Part 3

I have failed to find any statistics proving that the circumcised masturbate less frequently, or are more virtuous than others; and the exposure of the tender skin to friction of clothing &c., tends to keep up a state of abnormal excitement during the early years of life.

'Where doctors differ, who shall decide?' And in face, therefore, of such directly contradictory opinions from professional witnesses, it is difficult to believe that ablation of the prepuce is of material avail, either in precluding masturbation, or in promoting the subsequent chastity of the adult individual.

On the third of the reasons assigned for advocating circumcision--the prevention of venereal disease when manhood is attained--Mr. Jonathan Hutchinson, whose testimony cannot but receive considerable weight, remarks that chancres are rare in the Jew. The observation has not been controverted; but must be received with a certain amount of hesitancy, in consequence of an evident bias in favour of radical measures of operative treatment. It seems rather to need confirmation by surgeons of the Jewish race, practising especially among their co-religionists. The present writer has been unable to discover any evidence in support from such a quarter. The authority last cited points out that cicatricial tissue is of all others least resistent to infection; and in the writer's own confessedly few opportunities for research in this particular field the number of Jews who have displayed remote but unmistakable indications of previous syphilitic taint has not appeared small. It is not improbable that a Hunterian sore developed upon scar-tissue, or upon the hardened integument of a denuded glans, would be far more trivial in character, more transient, less productive of inconvenience, and less easily recognisable, than the same in a normal state of the parts; the after-effects being, of course, identical. Such primary lesions in a people notoriously rather negligent of their person would seldom come under the notice of the medical practitioner. So, failing further evidence, the provisional verdict upon this question must be the Scotch one, 'Not proven.'

But even if the above assertion be accepted in respect of true syphilis, it assuredly fails to hold good with reference to other varieties of venereal disease. Thus Mr. Jonathan Hutchinson's oft-quoted statistics[15] (_Medical Times and Gazette_, December 1, 1885), in his own words, 'prove that, though in proportion of nearly a third to the other patients, they (Jews) furnish nearly half the cases of gonorrhoea.'

The last-named motive for circumcision, although, in the passage quoted at the beginning of this section, it has been stamped with the approval of the same high authority, needs but transient allusion. It is _a priori_ probable that congenital phimosis prolonged into adult life renders the subject thereof somewhat more likely to develop local malignant disease than any one not so circumstanced; the resulting attacks of inflammation and of unhealthy ulceration, &c., may be naturally expected to lead to the growth of papillomata, as well as to maintain a chronic condition of lowered vitality. But the comparative rarity of epithelioma in this particular locality would deprive the allegation, even if this were positively established as an indisputable fact, of any weight as an argument for the removal of the prepuce. Moreover, it is obviously a reason not for the routine performance of circumcision, but for the relief of phimosis; by whatever means attempted or proposed.

FOOTNOTES:

[11] In Druitt's _Surgeon'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 two _lateral_ incisions 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 oedema. 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 the _Lancet_, 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:

+------------+-----------+--------+-------------------------+ | Cases |Gonorrhoea |Syphilis|Proportion of gonorrhoea | | | | | to syphilis | +------------+-----------+--------+-------------------------+ |Not Jews 272| 107 | 165 | 0·6 to 1 | |Jews 58| 47 | 11 | 4·3 " 1 | +------------+-----------+--------+-------------------------+

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 gonorrhoea; 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.

V

DISADVANTAGES AND DANGERS OF CIRCUMCISION.

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. Maimonides inculcates 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]

The _Lancet_ of October 1, 1870, quotes from the _Wiener Med. Presse_ the 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; who stated 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 hæmorrhage _must_ occasionally 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 the _Lancet_ of 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 criminal manipulation; 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, in _Gaillard'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 delicate mucous 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 in _at least_ one instance.' (The italics are his own.) Mr. Reginald Harrison (_Diseases of Urinary Organs_, 3rd Edition, 1887) has treated two _varieties_ of urethral stricture after circumcision which have not turned out well; in two _cases_, the extremity of the glans penis, including the meatus, had been wounded in making the section of the prepuce; in a third, owing to 'oedema 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 to leave 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's _Cyclopædia 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 surgery have 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 remaining _long oedematous 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 time which 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 almost _nil_; 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 the _Boston 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 the _British Medical Journal_ of 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.'

VI

ABSENCE OF NECESSITY FOR CIRCUMCISION IN CASES OF CONGENITAL PHIMOSIS--THE RATIONAL TREATMENT OF THE LATTER.

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 to _mutilation_ for 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 there no 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 tissue undergoes, 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.