History of circumcision from the earliest times to the present

by P. C. Remondino

[96] Medical News of Philadelphia, page 115. Vol. for 1860.

[97] “Pertes Seminales.” In the fourth American edition of the English translation of McDougall of Lallemand we find that he fully appreciated the dangers that lurk in a prepuce. At page 216 he says: “Such is the condition which the parts present in cases of recent balanitis, and these are the inflammations and ulcerations that cause more or less extensive adhesions of the prepuce to the glans. Such adhesions are generally cellular, but sometimes fibrous or even cartilaginous, according to the severity and frequent repetition of the inflammation. Various degrees of induration also results according to the intensity, the duration, and the frequency of the phlogosis. Thus, I have often found a mucous membrane hardened, thickened, and covered with numerous papillæ, sometimes fibrous or cartilaginous, with three times its natural thickness. I have also met with cases in which the prepuce has become cancerous. I have operated in several cases of cancer of the penis, too, which certainly arose from no other cause. The patients were generally peasants between fifty and sixty years of age, who had never known other than their own wives, but who had frequently suffered from balanitis attended by abundant discharge, swelling of the prepuce, and excoriation of its opening, which was so contracted as to prevent the passage of the glans. I have seen one case, also, in which balanitis, irritated by a forced march and the abuse of alcoholic stimulants, passed into gangrene, by which the greater part of the glans was destroyed. Such have been the accidents which I have observed on those whose prepuce was too narrow to permit the glans being uncovered; accidents which I can only attribute to the long retention of the sebaceous matter in a kind of cul-de-sac, into which a certain quantity of urine passes every time the patient makes water.”

[98] Claparède. “La Circoncision.”

[99] Baron Boyer. “Traité des Maladies Chirurgicales,” vol. x, page 370.

[100] I have practiced considerably among the Jewish people, but I have never seen their elderly men suffer with prostatic troubles like our own people who are uncircumcised. From having observed the tendency to prostatic complications in young people with troublesome prepuces, and that the great number of the elderly people who are affected with prostatic disease or enlargement are the unlucky possessors of long or large prepuces, I have arrived at the conclusion that the prepuce can be entered as a factor in the etiology of enlarged prostate.

[101] I have now under my care a poor consumptive who has all the appearance of having always been as virtuous as Joseph, but who, unlike Joseph, has from infancy had as a constant companion a long, miserable, smegmanous, and annoying prepuce. The young man has an œdema which first affected his feet, but one day, owing to the irritation of a slight balanitis, the prepuce swelled at once; it proceeded through the penis integument to the scrotum; the penis itself retracted, leaving the integument and scrotum to assume a translucent, puffy, cork-screw appearance and attitude; from its labyrinthic passage the urine slowly dribbles during urination in a scalding stream. In addition to the physical sufferings, he is tormented by the knowledge that his friends attribute all his disease and troubles—since the occurence of the penile œdema—to the fact that his earlier manhood must have been indiscreet, as well as sinful. The laity cannot connect any penile, scrotal, or testicular disease with anything except venereal disease; and if the physician attempts to explain matters, they simply look upon it as the good-natured and well-intentioned efforts of the doctor to deceive them and to cover up the shortcomings of some frail mortal. Many a poor fellow has to leave this world under a cloud of mistrust and a bad odor of past deviltry to which he is not entitled, and suffer all this in addition to all his physical ills, owing to his having been ornamented through life with an annoying prepuce,—the luckless heritage of having been born a Christian. Columbus in chains moralizing on the ingratitude of this world is nothing to the poor invalid with a swollen prepuce, innocently acquired, silently “cussing” the ignorance of his relatives and friends.

[102] This patient, on convalescing, suffered considerable from the action of numerous small carbuncles, resulting from the toxæmic condition induced by the partial suppression of urine that he at times suffered from, and, when nearly well, brought on a serious relapse by the mail-bag appendage at the penis working up the organ into a state of erection. While so situated he had intercourse, and from 99° his temperature immediately rose to 104½°, where it remained for several days, lengthening out his illness by several weeks, into a long-protracted convalescence. The man is not yet circumcised, and, from the knowledge that I have of his tendency to uræmia, I feel that, although in his prime, a fever or an accident may take him off at any moment.

