The practical physician, however, sees in Professor von Jaksch’s summary the turning-point of many a poor fellow’s career,—from one of comparative health into one of organic disintegration, decay, and dissolution,—all the required processes starting visibly from the very smallest of beginnings; any obstruction in the urinary tract or intestinal canal being sufficient to start any of the conditions which end in toxæmia; and, from a careful observation running over several years, I do not think that I am assuming too much in saying that a balanitis is often the tiny match that lights the train that later explodes in an apoplectic attack or sudden heart-failure due to toxæmia; the organic and vascular systems being gradually undermined until, unannounced and unawares, the ground gives way and the final catastrophe occurs,—unfortunately, an occurrence or ending looked upon as unavoidable by the friends of the victim. They cannot see any danger; the idea that diseases have the road paved, not only for an easy entrance but an easy conquest, by the action of these toxic agents on the tissues, is something that they cannot grasp. These blood changes or blood conditions are things too intricate, and the physician who understands them is, to them, a visionary and unpractical man. These conditions are, however, neither new nor unknown, and there is really no excuse for the ignorance exhibited in these matters by the general public, as it is through the blood that this mischief takes place. They can reason in their impotent way, that they should drench themselves with “blood tonics” and all manner of nauseous compounds to “purify” their blood, but the simple, scientific truth is something beyond their understanding, as well as something that they steel themselves against.
Sir Lionel Beale, in observing the immense importance he attaches to blood composition and blood change in diseases of various organs, truly remarks that “blood change is the starting-point, and may be looked upon as the cause, of what follows,” the other factor being the “‘tendency’ or inherent weakness or developmental defect of the organ which is the subject of attack;” to which he adds that he feels convinced that, if only the blood could be kept right, thousands of serious cases of illness would not occur; while the persistence of a healthy state of the blood is the explanation of the fact that many get through a long life without a single attack of illness, although they may have several weak organs; and that an altered state of the blood, a departure from the normal physiological condition, often explains the first step in many forms of acute or chronic disease. Sir Lionel has been a pioneer in the field of thought that looks for the cause of the disease, which, however remote it may be, should not be overlooked as a really primary affection. His extensive labor in the microscopic field has fully convinced him that many of the pathological changes in the different organs are due to what might be called some intercellular substance that is deposited from the blood. (Beale: “Urinary and Renal Disorders.”)
Toxic elements in the blood affect the kidneys in a greater or less degree, and there produce changes at first unnoticed,—at least, as long as the kidney can perform its function,—but the day arrives when, as described by Fothergill, blood depuration is imperfect, and we get many diseases which are distinctly uræmic in character, and ending in any of the so-called kidney diseases, Bright’s disease being one of the most common. As observed by Fothergill, however, the kidney is not the starting-point, the new departure only taking place when the structural change on the kidney has reached that point that it is no longer equal to its function—the “renal inadequacy” of Sir Andrew Clarke. (J. Milner Fothergill, in the Satellite, February, 1889.)
During the Bradshawe lecture, Dr. William Carter made the following remarks: “According to Bonchard, one-fifth of the total toxicity of normal urines is due to the poisonous products re-absorbed into the blood from the intestines, and resulting from putrefactive changes which the residue of the food undergoes there.” In the course of the lecture, Dr. Carter fully explains that one of the benefits derived from milk diet in Bright’s disease is the small residuum deficient in toxic properties, and lays great stress on the employment of intestinal disinfectants or antiseptics that exercise their influence throughout the whole tract, suggesting naphthalin as peculiarly efficacious, thereby cutting off one source of blood contamination at its source. Although these are recent developments in medicine, Bonchard mentions that in the practice of M. Tapret cases treated on this principle did well. (Braithwaite’s Retrospect, January, 1889.)
Persons laboring under this toxic condition of the blood, with a consequent deterioration in the texture and the physiological function of the vital organs, are of that class that easily succumb to injuries or serious sickness, and of that class to whom a surgical operation of even medium magnitude is equal to a death-warrant.
