History of Circumcision from the Earliest Times to the Present Part 9

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 circ.u.mcised 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 a.s.sist 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 p.e.n.i.s, 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 p.e.n.i.s 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 p.e.n.i.s,--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 p.e.n.i.s 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 p.e.n.i.s, 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 p.e.n.i.s, observing that it would be interesting to know whether cancer of the p.e.n.i.s was a rarity among circ.u.mcised 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 pract.i.tioner 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 p.e.n.i.s 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 p.e.n.i.s 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 un.o.bjectionable 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 circ.u.mcision, nothing ever resulted in such a serious consideration of the subject as seeing a professional brother dying with a cancerous affection of the p.e.n.i.s. 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 circ.u.mcision more than once to his father, who also was a physician, but who, unfortunately for the son, could not see any merit in circ.u.mcision.

To his eyes there was nothing that circ.u.mcision 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 circ.u.mcision 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 Medicales," quotes from the third volume of the "Memoires de l'Academie 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 haemorrhagic 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 p.e.n.i.s 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. Circ.u.mcision is, therefore, an advisable prophylactic measure, where the const.i.tutional taint is known to exist."

CHAPTER XXI.

THE PREPUCE AND GANGRENE OF THE p.e.n.i.s.

Another accompaniment of that preputial appendage is gangrene of the p.e.n.i.s, which, like carcinoma, starting in at the prepuce, may invade the p.u.b.es and s.c.r.o.t.u.m. 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 pa.s.sive congestion that takes place in the integument of the p.e.n.i.s. 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 p.e.n.i.s (and especially that of the prepuce) in which, through the laxity of its tissues, pa.s.sive 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 p.e.n.i.s 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 pa.s.sage 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 p.e.n.i.s, 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 p.e.n.i.s or in the s.c.r.o.t.u.m, 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 p.e.n.i.s, 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 p.e.n.i.s; the local and const.i.tutional disturbance was not high, however, and the patient escaped with the simple loss of the prepuce.

Another case admitted to the Charite, aged thirty-six, was afflicted with a blennorrhagia, upon which an attack of low fever supervened. The p.e.n.i.s 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 p.e.n.i.s 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 Charite, 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 quant.i.ty 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 s.p.a.ce to its description, dividing the disease into two forms: the inflammatory, such as may follow venereal primary sores or operations on the p.e.n.i.s, not excepting circ.u.mcision; 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 Encyclopaedia 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 p.e.n.i.s 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 p.e.n.i.s 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 p.e.n.i.s 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 Medicales" by Patissier, wherein a man lost p.e.n.i.s and s.c.r.o.t.u.m 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 p.e.n.i.s 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 circ.u.mcision 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 princ.i.p.al cause--of the ease with which the phagedenic action was inaugurated. The case already mentioned as an example of spontaneous and natural circ.u.mcision 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 p.e.n.i.s; 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 a.s.sociation 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 p.e.n.i.s 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 pract.i.tioner cheerfully submitted to circ.u.mcision, 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 antic.i.p.ated 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 p.e.n.i.s engorgement; this increases the difficulty of urination, which, by the retention that results, in turn increases the constriction at the root of the p.e.n.i.s, and adds to the already difficult return circulation. The bladder by its urine, and the p.e.n.i.s by its blood, actually form, by their mutual pressures, an impa.s.sable 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 p.e.n.i.s.

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 p.e.n.i.s would have become gangrenous. The subject was an uraemic, irritable, nervous, leathery-prepuced individual; the organ was unusually large, the skin of the p.e.n.i.s 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 p.e.n.i.s was often dank, livid, and discolored from the pa.s.sive 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 p.e.n.i.s, retention having followed painful micturition, and the swelling of the p.e.n.i.s following the retention; the prepuce was enormously distended, and the p.e.n.i.s 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 p.e.n.i.s, with that of the pubis and on the front of the s.c.r.o.t.u.m. The man ran into a low form of fever, with uraemic 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 p.e.n.i.s, 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 uncirc.u.mcised 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 canon; 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 _taille a 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 p.e.n.i.s from being scratched by the briars or th.o.r.n.y 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 t.e.s.t.i.c.l.e. 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 circ.u.mcision.

