History of circumcision from the earliest times to the present

by P. C. Remondino

CHAPTER XXVI.
Surgical Operations Performed on the Prepuce.

In operative interference there is one point which should not be lost sight of, this being that the length and bulk of the prepuce in a great measure depends on the constriction at its orifice; if the orifice is small, the prepuce tight and inelastic, every erection, by putting the penis-integument on the stretch, adds to its bulk,—nature naturally trying to make up the deficiency,—the two points of resistance being where the glans pushes it ahead, having the constricting orifice for a hold or purchase, and the skin at the pubes, which is called upon to furnish the extra tissue for the time being needed during erection, which should be supplied by the prepuce—this being the only office which I have been able to assign to this otherwise useless but very mischievous appendage. In cases where preputial irritation produces more or less priapism, the continued stretching of this integument causes a marked increase in its growth, which is mostly added forward. It was on this principle or its recognition, that Celsus devised his operations, and on which the persecuted Jews undertook to recover their glans by manufacturing a prepuce; and, although the trial was not reported as being very successful, I do not doubt but that, if the skin could have been drawn sufficiently over so as to constrict it anteriorly so as to give the glans a purchase, as in the case of phimosis with an inelastic prepuce, the operation could be more of a success; all that is required is the continued extension and the prepuce might be made to rival in length the labia majoræ of the females of some African tribes, or the pendulous buttocks of the Hottentot Venus.

I have employed the knowledge of this elasticity and source of supply of the penis-integument, on more than one occasion, in recovering the denuded organ with skin. A number of cases are on record where, owing to the want of that artistic and mechanical knowledge without which no surgeon is perfect, the operator has drawn forward the skin too tight in circumcising, after which, owing to the natural elasticity of the skin, the integument has retracted, leaving the penis like a skinned eel or sausage. This accident is even liable to occur where the skin has not been tightly drawn, but where subsequent erections have torn through the sutures, and where the natural retraction of the skin has laid the organ bare for some distance. I have seen a number so recorded, but do not remember seeing any remedy suggested, it seemingly being accepted that the recovery must take place by gradual granulation,—a necessarily very slow process, owing to the constant interference by—the always present in such cases—unavoidable erections.

Several years ago I advised circumcision to a gentleman owing to a contracted condition of the muscles of one hip and thigh, which was threatening to render him a deformed cripple; he had a congenital phimosis and a very irritable glans penis. The operation was performed in a proper manner by a surgical friend, but this friend, unfortunately, was a great believer in antiseptic and wet dressings. A few days after the operation he called upon me to ask me to go and see the patient, as they were both in a pickle, the patient being exceedingly angry, being in constant misery, and the penis so denuded by the giving way of the sutures—owing to the erections—that it looked to the patient as if he never could have a whole penis again, and the doctor saw no way out of the difficulty; the penis was, in reality, a dilapidated and sorrowful-looking appendage, and anything else but a thing of beauty or pride; it was raw, angry-looking, and bleeding at every move; the first wink of sleep was followed by an attempt at erection that raised the patient as effectually as an Indian would in scalping him; so that, taken altogether, the penis, anxious countenance, and the flexed position of the whole body to relieve the tension on the organ, the man looked about as battered, cast down, and sorrowful as Don Quixote did in the garret of the old Spanish inn, with his plastered ribs and demolished lantern-jaw.

Luckily, the patient was seen before the retracted portion of the penile integument had had a chance to condense and indurate. The bed was slopping wet with the drenchings of carbolized water that the penis had undergone, the man’s clothing was necessarily damp, and the whole bedding and clothes were steamy,—all of which greatly added to his discomfort and tendency to erections. The man was washed, placed in a new, clean, and dry bed, and his clothing changed. The organ was then forced backward until the preputial frill or edge was approximated to the cut end of the penis-skin, where it was made fast by an uninterrupted suture around the whole of the circumference. A short catheter, about three inches in length,—the catheter being as full size as the urethra would comfortably hold, and of the best and thickest of the red, stiff variety,—was introduced into the urethra. This protruded about half an inch beyond the meatus. A stiff, square piece of card-board was pierced and slipped over this, and then adhesive rubber straps were brought from the integument to this little platform, the first being from the median line of the scrotum, lifting the sac forward and upward. The pubes were shaved and the next four straps started from the root of the penis, each strap being split at the glans-end so as to encircle the protruding end of the catheter. By these means the skin was brought back and firmly supported over the penis, toward the glans; and, in case of any erection, the act would only assist in drawing the covering farther over the penis as the pasteboard platform and adhesive straps formed the distal end of an artificial phimosis. The catheter allowed of free urination, and the scrotum was further held up in position by a flat suspensory bandage passed underneath the scrotum and fastened over the abdomen near each hip. The penis wound was then dressed with a very little benzoated oxide-of-zinc ointment passed between the adhesive straps; a bridge-support placed over the hips to support the bed-clothes, and all was finished, and full doses of bromide of sodium and chloral were ordered at bed-time. When the dressings were removed, five days afterward, all was healed, the sutures removed, and the suspensory alone replaced. The patient had not been troubled with any more erections or annoyances of any kind. These are the points which often do more or less mischief: wet dressings are uncomfortable and favor erections, while the effect of the weight and action of the scrotum in drawing backward on the integument should not be overlooked; in addition, it should not be overlooked that we have it in our power to produce, so to speak, an artificial phimotic action, which has the same traction on the penis-integument that the natural phimosis induces.

