CARCINOMA OF THE , WITH A REPORT OF SIXTY-SEVEN CASES

W. E. LEIGHTON, M.D. (From tha Bamrd Free Skin and Cancer Hospital, St. Louis) Jonathan Hutchinson, Jr. (I), lecturing before the London Hospital in 1899, opened with the following significant paragraph: "Epithelioma of the penis is, you may think, almost too rare a dis- ease to have devoted to it a whole lecture, but I can speak from experience on the subject and I wish to impress upon you that it is such rare affections as this which are worthy of your study, because it is their rarity which leads to mistakes in diagnosis at a time when treatment might be successful, and in epithelioma of the penis and the tongue there is much loss of life due' to such mistakes." The rarity of this disease is shown by the fact that it comprises only a small percentage of all carcinomata. Paget (2) says it forms but one per cent of all cases, while Billroth's estimate (3) is as high as three per cent. Barney (4)) in a study of the cases seen in the Massachusetts General Hospital for a period of thirty- three years, 1872-1905, found an average of about three cases per year. He found that many surgeons of large experience had had no cases of carcinoma of the penis in their practices. Sawtelle (5)) in an examination of 70,826 cases in the Marine Hospital service, during a space of five years, saw only 7 cases. At The Barnard Free Skin and Cancer Hospital 68 cases have been seen in the last twenty-six years. During the past five years, 1,364 males were admitted for cancer, 18 of whom had carcinoma of the penis, an average of over three cases a year, but a percentage of only 1.3 of all cancer in the male.

Carcinoma of the penis as a rule arises from the epithelium covering the prepuce or glans penis. In rare instances it starts from the mucous membrane of the urethra. The actual cause of the disease, as of all carcinoma, is unknown. 261 252 W. E. LEIGHTON Various factors appear to contribute to the beginning of this disease. A common contributory condition is phimosis, which is found to be of frequent occurrence in those cases where careful histories have been taken. It was noted in 13 of our patients. Barney (4) found it present in 85 per cent of those cases in which inquiry was made as to its occurrence, and Martin (6) found it in 6 out of 7 cases. Irritation from smegma under the tight prepuce of elderly men is frequently the starting point of carcinoma. The importance of this condition is emphasized by the fact that among the Jews and the Mohammedan population of India, by whom has been practised for ages, carcinoma of the penis is almost unknown. There were no Jews in the present series. Greensfelder (7)) however, reported a case occurring in a circum- cised Mohammedan among 202 cases collected in India, and Pacha (8)) of Constantinople, saw 5 cases of carcinoma of the penis in circumcised Mussulmen, in four years. Syphilis at times seems to be of etiological significance, since it is not uncommon to find cancer developing upon the site of a chancre. Martin (6) thinks the ground for this supposition is not tenable, although he has seen such a case. Sheild (9) and Green (10) also each saw a case. Barney (4) reports 2 cases, and De- marquay (11) in an analysis of 59 cases found a history of syphilis in 10. In 2 of our cases carcinoma developed at-thesite of a chancre. Seven of the patients gave a history of syphilis, 4 of whom had received treatment. A positive Wassermann reaction was ob- tained in 4 cases. A history of gonorrhea was obtained in 11 cases. Trauma probably plays the same r61e as in the etiology of other cancer. Kronlein (14) reports such a case. In the series reported here two cases developed following a crushing injury (cases 12 and 38) and in another case the cancer developed on the scar of an old laceration (case 11). Rodman (15) and Whiteford (16) each saw a carcinoma which had developed upon an earlier circumcision, and Barney (4) reported 6 such cases. Sixteen of our patients had been circumcised in adult life; in 11 of these the wound did not heal and a carcinoma developed. Dormanns (17)) in a period of eighteen months in , received for examination five specimens of cancer of the penis. Three had been removed from young men, twenty-four, twenty-six, and thirty-six years of age respectively. In all instances the skin was markedly inflamed and showed micro- scopic changes similar to those produced by tar. In seeking an explanation for this, it was found that gonorrhea, syphilis, and CARCINOMA OF THE PENIS 253 chancroid are treated by the local application of a highly irritating substance, the nature of which, however, Dormanns was unable to ascertain. Contagion, or rather implantation, has been suggested. In 1895, MacFarland (18), searching the literature, found eight cases of "contagion from wife to husband." Bernstien (19) reported a case of possible contagion from husband to wife. Bruce (20) saw a patient who developed cancer of the penis one year after his wife died from carcinoma of the uterus. Outland (21) reports a similar case, and Cornil (22) reports two cases which he thinks confirm the direct contagion of carcinoma. Frank (23) cites the case of a man of thirty-nine developing carcinoma of the penis five years after his wife died of carcinoma of the uterus. His case, however, is similar to case 9 of the present series, which would seem to be purely coincidental. Barney (4) reports a case of auto-im- plantation on the scrotum due to contact with cancer on the penis. Origin of the Growth: In 30 of our cases the disease began on the glans penis, and in 13 the first appearance was on the prepuce, while a few have thought that the growth began in the sulcus. Only 2 cases were recorded as beginning on the frenum. Barney (4) noted that in a few cases the growth waa limited to the point of origin but in most it had spread so as to involve both glans and prepuce. Our experience was similar. Demarquay (11) and Thomsen (12) state that the lesion occurs more frequently on the glans penis, while Kaufmann (13) reported 20 of 33 cases observed by him as occurring primarily on the prepuce, and only 13 on the glans. The origin of one of our cases, No. 62, was in the urethra at the peno-scrota1 junction. Age: The age at which carcinoma of the penis develops corre- sponds with that in carcinoma of other organs. Creite (24) re- ports a carcinoma of the penis in a boy of two years, Freyer (25) in a boy of fifteen years, Ralph (26) in a young man of twenty-two years, and Fielewicz (27) in a young man of twenty-six years. While a few cases occur in the twenties, the condition is most common between fifty and sixty. Forty-five of our cases occurred after fifty. The age of the patient on admission ranged from thirty to seventy-seven years. Seven patients were between thirty and forty; 12 between forty and fifty; 21 between fifty and sixty; 14 between sixty and seventy, and 2 between seventy and eighty. 254 W. 1. LEIGHTON Nationality: Fifty-four of the patients were born in America, 8 in Germany, and one each in Ireland, Holland, and Switzerland. In 2 cases the nationality was not recorded. Sixty-two patients were white, and 5 colored. No race is exempt from this affliction unless it be the Jews. Contrary to the experience of Rodman (15) and Barney (4)) who never saw a carcinoma of the penis in a negro, Thomas (28) and McCoy (29) each report a case occurring in a negro. Four out of five patients treated by Shivers (30) at his clinic at Atlantic City were colored, and Howze (31) reported six negroes in seventeen cases. There are five colored patients in the present series. PATHOLOGY Carcinoma of the penis develops from the epithelium of the prepuce or glans penis, occasionally from the urethra. It corre- sponds with the epithelial type of carcinoma found elsewhere. Microscopically it begins either as an ulcer or as a warty excres- pence, which proliferates rapidly, forming a cauliflower mass, which in time may involve the whole organ. Extensive ulceration may take place, and the whole penis become destroyed. Fre- quently the tumor persists for many years without causing much discomfort. The growth is more or less superficial, extension to the corpus cavernmum being prevented by its fibrous sheath. Hutchinson (1) was able to find only one pathological specimen in which extension to the corpus cavernosum had taken place. That this may occur, however, has been shown by Thomsen (12)) Kuttner (32), Pelagatti (33)) Oraison (34)) Bergeret (35), and others. The growth extends by means of the lymphatic channels which are superficially situated, involvement of the inguinal nodes occurring early. Kiittner (32)) in a study of 60 cases, found the inguinal glands enlarged in 71 per cent, although in only 32 per cent were they cancerous. While the inguinal nodes are often enlarged from inflammatory causes, as shown by these examina- tions and also by subsidence after operation without dissection of the groin, many authorities find a much larger percentage involved by cancer, notably Gussenbauer (36)) who states that the microscope will reveal carcinoma even though palpation fails to reveal enlarged glands. Among 48 cases he found 40 with carci- noma of the glands. A study of the lymphatics by Kuttner (32), who made a number of injections, brought out the fact that the superficial lymphatic CARCINOMA OF THE PENIS 255 channels empty into the inguinal glands, while the deep ones follow the blood vessels and empty into the pelvic nodes. Nicoll (37) says that the lymphatics of the anterior half of the penis pass almost wholly to the dorsum, the main channels passing back on either side of the dorsal vein to the oblique set of superficial glands of the groin in the first instance; secondarily thence to the deep inguinal glands lying along the external inguinal vessels on the brim of the pelvis. Few, if any, of the lymphatics of the anterior half of the penis pass to the deep lymphatic vessels of the root of the penis, which channels pass under the pubic arch to the intrapelvic glands. Cunningham (38) and Gray (39), on the other hand, state that the lymphatics from the glans penis, which is the expanded portion of the corpus spongiosum and the urethra, may pass directly into the external iliac chain either over or under the symphysis. While the disease involves the inguinal glands early, it has a tendency to become limited to these glands, which accounts for its usually slow growth and the fact that it may cover a long period of years. Even though recurrence takes place, the progress is slow. Visceral metastases are rare. Up to 1907, according to Barney (4))only 9 authentic cases of metastases were recorded in the literature. Mbnetrier (40) mentions a carcinoma of the peri- cardium secondary to a carcinoma of the penis. Death is usually due to cachexia or to hemorrhage following ulceration of the blood vessels. DIAGNOSIS The diagnosis of the well developed case of carcinoma of the penis is easy. The principal lesions to be excluded are papilloma and syphilis. Papilloma shows a tendency to proliferate, the base is not indurated, and it is not prone to ulcerate. The inguinal glands are not enlarged. If ulcerations occur from lack of cleanli- ness, the glands in the groin may be enlarged and the diagnosis becomes questionable. Under such conditions the safe plan is to excise a section at the margin of the growth with the healthy tissue for microscopic diagnosis. The differential diagnosis between carcinoma and syphilis is not always easy. Epithelioma-like chancre may appear in the urethra; usually, however, it is on the prepuce or glans penis. Age has nothing to do with the diagnosis: cancer may occur early in life, while syphilis is sometimes seen later in life. In doubtful cases a dark-field examination or the Wassermann reaction will clear up the diagnosis. 26 256 W. E. LEIGHTON Most important in the diagnosis of carcinoma of the penis is the recognition of the so-called precancerous lesions. It is well known that most cases of carcinoma of the penis appear to start from what-at first seems to be an insignificant local irritation, such as a wart, an ulcer, or irritation caused by smegma collecting under a tight foreskin. Leukoplakias and eczemas, or psoriasis pre- putialis, first described by Schuchardt, should be considered most serious when associated with phimosis in old men. Psoriasis is marked by the appearance of shiny, grayish-white plaques on the glans penis or foreskin and is usually due to local irritation. Carcinoma of the penis often starts with a warty vegetation, which itches and burns. In an examination of 33 cases, Kaufmann (13) found 29 beginning with such a lesion. In the present series 13 cases began as warty growths and 14 as ulcers. Of these, 8 were treated with caustics. This treatment I would especially warn against. Caustics, such as nitrate of silver, not only do not arrest the disease, but often stimulate it to serious proliferat'ion.