The above conditions are an almost constant attendant on that condition of the sphincter described by Agnew as sphincterismus, which also is productive of hæmorrhoids and fissure, and often of fistula. That sphincterismus is caused in many cases by preputial irritation is as evident as that the same affection, or hæmorrhoids or any other rectal or anal affection, will, in its turn, produce vesical and urethral reflex actions, and primarily functional and secondarily organic changes in those parts. Besides, the great number of cases wherein the gradual and progressive march of each pathological event could be traced with accuracy has convinced me of the true cause of the difficulty being the result of reflex irritation.
Delafield, in his “Studies in Pathological Anatomy,” gives, as the first form of pneumonia, that from heart disease; in the days of Broussais this would have sounded absurd, but, to-day, some forms of heart disease are known to be the regular sequences of some particular form of kidney disease, just as some form of pneumonia attends an affected heart and that some forms of pneumonia degenerate into phthisis. When the blood change is an established fact, it is only a question as to which is the weak organ, and the organism of the individual will decide whether it will be a simple sick-headache or the beginning of a pneumonia ending in phthisis.
I have purposely dwelt on this part of this subject, owing to the recent origin and publication of many of the views connected with it; also on account of the greater ease of making the subject plain by fully discussing each step of the process; and if the views of Sir Lionel will be recalled, that a toxic element in the blood is the starting-point, and that an irritable or weakened organ invites destruction,—the induction of serious and fatal kidney disorder by the transmitted irritability and consequent injury to the kidney produced by preputial irritation in the first instance, and the supplemental blood-poisoning by intestinal absorption of septic matter, which soon brings about Sir Andrew Clarke’s “inadequacy of kidney,”—all will be readily understood. When this point is reached, a too hearty meal, exposure to variable weather, or a little extra care or anxiety, are sufficient, as determining causes, to bring life into danger.
As pointed out, many cases of Bright’s disease or other renal difficulty have their origin in this distant but visible source, and, although malarial poisoning and a great number of other causes will produce the same particular organic changes and diseases, this condition must be admitted as one of the frequent causes. The influence of the genito-urinary tract on the rest of the economy, and the importance of the sympathy it excites, or how quickly, by its being irritated, some apparently dormant pathological condition will be awakened to life and activity, is not sufficiently appreciated. As observed by Hutchinson, a patient who has once been the subject of intermittent fever is more prone, on catheterization, to have a urethral chill and fever than one who had never had the fever. (Hutchinson: “Pedigree of Diseases.”)
Ralfe observes, in his “Kidney Diseases,” that long-standing disease of the genito-urinary passages must be reckoned as among the chief etiological factors of chronic interstitial nephritis (page 227). The condition of the kidneys in cases of strictures of long standing is known not to be a reliable one, and any incentive to dysuria or to retention, no matter how slight, is apt to lead, eventually—and that even in very young subjects—to that toxic condition mentioned in a former part of this chapter as one of von Jaksch’s subdivisions of toxæmia, the ammoniæmia of Frerichs; this condition being the fatal ending of the case of the two-year-old child mentioned by Henoch, who died after the relief of a retention due to phimosis and calculi resulting from the phimotic occlusion. Having seen so many cases wherein the conditions described in this chapter were so apparently—whether from ammoniæmia due to infection, or toxæmia from the urinary tract, or uræmic toxæmia from the intestinal tract—all due to some preputial interference or irritation, I cannot help but feel that in these conditions—which, singularly, are not so prevalent with the Hebrews as with Christians—we have one factor in the cause of the shorter and more precarious vitality of the latter.
Morel, in his “Traité des Dégénérescences Phisiques,” ably discusses the degenerative and morbific influences and results of toxæmia, as well as he clearly defines their sources. The connection between toxæmia and mental affections has already been shown, and Prof. Hobart A. Hare, in his instructive and interesting prize essay on “La Pathogénie et la Thérapeutique de l’Épilepsie (Bruxelles, 1890)”, mentions that convulsive disorders resulting from the presence of some toxic substance are of frequent occurrence. How much this may enter as a partial factor into many of the cases of epilepsy which are classed in the order of “reflex” may well challenge our consideration. Hare lays great stress on the necessity of circumcision wherever there is an indication of preputial local irritation. “If practicable, circumcision should be performed; it is an operation with but small risk or danger, and easy of performance. In such circumstances it is always permissible to circumcise, were it for no other end than an acknowledged attempt to reach a cure.”
