'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 gonorrhœa.'
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 œdema. Simple incision on a director was formerly preferred by many, though for congenital phimosis it has now probably fallen into disuse. In contrast with the careful devices for retaining part of the prepuce, or for ensuring that too much be not cut away, Sir W. Fergusson and Professor Humphrey find it best to amputate the structure as radically as possible. On this point see cases by Mr. Reginald Harrison, referred to at page 39.
[14] See 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: