History of circumcision from the earliest times to the present

by P. C. Remondino

Any dissertation on circumcision and its many uses, either prophylactic or curative, would be incomplete without a reference to enuresis; another reason for making a somewhat full reference to the subject would be the undecided position that this morbid condition seems to occupy in medical literature, as well as the meagre and unsatisfactory treatment it has received by the majority of those who have mentioned it. It is anomalous, to say the least, to find, in general or special literature, enuresis mentioned as a diseased condition peculiar from babyhood to puberty; to find it fully described and to have it stated that it is a widely-prevalent distemper, affecting both sexes alike; to know that it is an annoying, intractable, persistent condition, wearing to the child in every sense, subjecting it to a demoralizing mortification as well as to unmerited scoldings, humiliations, and punishments, and that its habit, in badly-ventilated quarters, will breed other diseases,[107] as well as that its continued action tends to the development of onanism, with its long and widely-ramifying trains of physical and social ills; and to find works especially devoted to children’s diseases silent on the subject. Knowing all these things, and also that Ultzmann, Lallemand, and others who have treated this affection, mention it as a children’s disease, it is unaccountable to reason out why most of our text-books and treatises on children’s diseases should be so remarkably and unreasonably silent. It certainly cannot be laid to its lacking in study material, as the author of “Quain’s Dictionary of Medicine” says: “It is one relative to which much might be written without exhausting the subject, the pathology of which has wide and manifold relations.... There appears to be something analogous between this condition and that which determines in after life the seminal emissions under similar circumstances.” Our American works are notably deficient in this regard; although Stewart, of New York, in his “Diseases of Children,” published over fifty years ago, devotes a chapter to dysuria and one to retention of urine, treating the subject quite fully, even down to the description of preputial calculi; he, however, failed to notice that the irritation of preputial constriction or adhesions will produce both conditions, and, following many of the authors of the time, as has been done since, he adopted the urino-digestion theory of acid and irritating urine, due to faulty digestion, of Prout and Magendie, who looked to regulating the digestion of the child, or the mother who nursed it, as the only method of cure; the lithic-acid diathesis being, in their opinion, the main thing to be guarded from.

Other works that mention these conditions are equally on the wide sea of speculation, as they all, more or less, look upon the treatment that they advise as indefinite and unsatisfactory, showing an equal want of sound anchorage-grounds for their etiological reasonings. Dillnberger, of Vienna, in his hand-book of children’s diseases, mentions enuresis, but has nothing better to offer for its relief than that advised by Bednar, who followed a systematically-timed period of awakening, gradually lengthened out, from the time of putting the child to bed. In addition, he advises internal medication, and, like Ultzmann, he recognizes the possibility of a local cause in little girls, in whom he advises the local application of nitrate of silver. Edward Ellis mentions dysuria, and a long prepuce is noticed among its numerous causes. The works that give the subject the most intelligent treatment (the word “intelligent” is here used advisedly, and is in reference to the results obtained) are those of West, of London, and Henoch, of Berlin. West, in his “Diseases of Children,” says: “In the child, however, we sometimes find the symptoms produced by difficulty in making water owing to the length of the prepuce and the extreme narrowness of its orifice, which may even be scarcely large enough to admit the head of a pin. This congenital phimosis is, I may add, not an infrequent occasion of incontinence of urine in children, and is also an exciting cause of the habit of masturbation, owing to the discomfort and irritation which it constantly keeps up. In every case, therefore, where any difficulty attends the passing or the retention of the urine, or where the practice of masturbation is suspected, the penis ought to be examined, and circumcision performed if the preputial opening is too small. This little operation, too, ought never to be delayed, since, if put off, adhesions are very likely to form between the glans and the foreskin, which render the necessary surgical proceeding less easy and more severe.”

In the “Lectures on Diseases of Children,” Henoch, of Berlin, says: “I need scarcely add that an examination of the external genitals should never be omitted in any case of dysuria during childhood. You will not infrequently discover a phimosis which interferes more or less with the discharge of urine and retains portions of the latter behind the foreskin, where it may decompose and give rise to an inflammatory condition of the prepuce, with painful dysuria.... This is also true of the occasional adhesion of the labia minora in little girls, like the similar adhesion of the foreskin in boys. It is almost constant in the first period of life, but sometimes persists to the end of the first year; can usually be torn by the handle of the scalpel, and rarely requires an incision. In a few cases this adhesion appeared to me to be the cause of the dysuria, which disappeared after the separation of the labia from one another.”

Henoch, however, does not seem to have grasped the full relation that the natural phimosis of young children bears to dysuria, as he here follows the prevailing opinion, that where by dint, push, hauling, and hard work the prepuce can be pushed back phimosis does not exist, as well as the general apathy to the fact that a prepuce can exert a very injurious influence by its pressure, even when not adherent and very retractable; such a prepuce is often attended by balanitis and posthitis, with an accompanying difficult, frequent, and painful urination. In a case which will be related farther on, in the discussion of the systemic effects of a long, contracted prepuce, as it induces diseased action by continuity of tissues, there is an account of a death of a two-year-old child which we can assume to have had its original starting-point in a condition of phimosis. Henoch, however, rather attributes the death in that case to what may well be considered the result of a cause, leaving the original cause more to appear as a final accessory condition.

