History of circumcision from the earliest times to the present

by P. C. Remondino

It makes but little difference as to which operation is performed on the adult, but that the subsequent dressing will exercise a good or evil influence, and greatly assist not only in the present comfort or discomfort of the patient, but in the ultimate result as well. Bearing these points in view, Charles A. Ballance, of St. Thomas’s Hospital, has adopted the following procedure:—

“When the patient is etherized, the outline of the posterior border of the glans is marked on the skin with an aniline pencil. The skin of the prepuce is slit and removed up to the aniline line. The mucous membrane is next cut away, leaving only a free edge of about one-eighth of an inch in width. Any bleeding which occurs should be entirely arrested, and asepsis must be insured by frequent sponging with carbolic or sublimate solution. Numerous coarse-hair stitches are then inserted, so as to bring accurately together the fresh-cut edges of the skin and mucous membrane, and subsequently, after a further sponging and drying, a piece of gauze two layers of thickness, and wide enough to reach from the root of the penis nearly to the meatus, is wrapped loosely around the penis and secured by several applications of the collodion-brush. The setting of the collodion is hastened by the use of a fan, so that the air is kept in motion, and the patient should not be allowed to recover from the anæsthetic until the dressing is quite firm and hard. This dressing forms a carapace for the penis, protecting it from the bedclothes and effectually preventing the annoying and distressing erections. Mr. Ballance reports excellent results from this dressing.” (Braithwaite’s Retrospect, July, 1888.)

In applying the above dressing, the shrinking incident to the drying of the collodion must not be overlooked, and the gauze layers must be loosely applied, as they would otherwise become too tight. The dressing is a very ingenious and serviceable one.

Mr. A. G. Miller, at a meeting of the Edinburgh Medico-Chirurgical Society, reported a new method of dressing after circumcision. “It consisted in first closely suturing the skin and mucous membrane by numerous catgut sutures, then painting the surface with Friar’s balsam and covering it over with two or three layers of cotton wadding, on which the balsam is poured. The glans penis was left sufficiently free to allow of water passing. The band or ring of dressing should be at least one inch broad. The dressing was not suitable for young infants who were frequently wetting. In the case of older children, they might be allowed to go about on the second or third day, when the dressing would be quite dry, and would not be required to be changed or renewed.” (Braithwaite’s Retrospect, January, 1888.)

Any constricting or immovable and inelastic dressing is subject to the same objections as plaster-of-Paris dressings in thigh-fractures,—that of being dangerous and not expedient, unless the patient is constantly under your eye.

Dr. Neil Macleod, in the Edinburgh Medical Journal for March, 1883, advises a procedure that has always looked favorably to me, and which I once put in practice through the means of the ordinary ptosis fenestrated forceps, in place of the ordinary circumcision forceps, the sutures being introduced through the fenestra and the prepuce cut off on the outer side of the forceps, the thickness of the steel arm on the outer side of the fenestra allowing of the properly-sized border for the hold of the sutures. Dr. Macleod places his sutures all in position before making any incisions,—a procedure which will be found to save the patient considerable pain; as with many the seizing and holding of the edges of the skin and mucous membrane and the forcible pressure exerted by the fingers or forceps while the needle is being forced through is the most painful part of the operation. In doing this, care must be taken to allow sufficient length to each thread to make two sutures, as well as care must be taken to properly pull out the thread in the centre between the four folds of tissue and to cut it equidistant, after the ablation of the prepuce, a blunt hook being used to fish up the threads from the preputial opening.

Erichsen favors the Jewish operation in young children, as being the easiest and safest of performance. Slitting, or the inferior or superior incision, he thought, left too much of the prepuce, which, wherever there is a tendency to phimosis, should be entirely removed, “with a view of preserving the health and cleanliness of the parts in after life.” In the phimosis that is acquired by old men, he found dilatation with a two-bladed instrument to be sufficient, provided the indurated circle was made to yield. For the circumcision of adults he has invented an adjustable shield, something like the Jewish spatula, with which he protects the glans.

Gross (the elder) used both slitting on the dorsum and circumcision. He found neither objection nor deformity in the flaps left by the dorsal incision, as they were only temporary; in some cases, he simply followed the practice of Cullerier, of making multiple slits in the constricting and inelastic mucous membrane.

Agnew believes in circumcision in the treatment of reflex troubles. He relates a case, in the second volume of his “Surgery,” of eczema extending over the abdomen, of over a year’s standing, cured in a child by circumcision; he operates by incision on the dorsum, in which he leaves nature to make away with the flaps, or he circumcises by the Bumstead method.

Van Buren and Keyes recommend both the incision on the dorsum and the operation of Ricord; where the mucous membrane alone is tight and constricted, they follow Cullerier’s method of either single or multiple incisions of the inner coat. They lay great stress on the necessity of keeping the patient quietly in bed to insure rapid and complete union.