IV CUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED ADVANTAGES.

From the preceding, the evils or dangers incurred by permitting a male child to reach adult life; or, in the event of pressing symptoms, to pass even a few weeks or months with this disability unrelieved; are sufficiently obvious. Although, as Dr. Willard (op. cit.) states, the adhesions between prepuce and glans can nearly always be broken down with sufficient readiness during the first few weeks after birth, there can be little doubt that, without conspicuous necessity, the medical practitioner will seldom care to 'make the baby cry,' and thus draw down upon himself vigorous maternal reproaches. It seems, moreover, hardly judicious to encourage any tampering by nurses or midwives, probably more or less ignorant and unskilled. We may take it for granted, therefore, that nothing will usually be done until the child is several months old; when some more energetic treatment will be requisite to remedy the condition in question. In milder cases no notice will probably be taken of the abnormality for at least several years, and its presence may be detected only by accident; the adhesions in such are trivial, and do not interfere with normal growth; hence are, as a rule, easily overcome.[11]

Although less severe measures have been from time to time brought forward and advocated, the operation of circumcision is, to all intents and purposes, the only procedure in general use for remedying congenital phimosis; and as the latter is very common, so also is the performance of this ancient sacrificial rite among that large majority of the population who are otherwise in no way committed to it. There is a simplicity and thoroughness about the little amputation which may perhaps commend it to the surgical mind; and there are unquestionably certain superficial advantages of a hygienic nature about the patient's subsequent condition; though it may be doubted whether these are by any means so considerable as has been made to appear.

However this may be, it goes without saying that no other curative proceeding has so far met with any wide favour in the medical profession; and, if one may judge from their published opinions, the leading exponents of medical practice and opinion, in this country at least, are so pleased with circumcision and its results that they would willingly see the Mosaic Laws in this particular extended to the whole Christian population, whether affected by phimosis or not. Witness Mr. Jonathan Hutchinson:

It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of the removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare.—Archives of Surgery.

Arguments by this distinguished surgeon, in favour of extension of the custom as a matter of ordinary routine to every male Gentile, are to be found in the Medical Times and Gazette, December 1, 1855; together with a reference to previous utterances in an identical sense.

Erichsen (Surgery, Ninth Edition, 1888, vol. ii. p. 1188) says:

Every child who has a congenital phimosis ought to be circumcised; and even those who, without having phimosis, have an abnormally long and lax prepuce, would be improved greatly in cleanliness, health, and morals by being subjected to the same operation. It would be well if the custom of Eastern nations, whether it be regarded as a religious rite or only as a time-honoured observance, were introduced amongst us.

In Holmes's System of Surgery, 1883, we read:

Circumcision is the operation required in children; and it is best adapted for adults also when the skin is redundant, and the margins of the preputial opening are thickened.

Mr. W. H. Jacobson (Operations of Surgery, 1889) says:

This operation is still not practised often enough, especially among poorer patients; amongst whom many practitioners still treat phimosis as a matter of but little importance.

Some of the pretensions set forth above on behalf of circumcision will be subsequently referred to; but on the plea for a general extension of the rite to nations not impelled thereto by special Divine command, it may be remarked that several Jewish surgeons who have written upon the topic by no means regard this with an eye of favour; and have, in fact, gone even so far as to denounce in the strongest terms its compulsory performance among their co-religionists.[12]

For their dislike, they advance what appear to be very adequate reasons; and, in such a matter they must have enjoyed a far wider special experience than any practitioner without the Hebrew pale.

The following extract from Erichsen's Science and Art of Surgery (Ninth Edition, 1888) may be regarded as a typical account of the ordinary surgical operation in vogue at the present day. The italics are the present writer's:

Circumcision in boys or adults may be most conveniently performed in the following way. The surgeon restrains hæmorrhage during the operation by tying a tape tightly around the root of the penis, or by compressing the organ in Clover's circumcision tourniquet, a most useful instrument, which can be slackened or tightened at any time. He next draws the elongated prepuce slightly forwards, until the portion of it which corresponds to the back of the glans is brought just in front of that structure. He then seizes the projecting prepuce immediately in front of the glans with a pair of narrow-bladed polypus-forceps, which he gives to an assistant, who must hold them tightly; or he grasps it and protects the glans by means of a plate which I have had constructed for this purpose. With one sweep of the bistoury he cuts off all that portion of the integument which projects beyond the forceps, which are then taken away. It will now be found that he has removed only a circle of skin, but that the mucous membrane lining it still tightly embraces the glans; this he slits up, by introducing the point of a pair of scissors at the preputial orifice; and then, trimming off the angles of the flaps, he turns back the mucous membrane and attaches it to the edge of the cutaneous incision by a sufficient number of fine catgut sutures. Before introducing these, he will generally find it necessary to ligature a small artery on each side of the penis, and one or two in the frænum. The best dressing in children will be some simple ointment, such as boracic acid ointment, or the glans may be simply smeared with a little vaseline. After every act of micturition the parts should be well sponged with boracic acid lotion or Condy's fluid and water. In the adult, union by first intention may often be obtained by a dry dressing of iodoform-wool thickly covered with collodion, so as to protect it from the urine. This may be left unchanged for four or five days. There is usually a good deal of swelling of the mucous membrane about the frænum, and some solid œdema usually remains for some weeks after the operation. This gradually subsides, and a linear cicatrix remains, which causes the patient no inconvenience....

The chief points to be attended to in the performance of this operation, and on which its after-success is most dependent, are—1. That too much skin be not removed; 2. That the mucous membrane be slit up to the base of the glans; 3. That too much of it be not removed; 4. That all bleeding vessels be tied with catgut ligatures, which must be cut short; 5. That the mucous membrane be well turned back, so as to cover the gap left by the retracted skin; 6. That all sutures be of catgut, which will be absorbed, and thus save the pain of taking them out.

The modus operandi of different surgeons varies in particular details, usually of a slight and unimportant character. The pithy description contained in Maunders Operative Surgery may be appropriately quoted:

The extremity of the foreskin being seized with forceps is drawn well forwards; the whole prepuce is embraced with the blades of dressing-forceps, immediately anterior to the glans penis, and cut off in front of the latter instrument. As soon as the forceps are removed, the skin will become retracted, leaving the mucous membrane still about the glans; this is slit up longitudinally as far as the corona, when it may be turned back, and its edge will come into apposition with the circular wound in the skin. The operation is now complete; but in the adult it will be well to introduce a few interrupted sutures.

The prepuce has sometimes been slit up longitudinally on a director. Although well suited to cases of adventitious phimosis in the adult, the method is in no way adapted to the congenital form, and has never found general favour with the medical profession. It has no advantages over circumcision; although retaining the prepuce, it still leaves the glans largely uncovered; and the sharp corners of the divided skin, unless trimmed and rounded off, produce a very unsightly after-appearance.

In performing circumcision many surgeons hold the clamp or dressing forceps which protect the glans inclined obliquely downwards and forwards, so as to leave a portion of the prepuce in the neighbourhood of the frænum unremoved. As one of the main advantages claimed for the operation is the prevention of future infection by retention of morbid material in the preputial folds, such a practice would seem to indicate a lurking disbelief in the validity of this pretension. If it be reasonable and right to excise the structure on these grounds, and if that proceeding be attended by such salutary effects; it is only logical not to do things by halves, but to make the excision as complete as possible. Thus Liston made his section near the frænum, 'so as to retain the skin on the glans, which is of advantage.' The use of the elastic ligature, and of the écraseurs, both ordinary and galvanic, for the performance of circumcision, are cruel and fantastic modes of effecting that object, which hardly need any expression of condemnation; and which it is difficult to believe can ever have been seriously advocated. Keyes (Diseases of the Urinary Organs, 1888), after breaking up adhesions with an oiled probe, marks an aniline line around the foreskin, and amputates the skin, &c., in front of this mark; thus previously estimating the amount of tissue to be removed.[13]

For operations involving the amputation of the whole, or nearly the whole prepuce, the following advantages are claimed:—

(a) Greatly enhanced local cleanliness throughout after-life.

(b) Greater chastity; and the preclusion of immoral personal habits.

(d) A diminished proneness to eventual cancerous disease.

In respect of the first of these it may be conceded that, among a people naturally of uncleanly habits, abstraction of the prepuce would at any rate prevent mischief resulting from compulsory retention of the smegma. Whether it would lead to more frequent ablutions is perhaps doubtful; as also whether the plea has any valid efficacy in regard of persons belonging to the better classes, or to nations not specially distinguished (like the Oriental) for their disregard of the most elementary laws of personal hygiene. With savage tribes or with such races as the Chinese (many of whom are said to be completely washed from head to foot on two occasions only—when they enter the world, and when they have quitted it), anything conducing to more complete bodily cleanliness in after-life is certainly worthy of consideration; and probably of approval, even when it necessitates a surgical operation. But to apply this reasoning to more civilised peoples seems hardly warrantable on the facts in view. Shaving the head, or plucking out the nails would materially conduce to subsequent freedom from dirt; but no one would seriously advocate either of these as habitual customs; and the practice under discussion in no way differs from them, so far as the principle involved is concerned.

