History of circumcision from the earliest times to the present

by P. C. Remondino

Claparède sums up the inconveniences and dangers to which the possessor of a prepuce is liable to suffer from, as follows: “The retention of the sebaceous secretion is liable to alter its character, converting it into an acrid, irritating discharge, which induces more or less burning, smarting, itching, excoriations, and swelling, which, affecting the little glands situated about the corona and sulcus, induces them to secrete an altered and vicious secretion. In this manner a simple elongation of the prepuce will produce an inflammation of the surface of the glans (balanitis), or that of the prepuce itself (posthitis), or the two conjoined (balano-posthitis), complicated possibly with phimosis. By an extension to the mucous membrane of the urethra of the same condition of the inflammatory process, we have blennorrhagia; blennorrhagia is liable to be followed by inguinal swellings or tenderness, orchitis, stricture, and prostatic disease; the formation of preputial calculus, from retention of the urine in the prepuce; and cancer is apt to be the end of any of these conditions.”[98]

J. Royes Bell, in Ashhurst’s “International Encyclopædia of Surgery,” observes as follows: “Carcinoma attacking the genital organs usually assumes the form of epithelioma; the other kinds are rarely met with. Epithelioma may invade the prepuce, or the whole penis, or any part of it. The most common age for it is fifty years or over. In the great majority of cases there has existed a congenital or acquired phimosis. A contusion or a urinary fistula may be the exciting cause. With a phimosis the parts are not kept clean, but the gland is macerated and rendered tender and excoriated by retained secretions, and the irritation causes an epithelioma to grow in those predisposed to the disease, as is found to be the case when the tongue is irritated by a broken tooth, or the scrotum by the presence of soot in its folds. Syphilis has no direct influence in inducing the disease, but a syphilitic chap or ulcer may be the starting-point of an epithelioma. Two kinds of epithelioma affect the penis,—the indurated and the vegetating, or cauliflower growth.... The nature of the disease, in either the prepuce or the glans, is masked by a phimosis.... The prognosis in these cases is much more hopeful than in epithelioma, in other situations.... Sir William Lawrence operated on a patient who was quite well years afterward, and Sir William Ferguson amputated the penis of a man of note in the political world, who lived many years after the operation, and died at an advanced age.”

Agnew, of Philadelphia, describes an epithelioma of the prepuce occurring in persons past middle life, beginning as a tubercle, crack, or wart, for which he advises an early circumcision; he admits, however, to not having sufficient data to determine whether Jews and circumcised persons are exempt from carcinoma of the penis; but as its usual starting-point he evidently admits to be in the prepuce, circumcision must certainly be a preventive to its appearance. Gross gives substantially the same opinion as Agnew in this regard. Dr. John S. Billings, in his article on the “Vital Statistics of the Jews,” in the January North American Review, of 1891, on the subject of cancer, observes as follows:—

“As regards cancer and malignant tumors, we find that the deaths from these causes among the Hebrews occur in about the same proportion to deaths from other diseases as they do in the average population. But as the ratio of deaths to population is less among the Jews, so the ratio of deaths from malignant diseases to population is also less. Among the living population the proportion found affected with cancer among the Jews was 6.48 per 1000, while of those reported sick by the United States census of 1880, for the general population, the proportion was 10.01 per 1000.”

There are no convenient data as to the prevalence or percentage of cases of cancer among the Arabian or Mohammedan population of Asia and Africa, but the above comparison of 6.48 per 1000 among the Jews of the United States, against 10.01 per 1000 of the general population, shows that the circumcised race does, in the instance of cancer, certainly enjoy a certain amount of immunity, having in this regard not quite such an exemption as they enjoy from consumption, but still sufficient to assist in making them longer-lived and more able to enjoy life and die a less lingering and painful death.

It is surprising that, in view of the fact that carcinoma of the penis, starting with such frequency in the prepuce, should have left any doubt but that with the absence of this appendage there would follow less liability to cancer. Cullerier informs us that he had several times amputated the penis for cancerous diseases, but that he is unable to tell us whether the persons were affected with phimosis, remarking that on the last case he had observed the indurated remains of the prepuce; he had, however, recognized the necessity of freely exposing the gland in cases where, from continued irritation and inflammation, there was danger of cancer formation.

Nelaton describes two varieties of cancer that affect the penis,—that which attacks the integument and that which attacks the glans. The first of these varieties he observes as generally beginning as a hardened nodule in the prepuce, which becomes at once more or less thickened and indurated. He gives Lisfranc the credit of pointing out the fact, that, even in the most hopeless-looking case, the glans and body of the penis may be simply pushed back and compressed, but otherwise sound, and that before resorting to an amputation of the whole organ it is better to make a careful exploratory dissection in search of the penis, as it oftentimes happens that the prepuce and integument can be dissected off, leaving the organ intact. He also mentions that elephantiasis of the penile integument generally begins in the prepuce.

Baron Boyer believed that the vitiated preputial secretion allowed to remain beneath the prepuce was one of the causes of cancer of the penis, observing that it would be interesting to know whether cancer of the penis was a rarity among circumcised people, such as the Jews and Mohammedans.[99]

It is easy to perceive why or how Agnew, Gross, Cullerier, and many of those who have written on the subject, have failed to appreciate the existence of the prepuce as an exciting cause, or as being, in the majority of instances, the part primarily attacked. The nodule, excoriation, or abrasion that develops into a cancer generally produces more or less local disturbance; in many it produces a phimosis that is only relieved by the ulcerative process that exposes the gland, which may by that time itself be attacked or even destroyed. They are then seen by either the rural practitioner or the family physician, but before submitting to an operation they run the gauntlet of many physicians, and, when it comes to operating, they generally apply to some one of great skill and reputation. By this time there is little left of the organ, and, as a rule, the party is unable to tell where the disease originated, whether in the prepuce or glans, to them the swollen prepuce seeming to be the whole organ. Of late years, however, it has been pretty well established that it generally begins in the prepuce, and the great number of amputations of the penis on record for this disease does not lead one to believe that it is as rare a disease as was formerly believed. In Langenbeck’s Archiv, Bd. xii, 1870, Dr. Zielewicz reports fifty cases of amputation of the penis by the galvano-cautery loop, mostly for carcinoma, one of the fifty being for gangrene and one other for a large papillary tumor. That one surgeon was able to report forty-eight cases of carcinoma or cancer that were treated by one special system of operating tells us plainly enough that the unfortunate possessor of a prepuce, no matter how normal or unobjectionable it may seem to be in the prime of man’s existence, or however physiologically necessary it may be deemed, runs too many risks in holding on to his possessions.

The views set forth by Hutchinson in the beginning of this chapter are precisely those that are held by the writer, who would even go further, by advising all such as have, in their youth or since, suffered with balano-posthitis in any degree or form, or whose prepuce shows a tendency to elongation with age, to have the same removed at once; where the prepuce is not redundant, but only tight, a slight operation, such as slitting, will at once remove the possibility of any future danger, without keeping a man from his business a single day.