PHIMOSIS AND THE CONDITIONS THAT IT COMPLICATES IN THE ADULT. BY WILLIAM P. MUNN, M.D., OF DENVER, COL. J PROFESSOR OF GENITO-URINARY DISEASES AND CLINICAL SURGERY IN THE UNIVERSITY OF DENVER ; GENITO-URINARY SURGEON TO THE ARAPAHOE COUNTY HOSPITAL, AND CONSULTING SURGEON TO ST. LUKE'S HOSPITAL. FROM THE MEDICAL NEWS, March 24, 1894. [Reprinted from The MEDICAL NEWS, March 24, 1894.] PHIMOSIS AND THE CONDITIONS THAT IT COMPLICATES IN THE ADULT} By WILLIAM P. MUNN, M.D., OF DENVER, COL. J PROFESSOR OF GENITO-URINARY DISEASES AND CLINICAL SURGERY IN THE UNIVERSITY OF DENVER J GENITO-URINARY SURGEON TO THE ARAPAHOE COUNTY HOSPITAL, AND CONSULTING SURGEON TO ST. LUKE'S HOSPITAL. The patients shown you to-day will illustrate several phases of that rather common condition, phimosis, and the diseased conditions that are complicated and ren- dered more difficult of treatment by the presence of phimosis. First, let me direct your attention to these three cases circumcised some time ago and presenting resulting conditions of varying perfection. These meh had all of them redundant foreskins, and each of them was the victim of mixed venereal infection ; two con- tracted the initial lesion of syphilis and the simple venereal ulcer or chancroid at or about the same time ; one contracted syphilis and gonorrhea at the same time. In this first patient, Peter M., the sore, then recognized as chancroid only, was situated upon the prepuce just at the junction of the skin and mucous membrane, and was not only difficult to treat but was refractory to treatment. It was apparent that removal of the foreskin was neces- sary, and if neatly and cleanly done so that the oper- 1 A Clinical Lecture delivered at the Arapahoe County Hospital January 30, 1894. 2 ation-wound should not be contaminated, would lessen the difficulty of treatment by removing the sore at the same time. This was done and an eminently satisfactory result obtained. The fine linear scar can now hardly be seen, there is no thickening of the mucous membrane, and the very slight edema near the frenum will disappear in a few weeks. We have here, then, what may very properly be called an ideal result of the operation of circumcision. In the patient's left groin you observe the depressed, puckered scar left by the wound made in excising the bubo which occurred there as an accom- paniment of his chancroid. The incision healed almost entirely by first intention. In the time that has elapsed since the operation, mucous patches in the mouth and other secondary manifestations of syphilis have made their appearance, and the man is now taking mercury and potassium iodid in free dosage. The next man, you will remember, had secondary manifestations of syphilis and a free gonorrheal dis- charge. On account of his elongated prepuce it was not only difficult to effectively treat his gonorrhea, but the retained secretion excoriated the mucous membrane of the glans and of the prepuce. With this patient the circumcision was done by the method of first slitting the foreskin with scissors to a point back of the glans, then trimming off the corners of the flaps, and suturing the skin and mucous membrane. The result is not so perfect as in the first patient, but may still be considered satisfactory. In a few months the swelling and infiltra- tion will disappear and there will be little evidence left of operative procedure. This third patient I wish to place in contrast with the two already shown. He has been subjected to a simple incision of the prepuce in order to facilitate treatment of a mixed sore located on the frenum. As you see, the real object of the incision was not attained, for the long and flabby lower flap of the prepuce has remained in 3 continuous contact with the glans, and the chancroidal process, which was probably serpiginous, pursued its uninterrupted course and has quite destroyed the frenum. This is an excellent example of a bad result due to an incomplete operation. But the present condition is not such as to demand further immediate operation, as the chancroid is now undergoing cicatrization and will soon be quite well. Some points in reference to this man's mixed infection are of sufficient importance to justify a slight divergence from our main subject for their brief consideration. As he opens his mouth you can see the well-marked mucous patches becoming confluent upon the palate just to the right of the uvula ; his hair is also coming out, the spots upon the skin are very apparent, and as I now have him lean over and spread apart the buttocks so as to expose the anus you can observe characteristic mucous patches upon the anal mucous membrane. These are incontrovertible evidences of the second stage of syphilis. They are of especial im- portance in connection with the history given by the