FOOTNOTES:

FOOTNOTES:[11]In Druitt'sSurgeon's Vade-Mecum, 9th edition, p. 662, are the notes of a case of 'congenital phimosis of the tightest kind' in an adult of twenty-three. Circumcision was threatened; but the affection readily yielded to the injection of warm water daily. There are probably many similar.[12]Dr. Asher (op. cit.) does not disapprove of circumcision, but his evidently strong religious bias, and the fact that his whole work is composed from an ecclesiastical point of view, with the express sanction and co-operation of ecclesiastical dignitaries, constitutes him a far from independent (negative) witness.[13]An immense variety of operative procedures for phimosis, or even of details in the performance of ordinary circumcision, might be quoted.Quot homines, tot operationes.Their multiplicity, and the very contradictory nature of the advantages claimed for each, strongly indicate that neither the results of slitting operations, nor those of entire or partial excision of the prepuce, are found uniformly satisfactory. Thus, in addition to the methods described in the text, it may be noted that Jobert de Lamballe and others divide the foreskin on both sides of the frænum without excision; Van Buren makes two cuts, one on the dorsum and one near the frænum, subsequently removing the two flaps; Dr. R. W. Taylor (American Journal of Syphilis and Dermatology, October, 1872) makes twolateralincisions with scissors. While, as above stated, some surgeons prefer to hold the forceps which guard the glans obliquely, from above downwards and forwards, so as to leave a certain portion of the skin about the frænum; Mr. Howse (Guy's Hospital Reports) advocates the careful removal of the frænum, in order to prevent subsequent œdema. Simple incision on a director was formerly preferred by many, though for congenital phimosis it has now probably fallen into disuse. In contrast with the careful devices for retaining part of the prepuce, or for ensuring that too much be not cut away, Sir W. Fergusson and Professor Humphrey find it best to amputate the structure as radically as possible. On this point see cases by Mr. Reginald Harrison, referred to at page 39.[14]See theLancet, December 12, 1874. Dr. Asher (op. cit.) also takes the same view.[15]The following is Mr. Hutchinson's statistical table derived from his practice at the Out-patient department of the Metropolitan Hospital:CasesGonorrœaSyphilisProportion of gonorrhœato syphilisNot Jews 272Jews5810747165110·6 to 14·3 " 1On these figures a plausible inference might perhaps be founded, that what the Jew saves in immunity from syphilis he, to a certain extent, loses in increased proclivity to gonorrhœa; certainly the least of the two evils.Mr. Hutchinson goes on to state that of 252 children under the age of five years, 27 out of 179 Christians exhibited symptoms of congenital syphilis in a well-marked form; while only 3 out of 73 Jews were thus affected, the proportion thus being 1 in 6 among the Christians, while only 1 in 24 among the Jews. Again, of 97 women (two-thirds being married), of whom 92 were Christians and 5 Jews, 61 of the former were syphilised; against a blank return among the latter. Upon the evidence of these statistics, Mr. Hutchinson advocates a general adoption of the rite of circumcision by Western nations!Upon his own showing, however, the benefit to be derived from such a sweeping innovation, supposing that this were practicable, is not so very large; for 11 syphilised Jews out of a total of 58 with venereal disease, is a tolerably respectable proportion. The inferences here drawn, moreover, do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners; among whom those of Jewish birth should be able to give specially valuable testimony. The field of inquiry was comparatively small; statistics drawn from the out-patient department of a general hospital are, for obvious reasons, not always of the most reliable character; and the conclusions may be vitiated by the facts suggested in the text. Hence, although they refer to but one venereal malady, it is hardly possible to acquiesce in them implicitly, even in this limited respect; without some confirmation drawn from a much more extended field of research.

[11]In Druitt'sSurgeon's Vade-Mecum, 9th edition, p. 662, are the notes of a case of 'congenital phimosis of the tightest kind' in an adult of twenty-three. Circumcision was threatened; but the affection readily yielded to the injection of warm water daily. There are probably many similar.

[12]Dr. Asher (op. cit.) does not disapprove of circumcision, but his evidently strong religious bias, and the fact that his whole work is composed from an ecclesiastical point of view, with the express sanction and co-operation of ecclesiastical dignitaries, constitutes him a far from independent (negative) witness.

[13]An immense variety of operative procedures for phimosis, or even of details in the performance of ordinary circumcision, might be quoted.Quot homines, tot operationes.Their multiplicity, and the very contradictory nature of the advantages claimed for each, strongly indicate that neither the results of slitting operations, nor those of entire or partial excision of the prepuce, are found uniformly satisfactory. Thus, in addition to the methods described in the text, it may be noted that Jobert de Lamballe and others divide the foreskin on both sides of the frænum without excision; Van Buren makes two cuts, one on the dorsum and one near the frænum, subsequently removing the two flaps; Dr. R. W. Taylor (American Journal of Syphilis and Dermatology, October, 1872) makes twolateralincisions with scissors. While, as above stated, some surgeons prefer to hold the forceps which guard the glans obliquely, from above downwards and forwards, so as to leave a certain portion of the skin about the frænum; Mr. Howse (Guy's Hospital Reports) advocates the careful removal of the frænum, in order to prevent subsequent œdema. Simple incision on a director was formerly preferred by many, though for congenital phimosis it has now probably fallen into disuse. In contrast with the careful devices for retaining part of the prepuce, or for ensuring that too much be not cut away, Sir W. Fergusson and Professor Humphrey find it best to amputate the structure as radically as possible. On this point see cases by Mr. Reginald Harrison, referred to at page 39.

