History of circumcision from the earliest times to the present

by P. C. Remondino

These means, although not circumcision either in a surgical or in the Hebraic religious sense, are, nevertheless, sufficient in a medical sense for all desired purposes; provided, however, that there is no resulting constriction, or a mild condition of paraphimosis, back of the corona, and that the whole of the glans is sufficiently uncovered, and that no abnormal dog-ears are left to garnish each side of the penis like an Elizabethan frill or collar; although Agnew holds that, in slitting, the practice adopted by many of rounding off the corners is mostly superfluous, as nature will do so itself in time.

The ordinary way of performing the operation by modern surgeons is by what is known as the Bumstead circumcision. It was not an invention of Bumstead, but was adopted by him in preference to all others. The requisites are a sharp-pointed bistoury, blunt-pointed scissors, and a pair of Henry’s phimosis forceps, with fine needles and fine oculists’ suture silk. The penis is allowed to hang naturally and the position of the corona glandis marked on the outer skin with a pen and ink, which is to serve as a guide for the incision. The prepuce is now drawn forward until this line is brought in front of the glans and grasped between the blades of the forceps. The prepuce is now transfixed, and, with a downward cut, that portion is severed; the knife’s edge is now turned upward and the excision finished. The forceps are now removed and the integument allowed to retract; with the scissors the inner mucous fold is now split along the dorsum and trimmed off so as to leave about half an inch in front of the corona. The parts are then brought together with the continuous suture and dressed according to the fancy of the surgeon. Care must be taken not to bruise the parts with the forceps, as, in such cases, sloughing of the sutured edges will be the result instead of union. I have seen this accident happen more than once, in one case being followed by a penitis that seriously complicated matters.

It has been my practice to use fine silver-wire and catgut sutures in all operations on the prepuce; they excite less suppuration as well as less irritation. In case of need, the silver can be left in longer, and they are much easier of removal than the silk; besides, they have the advantage of not cutting. In the after-treatment the same general plan can be followed as with any amputated stump, except that it must not be forgotten that at the end of this organ dwells what has been termed the sixth sense, and that heat and moisture are very apt to awaken the dormant energies of the organ, even after it has undergone cruel mutilation, and even has suffered considerable loss of blood; for that reason it is best always to avoid wet or sloppy dressing, or too much ointment, as they are more apt to cause erection than to do any good. Besides, I find water does here, as elsewhere, interfere with the deposited plastic matter, properly organizing into cicatricial tissue; so that I prefer a snug, dry dressing, which is left on for four or five days without being interfered with, and light covering, plain diet, quiet, with fifteen grains each of bromide of sodium and chloral hydrate at bed-time to insure rest and freedom from annoying erections. Where the organ is large in its flaccid state, it is better to support it on a small oakum-stuffed pillow, made for the purpose, than to let it hang downward. Should the stitches give way and the skin tend to retract, the plan proposed on a previous page can be followed to advantage. In urinating, care must be taken not to soil the dressings; some patients are very careless about this if not warned. The penis should hang nearly perpendicular while in the act, and all dribbling should have ceased and the meatus and underneath be mopped dry with some soft cotton before raising the organ; nothing so irritates the parts, retards union, or is more offensive than a urine-saturated dressing.

Dr. Hue, of Rouen, uses an elastic ligature, which he introduces into the dorsal aspect of the prepuce by means of a curved needle. This he ties in front, and in three or four days it cuts its way through. Although Hue reports a large number so operated upon, the tediousness of the procedure and the swelling and œdema, as well as the active pain that must necessarily accompany the operation, will hardly recommend the ligature in preference to the incision by the knife.

Dr. Bernheim, the surgeon of the Israelitish Consistory of Paris, has operated on over eleven hundred circumcisions, besides the cases of phimosis occurring in his general practice. His opinion of the procedure of M. de Saint-Germain by dilatation is not favorable. He has employed it in a number of cases of phimosis, at the time unfit for a more radical operation. He has, however, observed that cicatricial thickenings and recontractions are very apt to occur, and, as to the septic accidents mentioned in connection with circumcision, he has noted that they are as liable to occur in hands that are as careless and slovenly with what they do with their dilating forceps as they are with what they do with their bistouries. Dr. Bernheim prefers the circumcision forceps of Ricord, as modified by M. Mathieu. This instrument he prefers by reason of its gentler pressure, which, at the same time, is all-sufficient to properly fix the prepuce. In applying the forceps, he includes as little as possible of the lower part, keeping away as much as possible from the frenic artery. The dorsum of the inner fold he cuts with the scissors. In children under two years of age, he simply turns this back over the free edge of the integument; in children over two years of age, he uses serres-fines. In children, he uses a piece of lint dressing steeped in a watery solution of boracic acid; in adults, he uses iodoform-gauze dressings. He finds cases unite in from three to ten days. Dr. Bernheim warns us against using antiseptics on infants or young children, in connection with the after-dressing of circumcision. Neither phenic acid, corrosive sublimate, nor iodoform are well borne by these young subjects, and he has seen serious results follow upon as light an application as a 1/100 solution of phenic acid. In a number of cases he reports operating with the galvano-cautery of Chardin, instead of the knife. These operations were bloodless, and cicatrization was as rapid as when the knife was used. He has in several cases operated by the dorsal incision, owing to disease of the prepuce not allowing any other operation.

