Chapter XXVI (1)

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 majorae 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 anaesthetic 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 haemmorrhages, 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 haemorrhage, 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 oedematous 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 Despres, 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.

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 oedema, 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, _a la_ Ricord or _a 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.

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 anaesthetic 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.

My friend, Dr. Robert J. Gregg, of San Diego, has lately operated on a number of cases, the operation being perfectly painless, the little patients submitting to it and feeling no more pain than if it were having its toe-nails trimmed, the local anaesthesia being produced by the hypodermatic injection of cocaine. This procedure is now used to a considerable extent throughout the country, and it is a far safer and more comfortable performance than either etherizing or chloroforming, as the sudden and spasmodic filling of the lungs of young children--who will resist and hold their breath for a long time, then suddenly inhale--with anaesthetic vapor is almost unavoidable, having in two instances nearly lost two children from such an accident.

Dr. G. W. Overall, in a late _Medical Record_, which is quoted in the _Journal of the American Medical Association_ of February 21, 1891, gives the description of a very good and painless method of producing this local anaesthesia; for it need hardly be said that with a nervous, irritable child the introduction of the hypodermatic needle is as formidable an operation as either slitting or the Jewish operation. Dr. Overall is in the habit of holding a solution within the preputial cavity and then to introduce the needle in the mucous fold, having previously applied a light rubber band back of the corona, on the outer integument, so as to act like a tourniquet and limit the action of the anaesthetic effect to the prepuce. By this procedure he avoids all pain and the operation can be performed while the child is even amusing itself, care being taken that it does not see it. Sutures that require removal should not be used, according to the Doctor, and the operation thereby becomes a perfectly painless and unalarming performance to the patient in all its details.

NOTES TO TEXT.

[1] "Letters of Certain Jews to Monsieur Voltaire, Containing an
Apology for their own People." Pages 451-476. Translated by
Dr. Lefann. Philadelphia, 1848.

[2] "Circoncision chez les Egyptiens." Brochure by F. Chabas. Paris,
1861.

[3] "Atlantis." By Ignatius Donnelly. Page 472.

[4] _Ibid._, page 115.

[5] _Ibid._, page 234.

[6] _Ibid._, page 178.

[7] "Circumcision." A. B. Arnold. _New York Med. Record_, Feb. 13,
1886.

[8] "Atlantis," page 178.

[9] This word is, in the Mandan, _Maho-peneta_; in the Welsh,
_Mawr-penaethir_. "Atlantis," page 115.

[10] "Cyclopedia of Biblical, Theological, and Ecclesiastical
Literature," vol. viii, page 58. Article, Phallus.

[11] "Origine, Signification et Histoire, de la Castration, de
l'eunuchism, et la circoncision." Par. F. Bergmann. Published
in the "Archivio per le Traditione Populaire," 1883.

[12] "Dictionaire des Sciences Medicales." Par une Societe de
medecins et de Chirurgiens. Paris, 1826, 60-volume edition.

[13] Dr. Delange mentions a peculiar social habit or custom among a
tribe of Arabians that in a sociological sense is worth
mentioning. He observes that for these dances females are
preferred, but owing to the peculiar habit about to be related
it is impossible to have any of the village women in Algeria
assist at this part of the festivities; hence the men have to
do the dancing. It appears that the females of one tribe--this
being the tribe of Ouleds-Nails, who live on the southern
borders of Algiers--are in the habit, when young, of
emigrating to the oases of the Sahara, which are occupied by
the French and traveling Arabs, where they give themselves up
to a life of prostitution. After having exercised this life
for some years they return to the tribe with a dowry in money,
besides an ample supply of clothes and jewelry,--the result of
their economy,--which enables them to contract favorable
marriages. This practice is so common in this one particular
tribe, and so much have they monopolized the profession of
courtesan, that the name of the tribe of Ouleds-Nails is in
Arabia synonymous with that of courtesan. These young women
dance every evening in the Arab cafes, and are at times
employed to do the dancing at Arab feasts. For this reason no
self-respecting Arab woman ever allows herself to dance in
public, or why the practice of both sexes dancing together is
not practiced in Algerian villages, as a man would thereby
consider himself disgraced.--Dr. Delange, in _Receuil de
Memoires de Medecine de Chirurgie et de Pharmacie Militaire_,
No. 105, August, 1868.

