{"collection":"philosophy-ethics","full_text_available":true,"graph_url":"https://unchartedknowledge.5gfusion.net/v2/api/page/gutenberg_57083/graph","html_url":"https://unchartedknowledge.5gfusion.net/v2/page/gutenberg_57083","id":"gutenberg_57083","license":"Public Domain (US)","rights_basis":"gutenberg_metadata_copyright_false","source":"gutenberg","source_url":"https://www.gutenberg.org/ebooks/57083","summary":null,"tags":["Category: Health & Medicine","Category: History - Other","Category: Philosophy & Ethics","Circumcision","Penis -- Abnormalities"],"text":"Produced by deaurider, Martin Pettit and the Online\nDistributed Proofreading Team at http://www.pgdp.net (This\nfile was produced from images generously made available\nby The Internet Archive)\n\n\n\n\n\n\nTHE\n\nBARBARITY OF CIRCUMCISION\n\nAS A REMEDY FOR\n\n_CONGENITAL ABNORMALITY_\n\nBY HERBERT SNOW, M.D. LOND. &c.\n\nSURGEON TO THE CANCER HOSPITAL\n\n[Illustration: Logo]\n\nLONDON\n\nJ. & A. CHURCHILL\n\n11 NEW BURLINGTON STREET\n\n1890\n\n\n\n\nPREFATORY NOTE\n\n\nTo state that the object of this little work is to 'put down\nCircumcision' under the circumstances indicated, would, besides\nsavouring of unpardonable arrogance, irresistibly suggest analogy to the\nexample of a too famous alderman, who was determined to 'put down\nSuicide.'\n\nIf, however, the facts and arguments therein set forth contribute in\nsome small measure towards the abolition of an antiquated practice\ninvolving the infliction of very considerable suffering upon helpless\ninfants; and sanctioned, on extremely questionable grounds, by men of\neminent authority; the following pages will not have been written in\nvain.\n\n\n     More evil is wrought by want of thought,\n       Than comes from want of heart.\n\n\nGLOUCESTER PLACE, PORTMAN SQUARE:\n_October 1890_.\n\n\n\n\nTHE BARBARITY OF CIRCUMCISION\nAS A REMEDY FOR CONGENITAL ABNORMALITY.\n\n\n\n\nI\n\nCIRCUMCISION AS A RELIGIOUS RITE.\n\n\nThe earliest historical or quasi-historical notice of circumcision is to\nbe found in Genesis xvii.; where Jahve enjoins upon Abraham the personal\nperformance of this mutilation, as a sign of the covenant henceforward\nto subsist between them. Abraham, his son Ishmael, and all his male\nslaves forthwith underwent the prescribed operation; which\nthence-forward remained obligatory upon their posterity, though not\nwithout transient periods of desuetude. It was suffered to lapse during\nthe passage of the Israelites through the wilderness, and was\nsubsequently revived by Joshua (v. 5); again in the reign of Antiochus\nEpiphanes, when some of the Jews seem to have submitted to a plastic\noperation in order to obliterate its effects.[1]\n\nThe compulsory performance of circumcision was re-enacted for the last\ntime by Mattathias, in the age of the Maccabees; and the law to this\neffect has remained in force until the present day.[2]\n\nThe terms in which the Deity addresses his commands to Abraham\npresuppose an already existing familiarity with the ritual ceremony on\nthe part of the latter. Accordingly we find that it previously prevailed\namong the Colchians, \u00c6thiopians, and ancient Egyptians of both the Upper\nand Lower Provinces (Gardner Wilkinson). Among the latter it appears to\nhave become restricted, by the dawn of the historical period, to the\npriestly caste, and to those who desired initiation into the sacred\nmysteries. In the temple of Chunsu at Karnak is a delineation of the\nrite as performed on two young children, probably sons of Rameses II.,\nthe founder of the building. It was apparently connected with the\nworship of Ra, the Sun God; and a seeming allusion to it in this\nconnection is to be found in chapter xvii. of the 'Book of the Dead.'\nNotices of circumcision also appear in ancient Phoenician mythology.\n\nThere can be no question of its very great antiquity, or of its wide\nprevalence among ancient nations. Traditional descent from a prim\u00e6val\nStone Age is betrayed by casual notices in Holy Writ. Thus, in Exodus\niv. 25, a sharp stone is the instrument of mutilation; and in Joshua v.\n2, the marginal rendering is 'knives of flints.'[3]\n\nThe Hivites, the Canaanites (Phoenician), and many if not most of the\nnations with whom the Israelites were brought into contact after\nsettlement in the Promised Land, appear to have practised circumcision\nat some period in their history. In the Old Testament we accordingly\nfind the designation of 'the uncircumcised' specially reserved for the\nPhilistines, and applied to these as a term of opprobrium.\n\nThe list of peoples by whom the circumcision of males has been, or is\nstill, an established custom is sufficiently long. Among such races at\nthe present day, 'an almost unbroken line may be traced from China to\nthe Cape of Good Hope,' and unless perhaps in Europe (where\ncomparatively slight traces of aboriginal manners and customs survive),\nwe find the ceremony characteristic not only of savage tribes, but of\nnations ranking fairly high in the scale of civilisation; for instance,\nthe Mexicans, and the ancient Aztec races of Central America. The Teanas\nand Manaos on the Amazon; the Salivos, Guamos, Otamocos, on the\nOrinoco; the negroes of the Congo, with many other tribes on both the\nwest and east coasts of Africa, notably the Kaffirs, Bechuanas, and\nHottentots; the Abyssinians (Christian), Nubians and modern Egyptians;\nthe natives of Madagascar; most of the Australian aborigines; the\nPapuans, New Caledonians, inhabitants of the New Hebrides, of Java, of\nthe Philippines, and of Fiji, are only a few that may be indicated. An\napproximation to the rite in the form of a slitting up of the prepuce\nwas noticed among the Friendly Islanders by Captain Cook. Although not\nenjoined in the Koran, it is a universal practice among the Mohammedans,\nas a tradition from the ante-Mohammedan period.\n\nA cognate operation upon _females_ obtains among the modern Egyptians,\nthe Nubians, the Abyssinians, as well as in many other parts of Africa\namong the negro races; also among the Malays on the shores of the\nPersian Gulf (Carsten Niebuhr), and on the banks of the Orinoco. As an\nancient custom in Arabia and Egypt, it is noticed by Strabo.\n\nLocal variations of detail are found; as in the case of the Friendly\nIslanders just cited; and of the Madagascarians, who cut the flesh at\nthree several times; the excised prepuce being eventually _swallowed_ by\nsome relative or other.\n\nThe date at which circumcision is performed varies considerably. Among\nthe Jews, the eighth day is, of course, the selected period; probably\nfrom consideration for the sacred number seven, for the seven days of\nuncleanness prescribed for the parturient mother (Lev. xii. 2), and for\nan idea that with the second cycle of seven days the infant then\nproperly commenced its earthly life. Among the Arabs, it is deferred\ntill the thirteenth year; the age at which their reputed ancestor,\nIshmael, was submitted to it. And every race seems to have selected for\nitself what was considered the most suitable time. The Turks, for\nexample, have chosen the seventh or eighth year; the Persians circumcise\nboys at thirteen, girls, between the ninth and the fifteenth year; and\nso on.\n\nIt is thus evident, not only that the rite is extremely ancient, but\nthat it is impossible to refer the practice of circumcision to any\nsingle source; or to doubt that it originally arose among many\nwidely-sundered peoples, as the result of a certain stage in man's\nmental evolution. The once widely-spread custom of the COUVADE, and\nother strange aboriginal practices, afford an illustrative analogy.[4]\n\nHerodotus seems to have been the author, or at least the introducer, of\nthe cleanliness theory; according to which the ceremony was invented\nfrom motives of hygiene. Philo Jud\u00e6us ascribes the custom to four\ncauses: 1. Cleanliness; 2. The avoidance of carbuncle (Qu. cancer?); 3.\nThe symbolisation of purity of heart; 4. The attainment of numerous\noffspring.\n\nOf these, it need hardly be said that the last has no foundation in\nfact; and the two preceding require no remark. The idea, however, that\ncircumcision was initiated for purposes of cleanliness has lasted to the\npresent day, and still appears to have considerable currency. Whatever\nmay have been the social condition of the ancient Egyptians and\nArabians, on behalf of both which races, as having been the source\nwhence Abraham derived his evident familiarity with the custom,\nplausible pretensions have been put forth; it is simply preposterous to\nimagine for a moment that the numerous savage tribes (witness the\nHottentots and the Australian aborigines) who practise it, could ever\nhave been actuated by any such considerations. Its world-wide diffusion,\nagain, totally forbids the supposition, either of its introduction into\nthese tribes by contact with other nations more highly civilised; or of\nits adoption, by the former, while in a higher stage of sociology, from\nwhich they have subsequently become degraded. And this explanation is\nput finally out of court by the phenomenon of an analogous rite applied\nin sufficiently numerous quarters to the persons of females. In order,\ntherefore, plausibly to account for the general prevalence of this\nstrange mutilation, we are compelled to look elsewhere; and an\nexamination of the religious ideas which are known to actuate primitive\nman, will afford a clue.\n\nCopious illustrations of the working of such ideas among peoples\nemerging from barbarism can be traced in almost every page of the\nearlier books of our Old Testament; and, even in classical mythology,\nalthough overlaid by the later developments of a high civilisation,\ntheir influence is still not entirely effaced. The principle of\nsubstitution was familiar to all the nations of antiquity, to the\nIsraelites not the least. Witness the universal resort to sacrifices,\nthe theory of which is well indicated by that of Isaac in Genesis xxii.\nFurther illustrative examples are afforded by the law of the scapegoat,\nin Leviticus xvi.; by the offering of children to Molech (Lev. xx. 2);\nand by the legend of Jephthah's daughter (Judg. xi.). With this, various\nceremonies, involving either mutilation or the shedding of blood, were\nin vogue--for example, the priests of Baal (1 Kings xviii. 28); even\ncutting off the hair seems to have been in the nature of a\nrepresentative sacrifice.[5]\n\nHence many German authorities cited in Keil's _Biblical Arch\u00e6ology_\n(vol. i. p. 415) consider circumcision as a relic of ancient sacrifice:\nthe consecration of a part of the body for the whole. The different\ngrades in the process of humanisation may be assumed to have been\nsuccessively attained as follows. In the earliest periods, human\nsacrifice was probably universal; in the Bible, we have the episode of\nJephthah's daughter, above referred to; and in the narrative of\nAbraham's purpose to offer Isaac there is not the slightest indication\nof surprise on the part of the patriarch when he received Jahve's\ncommands; whence may be argued evident acquaintance with such deeds.\nBesides which, we hear of human sacrifice among the tribes contiguous to\nthe Israelites, until a much later date. Even the Greeks and Romans\noccasionally resorted to this during the historical period; in the\nHomeric age, it appears to have been a not infrequent practice.