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Title: The Barbarity of Circumcision as a Remedy for Congenital Abnormality
Author: Herbert Snow
Release Date: May 3, 2018 [EBook #57083]
Language: English
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THE
BARBARITY OF CIRCUMCISION
AS A REMEDY FOR
_CONGENITAL ABNORMALITY_
BY HERBERT SNOW, M.D. LOND. &c.
SURGEON TO THE CANCER HOSPITAL
[Illustration: Logo]
LONDON
J. & A. CHURCHILL
11 NEW BURLINGTON STREET
1890
PREFATORY NOTE
To state that the object of this little work is to 'put down
Circumcision' under the circumstances indicated, would, besides
savouring of unpardonable arrogance, irresistibly suggest analogy to the
example of a too famous alderman, who was determined to 'put down
Suicide.'
If, however, the facts and arguments therein set forth contribute in
some small measure towards the abolition of an antiquated practice
involving the infliction of very considerable suffering upon helpless
infants; and sanctioned, on extremely questionable grounds, by men of
eminent authority; the following pages will not have been written in
vain.
More evil is wrought by want of thought,
Than comes from want of heart.
GLOUCESTER PLACE, PORTMAN SQUARE:
_October 1890_.
THE BARBARITY OF CIRCUMCISION
AS A REMEDY FOR CONGENITAL ABNORMALITY.
I
CIRCUMCISION AS A RELIGIOUS RITE.
The earliest historical or quasi-historical notice of circumcision is to
be found in Genesis xvii.; where Jahve enjoins upon Abraham the personal
performance of this mutilation, as a sign of the covenant henceforward
to subsist between them. Abraham, his son Ishmael, and all his male
slaves forthwith underwent the prescribed operation; which
thence-forward remained obligatory upon their posterity, though not
without transient periods of desuetude. It was suffered to lapse during
the passage of the Israelites through the wilderness, and was
subsequently revived by Joshua (v. 5); again in the reign of Antiochus
Epiphanes, when some of the Jews seem to have submitted to a plastic
operation in order to obliterate its effects.[1]
The compulsory performance of circumcision was re-enacted for the last
time by Mattathias, in the age of the Maccabees; and the law to this
effect has remained in force until the present day.[2]
The terms in which the Deity addresses his commands to Abraham
presuppose an already existing familiarity with the ritual ceremony on
the part of the latter. Accordingly we find that it previously prevailed
among the Colchians, Æthiopians, and ancient Egyptians of both the Upper
and Lower Provinces (Gardner Wilkinson). Among the latter it appears to
have become restricted, by the dawn of the historical period, to the
priestly caste, and to those who desired initiation into the sacred
mysteries. In the temple of Chunsu at Karnak is a delineation of the
rite as performed on two young children, probably sons of Rameses II.,
the founder of the building. It was apparently connected with the
worship of Ra, the Sun God; and a seeming allusion to it in this
connection is to be found in chapter xvii. of the 'Book of the Dead.'
Notices of circumcision also appear in ancient Phoenician mythology.
There can be no question of its very great antiquity, or of its wide
prevalence among ancient nations. Traditional descent from a primæval
Stone Age is betrayed by casual notices in Holy Writ. Thus, in Exodus
iv. 25, a sharp stone is the instrument of mutilation; and in Joshua v.
2, the marginal rendering is 'knives of flints.'[3]
The Hivites, the Canaanites (Phoenician), and many if not most of the
nations with whom the Israelites were brought into contact after
settlement in the Promised Land, appear to have practised circumcision
at some period in their history. In the Old Testament we accordingly
find the designation of 'the uncircumcised' specially reserved for the
Philistines, and applied to these as a term of opprobrium.
The list of peoples by whom the circumcision of males has been, or is
still, an established custom is sufficiently long. Among such races at
the present day, 'an almost unbroken line may be traced from China to
the Cape of Good Hope,' and unless perhaps in Europe (where
comparatively slight traces of aboriginal manners and customs survive),
we find the ceremony characteristic not only of savage tribes, but of
nations ranking fairly high in the scale of civilisation; for instance,
the Mexicans, and the ancient Aztec races of Central America. The Teanas
and Manaos on the Amazon; the Salivos, Guamos, Otamocos, on the
Orinoco; the negroes of the Congo, with many other tribes on both the
west and east coasts of Africa, notably the Kaffirs, Bechuanas, and
Hottentots; the Abyssinians (Christian), Nubians and modern Egyptians;
the natives of Madagascar; most of the Australian aborigines; the
Papuans, New Caledonians, inhabitants of the New Hebrides, of Java, of
the Philippines, and of Fiji, are only a few that may be indicated. An
approximation to the rite in the form of a slitting up of the prepuce
was noticed among the Friendly Islanders by Captain Cook. Although not
enjoined in the Koran, it is a universal practice among the Mohammedans,
as a tradition from the ante-Mohammedan period.
A cognate operation upon _females_ obtains among the modern Egyptians,
the Nubians, the Abyssinians, as well as in many other parts of Africa
among the negro races; also among the Malays on the shores of the
Persian Gulf (Carsten Niebuhr), and on the banks of the Orinoco. As an
ancient custom in Arabia and Egypt, it is noticed by Strabo.
Local variations of detail are found; as in the case of the Friendly
Islanders just cited; and of the Madagascarians, who cut the flesh at
three several times; the excised prepuce being eventually _swallowed_ by
some relative or other.
