Chapter 21

IS THE PREPUCE A NATURAL PHYSIOLOGICAL APPENDAGE?

By many surgeons the idea of circumcision, unless connected with an immediate demand for interference,--such as a phimosis unmanageable by any other means, an induced phimosis from gonorrhoea or other irritation, syphilis in its initiatory sore, cancer or some such cause,--is looked upon as an unwarrantable operation, a procedure not only barbarous, painful, and dangerous, but one that directly interferes with the intentions of nature. The prepuce is by many looked upon as a physiological necessity to health and the enjoyment of life, which, if removed, is liable to induce masturbation, excessive venereal desire, and a train of other evils. The question then resolves itself, What is the real physiological status of this appendage, if it has any, and, if it is a physiological appendage, when does it merge into a pathological appendage? As by some it is held that the prepuce enjoys the same right to live and exist as the nose, ear, or a limb, which are only subject to amputation in case of a serious disease, they should be reminded that they are not taking into consideration that the nose and ear are calculated to warn us of danger, and that our legs are very useful; as even the great orator Demosthenes, by the timely and rapid use of his legs, was enabled to escape from a battle, where his oratory was of no avail against the illiterate javelins of the unscholarly Macedonians. If the prepuce only was endowed with an olfactory sense,--as, for instance, if a nervous filament from the first pair of nerves had been sent down alongside of the pneumogastric and then, by following the track of the mammary and epigastric arteries, had at last reached the prepuce, where the olfactory sense could have been turned on at will, like an incandescent lamp,--it might have been a very useful organ, as in that sense it could have scented danger from afar, if not from near, and enabled man to avoid any of the many dangers into which he unconsciously drops. But, seeing that the prepuce, to say nothing of being neither nose, eye, nor ear to warn one away from danger, or a leg to run away on after once in it, having not even the precautionary sensitiveness of a cat's moustachios, it cannot, in any way that we can see, be compared to any other useful part of the body.

All attempts to find reasons for its existence that are of real benefit to man have so far proved unsatisfactory, and, unlike the reasons for its removal, are, as a rule, founded on speculation. To further reason out the why and wherefore of its existence or of its summary surgical execution, we must consider its shifting positions as to the effects it produces, as well as to its conditions at different ages, sitting on its case like an impartial jury in the case of some unconvicted but diabolically-inclined criminal.

As before remarked, we are, as a rule, born with this appendage, just as much as we are with the appendix vermiformis, which rises up, like Banquo's ghost, whenever we eat tomatoes or any small-seeded fruit. This prepuce is then long, and the penis is found at the end of an undilatable canal, which is formed by the constricted prepuce; at this early stage of our existence it is often additionally bound down to the glans by a greater or less number of adhesions. We are then in what many term a state of physiological phimosis, that being a perfectly natural condition, and one consistent with health; at least, we imagine it is normal.

Phimosis in childhood is generally considered a physiological state, only to be taken as a pathological condition under certain circumstances. Preputial adhesions may, according to many observers, also be classed as physiological at an early period of life, as it is by them considered as congenital, and common enough to warrant its being classed as normal. As to the first, or phimosis, it undoubtedly is a physiological condition during infancy; but why, we do not know; and it is also a fact that from birth to puberty it remains so in fully over one-half of the cases. Out of 98 children, from one week to sixteen years of age, examined by Dr. Packard, the prepuce was entirely unretractable in 54, partly so in 3, and wholly so in 36; while in 1 it only half-covered the glans and in 4 the glans was wholly uncovered, 1 of these 4 being an infant only five weeks old.

