CHAPTER VII.

THE GENITAL ORGANS.

THE sexes are about equally liable to cancer of the external parts of generation. Chimney-sweep's cancer of the penis and scrotum is a rare disease now, owing perhaps more to improved machinery than to the legislative changes which have endeavoured to put a limit to the system of climbing chimneys for the purpose of cleaning them; but, nevertheless, cancer of the penis is unfortunately by no means an uncommon disease, and the wards of the Cancer Hospital are rarely without five or six such cases; whilst private practice yields an occasional example amongst the richer classes.

The diagnosis of cancer in this region is generally sufficiently obvious to preclude any doubt, but I have met with persons having this disease who have been treated for syphilis; and on the contrary, I have known a prepuce excised as cancerous, which turned out eventually to be syphilitic. Syphilis is the only affection which can by possibility be mistaken for cancer in this climate. The elephantiasis of the East is unknown here, as affecting this organ; although the scrotum sometimes is seen very considerably hypertrophied. The induration of a Hunterian thancre compares certainly with that of epithelioma, the form of cancer to which the

penis is most commonly liable; but whilst the syphilitic ulcer is always defined, and elevated, and does not merge into the surrounding parts, the cancerous sore is less elevated, less defined, and does not present the same abrupt distinction between the affected and the nonaffected parts. The presence or absence of enlarged glands in the groins, of an eruption on the skin, of sore throat, and the other concomitants of syphilitic contagion, will of course clench the conclusion to which we may arrive, from the evidence afforded by the characters of the ulcer itself. The situation of these ulcers is also some diagnostic guide, for although a chancre may attack any part of the penis, it is generally on the inner face of the prepuce, and on the glans itself, that it is seated; whilst epithelioma invariably chooses the external skin of the prepuce for its primary develop

ment.

Beginning as a small pea-like nodule in the loose tissue of the foreskin, epithelial cancer gradually extends its base, and will probably involve the whole circle of the prepuce in its characteristic induration. Supposing it to be unchecked by operation or by applications, the induration may extend to the body of the penis itself, and the cavernous and spongy bodies may become a solid hard mass down to the root of the organ. In other cases the disease may confine itself to the prepuce and skin, and form huge unsightly crops of warty growth, which slough frequently, and after a time involve the glans in a similar destruction. Both forms are followed by enlargement of the inguinal glands, and it is generally owing to the exhaustion produced by the suppuration of these glands, assisted

perhaps by occasional hæmorrhages, that death eventually ensues.

The primary cause of the development of cancer in this position is of course a constitutional defect, but the secondary localizing cause may be a congenital phymosis, which by preventing the proper daily cleansing of the part, exposes it to irritation from the collection of glandular secretion beneath the prepuce. Given the constitutional predisposition, any accidental injury may also give rise to this disease. I am inclined to think it may also be developed in the seat of a syphilitic ulcer. There is a case mentioned in that very useful collection made by Mr. J. Hutchinson, and published in the "Medical Times,' of a man who had epithelial cancer of the penis, following long-standing venereal disease of the organ, and who was also the subject of congenital phymosis. I have seen a very bad case of extensive epithelioma of the labia following a venereal ulcer.

The time of life at which the penis is thus affected corresponds with the period generally chosen for the development of epithelial cancers in other parts of the body. From forty-five to sixty is the most common age, but it is occasionally seen both earlier and later.* As a local application in epithelial cancer of the pre

* The soot-cancer to which the scrotum of sweeps is liable, has not come much under my notice except in its secondary results as an aggravated state of ulceration of the inguinal glands ; when all that could be done was to support the patient, and use deodorizing applications to the parts. In only one instance have I had an opportunity of removing a soot-cancer from the scrotum, and not having heard of the patient afterwards, I am unable to say for how long the operation had freed him from the disease. In the Medical Times' of January 26, 1861, will be found a tabular statement of forty-four cases of soot-cancer collected by Mr. Hutchinson, and the results shown are most favourable to operation.

puce, nothing compares with the liquor plumbi and glycerine. An ounce of the former and two or three ounces of the latter in a pint of water, will, together with general tonic remedies and generous diet, keep in subjection the extension of the disease for a long period; so much so, indeed, as to make it doubtful whether life may not be prolonged as effectually by these means as by operation.

More decidedly than in the case of the lip would I protest against the use of caustics to this part. They give indescribable torture, and fail altogether in checking the progress of the disease. As soon as one portion is destroyed, the neighbouring part takes on the same action, and the extension is infinitely more rapid than if left entirely to itself. When the prepuce only is affected I should be disposed to remove it by the knife, trusting to the liquor plumbi and glycerine to keep in check any return of the induration or warty growth. If the body of the penis be attacked I would remove it by the knife, not by the écraseur, which is a clumsy instrument of torture, and does much mischief by leaving the stump in a bruised and congested condition, from which it recovers with difficulty. In advising amputation, however, it must always be ascertained that it is possible to remove the whole of the indurated portion, for otherwise the object of the operation-prolongation of life will be frustrated. Unfortunately in the majority of these cases the induration extends throughout the organ, and can be traced down to the crura. From the rapid recurrence of the disease after operation, seen in so many instances amongst the patients who come ultimately to the Cancer Hospital, I am induced to think

that the absolute isolation of the diseased part is not sufficiently insisted upon by surgeons in general previous to undertaking this operation: recovery takes place very readily, and the case is probably reported in the journals, but the surgeon rarely has the opportunity of knowing how long or how short is the immunity from suffering he has obtained for his patient. Of the thirtyfive cases of amputation of the penis collected by Mr. Hutchinson, one remained well a month after he left the hospital, and another died of hæmoptysis some months after the operation. There is no further history of the other thirty-three cases. Mr. Sibley gives thirty-four months as the average duration of life when no operation has been done. If we were to take the cases of return of the disease after amputation, at other hospitals, seen at the Cancer Hospital, a very unfavourable comparison with this statement would result. But it may be truly said that these are the bad cases, and as it is impossible to find out what proportion they bear to the good cases, it is evident that it would be unfair and illogical to quote them as illustrating the bad effects of the operation generally; but they may warn us that the enucleation, when undertaken, must be very perfect, and that if it be altogether abstained from, it is quite probable that the patient may live equally as long, although perhaps in greater discomfort.

Having had the opportunity of watching the progress of a case of this kind for more than two years, I think it may be instructive to give an outline of its varying phases.

A gentleman, aged 62, of irritable temperament, but generally healthy, and having no hereditary predis