orifice, another 
obstacle to the retraction of the prepuce is presented; it is found 
to be adherent in its whole circumference to the glans ; this ad- 
hesion can be torn loose without bleeding or without much pain; 
the prepuce being retracted back of the corona we find there lumps 
of hardened smegma, occasionally as large as grains of corn. 
It is no wonder that grave results may follow such condition of 
things when we consider the sensitiveness of the parts. 
One of the most common results of phymosis is general nerve 
irritation. 
The following case, though worse than the average, will illus- 
trate this variety : 
A German woman brought her child to me, giving the following 
history : The child for several years had been very nervous and 
irritable, its sleep was broken and fitful, every few days he would 
have a spasm simulating epileptic fits. He had been dosed with 
anthelmintics time after time, but no worms had appeared. I 
examined his penis, and, as I expected, I found a tight adherent 
prepuce which I dilated and stripped back and then found behind 
the corona lumps of hardened smegma. 
The child did not have another nervous spell, his sleep is un- 
broken, and his general health has improved. Within the past six 
months I have seen two other cases of the same kind, except that 
they were not so severe, and the same treatment relieved them 
both. 
When mothers bring male children to me with the diagnosis 
already made of “ worms,” I first look for abnormal prepuces, and 
not finding that, I consider intestinal irritation. It is nearly al- 
ways the male children that are supposed to have worms. 
Another class of cases, from the character of their symptoms, refer 
the physician at once to the origin of the difficulty—retention of 
urine or obstinate enuresis. One or the other of these troubles may 
occur, depending on whether the reflex spasm contracts the muscu- 
lar coat of the bladder or the cut-off muscle at its urethral orifice. 
I have frequently seen retention follow as a result of the irritation 
produced by a circumcision when the operation was performed for 
the relief of other symptoms. 
Occasionally phymosis causes severe tonic spasms of the lower Phymosis in Children. 
3 
extremities closely resembling tlie spasm which takes place in hip 
disease. The following ease came before rne in the dispensary of 
the hospital: Henry W., presented by liis mother September 23, 
1XHT ; nine years old, nervous temperament, poorly nourished, 
could not walk. Right leg flexed at hip at 130°, left leg slightly 
add ueted. I could not get a history of hip disease, sprain, bruise, 
rhematism, nor were there symptoms of periarthritis. The child 
had been in this condition for nearly a week, was irritable, but did 
not complain of pain. I was almost in despair, when the mother 
told me that he urinated with difficulty. I examined his penis and 
found an enlongated tight prepuce adherent to the glaus. I at once 
circumcised him, and in a few days the spasms disappeared. They 
disappeared while he was under the anaesthetic, but returned and 
remained until the inflammatory symtoms following the operation 
subsided. 
Sayer reports several eases of the same kind in his work on or- 
thopedic surgery. Among his cases of this class was a girl in 
whom the spasms were caused by an elongated clitoris. The re- 
cords of the Hospital for Ruptured and Crippled show quite a 
number of other cases of this class. 
It is a settled opinion that anterior poleomyelitis is produced by 
the peripheral irritation of nerves in a majority of cases. 
Mary Putnam Jacobi, in Pepper’s System of Medicine, says: 
“The traumatic irritation starting from the central extremity of an 
insulted nerve diffuses itself throughout the cord until it meets 
with a point of least resistance, and that is most frequently found 
in the lumbar cord. Might not another explanation be more satis- 
factorily given for the implication of the lumbar cord? That is, 
that the lumbar cord is in direct connection through the sacral 
plexus with the nerves of the penis. It is true that two-thirds of 
the cases of poleomyelitis are in male children, and though 1 
have gathered no statistics I have noticed that male children af 
feeted with this disease generally have phymosis.” 
Might not epilepsy also be caused by constant nerve irritation 
from phymosis ? 
It is almost invariably the case that boys with hip disease have 
phymosis. My experiencewith hip disease, which is a large one,- 
has taught me this. 
I have no explanation of my own to give, but will refer to what I 4 
Indiana State Medical Society. 
said above of the influence of spinal irritation over the trophic nerves. 
This is Barrwell’s explanation. In his classical work on diseases 
of the joints he says: “ In 1873 I began to notice the presence or 
absence of phymosis in hip disease. One hundred cases showed 
but six that had normal prepuces. I inquired at the Evelina Hos- 
pital, which is largely patronized by Jews, and received information 
that hip disease there was very rare.” He says further that while 
collecting these cases he found but seventy-four cases in girls, and 
a large portion of them had vulvitis, vaginitis or protruding nym- 
phse. It might be said against the theory.of spinal irritation as 
a cause of hip disease, that hip disease is now proven to be a tu- 
bercular disease. That is true, but as long as the nutrition of a 
joint is perfect, tubercle bacilli can not injure it, and depressed vi- 
tality caused by weakening of the trophic nerves of the part would 
make a very vulnerable point for the action of the bacilli. 
There is another class of cases which a physician of very large special 
experience attributes largely to the effects of phymosis. I)r. Jarvis, of 
New York, in an article in the Journal of Obstetrics and Diseases 
of Children, several years ago, said that from the almost constant as- 
sociation of phymosis and hernia in nude children he was forced to 
believe that a relationship existed between them. He gave statis- 
tics which were very convincing. I am sorry lean not reproduce 
them. I read the article but once and could not find it when pre- 
paring this paper. He attempted no explanation, but Barwell’s ex- 
planation of the irritation of the trophic nerves will apply equally 
to these cases as well as to hip disease—interference with nutri- 
tion so as to check development. 