[103] In looking over the literature of reflex neuroses and more direct injurious results, I find that George Macilwain, in a work on “Surgical Observations on the More Important Diseases of the Mucous Canals of the Body,” published in London in 1830, calls special attention to the case of a man aged thirty-eight, admitted to the Finsbury Dispensary, and who was in the care of Mr. Hancock. The patient was suffering from excruciating pain in different joints, the pain being so great that he was confined to his bed and unable to stand on his feet. He was unable to rest at nights, and neither rheumatic nor any other apparently suitable treatment was of any service. Rigors were soon added to his other troubles, and during their continuance the pain in his joints was greatly aggravated. He was referred to Mr. Macilwain for treatment, who promptly relieved him by the removal of a urethral stricture, which had quietly been the cause of all the disturbance. It is particularly interesting that even at that early day the reflex neuroses and complications that may arise from the irritability of the genito-urinary organs were so well understood. How well Dr. Macilwain appreciated the nicety of these relations can be seen from his remarks in connection with the above case, in which he says: “It may be observed that the severity of the symptoms is not always commensurate either with the duration of the disease or the degree of stricture, and that, although the progressive development of them varies considerably in rapidity, in different individuals, it is, nevertheless, in the latter stages, always more rapid.” Macilwain also graphically describes the insidious approach of these genito-urinary troubles. In speaking of stricture he says: “Although minute inquiry generally informs us that the stricture has been of some standing, and in some instances has existed for years, yet it may happen that it is only a few months or a year since the patient’s attention has been directed to the disease. This is very intelligible; for, in conformity with what we observe in other parts of the body, the bladder has a power of accommodating itself to a change of circumstances. Its strength, for a long time, may increase so correctly in proportion to the increase of the obstacle which opposes the ejection of its contents that a very considerable period elapses before the difficulty in making water becomes cognizable to the patient, or it occasions an annoyance so trifling as scarcely to excite his attention. This increase of strength in the bladder frequently renders the formation of stricture so insidious that the urethra at the affected part is very narrow before the individual is aware of the existence of any contraction whatever; the bladder, however, at length becomes unable to empty itself, and the abdominal muscles and diaphragm powerfully act as coadjutors, so that each effort to make water is accompanied by a straining which is very distressing, and the complete evacuation of the bladder is often not accomplished even by these combined forces. The straining which accompanies stricture, and which seems necessary to evacuate the bladder, although it be occasionally exceedingly annoying to the patient at the time, is more important with reference to the results which are its consequence. I am firmly of opinion that there are a great number of patients laboring under hernia which has been produced by no other cause. I must confess that I had seen a great number of instances of stricture in ruptured patients before I drew any inference from the observation of their co-existence.” The foregoing observations of Macilwain, made in 1830, are here reproduced for their clearness of expression and explanation, as well as to show what injuries can be produced on the young child afflicted with phimosis. We are, as surgeons, familiar with the anatomical and pathological changes there are undergone by the bladder and its lining membrane, as well as in the ureters and kidneys, in many cases of stricture, as well as of the great amount of prostatic irritability and enlargement that is due to the same cause. How similarly these results can be and are actually produced by phimosis is undeniably expressed by the post-mortem appearances in the poor infant described by Golding Bird to the London Medical Society, and mentioned in the London Lancet of May 16, 1846. The bladder and ureter were like those of a man who had long suffered from stricture. From the remarks of Dr. J. Lewis Smith, that phimosis may be productive of inguinal hernia and prolapsus of the rectum, and the observations of Edmund Owens and Arthur Kemp, both high authorities on children’s diseases, being both connected with children’s hospitals, as well as the remarks of Mr. Bryant in his “Surgical Diseases of Children,” who all concur in looking upon phimosis as a great factor in hernia, Bryant having observed thirty-one in fifty consecutive cases of phimosis, we are certainly warranted in assuming that phimosis is not only a mere local timely inconvenience that will disappear with the approach of puberty, but a condition which, in the more easily affected organism of the child,—lacking, as it does, that resistance that comes with our prime,—is productive of serious harm; as even the first few years of life, even a few months of infant life, with a phimosis, are sufficient to so change the structures of parts that the poor child will grow into a man with an impaired kidney or sacculated ureter. The strain required to induce a prolapsus of the bowel or a rupture into the inguinal canal is exerted as much on the bladder, ureter, and kidney as on the other localities. Physicians who have taken the pains to observe must have noticed, more than once, how the child afflicted with a phimosis has not only at times to wait for the stream of urine to appear, there seemingly being some obstruction to its starting, but how often such a case is afflicted with a stammering, halting urination. A child thus started out into life, with a defective kidney or kidneys, is sadly handicapped in his usefulness, comfort, or in properly competing in the race of life. No parent would for a moment think of starting his son in life by giving him a business that is heavily mortgaged at the start, but many a parent unconsciously launches the unsuspecting child into a life of such ill health—resulting from a simple narrow prepuce—beside which a heavy mortgage or a heavy yearly tribute would be but a mere trifle. I have seen such men, who in after life, broken-down and perfectly physical wrecks, would gladly have given all their wealth and been willing to have some genii set them down in the middle of the Sahara, shirtless and pennyless, provided they had their health. To say nothing of the trifling loss of the prepuce, these parties would gladly have had a foot or a leg go with the prepuce if necessary, and have their health.

[104] I have often performed dilatation where, for some reason, either the timidity of the parents or the health of the child seemed to contraindicate any more radical procedure. It is customary to advise mothers or the nurses to retract the skin daily, but even after a good dilatation I have found as sudden a recontraction, and even in the majority of cases, where daily drawing back the skin might have been practicable, the cries and struggles of the child are a positive prohibition to these instructions being carried out; it is not once in ten times that it can be carried out. I have seen two very annoying cases of paraphimosis resulting from this procedure, the struggles of the child having prevented the return of the prepuce to its proper place, and the violent crying and sobbing of the child having assisted to congest the organ.

[105] It may well be a question, considering the well-established fact that nervous injuries and affections are easily transmissible and become hereditary, how much feeble-mindedness is due to an heredity originally induced in either parent through reflex neuroses from the genital organs. The Jews have a very small percentage of feeble-minded; it is true that they have not any inebriates to assist in their manufacture, but still the absence of these well-pronounced cases of reflex neuroses among the race must be largely ascribed to their practice of circumcision, as that operation cures the gentiles so afflicted.