Chapter IV

CUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED ADVANTAGES.

From the preceding, the evils or dangers incurred by permitting a male child to reach adult life; or, in the event of pressing symptoms, to pass even a few weeks or months with this disability unrelieved; are sufficiently obvious. Although, as Dr. Willard (_op. cit._) states, the adhesions between prepuce and glans can nearly always be broken down with sufficient readiness during the first few weeks after birth, there can be little doubt that, without conspicuous necessity, the medical practitioner will seldom care to 'make the baby cry,' and thus draw down upon himself vigorous maternal reproaches. It seems, moreover, hardly judicious to encourage any tampering by nurses or midwives, probably more or less ignorant and unskilled. We may take it for granted, therefore, that nothing will usually be done until the child is several months old; when some more energetic treatment will be requisite to remedy the condition in question. In milder cases no notice will probably be taken of the abnormality for at least several years, and its presence may be detected only by accident; the adhesions in such are trivial, and do not interfere with normal growth; hence are, as a rule, easily overcome.[11]

Although less severe measures have been from time to time brought forward and advocated, the operation of circumcision is, to all intents and purposes, the only procedure in general use for remedying congenital phimosis; and as the latter is very common, so also is the performance of this ancient sacrificial rite among that large majority of the population who are otherwise in no way committed to it. There is a simplicity and thoroughness about the little amputation which may perhaps commend it to the surgical mind; and there are unquestionably certain superficial advantages of a hygienic nature about the patient's subsequent condition; though it may be doubted whether these are by any means so considerable as has been made to appear.

However this may be, it goes without saying that no other curative proceeding has so far met with any wide favour in the medical profession; and, if one may judge from their published opinions, the leading exponents of medical practice and opinion, in this country at least, are so pleased with circumcision and its results that they would willingly see the Mosaic Laws in this particular extended to the whole Christian population, whether affected by phimosis or not. Witness Mr. Jonathan Hutchinson:

It is surely not needful to seek any recondite motive for the
origin of the practice of circumcision. No one who has seen the
superior cleanliness of a Hebrew penis can have avoided a very
strong impression in favour of the removal of the foreskin. It
constitutes a harbour for filth, and is a constant source of
irritation. It conduces to masturbation, and adds to the
difficulties of sexual continence. It increases the risk of
syphilis in early life, and of cancer in the aged. I have never
seen cancer of the penis in a Jew, and chancres are
rare.--_Archives of Surgery._

Arguments by this distinguished surgeon, in favour of extension of the custom as a matter of ordinary routine to every male Gentile, are to be found in the _Medical Times and Gazette_, December 1, 1855; together with a reference to previous utterances in an identical sense.

Erichsen (_Surgery_, Ninth Edition, 1888, vol. ii. p. 1188) says:

Every child who has a congenital phimosis ought to be circumcised;
and even those who, without having phimosis, have an abnormally
long and lax prepuce, would be improved greatly in cleanliness,
health, and morals by being subjected to the same operation. It
would be well if the custom of Eastern nations, whether it be
regarded as a religious rite or only as a time-honoured observance,
were introduced amongst us.

In Holmes's _System of Surgery_, 1883, we read:

Circumcision is the operation required in children; and it is best
adapted for adults also when the skin is redundant, and the margins
of the preputial opening are thickened.

Mr. W. H. Jacobson (_Operations of Surgery_, 1889) says:

This operation is still not practised often enough, especially
among poorer patients; amongst whom many practitioners still treat
phimosis as a matter of but little importance.

Some of the pretensions set forth above on behalf of circumcision will be subsequently referred to; but on the plea for a general extension of the rite to nations not impelled thereto by special Divine command, it may be remarked that several Jewish surgeons who have written upon the topic by no means regard this with an eye of favour; and have, in fact, gone even so far as to denounce in the strongest terms its compulsory performance among their co-religionists.[12]

For their dislike, they advance what appear to be very adequate reasons; and, in such a matter they must have enjoyed a far wider special experience than any practitioner without the Hebrew pale.