Dr. Packard also gives the result of 172 examinations by himself, of from twelve to seventy-three years of age, and 106 examinations by Dr. Maury, a total of 278, in whom 100 had a long prepuce, 97 a partly-covered glans, and 81 (of whom 2 had been circumcised) in whom the glans was exposed.[83] As to adhesions, there is an unaccountable diversity of opinion as to their constancy as a natural condition, being frequent enough to class them as physiological occurrences. Dr. A. B. Arnold, of Baltimore, states that his experience in reference to preputial adhesions leads him to conclude that the frequency of its occurrence has been much overstated. In the number of children that he has circumcised, which exceeds 1000, he has met with it in less than four per cent. of the cases. He also mentions that in the adult the adhesions show greater firmness.[84]

On the other hand, Dr. Bernheim, of the Paris Israelitish Consistory, observes that, of over 3000 newborn whom he has examined, with but few exceptions he found the presence of preputial adhesions. He remarks, however, that in the majority these are detached or broken by the first attempt at erection.[85]

Bokai, out of 100 children, found 8 who were over seven years of age, who were perfectly free; while of the remaining 92 under that age 6 more showed no adhesions and 86 had various degrees of adhesions.[86]

Dr. Holgate, of the out-door department of Bellevue, considered that all phimosic cases have adhesions; while Dr. Moses, of New York, out of some fifty circumcisions performed at the eighth day, found only adhesions three times.[87]

These observations are, however, in perfect accord. If we connect the statement of Dr. Arnold, in regard to the increasing character of the firmness in the adhesions of the adult, with the statement of Dr. Bernheim, that the first erection is often sufficient to break up the existing adhesions in the infant, we must conclude that they are nothing more at first than a slight agglutination, which the slight manipulation required to properly locate the position of the glans, and to space out the prepuce preparatory to the operation of circumcision, must, in the majority of cases, be sufficient to liberate the prepuce from the glans; this is evident also from the statement of Dr. Moses, who only found six per cent. of the cases operated upon by him as being so affected.

The writer has been present at a large number of Hebrew circumcisions performed on the eighth day, and from that up to the sixth month (as in many communities they wait until a number of children are collected, so to speak, before sending for the mohel, who may reside at quite a distance), and in all of those witnessed he has never seen any complications from adhesions; but cases of adhesion have been often encountered from the second to the eighth year, and it has always been the case, as a rule, that the older the child the greater the firmness of the adhesion. In these cases the practice generally advised of using a probe is not practicable, as the person is more apt to wound the sound prepuce than to tear the adhesions; the practice most effectual is to hold the glans firmly but gently with the thumb and forefinger of the right hand, and then to draw the prepuce as firmly back with its fold held in the forefinger and thumb of the other. It is a more expeditious mode, and the least painful; by this method extensive adhesions can readily be broken up; vaselin and a piece of fine lint should then be interposed for a couple of days to prevent a re-adherence.

Another co-existing condition with phimosis, very often found, is a shortening of the frenum. Dr. Jansen, out of 3700 soldiers of the Belgian army, found 12.3 per cent. with this pathological condition and 2.5 per cent. with a narrow prepuce.[88]

Take the three conditions above enumerated,--phimosis, preputial adhesions, and short frenum,--all are but a departure from a normal, in a greater or less degree; and whether the resulting discomfort consists in mere mechanical impediment to urination, erection, or as a factor in nocturnal enuresis, dysuria, impotence, either through reflex action or interference with emission, malposition of the urethral orifice during copulation owing to any of these conditions, or in any of the nervous derangements that may accompany this condition, or in the more serious results, ending in positive deformity of body or limb, or in the warping of moral sentiments, or, even further, in inducing insanity, it cannot well be seen how the conditions that will certainly produce these results, in a more or less degree, can ever, in any logical sense, be considered a physiological condition.

There are certain conditions to life, up to the time of birth, which, unless they then cease at once to exist, immediately become from a physiological into very serious pathological conditions. These are well understood, and have their reasons for existing during our pre-natal existence; but the prepuce has no known function during uterine life or subsequently; and there being no valid reason for its existence, there are certainly no logical grounds for its being considered a physiological condition, especially when the serious results attending the most accentuated form of the above three conditions are considered, and as its necessity, in cases of its entire absence, has not yet been demonstrated.

It can well be said that about two-thirds of mankind are affected in a greater or less degree with these pathological conditions, causing them more or less annoyance. Of these, a certain percentage suffer a life of continued misery, as a direct or indirect result of these conditions.