\n\nAs, however, men progressed in culture and in humanity, such barbarity\nbecame impossible. Instead of putting their firstborn children (often by\ncruel methods, as in the sacrifices to Molech) to death, they\npropitiated the deity by an offer of the most precious member. Indeed,\nin the Genesis account of Abraham's circumcision, Mr. Moncure Conway\nconsiders (_Demonology and Devil Lore_, ii. 83) that the legend,\nsubsequently obscured by later traditions, originally points to the\nperformance of a much more severe operation. And when still more\nadvanced, even this became impossible; the excision of a very small\nportion of the organ, not of indispensable necessity to the fulfilment\nof its functions, being substituted. After many generations had then\npassed over, the custom had become so firmly implanted in the mind and\nhabits of the people, that its eradication was rendered a matter of\nextreme difficulty; even by new religious dispensations and more\nelevated modes of thought. Hence we find the rite among the Israelites\nmade an exception to the fierce denunciation of mutilations in general,\nuttered by Jahve or by his messengers; and hence also, we see it (though\nnot prescribed in the Koran) an ordinary modern custom throughout the\nwhole of Islam, as well as among the Christian Abyssinians.\n\nThe practice of self-emasculation in honour of a divinity was a common\nfeature in the worship of Chronos, of Cybele, and doubtless of many\nother among the earlier recipients of religious adoration; it is\nreferred to (and not in terms of reprobation) at Matthew xix. 12. It has\ndescended to modern times--witness the fanatical sects in Russia; and\neven persons of high intellectual calibre (as, for instance, Origen)\nhave submitted to it. What men regarded as honourable and meritorious in\nthemselves, they would be not unlikely to impose also on their children.\nThe existence of such ascetic practices among partially civilised\nnations must not be lost sight of in the present connection; as helping\nus to comprehend the mental religious attitude of prim\u00e6val man.\n\nThere can be little question that here we find our correct explanation\nof the origin and wide prevalence of circumcision. We are, however, no\nlonger permitted to regard this as a hygienic custom, but simply and\nsolely as a relic of barbarism; dating from an immemorial antiquity,\nlong anterior to the first historical records, and when man was little,\nif at all, removed from savagery. The venerable age of the prescriptive\nrite, as well as the various social and religious phases through which\nthe peoples adopting it have since successively passed, have effectually\nspiritualised it and have shed around it a certain halo of\nsentimentalism; but should not be suffered to obscure the only rational\nconception of its primary significance.\n\nThe sacrificial character of the act among the Israelites was indicated\nby a former custom of placing a pot of dust in the room where the\nceremony was to take place; that, as we read in the third chapter of\nGenesis, being the allotted food of the serpent. The practice seems to\nhave continued down to a recent period, but now to have fallen into\ndisuse.\n\nWe thus clearly see that, beside being the sign of the covenant with the\ntribal deity, there was also involved the idea of a propitiatory\nsacrifice to the awful evil demons. The most clear instance of\ncircumcision as an act intended to conciliate an offended divinity, or\nmalignant spirit, appears in the strange story of Zipporah at Exodus iv.\n24; where the vicarious nature of the rite is also plainly set forth.\nThere is no apparent reason for identifying the Lord ('Adonai'); who\nsought to slay Moses, with Jahve; from whom Moses had just parted upon\nexcellent terms. And there can be little doubt that Samael, to whom the\nscapegoat was subsequently offered (Lev. xvi. 20), or some similar dread\npower of darkness, is here meant.[6]\n\nIf the writer is not greatly in error, an impression prevails in some\nquarters that _Moses_ either instituted anew or effectually perpetuated\nthe rite of circumcision among the Israelites; as a useful measure of\nsanitation. However deservedly high the reputation of the great Hebrew\nlawgiver as a sanitarian, he does not seem entitled to credit in this\nconnection; and alludes but casually to the ceremony, as to an already\nwell-established custom, among certain directions for the treatment of\nthe parturient woman at Leviticus xxii. 3. There is plainly no question\nof hygiene here involved. Dr. Asher (_The Jewish Rite of Circumcision_)\nconsiders that CHASTITY was the main purpose aimed at in the Divine\ninjunction to Abraham; but, for reasons subsequently adduced, such a\ntheory will be seen to have no foundation in fact.[7]\n\nAs the present is not an antiquarian treatise, only a very cursory\nhistoric or ethnic account of ritual circumcision is here inserted; many\nother curious and interesting particulars may be found in the\nauthorities cited at the end of this volume, as well as in the copious\nGerman literature on the same subject. All that has been attempted in\nthe preceding pages is to exhibit the custom in its original character;\nand (in so far as the pretensions advanced upon its behalf as a surgical\nprocedure are concerned), divested of the traditional sanctity which is\npossibly largely answerable for some of the views promulgated by medical\nauthors; whereby the general habit and practice of the medical\nprofession become also of necessity deeply tinged.[8]\n\nFOOTNOTES:\n\n[1] An account of the operation (seemingly then not infrequently\nresorted to) performed at a much later date for the above purpose, is to\nbe found in _Celsus_, lib. vii. cap. xxv.\n\n[2] According to Keating's _Cyclop\u00e6dia of the Diseases of Children_,\n1890, vol. iii., some of the rabbins now omit it; \"in the teeth of a\nstrong and growing popular prejudice.\" I am informed, however, by the\nRev. S. Singer, to whom I am greatly indebted for a courteous reply to\ninquiry on the subject, that these congregations would not be regarded\nas orthodox; and that the innovation is unknown in the Old World.\n\n[3] In the _Lancet_ of April 20, 1889, is figured a curious circumcising\nInstrument used by the Malays, who perform the rite upon boys at the age\nof eight years; and also upon females, about 1/8th inch being nipped off\nthe extremity of the clitoris. In the ceremony performed on female\nchildren, variations exist; other tribes remove the nymph\u00e6.\n\n[4] _La Couvade_ was the designation of the unwritten law, according to\nwhich, directly an infant was brought into the world, the husband\nretired to bed and was sedulously nursed for a certain prescribed\nperiod; the mother, on the other hand, getting up and attending to the\naffairs of the household. Tylor speaks of it as \"this once world-wide\ncustom\" (_Primitive Culture_, i. 76).\n\n[5] Examples of the substitution principle among various _modern_ races\nare to be found in Tylor's _Primitive Culture_, vol. ii. p. 36 _et seq._\n\n[6] The imposition of circumcision by the Jews upon vanquished enemies,\nas the Idumeans and Itureans (Josephus, _Antiq._ B. 13) sounds the like\nnote; there could hardly be any question of proselytism. At an earlier\ndate these people would have been ruthlessly massacred _en masse_, like\nthe Amalekites (1 Sam. xv. 8); slaughtered in great part, like the\nMoabites (2 Sam. viii.); or sacrificed, like Agag (1 Sam. xv. 3), to the\ndeity of the conquerors.\n\n[7] According to the same writer, it is absolutely impossible to say, in\nany given case among the Mohammedans, whether circumcision has been\nperformed or not; for, as the muco-cutaneous membrane has not been\ndivided, 'the soft elastic skin of the penis easily comes forward and\nre-covers the glans.' He states that the performance of that particular\nportion of the ceremony which consists in tearing and removing the\nmembrane in question, completely distinguishes the Jews from all the\nother nations of the world who practise the operation as a religious\nrite.\n\n[8] Two cases of interest in this connection may be here noticed. Dr.\nLevy, a Jew dentist of Stettin, states (_Medical Record_, May 3, 1890)\nthat, like his father before him, he was born without a foreskin;\nfurther, that his four brothers, who died in childhood, were similarly\ncircumstanced.\n\nThe late Dr. Asher (_op. cit._), who must be considered a high authority\nin such a matter (so far at least as concerns his co-religionists),\nsays: 'No part of the human body is subject to so many varieties and\nirregularities as the penis and foreskin.' He believes total absence of\nthe prepuce to be extremely rare, and doubts whether such a phenomenon\nhas ever occurred; but seems to regard a partial deficiency as nothing\nunusual. He states that in most, if not all, instances of supposed\ncongenital absence of this structure, a small portion of the skin will\nbe found prolonged to the glans across the intervening fossa; which\nmorsel, however small, must be excised by the Mohel, with the usual\nformalities. A note informs us that, according to Jewish tradition, the\nfollowing personages never had foreskins: Adam, Seth, Noah, Shem,\nMelchizedek, Jacob, Joseph, Job, Moses, Balaam, Samuel, David, Jeremiah,\nZerubbabel.\n\nThe second case bears upon the very heterodox theory of maternal\nimpressions, and is reported in the same periodical, of dates Nov. 3,\n1888, and March 23, 1889. It is that of a child born accurately\ncircumcised, seven months and twenty days after the like operation on\nhis elder brother (presumably in presence of the mother, although this\nis not stated). The local appearances in the two children are affirmed\nby Dr. Harvey, of Illinois, to have been exactly alike; 'the congenital\ncase even showing the marks of the sutures.'\n\nBoth of the above cases, together with Dr. Asher's experiences, may be\nrespectfully commended to the notice of Professor Weismann.\n\n\n\n\nII\n\nNATURE OF CONGENITAL PHIMOSIS--PHYSIOLOGICAL IMPORTANCE OF THE PREPUCE.\n\n\nThe word 'phimosis' ([Greek: phimo\u00f4], I bind) signifies that condition\nof the penis in which the prepuce cannot be retracted beyond the _corona\nglandis_; and which may be either congenital or factitious.\n\nThe latter is a pathological phenomenon, the product of injury or of\ndisease. To apply the term 'abnormal' to the former is, however, hardly\npermissible, except when the difficulties in retraction are permanent\nand extreme; when they cannot be overcome by judicious perseverance, and\nby careful manipulation in the early weeks of infant life. A certain\namount of adhesion between the two contiguous surfaces of mucous\nmembrane is almost constantly present at birth, as a continuation of\nthe normal intra-uterine agglutination (Keating's _Cyclop\u00e6dia of the\nDiseases of Children_, 1890, vol. iii.; article by Dr. De Forest\nWillard).\n\nThe radical defect in congenital phimosis is thus the adhesion or\nimperfect separation of two muco-cutaneous surfaces, normally developed\nin close contact. As a rule, these are so slightly connected that a very\nslight degree of force is sufficient to part them; but in a considerable\nminority of instances the defect eventually becomes permanent; with the\nnatural growth of the organ more difficulty is experienced in procuring\nretraction; and various disagreeable, or even dangerous, symptoms are\nprone then to make their appearance.\n\nThe complaint, however, is simply one of degree. If the adhesions at the\nmargin of the urethral meatus are so tight that they fail to be quickly\nseparated by the stream of urine directed against them--the force of\nwhich necessarily varies in different infants--considerable impediment\nto micturition results; and, perhaps usefully, serves to direct early\nattention to the state of the parts. In rare cases, no opening at all\ninto the urethra has been discoverable; and complete retention has\nnecessarily ensued. Very often, however, nothing of this sort happens\nfor several weeks, months, or even years; and the existence, or rather\npersistence, of the disability may not be noticed at all until\nadolescence of adult life. The majority of instances lie between these\nextremes; not seldom unpleasant symptoms begin to be observed when the\nboy is a few months old; but there is a wide range of variation.\n\nThe penile and preputial layers of mucous or quasi-mucous membrane being\nfirmly adherent, and growth of the glans penis proceeding apace, certain\nconsequences necessarily follow.\n\nThe prepuce being (in extreme cases) tightly fixed to the margins of the\nurethral orifice, the _meatus urinarius_ still retains the same calibre\nas when birth took place, and becomes far too small for the needs of the\nrapidly growing child. A difficulty in effectually voiding the bladder\nis experienced, and may eventually result in complete retention. The\nlittle patient tugs at the seat of unpleasant sensation; and this\nelongates the folds of skin at the extremity of the penis, normally\nsomewhat redundant, and extremely distensile. The muscular force of the\nbladder being spent upon overcoming the obstruction at the narrow\nmeatus, the urine trickles out feebly, and 'balloons' in the soft\npouches beyond, which continuously retain a few drops. Hence great local\nirritation and excoriation.\n\nIt is not warrantable, however, to speak of _contraction_ of the penile\nmucous membrane. No contraction takes place, except as a consequence of\ninflammatory attacks; and these, in the infant, are rarely sufficient to\ncause any material shrinking. The phenomenon is simply one of natural\ndevelopment under a rigid restraining envelope; and though eventually\nthe aperture is found narrow enough, the 'contraction' is relative only.\nSo also, in every male child there is more or less seeming redundancy of\nskin at the end of the penis;--for natural physiological reasons. The\ncondition is apt, as first stated, to become factitiously enhanced under\nthe pressure of urinary obstruction. But there is seldom or never a\n_real superfluity of integument_ in this locality _ab initio_; in excess\nof what the subsequent needs of the full-developed organism may be\nreasonably supposed to warrant. It is requisite to lay some stress on\nthese two points, as tending materially to influence our conceptions of\nthe practice condemned in this pamphlet.\n\nAlthough plainly not absolutely essential to the due increase in bulk of\nthe penis, or to the subsequent performance of its functions, it is\n_prima facie_ obvious that the prepuce must be intended to subserve some\nuseful purpose. That, according to Dr. Willard (Keating's _Cyclop\u00e6dia_),\n'is to protect the head of the organ, during the years when the penis is\nbut a portion of the urinary apparatus; and later, by its friction over\nthe sensitive corona, to enhance the ejaculatory orgasm.' The latter\nhalf of this statement may fairly be questioned, as the prepuce is\ncompletely retracted during coition; and so no friction over 'the\ncorona' can well take place under ordinary conditions. The first part,\nhowever, is unimpugnable; and to it may be added some consideration of\nthe protection afforded during the first efforts at functional use.\n\nSome measure of the degree in which the glans penis is shielded from\nexternal irritating agencies is afforded by the sensations of the adult\nfor the first time deprived of this appendage; or in whom the latter is\nkept retracted for any length of time, contrary to preceding habit.\nExtreme discomfort, indeed considerable soreness and actual pain, are\ncomplained of; until tolerance becomes established, and until the\ndelicate membrane has by exposure and friction become so hardened that\nthe absence of its former covering is no longer noticed, a period\noccupying commonly several weeks.[9]\n\nIn the case of young children, the unpleasant sensations involved must\nbe relatively far greater; considering their physical helplessness and\ntheir more impressionable nervous system.\n\nAccording, moreover, to the authority previously cited, early removal of\nthe prepuce is apt to be followed by _progressive sclerosis_, with\nattendant evils of _contracted meatus_, _balanitis_, &c. And, failing\nthis, 'the exposure of the tender skin to the friction of the clothing,\n&c. tends to keep up a state of abnormal excitement during the early\nyears of life.'\n\nIt thus becomes apparent that, apart from any risks involved by\noperative procedures, ablation of the prepuce, whether in infant or in\nadult, is not a measure to be undertaken lightly, or without\nsatisfactory evidence of positive necessity.\n\nFOOTNOTE:\n\n[9] The fact that many adults, of not too sensitive organisation,\ngradually acquire a habit of retaining the foreskin partially or even\nentirely retracted, is of course not lost sight of. But this in no way\naffects the question of its _sudden_ removal, or of the protection\nafforded by the structure in question to infants of tender years.\n\n\n\n\nIII\n\nDANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS.\n\n\nA perfectly healthy condition of the male generative organs is\ncompatible only with perfect mobility of the prepuce over the gland\nwhich it envelopes. So, in the absence of this, we encounter a number of\nill consequences, some local only; some affecting the well-being, and\neven the life, of the entire organism.\n\nThe parts being extremely vascular, and in very intimate relation with\nthe central nervous system; we very naturally find that congenital\nphimosis, interfering with the normal growth of the glans penis, is\nprone to develop various reflex neurotic disorders or diseases; of which\nsome have been minutely described by Dr. Sayre.[10] Thus forms of\n_paralysis_ may ensue; either confined to a single group of muscles, and\nsimulating club-foot, or of a more general character. _Epilepsy_,\n_reflex cough_, _convulsions_, _choreic movements of the limbs_, are\nextreme examples; but a milder instance of the same causes in operation\nshows itself in young infants, as _nocturnal restlessness with defective\nnutrition_. _Hip-joint disease_ and _spinal caries_ may be simulated,\nand the mal-assimilation of food may eventually produce such gross\ndeformities as _bowing of the legs_. Chronic _priapism_ is a not\nuncommon occurrence.\n\nObstruction to the free discharge of urine may produce symptoms of\nsevere _vesical irritation_, occasionally supposed to indicate stone in\nthe bladder. The straining efforts at micturition may cause _hernia_ or\n_prolapse of the rectum_; the _nocturnal incontinence_ of children is\nnot unfrequently traceable to the same source. _Epistaxis_ has been\ndescribed. Retention of urine in the folds of the elongated foreskin,\ntogether with the child's habit of pulling this, induce a condition of\nsoreness which causes great smarting whenever micturition takes place,\nand induces the patient to defer that act as long as possible. Hence may\nin time result _dilatation of the bladder, cystic kidneys, and death_.\nEven _eczema_ of the abdominal wall has been thus produced; and has\ndisappeared when the cause was removed, as in a case cited by Dr. Hayes\nAgnew (_Principles of Surgery_, 1881).\n\nWhen the patient is allowed to reach adult life with the disability\nunrelieved, he becomes subject to attacks of _balanitis_; and the parts\nmay ulcerate or even slough. In a case seen by the writer, where at the\ntime no symptoms of inflammation were present, the retained deposits of\nsmegma had ulcerated through the prepuce at various points--projecting\nfrom this exactly like chalk-stones from the fingers of a gouty person.\nIn a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no\nfewer than 426 calculi, varying in size from a pin's head to a small\nbean, from this situation, in the person of a native of India, sixty\nyears of age, who came under treatment for what appeared to be a large\ntumour at the end of the penis, the true nature of which was not\ndetected until, on removing it, the knife grated against the contained\ncalculi.' The defect constitutes a serious impediment to impregnation;\nin the event of an acquired local disorder, its presence seriously\nhinders diagnosis, and altogether precludes appropriate treatment. It\nhas been supposed, and not without plausibility, to predispose to\n_epithelioma_. A case is given by Mr. Oliver Pemberton; and others have\nbeen reported. There can be no question that, under such circumstances,\nthe presence of malignant disease about the glans would much longer\nremain undetected than in a normal state of the parts; and that the\nprospects of cure by operative removal would be proportionately\nlessened. Only comparatively mild examples of phimosis, in which the\nadhesions produced little or no constriction, and did not at all\ninterfere with urination, could thus have been suffered to pass\nunrelieved until the subjects were far past maturity.\n\nPhimosis, as an _acquired_ condition, is of frequent occurrence in an\n_acute_ form; as the result of inflammatory oedema of the prepuce in\nyouths and adults. This, again, may be a consequence of simple\nbalanitis, the result of want of cleanliness, combined with disordered\ngeneral health and a catarrhal state of all the mucous membranes; in\nwhich event it usually yields to mild measures, such as the injection\nof warm fluids under the foreskin. In by far the greater number of\ninstances it is produced by venereal infection; and imperatively needs\nprompt operation, usually in the guise of slitting up the structure on a\ndirector. In a _chronic_ form, slowly and gradually coming on, and very\nintractable to remedial measures, it is not seldom seen in old men of\ngouty habit; and of consequently unhealthy and irritable mucous\nmembranes.\n\nThe pathology and treatment of ACQUIRED phimosis do not fall within the\nscope of the present work, but it is necessary to point out that these\nare essentially different from those of the congenital; and that the\nlatter needs consideration upon principles totally diverse.\n\nIn the congenital we have to deal with tissues _perfectly healthy_, and\nwith skin peculiarly elastic and distensile. In the factitious, all the\nparts are more or less altered by _disease_, acute or chronic; and as a\nsequel to the latter, or to repeated attacks of the former, _true\ncontraction_ takes place; the prepuce often attaining a hard and gristly\nconsistence, under which condition simple dilatation is difficult or\nimpossible. The phenomenon is rarely, if ever, seen in association with\ncongenital phimosis; barring gout or venereal taint in addition.\n\n\n     NOTE.--The infrequency of _cancerous disease_ attacking the penis,\n     renders it unsafe to dogmatise upon any supposed causal\n     relationship between that malady and the presence or absence of the\n     foreskin, and does not appear to warrant any stronger assertion on\n     this point than that which is recorded on the previous page.\n\nFOOTNOTE:\n\n[10] _Orthop\u00e6dic Surgery_, p. 14. See also Hilton, _Rest and Pain_, p.\n276.\n\n\n\n\nIV\n\nCUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED\nADVANTAGES.\n\n\nFrom the preceding, the evils or dangers incurred by permitting a male\nchild to reach adult life; or, in the event of pressing symptoms, to\npass even a few weeks or months with this disability unrelieved; are\nsufficiently obvious. Although, as Dr. Willard (_op. cit._) states, the\nadhesions between prepuce and glans can nearly always be broken down\nwith sufficient readiness during the first few weeks after birth, there\ncan be little doubt that, without conspicuous necessity, the medical\npractitioner will seldom care to 'make the baby cry,' and thus draw down\nupon himself vigorous maternal reproaches. It seems, moreover, hardly\njudicious to encourage any tampering by nurses or midwives, probably\nmore or less ignorant and unskilled. We may take it for granted,\ntherefore, that nothing will usually be done until the child is several\nmonths old; when some more energetic treatment will be requisite to\nremedy the condition in question. In milder cases no notice will\nprobably be taken of the abnormality for at least several years, and its\npresence may be detected only by accident; the adhesions in such are\ntrivial, and do not interfere with normal growth; hence are, as a rule,\neasily overcome.