The following extract from Erichsen's _Science and Art of Surgery_ (Ninth Edition, 1888) may be regarded as a typical account of the ordinary surgical operation in vogue at the present day. The italics are the present writer's:

Circumcision in boys or adults may be most conveniently performed
in the following way. The surgeon restrains hæmorrhage during the
operation by tying a tape tightly around the root of the penis, or
by compressing the organ in Clover's circumcision tourniquet, a
most useful instrument, which can be slackened or tightened at any
time. He next draws the elongated prepuce slightly forwards, until
the portion of it which corresponds to the back of the glans is
brought just in front of that structure. He then seizes the
projecting prepuce immediately in front of the glans with a pair of
narrow-bladed polypus-forceps, which he gives to an assistant, who
must hold them tightly; or he grasps it and protects the glans by
means of a plate which I have had constructed for this purpose.
With one sweep of the bistoury he cuts off all that portion of the
integument which projects beyond the forceps, which are then taken
away. It will now be found that he has removed only a circle of
skin, but that the mucous membrane lining it still tightly embraces
the glans; this he slits up, by introducing the point of a pair of
scissors at the preputial orifice; and then, trimming off the
angles of the flaps, he turns back the mucous membrane and attaches
it to the edge of the cutaneous incision by a sufficient number of
fine catgut sutures. Before introducing these, he will generally
find it necessary _to ligature a small artery on each side of the
penis, and one or two in the frænum_. The best dressing in children
will be some simple ointment, such as boracic acid ointment, or the
glans may be simply smeared with a little vaseline. After every act
of micturition the parts should be well sponged with boracic acid
lotion or Condy's fluid and water. In the adult, union by first
intention may often be obtained by a dry dressing of iodoform-wool
thickly covered with collodion, so as to protect it from the urine.
This may be left unchanged for four or five days. _There is usually
a good deal of swelling of the mucous membrane about the frænum,
and some solid oedema usually remains for some weeks after the
operation._ This gradually subsides, and a linear cicatrix
remains, which causes the patient no inconvenience....

_The chief points to be attended to in the performance of this
operation, and on which its after-success is most dependent,
are_--1. That too much skin be not removed; 2. That the mucous
membrane be slit up to the base of the glans; 3. That too much of
it be not removed; 4. That all bleeding vessels be tied with catgut
ligatures, which must be cut short; 5. That the mucous membrane be
well turned back, so as to cover the gap left by the retracted
skin; 6. That all sutures be of catgut, which will be absorbed, and
thus save the pain of taking them out.

The _modus operandi_ of different surgeons varies in particular details, usually of a slight and unimportant character. The pithy description contained in Maunders _Operative Surgery_ may be appropriately quoted:

The extremity of the foreskin being seized with forceps is drawn
well forwards; the whole prepuce is embraced with the blades of
dressing-forceps, immediately anterior to the _glans penis_, and
cut off in front of the latter instrument. As soon as the forceps
are removed, the skin will become retracted, leaving the mucous
membrane still about the glans; this is slit up longitudinally as
far as the corona, when it may be turned back, and its edge will
come into apposition with the circular wound in the skin. The
operation is now complete; but in the adult it will be well to
introduce a few interrupted sutures.

The prepuce has sometimes been _slit up longitudinally on a director_. Although well suited to cases of adventitious phimosis in the adult, the method is in no way adapted to the congenital form, and has never found general favour with the medical profession. It has no advantages over circumcision; although retaining the prepuce, it still leaves the glans largely uncovered; and the sharp corners of the divided skin, unless trimmed and rounded off, produce a very unsightly after-appearance.

In performing circumcision many surgeons hold the clamp or dressing forceps which protect the glans inclined obliquely downwards and forwards, so as to leave a portion of the prepuce in the neighbourhood of the frænum unremoved. As one of the main advantages claimed for the operation is the prevention of future infection by retention of morbid material in the preputial folds, such a practice would seem to indicate a lurking disbelief in the validity of this pretension. If it be reasonable and right to excise the structure on these grounds, and if that proceeding be attended by such salutary effects; it is only logical not to do things by halves, but to make the excision as complete as possible. Thus Liston made his section near the frænum, 'so as to retain the skin on the glans, which is of advantage.' The use of the _elastic ligature_, and of the _écraseurs_, both ordinary and galvanic, for the performance of circumcision, are cruel and fantastic modes of effecting that object, which hardly need any expression of condemnation; and which it is difficult to believe can ever have been seriously advocated. Keyes (_Diseases of the Urinary Organs_, 1888), after breaking up adhesions with an oiled probe, marks an aniline line around the foreskin, and amputates the skin, &c., in front of this mark; thus previously estimating the amount of tissue to be removed.[13]

For operations involving the amputation of the whole, or nearly the whole prepuce, the following advantages are claimed:--

(_a_) Greatly enhanced local cleanliness throughout after-life.

(_b_) Greater chastity; and the preclusion of immoral personal habits.

(_c_) A smaller liability to venereal contagion in after-life.

(_d_) A diminished proneness to eventual cancerous disease.

