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.