My reasons for this view of the subject are simply owing to the fact that I do not believe that a child can long be afflicted with the ischuria phimosica of Sauvages without having the urinary organs beyond more or less seriously affected from the mere retention alone, irrespective of any reflex irritation from the pressure on the glans or of any from the irritation of the peripheral nerves; the dilatation of the adjacent cavities or channels and the deposit of calcareous matter being facilitated by the retention of urine and its naturally altered condition owing to that retention. So that dysuria in young children, beginning in a slightly phimosed condition, or in the irritability of the glans and meatus, due to its preputial covering, it is safe to assume, may produce a train of symptoms ending in permanently-injured health, or even death. The irritating urine of a slight access of fever may, by its passage over the irritable mucous lining of the prepuce, be the initial starting-point of a serious or fatally-ending disease. In all of these, it must be admitted, the presence of the prepuce is either actively or passively the cause of the most serious disease processes that may follow.

Ultzmann, of Vienna, in his work on the “Neuroses of the Genito-Urinary Organs,” gives the subject of enuresis considerable attention. It is not a work on diseases of children, but it, nevertheless, goes into the subject as if it were, and furnishes the profession with considerable information. He defines enuresis to be the passage of urine of a normal quality in a child who, with the exception of this involuntary urination, is healthy. In the first periods of life, a slight vesical or intestinal expulsive effort is sufficient to overcome the guarding sphincter muscles at their outlet; the child first obtains a voluntary control of the rectal sphincter; and, generally, with the second year it gains control of the vesical. Those who pass their second year without obtaining this control, but in whom the organs and urine are normal, may be said to be afflicted with enuresis. He divides enuresis into three varieties; that involuntary urination which takes place at night during sleep he terms the nocturnal; that which takes place while climbing, laughing, coughing, or in the course of any violent muscular exercise is the diurnal; and that wherein the involuntary evacuation takes place day and night alike he terms as the continued. This last is again subdivided into the continuous and periodical. As a cause, he cites anæmia, scrofula, rachitis; but adds that physical debility is not necessary for its presence, as well-developed, vigorous, puffy children are as liable to be affected as thin and scrawny ones; while not all scrofulous or rachitic children are so affected, only a small portion being enuretic. Sex has no influence on the liability that tends to being attacked, the proportion between the sexes being about equal. As to age, he finds the greatest proportion to be between three and ten years, but he has often treated those of either sex even at the age of fourteen and up to seventeen years. It is absolutely necessary to examine the external genitals and the urine of those affected by this disease, as phlegmasiæ of the vagina, of the vestibule or urethra in girls, or the practice of onanism, or lithiasis, cystitis, or pyelitis may be the cause of the disease. Girls are apt to be found affected with polypoid excrescences at the meatus, which when removed will cause the enuresis to disappear.

From the above it will be observed that Ultzmann has paid much attention to these neuroses; but it will also be remarked that neither the balanitis, collection of infantile smegma, preputial adhesions nor irritations are taken into any account as possible factors of either dysuria or enuresis; he has followed more or less an electrical form of treatment for genito-urinary neuroses, the rectal rheophore being one of his favorite modes of treating enuresis; in his etiological views of these disturbances he has adhered more or less to the views of Trousseau, Bretonneau, and Dessault, who looked upon a debilitated or anomalous condition of the vesical neck as the cause of the majority of neuroses in that region.

It may be asked why these celebrated and observing physicians have neglected the preputial condition, if, as it is claimed, it is, in itself, so important and sure a factor of the derangements at the vesical neck? To answer this, or to explain any marked discrepancy that may occur in medicine between minds equally as acute and observing, it is but necessary to observe that there is, in medicine, to a certain extent, a like rule of inheritance, education, with fashion or custom of habit of thought and practice, as we find in religion. Canon Kingsley and Froude are equally as acute and discerning as the late Cardinal Newman, but that did not necessitate their following that prelate into the foremost ranks of the Catholic Church; and Pere Hyacynthe was equally as intelligent as Cardinal Newman, but that did not prevent him from leaving the fold into which the Cardinal had entered from out of the Reformed Church. Some are born Catholics or Protestants, and are so with vehemence; others are born in these religions, but are only lukewarm in their doctrinal observance; while others reason and jump the traces in either direction. The followers of the destructive theories of Bronssais could not see the errors of their ways, and neither could they be made to see the merits of a less interfering form of medical practice. Trousseau was himself at one time tainted with Bronssaisism, but, like Paul of Tarsus, he was made to see the error of his way, as he relates, through a case of gout that he nearly laid out in trying to lay out the disease antiphlogistically.

I do not assume that preputial irritation is at the bottom of all cases of dysuria or enuresis, any more than it would be rational to deny that cases of circumcision performed in some cases of diabetic enuresis have proved fatal as a result of the operative interference; but it is safe to assume that, in the great number of cases in whom some irritating conditions were found and removed, the enuresis or dysuria was due to such preputial irritation. It is also logical to assume, with West and Henoch, that the organ should in all cases be examined, and its condition rendered as harmless as possible. That the condition of preputial irritation has not been fully recognized by all parties as a cause of enuresis does not do away with the fact that it does exist, any more than the refusal of the prelates and doctors of Salamanca to listen to Columbus did away with the fact of the existence of the American continents.

A. L. Ranney, in his “Lectures on Nervous Diseases,” pages 174, 175, speaks of enuresis in children as being a reflex cachexia, “excessive stimulation of the centripetal nerves connected with the so-called ‘vesical centres’ of the spinal cord,”—a condition which may be produced by either worms in the intestines or by preputial irritation. Ranney advises a careful exploration of the urethra and rectum in these cases, and the elimination of all local causes of the conditions.