anæsthetised; the tissues involved are extremely sensitive, and the
administration of ether (or of chloroform in the case of a young
child), besides relaxing the parts, enables the measure to be carried
out much more efficiently than would otherwise be the case. Although the
necessary dilatation can usually be very speedily effected, it often
takes some little time thoroughly to remove the adherent smegma, not
seldom of gritty and calcareous consistence. This, besides being the
longest, is the most painful part of the manipulation. The use of
cocaine as a local anæsthetic for such a purpose, precluding the
administration of ether or chloroform, is not to be recommended. The
wide surface involved renders its influence incomplete; and it is of
considerable advantage to have the patient, particularly when of tender
years, oblivious to what is going on.[23]
If the distension be too timidly effected, so that the foreskin can be
retracted over the glans only with difficulty; an equal difficulty will
be found in pulling it forwards again, and temporary paraphimosis may
result. Under anæsthesia, however, this cannot but prove transient; but
if free dilatation be procured in the first instance, there is not the
least fear of its occurrence at all.
On the other hand, care is requisite not to lacerate unnecessarily the
delicate membrane; after which more or less inflammatory trouble
supervenes, and the necessary daily retraction of the foreskin, to be
subsequently insisted on, becomes difficult and painful. Should much
oedema thus occur, it is best to discontinue for a few days the
retraction, until the inflammation has subsided; substituting the daily
injection with a syringe under the prepuce of warm carbolised oil, in
such a manner that (the orifice being closed), the fluid is made to
distend and 'balloon' that envelope as much as possible.
The ideal dilatation-procedure is how to effect the maximum of
dilatation with the minimum of laceration. In boys of seven or eight and
upwards, it is often easy to stretch the parts sufficiently to allow of
easy retraction and of free movement backwards and forwards without a
single rent in the membrane, and without the loss of a single drop of
blood. In younger children, however, this structure is necessarily much
more delicate, and easily torn, especially if there be struggling. In
the latter case complete anæsthesia, plenty of deliberation, and the use
of not too large an instrument, are elements of importance.
The following is the usual method of performing this
manipulation--'operation' is much too grave a word: The only instrument
needed is an ordinary dressing-forceps of average size in the case of an
adult or boy of age above indicated; proportionately smaller with young
infants, in whom, indeed, a probe will sometimes effect all that is
requisite.
The patient being well anæsthetised, the surgeon, taking the organ
in his left hand, retracts as far as possible the foreskin. With
his right he introduces the closed dressing-forceps as far as it
will enter; making sure, of course, that he has not passed it into
the meatus. He then widely expands the two limbs of the handle,
holding these apart for a few seconds. Complete retraction of the
foreskin behind the corona glandis is then usually at once easy;
adherent spots being separated with the thumb-nail. Should there be
any difficulty the tissue is gradually peeled off by manipulation
with the fingers; and the collections of inspissated smegma scraped
off with the nail or with an ear-scoop. Finally, the operator pulls
the prepuce backwards and forwards two or three times, making sure
that it is perfectly loose; anoints the glans well with vaseline,
and leaves it covered by the foreskin as in the normal state.
Subsequently, complete retraction is necessary on each of the first four
or five days; after which it may be gradually intermitted, being
subsequently resorted to only for purposes of cleanliness. The daily
washing recommended by some American writers seems wholly unnecessary;
and, as before remarked, the less tampering with these organs (except
when absolutely unavoidable) the better. When free movement of the
foreskin on the glans has been attained, together with healing of any
excoriation or sore, there is no fear of subsequent contraction. Any
seeming redundance of the prepuce is in no way detrimental; it should
only serve to induce a more careful habit of cleanliness, and the
habitual use of those ablutions to which every man naturally resorts
upon attaining years of discretion.
Dilatation thus effected can at the least do no harm, and cannot
possibly place the subject in a worse position than he was
previously;--which the examples in previous chapters show to be far from
the case, with the operation of circumcision. If carried out as here
indicated, it will be found thoroughly effectual; the reasons why it
appears to have failed in some hands apparently being: (_a_) neglect of
after-treatment, and of care to retract the prepuce daily throughout the
first few days; (_b_) insufficient dilatation at the time, so that
retraction has never been perfectly easy; (_c_) avoidable and
unnecessary laceration of the muco-cutaneous structures, followed by
inflammatory mischief.[24]
The adoption of a special instrument for the above purpose has been
advocated from time to time by several writers, who speak in glowing
terms of the favourable results they have thus attained. A rather
formidable-looking one, used by Nélaton, is depicted in the _Gazette des
Hôpitaux_, 31, 1868; this has three blades at right angles to the stem,
and is somewhat on the model of an ordinary urethral dilator. Several
successful cases are described, with one of failure. In the latter, a
youth of seventeen, incision had to be resorted to, as the prepuce could
not be stretched sufficiently with the instrument; and in this there
was doubtless true contraction, probably as a result of venereal
infection.