[14]See theLancet, December 12, 1874. Dr. Asher (op. cit.) also takes the same view.

[15]The following is Mr. Hutchinson's statistical table derived from his practice at the Out-patient department of the Metropolitan Hospital:CasesGonorrœaSyphilisProportion of gonorrhœato syphilisNot Jews 272Jews5810747165110·6 to 14·3 " 1On these figures a plausible inference might perhaps be founded, that what the Jew saves in immunity from syphilis he, to a certain extent, loses in increased proclivity to gonorrhœa; certainly the least of the two evils.Mr. Hutchinson goes on to state that of 252 children under the age of five years, 27 out of 179 Christians exhibited symptoms of congenital syphilis in a well-marked form; while only 3 out of 73 Jews were thus affected, the proportion thus being 1 in 6 among the Christians, while only 1 in 24 among the Jews. Again, of 97 women (two-thirds being married), of whom 92 were Christians and 5 Jews, 61 of the former were syphilised; against a blank return among the latter. Upon the evidence of these statistics, Mr. Hutchinson advocates a general adoption of the rite of circumcision by Western nations!Upon his own showing, however, the benefit to be derived from such a sweeping innovation, supposing that this were practicable, is not so very large; for 11 syphilised Jews out of a total of 58 with venereal disease, is a tolerably respectable proportion. The inferences here drawn, moreover, do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners; among whom those of Jewish birth should be able to give specially valuable testimony. The field of inquiry was comparatively small; statistics drawn from the out-patient department of a general hospital are, for obvious reasons, not always of the most reliable character; and the conclusions may be vitiated by the facts suggested in the text. Hence, although they refer to but one venereal malady, it is hardly possible to acquiesce in them implicitly, even in this limited respect; without some confirmation drawn from a much more extended field of research.

[15]The following is Mr. Hutchinson's statistical table derived from his practice at the Out-patient department of the Metropolitan Hospital:

On these figures a plausible inference might perhaps be founded, that what the Jew saves in immunity from syphilis he, to a certain extent, loses in increased proclivity to gonorrhœa; certainly the least of the two evils.

Mr. Hutchinson goes on to state that of 252 children under the age of five years, 27 out of 179 Christians exhibited symptoms of congenital syphilis in a well-marked form; while only 3 out of 73 Jews were thus affected, the proportion thus being 1 in 6 among the Christians, while only 1 in 24 among the Jews. Again, of 97 women (two-thirds being married), of whom 92 were Christians and 5 Jews, 61 of the former were syphilised; against a blank return among the latter. Upon the evidence of these statistics, Mr. Hutchinson advocates a general adoption of the rite of circumcision by Western nations!

Upon his own showing, however, the benefit to be derived from such a sweeping innovation, supposing that this were practicable, is not so very large; for 11 syphilised Jews out of a total of 58 with venereal disease, is a tolerably respectable proportion. The inferences here drawn, moreover, do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners; among whom those of Jewish birth should be able to give specially valuable testimony. The field of inquiry was comparatively small; statistics drawn from the out-patient department of a general hospital are, for obvious reasons, not always of the most reliable character; and the conclusions may be vitiated by the facts suggested in the text. Hence, although they refer to but one venereal malady, it is hardly possible to acquiesce in them implicitly, even in this limited respect; without some confirmation drawn from a much more extended field of research.

As a surgical operation, circumcision is commonly performed with so much impunity that many surgeons will probably not be disposed to admit the possibility of its being attended by any danger to life; and there can be no doubt that it is but seldom followed by a fatal result. Still, with any breach of surface whatever, there must be a chance of blood-poisoning and of the absorption of septic materials; and, in the case of a child liable to hæmophilia, it cannot be doubted that serious consequences might readily ensue.

Thus, in the third century it was enacted by the rabbins (Talmud, Treatise Jebamoth, 646) that, after two deaths in the same family from this cause, the ceremony was to be omitted; and the prohibition has continued in force ever since. Maimonidesinculcates the utmost caution in the performance of the rite, and insists that 'in case of doubtful sickness, a child must not be circumcised; since danger to life overrides the whole ceremonial law.' (Maimonides on Circumcision, ch. i.). At the present date it is always effected by an expert (Mohel), who is not infrequently a qualified medical man; and accidents are guarded against with jealous care.[16]

The ancient plan, according to which the operator received in his mouth (previously filled with wine) the extremity of the lacerated member, is now wholly or in great part abolished among the Jewish community; it being found that both syphilis and tuberculosis were thus communicated to the infant.[17]

TheLancetof October 1, 1870, quotes from theWiener Med. Pressethe particulars of two cases, reported by Dr. Schwartz, of boys circumcised at the usual period; who subsequently died from phlegmonous inflammation and sloughing of the part, one five and the other twenty-five days subsequently to the operation. In the same periodical for December 5, 1874, may be found allusion to the experience of Dr. Kohn, himself a Jew; whostated at a medical society in Vienna, that during a practice of thirty-five years he had known six deaths from this source (Allg. Wiener Med. Zeit.November 17, 1874). He himself had thus lost a child of his own.