A favorable prognosis depends upon early diagnosis and prompt treatment. When the disease is confined to small irritations the outlook should be good, but with its further development the prog- nosis should be more guarded. Age and the type of operation will influence the result. In the young cancer is most malignant, and even the most radical operation will be followed by a recurrence. In one such case brought to my attention within the past few months total extirpation was followed by recurrence in the scar and death from hemorrhage. Partial amputation with removal of the inguinal glands is frequently followed by recurrence in the scar. The prognosis has been changed considerably in recent years. In 1899, Taylor (41) stated that when the inguinal glands were involved death inevitably followed and that operative procedures in such cases constituted surgical vandalism, since it was impossible to remove all the diseased tissue. At the present time we are encouraged to give a much more favorable prognosis by our knowl- edge of the apparent limitation of the extension of the growth to the inguinal glands, and by a careful analysis of statistics such as Barney's (4), who reports a mortality of 32 per cent, but found that operation prolonged life on an average of about five years, even though the cancer terminated fatally. CARCINOMA OF THE PENIS 257 If we would treat this disease as we do cancer of the breast I believe we would increase the cures to a considerable extent. We are encouraged to do so because of the fact that many cases (Jack- son, 42; Boone, 43; Green, 44; Fischer, 45; Thomas, 28; Dax, 46; Hadda, 47; Annandale, 48) are reported in which total extirpa- tion resulted in apparent cure lasting for mont,hs or years, in spite of the fact that there had been extensive glandular involve- ment. The prognosis depends not on the extent of the ulcerating growth or glandular involvement, as some state, but on the thor- oughness with which we remove the growth, glands, and interven- ing lymphatics.