In respect of the first of these it may be conceded that, among a people naturally of uncleanly habits, abstraction of the prepuce would at any rate prevent mischief resulting from compulsory retention of the smegma. Whether it would lead to more frequent ablutions is perhaps doubtful; as also whether the plea has any valid efficacy in regard of persons belonging to the better classes, or to nations not specially distinguished (like the Oriental) for their disregard of the most elementary laws of personal hygiene. With savage tribes or with such races as the Chinese (many of whom are said to be completely washed from head to foot on two occasions only--when they enter the world, and when they have quitted it), anything conducing to more complete bodily cleanliness in after-life is certainly worthy of consideration; and probably of approval, even when it necessitates a surgical operation. But to apply this reasoning to more civilised peoples seems hardly warrantable on the facts in view. Shaving the head, or plucking out the nails would materially conduce to subsequent freedom from dirt; but no one would seriously advocate either of these as habitual customs; and the practice under discussion in no way differs from them, so far as the principle involved is concerned.

The second of the reasons above assigned is one which has probably great weight in determining the practice of many surgeons; and it has even been gravely contended by one of the Jewish communion that the Deity instituted the rite among the Israelites in order to promote their greater purity and continence.[14]

This suggests the irrepressible commentary that, whatever the case in bygone years, the operation seems now to have wholly lost its salutary effects in the direction indicated, as Mr. Jonathan Hutchinson (_Medical Times and Gazette_, _loc. cit._) himself testifies.

Doubtless anything which might tend to enhance the chastity of many modern nations would be well worthy of serious consideration; with a view to its universal adoption. Strange to say, however, certain of those medical men who have investigated the question with opportunities of special experience, largely base their opposition to the practice of ritual circumcision upon the ground that removal of the foreskin in early life leads to premature sexual excitement, and a corresponding disposition to onanism. (Levit, _Allg. Wiener med. Zeit._, November 17, 1874.)

In the _Lancet_ of April 4, 1869, two cases materially bearing upon this point are reported. One is that of a Jew, aged thirty-five, suffering from 'spinal paralysis,' which he attributed to a habit of persistent masturbation in childhood or youth. And allusion is made to a younger brother of the same patient; who, as a consequence of the same, had acquired spermatorrhoea, Dr. Willard (Keating's _Cyclopædia_) says:

I have failed to find any statistics proving that the circumcised
masturbate less frequently, or are more virtuous than others; and
the exposure of the tender skin to friction of clothing &c., tends
to keep up a state of abnormal excitement during the early years of
life.

'Where doctors differ, who shall decide?' And in face, therefore, of such directly contradictory opinions from professional witnesses, it is difficult to believe that ablation of the prepuce is of material avail, either in precluding masturbation, or in promoting the subsequent chastity of the adult individual.

On the third of the reasons assigned for advocating circumcision--the prevention of venereal disease when manhood is attained--Mr. Jonathan Hutchinson, whose testimony cannot but receive considerable weight, remarks that chancres are rare in the Jew. The observation has not been controverted; but must be received with a certain amount of hesitancy, in consequence of an evident bias in favour of radical measures of operative treatment. It seems rather to need confirmation by surgeons of the Jewish race, practising especially among their co-religionists. The present writer has been unable to discover any evidence in support from such a quarter. The authority last cited points out that cicatricial tissue is of all others least resistent to infection; and in the writer's own confessedly few opportunities for research in this particular field the number of Jews who have displayed remote but unmistakable indications of previous syphilitic taint has not appeared small. It is not improbable that a Hunterian sore developed upon scar-tissue, or upon the hardened integument of a denuded glans, would be far more trivial in character, more transient, less productive of inconvenience, and less easily recognisable, than the same in a normal state of the parts; the after-effects being, of course, identical. Such primary lesions in a people notoriously rather negligent of their person would seldom come under the notice of the medical practitioner. So, failing further evidence, the provisional verdict upon this question must be the Scotch one, 'Not proven.'

But even if the above assertion be accepted in respect of true syphilis, it assuredly fails to hold good with reference to other varieties of venereal disease. Thus Mr. Jonathan Hutchinson's oft-quoted statistics[15] (_Medical Times and Gazette_, December 1, 1885), in his own words, 'prove that, though in proportion of nearly a third to the other patients, they (Jews) furnish nearly half the cases of gonorrhoea.'