The date at which circumcision is performed varies considerably. Among
the Jews, the eighth day is, of course, the selected period; probably
from consideration for the sacred number seven, for the seven days of
uncleanness prescribed for the parturient mother (Lev. xii. 2), and for
an idea that with the second cycle of seven days the infant then
properly commenced its earthly life. Among the Arabs, it is deferred
till the thirteenth year; the age at which their reputed ancestor,
Ishmael, was submitted to it. And every race seems to have selected for
itself what was considered the most suitable time. The Turks, for
example, have chosen the seventh or eighth year; the Persians circumcise
boys at thirteen, girls, between the ninth and the fifteenth year; and
so on.
It is thus evident, not only that the rite is extremely ancient, but
that it is impossible to refer the practice of circumcision to any
single source; or to doubt that it originally arose among many
widely-sundered peoples, as the result of a certain stage in man's
mental evolution. The once widely-spread custom of the COUVADE, and
other strange aboriginal practices, afford an illustrative analogy.[4]
Herodotus seems to have been the author, or at least the introducer, of
the cleanliness theory; according to which the ceremony was invented
from motives of hygiene. Philo Judæus ascribes the custom to four
causes: 1. Cleanliness; 2. The avoidance of carbuncle (Qu. cancer?); 3.
The symbolisation of purity of heart; 4. The attainment of numerous
offspring.
Of these, it need hardly be said that the last has no foundation in
fact; and the two preceding require no remark. The idea, however, that
circumcision was initiated for purposes of cleanliness has lasted to the
present day, and still appears to have considerable currency. Whatever
may have been the social condition of the ancient Egyptians and
Arabians, on behalf of both which races, as having been the source
whence Abraham derived his evident familiarity with the custom,
plausible pretensions have been put forth; it is simply preposterous to
imagine for a moment that the numerous savage tribes (witness the
Hottentots and the Australian aborigines) who practise it, could ever
have been actuated by any such considerations. Its world-wide diffusion,
again, totally forbids the supposition, either of its introduction into
these tribes by contact with other nations more highly civilised; or of
its adoption, by the former, while in a higher stage of sociology, from
which they have subsequently become degraded. And this explanation is
put finally out of court by the phenomenon of an analogous rite applied
in sufficiently numerous quarters to the persons of females. In order,
therefore, plausibly to account for the general prevalence of this
strange mutilation, we are compelled to look elsewhere; and an
examination of the religious ideas which are known to actuate primitive
man, will afford a clue.
Copious illustrations of the working of such ideas among peoples
emerging from barbarism can be traced in almost every page of the
earlier books of our Old Testament; and, even in classical mythology,
although overlaid by the later developments of a high civilisation,
their influence is still not entirely effaced. The principle of
substitution was familiar to all the nations of antiquity, to the
Israelites not the least. Witness the universal resort to sacrifices,
the theory of which is well indicated by that of Isaac in Genesis xxii.
Further illustrative examples are afforded by the law of the scapegoat,
in Leviticus xvi.; by the offering of children to Molech (Lev. xx. 2);
and by the legend of Jephthah's daughter (Judg. xi.). With this, various
ceremonies, involving either mutilation or the shedding of blood, were
in vogue--for example, the priests of Baal (1 Kings xviii. 28); even
cutting off the hair seems to have been in the nature of a
representative sacrifice.[5]
Hence many German authorities cited in Keil's _Biblical Archæology_
(vol. i. p. 415) consider circumcision as a relic of ancient sacrifice:
the consecration of a part of the body for the whole. The different
grades in the process of humanisation may be assumed to have been
successively attained as follows. In the earliest periods, human
sacrifice was probably universal; in the Bible, we have the episode of
Jephthah's daughter, above referred to; and in the narrative of
Abraham's purpose to offer Isaac there is not the slightest indication
of surprise on the part of the patriarch when he received Jahve's
commands; whence may be argued evident acquaintance with such deeds.
Besides which, we hear of human sacrifice among the tribes contiguous to
the Israelites, until a much later date. Even the Greeks and Romans
occasionally resorted to this during the historical period; in the
Homeric age, it appears to have been a not infrequent practice.
As, however, men progressed in culture and in humanity, such barbarity
became impossible. Instead of putting their firstborn children (often by
cruel methods, as in the sacrifices to Molech) to death, they
propitiated the deity by an offer of the most precious member. Indeed,
in the Genesis account of Abraham's circumcision, Mr. Moncure Conway
considers (_Demonology and Devil Lore_, ii. 83) that the legend,
subsequently obscured by later traditions, originally points to the
performance of a much more severe operation. And when still more
advanced, even this became impossible; the excision of a very small
portion of the organ, not of indispensable necessity to the fulfilment
of its functions, being substituted. After many generations had then
passed over, the custom had become so firmly implanted in the mind and
habits of the people, that its eradication was rendered a matter of
extreme difficulty; even by new religious dispensations and more
elevated modes of thought. Hence we find the rite among the Israelites
made an exception to the fierce denunciation of mutilations in general,
uttered by Jahve or by his messengers; and hence also, we see it (though
not prescribed in the Koran) an ordinary modern custom throughout the
whole of Islam, as well as among the Christian Abyssinians.
The practice of self-emasculation in honour of a divinity was a common
feature in the worship of Chronos, of Cybele, and doubtless of many
other among the earlier recipients of religious adoration; it is
referred to (and not in terms of reprobation) at Matthew xix. 12. It has
descended to modern times--witness the fanatical sects in Russia; and
even persons of high intellectual calibre (as, for instance, Origen)
have submitted to it. What men regarded as honourable and meritorious in
themselves, they would be not unlikely to impose also on their children.
