ON CYSTS OF THE PREPUCE AND RAPHE, WITH AN ILLUSTRATIVE CASE* By GEO. HENRY EDINGTON, M.D., M.R.C.S. Eng., Surgeon to the Central Dispensary, and Extra Surgeon to the Dispensary of the Western Infirmary, Glasgow. Cysts of the prepuce receive but scant notice in the general text-books of surgery, and it is partly on this account that I now record the following case. I have been led, however, to do so also from the fact that recently cysts in this region have been engaging the minds of some writers in connection with their probable origin in a congenital abnormality. I shall first notice a case which has come under my own observation, and then refer to the literature of the subject. Willie D., aged 1 year, was brought to the Central Dispensary on 27th October, 1897, on account of his being the subject of " phimosis, accompanied by a small lump" at the distal extremity of the prepuce. This lump was first observed when he was 3 months old, and it increased in size till he reached the age of 6 months, since when no alteration in dimension had been noticed. It was stated, however, that, after ceasing to enlarge, the swelling had become harder than when first noticed. The prepuce (Fig. 1, p. 423), which was long, presented on inspection a spherical swelling on the under aspect of the free margin, with the antero-posterior vertical meridian corres- * Paper read and specimen shown at the meeting of the Glasgow Pathological and Clinical Society, 11th April, 1898. Dr. Edington?Cysts of the Prepuce and Baphe. 423 ponding to the raphe. The skin over the upper surface of the swelling was apparently much thinned, and there was some translucency apparent, although this was not tested with artificial light. On palpation there was some tenseness, but the impression conveyed was that we were dealing with a cyst, probably sebaceous, and not a solid tumour. The growth was purely preputial in its connections, and moved freely with Fig. 1. natural size. Parts removed by circumcision ; natural size. the foreskin, being without attachment to the glans. The preputial orifice was contracted so that the glans could not be uncovered, but the cyst took no part in preventing retraction of the foreskin. The child was otherwise normally formed, but was small for its age. Circumcision was performed on account of the phimosis, and the part removed was placed to harden in spirit, the swelling being left unopened. After hardening, the specimen was opened up along the raph^, and on opening into the swelling Fiq.Fig. 2. of material shown on Specimen opened up from below in line of raph?.raph6. Irregular deposit of fatty material shown on raw subcutaneous surface of the surface of cyst wall. Behind the cyst is the raw subcutaneous surface of the prepuce, also a fringe of the mucous layer. it was found to be a cyst, situated in the skin portion of the prepuce and abutting behind and slightly above on the under surface of the mucous portion (Fig. 2). The diameter of the cyst was *8 cm. The cavity was empty in great part, and on the inner wall was a somewhat irregular deposit of fatty material. This presented an uneven surface, the deposit being thicker in some parts than in others, and where the wall of the cyst was visible it had a smooth, almost glistening, appearance. The 424 Dr. Edington?Cysts of the Prejpnce and RapM. emptiness of the cyst was due evidently to absorption of the fluid part of the contents during the hardening process. The solid contents were examined microscopically, and were seen to consist of squamous epithelial cells and a few leucocytes, all more or less showing fat-droplets in their substance, also free fat-droplets. The epithelial nuclei were easily stained with carmalum, but the leucocytes did not take up the colouring matter. No crystals were observed. Fig. 3. Portion of cyst wall, from proximal part of specimen, showing (a) loose subcutaneous tissue firmer of of with large vessels ; (ft)(b) firmer layer of connective tissue forming part of wall; (c) epithelial of detritus in of a lining cyst; (d) detritus in cyst cavity (desquamated layers of epithelium). (From a micro-photograph taken by Mr. Archibald Young, M.B.) A portion of the cyst was embedded in paraffin, and sections were cut comprising the complete circumference in the antero- posterior vertical direction. They were stained in the following, different ways :?(a) with acid hsemalum; (b) carmalum and picric alcohol; and (c) by Gram's method. After staining, the sections were cleared with xylol, and mounted in Canada balsam. Microscopic examination.?With Zeiss objective AA and No. 3 eyepiece, the cyst was seen to possess a lining mejnbranp, Dr. Edington?Cysts of the Prepuce and Rapht. 