As to the actual necessity of a prepuce existing, or as to what annoyances or diseases persons are subjected to who are born without it, there is a most singular and expressive silence in medical literature. It stands to reason that, if it is a necessity, some one person should have found it out long ago, and there should then be some evidence to present in relation thereto. There are cases reported in some of the older surgeries wherein an attempt has been made, in the absence of a prepuce, to restore or manufacture one by means of a plastic operation. Vidal describes such an operation,[89] but there is no reason given as to why the operation was undertaken; there is no record of any diseased condition which it was intended either to cure or to alleviate; so that we are left to infer that the person simply submitted to the operation from purely cosmetic reasons. The Hebrews of Palestine, after the Roman conquest, or those in Italy or Spain, attempted a like operation, but not from any reason of lessened health or to restore any lacking physiological action, their aim having simply been to hide their identity, for the purpose of escaping persecutions, exactions, or annoyances, either from their rulers or their fellow-citizens.

Dr. A. B. Arnold, in a paper on circumcision, read before the Academy of Medicine of Baltimore, argues that it is not difficult to divine the purposes of the prepuce, holding that it is necessary to protect the tactile sensibility of the glans, due to the presence of the Pacinian bodies which Schweigger Seidel discovered in the nerves, and that a better provision than the anatomy of the prepuce cannot be conceived for shielding the very vascular and sensitive structure of the glans from external sources of irritation and friction, that might rouse the sensibility of this organ, which, on physiological grounds, may cause early masturbation; further arguing that, the corona being undoubtedly the most excitable part of the glans, its denudation by circumcision leaves it more apt to be affected by chance titillations.[90] In this latter view of the case the preponderance of views is, however, in the opposite direction. J. Royes Bell states that, owing to the induration of the glans through the means of circumcision, masturbation and syphilis are less rife amongst the circumcised than amongst the uncircumcised.[91] M. Lallemand, whose experience in the treatment of seminal emissions is of the greatest value, looked upon circumcision as one of the means of curing those diseases, looking on the diminished irritability of the glans resulting from the operation as the curative element.[92] Dr. Cahen, in a "Dissertation sur la Circoncision," in 1816, before the Faculty of Medicine of Paris, called the attention to the diminished sensibility of the glans induced by circumcision. Dr. Vanier, of Havre, looks upon the prepuce as the most frequent cause of onanism. "If the prepuce is lax, its mobility produces an irritation to the highly irritable and sensitive nervous system of the child by the titillation in its movements on the glans; if too tight and constricted, then it compresses the glans, and by its irritation it leads the child to seize the organ."[93] So that in either case he looks upon the prepuce, through the sensitiveness it retains and induces in the glans, as the principle cause of masturbation. M. Debreyne, the Trappist monk and physician of La Trappe, who has paid considerable attention to medicine as applied to morality, practically makes the same observations. In children who have not yet the suggestions of sexual desire imparted by the presence of the spermatic fluid, the presence of the prepuce seems to anticipate those promptings. Circumcised boys may, in individual cases, either through precept or example, physical or mental imperfection, be found to practice onanism, but in general the practice can be asserted as being very rare among the children of circumcised races, showing the less irritability of the organs in the class; neither in infancy are they as liable to priapism during sleep as those that are uncircumcised.

Dr. Bernheim says that "the prepuce may be said in general to be an appendage to man, if not positively harmful in some cases, at least useless, requiring constant care, the neglect of which is liable to entail disease and suffering; the irritation it produces through the sebaceous secretion is a frequent cause of masturbation which nothing short of circumcision will remedy."

Through middle life, unless the prepuce be the subject of some vicious conformation, little inconvenience may result from its presence, except it be from the dangers to infections already pointed out during this period of life; an ordinarily movable and retractable prepuce will not acquire the condition of phimosis, unless it be through disease or accident; but with our entrance into old age, or after having passed our vigorous prime, the torment of the days of our infancy and childhood come to harass us again. Persons given to corpulency, with a long prepuce, are apt to become affected with phimosis in their latter years, as such persons are more subject to loss of their sexual vigor and power of erection than lean and spare people; in these, the gradual diminution of the size of the erectile tissues of the organ and its retraction allows of the reconstriction of the preputial opening, which, in the end, will not allow the prepuce to be drawn back over the gland. These conditions are followed by the irritating affections incident to phimosis of our earlier life, with the modification that age has induced in making us subject to more serious and fatal ailments, both locally and generally.