The existence of such ascetic practices among partially civilised
nations must not be lost sight of in the present connection; as helping
us to comprehend the mental religious attitude of primæval man.
There can be little question that here we find our correct explanation
of the origin and wide prevalence of circumcision. We are, however, no
longer permitted to regard this as a hygienic custom, but simply and
solely as a relic of barbarism; dating from an immemorial antiquity,
long anterior to the first historical records, and when man was little,
if at all, removed from savagery. The venerable age of the prescriptive
rite, as well as the various social and religious phases through which
the peoples adopting it have since successively passed, have effectually
spiritualised it and have shed around it a certain halo of
sentimentalism; but should not be suffered to obscure the only rational
conception of its primary significance.
The sacrificial character of the act among the Israelites was indicated
by a former custom of placing a pot of dust in the room where the
ceremony was to take place; that, as we read in the third chapter of
Genesis, being the allotted food of the serpent. The practice seems to
have continued down to a recent period, but now to have fallen into
disuse.
We thus clearly see that, beside being the sign of the covenant with the
tribal deity, there was also involved the idea of a propitiatory
sacrifice to the awful evil demons. The most clear instance of
circumcision as an act intended to conciliate an offended divinity, or
malignant spirit, appears in the strange story of Zipporah at Exodus iv.
24; where the vicarious nature of the rite is also plainly set forth.
There is no apparent reason for identifying the Lord ('Adonai'); who
sought to slay Moses, with Jahve; from whom Moses had just parted upon
excellent terms. And there can be little doubt that Samael, to whom the
scapegoat was subsequently offered (Lev. xvi. 20), or some similar dread
power of darkness, is here meant.[6]
If the writer is not greatly in error, an impression prevails in some
quarters that _Moses_ either instituted anew or effectually perpetuated
the rite of circumcision among the Israelites; as a useful measure of
sanitation. However deservedly high the reputation of the great Hebrew
lawgiver as a sanitarian, he does not seem entitled to credit in this
connection; and alludes but casually to the ceremony, as to an already
well-established custom, among certain directions for the treatment of
the parturient woman at Leviticus xxii. 3. There is plainly no question
of hygiene here involved. Dr. Asher (_The Jewish Rite of Circumcision_)
considers that CHASTITY was the main purpose aimed at in the Divine
injunction to Abraham; but, for reasons subsequently adduced, such a
theory will be seen to have no foundation in fact.[7]
As the present is not an antiquarian treatise, only a very cursory
historic or ethnic account of ritual circumcision is here inserted; many
other curious and interesting particulars may be found in the
authorities cited at the end of this volume, as well as in the copious
German literature on the same subject. All that has been attempted in
the preceding pages is to exhibit the custom in its original character;
and (in so far as the pretensions advanced upon its behalf as a surgical
procedure are concerned), divested of the traditional sanctity which is
possibly largely answerable for some of the views promulgated by medical
authors; whereby the general habit and practice of the medical
profession become also of necessity deeply tinged.[8]
FOOTNOTES:
[1] An account of the operation (seemingly then not infrequently
resorted to) performed at a much later date for the above purpose, is to
be found in _Celsus_, lib. vii. cap. xxv.
[2] According to Keating's _Cyclopædia of the Diseases of Children_,
1890, vol. iii., some of the rabbins now omit it; "in the teeth of a
strong and growing popular prejudice." I am informed, however, by the
Rev. S. Singer, to whom I am greatly indebted for a courteous reply to
inquiry on the subject, that these congregations would not be regarded
as orthodox; and that the innovation is unknown in the Old World.
[3] In the _Lancet_ of April 20, 1889, is figured a curious circumcising
Instrument used by the Malays, who perform the rite upon boys at the age
of eight years; and also upon females, about 1/8th inch being nipped off
the extremity of the clitoris. In the ceremony performed on female
children, variations exist; other tribes remove the nymphæ.
[4] _La Couvade_ was the designation of the unwritten law, according to
which, directly an infant was brought into the world, the husband
retired to bed and was sedulously nursed for a certain prescribed
period; the mother, on the other hand, getting up and attending to the
affairs of the household. Tylor speaks of it as "this once world-wide
custom" (_Primitive Culture_, i. 76).
[5] Examples of the substitution principle among various _modern_ races
are to be found in Tylor's _Primitive Culture_, vol. ii. p. 36 _et seq._
[6] The imposition of circumcision by the Jews upon vanquished enemies,
as the Idumeans and Itureans (Josephus, _Antiq._ B. 13) sounds the like
note; there could hardly be any question of proselytism. At an earlier
date these people would have been ruthlessly massacred _en masse_, like
the Amalekites (1 Sam. xv. 8); slaughtered in great part, like the
Moabites (2 Sam. viii.); or sacrificed, like Agag (1 Sam. xv. 3), to the
deity of the conquerors.
[7] According to the same writer, it is absolutely impossible to say, in
any given case among the Mohammedans, whether circumcision has been
performed or not; for, as the muco-cutaneous membrane has not been
divided, 'the soft elastic skin of the penis easily comes forward and
re-covers the glans.' He states that the performance of that particular
portion of the ceremony which consists in tearing and removing the
membrane in question, completely distinguishes the Jews from all the
other nations of the world who practise the operation as a religious
rite.
[8] Two cases of interest in this connection may be here noticed. Dr.