TREATMENT The extent of the operation necessary to remove the disease depends upon the stage when the lesion is seen. If only a spot of psoriasis or small warty growth is present, the actual cautery should be used, as the burning will prevent the stimulation of cell growth, and the resulting slough will remove quite a wide area of tissue. The use of nitrate of silver and other caustics should be avoided, as they tend to stimulate proliferation. When the disease is well established, amputation becomes necessary. The extent of the growth may determine the point of the amputation, but in every case the groins should be freely opened and the entire chain of lymphatics should be removed. The first suggestion of this is found in Morrow's System of Genito- Urinary Diseases (1893), in which Horteloup (49) is quoted as follows: "In performing an amputation for epithelioma of the penis always remove the inguinal glands on both sides." In the American Textbook of Genito-Urinary Diseases and Syphilis (1898), Curtis (50) advises removing the inguinal glands en bloc. Removal of the inguinal nodes was first performed by MacCormac (53) in 1885. Historical Review of the Radical Operation for Carcinoma of the Penis: In 1875, before the Association of German Surgeons, Thiersch (51) of Leipzig first called attention to the method of splitting the scrotum in extensive epithelioma of the penis and removing the entire penis with transplantation of the urethra into the lower angle of the wound. In 1877 he amputated the penis and transplanted the urethra into the perineum through a stab wound. In 1882 Gould (52) described a method of radical ampu- tation of the penis by first splitting the scrotum and then separat- 258 W. E. LEIGHTON ing the corpus spongiosum from the body of the penis and dividing it and detaching the crura from the pubic bone with a periosteal ele- vator. The corpus spongiosum was then split on the under surface for one-half inch and sutured to the lower angle of the scrotum. In 1886 MacCormac (53) reported five cases of carcinoma of the penis treated by division of the scrotum with transplantation of the urethra into the perineum. In addition he removed the enlarged inguinal lymph nodes through a bilateral incision. He discussed at length the advantage of the perineal urethra. The radical operation with removal of the inguinal nodes was advocated by Martin (6) as early as 1895, although he reported a recurrence in two out of three cases. Nicoll (37) in 1909 described an elaborate bloc dissection of the inguinal lymph nodes together with the lymphatics on the stump of the penis, which was amputated close to the symphysis. Young (54) advocated a similar procedure, which is illustrated in his Textbook of Urology. The only advantage of this would appear to be the questionable one of leaving a rudimentary penis. Cunning- ham (38), Kretschmer (55), Eisendrath (56), and others remove the entire penis and insert the urethra into the perineum. The proper place for insertion of the urethra has been the subject of consider- able discussion. Objection to a perineal urethra is not well founded in our experience. Regardless of whether or not total ablation has been done, we have found the perineal urethra neither inconvenient nor a source of irritation if a wide opening has been provided. Splitting the urethra to avoid stricture when amputat- ing the penis was advocated by Teale (57) as early as 1878, and further emphasized by Gould (52) in 1882. In dealing with carcinoma of other tissues, it is an axiom to re- move a wide area about the growth, together with the lymphatic channels leading to the enlarged regional glands. For this reason the safest plan to avoid recurrence would seem to be removal of the penis in toto after the method of Gould (52), first removing the inguinal glands and fat, as described by Nicoll (37). Dissection is begun in the groin with the removal of all the structures en masse, without cutting across the intervening lymphatic channels. Emas- culation is advocated by some (Hadda, 47; Dax, 46; Falcone, 58; BBrard and Chalier, 59; Menocal, 60; Dabney, 61; Lepoutre, 62; Rivet, 63), notably by Alexander (64), as the scrotum is in the way of urination. Others condemn this procedure on account of the resulting mental depression. This last I think is exaggerated, for these patients come to operation, as a rule, in the later periods of CARCINOMA OF THE PENIS 259 life when the factor of internal secretion plays little part in the body physiology, and rather than being depressed by the loss of the , they are grateful to be relieved of the sloughing mass with which they have been afflicted. Scanga (65), to overcome the loss of the testicular secretions when emasculation is necessary, transplants one testis into the space between the transversalis fascia and the internal oblique. Bielitski (66), for the same reason, transplants the under the skin of the thigh. Operative Technic: To perform properly any operation, a knowl- edge of the anatomy of the part is necessary. In cancer surgery a comprehension of the lymphatic system is most essential, as me- tastasis takes place through the lymph channels. The lymphatics of the penis and scrotum empty into the superficial lymph glands, ten to twenty in number, in the superficial fascia below Poupart's ligament in Scarpa's triangle. The superior group is parallel to Poupart's ligament, while those of the inferior group are arranged vertically on either side of a line perpendicular to the center of the saphenous opening. The superficial glands anastornose through the cribriform fascia with the deep inguinal or deep femoral lym- phatic glands, two or three in number, which lie beneath the fascia lata. The upper one, known as the gland of Cloquet, or gland of Rosenmiiller, is in the crural canal and often projects into the pelvis, where it is in close contact with the internal retro-crural gland, a part of the external iliac chain. The deep inguinal glands may receive vessels directly from the glans penis or clitoris, and in turn send vessels to the external iliac tract. The lymphatics of the urethra empty, some in the deep group of inguinal glands, and others in the internal chain of the external iliac glands, while still others pass over the symphysis, between the recti muscles, to terminate directly in the external iliac gland or in the internal retro- crural gland. Since our first case of carcinoma of the penis (1906) we have, as a rule, performed a total amputation together with a dissection of the inguinal glands. The operation which we have advocated was described in the St. Louis Medical Review in 1910. The penis, with the cancer, is wrapped with gauze soaked in iodine and covered with a rubber dam which is fastened with a towel clip to the organ, to prevent displacement, or a condom may be used, as advocated by Lyons (67) and Cunningham (38). A curved incision is made from one anterior superior spine of the ilium along the fold of the groin across the pubis to meet a similar incision on the opposite 260 w. E. LEIGHTON side. The skin flap is reflected upward. The fat and fascia down to the external oblique aponeurosis are dissected downward to the region of Poupart's ligament. An incision encircles the penis through the skin and fascia of the scrotum. The lower skin flap over Scarpa's triangle is then reflected downward to expose its contents, Beginning at the outer side, the fat and fascia, with the enclosed lymphatic glands, are dissected from the deep fascia toward the inner side of the thigh. The deep femoral glands may form a mass continuous with the superficial glands and should be removed at the same time. It may be necessary to divide the fascia later and even Poupart's ligament in order to reach the gland of Cloquet, but often it is easily removed from the crural canal without division of the ligament. Several vessels will require ligation, as they penetrate the deep fascia from the femoral vessels, namely, the superficial epigastric, the superficial circumflex iliac, and the superficial external pudic arteries. The inguinal dissection having been completed, the patient is placed in the lithotomy position. The scrota1 contents are easily separated from the crura of the penis without bisecting the scrotum, but at times a division of the scrotum along the median raphe is expedient. The corpus spongiosum is separated from the body of the penis and divided anterior to the bulb at the proper length for insertion in the perineum. A sound is then placed in the bladder to facilitate further freeing of the urethra. The suspensory ligament is divided and the dorsal vessels are clamped. The crura are separated from the rami of the ischii with a raspatory or per- iosteal elevator and each crus clamped with Ochsner forceps and divided. The entire penis, with attached fat, fascia, and lymph glands, is then removed in toto. All vessels are then ligated. The crura are transfixed with needle and catgut. The urethra is inserted in the perineum through a stab wound at the base of the scrotum or at the lower angle if the scrotum has been bisected. The urethra should be split in the median line beneath to prevent a stricture, and sutured to the skin margins with fine silk. A self- retaining catheter is inserted into the bladder. The inguinal wound is carefully closed. Silkworm-gut sutures are employed and the skin carefully approximated. Rubber dam is employed for drainage, being inserted sometimes in each angle of the wound and again through a stab wound at the apex of Scarpa's triangle on each side. A large dressing is employed to compress the skin over the groin and obliterate dead space. Necrosis of the edges CARCINOMA OF THE PENIS 261 of the lower flap in the groin often takes place, but does no harm, as a secondary suture or adhesive straps may be employed. Com- plete healing usually takes place in from two to six weeks. Conclusion: From the analysis of the following cases and a careful review of the literature on the subject, it would seem justi- fiable to conclude that the more radical the operation the better the end-result.

