History of circumcision from the earliest times to the present

by P. C. Remondino

Another case admitted to the Charité, aged thirty-six, was afflicted with a blennorrhagia, upon which an attack of low fever supervened. The penis inflamed, became engorged and livid, and soon gangrenous symptoms presented themselves, making rapid progress; at first the integument alone was affected, but later all the structures became implicated and the penis was completely destroyed, the sloughs detaching themselves in shreds, leaving a conical stump that healed but slowly.

One case, a young man of twenty, also at the Charité, was admitted with adynamic fever; a few days after admission the prepuce was observed to be somewhat inflamed; in spite of all treatment this progressed so rapidly that the purple discoloration presaged a gangrene, which was not slow in following; the focus seemed to be at the superior and back portion of the prepuce; an incision evacuated a quantity of purulent, serous fluid; the disease, however, extended up the organ as far as its middle before its actions ceased; the sloughs were then cast off, when it was found that part of the gland and a portion of the cavernous body had followed the integument in the general wreck, subjecting the patient to intolerable pain during micturition. After the recovery from the fever, the remaining portion of the gland and the mutilated parts of the cavernous body were amputated to remedy this condition; the patient subsequently admitted to have had a blennorrhagia at the time of his admission to the hospital.

The gangrenous action may, in proportion to the low condition of the patient, be as proportionately rapid. Another case from Boyer, quoted from the works of Forestus, relates how the whole organ underwent such speedy disorganization that its liquefied remains were found in a poultice, which had been applied with a view of relieving the congestion,—a very dear price to pay for retaining the prepuce, that the exquisite sensitiveness of the tactile faculty for enjoyment, resident in the corona of the gland, might not be interfered with.

Gross does not mention this affection in his work on surgery, but Agnew devotes considerable space to its description, dividing the disease into two forms: the inflammatory, such as may follow venereal primary sores or operations on the penis, not excepting circumcision; and the obstructive variety, such as may follow embolism or any mechanical obstruction, either purposely or accidentally applied. Of the latter he gives a number of quoted instances; he only admits seeing one case, that of an aged man in the Pennsylvania Hospital, in whom the disease was caused by embolism of the dorsal artery.

J. Royes Bell, in the “International Encyclopædia of Surgery,” pays more attention to it than any of our American authors; mentioning, among the causes which may give rise to it, the exanthemata, especially small-pox, and the poisoning by ergot of rye and erysipelas. Among the local causes lie mentions phimosis, paraphimosis, and balano-posthitis.

Bell quotes the case reported by Mr. Partridge, in the sixteenth volume of the “Transactions of the Pathological Society of London,” wherein a sober man, aged forty, lost the whole of his penis up to the root, during the course of a typhus fever. Also the case reported by Mr. Gay, in the thirtieth volume of the same “Transactions,” wherein a cabinet-maker, aged thirty-one, lost his penis through the probable results of rheumatic phlebitis, and due to the presence of a plug in the internal iliac vein. In the twelfth volume of the “Transactions” of the same society he finds the record of the case of a soldier who lost his penis through gangrene induced by syphilitic phagedena.

In the consideration of the subject of the prepuce as connected with penile gangrene, it must not be overlooked that the presence of a prepuce may be the inciting cause of some rheumatic affection (the writer has repeatedly seen such), just as such cases are often the result of stricture; as cases of rheumatism that have resisted all remedial means, but that have readily given way to the dilatation of a stricture, are by no means uncommon; not a mere muscular reflex rheumatic pain, but even when accompanied by a rheumatic blood condition. So that even in such a case as above reported as being due to rheumatic phlebitis, or the case reported in the fortieth volume of the “Dictionaire des Sciences Médicales” by Patissier, wherein a man lost penis and scrotum through gangrene, induced by urinous infiltration, may all in the origin be due, if not to the immediate, to the remote effects of the presence of the prepuce.

In the first volume of the Journal of Venereal and Cutaneous Diseases the writer reported a case of the complete loss of penis in a young man as a result of phagedena due to syphilis. The man had had a long and pendulous prepuce; in his case, had circumcision been performed in early childhood, it would have lessened the chances of primary infection, and had it been performed after his infection, it would have removed one cause—if not the principal cause—of the ease with which the phagedenic action was inaugurated. The case already mentioned as an example of spontaneous and natural circumcision belongs to the gangrenous results following phimosis, ending with the loss of the prepuce. In Maclise’s “Surgical Anatomy” several specimens of deformity are figured, showing the results of this mildest of the effects of a phagedenic action. The beginning of the interference in the return preputial circulation undoubtedly always takes place over the superior aspect of the corona, where the pressure of the glans is most sharply defined against the inner fold of the prepuce.

There are milder conditions, wherein the circulation of the prepuce is materially interfered with, both through the lax tissues of the parts and the peculiar anatomical construction and shape of the neighboring parts, wherein, without going as far as gangrenous breakdown, the person suffers considerably nevertheless, and is placed in danger of losing his penis; for, as observed by Patissier, whenever a person affected with a gonorrhœa is attacked by a putrid or any low-grade fever, he runs the greatest danger of losing his virile member through gangrene.

Even where phimosis does not exist, but only the long, lax, and retractable prepuce, that is considered a perfectly physiological condition, the prepuce is liable to cause very distressing and complicating annoyances during the progress of other diseases. The writer has noticed that cases with a thick, leathery, and redundant prepuce, even when perfectly retractable, are more liable to require the use of the catheter during the course of a continued fever. Such a condition is also a very frequent accompaniment of prostatic obstruction. So often has this been noticed that its association with prostatic trouble or disease tends to the belief that the irritation produced by this condition of prepuce often lays the foundation for prostatic disease in not a few cases.[100] In elderly people, with the atrophied penis and elongating prepuce, the constant moisture from the urine on the inner fold and glans adds greatly to the irritation as well as to the discomfort of the patient.