[11]\n\nAlthough less severe measures have been from time to time brought\nforward and advocated, the operation of circumcision is, to all intents\nand purposes, the only procedure in general use for remedying congenital\nphimosis; and as the latter is very common, so also is the performance\nof this ancient sacrificial rite among that large majority of the\npopulation who are otherwise in no way committed to it. There is a\nsimplicity and thoroughness about the little amputation which may\nperhaps commend it to the surgical mind; and there are unquestionably\ncertain superficial advantages of a hygienic nature about the patient's\nsubsequent condition; though it may be doubted whether these are by any\nmeans so considerable as has been made to appear.\n\nHowever this may be, it goes without saying that no other curative\nproceeding has so far met with any wide favour in the medical\nprofession; and, if one may judge from their published opinions, the\nleading exponents of medical practice and opinion, in this country at\nleast, are so pleased with circumcision and its results that they would\nwillingly see the Mosaic Laws in this particular extended to the whole\nChristian population, whether affected by phimosis or not. Witness Mr.\nJonathan Hutchinson:\n\n\n     It is surely not needful to seek any recondite motive for the\n     origin of the practice of circumcision. No one who has seen the\n     superior cleanliness of a Hebrew penis can have avoided a very\n     strong impression in favour of the removal of the foreskin. It\n     constitutes a harbour for filth, and is a constant source of\n     irritation. It conduces to masturbation, and adds to the\n     difficulties of sexual continence. It increases the risk of\n     syphilis in early life, and of cancer in the aged. I have never\n     seen cancer of the penis in a Jew, and chancres are\n     rare.--_Archives of Surgery._\n\n\nArguments by this distinguished surgeon, in favour of extension of the\ncustom as a matter of ordinary routine to every male Gentile, are to be\nfound in the _Medical Times and Gazette_, December 1, 1855; together\nwith a reference to previous utterances in an identical sense.\n\nErichsen (_Surgery_, Ninth Edition, 1888, vol. ii. p. 1188) says:\n\n\n     Every child who has a congenital phimosis ought to be circumcised;\n     and even those who, without having phimosis, have an abnormally\n     long and lax prepuce, would be improved greatly in cleanliness,\n     health, and morals by being subjected to the same operation. It\n     would be well if the custom of Eastern nations, whether it be\n     regarded as a religious rite or only as a time-honoured observance,\n     were introduced amongst us.\n\n\nIn Holmes's _System of Surgery_, 1883, we read:\n\n\n     Circumcision is the operation required in children; and it is best\n     adapted for adults also when the skin is redundant, and the margins\n     of the preputial opening are thickened.\n\n\nMr. W. H. Jacobson (_Operations of Surgery_, 1889) says:\n\n\n     This operation is still not practised often enough, especially\n     among poorer patients; amongst whom many practitioners still treat\n     phimosis as a matter of but little importance.\n\n\nSome of the pretensions set forth above on behalf of circumcision will\nbe subsequently referred to; but on the plea for a general extension of\nthe rite to nations not impelled thereto by special Divine command, it\nmay be remarked that several Jewish surgeons who have written upon the\ntopic by no means regard this with an eye of favour; and have, in fact,\ngone even so far as to denounce in the strongest terms its compulsory\nperformance among their co-religionists.[12]\n\nFor their dislike, they advance what appear to be very adequate reasons;\nand, in such a matter they must have enjoyed a far wider special\nexperience than any practitioner without the Hebrew pale.\n\nThe following extract from Erichsen's _Science and Art of Surgery_\n(Ninth Edition, 1888) may be regarded as a typical account of the\nordinary surgical operation in vogue at the present day. The italics are\nthe present writer's:\n\n\n     Circumcision in boys or adults may be most conveniently performed\n     in the following way. The surgeon restrains h\u00e6morrhage during the\n     operation by tying a tape tightly around the root of the penis, or\n     by compressing the organ in Clover's circumcision tourniquet, a\n     most useful instrument, which can be slackened or tightened at any\n     time. He next draws the elongated prepuce slightly forwards, until\n     the portion of it which corresponds to the back of the glans is\n     brought just in front of that structure. He then seizes the\n     projecting prepuce immediately in front of the glans with a pair of\n     narrow-bladed polypus-forceps, which he gives to an assistant, who\n     must hold them tightly; or he grasps it and protects the glans by\n     means of a plate which I have had constructed for this purpose.\n     With one sweep of the bistoury he cuts off all that portion of the\n     integument which projects beyond the forceps, which are then taken\n     away. It will now be found that he has removed only a circle of\n     skin, but that the mucous membrane lining it still tightly embraces\n     the glans; this he slits up, by introducing the point of a pair of\n     scissors at the preputial orifice; and then, trimming off the\n     angles of the flaps, he turns back the mucous membrane and attaches\n     it to the edge of the cutaneous incision by a sufficient number of\n     fine catgut sutures. Before introducing these, he will generally\n     find it necessary _to ligature a small artery on each side of the\n     penis, and one or two in the fr\u00e6num_. The best dressing in children\n     will be some simple ointment, such as boracic acid ointment, or the\n     glans may be simply smeared with a little vaseline. After every act\n     of micturition the parts should be well sponged with boracic acid\n     lotion or Condy's fluid and water. In the adult, union by first\n     intention may often be obtained by a dry dressing of iodoform-wool\n     thickly covered with collodion, so as to protect it from the urine.\n     This may be left unchanged for four or five days. _There is usually\n     a good deal of swelling of the mucous membrane about the fr\u00e6num,\n     and some solid oedema usually remains for some weeks after the\n     operation._ This gradually subsides, and a linear cicatrix\n     remains, which causes the patient no inconvenience....\n\n     _The chief points to be attended to in the performance of this\n     operation, and on which its after-success is most dependent,\n     are_--1. That too much skin be not removed; 2. That the mucous\n     membrane be slit up to the base of the glans; 3. That too much of\n     it be not removed; 4. That all bleeding vessels be tied with catgut\n     ligatures, which must be cut short; 5. That the mucous membrane be\n     well turned back, so as to cover the gap left by the retracted\n     skin; 6. That all sutures be of catgut, which will be absorbed, and\n     thus save the pain of taking them out.\n\n\nThe _modus operandi_ of different surgeons varies in particular details,\nusually of a slight and unimportant character. The pithy description\ncontained in Maunders _Operative Surgery_ may be appropriately quoted:\n\n\n     The extremity of the foreskin being seized with forceps is drawn\n     well forwards; the whole prepuce is embraced with the blades of\n     dressing-forceps, immediately anterior to the _glans penis_, and\n     cut off in front of the latter instrument. As soon as the forceps\n     are removed, the skin will become retracted, leaving the mucous\n     membrane still about the glans; this is slit up longitudinally as\n     far as the corona, when it may be turned back, and its edge will\n     come into apposition with the circular wound in the skin. The\n     operation is now complete; but in the adult it will be well to\n     introduce a few interrupted sutures.\n\n\nThe prepuce has sometimes been _slit up longitudinally on a director_.\nAlthough well suited to cases of adventitious phimosis in the adult, the\nmethod is in no way adapted to the congenital form, and has never found\ngeneral favour with the medical profession. It has no advantages over\ncircumcision; although retaining the prepuce, it still leaves the glans\nlargely uncovered; and the sharp corners of the divided skin, unless\ntrimmed and rounded off, produce a very unsightly after-appearance.\n\nIn performing circumcision many surgeons hold the clamp or dressing\nforceps which protect the glans inclined obliquely downwards and\nforwards, so as to leave a portion of the prepuce in the neighbourhood\nof the fr\u00e6num unremoved. As one of the main advantages claimed for the\noperation is the prevention of future infection by retention of morbid\nmaterial in the preputial folds, such a practice would seem to indicate\na lurking disbelief in the validity of this pretension. If it be\nreasonable and right to excise the structure on these grounds, and if\nthat proceeding be attended by such salutary effects; it is only logical\nnot to do things by halves, but to make the excision as complete as\npossible. Thus Liston made his section near the fr\u00e6num, 'so as to retain\nthe skin on the glans, which is of advantage.' The use of the _elastic\nligature_, and of the _\u00e9craseurs_, both ordinary and galvanic, for the\nperformance of circumcision, are cruel and fantastic modes of effecting\nthat object, which hardly need any expression of condemnation; and which\nit is difficult to believe can ever have been seriously advocated. Keyes\n(_Diseases of the Urinary Organs_, 1888), after breaking up adhesions\nwith an oiled probe, marks an aniline line around the foreskin, and\namputates the skin, &c., in front of this mark; thus previously\nestimating the amount of tissue to be removed.[13]\n\nFor operations involving the amputation of the whole, or nearly the\nwhole prepuce, the following advantages are claimed:--\n\n(_a_) Greatly enhanced local cleanliness throughout after-life.\n\n(_b_) Greater chastity; and the preclusion of immoral personal habits.\n\n(_c_) A smaller liability to venereal contagion in after-life.\n\n(_d_) A diminished proneness to eventual cancerous disease.\n\nIn respect of the first of these it may be conceded that, among a\npeople naturally of uncleanly habits, abstraction of the prepuce would\nat any rate prevent mischief resulting from compulsory retention of the\nsmegma. Whether it would lead to more frequent ablutions is perhaps\ndoubtful; as also whether the plea has any valid efficacy in regard of\npersons belonging to the better classes, or to nations not specially\ndistinguished (like the Oriental) for their disregard of the most\nelementary laws of personal hygiene. With savage tribes or with such\nraces as the Chinese (many of whom are said to be completely washed from\nhead to foot on two occasions only--when they enter the world, and when\nthey have quitted it), anything conducing to more complete bodily\ncleanliness in after-life is certainly worthy of consideration; and\nprobably of approval, even when it necessitates a surgical operation.\nBut to apply this reasoning to more civilised peoples seems hardly\nwarrantable on the facts in view. Shaving the head, or plucking out the\nnails would materially conduce to subsequent freedom from dirt; but no\none would seriously advocate either of these as habitual customs; and\nthe practice under discussion in no way differs from them, so far as the\nprinciple involved is concerned.