Part 7

The present writer has seen this operation performed in one instance, and the after-results were in the highest degree satisfactory. As contrasted with circumcision, the procedure merits warm commendation; preserving the useful foreskin, and followed by a much more speedy recovery than may be expected from the former. For the lacerations which may result from forcible dilatation, small nicks with a pair of scissors are substituted. The only objection is that even this operation, trivial as it appears, is seldom necessary; and that sufficient distension of the foreskin may often be procured without any breach of surface whatever. Moreover, some confinement to bed or to the sofa is subsequently requisite; whereas, after the effects of the anæsthetic have passed off, the patient, young or old, whose foreskin has been dilated, can behave exactly as usual.

Mr. Jordan's operation is, however, a very useful corollary to the dilatation-method in the chronic phimosis (often associated with gout) of men in advanced life; when the parts are usually in a very gristly condition; and when, if it be found impossible to procure retraction by stretching, the contracted tissues may be advantageously nicked with scissors in the mode here indicated.

FOOTNOTES:

For instance, Mr. Erichsen (op. cit.) dismisses the measure with the cursory allusion of a brief paragraph; against the long and elaborate account, previously detailed, of circumcision; it is not mentioned at all in the earlier editions of his work. Ashby and Wright speak of it with great disfavour. Mr. Jacobson (Operations of Surgery, 1890) does not introduce it at all; possibly because hardly worthy to be dignified by the title 'operation.'

In adults, or in boys approaching manhood, gradual dilatation by the daily introduction of a sponge tent has been recommended. It might be resorted to in the case of an exceptionally timid and patient individual, but hardly for any other.

Mr. R. W. Parker (Brit. Med. Journal, July 19, 1879) recommends gradual dilatation with a special screw-forceps, which he has used in a considerable number of cases at the Children's Hospital, 'always with good results.'

In the paper above quoted, by Dr. Cruise, of Dublin (1868), that surgeon speaks of Dr. Hutton having used dressing-forceps for the cure of phimosis fifteen years previously. Very probably the adoption of that instrument for the same purpose would be found on inquiry to date back still further; and no pretension of originality can be here put forth for the advocacy of a simple common-sense practice, which must have been repeatedly resorted to by many practitioners of the past.

M. Faure has also described a somewhat analogous 'nicking' operation.

VII

SUMMARY.

I. Circumcision as a sacrificial rite has been practised by very numerous races of diverse origin, and dates from an extremely remote antiquity; probably from the Stone Age, as suggested by the internal evidence of Biblical records.

II. This fact, together with that of its application by many tribes to the persons of female children, deprives the religious ceremony of any title to the hygienic character and purpose, which have been frequently attributed to it.

III. The surgical operation of circumcision, especially where infants are concerned, has therefore to be discussed solely on its own merits, wholly apart from any theory of Divine intentions, based upon theological considerations. It appears to be erroneous in principle.

IV. It consists in a mutilation; in the removal of a perfectly normal structure, with which, for patent physiological reasons, every male child is endowed by nature. The morality of such a practice, without grave necessity, is open to question.

V. Unless as the result of subsequent disease, no deformity, and indeed no actual abnormality, exist as factors productive of the condition designated 'Congenital Phimosis.' Almost every male child suffers at birth from some degree of the same phenomenon--the imperfect separation of two muco-cutaneous surfaces, developed in contiguity.

VI. Symptoms ascribed to a 'contracted prepuce' are due to natural growth of the glans penis, when this physiological separation is very incomplete, and when, therefore, a rigid constricting envelope prevents development. No true contraction exists, except as the result of superadded inflammation; and is rarely of much importance, unless an element of contagion has been introduced.

VII. The rational treatment of congenital phimosis primarily consists in the efficient execution of the process originally intended by nature, but imperfectly carried out. And, secondarily, in precautions to ensure the permanently free mobility of the prepuce upon the glans penis.

VIII. Such complete separation of the two contiguous layers of membrane may almost invariably be effected by very simple means; and, with some slight attention to after-treatment, will permanently secure all that is desired, without risk and without even transient disability.

IX. The treatment of congenital phimosis by dilatation is the common-sense remedy for this condition. It has been carried out by many practitioners with different instruments and variations of detail; and all who have thus attempted it with ordinary care (including the present writer) seem eminently satisfied with the results.

X. When diseased processes co-exist with congenital phimosis, the case must necessarily be treated on its own merits. Simple dilatation, even if practicable, is not always sufficient, but should be combined with incisions of as limited a nature as possible. Mr. Furneaux Jordan's operation is then useful.

XI. In the event of disease, the operation of circumcision is not devoid of risk, and should be reserved as far as possible for extreme cases, in which removal of the whole prepuce is obviously a matter of necessity.

XII. In healthy children the operation seems to be rarely fatal in this country. Many cases of death directly traceable to circumcision have, however, been reported on the Continent.

XIII. The immediate effects of circumcision, especially when performed on young infants, involve considerable and protracted suffering.

XIV. The most conspicuous remote result is that of an extremely contracted meatus urinarius, as the consequence of subsequent inflammatory processes, due to the exposure and continual friction of the unprotected glans.

XV. The compulsory enforcement of local cleanliness procured by circumcision seems hardly a sufficient argument for the general adoption of the practice by peoples not utterly indifferent to all laws of hygiene; and has little weight even in individual cases.

XVI. The superior chastity and purity of mind and body supposed to be procured for its recipients by ritual circumcision, lie open to very considerable question, in the face of abundant well-known facts.

XVII. The advantage of circumcision in obviating future venereal contagion is restricted by its principal advocate to one form (albeit the most important) of such disease. Even in this limited field the facts adduced appear open to dispute, and greatly to need confirmation by independent observers.

XVIII. In the hands of careless or inexperienced operators the surgical operation of circumcision has been followed by the most disastrous permanent consequences.