patient. Before entering the hospital he had been under treatment by an irregular syphilis-specialist who had so dosed him with mercury on the appearance of the mixed sore upon his penis, that he was thoroughly ptyalized before the appearance of the secondary manifestations. Now note that the saturation of the system with mercury did not prevent the occurrence of the secondary signs. This remedy antagonizes the effects of syphilis, but does not prevent the action of the syphilitic poison or germ. The medication was ill advised because at the time it was given the disease was still a local process and there were no constitutional manifestations to be met by the administration of mercury as a constitutional remedy. The result was the development of ptyalism without any arrest of the onward progress of the disease. To return to our original subject, phimosis and its relief by circumcision. The man who has just been 4 anesthetized is over seventy years of age. He has an extremely long and very tight foreskin, and in addition you will notice that there is present a free, purulent dis- charge from the urethra. This discharge is a typical gonorrheal flow, and he gives a history of venereal exposure some ten or twelve days prior to the inception of the discharge. The fact deserves emphasis, that no age is exempt from gonorrhea if exposure occurs. It is usually a disease of young adult life, but it may occur at any age, as I have before seen it in men of about the same age as this patient, and also in little children. Last year we had in the hospital a girl four years old with a gonor- rheal vulvitis due to wearing clothes soiled with the discharge from an older patient; a boy five years old who had acquired it in some unknown manner, and a boy eight years old who had gotten it by attempted sexual intercourse with an older girl. This man's prepuce is so long that it has thus far absolutely prevented not only treatment of the urethra but has rendered cleansing of the fossa back of the glans practically impossible. Immediate circumcision is the only proper treatment for this condition. Dr. Stover, the surgical resident, will perform the operation. Instead of following any of the elaborate and somewhat fantastic methods that have been devised, we follow a method which is simplicity itself and which gives results as nearly ideal as any of which I know. The end of the prepuce is held either between the thumb and forefinger of the left hand or grasped in a forceps held in the left hand. With scissors curved on the flat, the redundant foreskin is then removed at one stroke. Danger of wounding the glans penis by this method amounts to nothing, for the glans glides back from the scissors so quickly and easily that it would be impossible to nip it if the effort were made. As the skin of the sheath retracts the mucous membrane is seen still encircling the glans. Before proceeding any further it is well to 5 arrest all hemorrhage. Firm pressure with a gauze sponge will frequently suffice, but if the artery of the frenum bleeds freely, as in this case, it is seized with artery-forceps and twisted with five or six full turns of the forceps. The mucous membrane is now slit back- ward on the dorsum of the glans nearly to the corona glandis and the flaps rolled back. There is one precau- tion to be taken at this point, and that is to avoid entering the scissors-blade in the meatus. Little likely to occur as this seems to be, yet it has occurred, and careless operators have clipped through the glans as well as the preputial mucous membrane. The corners of the re- flected mucous flaps are now trimmed off with the scissors, and, after thoroughly cleansing the glans and removing accumulated smegma from behind the corona, the mucous membrane and the skin are sutured with interrupted silkworm-gut sutures. Ten stitches are inserted in this case. The dressing is a simple anti- septic one, powdered iodoform being rubbed into the wound-surface; several layers of iodoform-gauze are applied and held in place by a rubber band. The stitches may be removed in a week, and I anticipate complete primary union. Our next patient is a younger man, about twenty-five years old. The foreskin is long and lax-no tightness whatever. You can see no sore and there is no dis- charge present, but as he retracts the foreskin there appear some of the results of irritation from the con- tinuous moisture of retained secretions. The inner surface of the prepuce, and the glans penis as well, are covered with mushroom-like growths varying from an eighth to a half inch in diameter. These vegetations are venereal warts, and this man has about as large a crop of them as you will often see. He has been in the hospital before and had a number of warts clipped off or burned with acids, but there is very