Levy, a Jew dentist of Stettin, states (_Medical Record_, May 3, 1890)
that, like his father before him, he was born without a foreskin;
further, that his four brothers, who died in childhood, were similarly
circumstanced.
The late Dr. Asher (_op. cit._), who must be considered a high authority
in such a matter (so far at least as concerns his co-religionists),
says: 'No part of the human body is subject to so many varieties and
irregularities as the penis and foreskin.' He believes total absence of
the prepuce to be extremely rare, and doubts whether such a phenomenon
has ever occurred; but seems to regard a partial deficiency as nothing
unusual. He states that in most, if not all, instances of supposed
congenital absence of this structure, a small portion of the skin will
be found prolonged to the glans across the intervening fossa; which
morsel, however small, must be excised by the Mohel, with the usual
formalities. A note informs us that, according to Jewish tradition, the
following personages never had foreskins: Adam, Seth, Noah, Shem,
Melchizedek, Jacob, Joseph, Job, Moses, Balaam, Samuel, David, Jeremiah,
Zerubbabel.
The second case bears upon the very heterodox theory of maternal
impressions, and is reported in the same periodical, of dates Nov. 3,
1888, and March 23, 1889. It is that of a child born accurately
circumcised, seven months and twenty days after the like operation on
his elder brother (presumably in presence of the mother, although this
is not stated). The local appearances in the two children are affirmed
by Dr. Harvey, of Illinois, to have been exactly alike; 'the congenital
case even showing the marks of the sutures.'
Both of the above cases, together with Dr. Asher's experiences, may be
respectfully commended to the notice of Professor Weismann.
II
NATURE OF CONGENITAL PHIMOSIS--PHYSIOLOGICAL IMPORTANCE OF THE PREPUCE.
The word 'phimosis' ([Greek: phimoô], I bind) signifies that condition
of the penis in which the prepuce cannot be retracted beyond the _corona
glandis_; and which may be either congenital or factitious.
The latter is a pathological phenomenon, the product of injury or of
disease. To apply the term 'abnormal' to the former is, however, hardly
permissible, except when the difficulties in retraction are permanent
and extreme; when they cannot be overcome by judicious perseverance, and
by careful manipulation in the early weeks of infant life. A certain
amount of adhesion between the two contiguous surfaces of mucous
membrane is almost constantly present at birth, as a continuation of
the normal intra-uterine agglutination (Keating's _Cyclopædia of the
Diseases of Children_, 1890, vol. iii.; article by Dr. De Forest
Willard).
The radical defect in congenital phimosis is thus the adhesion or
imperfect separation of two muco-cutaneous surfaces, normally developed
in close contact. As a rule, these are so slightly connected that a very
slight degree of force is sufficient to part them; but in a considerable
minority of instances the defect eventually becomes permanent; with the
natural growth of the organ more difficulty is experienced in procuring
retraction; and various disagreeable, or even dangerous, symptoms are
prone then to make their appearance.
The complaint, however, is simply one of degree. If the adhesions at the
margin of the urethral meatus are so tight that they fail to be quickly
separated by the stream of urine directed against them--the force of
which necessarily varies in different infants--considerable impediment
to micturition results; and, perhaps usefully, serves to direct early
attention to the state of the parts. In rare cases, no opening at all
into the urethra has been discoverable; and complete retention has
necessarily ensued. Very often, however, nothing of this sort happens
for several weeks, months, or even years; and the existence, or rather
persistence, of the disability may not be noticed at all until
adolescence of adult life. The majority of instances lie between these
extremes; not seldom unpleasant symptoms begin to be observed when the
boy is a few months old; but there is a wide range of variation.
The penile and preputial layers of mucous or quasi-mucous membrane being
firmly adherent, and growth of the glans penis proceeding apace, certain
consequences necessarily follow.
The prepuce being (in extreme cases) tightly fixed to the margins of the
urethral orifice, the _meatus urinarius_ still retains the same calibre
as when birth took place, and becomes far too small for the needs of the
rapidly growing child. A difficulty in effectually voiding the bladder
is experienced, and may eventually result in complete retention. The
little patient tugs at the seat of unpleasant sensation; and this
elongates the folds of skin at the extremity of the penis, normally
somewhat redundant, and extremely distensile. The muscular force of the
bladder being spent upon overcoming the obstruction at the narrow
meatus, the urine trickles out feebly, and 'balloons' in the soft
pouches beyond, which continuously retain a few drops. Hence great local
irritation and excoriation.
It is not warrantable, however, to speak of _contraction_ of the penile
mucous membrane. No contraction takes place, except as a consequence of
inflammatory attacks; and these, in the infant, are rarely sufficient to
cause any material shrinking. The phenomenon is simply one of natural
development under a rigid restraining envelope; and though eventually
the aperture is found narrow enough, the 'contraction' is relative only.
So also, in every male child there is more or less seeming redundancy of
skin at the end of the penis;--for natural physiological reasons. The
condition is apt, as first stated, to become factitiously enhanced under
the pressure of urinary obstruction. But there is seldom or never a
_real superfluity of integument_ in this locality _ab initio_; in excess
of what the subsequent needs of the full-developed organism may be
reasonably supposed to warrant. It is requisite to lay some stress on
these two points, as tending materially to influence our conceptions of
the practice condemned in this pamphlet.