However such fatality may be attributed to the neglect of all hygienic rules among the poorer classes of Jews; it can hardly be doubted that, under even the most favourable conditions, septic poisoning or uncontrollable hæmorrhagemustoccasionally happen, albeit extremely rare; and this whether the operation has been performed from ritual or from surgical motives. To the absence of such cases reported in medical literature, too much weight must not be attributed.[18]

It is rather upon the minor consequences, immediate or subsequent, that those who object to the practice have founded their opposition; and of such there has been no lack, especially among medical men who have been themselves Jews, and who have thus necessarily enjoyed the fullest experience of its effects. Thus theLancetof December 5, 1874, mentions a pamphlet by Dr. Levit, demonstrating the evils of the custom. He speaks of the premature beginning of sexual excitement in boys deprived of their prepuce, and the disposition to onanism so common to Eastern nations; he regards circumcision as a criminalmanipulation; and calls upon the medical profession to oppose the practice, even at the risk of losing favour at the hands of the Jewish families they attend. And his arguments are effectually sustained by Dr. Kohn. Dr. Schwartz, in recording the fatal cases above quoted, 'deprecates the custom with great warmth, and expresses the wish that it may be laid aside.'

Mr. R. W. Parker (British Medical Journal, July 19, 1879) refers to a child (one of a family of bleeders) who, being circumcised, nearly bled to death. He also says: 'Diffuse cellulitis of the penis is not an uncommon complication after this operation in unhealthy, ill-fed, and badly-cared-for children.'

Dr. Mastin, inGaillard's Medical Journal, speaks of the great frequency with which he has been consulted by Jews for chronic urethral discharges, irritable urethra, and other affections of the genito-urinary organs. He describes 'the preternaturally small meatus which results from early removal of the prepuce by circumcision.' (Medical Record, December 10, 1885.) Elsewhere in the same periodical (Medical Record, vol. xxi.) we are informed that 95 per cent. of young male Jew adults have this contracted meatus.

Shorn of its natural protective covering, the muco-cutaneous covering of the glans soon becomes true dermoid tissue. Mr. J. Hutchinson (loc. cit.) speaks of 'every one who is acquainted with the effects of circumcision in rendering the delicatemucous membrane of the glans hard and skin-like.' Contact with the clothing, &c., necessarily induces a chronic inflammatory condition of the part, followed commonly by contraction and condensation. We cannot with impunity rashly interfere with any of Nature's dispositions, however seemingly insignificant.

This hard skinlike condition of the integument upon the glans penis, with its concomitant of narrowed urethral aperture, may be regarded as the normal result of circumcision. In the hands of bungling operators, however, far worse consequences may follow. Thus J. Bell (Manual of Operations in Surgery, 1866) 'has known the glans penis included in the incision inat leastone instance.' (The italics are his own.) Mr. Reginald Harrison (Diseases of Urinary Organs, 3rd Edition, 1887) has treated twovarietiesof urethral stricture after circumcision which have not turned out well; in twocases, the extremity of the glans penis, including the meatus, had been wounded in making the section of the prepuce; in a third, owing to 'œdema and difficulty of ascertaining where the glans was, amputation had been performed, and the end of the glans included.' The second variety of stricture was caused by the prepuce being divided too high up, or, what amounts to the same thing, being drawn down too much over the glans penis, before being included in the forceps for the purpose of making the necessary section. On bringing together the parts with sutures, the tension on them was so great as to cause ulceration, and toleave behind a broad cicatrix, capable of exercising a contractile pressure on the under surface of the urethra; sufficient to impede micturition and to cause other discomfort.'[19]

Dr. Hyde (Boston Medical and Surgical Journal, June 26, 1890) has seen disastrous results from circumcision; and Dr. Willard (in Keating'sCyclopædia of the Diseases of Children) says that, after circumcision, hardening of the glans occurs; and the evils of contracted meatus, balanitis, &c. follow, as pointed out by Otis, Mastin and others. So far, therefore, as the remote consequences of circumcision are concerned, there is strong evidence that the operation is by no means an unmixed blessing to its recipient.[20]

Turning to the more immediate effects and consequences, the italicised passages in Mr. Erichsen's elaborate description concur with the experience since cited of other writers, to show the need of considerable caution in the performance of this surgical procedure. Septic infection, hæmorrhage, and subsequent sloughing of the part have to be sedulously guarded against; and on the Continent, at least, the resources of modern antiseptic surgeryhave been specially invoked. Without careful ligature of the arteries, these may, we are told, give rise to troublesome and long unnoticed hæmorrhage when the patient is put back to bed. The examples above quoted, and the varying practice of different surgeons, show, moreover, that discrimination and judgment are essential as to the excision of either too much or too little of the foreskin; both of which events may be disadvantageous.

Mr. W. H. Jacobson (Operations of Surgery, 1889) says that after circumcision 'an adult should lie in bed for forty-eight hours, and keep on the sofa for a week, alternate stitches being removed at intervals. If he insist on getting about too early, he must run the risk of the parts remaininglong œdematous and tender. And for this reason, with hospital patients, who have to come backwards and forwards,early and complete healing is not to be expected. (The italics are the present writer's.)

