Circumcision of a Father of Five:
Hard, hard, hard work plus naiveté does not make you perfectly suited to perform this operation.
In addition to the fact that we were operating on an area of the human body of special interest, the practical and technical aspects of the operation also held my intensely concentrated attention to detail on that day in January 1964, in OR room 6 at Yale, a “nice” hospital compared to “Ass General.” (MGH) which typically has a number of arrogant bastards among the highly intelligent staff. Yale was the alternate Choice after the Attitude of superiority at Boston had turned us off.
Yale and I had been brought together by the mastercomputer: The hard hard hard work of the Midwest educational system and The Midwest way of life had produced two Senior medical student candidates into the circle of eligibility for admission at either institution. Medical slave laborers at Yale had it better than MGH when comparing using our seven comparative points. Neither place would ever be designated as a Nirvana. As a surgical intern competing with 15 others for survival in the next selection step, I put in work that was hard hard hard, was superior to that of other interns, and I was aware of the fact that selection for survival is based on a rather complex number of factors with which I fortunately was thoroughly familiar.
On the urology service, the several cases caused a number of heads to turn and eyes to open. One was the case of post urinary obstruction diuresis. The vice president of Remington razor in Stamford, Connecticut encountered sclerosis of both the ureters after x-ray therapy administered to alleviate severe retroperitoneal fibrosis had been associated with raging scarring
On small kids we used a circumcision device that consisted of two concave stainless steel cups with very sharp edges, which were fitted in place and pressed together mechanically, an automatic circumciser. But in the larger people we surgically marched around the glans, clamping and cutting the skin and subcutaneous tissue, using the Bovie electrocautery to immediately seal the vessels permanently; we clamped and cut with forceps and scissors again and again.
Urology resident George Michaels: “Take a straight hemostat clamp, place it right here on the dorsal prepuce midline vertically down to near the corona. Now clamp it down hard, to squash that tissue between the teeth of the clamp. Wait. After four seconds, undo the clamp, and the crushed tissue will have been avascularized and won’t bleed a drop!”
Lo and behold! No bleeding from what was expected to be a formidably bloody area. A miracle had occurred. And I, hungry for technical knowledge, memorized every little nuance of the maneuver that George carefully showed me.
Postoperatively it was here that my plastic surgery “background” was able to “contribute to circumcision” by use of the “tie-over pressure dressing.” A nonstick Vaseline gauze was laid on the wound and sutured with 5-0 chromic catgut resorbable, which were tied over the dressing using just the exact amount of pressure to allow circulation to the distal part, yet with enough pressure to resist any tendency for the several cauterized vessels to possibly pour out any drop of blood.
The postop care was specific, the advice oriented toward prevention of bleeding. “To prevent postoperative bleeding, stay relaxed and calm. No raising the blood pressure. No raising the head above the level of the body. No family arguments. No family relations.” It would be a relative catastrophe to have a ball of blood collect right at the end of a nice new penis. The directions continued: “Remain in bed in the supine position, penis elevated a little bit on a small sort of platform. Apply cold (with ice, but not enough to kill the injured tissue). Don’t give any aspirin; it causes bleeding. No erection of the organ whatsoever.” Some minor pain would help prevent motion, but a greater amount of pain should be avoided because it tends to raise the blood pressure. “Provide a calming environment. Use sterile hygienic nursing care. Apply antibiotic ointment to the skin around the area of the surgery.”
I was so pleased at my perfect surgical operation. It was one of my first performances at Yale, and it had to be perfect because this opportunity was a reward for having done good, for hard, hard work. I wanted to show that since I was already tagged as a plastic surgeon, that this “new” specialty could contribute to urologic surgery. Arrangements had been made to preclude even a drop of blood. Please. In my mind I wore a virtual smile.
At 4:00 p.m. the first call came in from Sheila, his wife. “Doctor, he has pain.”
“Where is the pain?”
“In his head.”
The brilliant know-it-all surgeon replied, “Oh yes, I know what that is. We gave him a spinal anesthetic, which causes some cerebrospinal fluid to be lost through the needle puncture. The brain settles down in the foramen magnum of the vertebral column and it impinges on bone. That hurts. How bad is it?”
“Okay, I’ll order some codeine. Do not give him any aspirin.” I called Walgreen’s for some Tylenol with codeine, 30 mg.
At 9:00 p.m. the second call came in. “It’s still hurting, Doctor. I’ve done everything according to your instructions. What can we do?”
“I’ll order a stronger medication. And by the way, be absolutely sure that you keep his head down, level with the body. That should fix that spinal anesthetic problem.” I ordered several 50 mg Demerol tablets. I was assuming this problem was due to the anesthesia resident’s inexperience.
But Sheila said, “Doctor, I have very little control over him. Sometimes he has the head up.”
“No! You can’t have the head up even a half inch with this anesthetic. Keep it down all the time.”
“But I can’t control that.”
“Yes you can. Stay right beside him in bed. When he puts his head up, you push it down. Okay?”
The third call came in two hours later, to my home. “It’s worse. Not only does he still have pain, but the head is bleeding. We have to do something!”
Hello? Oh! One-upmanship has struck again. Just when you think you know it all, you fall down to the bottom of the ladder, you dumb guy. It’s the head of the penis we’ve been talking about. What else, smarty pants?