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Clinical SurgeryIN THE

UNIVERSITY OF EDINBURGH.

ON

P H Y M O S I S.

BY JAMES SYME, ESQ.,PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.

THIS man, J. T-, aged sixty-two, complains of an inabilityto pass his urine, on account of tightness at the orifice of the

prepuce, which is so contracted, that when the skin is drawnback it can hardly be discerned, and admits with difficulty acommon probe. He says that difficulty had been experiencedin uncovering the glans for years until some months ago, when,without any obvious reason or assignable cause, he graduallyfelt himself unable to do so, and at length began to perceivethat the flow of urine was obstructed. Before explaining whatI propose to do for his relief it may be well to consider the sub-

ject in a general way.Phymosis, you are aware, is either congenital or acquired.

When acquired, it is either temporary or permanent, and thisdifference is of great importance in practice, since the meansof treatment requisite for the latter are in general neither neces-sary nor expedient for the former condition. The temporarycontraction usually depends upon the swelling connected withinflammation, or the irritation of gonorrhoeal discharge, sores,or warty excrescences. It used to be the fashion to slit openthe prepuce upon all such occasions, to relieve the patient frompresent suffering and to facilitate the treatment of his case.’But as the cut surface almost always took on an unhealthyaction, greatly aggravating the case, protracting recovery, anddeforming the organ, it is certainly desirable to avoid, if pos-sible, any such interference. Therefore, if you find that a pre-putial gonor rhcea or sores have produced the effect, instead ofresorting to incision, you should make the patient inject someblack wash three or four times a day, and live quietly on ab-stemious diet. Under this system, the contraction, if tempo-rary, will speedily disappear; and, if permanent, will soon bedisentangled from the diseased condition of texture whichwould oppose the successful issue of any operation. The lay-ing open of an inflamed prepuce was formerly held to be fre-quently necessary, for the prevention of sloughing from theintensity of action, but is hardly ever found necessary for thispurpose where the use of mercury for the treatment of venerealcomplaints has been abandoned, or restricted within such narrowlimits as to prevent the evils attending its profuse and indis-criminate employment. The only case of temporary phymosisrequiring an operation is that of warty excrescences within theprepuce so large and numerous as to resist the effects of reme-dial agents, a condition fortunately so rare as to be of littleconsequence.The acquisition of permanent phymosis depends upon con-

traction of the internal lining membrane, and this usually pro-ceeds from the cicatrization of sores, but may also result from agradual thickening and shrinking of the mucous membrane, in-dependently of any breach in the continuity of its surface. This

change generally takes place at an advanced period of life, as in,the case now before you, and may occur without the influence ofany local or general derangement that can be recognised, althoughthere can be little doubt that irritation of one sort or another isconcerned. The late distinguished surgeon of Berlin, ProfessorDieffenbach, in noticing the apparently spontaneous contractionto which the orifices of mucous canals are subject, has mentionedthat even the mouth is not free from this change, so as to haveits capacity reduced to an extent insufficient not merely forarticulation and the ordinary introduction of food, but even forsupplying nourishment essential for the patient’s wants. Heremarked that cases of this kind occurred chiefly in personswho had taken mercury in large quantities, and it may pro-bably be from the horror of that poison entertained in this partof the world, that we seldom meet with such distressing re-

suits of bad practice. The portrait I now show you representsa patient on whom I operated in this hospital for a prettynearly complete closure of the mouth, -which originated from.the same poisoning process that had deprived him of his nose,in accordance with the theory and practice of certain citieswhich shall be nameless.