In the _Dublin Quarterly Journal_, No. xlviii. p. 482, Dr. Cruise, of
Dublin, figures a somewhat analogous instrument with two blades, and
speaks of numerous cases ('in which with due care the result has been
perfect') in his own hands and in those of his friends. He, however,
kept the foreskin subsequently retracted for twenty-four to forty-eight
hours, a proceeding which entails upon the patient very considerable
discomfort, and is unnecessary. Dr. Hayes Agnew (_Principles of
Surgery_) figures a special 'phimosis-forceps,' which appears in no
essential particular to differ from ordinary dressing-forceps; the only
noticeable peculiarity being that the blades are a little longer than
usual. Levis's dilatation-instrument, described in Keating's
_Cyclopædia_, vol. iii. p. 643, is worked by screw-power, and is stated
to be 'very effective;' it resembles an ordinary pair of
dissecting-forceps, with a screw placed close to the handle, which
effects separation of the two blades. This is, no doubt, satisfactory in
its results, but seems to be unnecessarily severe for the purpose to
which it is applied; in which very little force is usually needed, or,
indeed, is desirable, for obvious reasons. Mr. R. W. Parker's
dilatation-instrument has been referred to on the previous page; and
there are doubtless many others.
Dr. F. H. Stuart, of Brooklyn (_Medical Record_, December 4, 1886), in
advocating a manipulation very similar to the one here described (he
introduces first a probe to break down adhesions, then the
dressing-forceps, turning the latter round); comes to the conclusion
that 'the number of cases which really require circumcision is extremely
small.' And it may be generally remarked that no one who has really
tried the dilatation plan with due care and without prejudice, appears
to have subsequently relinquished it; or to have been otherwise than
highly satisfied with its effects, whatever the precise method adopted.
Those surgeons who speak of having seen unsatisfactory results generally
convey the idea that these have taken place in other hands; and have
never, in any publication seen by the present writer, condescended to
details.[25]
To the case of boys past the early years of childhood, and still more to
that of adults, the arguments in favour of the substitution of a simple
dilatation-process for the unnecessarily severe operation of
circumcision, apply with redoubled force. As in these no symptoms
directing attention to the phimosis have previously existed for any
length of time, it may be taken at once for granted that, however tight
the so-called 'contraction' may seem on inspection, the condition is
present in only a minor degree; that under an anæsthetic the adhesions
will yield to very slight force, and satisfactory retraction, with
subsequent free mobility, be procured without the slightest difficulty.
With adults, moreover, the avoidance of any need for confinement to bed,
of even to the house, is an important consideration. In such the tissues
are necessarily more elastic and less fragile than in young infants;
there is much less prospect of laceration, with consequent tenderness
and swelling.
An operation for the relief of congenital phimosis advocated by Mr.
Furneaux Jordan (_British Medical Journal_, May 2, 1863) may be here
alluded to.
Mr. Jordan passes one blade of a small round-pointed scissors
(Critchett's strabismus-scissors answer well) through the orifice;
skin and mucous membrane are divided to the length of a quarter of
an inch on one side, the same being repeated on the other. The
prepuce is now retracted as far as possible; this exposes more
lining membrane between the lips of the wound, and this again is
divided by a second incision on each side. The operation is now
complete, and the foreskin may easily be retracted.
The incisions which were made in the long axis of the penis after
retraction become linear in a vertical direction, and almost
imperceptible in the circular folds of retracted foreskin. In the
after-treatment the prepuce should be kept back, or frequently
retracted. In children retraction once daily for a week or ten
days, till the wounds have healed, is quite sufficient. The extent
of the incisions should, of course, be a little less in children, a
little greater in the adult.
The present writer has seen this operation performed in one instance,
and the after-results were in the highest degree satisfactory. As
contrasted with circumcision, the procedure merits warm commendation;
preserving the useful foreskin, and followed by a much more speedy
recovery than may be expected from the former. For the lacerations which
may result from forcible dilatation, small nicks with a pair of scissors
are substituted. The only objection is that even this operation, trivial
as it appears, is seldom necessary; and that sufficient distension of
the foreskin may often be procured without any breach of surface
whatever. Moreover, some confinement to bed or to the sofa is
subsequently requisite; whereas, after the effects of the anæsthetic
have passed off, the patient, young or old, whose foreskin has been
dilated, can behave exactly as usual.[26]
Mr. Jordan's operation is, however, a very useful corollary to the
dilatation-method in the chronic phimosis (often associated with gout)
of men in advanced life; when the parts are usually in a very gristly
condition; and when, if it be found impossible to procure retraction by
stretching, the contracted tissues may be advantageously nicked with
scissors in the mode here indicated.