[14] "Tractatus, Alberti Bobovii, Turcarum Imp. Mohammedis IV olim
Interpretis primarii, De Turcarum Liturgia, peregrinatione
Meccana, Circumcisione, AEgrotorum Visitatione," etc. Oxonii,
1690.

[15] Michel Le Feber. "Le Theatre de la Turquie." Paris, 1681.

[16] "La Circoncision, Sa Signification Social et Religieuse." Par
M. Paul Lafargue, in the _Bulletins de la Societe
d'Anthropologie de Paris_. Tome x, 3d fascicule, Juin a
Octobre, 1887.

[17] "Circumcision." By A. B. Arnold. _New York Med. Record_, Feb.
13, 1886.

[18] Bancroft's "Native Races," vol. ii, page 278.

[19] "Recherches Philosophiques sur les Americains, ou Memoires
Interessants pour servir a l'Histoire de l'Espece Humaine."
Par M. de P. Edition par Dom Pernety. Tome ii. Article,
Circoncision, Berlin, 1774.

[20] "The Family, a Historical and Social Study." By Charles
Franklin Thwing. Boston, 1887.

[21] The "Recherches Philosophiques sur les Americains" and Virey,
in the 24th volume of the "Dictionaire des Sciences
Medicales," are very full on this subject, and for fuller
information the reader is referred to those works.

[22] "Cause Morale de la Circoncision des Israelites, Institution
Preventive de l'Onanisme des Enfants." Par le Docteur Vanier,
du Havre. Paris, 1847.

[23] "Annual Report of the Bureau of Ethnology." By J. W. Powell.
Washington, 1881, 1882.

[24] "Among Cannibals, or Four Years' Travels in Australia." By Carl
Lumholtz. Page 46. Charles Scribner & Son, 1889.

[25] These interesting historical facts in relation to the holy
prepuce were published in the _Journal l'Excommunier_ in
January of 1870, when the writer was in France. They were
contributed by A. S. Morin, of Miron, a learned
historiographer and antiquary. Europe has not recovered from
its love of the supernatural that it had so strongly in the
middle ages. The blood of St. Gennaro still liquefies once a
year, and many churches still claim to possess the identical
winding sheet that served our Lord prior to his resurrection,
as well as more than one church has the holy cloth that St.
Veronica used on the way to Calvary, which has an impression
of the face of the Saviour.

[26] This church has a remarkable history connected with its
foundation. The tradition relates that in the dark ages some
sacrilegious soldier had robbed a church in the neighborhood
of its holy vessels of gold and silver. In the vessel in the
Tabernacle there happened to be a consecrated wafer. The
soldier journeyed on to Turin to dispose of his plunder, when,
on arriving at the spot on which the church now stands, the
wafer is said to have ascended miraculously to some distance
above the soldier's head, while at the same time the mule he
rode, being imbued with more religious piety than his master,
reverently knelt down on his front legs. The holy wafer was
now encircled by a halo of shining light; this, with the
kneeling donkey and the soldier raining blows on the pious
animal, while he himself was unconscious of the presence of
the host above him, attracted the attention of the populace,
who apprehended the soldier, on whom the stolen vessels were
found. The bishop in his pontificial robes, in solemn
procession, received the consecrated wafer, which promptly
descended into pious hands. The donkey was adopted by the
bishop and the soldier was promptly hanged, in accordance with
the general treatment of thieves in those days. The writer has
more than once seen a flagstone inclosed within a railing that
occupies the central spot of the floor or pavement of the
church, it being the identical spot on which the donkey knelt.

