The Toad in the Hole Circumcision - A Surgical Bugbear

Boston Medical and Surgical Journal, Volume 191, Issue 26: Pages 1216-1218, 26 December 1924.

Douglas H. Stewart, M.D., F.A.C.S.

The term “Toad in the Hole” is derived from the Hebrew kitchens and cook-books; and it is here used because the writer never has heard any other name for the condition about to be described. The clearest mention of the matter is the following paragraph from the pen of Dr. Thomas H. Lanman of Boston*: “There is one type of case that should be especially mentioned because it is the sort for which circumcision is inadvisable. It is that the boy has a very small penis and a large pad of suprapubic fat, and post-operative care and cleanliness are made very difficult. Extreme cases present the appearance of an umbilical polyp, and this is alarming to the parents.

The present writer admits at once that he has never produced a toad in the hole, therefore there is no case here of a burnt child dreading fire. It is somewhat like the child who fears and shuns fire because he has seen a friend and companion burnt. While it is true that the writer has no troublesome case of his own, it is equally true that he has had troubles sufficient in explaining away the results obtained by others. As Dr. Lanman states, those “results” are “alarming,” and this is so whether the operation has been performed by a surgeon or a mohl.

As to the religious rite when performed by mohl, the parents are much overwrought by a toad in the hole result; because they hold tenaciously to the opinion that if a surgeon had done the work, the accident would not have occurred. Instances, facts of a sort, gossip, and so called evidence furnish a perfect deluge of words by way of proof of this contention. On the contrary, when the operator was a surgeon, orthodox relatives, perhaps not unstimulated by mohl and rabbi, make it their duty to impress upon the parents that the calamity (so called) is a direct visitation of a just God in his wrath for a sinful violation of the plain written law. To add to the hurly-burly, the wretched parents assert and are assured that their child is forever impotent and will have no children. Surely under all the circumstances one may easily understand that some unenlightened people are brewing a very pretty kettle of obstinately maintained misapprehensions which soon are to be masqueraded as facts.

Why the matter has not been brought into the courts is incomprehensible; because the people interested have a way of talking things over and stirring each other up, until their outlook become vicious and their hatred for the operator grows boundless. What decision a judge and jury would come to is unfathomable. Particularly so in view of the fact that physicians themselves, who are not familiar with the condition under discussion, appear to maintain a condemnatory silence when brought into its presence. There are now two patients under observation (aged 4 years and 63 years) who have presented about all of the angles of the toad in the hole result. The operations were performed by two different and competent surgeons. For the purpose of this paper the writer has taken them aside in private and has asked them the hypothetical question: “If placed under oath, would you feel bound to say that the operator was at fault?” Thus far the answers have been affirmative. At the same time it should be clearly stated that explanation and demonstration always caused a reversal of opinion. The writer’s opinion is that, of an exhibition of a toad in the hole patient to a jury could be managed, the verdict would coincide with the amount demanded and the defendant in a malpractice suit would pass many unhappy hours, not matter how innocent he might be. And he would have the greatest trouble to escape punitive damages, if he did finally escape. Yet the whole thing us but a bugbear, and like most bugbears, no matter how slight itself, it makes for a very real alarm. All one has to do is to show that the alarm is unwarranted and unjustified by any fact of the case. Yet this is not a simple matter, since it include explaining away of a parent’s insistence on believing what he sees with his own eyes; untaught and untrained as they are. “He saw with his own eyes that the child had a penis before operation; and he now sees that the child has no penis, or has only a damaged one.”

The way some of the mothers howl and cry over the toad in the hole condition is most startling. One woman made such a terrific noise that all the ambulant patients rushed out of the building and into the street in a panic. The psychology of the unreasoning expression of terror that can be evidenced by Russ-pol Jewess is most interesting, but would carry us too far afield; therefore this sketchy portrait will furnish example enough.

In managing toad in the hole patients it is well for the physician to be forearmed with some sort of formula that will carry hope, comfort and peace to the nervous, frightened parents—something that the wayfaring man, though a fool, cannot mistake. Here is one: “Stop fussing. We will get the boy a good wife yet.” The language may not be polished but the people understand it, and its effect as a wiper away of tears is prompt and satisfactory; whereas gentleness and kindness would be misunderstood, unappreciated and might add fuel to the fire.

Photographs of the toad in the hole condition have not been satisfactory, because the picture shown the penis plainly and not at all as seen by the untrained or careless eye. In reality the parts all fit together with a marvelous adjustment. So perfect is it at times that two ellipses, one within the other, drawn upon the back of the clenched fist will make a good illustration. Let the inner ellipse represent the glans and penis. Let the outer ellipse represent the rime of the socket or curb of the well, as it were. Then with a cotton swab and some tinct. Iodine or other color let this be drawn (as stated, upon the dorsum of the first).



In some instances with a flaccid penis at rest in the hole there is little or no protrusion or protuberance. The penis can be lifted or drawn out of the socket, or the pad of fat can be pushed back; but when erect the penis climbs out, as it were. In the child patient at present under observation the non-protrusion and smoothness would have to be seen to be appreciated.

The treatment of the child is planned according to a routine that was formulated many years ago and it has served its purpose well. It is merely the diet for and the treatment for obesity. The child is supposed to be weighted weekly and its diet so regulated that the weight is kept down to standard for age. As has already been pointed out, the condition is brought about by a more or less localizied obesity, together with a small sized penis. After severance of the foreskin, which in this instance may be compared to a sort of suspensory ligament, the penis sinks into a sort of well in the excessive supra-pubic fat pad. The curb of the well is formed by a fold of the skin. For cleansing purposes, fill the hole and applying freely in its neighborhood, one heaping teaspoonful of Sod. Bicarb. Plus one level teaspoonful of Sod. Perborate dissolved in a tumblerful of warm water acts like an alkaline non-irritant H2O2 and thus lessens the usual difficulty of maintaining post-operative cleanliness.

The adult (aged 63) under observation states that he always needed circumcision and was so advised by various physicians. However, the matter was put off until he was 40 years of age, when he wished to marry and therefore had a circumcision performed; after which his penis promptly fell down the hole. He found no trouble with sexual intercourse that was satisfactory to both parties. His wife has three healthy children. He can have intercourse when he wishes but is rationally abstentious. In this patient when the penis is flaccid all is so smooth that a cursory glance from the side (lateral), when the man is lying down on his back, might mistake pad, penis, and socket for a vulva. However, at the least erection the lips of the socket are shoved apart sidewise and the penis projects quite as it should. Manifestly this patient neither required nor desires treatment. He came for a herniotomy which was successfully performed.

A colleague suggests by way of conclusion that about the most valuable thing in treatment is a suggestion, that comes from the writer’s advice to the mothers: “Bring your child to me on the fourth Thursday of each month and I will watch over his development.” This it appears works out pretty well in keeping the mother from wandering about with her child and thus obtaining all sorts of misunderstood and disquieting opinions. The patients are usually brought for two or three months and by that time the parents have seen the child with an erect penis; or they have become accustomed to the appearance of things so that they are persuaded that the child has a penis, or they have become convinced by some weird and unknown reason that all their worry was but a false alarm in every way. After such conviction they come occasionally, perhaps once in five years. At least they come if they are at all uneasy in mind, or they come to show the doctor how well the child did come along. In one instance they came to talk about the child’s fruitful marriage and to make arrangements for his wife’s approaching confinement.

*Boston Med. and Surg. Jour., p. 628, April 10, 1924.


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