FOOTNOTES:
[22] For instance, Mr. Erichsen (_op. cit._) dismisses the measure with
the cursory allusion of a brief paragraph; against the long and
elaborate account, previously detailed, of circumcision; it is not
mentioned at all in the earlier editions of his work. Ashby and Wright
speak of it with great disfavour. Mr. Jacobson (_Operations of Surgery_,
1890) does not introduce it at all; possibly because hardly worthy to be
dignified by the title 'operation.'
[23] In adults, or in boys approaching manhood, gradual dilatation by
the daily introduction of a sponge tent has been recommended. It might
be resorted to in the case of an exceptionally timid and patient
individual, but hardly for any other.
[24] Mr. R. W. Parker (_Brit. Med. Journal_, July 19, 1879) recommends
gradual dilatation with a special screw-forceps, which he has used in a
considerable number of cases at the Children's Hospital, 'always with
good results.'
[25] In the paper above quoted, by Dr. Cruise, of Dublin (1868), that
surgeon speaks of Dr. Hutton having used dressing-forceps for the cure
of phimosis fifteen years previously. Very probably the adoption of that
instrument for the same purpose would be found on inquiry to date back
still further; and no pretension of originality can be here put forth
for the advocacy of a simple common-sense practice, which must have been
repeatedly resorted to by many practitioners of the past.
[26] M. Faure has also described a somewhat analogous 'nicking'
operation.
VII
SUMMARY.
I. Circumcision as a sacrificial rite has been practised by very
numerous races of diverse origin, and dates from an extremely remote
antiquity; probably from the Stone Age, as suggested by the internal
evidence of Biblical records.
II. This fact, together with that of its application by many tribes to
the persons of female children, deprives the religious ceremony of any
title to the hygienic character and purpose, which have been frequently
attributed to it.
III. The surgical operation of circumcision, especially where infants
are concerned, has therefore to be discussed solely on its own merits,
wholly apart from any theory of Divine intentions, based upon
theological considerations. It appears to be erroneous _in principle_.
IV. It consists in a _mutilation_; in the removal of a perfectly normal
structure, with which, for patent physiological reasons, every male
child is endowed by nature. The morality of such a practice, without
grave necessity, is open to question.
V. Unless as the result of subsequent disease, no deformity, and indeed
no actual abnormality, exist as factors productive of the condition
designated 'Congenital Phimosis.' Almost every male child suffers at
birth from some degree of the same phenomenon--the imperfect separation
of two muco-cutaneous surfaces, developed in contiguity.[27]
VI. Symptoms ascribed to a 'contracted prepuce' are due to natural
growth of the glans penis, when this physiological separation is very
incomplete, and when, therefore, a rigid constricting envelope prevents
development. _No true contraction_ exists, except as the result of
superadded inflammation; and is rarely of much importance, unless an
element of contagion has been introduced.
VII. The rational treatment of congenital phimosis primarily consists in
the efficient execution of the process originally intended by nature,
but imperfectly carried out. And, secondarily, in precautions to ensure
the permanently free mobility of the prepuce upon the glans penis.
VIII. Such complete separation of the two contiguous layers of membrane
may almost invariably be effected by very simple means; and, with some
slight attention to after-treatment, will permanently secure all that is
desired, without risk and without even transient disability.
IX. The treatment of congenital phimosis by dilatation is the
common-sense remedy for this condition. It has been carried out by many
practitioners with different instruments and variations of detail; and
all who have thus attempted it with ordinary care (including the present
writer) seem eminently satisfied with the results.[28]
X. When diseased processes co-exist with congenital phimosis, the case
must necessarily be treated on its own merits. Simple dilatation, even
if practicable, is not always sufficient, but should be combined with
incisions of as limited a nature as possible. Mr. Furneaux Jordan's
operation is then useful.
XI. In the event of disease, the operation of circumcision is not devoid
of risk, and should be reserved as far as possible for extreme cases, in
which removal of the whole prepuce is obviously a matter of
necessity.[29]
XII. In healthy children the operation seems to be rarely fatal in this
country. Many cases of death directly traceable to circumcision have,
however, been reported on the Continent.
XIII. The immediate effects of circumcision, especially when performed
on young infants, involve considerable and protracted suffering.