It may be reasonably assumed that no sane man, who possessed the advantages of a sound and entire prepuce, would willingly sacrifice it without just and sufficient cause being shown. And his natural repugnance to such a deprivation would probably be in no wise lessened by a perusal of the passage last cited. It would be without doubt in the highest degree edifying in the present connection, were the sensations of some educated adult of average sensitiveness, who had submitted to the operation, placed on record; together with a statement of the timewhich elapsed before perfect tolerance became established; and before the 'hard skinlike condition,' so much approved of by Mr. J. Hutchinson, and the other more or less enthusiastic advocates of circumcision, was satisfactorily attained. In the absence of such a delineation, however, we can only surmise the feelings of the patient; and conclude that, as with catheterisation, and other manipulations addressed to a delicate mucous membrane, they would in some instances be almostnil; but that in the man of highly sensitive organisation, they would amount to keen and long-protracted torture.

Infants of tender years must of necessity be classed in the latter of these two categories; in their case, there are also certain circumstances which tend to enhance the barbarity of the procedure; and largely to aggravate the suffering involved. Thus an American operator (at the association meeting of genito-urinary surgeons, reported in theBoston Med. and Surg. Journal, June 26, 1890) speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins, and other clothing, must long be very painful. There can be little doubt what would be the verdict—could they only give it utterance—upon the immediate results of the operation in question; returned by these inarticulate (if far from mute) victims of hygienic orthodoxy.[21]

FOOTNOTES:[16]The most scrupulous and minute precautions for obviating any danger to life are enjoined by the Talmud. The ceremony is not permitted to take place at all unless the child is in perfectly sound health; and that Mohel, whose conscience may convict him of having caused the death of an infant by his negligence, is forbidden ever to officiate again.[17]A case of tuberculosis thus contracted is reported in theBritish Medical Journalof March 5, 1887; and twelve other instances are also mentioned in the same paragraph.[18]The writer has been unable to discover any mortality statistics of ritual circumcision, and apparently none exist. Dr. Asher (op. cit.) makes a remark to the same effect.[19]In the same work its author states that an unnatural smallness of the urethra is a not infrequent cause of incontinence of urine in children. In some cases therefore ascribed to congenital phimosis, may not the incontinence be merely a concomitant, and not an effect, of the latter condition?[20]Dr. Keyes (Diseases of Urinary Organs, 1888) has been 'twice called upon to relieve by operation a phimosis resulting from a former operation.'[21]An objection to circumcision, of wholly sentimental character, yet not the less worthy of practical consideration, may, in addition to those set forth in the text, be here noted. The parents of any child, in whom the necessity of some remedial measure for congenital phimosis has become apparent, usually express considerable relief when told that it is not necessary to make the infant 'a little Jew.'

[16]The most scrupulous and minute precautions for obviating any danger to life are enjoined by the Talmud. The ceremony is not permitted to take place at all unless the child is in perfectly sound health; and that Mohel, whose conscience may convict him of having caused the death of an infant by his negligence, is forbidden ever to officiate again.

[17]A case of tuberculosis thus contracted is reported in theBritish Medical Journalof March 5, 1887; and twelve other instances are also mentioned in the same paragraph.

[18]The writer has been unable to discover any mortality statistics of ritual circumcision, and apparently none exist. Dr. Asher (op. cit.) makes a remark to the same effect.

[19]In the same work its author states that an unnatural smallness of the urethra is a not infrequent cause of incontinence of urine in children. In some cases therefore ascribed to congenital phimosis, may not the incontinence be merely a concomitant, and not an effect, of the latter condition?

[20]Dr. Keyes (Diseases of Urinary Organs, 1888) has been 'twice called upon to relieve by operation a phimosis resulting from a former operation.'

[21]An objection to circumcision, of wholly sentimental character, yet not the less worthy of practical consideration, may, in addition to those set forth in the text, be here noted. The parents of any child, in whom the necessity of some remedial measure for congenital phimosis has become apparent, usually express considerable relief when told that it is not necessary to make the infant 'a little Jew.'

From what has been already set forth, it is sufficiently evident that no male should be suffered to reach adult life with this congenital disability unrelieved; and that in the majority of instances radical treatment is requisite at a far earlier date. There can be no doubt that it is infinitely better for an infant to be subjected to circumcision, than to pass many months or years with the unpleasant or even dangerous symptoms previously detailed. The point now to be considered, therefore, is whether these symptoms can be obviated by any less heroic measure, and whether the suffering thus incurred is a matter of absolute necessity; whether, indeed, it is right and proper to subject the child tomutilationfor the benevolent purpose indicated.

For by no less term can the procedure in question be characterised. It consists in the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were thereno necessity for its presence, it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ.

As indicated above, congenital phimosis may be said in some slight degree to occur in every new-born male child. Two layers of muco-cutaneous membrane are developed in close contact, and are commonly agglutinated in a measure; but it is only when the separation is very incomplete that any defect producing consequences of importance is found. There is no deformity or deficiency of parts; and, except as a consequence of long-continued inflammation, no contraction occurs. What is commonly spoken of as 'a contracted prepuce' simply signifies the natural growth of the glans under a rigid envelope, primarily of normal proportions.