Although plainly not absolutely essential to the due increase in bulk of
the penis, or to the subsequent performance of its functions, it is
_prima facie_ obvious that the prepuce must be intended to subserve some
useful purpose. That, according to Dr. Willard (Keating's _Cyclopædia_),
'is to protect the head of the organ, during the years when the penis is
but a portion of the urinary apparatus; and later, by its friction over
the sensitive corona, to enhance the ejaculatory orgasm.' The latter
half of this statement may fairly be questioned, as the prepuce is
completely retracted during coition; and so no friction over 'the
corona' can well take place under ordinary conditions. The first part,
however, is unimpugnable; and to it may be added some consideration of
the protection afforded during the first efforts at functional use.
Some measure of the degree in which the glans penis is shielded from
external irritating agencies is afforded by the sensations of the adult
for the first time deprived of this appendage; or in whom the latter is
kept retracted for any length of time, contrary to preceding habit.
Extreme discomfort, indeed considerable soreness and actual pain, are
complained of; until tolerance becomes established, and until the
delicate membrane has by exposure and friction become so hardened that
the absence of its former covering is no longer noticed, a period
occupying commonly several weeks.[9]
In the case of young children, the unpleasant sensations involved must
be relatively far greater; considering their physical helplessness and
their more impressionable nervous system.
According, moreover, to the authority previously cited, early removal of
the prepuce is apt to be followed by _progressive sclerosis_, with
attendant evils of _contracted meatus_, _balanitis_, &c. And, failing
this, 'the exposure of the tender skin to the friction of the clothing,
&c. tends to keep up a state of abnormal excitement during the early
years of life.'
It thus becomes apparent that, apart from any risks involved by
operative procedures, ablation of the prepuce, whether in infant or in
adult, is not a measure to be undertaken lightly, or without
satisfactory evidence of positive necessity.
FOOTNOTE:
[9] The fact that many adults, of not too sensitive organisation,
gradually acquire a habit of retaining the foreskin partially or even
entirely retracted, is of course not lost sight of. But this in no way
affects the question of its _sudden_ removal, or of the protection
afforded by the structure in question to infants of tender years.
III
DANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS.
A perfectly healthy condition of the male generative organs is
compatible only with perfect mobility of the prepuce over the gland
which it envelopes. So, in the absence of this, we encounter a number of
ill consequences, some local only; some affecting the well-being, and
even the life, of the entire organism.
The parts being extremely vascular, and in very intimate relation with
the central nervous system; we very naturally find that congenital
phimosis, interfering with the normal growth of the glans penis, is
prone to develop various reflex neurotic disorders or diseases; of which
some have been minutely described by Dr. Sayre.[10] Thus forms of
_paralysis_ may ensue; either confined to a single group of muscles, and
simulating club-foot, or of a more general character. _Epilepsy_,
_reflex cough_, _convulsions_, _choreic movements of the limbs_, are
extreme examples; but a milder instance of the same causes in operation
shows itself in young infants, as _nocturnal restlessness with defective
nutrition_. _Hip-joint disease_ and _spinal caries_ may be simulated,
and the mal-assimilation of food may eventually produce such gross
deformities as _bowing of the legs_. Chronic _priapism_ is a not
uncommon occurrence.
Obstruction to the free discharge of urine may produce symptoms of
severe _vesical irritation_, occasionally supposed to indicate stone in
the bladder. The straining efforts at micturition may cause _hernia_ or
_prolapse of the rectum_; the _nocturnal incontinence_ of children is
not unfrequently traceable to the same source. _Epistaxis_ has been
described. Retention of urine in the folds of the elongated foreskin,
together with the child's habit of pulling this, induce a condition of
soreness which causes great smarting whenever micturition takes place,
and induces the patient to defer that act as long as possible. Hence may
in time result _dilatation of the bladder, cystic kidneys, and death_.
Even _eczema_ of the abdominal wall has been thus produced; and has
disappeared when the cause was removed, as in a case cited by Dr. Hayes
Agnew (_Principles of Surgery_, 1881).
When the patient is allowed to reach adult life with the disability
unrelieved, he becomes subject to attacks of _balanitis_; and the parts
may ulcerate or even slough. In a case seen by the writer, where at the
time no symptoms of inflammation were present, the retained deposits of
smegma had ulcerated through the prepuce at various points--projecting
from this exactly like chalk-stones from the fingers of a gouty person.
In a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no
fewer than 426 calculi, varying in size from a pin's head to a small
bean, from this situation, in the person of a native of India, sixty
years of age, who came under treatment for what appeared to be a large
tumour at the end of the penis, the true nature of which was not
detected until, on removing it, the knife grated against the contained
calculi.' The defect constitutes a serious impediment to impregnation;
in the event of an acquired local disorder, its presence seriously
hinders diagnosis, and altogether precludes appropriate treatment. It
has been supposed, and not without plausibility, to predispose to
_epithelioma_. A case is given by Mr. Oliver Pemberton; and others have
been reported. There can be no question that, under such circumstances,
the presence of malignant disease about the glans would much longer
remain undetected than in a normal state of the parts; and that the
prospects of cure by operative removal would be proportionately
lessened. Only comparatively mild examples of phimosis, in which the
adhesions produced little or no constriction, and did not at all
interfere with urination, could thus have been suffered to pass
unrelieved until the subjects were far past maturity.
