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.