Circumcision from the Historic Viewpoint

There has been recent debate over whether circumcision should be made mandatory as a way to prevent the spread of HIV, so I thought I would share the section on circumcision from the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD.

Circumcision

This little operation can be performed in a number of ways.  The practice among the Hebrews when circumcision is performed as a religious rite is to draw the foreskin well forward, to cut it off with one stroke of a long knife, to immerse the penis in wine held in the mouth of the rabbi to stop the hemorrhage, and then to wrap it in linen rags.  It is not surprising that dangerous hemorrhage and infection sometimes follow this procedure, and a few lives have been lost in consequence.

Equally reprehensible is the practice among some surgeons of trying to perform this little operation in the shortest possible time.  For this purpose clamps have been devised to hold the foreskin so that both the external and reflected portions can be cut away by a single stroke of the knife.  It is obvious that the amount of skin thus removed cannot be controlled with certainty, and even if the line of incision be a perfectly smooth circular one, a thing which rarely happens, the adjustment in length of the external and internal portions of the prepuce is at best uncertain.  There is no part of the body concerning which most patients are more sensitive, so that the surgeon ought to be willing to give up a few minutes of his time in order to secure a perfect result.

[When I was taught to do this procedure as a medical student on the pediatric surgery service, the attending often told me “Make it look good so he won’t be embarrassed on a car date.”]

An extensive experience, both in the performance of this operation and in the observance of the operation as performed by others, has convinced the writer that a perfect result is most likely to be attained in the following manner:  The patient, if a very young baby, requires no anesthetic, or ether may be given.  A local anesthetic had better not be employed in patients under six or eight years of age, as it will not remove the fright of an infant or a young child.  The parts should be carefully washed with soap and warm water and a weak solution of bichlorid of mercury 1:2,000 or weaker.  Two sharp nosed artery clamps should be fixed upon the orifice of the foreskin to the right and left of the dorsal median line.  If the orifice is too small to permit this, it should first be snipped dorsally with a pair of scissors.  Traction being upon the clamps, the foreskin is drawn well beyond the head of the penis and one blade of a straight scissors is passed between the head of the penis and the foreskin.  An incision is made which extends nearly back to the reflection of the foreskin.

In drawing the foreskin forward in this manner there is danger that its outer portion will be cut farther back than will its inner portion; hence, after the first clip of the scissors the traction upon the clamps should be relaxed and the reflected portion of the foreskin should be cut farther if necessary.  Two clamps are then placed upon the orifice of the foreskin at its lower edge and an incision is made between them.  This incision is far shorter than the dorsal one.  The two clamps on the left side are then drawn outward and left half of the foreskin is removed, care being taken that the incision through the inner layer of the foreskin shall be nearly parallel to the corona of the glans, and that the incision through the external layer shall be directly opposite to it when only slight traction is made upon the clamps.  The best result is obtained when the portion of the inner layer which is left is a third or a half of an inch in width.  The right half of the foreskin is next cut away.  Any bleeding points are clamped and tied if necessary with very fine catgut.  If the hemorrhage can be stopped by pressure, so much the better.  The edges of the external and internal layers of the foreskin are then approximated by eight or twelve stitches of fine black silk.  The sum of the penis, the third and fourth in the middle of the right and left sides respectively.  In each of the four spaces thus marked off two or three stitches should be placed.  When sutured in this manner the foreskin will not be drawn unevenly in any direction.  If preferred, the stitch at the frenum and the dorsal stitch may be introduced before the sides of the divided foreskin are removed.  These stitches, if left long, will serve as retractors.  In infants no dressings is required, except a little sterile gauze placed between the penis and diaper.  The mother should be told to keep the penis clean by letting a little cooled boiled water run over it after each urination.  In four or five days the stitches should be removed. 

Silk is better than catgut, the latter gives way sometimes and is, besides, more irritating to the tender skin.  In older persons the skin should be well retracted and a circular bandage of sterile gauze wound around the penis behind the glans.  If this becomes soiled with urine it should be immediately changed.  Attention on the part of the patient will usually prevent this accident.  A  good precaution is to lie down to urinate, turning almost upon the face.  This prevents any backward dripping of the urine. Dressed in the manner described, the two cut edges of skin are closely approximated, and will unite with the minimum amount of adhesions.

Complications and Late Results

Painful Micturition – The disability following a properly performed circumcision is very slight.  There may be a little burning during the passage of urine for one or two times.  In an adult, if an erection occurs, it will only be painful in case the dressing is too tight.  It can be relieved at once by loosening or removing the bandage.

Hemorrhage is unlikely if all bleeding points have been ligated.  If it does take place it is usually subcutaneous, and opportunity should be given for the escape of the blood through a gap in the skin incision.  If bleeding is free, and is not controlled by digital pressure or cold, the skin wound should be opened sufficiently to permit proper ligation of the bleeding vessel.  This does not delay complete repair nearly as much as the presence of a subcutaneous hematoma.

Edema is usually due to faulty technique, either mal-approximation of the skin, tearing of the tissues, or hemorrhage beneath the skin.  It shows itself chiefly about the frenum, and may persist long after the wound is healed.  It will ultimately disappear.  Its disappearance may be hastened by hot applications, counter-irritants, pricking with a glover’s needle, etc.

Infection – If the wound becomes infected it should be drained at once by the removal of one or two stitches, by soaking the penis frequently in a mild, hot antiseptic solution, and by wet dressings of creolin 1:200, borolyptol 1:4, etc.   Retraction is likely to follow the removal of stitches, so that in a suppurative case they should be allowed to remain until granulations have fixed the skin edges in contact.

Retraction of the skin of the penis, so that its cut edge is everywhere separated from the cut edge of the mucous membrane, takes place in some cases of infection; and sometimes without infection, if so much skin has been removed that there is undue tension upon the sutures.  The immediate result is a circular band of granulations, over which new epithelium will creep in the course of a couple of weeks.  The ultimate result is generally good, although the immediate result is so discouraging.  The skin of the penis is capable of great stretching, so that erection is not permanently interfered with, even by the removal of too much skin.

Irregularity in Outline  --  An uneven section of the skin should be corrected at the time of operation, but if not noticed then it is better to correct it by a subsequent operation than to allow a patient to go away dissatisfied.  A common error is to leave too much skin at the frenum.  This projects beneath the tip of the penis and catches the last drops of urine, besides being unsightly.

If circumcision is performed to aid the patient in overcoming the habit of masturbation, superfluous skin about the frenum should never be left, since it is most abundantly supplied with sensory nerves, and especially invites manipulation.

Recurrence of Phimosis  --  If the inner layer is left long, say half an inch or more, and the suturing or the dressing has been carelessly done, it may happen that the inner and the outer layers of the foreskin will firmly unite for a distance of a quarter of an inch or more from their free edges.  There will then be formed a strong hand of cicatricial  tissue completely encircling the penis, which by its contraction may so reduce the orifice of the foreskin as to render necessary a second operation.