Phimosis, as an _acquired_ condition, is of frequent occurrence in an
_acute_ form; as the result of inflammatory oedema of the prepuce in
youths and adults. This, again, may be a consequence of simple
balanitis, the result of want of cleanliness, combined with disordered
general health and a catarrhal state of all the mucous membranes; in
which event it usually yields to mild measures, such as the injection
of warm fluids under the foreskin. In by far the greater number of
instances it is produced by venereal infection; and imperatively needs
prompt operation, usually in the guise of slitting up the structure on a
director. In a _chronic_ form, slowly and gradually coming on, and very
intractable to remedial measures, it is not seldom seen in old men of
gouty habit; and of consequently unhealthy and irritable mucous
membranes.
The pathology and treatment of ACQUIRED phimosis do not fall within the
scope of the present work, but it is necessary to point out that these
are essentially different from those of the congenital; and that the
latter needs consideration upon principles totally diverse.
In the congenital we have to deal with tissues _perfectly healthy_, and
with skin peculiarly elastic and distensile. In the factitious, all the
parts are more or less altered by _disease_, acute or chronic; and as a
sequel to the latter, or to repeated attacks of the former, _true
contraction_ takes place; the prepuce often attaining a hard and gristly
consistence, under which condition simple dilatation is difficult or
impossible. The phenomenon is rarely, if ever, seen in association with
congenital phimosis; barring gout or venereal taint in addition.
NOTE.--The infrequency of _cancerous disease_ attacking the penis,
renders it unsafe to dogmatise upon any supposed causal
relationship between that malady and the presence or absence of the
foreskin, and does not appear to warrant any stronger assertion on
this point than that which is recorded on the previous page.
FOOTNOTE:
[10] _Orthopædic Surgery_, p. 14. See also Hilton, _Rest and Pain_, p.
276.
IV
CUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED
ADVANTAGES.
From the preceding, the evils or dangers incurred by permitting a male
child to reach adult life; or, in the event of pressing symptoms, to
pass even a few weeks or months with this disability unrelieved; are
sufficiently obvious. Although, as Dr. Willard (_op. cit._) states, the
adhesions between prepuce and glans can nearly always be broken down
with sufficient readiness during the first few weeks after birth, there
can be little doubt that, without conspicuous necessity, the medical
practitioner will seldom care to 'make the baby cry,' and thus draw down
upon himself vigorous maternal reproaches. It seems, moreover, hardly
judicious to encourage any tampering by nurses or midwives, probably
more or less ignorant and unskilled. We may take it for granted,
therefore, that nothing will usually be done until the child is several
months old; when some more energetic treatment will be requisite to
remedy the condition in question. In milder cases no notice will
probably be taken of the abnormality for at least several years, and its
presence may be detected only by accident; the adhesions in such are
trivial, and do not interfere with normal growth; hence are, as a rule,
easily overcome.[11]
Although less severe measures have been from time to time brought
forward and advocated, the operation of circumcision is, to all intents
and purposes, the only procedure in general use for remedying congenital
phimosis; and as the latter is very common, so also is the performance
of this ancient sacrificial rite among that large majority of the
population who are otherwise in no way committed to it. There is a
simplicity and thoroughness about the little amputation which may
perhaps commend it to the surgical mind; and there are unquestionably
certain superficial advantages of a hygienic nature about the patient's
subsequent condition; though it may be doubted whether these are by any
means so considerable as has been made to appear.
However this may be, it goes without saying that no other curative
proceeding has so far met with any wide favour in the medical
profession; and, if one may judge from their published opinions, the
leading exponents of medical practice and opinion, in this country at
least, are so pleased with circumcision and its results that they would
willingly see the Mosaic Laws in this particular extended to the whole
Christian population, whether affected by phimosis or not. Witness Mr.
Jonathan Hutchinson:
It is surely not needful to seek any recondite motive for the
origin of the practice of circumcision. No one who has seen the
superior cleanliness of a Hebrew penis can have avoided a very
strong impression in favour of the removal of the foreskin. It
constitutes a harbour for filth, and is a constant source of
irritation. It conduces to masturbation, and adds to the
difficulties of sexual continence. It increases the risk of
syphilis in early life, and of cancer in the aged. I have never
seen cancer of the penis in a Jew, and chancres are
rare.--_Archives of Surgery._
Arguments by this distinguished surgeon, in favour of extension of the
custom as a matter of ordinary routine to every male Gentile, are to be
found in the _Medical Times and Gazette_, December 1, 1855; together
with a reference to previous utterances in an identical sense.
Erichsen (_Surgery_, Ninth Edition, 1888, vol. ii. p. 1188) says:
Every child who has a congenital phimosis ought to be circumcised;
and even those who, without having phimosis, have an abnormally
long and lax prepuce, would be improved greatly in cleanliness,
health, and morals by being subjected to the same operation. It
would be well if the custom of Eastern nations, whether it be
regarded as a religious rite or only as a time-honoured observance,
were introduced amongst us.
In Holmes's _System of Surgery_, 1883, we read:
Circumcision is the operation required in children; and it is best
adapted for adults also when the skin is redundant, and the margins
of the preputial opening are thickened.
Mr. W. H. Jacobson (_Operations of Surgery_, 1889) says:
This operation is still not practised often enough, especially
among poorer patients; amongst whom many practitioners still treat
phimosis as a matter of but little importance.
Some of the pretensions set forth above on behalf of circumcision will
be subsequently referred to; but on the plea for a general extension of
the rite to nations not impelled thereto by special Divine command, it
may be remarked that several Jewish surgeons who have written upon the
topic by no means regard this with an eye of favour; and have, in fact,
gone even so far as to denounce in the strongest terms its compulsory
performance among their co-religionists.[12]
For their dislike, they advance what appear to be very adequate reasons;
and, in such a matter they must have enjoyed a far wider special
experience than any practitioner without the Hebrew pale.