CASE1 (History 50). H. D., aged forty, married, an American, was admitted March 19, 1906, with a history of a wart on the glans penis for five months. He had had gonorrhea some years previously and three years ago had been circumcised. Examination showed one-half the penis destroyed, and enlargement of the inguinal nodes on the right side. On March 28 a total emasculation was performed. The pathological diag- nosis was squamous-cell carcinoma, grade I, with hyperplasia of lymph nodes. There has been no recurrence, and the patient reported well in May 1931. CASE2 (History 66). C. W. N., aged fifty-nine, married, an American, was admitted June 8, 1906, with a history of a wart on the glans near the urethra for two years. He denied venereal infection. Examination showed the penis entirely gone, a large ulcer in each groin, and both testicles enlarged. The patient had been operated upon previously. He received no treatment, and his subsequent history is unknown. CASE3 (History 118). W. G. N., aged fifty-eight, married, Irish, was admitted June 9, 1907, with a history of an excoriation following inter- course. He denied venereal disease. Examination showed a growth on the left side of the frenum. There was no glandular enlargement. Treat- ment was refused, and the subsequent history is unknown. CASE 4 (History 275). G. L., aged forty-seven, an American, was admitted Nov. 22, 1907, with a history of a lump on the frenum, of two years' duration. He had been circumcised but the wound did not heal. He denied venereal disease. Examination showed the frenum and the corona obliterated by an ulcer. Treatment was refused, and the subse- quent history is unknown. CASE5 (History 283). J. E. B., aged sixty, a German, was admitted Dec. 9, 1907, with a history of a wart on the dorsum of the prepuce for eighteen months. Examination showed a papillomatous mass on the dorsum of the prepuce with no inguinal enlargement. Treatment was refused, and the subsequent history is unknown. CASE6 (History 468). W. B., aged fifty-seven, married, an American, was admitted Sept. 10, 1908, with a history of an ulcer on the glans penis for nine months. Examination showed complete destruction of the penis, involvement of the scrotum in the ulceration, and abscess formation in the right inguinal nodes. On Sept. 11 a total emasculation was performed. The pathological diagnosis was squamous-cell carcinoma, grade 111, with 262 W. E. LEIGHTON metastasis to lymph nodes. Death occurred a few days later, from pneumonia. CASE7 (History 474). J. M. B., aged thirty-six, an American, was admitted Sept. 18, 1908, with a history of a pimple on the corona for two years. He had been circumcised for venereal warts, but the wound had never healed. Examination showed tjhe penis entirely gone and granular involvement in both groins. Total emasculation was performed. The pathological diagnosis was squamous-cell carcinoma, grade IV, in lymph nodes. The patient dropped dead in October, but the cause was unknown. CASE8 (History 541). H. H., aged fifty-five, married, a Hollander, was admitted Dec. 17, 1908, with a history of a pimple of the glans of two years' duration. This had been excised, but without improvement, and caustics and pastes had been applied, resulting in complete destruc- tion of the penis. The scr~t~umand inguinal nodes were involved. A

total emasculation was performed Dec. 21. The pathological diagnosis was squamous-cell carcinoma, grade 11, with hyperplasia of lymph nodes. The patient was alive and well several years later, but his present status is unknown. CASE9 (History 704). A. L., aged seventy-three, married, a German, was admitted Aug. 18, 1909. He had had an ulcer for six years, the origin of which was uncertain. There was phimosis, and the entire anterior third of the penis was involved in a papillomatous tumor. Treatment was refused, and the subsequent history is unknown. This patient's wife had died twenty years before of carcinoma of the uterus. CASE10 (History 714; 22962). G. W. B., aged fifty-eight, married, an American, was admitted Aug. 31,1909, with a history of phimosis followed by irritation and a sore on the glans penis. Examination showed a nodu- lar mass on the penis. The scrotum was edematous, and the inguinal nodes enlarged. A total emasculation was performed Sept. 3. The pathological diagnosis was squamous-cell carcinoma, grade 11, with hyper- CARCINOMA OF THE PENIS 263 plasia of lymph nodes. The patient lived eighteen years, with no recur- rence of the carcinoma, and died of cerebral hemorrhage. CASE 11 (History 765). L. H. I<., aged seventy-two, married, a German, was admitted Nov. 6, 1909, with a history of laceration of the prepuce in boyhood. A year and a half before admission an ulcer had appeared on this scar. Examination showed an ulcer of the glans penis at the corona. Biopsy showed a squamous-cell carcinoma, grade 11. Further treatment was refused, and the subsequent history is unknown. CASE12 (History 767). C. T. B., aged fifty, an American, was ad- mitted Nov. 13, 1909. While riding horseback, he had injured the penis between the pummel of the saddle and a six-shooter. A growth developed

and a partial amputlation had been performed. This was unsuccessful, and the ulcer returned. Examination showed the penis gone, the scrotum involved in a hard mass, and the inguinal glands on both sides enlarged. Treatment was refused, and the subsequent history is unknown. CASE 13 (History 776). M. T., aged forty-eight, an American, was admitted Nov. 27, 1909. He had been circumcised for a wart on the prepuce, but this treatment had proved ineffectual, and the growth had been excised. This also was of no avail, and pastes were applied. Examinat,ion showed a cauliflower growth on the stump of the penis. 264 W. E. LEIGHTON

The patient refused treatment, and the subsequent history is unknown. CASE 14 (History 1075). W. C., aged seventy-one, married, a German, was admitted March 3, 1911, with a history of a wart on the glans penis, followed by an ulceration of the prepuce. Salves had been applied and later an amputation of the penis had been performed, but the growth recurred. Examination showed an ulceration at the line of incision, with no glandular involvement in the groin. On April 2 a total emasculation was done. The pathological diagnosis was squamous-cell carcinoma, grade 11, with metastasis. Recurrence followed, from which the patient died on Jan. 8, 1912. CASE15 (History 1178). C. H., aged thirty-six, married, a German, was admitted Aug. 17, 1911. He had been circumcised in 1897, but the wound had never healed properly. The penis had been amputated for a growth in 1909. Examination showed the penis gone, an ulcer in the right groin, the left inguinal glands enlarged, and the scrotum edematous. A total emasculation was performed Aug. 22. The pathological dia,gnosis was squamous-cell carcinoma, grade 111. The patient died Aug. 28. CASE16 (History 1187). L. H., aged seventy-two, married, an Ameri- can, was admitted Sept. 1, 1911, with a history of a wart on the prepuce for two years. Examination showed a growth the size of a dime on the prepuce and enlargement of the inguinal glands. A total amputation of the penis with bilateral dissection of the groins was performed Sept. 6. The pathologist reported a squamous-cell carcinoma, grade 11. There had been no recurrence of the cancer up to the time of the patient's death from "flu," Jan. 21, 1917. CASE17 (History 1382). J. H., aged sixty-five, married, an American, was admitted Aug. 5, 1912, with a history of a nodule on the dorsum of the penis for four years. Examination showed a tumor on the dorsal aspect of the penis and enlarged inguinal nodes. On Aug. 6 a total emasculation was performed. The pathological report was squamous-cell carcinoma, grade 11. The patient is dead, but the date and cause are unknown. CASE 18 (History 1458). J. S., aged forty-two, an American, was admitted Dec. 4, 1912, with a history of a phimosis and adherent prepuce, and an induration of two years' standing, which had perforated the pre- puce a year ago. Examination showed the penis gone. The patient refused treatment, and died of carcinoma Feb. 6, 1913. CASE 19 (History 1481). E. P., an American, was admitted Jan. 2, 1913, wit,h a history of an irritation at the base of the penis and scrotum of ten months' duration, for which salves had been applied. Examination showed the penis to be edematous, with ulceration of the scrotum and bilateral enlargement of the inguinal nodes. Palliative treatment was administered. Death ensued Jan. 29, 1913. CASE 20 (History 1718). C. W. D., aged fifty-eight, married, an American, was admitted Nov. 25, 1913, giving a history of phimosis, for which he had been circumcised twelve or fourteen years before, following which an ulcer formed, which had never healed. He had gonorrhea. Examination showed an ulcer on the glans penis. A partial amputation of the penis with dissection of the inguinal region was performed Nov. 29. CARCINOMA OF THE PENIS 265