In operating for the remedy of permanent phymosis, whethercongenital or acquired, the main objects are, of course, to allowthe urine free egress, and to permit exposure of the glans; butparticular circumstances may occur to render a choice of meansfor this purpose desirable. The simplest method, no doubt, isslitting open the prepuce, which, however, deprives the glansof a covering, and leaves t flap of skin, which, instead ofdiminishing, may become thickened, and so inconvenient thatI have been requested to remove it long after the performanceof this clumsy operation. Removal of the prepuce by circularincision prevents any such troublesome consequence, but de-prives the glans of its covering, and therefore should not beemployed except when the part has become morbidly thickenedor elongated. Some years ago I was sent for to the country tosee an old gentleman, considerably upwards of eighty, who hadlong suffered from phymosis, but latterly to an extent hardlyeither conceivable or credible. Day and night he was per-petually trying to pass urine, and by the strongest efforts couldnever evacuate it but by drops. I found the prepuce enor-mously thickened and elongated, whilst the orifice was sotightly contracted that it admitted with difficulty a commonprobe. Having slit open the bag thus formed, I found that itconstituted a sort of subsidiary bladder, of which the liningmembrane was so indurated as to resemble leather, andthroughout its whole extent presented an incrustation of phos-phatic deposit. As no advantage could have accrued from leavingsuch a mass of disordered texture, I cut it all away, with the ex-ception of what was necessary to form a union between the skinand mucous membrane at the base of the glans. The patientwas at once relieved, and lived in comfort for several yearsafterwards. You may be surprised at the performance of sosevere an operation at such an advanced period of life, but you.should recollect that liberties may be taken with the trunk ofthe body in old age which would not be warrantable in theextremities. In the lower limbs, especially of old people, youshould, as far as possible, avoid the slightest incision, whileoperations, even of considerable importance, may be performedwith a favourable prognosis at the most advanced a,ge on thetrunk of a healthy patient. I was once asked to operate uponan old military officer of rank, for a phymosis somewhat similarto that which has been described, and for the same reasonadopted a similar course. On leaving the house, I was askedsome questions as to diet by the patient’s daughter, who re-marked that her father was a remarkably healthy man for histime of life. Having supposed from his appearance that hemight be about seventy, I inquired what was his age, to which

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she replied he had just entered his ninetieth year. Thoughsomewhat startled by this information, I comforted myselfwith the principle just mentioned, and found it verified by theresult.When the textures concerned are in a sound state, and the

object of operating is merely to remove undue constriction ofthe preputial orifice, the best way of proceeding is a modifictionof the Jewish process of circumcision. The surgical part of thisceremony, as I have witnessed it, is performed by drawing the ex-ternal skin of the prepuce through the slit in a silver plate, andcutting it off by a razor-shaped knife, then tearing open the in-ternal membrane which covers the glans, and turning it backso as to place its edge in contact with that of the external in-tegument. Instead of adopting this procedure, which deprivesthe glans of its proper covering, it is better to remove no morethan a ring at the orifice, which may be easily done by meansof catch-forceps and scissors, and then drawing back the outerskin so as to expose the inner one so far as it is not sufficientlywide to allow exposure of the glans. The scissors should thenbe applied laterally on both sides, so as to divide it to the sameextent; after which the two flaps thns formed being turnedback are connected by a few stitches to the edge of the ex-ternal covering. If the prepuce, instead of being tightly con-tracted, is merely narrowed beyond the limit of convenience,it may be widened still more simply without removing anyportion of it, by simply snipping the edge of the orifice, draw-ing back the prepuce so as to bring its inner lining into view,and dividing it in the same way sufficiently far for the pur-pose, and then introducing a single stitch through the terminalpoints of the two incisions; or this process may be performedlaterally on both sides of the prepuce.

][The patient was then brought in, and Mr. Syme performedthe operation in the way that has been described. He firstdrew back the prepuce, so as to expose the contracted orifice,seized it by the catch artery-forceps, removed a narrow ringof the surrounding textures, retracted the skin, and dividedthe inner membrane on each side, turning the flaps backwards,and stitched them to the cut edge of skin. The patient suf-ered no further inconvenience.] ]

Correspondence.

THE MEDICAL PROFESSION AND THE "COLDSHADE."

" Audi alteram partem."

To the Editor of THE LANCET.SIR,—You did me the honour to publish a letter of mine in

THE LANCET of December 1st last, in reference to the import-ance of forming an association for promoting the election ofmedical coroners throughout the country.

Feeling, as I do, how much our profession is barred fromfilling public offices of emolument and distinction, a physician(a friend of mine) made a strenuous, but of course an ineffec-tual effort to obtain the lately-vacated office of secretary tothe Commissioners in Lunacy. Having heard that their secre-tary, Mr. Lutwidge, was about to be promoted to a seat at the.Board, my friend lost no time in applying to the Lord Chan-cellor for permission to be a candidate for the secretaryship.A polite note from his lordship’s secretary informed him thatthe appointment was in the gift of the Commissioners. Hethen immediately made a similar application to the Commis-sioners, setting forth his diplomas and other qualifications,-that he is physician to three public institutions, an author ofsome standing, could give testimonials of all kinds, and hadarrived at the discreet age of forty, and had been engagedseventeen years in considerable private and public practice.Mr. Lutwidge (as secretary still) then shortly acknowledgedthe receipt of the letter in the usual pithy style, and most ’,likely popped it in the fire ! Sir, the fact is not properlyknown to our labouring persecuted faculty, that we, as a body,have no patronage, no public friends,-we are the turnspits ofthe three professions. Do divines preach, or lawyers plead inWestminster Hall as we practise in hospitals, and in thefilthy habitations of the refuse of humanity, gratuitously ?The barber-surgeons kept a better eye to their interests;

they came to the resolution, " that no member shaves TimothyBowman till he pays what he owes to brother Robert Shafto."