XIV. The most conspicuous _remote_ result is that of an extremely
contracted _meatus urinarius_, as the consequence of subsequent
inflammatory processes, due to the exposure and continual friction of
the unprotected glans.
XV. The compulsory enforcement of local cleanliness procured by
circumcision seems hardly a sufficient argument for the general adoption
of the practice by peoples not utterly indifferent to all laws of
hygiene; and has little weight even in individual cases.
XVI. The superior chastity and purity of mind and body supposed to be
procured for its recipients by ritual circumcision, lie open to very
considerable question, in the face of abundant well-known facts.
XVII. The advantage of circumcision in obviating future venereal
contagion is restricted by its principal advocate to one form (albeit
the most important) of such disease. Even in this limited field the
facts adduced appear open to dispute, and greatly to need confirmation
by independent observers.
XVIII. In the hands of careless or inexperienced operators the surgical
operation of circumcision has been followed by the most disastrous
permanent consequences.
XIX. In face of the facts here set forth, it is NOT advisable to apply
the operation of circumcision, as a remedy for congenital phimosis, to
Christian infants; much less to extend this, as a routine custom, to the
whole male population.
FOOTNOTES:
[27] The word 'adhesion' in the previous pages is employed solely as a
term of convenience, to denote this imperfect separation, and does not
imply any analogy to inflammatory processes.
[28] The writer first drew attention to the advantages of this method of
treatment in the _British Medical Journal_, Nov. 15, 1874. Having
instituted a tolerably extensive search through the medical literature
of the preceding three or four decades, he is unable to find any account
of a case in which the procedure failed to effect a permanent cure,
unless there had existed previous disease.
[29] A fatal case, after circumcision for gonorrhoeal inflammation, in a
youth of 17, is reported in the _Lancet_, Feb. 25, 1882. Death took
place on the eighth day apparently from septicæmic pneumonia.
_BIBLIOGRAPHY._
PUBLISHED WORKS.
I.--MEDICAL.
Erichsen's _Surgery_, Ninth Edition; Holmes's _System of Surgery_, Third
Edition; Maunder's _Operative Surgery_; Joseph Bell's _Manual of
Surgical Operations_; Jacobson's _Operations of Surgery_; Reginald
Harrison's _Diseases of Urinary Organs_, Third Edition; Keyes's
_Diseases of Urinary Organs_; Keating's _Cyclopædia of the Diseases of
Children_; Ashby and Wright's _Diseases of Children_; Jaffé's _Die
rituelle Circumcision im Lichte der antiseptischen Chirurgie_; Asher's
_The Jewish Rite of Circumcision_; Wunderbar's _Biblisch-Talmudische
Medicin_; Gideon Bircher's _Die Beschneidung der Israeliten_; Dr. Hayes
Agnew's _Principles of Surgery_; Sayre's _Orthopædic Surgery_; Hilton's
_Rest and Pain_; _International Encyclopædia of Surgery_, 1886; _Guy's
Hospital Reports_; _American Journal of Syphilis and Dermatology_,
October 1872; Walsham's _Theory and Practice of Surgery_, &c. &c.
II.--HISTORICAL AND MISCELLANEOUS.
_The Testaments, Old and New_; _The Talmud_; _Maimonides on
Circumcision_; Tylor's _Primitive Culture_; Moncure Conway's _Demonology
and Devil Lore_; Keil's _Biblical Archæology_; Smith's _Dictionary of
the Bible_; Calmet, _Dictionary of the Bible_, _Encyclopædia Americana_,
_Encyclopædia Britannica_; Howard, _Royal Encyclopædia_; _Penny
Cyclopædia_; _Chambers's Encyclopædia_; _Encyclopædia Metropolitana_;
Winer's _Realwörth_; Brewster, _Edinburgh Encyclopædia_; _English
Cyclopædia_; Wilkes's _Encyclopædia Londinensis_; _Globe Encyclopædia_,
&c.
PERIODICALS.
_The Lancet_, _British Medical Journal_, _Medical Times and Gazette_,
_Medical Record_, _Dublin Journal_, _Boston Medical and Surgical
Journal_, _Chicago Medical Standard_, _Gazette des Hôpitaux_,
_Allgemeine Wiener Med. Zeitung_, _Wiener Med. Presse_, &c.
BY THE SAME AUTHOR.
THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the
Opium Pipe.) 2_s._ 6_d._
THE REAPPEARANCE OF CANCER AFTER OPERATION. 5_s._ 6_d._
THE GENERAL THEORY OF CANCER-FORMATION. 1_s._
CLINICAL NOTES ON CANCER. 3_s._ 6_d._
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