The pathological diagnosis was squamous-cell carcinoma, grade 11, with hyperplasia of lymph nodes. The subsequent history is unknown. CASE21 (History 13262). F. L., aged fifty-six, married, an American, was admitted Aug. 12, 1914, with a history of warts on the glans penis. Examination showed an ulcer the size of a quarter, on the glans. There was an enlarged left inguinal node; the right inguinal nodes had been re- moved. The patient refused treatment, and the subsequent history is unknown. CASE 22 (History 18167). A. L. A,, aged sixty-seven, married, an American, was admitted Nov. 16, 1917, with a history of a sore on the dorsum of the penis, above the glans. He admitted syphilis at the age of twenty-four, and a gonorrheal infection. On Jan. 22, 1918, a total emasculation was performed. The pathological diagnosis was squamous- cell carcinoma, grade 11, with hyperplasia of lymph nodes. There had been no recurrence of the carcinoma at the time of the patient's death, of pneumonia, in 1923. CASE23 (History 18278). N. H. B., aged thirty, married, an Ameri- can, was admitted Dec. 27, 1917. He gave a history of syphilis and the Wassermann reaction was four plus. An amputation of the penis for an ulcer had been done elsewhere. Examination showed an ulcer in the scar of amputation. A biopsy had been done elsewhere and a report of carci- noma made. Radium treatment was given, but the patient died May 25, 1918. CASE24 (History 19326). W. W., aged fifty-three, single, an Ameri- can, was admitted Sept. 30, 1918, with a history of having had a sore near the meatus for two and a half years. Twenty years previously he had had gonorrhea, from which a stricture developed. Examination showed an erosion of the glans but no inguinal involvement. A partial amputation with dissection of the inguinal glands was performed Oct. 12. The pathological report was squamous-cell carcinoma, grade 111, with hyperplasia of lymph nodes. The subsequent history of the case is unknown. CASE25 (History 19361). A. S., aged sixty-nine, married, a German, was admitted Oct. 10, 1918, with a history of having had a lump on the glans penis for one year. Examination showed a tumor mass on the frenum and bilateral enlargement of the inguinal glands. The patient refused treatment. He died in December 1918 from "flu" and carcinoma. CASE26 (History 19665). D. W., aged fifty-six, single, an American, was admitted Jan. 29, 1919. No history was taken, and no physical examination made. A partial amputation with removal of the inguinal glands was performed on Feb. 5. Squamous-cell carcinoma, grade 11, with glandular involvement was reported by the pathologist. The sub- sequent history is unknown. CASE 27 (History 19970). J. H., aged forty-three, married, an American, was admitted April 23, 1919. Examination showed a huge ulcerating cauliflower mass of the glans and shaft. The inguinal glands were enlarged, and the entire penis and scrotum were edematous. The patient refused treatment, and the subsequent history is unknown. 266 W. E. LEIGHTON

CASE28 (History 21395). F. C., aged forty-one, married, an Ameri- can, was admitted March 3, 1920, with a history of a sore on the dorsum of the glans penis of six months' duration. He had had gonorrhea at twenty-one, and a subsequent attack of gonorrhea for which he was treated by a dorsal incision. Examination showed an ulcerating edema- tous mass involving the entire penis, with bilateral inguinal enlargement. The biopsy report was squamous-cell carcinoma, grade 11. The present condition is unknown. CASE29 (History 22468). H. P., aged fifty-five, single, an American, was admitted Nov. 9, 1920, with a history of an abscess on the glans penis of five months' duration. He was treated for syphilis, but without improvement. Examination showed a cauliflower mass involving the penis and scrotum and extending to the pubis. On Nov. 19, a complete emasculation was performed. The pathological diagnosis was squamous- cell carcinoma, grade 11, with hyperplasia of the lymph nodes. The patient is alive and well to-day (1931). CASE 30 (History 22696). F. J., aged thirty-seven, married, an American, was admitted Jan. 20, 1921, with a three years' history of phimosis with irritation, for which he was circumcised. He had had gonorrhea. Examination showed the glans eroded and the inguinal glands enlarged. He refused treatment. CASE31 (History 23129). S. P.: aged sixty-nine, married, an Ameri- can, was admitt>edApril 13, 1921. He gave a history of a pigmented wart on t,he dorsum of the penis, which had been caut,erized. Venereal infec- tion was denied. Examination showed an indurated nodule on the glans penis along the shaft, with bilateral inguinal enlargement. The patient refused treatment, and the subsequent history is not known. CASE32 (History 23272). S. R. S., fifty-six, married, an American, was admitted Aug. 17, 1921, with a history of a pimple on the corona of the glans dating back six years, for which a paste was applied. Examina- tion showed the entire penis gone and the scrotum edematous. The patient refused treatment, and the subsequent history of the case is unknown. CASE33 (Hist,ory 23907). J. H., aged sixty-two, married, an Ameri- can, was admitted Sept. 10, 1921, with a history of having had a wart on the prepuce for seven months. He denied venereal infection. Examina- tion showed a verrucous growth on the prepuce and glans penis and bi- lateral enlargement of the inguinal glands. The patient refused treat- ment. He has since died, but the cause of death is unknown. CASE34 (History 23929). A. G., aged fifty-eight, married, a German, was admitted Sept. 16, 1921, with a history of having had a sore on the prepuce nine years before. This had been excised elsewhere but the wound had never healed. Venereal infection was denied. Examination showed a cauliflower mass on the glans penis. Total amputation of the penis with a bilateral dissection of the inguinal glands was performed March 17, 1922. The pathological diagnosis was squamous-cell carci- noma, grade I, with marked hyperplasia of lymph nodes. The patient is alive and well at the present time (1931). CARCINOMA OF THE PENIS 267

CASE35 (History 23979). J. R., aged thirty-one, single, an American, was admitted Sept. 26, 1921, with a history of having had a pimple on the corona of the glans for seven months. He had been circumcised eight years previously, had been treated for syphilis, and had had gonorrhea twice. Examination showed a cauliflower mass on the glans penis with bilateral enlargement of the inguinal nodes. A total amputation with bilateral dissection of the inguinal region was done Oct. 19, 1921. The pathological diagnosis was squamous-cell carcinoma, grade 11, with metastasis to the lymph nodes. The patient is alive and well at the present time.

Fro. 4. CASE 35: CARCINOMAOF PENIB:A. BEFOREOPERATION. B. AFTER TOTALAMPUTATION WITH BILATERALREMOVAL OF INGUINALLYMPH NODES. C. PERINEALURETHRA.