[27] Rush's "Medical Inquiries," vol. i, page 217.

[28] Fothergill. "Gout in its Protean Aspects," page 158.

[29] "Philosophy of Magic," from the French of Eusebe Salverte, vol.
ii, page 143.

[30] "Dictionaire des Sciences Medicales." Cullerier. Article,
Phimosis. Vol. xli.

[31] Bergmann has gone into this subject at length, and the writer
has drawn freely from his brochure on "Castration and
Eunuchism," reprinted from the "Archivio per le Traditione
Populaire" of 1883.

[32] "The Hermit." By the Rev. Charles Kingsley. See Introduction.

[33] "Dictionaire des Sciences Medicales," vol. liv, page 570.

[34] _Ibid._, page 567.

[35] _Ibid._, page 570.

[36] "Cyclopedia of Biblical, Theological, and Ecclesiastical
Literature," vol. iii, page 351.

[37] Smollett gives a good account of the Carthagena expedition in
his "Roderick Random," and for a good satisfactory detail of
the blundering Walcheren expedition the reader is referred to
Harriet Martineau's "History of England," vol. i, pages 269,
272, 273, and 354.

[38] Schoopanism, or paederastia, is at times practiced by the
Omahas, and the man or boy who suffers as the passive agent is
called _min-quga_, or hermaphrodite.--"Third Annual Report of
the Bureau of Ethnology." By J. W. Powell. Washington, 1881,
1882.

[39] When the missionaries first arrived in this region they found
men dressed as women and performing women's duties who were
kept for unnatural purposes. From their youth up they were
treated, instructed, and used as females, and were even
frequently publicly married to the chiefs or great
men.--Bancroft's works, vol. i, "Native Races," page 415.

[40] "Recherches Philosophiques sur les Americains," tome ii.

[41] "The History of the Hebrew Commonwealth." From the German of
John Jahn, D.D. Page 25. Oxford, 1840.

[42] "L'Hermaphrodite devant le Code Civil." Par le Docteur Charles
Debierre. Bailliere et Fils. Paris, 1886.

[43] "Recherches Philosophiques sur les Americains," tome ii, page
78.

[44] "L'Hermaphrodite devant le Code Civil." Debierre.

[45] _Occidental Medical Times_, Sacramento, Cal., October, 1890,
page 543.

[46] "Dictionaire des Sciences Medicales," vol. xxxi., page 41.

[47] _British and Foreign Medico-Chirurgical Review_, vol. xviii,
1856.

[48] "L'Hermaphrodite devant le Code Civil." Debierre.

[49] Sir Thomas Brown's works, vol. ii, "Religio Medici."

[50] "The Bible and other Ancient Literature in the Nineteenth
Century." L. T. Townsend, D.D. Chautauqua press, 1889. See
pages 32-45.

[51] "The Religions of the Ancient World." George Rawlinson, M.A.
Alden edition of 1885. Page 174.

[52] "The Intellectual Development of Europe." John W. Draper. Vol.
ii, page 113.

[53] _Ibid._ vol. ii, page 122.

[54] In "Clarke's Commentary," vol. i, page 113, the reason of
choosing the eighth day is given. Circumcision was not only a
covenant, but an offering to God; and all born, whether human
or animal, were considered unclean previous to the eighth day.
Neither calf, lamb, or kid was offered to God until it was
eight days old.--Lev., xxii, 27.

[55] A father circumcised his children and the master his slaves. In
case of neglect the operation was performed by the magistrate.
If its neglect was unknown to the magistrate, then it became
the duty of the Hebrew, upon arriving of age, to either do it
himself or have it done.--"Clarke's Commentary," vol. i, page
113.