All, then, that is requisite to remedy this condition in the first instance, is the due separation of the two contiguous layers of muco-cutaneous membranes, which in the new-born may generally be effected with ease. As the infant grows, however, there is apt to supervene relative disparity of size; the tissues cannot be sufficiently expanded to allow of the ideal state of the organ—a prepuce movable freely and loosely upon its included glans—without some laceration. And, unless care be taken, the wounds in the parietal layer of muco-cutaneous membrane again quickly heal; the new cicatricial tissueundergoes, perhaps, a little real contraction; and matters remain as they were before. Hence, probably, the disfavour with which procedures, involving dilatation of the prepuce, seem to have been hitherto regarded by most surgeons.[22]Some amount of reunion between the two surfaces may also take place at the spots where the adhesions have been ruptured.

The principle to be aimed at, however, is simply the separation of two contiguous and adherent layers of mucous or muco-cutaneous membrane. Few medical men are probably aware of the natural distensibility of the parts; of the ease with which (when the patient is rendered passive and unconscious by means of an anæsthetic) the glans can be brought completely into view, and the prepuce perfectly retracted behind the corona. All that is then necessary is, by the use of emollients and by daily retraction for a very brief period, to prevent reunion of adhesions or of fissures in the muco-cutaneous membrane; until a sufficient degree of dilatation has been secured to preclude all fear of any future difficulty.

Certain precautions are, of course, necessary. The patient should be anæsthetised; the tissues involved are extremely sensitive, and the administration ofether (or of chloroform in the case of a young child), besides relaxing the parts, enables the measure to be carried out much more efficiently than would otherwise be the case. Although the necessary dilatation can usually be very speedily effected, it often takes some little time thoroughly to remove the adherent smegma, not seldom of gritty and calcareous consistence. This, besides being the longest, is the most painful part of the manipulation. The use of cocaine as a local anæsthetic for such a purpose, precluding the administration of ether or chloroform, is not to be recommended. The wide surface involved renders its influence incomplete; and it is of considerable advantage to have the patient, particularly when of tender years, oblivious to what is going on.[23]

If the distension be too timidly effected, so that the foreskin can be retracted over the glans only with difficulty; an equal difficulty will be found in pulling it forwards again, and temporary paraphimosis may result. Under anæsthesia, however, this cannot but prove transient; but if free dilatation be procured in the first instance, there is not the least fear of its occurrence at all.

On the other hand, care is requisite not to lacerate unnecessarily the delicate membrane; after which more or less inflammatory trouble supervenes, andthe necessary daily retraction of the foreskin, to be subsequently insisted on, becomes difficult and painful. Should much œdema thus occur, it is best to discontinue for a few days the retraction, until the inflammation has subsided; substituting the daily injection with a syringe under the prepuce of warm carbolised oil, in such a manner that (the orifice being closed), the fluid is made to distend and 'balloon' that envelope as much as possible.

The ideal dilatation-procedure is how to effect the maximum of dilatation with the minimum of laceration. In boys of seven or eight and upwards, it is often easy to stretch the parts sufficiently to allow of easy retraction and of free movement backwards and forwards without a single rent in the membrane, and without the loss of a single drop of blood. In younger children, however, this structure is necessarily much more delicate, and easily torn, especially if there be struggling. In the latter case complete anæsthesia, plenty of deliberation, and the use of not too large an instrument, are elements of importance.

The following is the usual method of performing this manipulation—'operation' is much too grave a word: The only instrument needed is an ordinary dressing-forceps of average size in the case of an adult or boy of age above indicated; proportionately smaller with young infants, in whom, indeed, a probe will sometimes effect all that is requisite.

The patient being well anæsthetised, the surgeon, taking the organ in his left hand, retracts as far as possible the foreskin. With his right he introduces the closed dressing-forceps as far as it will enter; making sure, of course, that he has not passed it into the meatus. He then widely expands the two limbs of the handle, holding these apart for a few seconds. Complete retraction of the foreskin behind the corona glandis is then usually at once easy; adherent spots being separated with the thumb-nail. Should there be any difficulty the tissue is gradually peeled off by manipulation with the fingers; and the collections of inspissated smegma scraped off with the nail or with an ear-scoop. Finally, the operator pulls the prepuce backwards and forwards two or three times, making sure that it is perfectly loose; anoints the glans well with vaseline, and leaves it covered by the foreskin as in the normal state.

Subsequently, complete retraction is necessary on each of the first four or five days; after which it may be gradually intermitted, being subsequently resorted to only for purposes of cleanliness. The daily washing recommended by some American writers seems wholly unnecessary; and, as before remarked, the less tampering with these organs (except when absolutely unavoidable) the better. When free movement of the foreskin on the glans has been attained, together with healing of any excoriation or sore, there is no fear of subsequent contraction. Any seeming redundance of the prepuce is in no way detrimental; it should only serve to induce a more careful habit of cleanliness, and the habitual use of those ablutions to which every man naturally resorts upon attaining years of discretion.