\n\nThe second of the reasons above assigned is one which has probably great\nweight in determining the practice of many surgeons; and it has even\nbeen gravely contended by one of the Jewish communion that the Deity\ninstituted the rite among the Israelites in order to promote their\ngreater purity and continence.[14]\n\nThis suggests the irrepressible commentary that, whatever the case in\nbygone years, the operation seems now to have wholly lost its salutary\neffects in the direction indicated, as Mr. Jonathan Hutchinson (_Medical\nTimes and Gazette_, _loc. cit._) himself testifies.\n\nDoubtless anything which might tend to enhance the chastity of many\nmodern nations would be well worthy of serious consideration; with a\nview to its universal adoption. Strange to say, however, certain of\nthose medical men who have investigated the question with opportunities\nof special experience, largely base their opposition to the practice of\nritual circumcision upon the ground that removal of the foreskin in\nearly life leads to premature sexual excitement, and a corresponding\ndisposition to onanism. (Levit, _Allg. Wiener med. Zeit._, November 17,\n1874.)\n\nIn the _Lancet_ of April 4, 1869, two cases materially bearing upon this\npoint are reported. One is that of a Jew, aged thirty-five, suffering\nfrom 'spinal paralysis,' which he attributed to a habit of persistent\nmasturbation in childhood or youth. And allusion is made to a younger\nbrother of the same patient; who, as a consequence of the same, had\nacquired spermatorrhoea, Dr. Willard (Keating's _Cyclop\u00e6dia_) says:\n\n\n     I have failed to find any statistics proving that the circumcised\n     masturbate less frequently, or are more virtuous than others; and\n     the exposure of the tender skin to friction of clothing &c., tends\n     to keep up a state of abnormal excitement during the early years of\n     life.\n\n\n'Where doctors differ, who shall decide?' And in face, therefore, of\nsuch directly contradictory opinions from professional witnesses, it is\ndifficult to believe that ablation of the prepuce is of material avail,\neither in precluding masturbation, or in promoting the subsequent\nchastity of the adult individual.\n\nOn the third of the reasons assigned for advocating circumcision--the\nprevention of venereal disease when manhood is attained--Mr. Jonathan\nHutchinson, whose testimony cannot but receive considerable weight,\nremarks that chancres are rare in the Jew. The observation has not been\ncontroverted; but must be received with a certain amount of hesitancy,\nin consequence of an evident bias in favour of radical measures of\noperative treatment. It seems rather to need confirmation by surgeons of\nthe Jewish race, practising especially among their co-religionists. The\npresent writer has been unable to discover any evidence in support from\nsuch a quarter. The authority last cited points out that cicatricial\ntissue is of all others least resistent to infection; and in the\nwriter's own confessedly few opportunities for research in this\nparticular field the number of Jews who have displayed remote but\nunmistakable indications of previous syphilitic taint has not appeared\nsmall. It is not improbable that a Hunterian sore developed upon\nscar-tissue, or upon the hardened integument of a denuded glans, would\nbe far more trivial in character, more transient, less productive of\ninconvenience, and less easily recognisable, than the same in a normal\nstate of the parts; the after-effects being, of course, identical. Such\nprimary lesions in a people notoriously rather negligent of their person\nwould seldom come under the notice of the medical practitioner. So,\nfailing further evidence, the provisional verdict upon this question\nmust be the Scotch one, 'Not proven.'\n\nBut even if the above assertion be accepted in respect of true syphilis,\nit assuredly fails to hold good with reference to other varieties of\nvenereal disease. Thus Mr. Jonathan Hutchinson's oft-quoted\nstatistics[15] (_Medical Times and Gazette_, December 1, 1885), in his\nown words, 'prove that, though in proportion of nearly a third to the\nother patients, they (Jews) furnish nearly half the cases of\ngonorrhoea.'\n\nThe last-named motive for circumcision, although, in the passage quoted\nat the beginning of this section, it has been stamped with the approval\nof the same high authority, needs but transient allusion. It is _a\npriori_ probable that congenital phimosis prolonged into adult life\nrenders the subject thereof somewhat more likely to develop local\nmalignant disease than any one not so circumstanced; the resulting\nattacks of inflammation and of unhealthy ulceration, &c., may be\nnaturally expected to lead to the growth of papillomata, as well as to\nmaintain a chronic condition of lowered vitality. But the comparative\nrarity of epithelioma in this particular locality would deprive the\nallegation, even if this were positively established as an indisputable\nfact, of any weight as an argument for the removal of the prepuce.\nMoreover, it is obviously a reason not for the routine performance of\ncircumcision, but for the relief of phimosis; by whatever means\nattempted or proposed.\n\nFOOTNOTES:\n\n[11] In Druitt's _Surgeon's Vade-Mecum_, 9th edition, p. 662, are the\nnotes of a case of 'congenital phimosis of the tightest kind' in an\nadult of twenty-three. Circumcision was threatened; but the affection\nreadily yielded to the injection of warm water daily. There are probably\nmany similar.\n\n[12] Dr. Asher (_op. cit._) does not disapprove of circumcision, but his\nevidently strong religious bias, and the fact that his whole work is\ncomposed from an ecclesiastical point of view, with the express sanction\nand co-operation of ecclesiastical dignitaries, constitutes him a far\nfrom independent (negative) witness.\n\n[13] An immense variety of operative procedures for phimosis, or even of\ndetails in the performance of ordinary circumcision, might be quoted.\n_Quot homines, tot operationes._ Their multiplicity, and the very\ncontradictory nature of the advantages claimed for each, strongly\nindicate that neither the results of slitting operations, nor those of\nentire or partial excision of the prepuce, are found uniformly\nsatisfactory. Thus, in addition to the methods described in the text, it\nmay be noted that Jobert de Lamballe and others divide the foreskin on\nboth sides of the fr\u00e6num without excision; Van Buren makes two cuts, one\non the dorsum and one near the fr\u00e6num, subsequently removing the two\nflaps; Dr. R. W. Taylor (_American Journal of Syphilis and Dermatology_,\nOctober, 1872) makes two _lateral_ incisions with scissors. While, as\nabove stated, some surgeons prefer to hold the forceps which guard the\nglans obliquely, from above downwards and forwards, so as to leave a\ncertain portion of the skin about the fr\u00e6num; Mr. Howse (_Guy's Hospital\nReports_) advocates the careful removal of the fr\u00e6num, in order to\nprevent subsequent oedema. Simple incision on a director was formerly\npreferred by many, though for congenital phimosis it has now probably\nfallen into disuse. In contrast with the careful devices for retaining\npart of the prepuce, or for ensuring that too much be not cut away, Sir\nW. Fergusson and Professor Humphrey find it best to amputate the\nstructure as radically as possible. On this point see cases by Mr.\nReginald Harrison, referred to at page 39.\n\n[14] See the _Lancet_, December 12, 1874. Dr. Asher (_op. cit._) also\ntakes the same view.\n\n[15] The following is Mr. Hutchinson's statistical table derived from\nhis practice at the Out-patient department of the Metropolitan Hospital:\n\n\n     +------------+-----------+--------+-------------------------+\n     |    Cases   |Gonorrhoea |Syphilis|Proportion of gonorrhoea |\n     |            |           |        |       to syphilis       |\n     +------------+-----------+--------+-------------------------+\n     |Not Jews 272|    107    |   165  |        0\u00b76 to 1         |\n     |Jews      58|     47    |    11  |        4\u00b73  \" 1         |\n     +------------+-----------+--------+-------------------------+\n\n\nOn these figures a plausible inference might perhaps be founded, that\nwhat the Jew saves in immunity from syphilis he, to a certain extent,\nloses in increased proclivity to gonorrhoea; certainly the least of the\ntwo evils.\n\nMr. Hutchinson goes on to state that of 252 children under the age of\nfive years, 27 out of 179 Christians exhibited symptoms of congenital\nsyphilis in a well-marked form; while only 3 out of 73 Jews were thus\naffected, the proportion thus being 1 in 6 among the Christians, while\nonly 1 in 24 among the Jews. Again, of 97 women (two-thirds being\nmarried), of whom 92 were Christians and 5 Jews, 61 of the former were\nsyphilised; against a blank return among the latter. Upon the evidence\nof these statistics, Mr. Hutchinson advocates a general adoption of the\nrite of circumcision by Western nations!\n\nUpon his own showing, however, the benefit to be derived from such a\nsweeping innovation, supposing that this were practicable, is not so\nvery large; for 11 syphilised Jews out of a total of 58 with venereal\ndisease, is a tolerably respectable proportion. The inferences here\ndrawn, moreover, do not appear to have been confirmed by careful\nstatistical observation carried out by other medical practitioners;\namong whom those of Jewish birth should be able to give specially\nvaluable testimony. The field of inquiry was comparatively small;\nstatistics drawn from the out-patient department of a general hospital\nare, for obvious reasons, not always of the most reliable character; and\nthe conclusions may be vitiated by the facts suggested in the text.\nHence, although they refer to but one venereal malady, it is hardly\npossible to acquiesce in them implicitly, even in this limited respect;\nwithout some confirmation drawn from a much more extended field of\nresearch.\n\n\n\n\nV\n\nDISADVANTAGES AND DANGERS OF CIRCUMCISION.\n\n\nAs a surgical operation, circumcision is commonly performed with so much\nimpunity that many surgeons will probably not be disposed to admit the\npossibility of its being attended by any danger to life; and there can\nbe no doubt that it is but seldom followed by a fatal result. Still,\nwith any breach of surface whatever, there must be a chance of\nblood-poisoning and of the absorption of septic materials; and, in the\ncase of a child liable to h\u00e6mophilia, it cannot be doubted that serious\nconsequences might readily ensue.\n\nThus, in the third century it was enacted by the rabbins (_Talmud,\nTreatise Jebamoth_, 646) that, after two deaths in the same family from\nthis cause, the ceremony was to be omitted; and the prohibition has\ncontinued in force ever since. Maimonides inculcates the utmost caution\nin the performance of the rite, and insists that 'in case of doubtful\nsickness, a child must not be circumcised; since danger to life\noverrides the whole ceremonial law.' (_Maimonides on Circumcision_, ch.\ni.). At the present date it is always effected by an expert (Mohel), who\nis not infrequently a qualified medical man; and accidents are guarded\nagainst with jealous care.[16]\n\nThe ancient plan, according to which the operator received in his mouth\n(previously filled with wine) the extremity of the lacerated member, is\nnow wholly or in great part abolished among the Jewish community; it\nbeing found that both syphilis and tuberculosis were thus communicated\nto the infant.[17]\n\nThe _Lancet_ of October 1, 1870, quotes from the _Wiener Med. Presse_\nthe particulars of two cases, reported by Dr. Schwartz, of boys\ncircumcised at the usual period; who subsequently died from phlegmonous\ninflammation and sloughing of the part, one five and the other\ntwenty-five days subsequently to the operation. In the same periodical\nfor December 5, 1874, may be found allusion to the experience of Dr.