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 majoræ 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 anæsthetic 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 hæmmorrhages, 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 hæmorrhage, 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 œdematous 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 Desprès, 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 œdema, 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, à la Ricord or à 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 anæsthetic until the dressing is quite firm and hard. This dressing forms a carapace for the penis, protecting it from the bedclothes and effectually preventing the annoying and distressing erections. Mr. Ballance reports excellent results from this dressing.” (Braithwaite’s Retrospect, July, 1888.)
In applying the above dressing, the shrinking incident to the drying of the collodion must not be overlooked, and the gauze layers must be loosely applied, as they would otherwise become too tight. The dressing is a very ingenious and serviceable one.
Mr. A. G. Miller, at a meeting of the Edinburgh Medico-Chirurgical Society, reported a new method of dressing after circumcision. “It consisted in first closely suturing the skin and mucous membrane by numerous catgut sutures, then painting the surface with Friar’s balsam and covering it over with two or three layers of cotton wadding, on which the balsam is poured. The glans penis was left sufficiently free to allow of water passing. The band or ring of dressing should be at least one inch broad. The dressing was not suitable for young infants who were frequently wetting. In the case of older children, they might be allowed to go about on the second or third day, when the dressing would be quite dry, and would not be required to be changed or renewed.” (Braithwaite’s Retrospect, January, 1888.)
Any constricting or immovable and inelastic dressing is subject to the same objections as plaster-of-Paris dressings in thigh-fractures,—that of being dangerous and not expedient, unless the patient is constantly under your eye.
Dr. Neil Macleod, in the Edinburgh Medical Journal for March, 1883, advises a procedure that has always looked favorably to me, and which I once put in practice through the means of the ordinary ptosis fenestrated forceps, in place of the ordinary circumcision forceps, the sutures being introduced through the fenestra and the prepuce cut off on the outer side of the forceps, the thickness of the steel arm on the outer side of the fenestra allowing of the properly-sized border for the hold of the sutures. Dr. Macleod places his sutures all in position before making any incisions,—a procedure which will be found to save the patient considerable pain; as with many the seizing and holding of the edges of the skin and mucous membrane and the forcible pressure exerted by the fingers or forceps while the needle is being forced through is the most painful part of the operation. In doing this, care must be taken to allow sufficient length to each thread to make two sutures, as well as care must be taken to properly pull out the thread in the centre between the four folds of tissue and to cut it equidistant, after the ablation of the prepuce, a blunt hook being used to fish up the threads from the preputial opening.
Erichsen favors the Jewish operation in young children, as being the easiest and safest of performance. Slitting, or the inferior or superior incision, he thought, left too much of the prepuce, which, wherever there is a tendency to phimosis, should be entirely removed, “with a view of preserving the health and cleanliness of the parts in after life.” In the phimosis that is acquired by old men, he found dilatation with a two-bladed instrument to be sufficient, provided the indurated circle was made to yield. For the circumcision of adults he has invented an adjustable shield, something like the Jewish spatula, with which he protects the glans.
Gross (the elder) used both slitting on the dorsum and circumcision. He found neither objection nor deformity in the flaps left by the dorsal incision, as they were only temporary; in some cases, he simply followed the practice of Cullerier, of making multiple slits in the constricting and inelastic mucous membrane.
Agnew believes in circumcision in the treatment of reflex troubles. He relates a case, in the second volume of his “Surgery,” of eczema extending over the abdomen, of over a year’s standing, cured in a child by circumcision; he operates by incision on the dorsum, in which he leaves nature to make away with the flaps, or he circumcises by the Bumstead method.
Van Buren and Keyes recommend both the incision on the dorsum and the operation of Ricord; where the mucous membrane alone is tight and constricted, they follow Cullerier’s method of either single or multiple incisions of the inner coat. They lay great stress on the necessity of keeping the patient quietly in bed to insure rapid and complete union.
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 anæsthesia 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 anæsthetic 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 anæsthesia; 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 anæsthetic 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.