Dilatation thus effected can at the least do no harm, and cannot possibly place the subject in a worse position than he was previously;—which the examples in previous chapters show to be far from the case, with the operation of circumcision. If carried out as here indicated, it will be found thoroughly effectual; the reasons why it appears to have failed in some hands apparently being: (a) neglect of after-treatment, and of care to retract the prepuce daily throughout the first few days; (b) insufficient dilatation at the time, so that retraction has never been perfectly easy; (c) avoidable and unnecessary laceration of the muco-cutaneous structures, followed by inflammatory mischief.[24]

The adoption of a special instrument for the above purpose has been advocated from time to time by several writers, who speak in glowing terms of the favourable results they have thus attained. A rather formidable-looking one, used by Nélaton, is depicted in theGazette des Hôpitaux, 31, 1868; this has three blades at right angles to the stem, and is somewhat on the model of an ordinary urethral dilator. Several successful cases are described, with one of failure. In the latter, a youth of seventeen, incision had to be resorted to, as the prepuce could not be stretched sufficiently with theinstrument; and in this there was doubtless true contraction, probably as a result of venereal infection.

In theDublin Quarterly Journal, No. xlviii. p. 482, Dr. Cruise, of Dublin, figures a somewhat analogous instrument with two blades, and speaks of numerous cases ('in which with due care the result has been perfect') in his own hands and in those of his friends. He, however, kept the foreskin subsequently retracted for twenty-four to forty-eight hours, a proceeding which entails upon the patient very considerable discomfort, and is unnecessary. Dr. Hayes Agnew (Principles of Surgery) figures a special 'phimosis-forceps,' which appears in no essential particular to differ from ordinary dressing-forceps; the only noticeable peculiarity being that the blades are a little longer than usual. Levis's dilatation-instrument, described in Keating'sCyclopædia, vol. iii. p. 643, is worked by screw-power, and is stated to be 'very effective;' it resembles an ordinary pair of dissecting-forceps, with a screw placed close to the handle, which effects separation of the two blades. This is, no doubt, satisfactory in its results, but seems to be unnecessarily severe for the purpose to which it is applied; in which very little force is usually needed, or, indeed, is desirable, for obvious reasons. Mr. R. W. Parker's dilatation-instrument has been referred to on the previous page; and there are doubtless many others.

Dr. F. H. Stuart, of Brooklyn (Medical Record,December 4, 1886), in advocating a manipulation very similar to the one here described (he introduces first a probe to break down adhesions, then the dressing-forceps, turning the latter round); comes to the conclusion that 'the number of cases which really require circumcision is extremely small.' And it may be generally remarked that no one who has really tried the dilatation plan with due care and without prejudice, appears to have subsequently relinquished it; or to have been otherwise than highly satisfied with its effects, whatever the precise method adopted. Those surgeons who speak of having seen unsatisfactory results generally convey the idea that these have taken place in other hands; and have never, in any publication seen by the present writer, condescended to details.[25]

To the case of boys past the early years of childhood, and still more to that of adults, the arguments in favour of the substitution of a simple dilatation-process for the unnecessarily severe operation of circumcision, apply with redoubled force. As in these no symptoms directing attention to the phimosis have previously existed for any length of time, it may be taken at once for granted that, however tight the so-called 'contraction' may seem oninspection, the condition is present in only a minor degree; that under an anæsthetic the adhesions will yield to very slight force, and satisfactory retraction, with subsequent free mobility, be procured without the slightest difficulty. With adults, moreover, the avoidance of any need for confinement to bed, of even to the house, is an important consideration. In such the tissues are necessarily more elastic and less fragile than in young infants; there is much less prospect of laceration, with consequent tenderness and swelling.

An operation for the relief of congenital phimosis advocated by Mr. Furneaux Jordan (British Medical Journal, May 2, 1863) may be here alluded to.

Mr. Jordan passes one blade of a small round-pointed scissors (Critchett's strabismus-scissors answer well) through the orifice; skin and mucous membrane are divided to the length of a quarter of an inch on one side, the same being repeated on the other. The prepuce is now retracted as far as possible; this exposes more lining membrane between the lips of the wound, and this again is divided by a second incision on each side. The operation is now complete, and the foreskin may easily be retracted.The incisions which were made in the long axis of the penis after retraction become linear in a vertical direction, and almost imperceptible in the circular folds of retracted foreskin. In the after-treatment the prepuce should be kept back, or frequently retracted. In children retraction once daily for a week or ten days, till the wounds have healed, is quite sufficient. The extent of the incisions should, of course, be a little less in children, a little greater in the adult.

The incisions which were made in the long axis of the penis after retraction become linear in a vertical direction, and almost imperceptible in the circular folds of retracted foreskin. In the after-treatment the prepuce should be kept back, or frequently retracted. In children retraction once daily for a week or ten days, till the wounds have healed, is quite sufficient. The extent of the incisions should, of course, be a little less in children, a little greater in the adult.

The present writer has seen this operation performed in one instance, and the after-results were in the highest degree satisfactory. As contrasted with circumcision, the procedure merits warm commendation; preserving the useful foreskin, and followed by a much more speedy recovery than may be expected from the former. For the lacerations which may result from forcible dilatation, small nicks with a pair of scissors are substituted. The only objection is that even this operation, trivial as it appears, is seldom necessary; and that sufficient distension of the foreskin may often be procured without any breach of surface whatever. Moreover, some confinement to bed or to the sofa is subsequently requisite; whereas, after the effects of the anæsthetic have passed off, the patient, young or old, whose foreskin has been dilated, can behave exactly as usual.[26]

Mr. Jordan's operation is, however, a very useful corollary to the dilatation-method in the chronic phimosis (often associated with gout) of men in advanced life; when the parts are usually in a very gristly condition; and when, if it be found impossible to procure retraction by stretching, the contracted tissues may be advantageously nicked with scissors in the mode here indicated.