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 p.e.n.i.s. It appears that there is a powerful moral effect that follows this loss, as might, in the majority, be antic.i.p.ated. According to the experience of Civiale, many who have lost the p.e.n.i.s, through amputation for disease or through disease itself, end in suicide. He mentions particularly a patient at the Charite who had lost his p.e.n.i.s, 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 p.e.n.i.s amputation for disease. M. Roux, who amputated the p.e.n.i.s of a brother of Buffon, in 1810, reported that, in that case, M. Buffon lost none of his customary gayety.

CHAPTER XXII.

THE PREPUCE, CALCULI, AND OTHER ANNOYANCES.

From an article published in the New York _Medical Times_ of March, 1872, from the pen of Dr. J. G. Kerr, of Canton, China, we learn that phimosis is not an uncommon occurrence among the Chinese. As has been demonstrated by C. H. Mastin, of Mobile, climate is a great factor of calculus. ("Transactions International Medical Congress" of 1876, page 609.) That of China seems a most favorable climate in this regard; so that, between the prevalence of phimosis among the Chinese and the calculus-producing tendency of the climate, China may be said to be the cla.s.sic land of preputial calculi, as England is that of the gout, or the United States that of delirium tremens. From Dr. Kerr we learn that the occurrence of these concretions were, as a rule, multiple, and that in two cases that fell under his observation the number of stones from each individual exceeded one hundred. In one case there were forty, and in three cases there were between twenty and thirty. These were of different sizes and weight, some being an inch and five-eighths in diameter, and from that size down to where one hundred and sixteen taken from one individual case only weighed one ounce. The tendency to calculous disease in that climate may well be imagined, when the same observer relates a case of urinary infiltration into the skin on the under side of the p.e.n.i.s that gave rise to the formation of a collection of calculi in that locality, four of which were the size of pigeons'

eggs; and another case in which a urinary fistula induced the formation of a calculus in the groin, near the s.c.r.o.t.u.m, the calculus weighing two and a half drachms and measuring one and a half inches by three-quarters of an inch in diameter.

Claparede mentions a case in the practice of M. Dumeril, in which the stone extracted from the prepuce weighed two hundred and twenty-five grammes, or about eight ounces. Civiale speaks of a young man of twenty with phimosis, who, after practicing s.e.xual connection for the first time, experienced pain and a purulent discharge, from whom, on examination, he removed five stones as large as prunes. The patient had felt them in their position, but had imagined the condition to be a natural one.

E. L. Keyes gives their composition as being of calcified s.m.e.g.m.a, urate of ammonium, triple and earthy phosphates and mucus, and as symptoms and results: pain, purulent discharges, interference with urination and the s.e.xual act, involuntary emission, ulceration of the preputial cavity, and impotence.

Enoch mentions a child of two years in the Charite, who, being operated upon for phimosis, was found to have a preputial calculus occluding the urethral meatus. At the autopsy a calculus as large as an egg was found in the bladder.

The presence of these formations, although not necessarily dangerous in themselves, may, by their effects and in the irritation they induce, be the means of producing serious mischief. The only preventive or remedy for this condition is circ.u.mcision.

Acquired phimosis has been mentioned as a result of inflammatory lotion, such as is connected with balano-posthitis; it sometimes happens that, the act of coitus being done forcibly, especially with public women, who are apt to use very astringent and constricting washes, the prepuce becomes injured, with the result of producing a phimosis. One man will produce the same results through the means of some vaunted wash or dip which is supposed to act as a prophylactic to any venereal infection.

One patient had developed a chronic herpetic affection by the constant use of an iodized ointment which he regarded as an infallible prophylactic. Many cases of phimosis result from the attending inflammation that follows on the liberal domestic application of nitrate of silver to an abrasion after connection, in the mistaken idea that the party labors under, that he is destroying some venereal virus.