CASE 36 (History 24559). J. M. E., aged sixty-one, married, an American, was admitted Jan. 4, 1922, with a history of an induration of the shaft of the penis behind the glans for six years. He had had gonor- rhea in 1904. Examination showed a nodular tumor of the glans penis with no inguinal enlargement. Radium was applied. The subsequent history is unknown. CASE 37 (History 24959). C. L., aged forty-nine, married, an American, was admitted March 24,1922, with a history of phimosis and a pimple on the corona, of one year's duration. He denied venereal infec- tion. Examination showed a nodular glans penis covered by the prepuce and bilateral inguinal enlargement with the skin adherent on the left side. Total amputation with a bilateral inguinal dissection was performed March 29. Pathological diagnosis showed a squamous-cell carcinoma, grade 111, with metastasis to the lymph nodes. The patient died Nov. 17, 1922, with metastases. CASE38 (History 26189). J. W., aged forty-six, single, an American, was admitted Dec. 5, 1922, with a history of having injured the penis on the pummel of a saddle. A growth appeared, and he was circumcised. The pathological report was carcinoma. Recurrence had taken place in 268 W. E. LEIGHTON the inguinal nodes, which were dissected, and x-ray treatments were given. Examination showed an edematous penis with an enlarged left inguinal node. The patient refused treatment, and the subsequent history is un- known. CASE39 (History 26465). 0. B., aged thirty-one, single, an Ameri- can, was admitted Feb. 12, 1923, with a history of circumcision for phi- mosis in 1922. The wound had never healed. The patient had had gonorrhea in 1910, and had a four plus Wassermann. Examination showed a cauliflower mass about the glans penis with bilateral enlargement of the inguinal nodes. A biopsy was performed, and the pathologist re- ported a squamous-cell carcinoma, grade 11. Operation was refused by the patient, and the subsequent history is unknown. CASE40 (History 27325). R. V., aged fifty-one, married, an Ameri- can, colored, was admitted July 17, 1923. He had had an amputation of the penis, and examination showed a recurrence in the scar with enlarged inguinal nodes. He refused treatment, and the subsequent history is unknown. CASE41 (History 27258). C. L., aged fifty-two, married, an Ameri- can, colored, was admitted July 20, 1923. He had had a sore on the glans for thirteen years, for which an amputation was performed in 1913. There had been a recurrence of the disease four months before admission. Examination showed amputation at about the middle third. There was no inguinal enlargement, but the left testicle was enlarged. The patient was not treated, and the subsequent history is unknown. CASE 42 (History 27541). C. J. L., aged sixty-eight, married, an American, was admitted Sept. 3, 1923, with a history of a sore on the penis for which a partial amputation had been performed in 1923, fol- lowed by a recurrence. Examination showed the penis amputated at the base, and massive recurrence in the right groin. The patient refused treatment, and the subsequent history is unknown. CASE 43 (History 28760). M. T., aged seventy-seven, single, an American, was admitted March 31, 1924, with a growth on the glans penis. He admitted contracting a venereal disease many years before. Examination showed phimosis with a growth on the glans penis. There was no inguinal enlargement. The patient refused treatment, and the subsequent history is unknown. CASE44 (History 29317). N. S., aged sixty-three, married, an Ameri- can, was admitted July 7, 1924, with a history of phimosis and a growth on the frenum, for which he had been circumcised in 1923. Examination showed a new growth at the frenum. Amputation with a bilateral in- guinal dissection was performed July 11, 1924. The pathological report was squamous-cell carcinoma, grade 11, with hyperplasia of lymph nodes. The patient was alive and well Dec. 24, 1930. CASE45 (History 29595). J. F., single, an American, was admitted Aug. 17, 1924, with a history of a small growth on the glans penis of eighteen months' duration. Examination showed an extensive mass in- volving the penis and scrotum. A cautery excision of thc area was per- formed, followed by severe shock. The pathological report was squa- mous-cell carcinoma, grade I. Death occurred the day after operation, CARCINOMA OF THE PENIS 269

CASE46 (History 29912). W. C., aged fifty-eight, married, an Ameri- can, colored, was admitted Oct. 8, 1924, with a history of a sort: on the penis of eighteen months' duration, preceded by a chancre of about the same duration. Examination showed the penis entirely gone, bilateral inguinal enlargement, and bilateral enlargement of the testicles. The patient refused treatment, and the subsequent history is unknown. CASE 47 (History 30809). M. S. W., aged fifty-seven, married, an American, was admitted March 3, 1925, with a growth on the glans penis of five months' duration, and a lump in the groin of two months' duration. Venereal disease was denied. Examination showed the penis edematous with bilateral inguinal enlargement. A total amputation with bilateral inguinal dissection was performed March 7. The pathological report was squamous-cell carcinoma, grade 11, with hyperplasia of the lymph nodes. The patient was alive and well in 1929. CASE48 (History 33215). J. M., an American, colored, was admitted March 25, 1926, with a history of having had a blister on the prepuce for three years. He had been circumcised elsewhere and a pathological re- port of carcinoma had been made. A paste had been applied, but the growth recurred. Examination showed an ulcer on the glans penis with no inguinal enlargement. The patient was not treated, and the subse- quent history is unknown. CASE49 (History 33449). J. R., aged forty-two, married, an Ameri- can, was admitted April 30, 1926, with a history of having had a pimple on the corona since January. He had had gonorrhea nine years before. Examination showed an ulcer on the corona and bilateral inguinal enlarge- ment. Biopsy was performed and the pathologist reported squamous- cell carcinoma, grade 11. The patient was reported well June 8, 1931. CASE 50 (History 34182). J. D., aged forty-four, married, an American, was admitted Aug. 23, 1926, with a history of having had an ulcer on the glans penis for six months. Examination showed the entire glans sloughing. The patient refused treatment, and the subsequent history is unknown. CASE 51 (History 34787). N. F., aged seventy-five, married, an American, was admitted Nov. 26, 1926, with an ulcer on the prepuce of one year's duration. Examination showed phimosis, with a hard, nodular glans penis. There were no inguinal enlargements. A partial amputa- tion was performed Oct. 12, 1927. The pathological report was squa- mous-cell carcinoma, grade 11. Death occurred Nov. 10, 1928, cause unknown. There had been no recurrence of the carcinoma. CASE 52 (History 35601). W. H. S., aged forty-eight, married, an American, was admitted March 16, 1927, with a history of phimosis with itching and bleeding for twelve months. Circumcision had been per- formed. An abscess in the right groin had been incised eighteen weeks previously, and an abscess in the left groin twelve weeks previously. Examination showed the entire penis swollen and the anterior two-thirds of the dorsum destroyed. A total emasculation was performed with a bilateral inguinal dissection, May 11. The pathological report was squamous-cell carcinoma, grade 11, with metastasis to the lymph nodes. The patient was alive and well Nov. 10, 1930. 270 W. E. LEIGHTON