FOOTNOTES:[22]For instance, Mr. Erichsen (op. cit.) dismisses the measure with the cursory allusion of a brief paragraph; against the long and elaborate account, previously detailed, of circumcision; it is not mentioned at all in the earlier editions of his work. Ashby and Wright speak of it with great disfavour. Mr. Jacobson (Operations of Surgery, 1890) does not introduce it at all; possibly because hardly worthy to be dignified by the title 'operation.'[23]In adults, or in boys approaching manhood, gradual dilatation by the daily introduction of a sponge tent has been recommended. It might be resorted to in the case of an exceptionally timid and patient individual, but hardly for any other.[24]Mr. R. W. Parker (Brit. Med. Journal, July 19, 1879) recommends gradual dilatation with a special screw-forceps, which he has used in a considerable number of cases at the Children's Hospital, 'always with good results.'[25]In the paper above quoted, by Dr. Cruise, of Dublin (1868), that surgeon speaks of Dr. Hutton having used dressing-forceps for the cure of phimosis fifteen years previously. Very probably the adoption of that instrument for the same purpose would be found on inquiry to date back still further; and no pretension of originality can be here put forth for the advocacy of a simple common-sense practice, which must have been repeatedly resorted to by many practitioners of the past.[26]M. Faure has also described a somewhat analogous 'nicking' operation.

[22]For instance, Mr. Erichsen (op. cit.) dismisses the measure with the cursory allusion of a brief paragraph; against the long and elaborate account, previously detailed, of circumcision; it is not mentioned at all in the earlier editions of his work. Ashby and Wright speak of it with great disfavour. Mr. Jacobson (Operations of Surgery, 1890) does not introduce it at all; possibly because hardly worthy to be dignified by the title 'operation.'

[23]In adults, or in boys approaching manhood, gradual dilatation by the daily introduction of a sponge tent has been recommended. It might be resorted to in the case of an exceptionally timid and patient individual, but hardly for any other.

[24]Mr. R. W. Parker (Brit. Med. Journal, July 19, 1879) recommends gradual dilatation with a special screw-forceps, which he has used in a considerable number of cases at the Children's Hospital, 'always with good results.'

[25]In the paper above quoted, by Dr. Cruise, of Dublin (1868), that surgeon speaks of Dr. Hutton having used dressing-forceps for the cure of phimosis fifteen years previously. Very probably the adoption of that instrument for the same purpose would be found on inquiry to date back still further; and no pretension of originality can be here put forth for the advocacy of a simple common-sense practice, which must have been repeatedly resorted to by many practitioners of the past.

[26]M. Faure has also described a somewhat analogous 'nicking' operation.

I. Circumcision as a sacrificial rite has been practised by very numerous races of diverse origin, and dates from an extremely remote antiquity; probably from the Stone Age, as suggested by the internal evidence of Biblical records.

II. This fact, together with that of its application by many tribes to the persons of female children, deprives the religious ceremony of any title to the hygienic character and purpose, which have been frequently attributed to it.

III. The surgical operation of circumcision, especially where infants are concerned, has therefore to be discussed solely on its own merits, wholly apart from any theory of Divine intentions, based upon theological considerations. It appears to be erroneousin principle.

IV. It consists in amutilation; in the removal of a perfectly normal structure, with which, for patent physiological reasons, every male child is endowed by nature. The morality of such a practice, without grave necessity, is open to question.

V. Unless as the result of subsequent disease, no deformity, and indeed no actual abnormality, exist as factors productive of the condition designated 'Congenital Phimosis.' Almost every male childsuffers at birth from some degree of the same phenomenon—the imperfect separation of two muco-cutaneous surfaces, developed in contiguity.[27]

VI. Symptoms ascribed to a 'contracted prepuce' are due to natural growth of the glans penis, when this physiological separation is very incomplete, and when, therefore, a rigid constricting envelope prevents development.No true contractionexists, except as the result of superadded inflammation; and is rarely of much importance, unless an element of contagion has been introduced.

VII. The rational treatment of congenital phimosis primarily consists in the efficient execution of the process originally intended by nature, but imperfectly carried out. And, secondarily, in precautions to ensure the permanently free mobility of the prepuce upon the glans penis.

VIII. Such complete separation of the two contiguous layers of membrane may almost invariably be effected by very simple means; and, with some slight attention to after-treatment, will permanently secure all that is desired, without risk and without even transient disability.

IX. The treatment of congenital phimosis by dilatation is the common-sense remedy for this condition. It has been carried out by many practitioners with different instruments and variations ofdetail; and all who have thus attempted it with ordinary care (including the present writer) seem eminently satisfied with the results.[28]

X. When diseased processes co-exist with congenital phimosis, the case must necessarily be treated on its own merits. Simple dilatation, even if practicable, is not always sufficient, but should be combined with incisions of as limited a nature as possible. Mr. Furneaux Jordan's operation is then useful.

XI. In the event of disease, the operation of circumcision is not devoid of risk, and should be reserved as far as possible for extreme cases, in which removal of the whole prepuce is obviously a matter of necessity.[29]

XII. In healthy children the operation seems to be rarely fatal in this country. Many cases of death directly traceable to circumcision have, however, been reported on the Continent.

