MALIGNANT DISEASE.-With the ex ception of epithelioma, malignant dis ease of the penis is rare, although malig nant tumors arc much more commonly observed than the benign varieties.
Epithelioma of the penis may exist in the form of an ulcer or cauliflower-like growth. A redundant prepuce or phi mosis predisposing to balanoposthitis, with consequent maceration, may act as a predisposing cause.
Symptoms.—The disease usually be gins as an insignificant ulcer or wart, beginning most frequently at the prEe putial orifice or coronary sulcus. It grows slowly, and gradually infiltrates the surrounding tissue. The prepuce is finally destroyed, and an offensive, icho rous discharge covers the ulcer, which shows great tendency to bleed on the slightest manipulation. As the disease extends backward, the cavernous bodies become indurated, the skin adherent, and the inguinal lymphatic glands become enlarged and ulcerate.
There is usually no difficulty in mak ing a diagnosis except in the very earliest stages. Under such circumstances a small section might be removed under cocaine and a microscopical examination made.
The prognosis is exceedingly bad un less the growth is removed very early.
Treatment.—Amputation or extirpa tion of the penis, depending upon the amount of tissue involved, is indicated. The infected lymphatics from both groins should always be removed at the time of operation in order to prevent re currence.
Analysis of 359 eases. Epithelioma is by far the most frequent form of carci noma of the penis, and its frequency is about 2 per cent. of all cancers. Phi mosis is a strong predisposing factor by causing chronic irritation. As a rule, epithelioma is more frequent after middle life. though, like every other rule, this has its exceptions. The syphi litic virus has absolutely nothing to do with epithelioma, the sear of the old specific lesion being nothing more than an area of decreased resistance or a cause of chronic irritation. Traumatism is a predisposing factor by causing an area of decreased resistance. The ques tion of the contagiousness of epithe lioma is still to be decided. Epithelioma more commonly begins in the glans or prepuce; an origin in the urethra is very rare. Visceral metastasis is also very rare. The prognosis in the pre cancerous stage is favorable if radical treatment be at once instituted; later it is only guardedly so. The only safe treatment in any stage consists in the thorough eradication of the area of dis ease and of all lymphatic glands that are involved. F. D. Patterson (Univ. of Penna. Med. Bull., -July, 1901).
Amputation of the Penis.—Amputa tion of the penis is indicated for the re lief of tuberculosis and malignant dis ease.
The operation may be performed either by the flap or circular method; the former, however, is to be preferred. limmorrhage is to be provided against by transfixing the root of the penis with two long pins, and surrounding the organ with an elastic bandage above. These prevent the ligature from prematurely slipping after the organ has been re moved. The position and shape of the flaps is to be governed by the limits of . the disease. Whenever possible, a long anterior flap is to be preferred.
A narrow-bladed knife is introduced between the cavernous and spongy bodies at a point at least one inch behind the disease, and a small posterior flap is then cut forward and downward. From this flap the urethra is to be dissected free. A flap of sufficient length is cut from the dorsum and sides of the penis, re flected backward, and the cavernous bod ies divided on a level with the line of reflection. The dorsal artery is now tied, the tourniquet removed, and any spurting vessels ligated with fine catgut. The stumps of the cavernous bodies are now covered by suturing together their fibrous envelopes (tunica albuginea). The anterior flap is punctured, the urethra drawn through it, slit up, and sutured in place. The two flaps are now united with silk-worm-gut sutures. A Nelaton catheter should be tied in place for a week, and then a meatal boogie passed at regular intervals to prevent contraction of the new urethral orifice.
Extirpation of the Penis.—Extirpation of the penis is indicated when malignant disease has extended as far back as the scrotum.
The patient should be placed in the lithotomy position, and the scrotum split along the entire length of the raphe. After exposing the anterior layer of the triangular ligament, the spongy body is dissected free and cut off, leaving suffi cient to bring out through the perineal incision. With an elevator, the crura are dissected from the pubic arch; the in cision is prolonged about the penis above, the suspensory ligament divided, and the dorsal arteries secured. The stump of the spongy body containing the urethra is now slit up, stitched in the posterior part of the scrotal incision, and the external wound is closed. A catheter should be introduced into the bladder and retained in place for a week.
Diseases of the Testicles.
Anomalies.—PoLyoncrusm.—Quite a number of cases have been reported of men who have three, four, or six testicles, but only in very few authentic cases has the anomaly been verified by post-mor tem or operation. In some of the sup posed cases tumors, hernias, and hydro celes have been found.