\nKohn, himself a Jew; who stated at a medical society in Vienna, that\nduring a practice of thirty-five years he had known six deaths from this\nsource (_Allg. Wiener Med. Zeit._ November 17, 1874). He himself had\nthus lost a child of his own.\n\nHowever such fatality may be attributed to the neglect of all hygienic\nrules among the poorer classes of Jews; it can hardly be doubted that,\nunder even the most favourable conditions, septic poisoning or\nuncontrollable h\u00e6morrhage _must_ occasionally happen, albeit extremely\nrare; and this whether the operation has been performed from ritual or\nfrom surgical motives. To the absence of such cases reported in medical\nliterature, too much weight must not be attributed.[18]\n\nIt is rather upon the minor consequences, immediate or subsequent, that\nthose who object to the practice have founded their opposition; and of\nsuch there has been no lack, especially among medical men who have been\nthemselves Jews, and who have thus necessarily enjoyed the fullest\nexperience of its effects. Thus the _Lancet_ of December 5, 1874,\nmentions a pamphlet by Dr. Levit, demonstrating the evils of the custom.\nHe speaks of the premature beginning of sexual excitement in boys\ndeprived of their prepuce, and the disposition to onanism so common to\nEastern nations; he regards circumcision as a criminal manipulation;\nand calls upon the medical profession to oppose the practice, even at\nthe risk of losing favour at the hands of the Jewish families they\nattend. And his arguments are effectually sustained by Dr. Kohn. Dr.\nSchwartz, in recording the fatal cases above quoted, 'deprecates the\ncustom with great warmth, and expresses the wish that it may be laid\naside.'\n\nMr. R. W. Parker (_British Medical Journal_, July 19, 1879) refers to a\nchild (one of a family of bleeders) who, being circumcised, nearly bled\nto death. He also says: 'Diffuse cellulitis of the penis is not an\nuncommon complication after this operation in unhealthy, ill-fed, and\nbadly-cared-for children.'\n\nDr. Mastin, in _Gaillard's Medical Journal_, speaks of the great\nfrequency with which he has been consulted by Jews for chronic urethral\ndischarges, irritable urethra, and other affections of the\ngenito-urinary organs. He describes 'the preternaturally small meatus\nwhich results from early removal of the prepuce by circumcision.'\n(_Medical Record_, December 10, 1885.) Elsewhere in the same periodical\n(_Medical Record_, vol. xxi.) we are informed that 95 per cent. of young\nmale Jew adults have this contracted meatus.\n\nShorn of its natural protective covering, the muco-cutaneous covering of\nthe glans soon becomes true dermoid tissue. Mr. J. Hutchinson (_loc.\ncit._) speaks of 'every one who is acquainted with the effects of\ncircumcision in rendering the delicate mucous membrane of the glans\nhard and skin-like.' Contact with the clothing, &c., necessarily induces\na chronic inflammatory condition of the part, followed commonly by\ncontraction and condensation. We cannot with impunity rashly interfere\nwith any of Nature's dispositions, however seemingly insignificant.\n\nThis hard skinlike condition of the integument upon the glans penis,\nwith its concomitant of narrowed urethral aperture, may be regarded as\nthe normal result of circumcision. In the hands of bungling operators,\nhowever, far worse consequences may follow. Thus J. Bell (_Manual of\nOperations in Surgery_, 1866) 'has known the glans penis included in the\nincision in _at least_ one instance.' (The italics are his own.) Mr.\nReginald Harrison (_Diseases of Urinary Organs_, 3rd Edition, 1887) has\ntreated two _varieties_ of urethral stricture after circumcision which\nhave not turned out well; in two _cases_, the extremity of the glans\npenis, including the meatus, had been wounded in making the section of\nthe prepuce; in a third, owing to 'oedema and difficulty of ascertaining\nwhere the glans was, amputation had been performed, and the end of the\nglans included.' The second variety of stricture was caused by the\nprepuce being divided too high up, or, what amounts to the same thing,\nbeing drawn down too much over the glans penis, before being included in\nthe forceps for the purpose of making the necessary section. On bringing\ntogether the parts with sutures, the tension on them was so great as to\ncause ulceration, and to leave behind a broad cicatrix, capable of\nexercising a contractile pressure on the under surface of the urethra;\nsufficient to impede micturition and to cause other discomfort.'[19]\n\nDr. Hyde (_Boston Medical and Surgical Journal_, June 26, 1890) has seen\ndisastrous results from circumcision; and Dr. Willard (in Keating's\n_Cyclop\u00e6dia of the Diseases of Children_) says that, after circumcision,\nhardening of the glans occurs; and the evils of contracted meatus,\nbalanitis, &c. follow, as pointed out by Otis, Mastin and others. So\nfar, therefore, as the remote consequences of circumcision are\nconcerned, there is strong evidence that the operation is by no means an\nunmixed blessing to its recipient.[20]\n\nTurning to the more immediate effects and consequences, the italicised\npassages in Mr. Erichsen's elaborate description concur with the\nexperience since cited of other writers, to show the need of\nconsiderable caution in the performance of this surgical procedure.\nSeptic infection, h\u00e6morrhage, and subsequent sloughing of the part have\nto be sedulously guarded against; and on the Continent, at least, the\nresources of modern antiseptic surgery have been specially invoked.\nWithout careful ligature of the arteries, these may, we are told, give\nrise to troublesome and long unnoticed h\u00e6morrhage when the patient is\nput back to bed. The examples above quoted, and the varying practice of\ndifferent surgeons, show, moreover, that discrimination and judgment are\nessential as to the excision of either too much or too little of the\nforeskin; both of which events may be disadvantageous.\n\nMr. W. H. Jacobson (_Operations of Surgery_, 1889) says that after\ncircumcision 'an adult should lie in bed for forty-eight hours, and keep\non the sofa for a week, alternate stitches being removed at intervals.\nIf he insist on getting about too early, he must run the risk of the\nparts remaining _long oedematous and tender_. And for this reason, with\nhospital patients, who have to come backwards and forwards, _early and\ncomplete healing is not to be expected_. (The italics are the present\nwriter's.)\n\nIt may be reasonably assumed that no sane man, who possessed the\nadvantages of a sound and entire prepuce, would willingly sacrifice it\nwithout just and sufficient cause being shown. And his natural\nrepugnance to such a deprivation would probably be in no wise lessened\nby a perusal of the passage last cited. It would be without doubt in the\nhighest degree edifying in the present connection, were the sensations\nof some educated adult of average sensitiveness, who had submitted to\nthe operation, placed on record; together with a statement of the time\nwhich elapsed before perfect tolerance became established; and before\nthe 'hard skinlike condition,' so much approved of by Mr. J. Hutchinson,\nand the other more or less enthusiastic advocates of circumcision, was\nsatisfactorily attained. In the absence of such a delineation, however,\nwe can only surmise the feelings of the patient; and conclude that, as\nwith catheterisation, and other manipulations addressed to a delicate\nmucous membrane, they would in some instances be almost _nil_; but that\nin the man of highly sensitive organisation, they would amount to keen\nand long-protracted torture.\n\nInfants of tender years must of necessity be classed in the latter of\nthese two categories; in their case, there are also certain\ncircumstances which tend to enhance the barbarity of the procedure; and\nlargely to aggravate the suffering involved. Thus an American operator\n(at the association meeting of genito-urinary surgeons, reported in the\n_Boston Med. and Surg. Journal_, June 26, 1890) speaks of the difficulty\nof keeping children's knees out of the way after removal of the prepuce,\nand of the consequent torture to them. Even after healing, contact with\nflannel napkins, and other clothing, must long be very painful. There\ncan be little doubt what would be the verdict--could they only give it\nutterance--upon the immediate results of the operation in question;\nreturned by these inarticulate (if far from mute) victims of hygienic\northodoxy.[21]\n\nFOOTNOTES:\n\n[16] The most scrupulous and minute precautions for obviating any danger\nto life are enjoined by the Talmud. The ceremony is not permitted to\ntake place at all unless the child is in perfectly sound health; and\nthat Mohel, whose conscience may convict him of having caused the death\nof an infant by his negligence, is forbidden ever to officiate again.\n\n[17] A case of tuberculosis thus contracted is reported in the _British\nMedical Journal_ of March 5, 1887; and twelve other instances are also\nmentioned in the same paragraph.\n\n[18] The writer has been unable to discover any mortality statistics of\nritual circumcision, and apparently none exist. Dr. Asher (_op. cit._)\nmakes a remark to the same effect.\n\n[19] In the same work its author states that an unnatural smallness of\nthe urethra is a not infrequent cause of incontinence of urine in\nchildren. In some cases therefore ascribed to congenital phimosis, may\nnot the incontinence be merely a concomitant, and not an effect, of the\nlatter condition?\n\n[20] Dr. Keyes (_Diseases of Urinary Organs_, 1888) has been 'twice\ncalled upon to relieve by operation a phimosis resulting from a former\noperation.'\n\n[21] An objection to circumcision, of wholly sentimental character, yet\nnot the less worthy of practical consideration, may, in addition to\nthose set forth in the text, be here noted. The parents of any child, in\nwhom the necessity of some remedial measure for congenital phimosis has\nbecome apparent, usually express considerable relief when told that it\nis not necessary to make the infant 'a little Jew.'\n\n\n\n\nVI\n\nABSENCE OF NECESSITY FOR CIRCUMCISION IN CASES OF CONGENITAL\nPHIMOSIS--THE RATIONAL TREATMENT OF THE LATTER.\n\n\nFrom what has been already set forth, it is sufficiently evident that no\nmale should be suffered to reach adult life with this congenital\ndisability unrelieved; and that in the majority of instances radical\ntreatment is requisite at a far earlier date. There can be no doubt that\nit is infinitely better for an infant to be subjected to circumcision,\nthan to pass many months or years with the unpleasant or even dangerous\nsymptoms previously detailed. The point now to be considered, therefore,\nis whether these symptoms can be obviated by any less heroic measure,\nand whether the suffering thus incurred is a matter of absolute\nnecessity; whether, indeed, it is right and proper to subject the child\nto _mutilation_ for the benevolent purpose indicated.\n\nFor by no less term can the procedure in question be characterised. It\nconsists in the abstraction of a structure, not indeed of paramount\nimportance to the organism, but obviously evolved by Nature for wise\nends as a protective covering. Were there no necessity for its\npresence, it would not occur; and without overwhelming evidence that\nsuch mutilation is unavoidable and beneficial, it must be held ethically\ncriminal thus to lay rough hands upon a perfectly normal organ.