CASE53 (History 36109). W. I<., aged fifty, married, an American, was admitted May 15, 1927, with a history of a warty pimple on the glans penis for fourteen months. He had been treated with 606 and x-ray. Examination showed the entire glans destroyed by a cauliflower mass which involved the scrotum and testicle. The inguinal nodes were small and hard. A total emasculation with a bilateral inguinal dissection was performed May 25. The pathological report was squamous-cell carci- noma, grade 11, with hyperplasia of the lymph nodes. The patient has not been heard from since 1927. CASE54 (History 36920). J. 0.)aged sixty-three, mikrried, was ad- mitted Sept. 10, 1927, with a lump under the prepuce. Examination showed phimosis, a hard edematous prepuce and glans penis, and bi- lateral enlargement of the inguinal nodes. A total emasculation with inguinal dissection was performed Sept. 17. The pathological report was squamous-cell carcinoma, grade 11, with hyperplasia of lymph nodes. The patient is alive and well at the present time. CASE55 (History 37074). J. H., aged fifty-two, single, an American, was admitted Sept. 30, 1927, with a history of itching of the glans penis and phimosis. Circumcision had been performed six months before and a report of carcinorna made. Examination showed a nodular tumor of the glans penis with no inguinal chnlargement. A partial amputation with bilateral inguinal dissection was performed Oct. 8. The pathological report was squamous-cell carcinoma, grade I, with hyperplasia of lymph nodes. The patient was reported well in May 1931. CASE 56 (History 37651). C. W. C., aged fifty-four, married, an American, was admitted Jan. 20, 1928. He had had a pimple on the right side of the prepuce for eighteen months, and gave a history of syphilis sixteen years before. Fxamination showed the entire penis in- volved to the peno-scrota1 junction. There was a palpable left inguinal node. The right nodes were not enlarged. The patient refused treat- ment and died the following October from cancer. CASE57 (History 38820). A. R., aged fifty-nine, married, Swiss, was admitted June 4, 1928, with a history of syphilis in 1894, venereal warts for ten years, and phimosis for eleven years. For the phimosis a dorsal slit had been made, and biopsy showed carcinoma. Exanlination showed involvement of onc-half of the glans penis and bilateral inguinal enlarge- ment. Operation was done elsewhere. CASE 58 (History 39026). A. F., aged seventy-one, married, an American, was admitted June 27, 1928, with a history of a red lump on the prepuce near the frenum. Examination showed involvement of the glans penis and bilateral inguinal enlargement. A total amputation with bilateral inguinal dissection was performed Aug. 18. The pathological report was squamous-cell carcinoma, grade 11, with metastasis to the lymph nodes. The patient was reported alive and well in 1931. CASE 59 (History 40286). C. R., aged seventy-five, married, an American, was admitted Dcc. 17, 1928, with a history of having had an ulcer on the penis for two months. He denied venereal disease. Exam- ination showed a granular mass on the dorsum of the penis with bilateral CARCINOMA OF THE PENIS 271 inguinal enlargement. A total emasculation with bilateral dissection of the inguinal glands was performed Jan. 22, 1929. The diagnosis was squamous-cell carcinoma, grade 111, with metastasis to the lymph nodes. Death occurred Jan. 28 from pneumonia. CASE60 (History 40934). J. T., aged seventy, an American, was ad- mitted March 19, 1929, with a history of having had a lump on the glans penis for a year. E~aminat~ionshowed a cauliflower lesion on the left side of the glans without palpable inguinal nodes. A partial amputation with bilateral inguinal dissection was performed March 30. The patho- logical report was squamous-cell carcinoma, grade 11, with hyperplasia of lymph nodes. The patient was alive and well May 16, 1931.

FIG. 5. CASE6": CARCINOMAOF THE URETHRA:URETHRAL FISTULA INVOLV~NG SCHOTCJM AND LEFT TESTICLE

CASE61 (History 41640). J. D., aged forty-six, married, an American, was admitted June 13, 1929, with an ulcer on the prepuce of a year's duration. He had been circumcised, but the wound did not heal. Examination showed an ulcerating mass on the glans penis and bilateral inguinal enlargement with an infection on the left side. The case was judged inoperable and x-ray treatment was given. Death occurred Oct. 15. CASE62. H. G., aged thirty-three, married, an American, was ad- mitted in July 1929, with a history of bleeding from the urethra for a year, and a nodular condition at the peno-scrota1 junction. He com- plained of kinking of the penis on erection. Examination showed a fistula on the left side of the shaft of the penis at the scrota1 junction, in the center of a hard mass which involved the left testicle. There was 2 7 272 W. E. LEIGHTON bilateral inguinal enlargement. A total amputation with removal of the left testicle and a bilateral inguinal dissection was performed in July 1929. The pathological diagnosis was squamous-cell carcinoma. The patient is alive and well with no recurrence. CASE63 (History 44194). G. W., aged sixty, married, an American, was admitted May 28, 1930, with a history of a lump on the glans penis of five months' duration with bleeding. Examination showed induration of the glans near the urethra. Biopsy showed squamous-cell carcinoma, grade 11. The patient refused further treatment. The present condi- tion is unknown. CASE64 (History 44472). G. L., aged fifty-nine, married, a German, was admitted Aug. 8, 1930, with a history of a swelling on the glans penis and phimosjs, for which circumcision had been done. Examination

showed a granulomatous mass involving the glans, with no inguinal en- largement. A partial amputation was done Sept. 20. The pathological report was squamous-cell carcinoma, grade 11. The patient was alive and well May 13, 1931. CASE 65 (History 46400). L. V., aged sixty-four, married, an American, was admitted Feb. 20, 1931, with a history of having had an ulcer on the prepuce for nineteen months, for which a paste had been applied six months ago. A total amputation with a bilateral inguinal dis- section was performed March 11. The pathological report was squamous- cell carcinoma, grade 111, with hyperplasia of lymph nodes. The patient died March 31 in delirium. CASE 66 (History 46428). R. B., aged sixty-three, married, an American, was admitted Feb. 23, 1931, with a history of a lesion on the CARCINOMA OF THE PENIS 273 glans for seven years. He had had phimosis. Examination showed a tumor mass of the glans 39 x 29 cm., a left inguinal mass 6 x 7 cm., and a hard node in the right inguinal region. There was also evidence of metas- tasis in the lung. X-ray therapy was given. Death occurred June 29, 1931. CASE 67 (History 47095). D. Y., aged seventy-seven, married, an American, was admitted May 5,1931, with a history of a sore on the glans penis for four or five years, for which salves had been applied two years previously. He denied venereal disease. Examination showed an ulcera- tion of the glans and a fissure, but no palpable inguinal enlargement. A total amputation without gland dissection was performed. The patho- logical report was squamous-cell carcinoma, grade I. The patient is alive and well at the t.ime of this report. Summary: A summary of the 67 cases reveals that 24 patients refused operation or for some other reason were not treated, while 43 received treatment. Of the patients refusing treatment, 3 are known to have died of cancer and one of an unknown cause; 19 have not been heard from, and one was operated on elsewhere. Ten patients had had a partial amputation before coming to the clinic, and in all of these recurrence of the cancer had taken place. Of the forty-three patients receiving treatment, 4 received x-ray or radium. Of these, 3 died and one is untraced. Five biopsies showed carcinoma. In one of these cases (49) amputation was performed elsewhere and the patient was reported well a year later. The condition of the other four is unknown. (a) Thirty-four patients were operated upon as follows: Three partial amputations were done. Of the 3 patients, 2 died, one of recurrence, and one of cancer of the face. One patient is living one year following operation. (b) Five partial amputations with inguinal dissection were done. Three of these patients cannot be traced. One is living four years following operation, and one is living one year following operation. (c) One total amputation was done and the patient is living six months following operation. (d) Eleven total amputations with inguinal dissection were done. Of these patients, 3 died: one of acute delirium, one of recurrence eight months later, and one of "flu" without recurrence, six years later. Eight are living as follows: two two years after operation; two three years after operation; one four years after operation; one six years after operation; one ten and one eleven years after oper- ation. (e) Fourteen total emasculations were done. Of these patients two have not been heard from. Nine died: one of recurrence 274 W. E. LEIGHTON within a year; two within a week after operation; two of pneumonia a few days after operation; one of pneumonia six years after opera- tion; one of apoplexy eighteen years after operation. In two cases the cause of death was unknown. Three patients are still living, four, eleven and twenty-five years after operation. Of the 34 patients operated upon, 5 have not been heard from. Fourteen died, 2 postoperatively and 3 of recurrence; 9 lived from one month to eighteen years, dying of other causes than cancer. Nineteen are living from six months to twenty-five years. A study of the pathological specimens with respect to the ma- lignancy of the cancer according to Brodersl cla.ssification revealed that 5 were in group I; 19 were in group 11; 6 were in group 111; and one was in group IV. There were only three deaths from recurrence in the series. In each of these there was a metastasis in the inguinal lymph nodes at the time of operation. In one there was ,z group I1 tumor and in one a group 111 tumor. On the other hand, five patients with group I1 tumors with inguinal metastases at the time of operation are still alive and free from recurrence.