prompt recurrence because the predisposing causes, this elongated prepuce 6 and his uncleanly habits, still persist. He has, as you see, no specific venereal disease, and these papillomata are but the results of long-continued irritation and maceration of the mucous membrane. These growths were not apparent until the prepuce was retracted, yet there is a large mass of them demanding immediate interference. This emphasizes the necessity of making a thorough examination of each case by retracting or causing to be retracted the redundant prepuce. Until this is done it is impossible to know or even guess what may be concealed ; perhaps such growths as these are, perhaps a malignant growth, an initial lesion, a chan- croid, an injury, a mass of retained secretions, or even a calculus. I remember especially the case of a man who was in the medical ward last year, with obscure febrile symptoms. After several days he incidentally gave a history of passing blood with his urine, and it was pre- sumed that it came from his bladder or kidney. On examining him I found that it came either from the penis or the urethra, and at first glance I thought he might have introduced some foreign body into the urethra, but upon retraction of a long and rather tight prepuce there was exposed back of the glans a serpiginous chancroid nearly an inch and a half in its greatest diameter which had eaten into the body of the penis and opened the artery of the dorsum. A few days' further delay in dis- covering the sore would probably have resulted in entire loss of the glans penis. The treatment of the present case will be removal of the warts and of the prepuce, and I will ask Dr. Mack, the chief resident, to perform the operation. We will employ cocain-anesthesia in this case. As a preliminary the penis is first rendered bloodless by pressure, after having been wrapped with bichlorid gauze. A rubber band is now placed at the root of the penis and serves to control the return circulation. We employ a ten per cent, solution of cocain and inject two or three drops 7 upon the dorsum, upon each side and near the frenum ; in all ten drops are used, representing about one grain of cocain. As the warts are removed, their bases are freely touched with Monsel's solution. The prepuce is re- moved in the same manner as in the former case, and the artery of the frenum requires torsion here also. Suturing and dressing are the same as before. The result of continued neglect of the benign papil- lomata which occur in patients like this may be the con- version of a benign into a malignant process. Almost all cases of epithelioma of the penis occur in patients having just such long foreskins, and the continuous irritation of the retained secretions has been the active factor in causing malignant development. Here comes the last patient for to-day's clinic. His penis and what is left of his prepuce present a peculiar appearance. He has been circumcised before, but who- ever operated upon him failed to break up the adhesions between the glans and the prepuce, and as a result only the end of the glans is visible. All of the movable mucous membrane of the prepuce has also been re- moved, and so we have the skin almost directly united to the glans, with only the slightest amount of retraction possible. I shall endeavor to improve the present con- dition, although it is quite impossible to secure a perfect result. The patient is now under chloroform, and I dissect with scissors between the prepuce and the glans until the corona is reached and exposed as fully as pos- sible. In the same careful way, by a circular dissection, the thick, bulging scar-tissue left by the former operation is removed, and what little mucous membrane has been raised from the surface of the glans by dissection is carefully sutured to the edge of the skin. This is not, by any means, a beautiful result, but it promises to be a great improvement over his former condition both as to the appearance of the member and in increasing the patient's comfort. 8 In conclusion, gentlemen, it may seem to you that we have given a great deal of time to a trivial and some- what disagreeable subject. I am aware that abdominal and cranial operations are more attractive to both students and practising physicians than are minor genito- urinary operations, but I am convinced that you will all have to perform such operations as circumcision per- haps many times before you undertake the major oper- ations. There is often more of reputation and of profit for the young physician in a neatly done circumcision, with a good result, than in all the major surgery that comes to him. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHL YMEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7.30 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.