425 separated from the preputial epidermis by a layer?varying in thickness and being much thinned out at the distal portion of the cyst?of fibrous tissue, corresponding to the dermis. No layer of true subcutaneous tissue was present, save at proximal part, i.e., between cyst and meatus, and here there were many vessels in the large loose fibrous tissue (Fig. 3, p. 424). The lining membrane was very distinctly stained, and its appear- ance suggested an epithelial structure. With D objective, the lining membrane was seen to consist of several layers of flattened epithelium. Externally the stained nuclei were seen closely packed, but as one passed towards the cyst cavity they became much fewer, and the superficial layers (next the cyst cavity) assumed a homogeneous yellowish appearance, con- trasting with the deeply-stained stratum corneam of the epidermis. The nuclei were elliptical and were arranged with long axis parallel to the surface of the wall. On the surface of the cyst wall was seen fatty debris peeling off in layers. The wall presented no prominences, and no papillae were present in the surrounding fibrous tissue. The above description is from a specimen stained by hsemalum alone; the carmalum and picric alcohol showed innermost layers of cyst wall as a deep yellow homogeneous structure. Examination of section stained by Gram's method demonstrated the presence of eleidin-holding cells. These cells were irregularly situated, and did not form a continuous stratum. Literature. One finds little mention made of the condition in the general surgical text-books. Erichsen1 states that "sebaceous cysts are occasionally met wTith, usually on the under surface of the are rare have penis or prepuce. Dermoid cysts very ; they been found in the raphe, on the under surface of the penis, which the two halves unite to close the urethra." along " Henry Morris2 writes, Sebaceous cysts occasionally occur . with the in the prepuce. Cysts connected glands behind the corona have been met with, sometimes single and in as large as a hen's egg; sometimes multiple and varying size from a shot to a horse-bean." In Heath's Dictionary, Jacobson3 mentions sebaceous tumours " as being occasionally met with on the penis. On looking into works dealing specially with affections of are the the genito-urinary organs, references made to subject under notice somewhat as follows:? Jacobson4 mentions that sebaceous cysts are occasionally 426 Dr. Edington?Cysts of the Prepuce and Raphe. met with in the long prepuce of boys. The duct of a sebaceous follicle may readily become blocked owing to irritation accom- panying a phimosis. He removed two by circumcision, each on the under surface of the penis, with the raph^ running over it. One was the size of an olive, the other of a small pea. He also quotes Cruveilhier5 as to the occurrence of cysts developed from the modified sebaceous glands behind the corona. Podrazki6 simply remarks that new formations occur in the prepuce not at all seldom; that sebaceous cysts are to be observed fairly often, singly or in groups, pedunculated or sessile. Kocher7 describes cysts with fluid contents, and also athero- matous cysts. He considers both forms to be regarded as retention cysts, and mentions the raphd as being their common situation. Kaufmann8 states that atheromatous cysts are more common in connection with Tyson's glands than with those of skin of penis. The smaller cysts are usually multiple;. the larger, solitary. He mentions four cases of large cysts, one of them observed by himself. Bland Sutton9 mentions that sebaceous cysts "are not uncommon in the skin of the penis and scrotum." On turning up the recorded cases, one finds that the cystic formations in this region may be divided into four groups:? 1. Sebaceous. 2. Mucous. 3. Congenital (this last may include the former two). 4. Traumatic epithelial (implantation). 1. Sebaceous arise in connection with two sets of glandular structures?(a) those on the inner aspect of the prepuce (Tyson's), and (b) those on the outer aspect. (a) From Tysons glands.?Instances of these are reported by Cruveilhier,5 who mentions a cyst the size of a small hen egg being found in a cadaver. The cyst lay between the mucous and cutaneous portions of the prepuce, and, in his opinion, originated in one of the follicles on the inner surface of the foreskin. Dunlop10 reports a case in which several small nut-like bodies occurred on the corona. These bodies were hard and to the touch. On pressure, one of them discharged pus. horny" Growths" had been removed two years before, and then reappeared. On removing the recurrent nodules they were found to be cysts containing sebaceous matter undergoing change. Fano11 mentions the occurrence of a cyst in a case of Dr.