The foregoing method, to be used in these cases, has proved very serviceable in my hands, and it is here given that it may assist others; as there is no need of waiting for granulations or of allowing the patient to undergo so much misery, which, besides the local injury, cannot help but affect the general health very injuriously. The penis can stand any amount of forcing backward; it stands this in cancer or hypertrophy of the prepuce, or in the inflammatory thickenings that precede gangrene of the prepuce, in any extended degree; becoming, for the time being, more or less atrophied. As has been shown by Lisfranc, the penis can be made nearly to disappear into the pubes; so that we are not as helpless in these cases as our text-books would have us believe.

In infants, and in young children below the age of ten or twelve, the Jewish operation, as modified and done in accordance with the dictates of modern surgery, will be found the most expedient. By this method we avoid the need of any anæsthetic agents, which are more or less dangerous with children, as well as the need of sutures, which are painful of adjustment and very annoying to remove in those little fellows who dread new harm; there is also much less risk of hæmmorrhages, as the frenal artery is not wounded. In children of a year or over, a very good result will be found often to follow Cloquet’s operation, care being taken to carry the slitting well back, as well as care in taking it on one side of the frenum, so as to avoid any wound of that artery, the subsequent dressing being a small Maltese-cross bandage, pierced so as to admit the glans to pass through; the prepuce is retracted and the tails folded over each other and held there by a small strip of rubber adhesive plaster; a little vaselin prevents the soiling by urine underneath. This last operation is short and very easy, is not painful, nor does it require much manipulation; it is only one quick cut on the grooved director and it is over; by the retraction of the prepuce, the longitudinal cut becomes a transverse one, making the prepuce wider and shorter at once; the glans soon develops and remains uncovered. As there is a very small wound to heal over, the repair is very prompt.

In adults with a very narrow, thin, not overlong prepuce, a very good result often follows a combination of the dorsal slit with the inferior slit alongside of the frenum of Cloquet. The narrower and tighter the prepuce, the better the result, as the cuts are at once converted from longitudinal into transverse wounds, and the organ at once assumes the shape and condition of a circumcised organ, without having suffered any loss of substance; three stitches or sutures in each cut (silver or catgut) adjust the cut edges; a small roller of lint and adhesive plaster, placed so as to shoulder up against the corona, completes the dressing. Where this operation is practicable, by the thinness and narrowness of the prepuce, it has many advantages. I have repeatedly performed it on lawyers, book-keepers, clerks, and even laboring men, who have gone from the office to the courts, counting-rooms, or stores without the least resulting inconvenience or loss of time. In laborers it is better to perform the operation on a Saturday evening, which gives them a rest of thirty-six hours before going to their labor again. The operation is comparatively painless and almost bloodless, as there need not be more than half a teaspoonful of blood lost during the operation; there is no danger of any subsequent hæmorrhage, and, with proper precautions against the occurrence of erections, from seventy-two to ninety-six hours is sufficient for a complete union; the sutures are then removed and a simple lint and adhesive-plaster dressing worn for a few days more. In many, no more dressings are required. In many cases, with a properly adjusted dressing, that comes forward underneath so as to include the frenum, the simple dorsal slit is sufficient; but if any of the prepuce depasses the dressing underneath, it will puff and become œdematous and require frequent puncturing. To avoid it, it is better to make the Cloquet slit at once. This operation is of no value, and perfectly impracticable in a thick, pendulous prepuce. Absorption will often remove considerable preputial tissue, but where there is too much its very bulk interferes with its removal by any natural means.

Dilatation is recommended by a number of surgeons, but, I must admit, in my hands it has always proved a failure; it may be, that if the subsequent history of the cases reported as so operated upon had been carefully traced, the reports would not have been so good. Nelaton, whose dilating instrument is generally recommended, seems, himself, to prefer some of the circumcising methods, as in the volume on “Diseases of the Genito-Urinary Organs,” in his “Surgery,” being the sixth volume of the revised edition of 1884, by Desprès, Gillettte, and Horteloup, the subject of dilatation is dismissed in two short lines. St. Germain, of Paris, uses, as has been before observed, a two-bladed forceps, used after the manner of Nelaton, and reports good results. Dr. J. Lewis Smith agrees in his statements with Dr. St. Germain. Dr. Holgate, of New York, reports a like experience. In my own practice the prepuce has often been made temporarily lax and retractable, but with the usual results of the return of the contraction, with a possible thickening of the inner fold, as a result of the interference; so that only in case of any immediate demand, where the tight prepuce is producing irritation, either through pressure or adhesions, or retained sebaceous matter, do I ever resort to dilatation; always, however, even then, not as a final operation, but merely as preparatory procedure toward a future operation of a more efficient order.

In cases of timid adults, who refuse all kinds of operative interference, good results may be obtained by the use of a mild lead-wash or cold tea-baths and the introduction of flat layers of dry lint interposed between the prepuce and the glans; this has a very good effect in keeping the parts apart and dry, and may in time produce a certain amount of dilatation; but even when this is done, unless it will render the foreskin sufficiently loose to allow of its being kept finally back of the corona, it is, after all, but a temporary makeshift. The corona should be exposed and kept clear of the preputial covering; anything short of this will not give all the good results to be desired. I have more than once performed a secondary operation on Jews, who had been imperfectly circumcised by not having the prepuce removed sufficiently, and in whom the subsequent contraction of the preputial orifice had re-covered part of the glans, and only lately visited a four-year-old boy, circumcised when eight days old, in whom the prepuce covered half of the glans, the corona acting as a tractive point from which the penile integument was being drawn forward. In this case the simple pierced-lint Maltese cross was used, with an adhesive band to hold the tails down behind and around the penis just back of the corona.