[56] Bishop Newton points out the remarkable analogy that marks the
Hebrew race as descendants of Isaac and the Arab race as the
descendants of Ishmael, from whom sprung the Saracenic people.
These are the only two races that have gone on in their purity
from their beginning. They intermarry only among themselves
and have, alike, the same customs and habits as their fathers.
The sculptured faces of the Hebrew on the Babylonian monuments
are the same faces that are met in the synagogues of Paris or
New York. So with the descendants of Ishmael, in whom there
flows partly the blood of the dominant element of ancient
Egypt; neither custom, habit, nor physiognomy have changed. In
these two races, as observed by Bishop Newton, we have an
ocular demonstration of the Divine origin of our faith, if
verification of Scripture history is any criterion.--"Clarke's
Commentary," vol. i, page 111; also, Hosmer's "Story of the
Jews," page 5.

[57] "Cause Morale de la Circoncision." Vanier, du Havre. Pages
40-45.

[58] "De la Circoncision." Par le Dr. S. Bernheim. Page 7. Paris,
1889.

[59] "Cyclopedia of Biblical, Theological, and Ecclesiastical
Literature," vol. ii, page 350.

[60] Among the Semitic race, however, it seems possible to bring
forward better evidence than this of an early Stone Age. If we
follow one way of translating we find, in two passages of the
Old Testament, an account of the use of sharp stones or stone
knives for circumcision,--Exodus, iv, 25: "And Zipporah took a
stone"; and Joshua, v, 2: "At that time Jehovah said to
Joshua, Make thee knives of stone." ... The Septuagint
altogether favors the opinion that the knives in question were
of stone, by reading, in the first place, a stone or pebble,
and, in the second, stone knives of sharp-cut stone. These are
mentioned again in the remarkable passage which follows the
account of the death and burial of Joshua (Joshua, xxiv, 29,
30),--"And it came to pass, after these things, that Joshua,
the son of Nun, the servant of Jehovah, died, being a hundred
and ten years old, and they buried him in the border of his
inheritance in Timnath Serah, which is in Mount Ephraim, on
the north side of the hill of Gaash." Here follows, in the
LXX, a passage not in the Hebrew text, which has come down to
us: "And there they laid with him in the tomb, wherein they
buried him there, the stone knives wherewith he circumcised
the children of Israel at the Gilgals, when he led them out of
Egypt, as the Lord commanded. And they are there unto this
day." The rabbinical law, in connection with this subject,
reads as follows: "We may circumcise with anything, even with
a flint, with crystal (glass), or with anything that cuts,
except with the sharp edge of a reed, because enchanters made
use of that, or it may bring on a disease; and it is a
precept of the wise men to circumcise with iron, whether in
the form of a knife or scissors, but it is customary to use a
knife." This mention of the objectionable nature of the reed
as a circumcising medium is attributed to the danger that may
arise from splinters. The Fiji Islanders use both a rattan
knife and a sharp splinter of bamboo in performing
circumcision and in cutting the umbilical cord at child-birth.
Herodotus mentions the use of stone knives by the Egyptian
embalmers. Stone knives were supposed to produce less
inflammation than those of bronze or iron, and it was for this
reason that the Cybelian priests operated upon themselves with
a sherd of Samian ware (Samia testa), as thus avoiding danger.
There seems, on the whole, to be a fair case for believing
that among the Israelites, as in Arabia, Ethiopia, and Egypt,
a ceremonial use of stone instruments long survived the
general adoption of metal, and that such observances are to be
interpreted as relics of an earlier Stone Age.--"Researches
into the Early History of Mankind." By Edward B. Tylor. Pages
217-220. London, 1870.

[61] The cannibals of Australia do not eat white people, as the
flesh of these produces a nausea, which the flesh of the
vegetable-fed blacks does not do. The rice-fed Chinese are
considered a treat, and these are slaughtered in great number,
ten Chinamen having been served up at one dinner.--"Among
Cannibals." By Carl Lumholtz. Page 273.

[62] "Cause Moral de la Circoncision." Par le Dr. Vanier. Page 266.

[63] _Ibid._, page 288.