In France, the Bumstead operation is known under the title of Ricord’s procedure. Lisfranc, Malapert, M. Coster, and Vidal all have operations which are not as useful as Ricord’s, and have not, therefore, come into general use. M. Sedillot condemns the dorsal incision as leaving two unsightly-looking flaps. The reverse, or inferior incision of M. Jules Cloquet is likewise not in favor with either Malgaigne or Ricord. This inferior incision or section, alongside of the frenum was first advised by Celsus. M. Cullerier contented himself with slitting the inner preputial fold, longitudinally, from its junction with the skin backward to the corona. M. Chauvin, by the aid of a complicated instrument with barbed points, drew out the mucous fold as far as possible before excising.

There is something unaccountable in the difference in results that various operations give in the hands of different surgeons. It must be that all methods are correct with properly-chosen cases and when properly performed, as well as properly looked after subsequently to the operation. It must not be expected, however, that, in operations where the kindly assistance of nature is a thing contemplated in absorbing superfluous tissue, the case will at once give satisfaction to all. These cases must have the required time before judgment can be passed upon the merits of the operation, just as required time in cases of dilatation or in the method of M. Cullerier will often demonstrate that the benefits are but transient, and that often even cases that have been so operated upon will require a complete circumcision, à la Ricord or à la Bumstead, owing to the resulting thickening induration and overconstriction, when, if left alone, the dorsal slitting or the inferior incision of Cloquet would have previously given satisfactory results.

The final cosmetic results in the combined Cloquet and dorsal-slit operation, for instance, depend on, first, properly choosing the case. One on whom the operation is unadaptable it is useless to attempt it on, as a future circumcision or tedious and annoying re-operation of trimming would be required. The next care is to properly cut through all constricting bands, which, like fine, tough strings, will be found to encircle the penis. These must be carefully clipped with a fine pair of strabismus scissors, as these bands do not give way, either then or afterward, of their own accord, but form the nucleus for stronger constricting bands for the future. Then you must be sure to cut far enough back, either above or below, until you have reached where you obtain the normal and largest calibre of circumference of the penis. The adaptation of the edges of the parts and the proper application of a smooth, equal pressure, by means of the lint strap, is of the next importance; and then comes the strapping of the whole surface for about an inch and a half back of the corona, which should and must include all the tissues of the preputial part of the frenum. A neglect or careless performance of any of the details, or the carelessness of the patient in not keeping the dressing clean, necessitating its change before the fourth day, all tend not only to interrupt the union, but to mar the future cosmetic results as well. It may be asked why all this care and trouble, and not circumcise at once? As already observed, this operation admits of the patient following his business; whereas circumcision, on the male, will assuredly lay him up for four or five days, and perhaps ten days,—something that many, be they rich or poor, cannot afford, and will not submit to.

The cosmetic condition of the penis as a copulating organ is a thing of some importance, and this should not be overlooked; for, although the particular dimension, shape, or peculiarity of the penile end never figures prominently in the complaints of women who apply for divorce,—the charges being everything else under the sun,—it can safely be assumed that this organ and its condition is the original, silent and unseen, as well as unconscious power behind the throne that is at the bottom of the whole business in more than one case. Like the fable of the poor lamb that the wolf wished to devour: the real reason of his wishing to kill him was that he might eat him, the pretext set forth by the wolf that the lamb had encroached on his pasture, muddied his brook, or kept him awake by his bleating having been disproven by the lamb. Besides, it is well not to leave any distinctive or distinguishing mark, like an individual baronial crest, on the head of the organ.

To return, however, to the operative procedures, we find that Dr. Vanier finds that the operation of Cloquet by incision alongside of the frenum has the advantage of not leaving any deformity—contrary to the opinion of Ricord and Malgaigne. He, in fact, holds this procedure in such high esteem that he considers that Cloquet deserves great credit for reviving this old Celsian operation. H. H. Smith, in his “Operative Surgery,” coincides with Vanier in his favorable opinion of this method, as he there says: “Frequent opportunities of testing the advantages of the plan of Cloquet having satisfied me of its value, I do not hesitate to recommend it as that best adapted to the adult, because it fully exposes the glans and leaves little or no lateral deformity, as is frequently the case with the dorsal incision,”—an opinion that I can fully agree with, from the results of the same operation in my hands, although I have used the method even on infants. Vanier does not approve of the dorsal incision unless it is made V-shaped, as it otherwise leaves the unsightly lateral flaps, but thinks well of the modification of Cloquet’s practiced by M. Vidal de Cassis, which is performed in the following manner: The patient stands before the operator, who remains sitting; the operator seizes the prepuce on its dorsum and draws it toward him; he then introduces a narrow, sharp-pointed bistoury, with its point armed with a small waxen bullet, down alongside of the frenum until he reaches the pouched extremity of the preputial cavity at this point; the point of the bistoury is now made to transfix the waxen bullet and out through the skin, which from this point is divided from behind forward. Vanier very sensibly suggests that the operation that is effectual, and which can be accomplished in the least number of movements or temps, as being the least likely to cause extensive pain and agony, should be the one preferred, and that the aim of the surgeon should be to simplify the operation by reducing the number of necessary movements. For this reason, where an excision of considerable amount of tissue is required by the nature of the case, he prefers another operation, performed by Lallemand,—that of making a dorsal transfixion and cutting off the two lateral flaps, which can all be done in three movements.