The following extract from Erichsen's _Science and Art of Surgery_
(Ninth Edition, 1888) may be regarded as a typical account of the
ordinary surgical operation in vogue at the present day. The italics are
the present writer's:
Circumcision in boys or adults may be most conveniently performed
in the following way. The surgeon restrains hæmorrhage during the
operation by tying a tape tightly around the root of the penis, or
by compressing the organ in Clover's circumcision tourniquet, a
most useful instrument, which can be slackened or tightened at any
time. He next draws the elongated prepuce slightly forwards, until
the portion of it which corresponds to the back of the glans is
brought just in front of that structure. He then seizes the
projecting prepuce immediately in front of the glans with a pair of
narrow-bladed polypus-forceps, which he gives to an assistant, who
must hold them tightly; or he grasps it and protects the glans by
means of a plate which I have had constructed for this purpose.
With one sweep of the bistoury he cuts off all that portion of the
integument which projects beyond the forceps, which are then taken
away. It will now be found that he has removed only a circle of
skin, but that the mucous membrane lining it still tightly embraces
the glans; this he slits up, by introducing the point of a pair of
scissors at the preputial orifice; and then, trimming off the
angles of the flaps, he turns back the mucous membrane and attaches
it to the edge of the cutaneous incision by a sufficient number of
fine catgut sutures. Before introducing these, he will generally
find it necessary _to ligature a small artery on each side of the
penis, and one or two in the frænum_. The best dressing in children
will be some simple ointment, such as boracic acid ointment, or the
glans may be simply smeared with a little vaseline. After every act
of micturition the parts should be well sponged with boracic acid
lotion or Condy's fluid and water. In the adult, union by first
intention may often be obtained by a dry dressing of iodoform-wool
thickly covered with collodion, so as to protect it from the urine.
This may be left unchanged for four or five days. _There is usually
a good deal of swelling of the mucous membrane about the frænum,
and some solid oedema usually remains for some weeks after the
operation._ This gradually subsides, and a linear cicatrix
remains, which causes the patient no inconvenience....
_The chief points to be attended to in the performance of this
operation, and on which its after-success is most dependent,
are_--1. That too much skin be not removed; 2. That the mucous
membrane be slit up to the base of the glans; 3. That too much of
it be not removed; 4. That all bleeding vessels be tied with catgut
ligatures, which must be cut short; 5. That the mucous membrane be
well turned back, so as to cover the gap left by the retracted
skin; 6. That all sutures be of catgut, which will be absorbed, and
thus save the pain of taking them out.
The _modus operandi_ of different surgeons varies in particular details,
usually of a slight and unimportant character. The pithy description
contained in Maunders _Operative Surgery_ may be appropriately quoted:
The extremity of the foreskin being seized with forceps is drawn
well forwards; the whole prepuce is embraced with the blades of
dressing-forceps, immediately anterior to the _glans penis_, and
cut off in front of the latter instrument. As soon as the forceps
are removed, the skin will become retracted, leaving the mucous
membrane still about the glans; this is slit up longitudinally as
far as the corona, when it may be turned back, and its edge will
come into apposition with the circular wound in the skin. The
operation is now complete; but in the adult it will be well to
introduce a few interrupted sutures.
The prepuce has sometimes been _slit up longitudinally on a director_.
Although well suited to cases of adventitious phimosis in the adult, the
method is in no way adapted to the congenital form, and has never found
general favour with the medical profession. It has no advantages over
circumcision; although retaining the prepuce, it still leaves the glans
largely uncovered; and the sharp corners of the divided skin, unless
trimmed and rounded off, produce a very unsightly after-appearance.
In performing circumcision many surgeons hold the clamp or dressing
forceps which protect the glans inclined obliquely downwards and
forwards, so as to leave a portion of the prepuce in the neighbourhood
of the frænum unremoved. As one of the main advantages claimed for the
operation is the prevention of future infection by retention of morbid
material in the preputial folds, such a practice would seem to indicate
a lurking disbelief in the validity of this pretension. If it be
reasonable and right to excise the structure on these grounds, and if
that proceeding be attended by such salutary effects; it is only logical
not to do things by halves, but to make the excision as complete as
possible. Thus Liston made his section near the frænum, 'so as to retain
the skin on the glans, which is of advantage.' The use of the _elastic
ligature_, and of the _écraseurs_, both ordinary and galvanic, for the
performance of circumcision, are cruel and fantastic modes of effecting
that object, which hardly need any expression of condemnation; and which
it is difficult to believe can ever have been seriously advocated. Keyes
(_Diseases of the Urinary Organs_, 1888), after breaking up adhesions
with an oiled probe, marks an aniline line around the foreskin, and
amputates the skin, &c., in front of this mark; thus previously
estimating the amount of tissue to be removed.[13]
For operations involving the amputation of the whole, or nearly the
whole prepuce, the following advantages are claimed:--
(_a_) Greatly enhanced local cleanliness throughout after-life.
(_b_) Greater chastity; and the preclusion of immoral personal habits.
(_c_) A smaller liability to venereal contagion in after-life.
(_d_) A diminished proneness to eventual cancerous disease.