I add my testimony to that of Dr. Jarvis that phymosis and 
hernia are usually associated in male children. It is a significant 
fact that two-thirds of the cases of hernia in children are in male 
children. 
Besides these cases severe local troubles may arise ; a balano- 
posthitis may be set up under an unretractable prepuce. This is 
likely to occur, as the parts can not be cleaned and filth accumulates 
day after day. 
Circumcision or dilatation, which in children is a trifling opera- 
tion, becomes one of more importance in the adult. The prepuce 
should be loose on the glans as a prophylactic measure against se- 
rious complications which may arise in after years in venereal dis- Phymosis in Children. 
5 
eases. The physicians who have had patients with sub-preputial 
chancres or chancroids with phymosis will appreciate this. 
In infants circumcision will rarely be required ; the prepuce is 
very tender and can be very easily dilated with the blades of a 
small pair of forceps; then, if the mother is directed to retract it 
daily for some weeks, there need be no further trouble. 
Every physician should dilate the prepuce of male children 
within a few days after they are born. Last Thursday l dilated 
the preputial orifice of a babe three days old. It was contracted 
to the size of a pin hole and the prepuce was so firmly adherent 
to the glans that it had to be loosened with a probe. The child 
had difficulty in urinating, and as it was very delicate I believe it 
would have died if it had not received the attention I gave it. 
I think circumcision or its equivalent is worthy to be classed as 
a religious rite. I admire the Jewish custom. It had origin in 
something deeper than a freak; it is one of the most wholesome 
religious customs ever followed. As a symbol of true purity and 
cleanliness it is worthy to rank with baptism. 
DISCUSSION. 
l)r. T. B. Harvey, of Indianapolis—Mr. President, I have been 
very much entertained by the reading of the paper. I think it is 
well whenever we can add anything to science by way of statistics 
to do so. Last week I was called upon to see a child with double 
hernia, one year old. The boy was brought to me on account of 
hernia. T examined the child and found it had a very long pre- 
puce, and a very small opening. Upon inquiry I found that the 
child had been suffering with enuresis and with pain whenever it 
would undertake to pass water, which evidently was from the re- 
tention urofine around the glans penis, and the child was fre- 
quently crying, restless, and soon. Xow the point I want to come 
to is, that the reading of this paper gives me some information 
that I did not have before, but I thought of it at the time, and 
that is, that hernia is often found associated with adherent prepuce. 
In that ease, however, 1 slit it up. 1 had not tried dilating. I 
may not have operated sufficiently, but I did not have the confi- 
dence in dilatation that I did in slitting. I simply cut one slit far 
enough back to insure success, and it is remarkable how soon with 
one simple incision the parts will round up in the course of a few 6 
Indiana State Medical Society. 
months and look natural; and hence I call attention to this plan 
which is suggested as being more successful than dilatation. I 
have found the prepuce adhere to the glans over at least one-half. 
You can not cut it off. You must tear it off with your finger nail. 
I have no doubt that children who suffer with this condition are 
often nervous and fail to develop, have disease in the extremities 
and symptoms of spinal affection, hernia, and vesicle tenesmus. 
L fully approve of the proposition that it is the duty of the accou- 
cheur to look after the male child that is born under his care. It 
is his business to see, not to wait for the nurse to tell him, that the 
child is all right or otherwise. It is his business. 
Dr. J. W. Milan, Vincennes—Mr. President, if there is a prom- 
inent place in the proceedings or transactions of this convention, I 
trust this paper will be given that place. It is surely as important 
a paper as has been read during this session, so far as the ground 
it covers is concerned. Of course it is not on as important a sub- 
ject, perhaps, as some others, but this is a new idea — at least new 
to me, and it may be to the profession in general—about the con- 
nection between hernia and phymosis. This whole subject of the 
examination of the penis of little children when we find troubles, 
especially as the doctor says when we find a ready made diagnosis 
of worms, is certainly important. Again, I am struck with the 
thought, that never occurred to me before, that a large majority of 
the children that are brought to us with a ready-made worm diag- 
nosis arc boys. I had not thought of it until I heard this paper 
read, but now that 1 think about it, I believe three-fourths of the 
self-diagnosed worm cases are bovs; and that adds to the interest 
of the subject. 
Dr. L. D. Waterman, Indianapolis—Mr. President, I woidd add 
to the remarks already made one other, that I had one of the most 
distressing cases of what was called infantile colic, in which the 
child cried day and night, and 1 found it to be dependent upon 
this very condition of phymosis that was detected by me within a 
week after the birth of the child. It cried incessantly from the 
time it was born until it was relieved. I am inclined, in my per- 
sonal experience, to prefer dilatation to circumcision. I believe 
in nineteen out of twenty cases there is no trouble in dilating the 
prepuce and keeping it dilated. I have found adhesion present Phymosi* in Children. 
7 
right after birth. There is no doubt that this is the cause of a 
large number of those cases of night screaming and night colics, 
and while it is very easily relieved, organic changes may be brought 
about by neglecting that condition.