Herbert Snow

“ 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. ”

“ 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 ”

“ 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. ”

“ 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 ”

“ 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. ”

“ 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 ”

“ 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. ”

“ 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. ”

“ 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 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. ”

“ 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. ”

“ 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 [Pg 52] 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. ”

“ 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. ”

“ 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 ”

“ Should much œdema thus occur, it is best to discontinue for a few days the retraction, until the inflammation has subsided; substituting the daily injection with a syringe under the prepuce of warm carbolised oil, in such a manner that (the orifice being closed) , the fluid is made to distend and 'balloon' that envelope as much as possible.
The ideal dilatation-procedure is how to effect the maximum of dilatation with the minimum of laceration. ”

“ 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 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 ”

“ 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 [Pg 39] 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. ”

“ 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 [Pg 14] 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) . ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 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, [Pg 28] 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 ”

“ 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.
[Pg 48]
The patient being well anæsthetised, the surgeon, taking the organ in his left hand, retracts as far as possible the foreskin. ”

“ 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! ”

“ XIV. The most conspicuous remote result is [Pg 57] 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. ”

“ 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 [Pg 31] 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. ”

“ 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 ”