Sir, we have twelve inspectors of Poor-laws, including fivebarristers, one colonel, and six private gentlemen-not a

medical man amongst them! Who so fit to inspect the pro.ceedings of boards of guardians as the medical men who arebrought up in constant attendance on the suffering poor ? Canthe colonel, or six privates, or five barristers, inspect half sowell the clothing, diet, and general treatment of the pauper asthe medical practitioners? Can any, or all of them judge halfas well of the sanitary condition of poor-houses, or as to thetreatment of their sick, idiotic, and decrepit inhabitants ?The eleven Commissioners in Lunacy have three medical men

only amongst them. The Inspectors of Prisons, performingduties most appertaining to the science of medicine, in observingthe treatment of the human body under restraints and punish-ments, are but one of them medical men, nor had the Board ofHealth a medical member till lately !

Is the deeply-responsible office of Coroner still to be deniedto our profession ? Can any important case of poisoning—ofsuicide, or mysterious death for many years past be pointed out,but the ignorance of the non-medical coroner either darkened theinquiry, rendered detection difficult, or he entirely overlooked(unsuspected and undetected) those feeble scintillse of evidencewhich the medical eye would at once have recognised, unveiled,and sifted out for the discovery of guilt, and the ends of retri-butive justice?

Where the inquiry is not presided over by one completelyinformed in medicine, the tribunal is highly dangerous to thepublic, because it judicially disposes of, and finally cancels,cases of acknowledged doubt and difficulty.

Medical witnesses are bullied, cross-examined, and generallyled by the " advocate" coroner to give such answers only aswill speedily close the inquiry, and dispense with an autopsy,the horror of non-medical coroners.As a body we are careless about medical jurisprudence, and

why? Because few of us have any chance of gaining anyappointments or distinction in that arena, and we are badlytreated as witnesses; indeed we have every discouragement inprosecuting toxicological and pathological inquiries, by beingdeclared (as I was once) by the coroner, to be too anxious toget up a case for my own adulation and advantage.Ask the common class of coroner how many autopsies he

directs to be made in cases of sudden death. Will he say fiveper cent.? Juries are empanelled to ascertain the cause ofdeath; they swear, in their verdicts, that they have found it-viz., "by the visitation of God." Does such a generalization ofpathology tend to the security of the public ?-does it satisfy theobjects of registration, or the demands of science ?

I am, Sir, your obedient servant,Januarv. 1856. M.D.

POISONING BY ANTIMONY.

[LETTER FROM DR. WEBSTER.]To t7te Editor of THE LANCET.

SIR,—Observing one of your leading articles in last week’snumber, besides containing this remark, " We want to bereferred to researches, further states, " We are not acquaintedwith any decisive experiments demonstrating the length oftime required for the elimination of antimony," permit me tomention that some very interesting investigations are recordedby Orfila regarding tartar emetic and its action upon livingcreatures, in the fifth edition of his "Traité de Toxicologie,"published in Paris during 1852.At page 628 of vol. 1, amongst other experiments, this author

relates:-1. That, on dissecting a dog killed three months anda half after having taken three grammes, or forty-six grainsand a half, of tartar emetic during ten days, but none subse-quently, antimony was found, especially condensed in the fat;the liver contained some, as also the bones, and other tissues.2. In another dog, killed four months after taking threegrammes of tartar emetic during ten days, like the former, butnone in the interval, the metal was found, on dissection,accumulated in its bones, and the liver likewise containedmuch (beaucoup); the other tissues, however, gave very littleantimony. 3. A young bitch, then with pups, took tartaremetic during five days, and about fifteen days before shelittered. The puppies, having been born at the full time, werekilled, as also the mother. On dissection, the livers of thenew-born animals were found to contain a notable quantity ofantimony.

Believing these experiments are conclusive, it appears super-fluous to make additional quotations; nevertheless, as con-

siderable misapprehension sometimes prevails in reference tothe doses of tartar emetic which may be prescribed to sickpersons, not only without injury, but often beneficially, I would