The second of the reasons above assigned is one which has probably great weight in determining the practice of many surgeons; and it has even been gravely contended by one of the Jewish communion that the Deity instituted the rite among the Israelites in order to promote their greater purity and continence.[14]

This suggests the irrepressible commentary that, whatever the case in bygone years, the operation seems now to have wholly lost its salutary effects in the direction indicated, as Mr. Jonathan Hutchinson (Medical Times and Gazette, loc. cit.) himself testifies.

Doubtless anything which might tend to enhance the chastity of many modern nations would be well worthy of serious consideration; with a view to its universal adoption. Strange to say, however, certain of those medical men who have investigated the question with opportunities of special experience, largely base their opposition to the practice of ritual circumcision upon the ground that removal of the foreskin in early life leads to premature sexual excitement, and a corresponding disposition to onanism. (Levit, Allg. Wiener med. Zeit., November 17, 1874.)

In the Lancet of April 4, 1869, two cases materially bearing upon this point are reported. One is that of a Jew, aged thirty-five, suffering from 'spinal paralysis,' which he attributed to a habit of persistent masturbation in childhood or youth. And allusion is made to a younger brother of the same patient; who, as a consequence of the same, had acquired spermatorrhœa, Dr. Willard (Keating's Cyclopædia) says:

I have failed to find any statistics proving that the circumcised masturbate less frequently, or are more virtuous than others; and the exposure of the tender skin to friction of clothing &c., tends to keep up a state of abnormal excitement during the early years of life.

'Where doctors differ, who shall decide?' And in face, therefore, of such directly contradictory opinions from professional witnesses, it is difficult to believe that ablation of the prepuce is of material avail, either in precluding masturbation, or in promoting the subsequent chastity of the adult individual.

On the third of the reasons assigned for advocating circumcision—the prevention of venereal disease when manhood is attained—Mr. Jonathan Hutchinson, whose testimony cannot but receive considerable weight, remarks that chancres are rare in the Jew. The observation has not been controverted; but must be received with a certain amount of hesitancy, in consequence of an evident bias in favour of radical measures of operative treatment. It seems rather to need confirmation by surgeons of the Jewish race, practising especially among their co-religionists. The present writer has been unable to discover any evidence in support from such a quarter. The authority last cited points out that cicatricial tissue is of all others least resistent to infection; and in the writer's own confessedly few opportunities for research in this particular field the number of Jews who have displayed remote but unmistakable indications of previous syphilitic taint has not appeared small. It is not improbable that a Hunterian sore developed upon scar-tissue, or upon the hardened integument of a denuded glans, would be far more trivial in character, more transient, less productive of inconvenience, and less easily recognisable, than the same in a normal state of the parts; the after-effects being, of course, identical. Such primary lesions in a people notoriously rather negligent of their person would seldom come under the notice of the medical practitioner. So, failing further evidence, the provisional verdict upon this question must be the Scotch one, 'Not proven.'

But even if the above assertion be accepted in respect of true syphilis, it assuredly fails to hold good with reference to other varieties of venereal disease. Thus Mr. Jonathan Hutchinson's oft-quoted statistics [15] (Medical Times and Gazette, December 1, 1885), in his own words, 'prove that, though in proportion of nearly a third to the other patients, they (Jews) furnish nearly half the cases of gonorrhœa.'

The last-named motive for circumcision, although, in the passage quoted at the beginning of this section, it has been stamped with the approval of the same high authority, needs but transient allusion. It is a priori probable that congenital phimosis prolonged into adult life renders the subject thereof somewhat more likely to develop local malignant disease than any one not so circumstanced; the resulting attacks of inflammation and of unhealthy ulceration, &c., may be naturally expected to lead to the growth of papillomata, as well as to maintain a chronic condition of lowered vitality. But the comparative rarity of epithelioma in this particular locality would deprive the allegation, even if this were positively established as an indisputable fact, of any weight as an argument for the removal of the prepuce. Moreover, it is obviously a reason not for the routine performance of circumcision, but for the relief of phimosis; by whatever means attempted or proposed.