REFERENCES 1. HUTCHINSON,J.: Lancet 1: 1071, 1899. 2. PAGET:Quoted by Sheild (9). 3. BILLROTH:Quoted by Sheild (9). 4. BARNEY,J. D. : Ann. Surg. 46: 890, 1907. 5. SAWTELLE,H. W.: New York M. J. 57: 527, 1893. 6. MARTIN,E.: J. Cutan. & Gen.-Urin. Dis. 13: 95, 1895. 7. GREENSFELDER,L. A,: Internat. J. Surg. 27: 163, 1914. 8. PACHA,D.: Quoted by Krctschmer (55)) p. 272. 9. SHEILD,A. M.: Lancet 1: 75, 1900. 10. GREEN,T. M.: Charlotte M. J. 30: 182, 1907. 11. DEMARQUAY:Quoted by Martin (6), p. 98. 12. THOMSEN,A.: Brit. M. J. 2: 1841, 1897. 13. KAUFMANN:Quoted by Barney (4), p. 891. 14. KRONLEIN:Quoted by Martin (6), p. 97. 15. RODMAN,W. L. : Ann. S~trg.35: 655, 1902. 16. WHITEFORD,C. H.: Lancet 2: 1304, 1920. 17. DORMANNS:J. A. M. A. 93: 1516, 1929. 18. MACFARLAND:Quoted by Martin (6), p. 97. 19. BERNSTIEN,J.: Brit. Ail. J. 2: 986, 1927. 20. BRUCE:Quoted by Martin (6), p. 98. 21. OUTLAND,J. H.: Interstate M. J. 22: 1097, 1915. 22. CORNIL:Quoted by Martin (6))p. 97. CARCINOMA OF THE PENIS

23. FRANK,I..: Louisville Mo. J. M. & 9. 9: 252, 1902-03. 24. CREITE:Quoted by Kretschmer (55), p. 272. 25. FREYER:Quoted by Dabney (61), p. 444. 26. RALPH:Quoted by Kretschmer (55), p. 272. 27. FIELEWICZ:Quoted by Kretschmer (55)) p. 272. 28. THOMAS,B. A. : Ann. Surg. 63 : 755, 1916. 29. McCoy, S. C.: Urol. & Cutan. Rev. 20: 481, 1916. 30. SHIVERS,C. H. de T.: J. A. M. A. 89: 446, 1927. 31. HOWZE,C. P. : Virginia M. Month. 51 : 550, 1924. 32. K~TTNER,H. P.: Handbuch der praktischen Chirurgie, F. Enke, Stuttgart, 1921-23, vol. 5, p. 649. 33. PELAGATTI,M.: Dermat. Stud. 20: 318, 1910. 34. ORAISON,J.: Gaz. hebd. d. sc. m6d. de Bordeaux 33: 100, 1912. 35. BERGERLT:Arch. urol. clin. de Necker. 1: 344, 1914. 36. GUSSENBAUER:Quoted by Martin (6)) p. 99. 37. NICOLL,J. H : Ann. Surg. 49: 240, 1909. 38. CUNNINGHAM,J. H.: Surg. Gynec. & Obst. 19: 693, 1914. 39. Gray's Anatomy, Lea & Febiger, Philadelphia. 40. M~NETRIER:Bull. et m6m. Soc. mkd. de hap. de Paris 40: 1787, 1916. 41. TAYLOR,R. W.: J. Cutan. & Gen.-Urin. Dis. 7: 241, 1889. 42. JACKSON,V.: Lancet 2: 370, 1887. 43. BOONE,H. W.: Lancet 2: 658, 1887. 44. GREEN,T. M.: Ann. Surg. 60: 388, 1914. 45. FISCHER,H.: Ann. Surg. 64: 719, 1916. 46. DAX:Deutsche Ztschr. f. Chir. 172: 398, 1922. 47. HADDA,S.: Arch. f. klin. Chir. 117: 244, 1921. 48. ANNANDALE,T. : Lancet 2: 829, 1874. 49. HORTELOUP:Quoted by P. A. Morrow in System of Genito-Urinary Diseases, Syphilology and Dermatology, D. Appleton & Co., New York, 1805, vol. 1, p. 60. 50. CURTIS,B. F. : American Text-Book of Genito-Urinary Diseases and Syphilis, Bangs & Hardaway, Philadelphia, 1898. 51. THIERSCH:Quoted by Wedemeyer, Arch. f. Heilkunde 18: 562, 1877; also quoted by Gould (52) and MacCormac (53). 52. GOULD,A. P.: Lancet 1: 821, 1882. 53. MACCORMAC,W.: Brit. M. J. 1: 343, 1886. 54. YOUNG,H. H.: Practice of Urology, W. B. Saunders Co., Philadel- phia, 1926, vol. 1, p. 719. 55. KRETSCHMER,H. L.: Surg. Clinics, Chicago 2: 269, 1918. 56. EISENDRATH,D. N., AND ROLNICK,H. C : Text-book of Urology for Students and Practitioners, J. B. Lippincott, Philadelphia, 1928, p. 786. 57. TEALE,T. P.: Quoted by Van Buren and Keyes in: A Practical Treatise on the Surgical Diseases of the Genito-Urinary Organs in- cluding Syphilis, D. Appleton & Co., New York, 1879, p. 9. 58. FALCONE,R.: Clin. Chir., Milano 18: 2214, 1910. 59. BERARD,L., AND CHALIER,A.: Lyon m6d. 113: 700, 1909. 276 W. E. LEIGHTON

60. MENOCAL,It.: Rev. de mkd. y cir. de la Habana 14: 718, 1909. 61. DABNEY,M. Y. : Southern M. J. 11 : 443, 1918. 62. LEPOUTRF:,C.: Paris chir. 4: 26, 1912. 63. RIVET:Gaz. mbd. de Nantes 37: 368, 1914. 64. ALEXANDER,S.: Ann. Surg. 48: 450, 1908. 65. SCANGA,A.: Studium 17: 328, 1927. 66. BIELITSKI,I. M. : Khirurgia 32: 824, 1912. 67. LYONS,0.: Denver Med. Times 32: 324, 1912-13.