\n\nAs indicated above, congenital phimosis may be said in some slight\ndegree to occur in every new-born male child. Two layers of\nmuco-cutaneous membrane are developed in close contact, and are commonly\nagglutinated in a measure; but it is only when the separation is very\nincomplete that any defect producing consequences of importance is\nfound. There is no deformity or deficiency of parts; and, except as a\nconsequence of long-continued inflammation, no contraction occurs. What\nis commonly spoken of as 'a contracted prepuce' simply signifies the\nnatural growth of the glans under a rigid envelope, primarily of normal\nproportions.\n\nAll, then, that is requisite to remedy this condition in the first\ninstance, is the due separation of the two contiguous layers of\nmuco-cutaneous membranes, which in the new-born may generally be\neffected with ease. As the infant grows, however, there is apt to\nsupervene relative disparity of size; the tissues cannot be sufficiently\nexpanded to allow of the ideal state of the organ--a prepuce movable\nfreely and loosely upon its included glans--without some laceration.\nAnd, unless care be taken, the wounds in the parietal layer of\nmuco-cutaneous membrane again quickly heal; the new cicatricial tissue\nundergoes, perhaps, a little real contraction; and matters remain as\nthey were before. Hence, probably, the disfavour with which procedures,\ninvolving dilatation of the prepuce, seem to have been hitherto regarded\nby most surgeons.[22] Some amount of reunion between the two surfaces\nmay also take place at the spots where the adhesions have been ruptured.\n\nThe principle to be aimed at, however, is simply the separation of two\ncontiguous and adherent layers of mucous or muco-cutaneous membrane. Few\nmedical men are probably aware of the natural distensibility of the\nparts; of the ease with which (when the patient is rendered passive and\nunconscious by means of an an\u00e6sthetic) the glans can be brought\ncompletely into view, and the prepuce perfectly retracted behind the\ncorona. All that is then necessary is, by the use of emollients and by\ndaily retraction for a very brief period, to prevent reunion of\nadhesions or of fissures in the muco-cutaneous membrane; until a\nsufficient degree of dilatation has been secured to preclude all fear of\nany future difficulty.\n\nCertain precautions are, of course, necessary. The patient should be\nan\u00e6sthetised; the tissues involved are extremely sensitive, and the\nadministration of ether (or of chloroform in the case of a young\nchild), besides relaxing the parts, enables the measure to be carried\nout much more efficiently than would otherwise be the case. Although the\nnecessary dilatation can usually be very speedily effected, it often\ntakes some little time thoroughly to remove the adherent smegma, not\nseldom of gritty and calcareous consistence. This, besides being the\nlongest, is the most painful part of the manipulation. The use of\ncocaine as a local an\u00e6sthetic for such a purpose, precluding the\nadministration of ether or chloroform, is not to be recommended. The\nwide surface involved renders its influence incomplete; and it is of\nconsiderable advantage to have the patient, particularly when of tender\nyears, oblivious to what is going on.[23]\n\nIf the distension be too timidly effected, so that the foreskin can be\nretracted over the glans only with difficulty; an equal difficulty will\nbe found in pulling it forwards again, and temporary paraphimosis may\nresult. Under an\u00e6sthesia, however, this cannot but prove transient; but\nif free dilatation be procured in the first instance, there is not the\nleast fear of its occurrence at all.\n\nOn the other hand, care is requisite not to lacerate unnecessarily the\ndelicate membrane; after which more or less inflammatory trouble\nsupervenes, and the necessary daily retraction of the foreskin, to be\nsubsequently insisted on, becomes difficult and painful. Should much\noedema thus occur, it is best to discontinue for a few days the\nretraction, until the inflammation has subsided; substituting the daily\ninjection with a syringe under the prepuce of warm carbolised oil, in\nsuch a manner that (the orifice being closed), the fluid is made to\ndistend and 'balloon' that envelope as much as possible.\n\nThe ideal dilatation-procedure is how to effect the maximum of\ndilatation with the minimum of laceration. In boys of seven or eight and\nupwards, it is often easy to stretch the parts sufficiently to allow of\neasy retraction and of free movement backwards and forwards without a\nsingle rent in the membrane, and without the loss of a single drop of\nblood. In younger children, however, this structure is necessarily much\nmore delicate, and easily torn, especially if there be struggling. In\nthe latter case complete an\u00e6sthesia, plenty of deliberation, and the use\nof not too large an instrument, are elements of importance.\n\nThe following is the usual method of performing this\nmanipulation--'operation' is much too grave a word: The only instrument\nneeded is an ordinary dressing-forceps of average size in the case of an\nadult or boy of age above indicated; proportionately smaller with young\ninfants, in whom, indeed, a probe will sometimes effect all that is\nrequisite.\n\n\n     The patient being well an\u00e6sthetised, the surgeon, taking the organ\n     in his left hand, retracts as far as possible the foreskin. With\n     his right he introduces the closed dressing-forceps as far as it\n     will enter; making sure, of course, that he has not passed it into\n     the meatus. He then widely expands the two limbs of the handle,\n     holding these apart for a few seconds. Complete retraction of the\n     foreskin behind the corona glandis is then usually at once easy;\n     adherent spots being separated with the thumb-nail. Should there be\n     any difficulty the tissue is gradually peeled off by manipulation\n     with the fingers; and the collections of inspissated smegma scraped\n     off with the nail or with an ear-scoop. Finally, the operator pulls\n     the prepuce backwards and forwards two or three times, making sure\n     that it is perfectly loose; anoints the glans well with vaseline,\n     and leaves it covered by the foreskin as in the normal state.\n\n\nSubsequently, complete retraction is necessary on each of the first four\nor five days; after which it may be gradually intermitted, being\nsubsequently resorted to only for purposes of cleanliness. The daily\nwashing recommended by some American writers seems wholly unnecessary;\nand, as before remarked, the less tampering with these organs (except\nwhen absolutely unavoidable) the better. When free movement of the\nforeskin on the glans has been attained, together with healing of any\nexcoriation or sore, there is no fear of subsequent contraction. Any\nseeming redundance of the prepuce is in no way detrimental; it should\nonly serve to induce a more careful habit of cleanliness, and the\nhabitual use of those ablutions to which every man naturally resorts\nupon attaining years of discretion.\n\nDilatation thus effected can at the least do no harm, and cannot\npossibly place the subject in a worse position than he was\npreviously;--which the examples in previous chapters show to be far from\nthe case, with the operation of circumcision. If carried out as here\nindicated, it will be found thoroughly effectual; the reasons why it\nappears to have failed in some hands apparently being: (_a_) neglect of\nafter-treatment, and of care to retract the prepuce daily throughout the\nfirst few days; (_b_) insufficient dilatation at the time, so that\nretraction has never been perfectly easy; (_c_) avoidable and\nunnecessary laceration of the muco-cutaneous structures, followed by\ninflammatory mischief.[24]\n\nThe adoption of a special instrument for the above purpose has been\nadvocated from time to time by several writers, who speak in glowing\nterms of the favourable results they have thus attained. A rather\nformidable-looking one, used by N\u00e9laton, is depicted in the _Gazette des\nH\u00f4pitaux_, 31, 1868; this has three blades at right angles to the stem,\nand is somewhat on the model of an ordinary urethral dilator. Several\nsuccessful cases are described, with one of failure. In the latter, a\nyouth of seventeen, incision had to be resorted to, as the prepuce could\nnot be stretched sufficiently with the instrument; and in this there\nwas doubtless true contraction, probably as a result of venereal\ninfection.\n\nIn the _Dublin Quarterly Journal_, No. xlviii. p. 482, Dr. Cruise, of\nDublin, figures a somewhat analogous instrument with two blades, and\nspeaks of numerous cases ('in which with due care the result has been\nperfect') in his own hands and in those of his friends. He, however,\nkept the foreskin subsequently retracted for twenty-four to forty-eight\nhours, a proceeding which entails upon the patient very considerable\ndiscomfort, and is unnecessary. Dr. Hayes Agnew (_Principles of\nSurgery_) figures a special 'phimosis-forceps,' which appears in no\nessential particular to differ from ordinary dressing-forceps; the only\nnoticeable peculiarity being that the blades are a little longer than\nusual. Levis's dilatation-instrument, described in Keating's\n_Cyclop\u00e6dia_, vol. iii. p. 643, is worked by screw-power, and is stated\nto be 'very effective;' it resembles an ordinary pair of\ndissecting-forceps, with a screw placed close to the handle, which\neffects separation of the two blades. This is, no doubt, satisfactory in\nits results, but seems to be unnecessarily severe for the purpose to\nwhich it is applied; in which very little force is usually needed, or,\nindeed, is desirable, for obvious reasons. Mr. R. W. Parker's\ndilatation-instrument has been referred to on the previous page; and\nthere are doubtless many others.\n\nDr. F. H. Stuart, of Brooklyn (_Medical Record_, December 4, 1886), in\nadvocating a manipulation very similar to the one here described (he\nintroduces first a probe to break down adhesions, then the\ndressing-forceps, turning the latter round); comes to the conclusion\nthat 'the number of cases which really require circumcision is extremely\nsmall.' And it may be generally remarked that no one who has really\ntried the dilatation plan with due care and without prejudice, appears\nto have subsequently relinquished it; or to have been otherwise than\nhighly satisfied with its effects, whatever the precise method adopted.\nThose surgeons who speak of having seen unsatisfactory results generally\nconvey the idea that these have taken place in other hands; and have\nnever, in any publication seen by the present writer, condescended to\ndetails.[25]\n\nTo the case of boys past the early years of childhood, and still more to\nthat of adults, the arguments in favour of the substitution of a simple\ndilatation-process for the unnecessarily severe operation of\ncircumcision, apply with redoubled force. As in these no symptoms\ndirecting attention to the phimosis have previously existed for any\nlength of time, it may be taken at once for granted that, however tight\nthe so-called 'contraction' may seem on inspection, the condition is\npresent in only a minor degree; that under an an\u00e6sthetic the adhesions\nwill yield to very slight force, and satisfactory retraction, with\nsubsequent free mobility, be procured without the slightest difficulty.\nWith adults, moreover, the avoidance of any need for confinement to bed,\nof even to the house, is an important consideration. In such the tissues\nare necessarily more elastic and less fragile than in young infants;\nthere is much less prospect of laceration, with consequent tenderness\nand swelling.\n\nAn operation for the relief of congenital phimosis advocated by Mr.\nFurneaux Jordan (_British Medical Journal_, May 2, 1863) may be here\nalluded to.