XIII. The immediate effects of circumcision, especially when performed on young infants, involve considerable and protracted suffering.

XIV. The most conspicuousremoteresult isthat of an extremely contractedmeatus urinarius, as the consequence of subsequent inflammatory processes, due to the exposure and continual friction of the unprotected glans.

XV. The compulsory enforcement of local cleanliness procured by circumcision seems hardly a sufficient argument for the general adoption of the practice by peoples not utterly indifferent to all laws of hygiene; and has little weight even in individual cases.

XVI. The superior chastity and purity of mind and body supposed to be procured for its recipients by ritual circumcision, lie open to very considerable question, in the face of abundant well-known facts.

XVII. The advantage of circumcision in obviating future venereal contagion is restricted by its principal advocate to one form (albeit the most important) of such disease. Even in this limited field the facts adduced appear open to dispute, and greatly to need confirmation by independent observers.

XVIII. In the hands of careless or inexperienced operators the surgical operation of circumcision has been followed by the most disastrous permanent consequences.

XIX. In face of the facts here set forth, it isNOTadvisable to apply the operation of circumcision, as a remedy for congenital phimosis, to Christian infants; much less to extend this, as a routine custom, to the whole male population.

FOOTNOTES:[27]The word 'adhesion' in the previous pages is employed solely as a term of convenience, to denote this imperfect separation, and does not imply any analogy to inflammatory processes.[28]The writer first drew attention to the advantages of this method of treatment in theBritish Medical Journal, Nov. 15, 1874. Having instituted a tolerably extensive search through the medical literature of the preceding three or four decades, he is unable to find any account of a case in which the procedure failed to effect a permanent cure, unless there had existed previous disease.[29]A fatal case, after circumcision for gonorrhœal inflammation, in a youth of 17, is reported in theLancet, Feb. 25, 1882. Death took place on the eighth day apparently from septicæmic pneumonia.

[27]The word 'adhesion' in the previous pages is employed solely as a term of convenience, to denote this imperfect separation, and does not imply any analogy to inflammatory processes.

[28]The writer first drew attention to the advantages of this method of treatment in theBritish Medical Journal, Nov. 15, 1874. Having instituted a tolerably extensive search through the medical literature of the preceding three or four decades, he is unable to find any account of a case in which the procedure failed to effect a permanent cure, unless there had existed previous disease.

[29]A fatal case, after circumcision for gonorrhœal inflammation, in a youth of 17, is reported in theLancet, Feb. 25, 1882. Death took place on the eighth day apparently from septicæmic pneumonia.

PUBLISHED WORKS.

I.—Medical.

Erichsen'sSurgery, Ninth Edition; Holmes'sSystem of Surgery, Third Edition; Maunder'sOperative Surgery; Joseph Bell'sManual of Surgical Operations; Jacobson'sOperations of Surgery; Reginald Harrison'sDiseases of Urinary Organs, Third Edition; Keyes'sDiseases of Urinary Organs; Keating'sCyclopædia of the Diseases of Children; Ashby and Wright'sDiseases of Children; Jaffé'sDie rituelle Circumcision im Lichte der antiseptischen Chirurgie; Asher'sThe Jewish Rite of Circumcision; Wunderbar'sBiblisch-Talmudische Medicin; Gideon Bircher'sDie Beschneidung der Israeliten; Dr. Hayes Agnew'sPrinciples of Surgery; Sayre'sOrthopædic Surgery; Hilton'sRest and Pain;International Encyclopædia of Surgery, 1886;Guy's Hospital Reports;American Journal of Syphilis and Dermatology, October 1872; Walsham'sTheory and Practice of Surgery, &c. &c.

II.—Historical and Miscellaneous.

The Testaments, Old and New;The Talmud;Maimonides on Circumcision; Tylor'sPrimitive Culture; Moncure Conway'sDemonology and Devil Lore; Keil'sBiblical Archæology; Smith'sDictionary of the Bible; Calmet,Dictionary of the Bible,Encyclopædia Americana,Encyclopædia Britannica; Howard,Royal Encyclopædia;Penny Cyclopædia;Chambers's Encyclopædia;Encyclopædia Metropolitana; Winer'sRealwörth; Brewster,Edinburgh Encyclopædia;English Cyclopædia; Wilkes'sEncyclopædia Londinensis;Globe Encyclopædia, &c.

Periodicals.

The Lancet,British Medical Journal,Medical Times and Gazette,Medical Record,Dublin Journal,Boston Medical and Surgical Journal,Chicago Medical Standard,Gazette des Hôpitaux,Allgemeine Wiener Med. Zeitung,Wiener Med. Presse, &c.

THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the Opium Pipe.) 2s.6d.THE REAPPEARANCE OF CANCER AFTER OPERATION. 5s.6d.THE GENERAL THEORY OF CANCER-FORMATION. 1s.CLINICAL NOTES ON CANCER. 3s.6d.

THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the Opium Pipe.) 2s.6d.

THE REAPPEARANCE OF CANCER AFTER OPERATION. 5s.6d.

THE GENERAL THEORY OF CANCER-FORMATION. 1s.

CLINICAL NOTES ON CANCER. 3s.6d.

J. & A. CHURCHILL, New Burlington Street.

Back to Index Next