The Barbarity of Circumcision as a Remedy for Congenital Abnormality

by Herbert Snow

VI ABSENCE OF NECESSITY FOR CIRCUMCISION IN CASES OF CONGENITAL PHIMOSIS—THE RATIONAL TREATMENT OF THE LATTER.

From what has been already set forth, it is sufficiently evident that no male should be suffered to reach adult life with this congenital disability unrelieved; and that in the majority of instances radical treatment is requisite at a far earlier date. There can be no doubt that it is infinitely better for an infant to be subjected to circumcision, than to pass many months or years with the unpleasant or even dangerous symptoms previously detailed. The point now to be considered, therefore, is whether these symptoms can be obviated by any less heroic measure, and whether the suffering thus incurred is a matter of absolute necessity; whether, indeed, it is right and proper to subject the child to mutilation for the benevolent purpose indicated.

For by no less term can the procedure in question be characterised. It consists in the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were there no necessity for its presence, it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ.

As indicated above, congenital phimosis may be said in some slight degree to occur in every new-born male child. Two layers of muco-cutaneous membrane are developed in close contact, and are commonly agglutinated in a measure; but it is only when the separation is very incomplete that any defect producing consequences of importance is found. There is no deformity or deficiency of parts; and, except as a consequence of long-continued inflammation, no contraction occurs. What is commonly spoken of as 'a contracted prepuce' simply signifies the natural growth of the glans under a rigid envelope, primarily of normal proportions.

All, then, that is requisite to remedy this condition in the first instance, is the due separation of the two contiguous layers of muco-cutaneous membranes, which in the new-born may generally be effected with ease. As the infant grows, however, there is apt to supervene relative disparity of size; the tissues cannot be sufficiently expanded to allow of the ideal state of the organ—a prepuce movable freely and loosely upon its included glans—without some laceration. And, unless care be taken, the wounds in the parietal layer of muco-cutaneous membrane again quickly heal; the new cicatricial tissue undergoes, perhaps, a little real contraction; and matters remain as they were before. Hence, probably, the disfavour with which procedures, involving dilatation of the prepuce, seem to have been hitherto regarded by most surgeons.[22] Some amount of reunion between the two surfaces may also take place at the spots where the adhesions have been ruptured.

The principle to be aimed at, however, is simply the separation of two contiguous and adherent layers of mucous or muco-cutaneous membrane. Few medical men are probably aware of the natural distensibility of the parts; of the ease with which (when the patient is rendered passive and unconscious by means of an anæsthetic) the glans can be brought completely into view, and the prepuce perfectly retracted behind the corona. All that is then necessary is, by the use of emollients and by daily retraction for a very brief period, to prevent reunion of adhesions or of fissures in the muco-cutaneous membrane; until a sufficient degree of dilatation has been secured to preclude all fear of any future difficulty.

Certain precautions are, of course, necessary. The patient should be 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 œdema 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.