The last-named motive for circumcision, although, in the passage quoted at the beginning of this section, it has been stamped with the approval of the same high authority, needs but transient allusion. It is _a priori_ probable that congenital phimosis prolonged into adult life renders the subject thereof somewhat more likely to develop local malignant disease than any one not so circumstanced; the resulting attacks of inflammation and of unhealthy ulceration, &c., may be naturally expected to lead to the growth of papillomata, as well as to maintain a chronic condition of lowered vitality. But the comparative rarity of epithelioma in this particular locality would deprive the allegation, even if this were positively established as an indisputable fact, of any weight as an argument for the removal of the prepuce. Moreover, it is obviously a reason not for the routine performance of circumcision, but for the relief of phimosis; by whatever means attempted or proposed.

FOOTNOTES:

[11] In Druitt's _Surgeon's Vade-Mecum_, 9th edition, p. 662, are the notes of a case of 'congenital phimosis of the tightest kind' in an adult of twenty-three. Circumcision was threatened; but the affection readily yielded to the injection of warm water daily. There are probably many similar.

[12] Dr. Asher (_op. cit._) does not disapprove of circumcision, but his evidently strong religious bias, and the fact that his whole work is composed from an ecclesiastical point of view, with the express sanction and co-operation of ecclesiastical dignitaries, constitutes him a far from independent (negative) witness.

[13] An immense variety of operative procedures for phimosis, or even of details in the performance of ordinary circumcision, might be quoted. _Quot homines, tot operationes._ Their multiplicity, and the very contradictory nature of the advantages claimed for each, strongly indicate that neither the results of slitting operations, nor those of entire or partial excision of the prepuce, are found uniformly satisfactory. Thus, in addition to the methods described in the text, it may be noted that Jobert de Lamballe and others divide the foreskin on both sides of the frænum without excision; Van Buren makes two cuts, one on the dorsum and one near the frænum, subsequently removing the two flaps; Dr. R. W. Taylor (_American Journal of Syphilis and Dermatology_, October, 1872) makes two _lateral_ incisions with scissors. While, as above stated, some surgeons prefer to hold the forceps which guard the glans obliquely, from above downwards and forwards, so as to leave a certain portion of the skin about the frænum; Mr. Howse (_Guy's Hospital Reports_) advocates the careful removal of the frænum, in order to prevent subsequent oedema. Simple incision on a director was formerly preferred by many, though for congenital phimosis it has now probably fallen into disuse. In contrast with the careful devices for retaining part of the prepuce, or for ensuring that too much be not cut away, Sir W. Fergusson and Professor Humphrey find it best to amputate the structure as radically as possible. On this point see cases by Mr. Reginald Harrison, referred to at page 39.

[14] See the _Lancet_, December 12, 1874. Dr. Asher (_op. cit._) also takes the same view.

[15] The following is Mr. Hutchinson's statistical table derived from his practice at the Out-patient department of the Metropolitan Hospital:

+------------+-----------+--------+-------------------------+
| Cases |Gonorrhoea |Syphilis|Proportion of gonorrhoea |
| | | | to syphilis |
+------------+-----------+--------+-------------------------+
|Not Jews 272| 107 | 165 | 0·6 to 1 |
|Jews 58| 47 | 11 | 4·3 " 1 |
+------------+-----------+--------+-------------------------+

On these figures a plausible inference might perhaps be founded, that what the Jew saves in immunity from syphilis he, to a certain extent, loses in increased proclivity to gonorrhoea; certainly the least of the two evils.

Mr. Hutchinson goes on to state that of 252 children under the age of five years, 27 out of 179 Christians exhibited symptoms of congenital syphilis in a well-marked form; while only 3 out of 73 Jews were thus affected, the proportion thus being 1 in 6 among the Christians, while only 1 in 24 among the Jews. Again, of 97 women (two-thirds being married), of whom 92 were Christians and 5 Jews, 61 of the former were syphilised; against a blank return among the latter. Upon the evidence of these statistics, Mr. Hutchinson advocates a general adoption of the rite of circumcision by Western nations!

Upon his own showing, however, the benefit to be derived from such a sweeping innovation, supposing that this were practicable, is not so very large; for 11 syphilised Jews out of a total of 58 with venereal disease, is a tolerably respectable proportion. The inferences here drawn, moreover, do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners; among whom those of Jewish birth should be able to give specially valuable testimony. The field of inquiry was comparatively small; statistics drawn from the out-patient department of a general hospital are, for obvious reasons, not always of the most reliable character; and the conclusions may be vitiated by the facts suggested in the text. Hence, although they refer to but one venereal malady, it is hardly possible to acquiesce in them implicitly, even in this limited respect; without some confirmation drawn from a much more extended field of research.