[64] _Cincinnati Clinic_, vol. ii, page 165.

[65] "The Story of the Jews." Hosmer. Page 263.

[66] "Traite d'Hygiene, publique et privee." Michel Levy. 2d.
edition, vol. ii, page 754.

[67] _Ibid._

[68] "Diseases of Modern Life." B. W. Richardson. Page 19.

[69] "Longevity and other Biostatic Peculiarities of the Jewish
Race." By John Stockton Hough, M.D. _New York Med. Record_,
1873.

[70] "Vital Statistics of the Jews." By Dr. John S. Billings. _North
American Review_, No. 1, vol. 152, page 70, January, 1891.

[71] "On Regimen and Longevity." By John Bell, M.D. Page 13.

[72] _British and Foreign Medico-Chirurgical Review_, vol. xliii,
page 539.

[73] _Ibid._, vol. xlii, page 17.

[74] In "Influence of the Trades on Health," Thakrah mentions the
peculiar exemption enjoyed in this regard by the butcher
class. He quotes Tweedie in saying that he never saw a butcher
admitted to the fever hospital.

[75] Lancereaux. "Distribution de la Phthisie Pulmonaire."

[76] Ashhurst. "Int. Enc. Surgery."

[77] Horner. "Naval Practice."

[78] _Cincinnati Lancet and Observer._, vol. xvi, 1873.

[79] It may well be a question of some interest whether the atrophy
of the testicle in the aged may not at times be partly due to
the compression exercised by the prepuce on the glans through
reflex action, and whether at times the virility that is
departing cannot be restored by circumcision in such cases. I
have seen such results, being guided to the idea by the
Biblical relation in the case of Abraham.

[80] This patient subsequently died of a uraemic complication
following on an attack of fever. The man was in his prime, and
had been of most exemplary habits. The fever that he had was,
I had every reason to believe, directly due to the results of
imperfect blood depuration incident on the irritability of his
kidneys, which, retroactively, again allowed the uraemic
condition to assume that dangerous degree that suddenly and
very unexpectedly to his friends and family ushered the
patient into eternity. This man had only been merely
inconvenienced by his prepuce up to the time that it caused
his death. It is interesting to observe what little trifles
bring about the end of some men. The unlucky habit of putting
the royal countenance on paper brought Louis XVI to a sudden
halt at Varennes, and his head to the scaffold. The lucky
meeting of the _aides_ of Bonaparte and Desaix between Novi
and Marengo gave to France its empire and to Europe the
enlightenment that was diffused by that event. If such trifles
affect individuals and nations, we must not be astonished that
the little useless prepuce should be endowed with the
mischief-working power of the historical old cow and kerosene
lamp that reduced Chicago to ashes.

[81] In the London _Lancet_ for 1885 there is a very interesting
communication at page 46 on this subject. There is no doubt
but that the prepuce offers the best skin-grafting material.

[82] In the seventeenth volume (third series) of "Guy's Hospital
Reports" there is a most interesting report at page 243 of a
case of skin-grafting that was performed by Thomas Bryant. The
case was an extensive ulcer resulting from an injury. Bryant
took some skin-grafts from the man's arm and some from a
colored man in an adjoining bed. The account gives the daily
report as taken from the note-book of Mr. Clarke, and is
accompanied by a colored plate to illustrate the subject; the
proliferation of the black skin is astonishing. In closing the
report Mr. Clarke says: "But in the figures depicted the
amount of increase in the black patches will be well seen. In
ten weeks the four or five pieces of black skin, which
together were not larger than a grain of barley, had grown
twentyfold, and in an another month the black patch was more
than one inch long by half an inch broad, the black centres of
cutification having clearly grown very rapidly by the
proliferation of their own black cells."

[83] _American Journal Med. Sciences_, vol. lx.

[84] "Circumcision." By Dr. A. B. Arnold, of Baltimore.

[85] "De la Circoncision." By Dr. S. Bernheim. Paris.