\n\n\n     Mr. Jordan passes one blade of a small round-pointed scissors\n     (Critchett's strabismus-scissors answer well) through the orifice;\n     skin and mucous membrane are divided to the length of a quarter of\n     an inch on one side, the same being repeated on the other. The\n     prepuce is now retracted as far as possible; this exposes more\n     lining membrane between the lips of the wound, and this again is\n     divided by a second incision on each side. The operation is now\n     complete, and the foreskin may easily be retracted.\n\n     The incisions which were made in the long axis of the penis after\n     retraction become linear in a vertical direction, and almost\n     imperceptible in the circular folds of retracted foreskin. In the\n     after-treatment the prepuce should be kept back, or frequently\n     retracted. In children retraction once daily for a week or ten\n     days, till the wounds have healed, is quite sufficient. The extent\n     of the incisions should, of course, be a little less in children, a\n     little greater in the adult.\n\n\nThe present writer has seen this operation performed in one instance,\nand the after-results were in the highest degree satisfactory. As\ncontrasted with circumcision, the procedure merits warm commendation;\npreserving the useful foreskin, and followed by a much more speedy\nrecovery than may be expected from the former. For the lacerations which\nmay result from forcible dilatation, small nicks with a pair of scissors\nare substituted. The only objection is that even this operation, trivial\nas it appears, is seldom necessary; and that sufficient distension of\nthe foreskin may often be procured without any breach of surface\nwhatever. Moreover, some confinement to bed or to the sofa is\nsubsequently requisite; whereas, after the effects of the an\u00e6sthetic\nhave passed off, the patient, young or old, whose foreskin has been\ndilated, can behave exactly as usual.[26]\n\nMr. Jordan's operation is, however, a very useful corollary to the\ndilatation-method in the chronic phimosis (often associated with gout)\nof men in advanced life; when the parts are usually in a very gristly\ncondition; and when, if it be found impossible to procure retraction by\nstretching, the contracted tissues may be advantageously nicked with\nscissors in the mode here indicated.\n\nFOOTNOTES:\n\n[22] For instance, Mr. Erichsen (_op. cit._) dismisses the measure with\nthe cursory allusion of a brief paragraph; against the long and\nelaborate account, previously detailed, of circumcision; it is not\nmentioned at all in the earlier editions of his work. Ashby and Wright\nspeak of it with great disfavour. Mr. Jacobson (_Operations of Surgery_,\n1890) does not introduce it at all; possibly because hardly worthy to be\ndignified by the title 'operation.'\n\n[23] In adults, or in boys approaching manhood, gradual dilatation by\nthe daily introduction of a sponge tent has been recommended. It might\nbe resorted to in the case of an exceptionally timid and patient\nindividual, but hardly for any other.\n\n[24] Mr. R. W. Parker (_Brit. Med. Journal_, July 19, 1879) recommends\ngradual dilatation with a special screw-forceps, which he has used in a\nconsiderable number of cases at the Children's Hospital, 'always with\ngood results.'\n\n[25] In the paper above quoted, by Dr. Cruise, of Dublin (1868), that\nsurgeon speaks of Dr. Hutton having used dressing-forceps for the cure\nof phimosis fifteen years previously. Very probably the adoption of that\ninstrument for the same purpose would be found on inquiry to date back\nstill further; and no pretension of originality can be here put forth\nfor the advocacy of a simple common-sense practice, which must have been\nrepeatedly resorted to by many practitioners of the past.\n\n[26] M. Faure has also described a somewhat analogous 'nicking'\noperation.\n\n\n\n\nVII\n\nSUMMARY.\n\n\nI. Circumcision as a sacrificial rite has been practised by very\nnumerous races of diverse origin, and dates from an extremely remote\nantiquity; probably from the Stone Age, as suggested by the internal\nevidence of Biblical records.\n\nII. This fact, together with that of its application by many tribes to\nthe persons of female children, deprives the religious ceremony of any\ntitle to the hygienic character and purpose, which have been frequently\nattributed to it.\n\nIII. The surgical operation of circumcision, especially where infants\nare concerned, has therefore to be discussed solely on its own merits,\nwholly apart from any theory of Divine intentions, based upon\ntheological considerations. It appears to be erroneous _in principle_.\n\nIV. It consists in a _mutilation_; in the removal of a perfectly normal\nstructure, with which, for patent physiological reasons, every male\nchild is endowed by nature. The morality of such a practice, without\ngrave necessity, is open to question.\n\nV. Unless as the result of subsequent disease, no deformity, and indeed\nno actual abnormality, exist as factors productive of the condition\ndesignated 'Congenital Phimosis.' Almost every male child suffers at\nbirth from some degree of the same phenomenon--the imperfect separation\nof two muco-cutaneous surfaces, developed in contiguity.[27]\n\nVI. Symptoms ascribed to a 'contracted prepuce' are due to natural\ngrowth of the glans penis, when this physiological separation is very\nincomplete, and when, therefore, a rigid constricting envelope prevents\ndevelopment. _No true contraction_ exists, except as the result of\nsuperadded inflammation; and is rarely of much importance, unless an\nelement of contagion has been introduced.\n\nVII. The rational treatment of congenital phimosis primarily consists in\nthe efficient execution of the process originally intended by nature,\nbut imperfectly carried out. And, secondarily, in precautions to ensure\nthe permanently free mobility of the prepuce upon the glans penis.\n\nVIII. Such complete separation of the two contiguous layers of membrane\nmay almost invariably be effected by very simple means; and, with some\nslight attention to after-treatment, will permanently secure all that is\ndesired, without risk and without even transient disability.\n\nIX. The treatment of congenital phimosis by dilatation is the\ncommon-sense remedy for this condition. It has been carried out by many\npractitioners with different instruments and variations of detail; and\nall who have thus attempted it with ordinary care (including the present\nwriter) seem eminently satisfied with the results.[28]\n\nX. When diseased processes co-exist with congenital phimosis, the case\nmust necessarily be treated on its own merits. Simple dilatation, even\nif practicable, is not always sufficient, but should be combined with\nincisions of as limited a nature as possible. Mr. Furneaux Jordan's\noperation is then useful.\n\nXI. In the event of disease, the operation of circumcision is not devoid\nof risk, and should be reserved as far as possible for extreme cases, in\nwhich removal of the whole prepuce is obviously a matter of\nnecessity.[29]\n\nXII. In healthy children the operation seems to be rarely fatal in this\ncountry. Many cases of death directly traceable to circumcision have,\nhowever, been reported on the Continent.\n\nXIII. The immediate effects of circumcision, especially when performed\non young infants, involve considerable and protracted suffering.\n\nXIV. The most conspicuous _remote_ result is that of an extremely\ncontracted _meatus urinarius_, as the consequence of subsequent\ninflammatory processes, due to the exposure and continual friction of\nthe unprotected glans.\n\nXV. The compulsory enforcement of local cleanliness procured by\ncircumcision seems hardly a sufficient argument for the general adoption\nof the practice by peoples not utterly indifferent to all laws of\nhygiene; and has little weight even in individual cases.\n\nXVI. The superior chastity and purity of mind and body supposed to be\nprocured for its recipients by ritual circumcision, lie open to very\nconsiderable question, in the face of abundant well-known facts.\n\nXVII. The advantage of circumcision in obviating future venereal\ncontagion is restricted by its principal advocate to one form (albeit\nthe most important) of such disease. Even in this limited field the\nfacts adduced appear open to dispute, and greatly to need confirmation\nby independent observers.\n\nXVIII. In the hands of careless or inexperienced operators the surgical\noperation of circumcision has been followed by the most disastrous\npermanent consequences.\n\nXIX. In face of the facts here set forth, it is NOT advisable to apply\nthe operation of circumcision, as a remedy for congenital phimosis, to\nChristian infants; much less to extend this, as a routine custom, to the\nwhole male population.\n\nFOOTNOTES:\n\n[27] The word 'adhesion' in the previous pages is employed solely as a\nterm of convenience, to denote this imperfect separation, and does not\nimply any analogy to inflammatory processes.\n\n[28] The writer first drew attention to the advantages of this method of\ntreatment in the _British Medical Journal_, Nov. 15, 1874. Having\ninstituted a tolerably extensive search through the medical literature\nof the preceding three or four decades, he is unable to find any account\nof a case in which the procedure failed to effect a permanent cure,\nunless there had existed previous disease.\n\n[29] A fatal case, after circumcision for gonorrhoeal inflammation, in a\nyouth of 17, is reported in the _Lancet_, Feb. 25, 1882. Death took\nplace on the eighth day apparently from septic\u00e6mic pneumonia.\n\n\n\n\n_BIBLIOGRAPHY._\n\nPUBLISHED WORKS.\n\n\nI.--MEDICAL.\n\nErichsen's _Surgery_, Ninth Edition; Holmes's _System of Surgery_, Third\nEdition; Maunder's _Operative Surgery_; Joseph Bell's _Manual of\nSurgical Operations_; Jacobson's _Operations of Surgery_; Reginald\nHarrison's _Diseases of Urinary Organs_, Third Edition; Keyes's\n_Diseases of Urinary Organs_; Keating's _Cyclop\u00e6dia of the Diseases of\nChildren_; Ashby and Wright's _Diseases of Children_; Jaff\u00e9's _Die\nrituelle Circumcision im Lichte der antiseptischen Chirurgie_; Asher's\n_The Jewish Rite of Circumcision_; Wunderbar's _Biblisch-Talmudische\nMedicin_; Gideon Bircher's _Die Beschneidung der Israeliten_; Dr. Hayes\nAgnew's _Principles of Surgery_; Sayre's _Orthop\u00e6dic Surgery_; Hilton's\n_Rest and Pain_; _International Encyclop\u00e6dia of Surgery_, 1886; _Guy's\nHospital Reports_; _American Journal of Syphilis and Dermatology_,\nOctober 1872; Walsham's _Theory and Practice of Surgery_, &c. &c.\n\n\nII.--HISTORICAL AND MISCELLANEOUS.\n\n_The Testaments, Old and New_; _The Talmud_; _Maimonides on\nCircumcision_; Tylor's _Primitive Culture_; Moncure Conway's _Demonology\nand Devil Lore_; Keil's _Biblical Arch\u00e6ology_; Smith's _Dictionary of\nthe Bible_; Calmet, _Dictionary of the Bible_, _Encyclop\u00e6dia Americana_,\n_Encyclop\u00e6dia Britannica_; Howard, _Royal Encyclop\u00e6dia_; _Penny\nCyclop\u00e6dia_; _Chambers's Encyclop\u00e6dia_; _Encyclop\u00e6dia Metropolitana_;\nWiner's _Realw\u00f6rth_; Brewster, _Edinburgh Encyclop\u00e6dia_; _English\nCyclop\u00e6dia_; Wilkes's _Encyclop\u00e6dia Londinensis_; _Globe Encyclop\u00e6dia_,\n&c.\n\n\nPERIODICALS.\n\n_The Lancet_, _British Medical Journal_, _Medical Times and Gazette_,\n_Medical Record_, _Dublin Journal_, _Boston Medical and Surgical\nJournal_, _Chicago Medical Standard_, _Gazette des H\u00f4pitaux_,\n_Allgemeine Wiener Med. Zeitung_, _Wiener Med. Presse_, &c.\n\n\n\n\nBY THE SAME AUTHOR.\n\n     THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the\n     Opium Pipe.) 2_s._ 6_d._\n\n     THE REAPPEARANCE OF CANCER AFTER OPERATION. 5_s._ 6_d._\n\n     THE GENERAL THEORY OF CANCER-FORMATION. 1_s._\n\n     CLINICAL NOTES ON CANCER. 3_s._ 6_d._\n\n\nJ. & A. CHURCHILL, New Burlington Street.","title":"The Barbarity of Circumcision as a Remedy for Congenital Abnormality","tradition":"philosophy-ethics","translated_text":null,"word_count":14717}