Part 2

It is not warrantable, however, to speak of _contraction_ of the penile mucous membrane. No contraction takes place, except as a consequence of inflammatory attacks; and these, in the infant, are rarely sufficient to cause any material shrinking. The phenomenon is simply one of natural development under a rigid restraining envelope; and though eventually the aperture is found narrow enough, the 'contraction' is relative only. So also, in every male child there is more or less seeming redundancy of skin at the end of the penis;--for natural physiological reasons. The condition is apt, as first stated, to become factitiously enhanced under the pressure of urinary obstruction. But there is seldom or never a _real superfluity of integument_ in this locality _ab initio_; in excess of what the subsequent needs of the full-developed organism may be reasonably supposed to warrant. It is requisite to lay some stress on these two points, as tending materially to influence our conceptions of the practice condemned in this pamphlet.

Although plainly not absolutely essential to the due increase in bulk of the penis, or to the subsequent performance of its functions, it is _prima facie_ obvious that the prepuce must be intended to subserve some useful purpose. That, according to Dr. Willard (Keating's _Cyclopædia_), 'is to protect the head of the organ, during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm.' The latter half of this statement may fairly be questioned, as the prepuce is completely retracted during coition; and so no friction over 'the corona' can well take place under ordinary conditions. The first part, however, is unimpugnable; and to it may be added some consideration of the protection afforded during the first efforts at functional use.

Some measure of the degree in which the glans penis is shielded from external irritating agencies is afforded by the sensations of the adult for the first time deprived of this appendage; or in whom the latter is kept retracted for any length of time, contrary to preceding habit. Extreme discomfort, indeed considerable soreness and actual pain, are complained of; until tolerance becomes established, and until the delicate membrane has by exposure and friction become so hardened that the absence of its former covering is no longer noticed, a period occupying commonly several weeks.[9]

In the case of young children, the unpleasant sensations involved must be relatively far greater; considering their physical helplessness and their more impressionable nervous system.

According, moreover, to the authority previously cited, early removal of the prepuce is apt to be followed by _progressive sclerosis_, with attendant evils of _contracted meatus_, _balanitis_, &c. And, failing this, 'the exposure of the tender skin to the friction of the clothing, &c. tends to keep up a state of abnormal excitement during the early years of life.'

It thus becomes apparent that, apart from any risks involved by operative procedures, ablation of the prepuce, whether in infant or in adult, is not a measure to be undertaken lightly, or without satisfactory evidence of positive necessity.

FOOTNOTE:

[9] The fact that many adults, of not too sensitive organisation, gradually acquire a habit of retaining the foreskin partially or even entirely retracted, is of course not lost sight of. But this in no way affects the question of its _sudden_ removal, or of the protection afforded by the structure in question to infants of tender years.

III

DANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS.

A perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes. So, in the absence of this, we encounter a number of ill consequences, some local only; some affecting the well-being, and even the life, of the entire organism.

The parts being extremely vascular, and in very intimate relation with the central nervous system; we very naturally find that congenital phimosis, interfering with the normal growth of the glans penis, is prone to develop various reflex neurotic disorders or diseases; of which some have been minutely described by Dr. Sayre.[10] Thus forms of _paralysis_ may ensue; either confined to a single group of muscles, and simulating club-foot, or of a more general character. _Epilepsy_, _reflex cough_, _convulsions_, _choreic movements of the limbs_, are extreme examples; but a milder instance of the same causes in operation shows itself in young infants, as _nocturnal restlessness with defective nutrition_. _Hip-joint disease_ and _spinal caries_ may be simulated, and the mal-assimilation of food may eventually produce such gross deformities as _bowing of the legs_. Chronic _priapism_ is a not uncommon occurrence.

Obstruction to the free discharge of urine may produce symptoms of severe _vesical irritation_, occasionally supposed to indicate stone in the bladder. The straining efforts at micturition may cause _hernia_ or _prolapse of the rectum_; the _nocturnal incontinence_ of children is not unfrequently traceable to the same source. _Epistaxis_ has been described. Retention of urine in the folds of the elongated foreskin, together with the child's habit of pulling this, induce a condition of soreness which causes great smarting whenever micturition takes place, and induces the patient to defer that act as long as possible. Hence may in time result _dilatation of the bladder, cystic kidneys, and death_. Even _eczema_ of the abdominal wall has been thus produced; and has disappeared when the cause was removed, as in a case cited by Dr. Hayes Agnew (_Principles of Surgery_, 1881).

When the patient is allowed to reach adult life with the disability unrelieved, he becomes subject to attacks of _balanitis_; and the parts may ulcerate or even slough. In a case seen by the writer, where at the time no symptoms of inflammation were present, the retained deposits of smegma had ulcerated through the prepuce at various points--projecting from this exactly like chalk-stones from the fingers of a gouty person. In a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no fewer than 426 calculi, varying in size from a pin's head to a small bean, from this situation, in the person of a native of India, sixty years of age, who came under treatment for what appeared to be a large tumour at the end of the penis, the true nature of which was not detected until, on removing it, the knife grated against the contained calculi.' The defect constitutes a serious impediment to impregnation; in the event of an acquired local disorder, its presence seriously hinders diagnosis, and altogether precludes appropriate treatment. It has been supposed, and not without plausibility, to predispose to _epithelioma_. A case is given by Mr. Oliver Pemberton; and others have been reported. There can be no question that, under such circumstances, the presence of malignant disease about the glans would much longer remain undetected than in a normal state of the parts; and that the prospects of cure by operative removal would be proportionately lessened. Only comparatively mild examples of phimosis, in which the adhesions produced little or no constriction, and did not at all interfere with urination, could thus have been suffered to pass unrelieved until the subjects were far past maturity.

Phimosis, as an _acquired_ condition, is of frequent occurrence in an _acute_ form; as the result of inflammatory oedema of the prepuce in youths and adults. This, again, may be a consequence of simple balanitis, the result of want of cleanliness, combined with disordered general health and a catarrhal state of all the mucous membranes; in which event it usually yields to mild measures, such as the injection of warm fluids under the foreskin. In by far the greater number of instances it is produced by venereal infection; and imperatively needs prompt operation, usually in the guise of slitting up the structure on a director. In a _chronic_ form, slowly and gradually coming on, and very intractable to remedial measures, it is not seldom seen in old men of gouty habit; and of consequently unhealthy and irritable mucous membranes.

The pathology and treatment of ACQUIRED phimosis do not fall within the scope of the present work, but it is necessary to point out that these are essentially different from those of the congenital; and that the latter needs consideration upon principles totally diverse.

In the congenital we have to deal with tissues _perfectly healthy_, and with skin peculiarly elastic and distensile. In the factitious, all the parts are more or less altered by _disease_, acute or chronic; and as a sequel to the latter, or to repeated attacks of the former, _true contraction_ takes place; the prepuce often attaining a hard and gristly consistence, under which condition simple dilatation is difficult or impossible. The phenomenon is rarely, if ever, seen in association with congenital phimosis; barring gout or venereal taint in addition.

NOTE.--The infrequency of _cancerous disease_ attacking the penis, renders it unsafe to dogmatise upon any supposed causal relationship between that malady and the presence or absence of the foreskin, and does not appear to warrant any stronger assertion on this point than that which is recorded on the previous page.

FOOTNOTE:

[10] _Orthopædic Surgery_, p. 14. See also Hilton, _Rest and Pain_, p. 276.

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: