“From the foregoing, I think that we are justified in the conclusion that phimosis and adherent prepuce give rise to varied troubles of more or less gravity, manifesting themselves either in the muscular, osseous, or nervous systems; and that the removal of these abnormal conditions of the penis frequently affords marked relief, and, at times, perfect and permanent cure.”
In the discussion that followed the reading of Dr. Sayre’s paper, Dr. De Forest Willard, of Philadelphia, remarked that he had operated by simply stripping back the prepuce and that he did not circumcise, but that he looked upon the subsequent cleanliness of the parts as the greatest safeguard, not only as against reflex irritation, but also against masturbation. Retained filth and smegma are far more likely to call a boy’s attention to his penis by their unrecognized irritative effects than washing can possibly do. His practice is in accordance with the belief that young children can be relieved by the simpler methods, such as dilatation; but he also observes that when a child has reached eight or ten years of age, and has never been able to expose the glans, contraction is almost certain to be present, and circumcision must be performed. In adults there is rarely any escape when the prepuce is tight.
Dr. I. N. Love, of St. Louis, said: “It has been my judgment and my practice for many years, in these reflex irritations, to pursue the radical course of circumcision. I believe thoroughly in the Mosaic law, not only from a moral but also from a sanitary stand-point. All genital irritation should be thoroughly removed. It is all very well to instruct the mother or the nurse to keep the parts within the prepuce clean, but they can not or will not do it. Complete and proper removal of the covering to the glans takes away all the cause of disturbance. Dr. Sayre takes a more pronounced position on this subject than the majority of those who have discussed his paper. An improper performance of a surgical procedure is no argument against the operation, but rather against the operator. For the reasons I have given, I am in favor of the radical application of the Mosaic rite of circumcision.”
Dr. J. Lewis Smith, the president of the Section, believed in the evil results of the reflex irritation due to abnormality of the prepuce. In many instances the causative relation of the preputial disease to the symptoms which it produces is not so apparent as it may be in others, but after correct treatment of the prepuce they disappear. There was one result of phimosis which, he observed, neither Professor Sayre nor those who contributed to his paper noticed. The expulsive efforts accompanying urination sometimes cause prolapsus of the rectum, and frequently produce inguinal hernia. In a lecture before the Harveian Society (British Medical Journal, February 28, 1880), Edmund Owen, Surgeon to St. Mary’s Hospital and to the Hospital for Sick Children, says: “Perhaps the commonest cause of hernia in childhood is a small preputial or urethral orifice, and next to that I would put the smegma-hiding or adherent prepuce.” Arthur Kemp (London Lancet, July 27, 1878), Senior House-Surgeon to the Children’s Hospital, says: “Phimosis is a common occurrence, and numerous ill effects can undoubtedly be attributed to it;” and he alludes to the observation of Mr. Bryant, as published in his book on the “Surgical Diseases of Children”: “In fifty consecutive cases of congenital phimosis, thirty-one had hernia, five had double inguinal hernia, and many had umbilical hernia besides. In no one was the hernia congenital, its earliest occurrence being at three weeks. Circumcision was performed in these cases, and all were much benefited.”[103]
During the session of the Ninth International Congress, where the above paper was read and remarks made, which appear in the third volume of its “Transactions,” another paper was also presented by Dr. Saint-Germain, of Paris. The Doctor fully recognized the dangers from a narrow or adherent prepuce, but did not think that more than one case in three hundred really required circumcision; he believed in dilatation, as employed by Nelaton, with the exception that, whereas Nelaton employs three branches to his dilator, Saint-Germain preferred only a two-branch dilator.
