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A PRACTICAL MONTHLY JOURNAL of the medical sciences. HIRAM CHRISTOPHER, M. D., Editor. ASSOCIATE EDITORS: JACOB Geiger, M. D., SURGERY; J. W. HEDDENS, M.D., PATHOLOGY To contributors of Original Articles, a liberal number of copies of the HERALD will be given (or mailed free of expense if addresses are furnished), and the publishers will furnish reprints at cost, application for same to be made when copy is forwarded. Illustrations will be furnished FREE for all articles requiring same, if drawings are furnished. Original Articles, Clinical Reports, Society Proceedings, Correspondence and News invited. Address all articles for publication, books for review and exchanges to the EDITOR. Address all correspondence relating to subscriptions and advertisements to MEDICAL HERALD Co., Sixth and Charles Streets. (See Publishers Bureau.) Lecturer on Genito-Urinary Surgery and Venereal Diseases, Missouri Medical College; Consulting GenitoUrinary Surgeon to the Baptist Sanitarium; Consultant in Genito-Urinary Surgery to the Missouri Pacific Hospital, the City Hospital, the Female Hospital, and to St. Mary's Infirmary, Saint Louis; member of the American Association of Genito-Urinary Surgeons; the Much ingenuity has been bestowed on the seemingly little operation of circumcision, and many different instruments and forms of instruments have been devised with a view to perfecting it in the ease and celerity of its performance and the beauty of its effect. The older operation-that of following the removal of the tegumentary portion with a dorsal slit, and then resecting the mucous portion of the foreskin-is largely in use, even at the present day, notwithstanding its many disadvantageous and ungainly features. It is slow of performance-an especially unattractive feature, from the patient's standpoint. With it, the unpracticed hand is liable to take off too much or too little of the prepuce, making a result that may not be commendable from an esthetic point of view. In its execution at least three cuts are necessary, and with cocaine it is difficult to obtain effective anesthesia of so much tissue as is involved *Read before the Mississippi Valley Medical Association, at Hot Springs, Ark., Nov. 23d, 1894. 2 in these several cuts, rendering repeated injections of the agent necessary. The suturing is awkward, to say the least, and if not done with skillful celerity cocainization is liable to pass off before it is finished-evoking the plaints and criticisms of a nervous patient. And, finally, the suture-line cannot approach the mathematical precision afforded by the operation in which the sutures are placed before the cutting is done, with a fixed clamp for a support and guide. Later operations, intending to obviate these drawbacks, have been described. Skillern's and Briggs' fenestrated clamps enable the operator to do the sewing before the cutting, but in my experience, with these alone it is next to an impossibility to obtain a sufficiently short inner (mucous) layer of foreskin; on cutting off the skin in front of the clamp, the inner layer is found to cap the glans and leave only a small preputial orifice-necessitating additional shortening of that layer, together with removal and replacing of the sutures already piercing it, or, as Dr. Briggs' (through his assistant) suggests, "dividing the membrane on the dorsum between the sutures," to remedy the defect. With the operation and instruments I wish to present, one cut completes that part of the procedure, no appended cutting being required; no reconstruction of suturing is ever necessary, and the suture-line need never be marred or serrated to give freedom to a too long and tight mucous layer of prepuce and yet, in it, the suturing precedes the cutting, it is done with the clamp for a guide and support, conducing to ease and rapidity; hemorrhage is practically nil, and the patient reads the newspaper throughout its performance, so complete is cocainization. And, further, because of the exactitude of apposition and lack of interference with the wound-edges either by irregular cutting or suffusing them with cocaine solution, healing is accomplished with a promptitude that I have never seen following any of the other operations. The procedure is carried out in the following manner: Having secured a thoroughly aseptic condition of the penis by washing, etc., its body is encircled at about its base with an ordinary small-sized rubber band, for hemostasis, and to prevent cocaine-absorption into the system. The assistant adjusts the tractor (long arm upwards), as seen in Fig. I. He distends the arms sufficiently to firmly engage the serrations in the inner surface of the prepuce, and to draw on the latter, pulling on its mucous layer especially. While repressing the glans penis, the operator next applies the clamp, as in Fig. II. Since no cocaine has yet been injected, only moderate traction and clamp-pressure are exerted. Beginning now at the dorsal fold, a long hypodermic needle (2% or 3 inches) is inserted between the mucous and tegumentary layers of each side of the foreskin, enough of the cocaine solu 3 tion (10 per cent strength), to prevent pain, being injected as it is advanced. It must be carried as far as the frenum. Abundant solution may be used, as both the clamp and the rubber bands lay between it and possibility of general absorption, obviating danger of cocaine poisoning. With completion of anesthetization, the traction is to be strongly increased by the assistant, while the operator places six double-length (10inch) cat-gut sutures, running them at once clear through the four layers of foreskin. With strong scissors the prepuce is now removed, cutting close to the clamp, and this at the same time discontinues the use of the tractor. The assistant opens the clamp, allowing the operator to hook up and grasp with two pairs of pinceps the sutures at their middle between the apposed prepuce-layers. On cutting the threads between these two pinceps, two rows of sutures are found to be placed ready for tying. The clamp is removed, the rubber bands are cut, the one or two bleeding vessels secured, and two additional sutures are placed at positions previously occupied by the tractor, viz., at the frenum and the dorsum; 'whereupon, with the tying of the sutures, the operation is completed-usually in about sixteen minutes. The result then presenting is the only actual and living reproduction, which I have ever seen, of the very symmetrical and attractive-looking circumcision that text-books are wont to picture. My dressing consists of a square of antiseptic gauze, perforated for the meatus, and powdered with Fehr's borated talcum. This is lightly secured with moistened crinoline. bandage, after which my dressing-retainer (Fig. III) is adjusted, with the penis directed upwards. The patient walks without the slightest difficulty, and is at his usual employment on the following day. Healing occurs in from four to six days. At the second dressing (two days after the operation) I often find it of advantage to dress with an antiseptic ointment instead of a dry dressing; it allows of freer movement to the penis and allays any irritation connected with the swelling of the glans, etc. The A. S. Aloe Company, of St. Louis, has succeeded admirably in constructing the instruments herewith presented. The curvature of the clamp affords increased room for the glans penis, which, in its adjustment, is squeezed down as flat as possible. The one precaution that I would impress on the beginner with this operation, is to see that his assistant makes strong traction with the tractor at the time of introducing the sutures, bearing in mind that too much cannot easily be exerted, and that the danger of a fault lies in the direction of getting a too long mucous layer to the future prepuce. If this precaution is observed the result will be exactly correct. 1006 Olive street. |