In respect of the first of these it may be conceded that, among a
people naturally of uncleanly habits, abstraction of the prepuce would
at any rate prevent mischief resulting from compulsory retention of the
smegma. Whether it would lead to more frequent ablutions is perhaps
doubtful; as also whether the plea has any valid efficacy in regard of
persons belonging to the better classes, or to nations not specially
distinguished (like the Oriental) for their disregard of the most
elementary laws of personal hygiene. With savage tribes or with such
races as the Chinese (many of whom are said to be completely washed from
head to foot on two occasions only--when they enter the world, and when
they have quitted it), anything conducing to more complete bodily
cleanliness in after-life is certainly worthy of consideration; and
probably of approval, even when it necessitates a surgical operation.
But to apply this reasoning to more civilised peoples seems hardly
warrantable on the facts in view. Shaving the head, or plucking out the
nails would materially conduce to subsequent freedom from dirt; but no
one would seriously advocate either of these as habitual customs; and
the practice under discussion in no way differs from them, so far as the
principle involved is concerned.
The second of the reasons above assigned is one which has probably great
weight in determining the practice of many surgeons; and it has even
been gravely contended by one of the Jewish communion that the Deity
instituted the rite among the Israelites in order to promote their
greater purity and continence.[14]
This suggests the irrepressible commentary that, whatever the case in
bygone years, the operation seems now to have wholly lost its salutary
effects in the direction indicated, as Mr. Jonathan Hutchinson (_Medical
Times and Gazette_, _loc. cit._) himself testifies.
Doubtless anything which might tend to enhance the chastity of many
modern nations would be well worthy of serious consideration; with a
view to its universal adoption. Strange to say, however, certain of
those medical men who have investigated the question with opportunities
of special experience, largely base their opposition to the practice of
ritual circumcision upon the ground that removal of the foreskin in
early life leads to premature sexual excitement, and a corresponding
disposition to onanism. (Levit, _Allg. Wiener med. Zeit._, November 17,
1874.)
In the _Lancet_ of April 4, 1869, two cases materially bearing upon this
point are reported. One is that of a Jew, aged thirty-five, suffering
from 'spinal paralysis,' which he attributed to a habit of persistent
masturbation in childhood or youth. And allusion is made to a younger
brother of the same patient; who, as a consequence of the same, had
acquired spermatorrhoea, Dr. Willard (Keating's _Cyclopædia_) says:
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.
Certain precautions are, of course, necessary. The patient should be
anæsthetised; the tissues involved are extremely sensitive, and the
administration of ether (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, and the necessary daily retraction of the foreskin, to be
subsequently insisted on, becomes difficult and painful. Should much
oedema 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 the _Gazette 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 the instrument; and in this there
was doubtless true contraction, probably as a result of venereal
infection.
In the _Dublin 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's
_Cyclopædia_, 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 on inspection, 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 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.
VII
SUMMARY.
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 erroneous _in principle_.
IV. It consists in a _mutilation_; 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 child suffers 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 contraction_ exists, 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 of detail; 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 conspicuous _remote_ result is that of an extremely
contracted _meatus 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 is NOT advisable 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 the _British 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 gonorrhoeal inflammation, in a
youth of 17, is reported in the _Lancet_, Feb. 25, 1882. Death took
place on the eighth day apparently from septicæmic pneumonia.
_BIBLIOGRAPHY._
PUBLISHED WORKS.
I.--MEDICAL.
Erichsen's _Surgery_, Ninth Edition; Holmes's _System of Surgery_, Third
Edition; Maunder's _Operative Surgery_; Joseph Bell's _Manual of
Surgical Operations_; Jacobson's _Operations of Surgery_; Reginald
Harrison's _Diseases of Urinary Organs_, Third Edition; Keyes's
_Diseases of Urinary Organs_; Keating's _Cyclopædia of the Diseases of
Children_; Ashby and Wright's _Diseases of Children_; Jaffé's _Die
rituelle Circumcision im Lichte der antiseptischen Chirurgie_; Asher's
_The Jewish Rite of Circumcision_; Wunderbar's _Biblisch-Talmudische
Medicin_; Gideon Bircher's _Die Beschneidung der Israeliten_; Dr. Hayes
Agnew's _Principles of Surgery_; Sayre's _Orthopædic Surgery_; Hilton's
_Rest and Pain_; _International Encyclopædia of Surgery_, 1886; _Guy's
Hospital Reports_; _American Journal of Syphilis and Dermatology_,
October 1872; Walsham's _Theory and Practice of Surgery_, &c. &c.
II.--HISTORICAL AND MISCELLANEOUS.
_The Testaments, Old and New_; _The Talmud_; _Maimonides on
Circumcision_; Tylor's _Primitive Culture_; Moncure Conway's _Demonology
and Devil Lore_; Keil's _Biblical Archæology_; Smith's _Dictionary of
the Bible_; Calmet, _Dictionary of the Bible_, _Encyclopædia Americana_,
_Encyclopædia Britannica_; Howard, _Royal Encyclopædia_; _Penny
Cyclopædia_; _Chambers's Encyclopædia_; _Encyclopædia Metropolitana_;
Winer's _Realwörth_; Brewster, _Edinburgh Encyclopædia_; _English
Cyclopædia_; Wilkes's _Encyclopædia 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.
BY THE SAME AUTHOR.
THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the
Opium Pipe.) 2_s._ 6_d._
THE REAPPEARANCE OF CANCER AFTER OPERATION. 5_s._ 6_d._
THE GENERAL THEORY OF CANCER-FORMATION. 1_s._
CLINICAL NOTES ON CANCER. 3_s._ 6_d._
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