Dr. Lewis, the president of the Section, related a number of cases where the use of uncleanly instruments had resulted disastrously. But, for that matter, the same objection can be offered against dilatation, as a filthy instrument is as liable to infect the patient as a knife. There is no earthly excuse why a knife that has been used on a case of diphtheritic croup should be used some hours afterward to circumcise a child. As to the operation of dilatation practiced by Dr. Holgate, it can really be said to answer the immediate demands, but how far its utility is efficient as to permanent results Dr. Holgate has not given the profession any information.[104]
One of the most interesting and instructive papers that it was ever the fortune of the writer to listen to, touching on the subject of reflex nervous diseases or neuroses due to preputial adhesions, was one prepared by Dr. M. F. Price, of Colton, California, and read at the semi-annual meeting of the Southern California Medical Society, at its Pasadena meeting in December, 1889. In the course of the paper he gives a considerable number of examples, of which some extracts are herewith given: One case was a boy aged seven, who for two years had had frequent attacks of palpitation of the heart; when seen by Dr. Price the little heart was laboring hard, beating at a furious rate (far beyond counting), with a loud blowing or splashing sound, and the pulse at the wrist a mere flutter. The breath was inspired in a series of jerks, the face flushed and somewhat swollen. The chest-wall was visibly moved at every thump of the heart. The doctor attended the child for a month without the little patient making any appreciable improvement. Some time during this period of observation the father happened to mention that the boy sometimes complained of his penis hurting him at the time of an erection. This led the doctor to examine the parts, when he found a long prepuce, with a mucous membrane adherent to the glans, about a line beyond the corona, the whole circumference of the organ. With the use of cocaine and a blunt instrument the adhesions were removed, with an immediate amelioration of all the reflex symptoms. The very next paroxysm was lighter and less exhausting; the improvement was continuous. The child soon went to school and had no further trouble; but, in the doctor’s opinion, the two years’ hard struggle have not been without its evil results on the constitution and organism of the child.
The next case was born November 2, 1888; a large, healthy boy at birth. By June of the following year the child was afflicted with what the mother called “jerky spells;” up to this time the boy seemed listless, did not care to sit up, and seemed from some cause to be in more or less pain, with his eyes turned to the left. The parents dreaded that the child, their only one, would turn out idiotic. The spasmodic spells alluded to were of a tetanic nature, the body being thrown backward; his head and eyes continued to be turned to the left, and nothing could attract the child’s attention. The boy cried night and day, but he was in good flesh, had all the teeth he should have, bowels were regular, and the appetite good. Whatever the doctor did in the medical way seemed to be of no avail. One day, however, he thought of examining the prepuce, thinking, perhaps, that it might be contracted and that the convulsive movements might be reflexes from the parts. On examination the prepuce was found elongated and distended, with a very minute opening; this was dilated with difficulty, when the inner fold was found adhering almost the whole extent of the glans; the dilatation and breaking down of these adhesions was slowly persevered in, until sufficient dilatation was obtained and the glans was freed. From the very first operation the convulsions commenced to diminish, both in force and frequency, and a constant and rapid improvement of the child took place. Six months afterward the boy was perfectly normal, stood by himself, played with play-things, and was an interested member of the family circle.
Case No. 3 was a repetition of Case No. 2, except that, with the experience of the latter case, the doctor wasted no time with medication, but proceeded at once to examine the prepuce, which was found to be very long, and with a pin-hole opening. The dilatation of this and the breaking up of the adhesions gave immediate relief. During the course of the paper he quoted the case related by Brown-Séquard, and recorded in the New York Medical Record, vol. xxxiv, p. 314, where he “related a very interesting case that presented all the rational signs of advanced cerebral disease, a case that he considered quite hopeless, that was relieved by an operation for phimosis and the treatment of an inflammatory condition of the glans penis.” To use Brown-Séquard’s own words, “So rapid was the recovery that within six weeks from the day of the operation he presented himself at my office perfectly well in every respect.”
In the early part of this book, in speaking of female circumcision, it was mentioned that when the medical part of the volume should be reached some medical reasons for its necessity would be given. Dr. Price, in his paper, gives some information on this subject, which is of the greatest interest. In the course of the paper he says as follows: “Nor do I think these reflex neuroses from adherent prepuce wholly confined to the male sex. The preputium-clitoridis may be adherent and produce in the female similar reflexes. During the session of the American Medical Association, held in Chicago in 1874, I think, I attended one afternoon a clinical lecture by Dr. Sayre. A little girl, fourteen years of age, but about the size of a seven-year-old child, was brought in, who had never walked nor spoken, but with quite an intelligent countenance, who was in constant motion, and who presented very many nervous symptoms. Dr. Sayre examined her, and found the prepuce adherent the whole extent of the clitoris. He gave it as his opinion that here was the primary and sole cause of the symptoms, and that appropriate treatment shortly after birth would have prevented all the serious consequences so painfully apparent, and which was then too late to remedy.