,,the ,,barbarity ,,of ,,circumcision ,,as ,a ,,remedy ,,for ,,congenital ,,abnormality ,,by ,,herbert ,,snow1 ,m4,d4 ,,lond4 c4 ,,surgeon ,,to ,,the ,,cancer ,,hospital ,illustration3 ,logo ,,london ,j4 ,a4 ,,churchill #aa ,,new ,,burlington ,,street #ahij ,,prefatory ,,note ,to state that the object of this little work is to 'put down ,circumcision' under the circumstances indicated1 would1 besides savouring of unpardonable arrogance1 irresistibly suggest analogy to the example of a too famous alderman1 who was determined to 'put down ,suicide4' ,if1 however1 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 infants2 and sanctioned1 on extremely questionable grounds1 by men of eminent authority2 the following pages will not have been written in vain4 ,more evil is wrought by want of thought1 ,than comes from want of heart4 ,,gloucester ,,place1 ,,portman ,,square3 ,october #ahij4 ,,the ,,barbarity ,,of ,,circumcision ,,as ,a ,,remedy ,,for ,,congenital ,,abnormality4 ,i ,,circumcision ,,as ,a ,,religious ,,rite4 ,the earliest historical or quasi-historical notice of circumcision is to be found in ,genesis xvii42 where ,jahve enjoins upon ,abraham the personal performance of this mutilation1 as a sign of the covenant henceforward to subsist between them4 ,abraham1 his son ,ishmael1 and all his male slaves forthwith underwent the prescribed operation2 which thence-forward remained obligatory upon their posterity1 though not without transient periods of desuetude4 ,it was suffered to lapse during the passage of the ,israelites through the wilderness1 and was subsequently revived by ,joshua 7v4 #e72 again in the reign of ,antiochus ,epiphanes1 when some of the ,jews seem to have submitted to a plastic operation in order to obliterate its effects4#a ,the compulsory performance of circumcision was re-enacted for the last time by ,mattathias1 in the age of the ,maccabees2 and the law to this effect has remained in force until the present day4#b ,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 latter4 ,accordingly we find that it previously prevailed among the ,colchians1 thiopians1 and ancient ,egyptians of both the ,upper and ,lower ,provinces 7,gardner ,wilkinson74 ,among the latter it appears to have become restricted1 by the dawn of the historical period1 to the priestly caste1 and to those who desired initiation into the sacred mysteries4 ,in the temple of ,chunsu at ,karnak is a delineation of the rite as performed on two young children1 probably sons of ,rameses ,,ii41 the founder of the building4 ,it was apparently connected with the worship of ,ra1 the ,sun ,god2 and a seeming allusion to it in this connection is to be found in chapter xvii4 of the ',book of the ,dead4' ,notices of circumcision also appear in ancient ,phoenician mythology4 ,there can be no question of its very great antiquity1 or of its wide prevalence among ancient nations4 ,traditional descent from a primval ,stone ,age is betrayed by casual notices in ,holy ,writ4 ,thus1 in ,exodus iv4 #be1 a sharp stone is the instrument of mutilation2 and in ,joshua v4 #b1 the marginal rendering is 'knives of flints4'#c ,the ,hivites1 the ,canaanites 7,phoenician71 and many if not most of the nations with whom the ,israelites were brought into contact after settlement in the ,promised ,land1 appear to have practised circumcision at some period in their history4 ,in the ,old ,testament we accordingly find the designation of 'the uncircumcised' specially reserved for the ,philistines1 and applied to these as a term of opprobrium4 ,the list of peoples by whom the circumcision of males has been1 or is still1 an established custom is sufficiently long4 ,among such races at the present day1 'an almost unbroken line may be traced from ,china to the ,cape of ,good ,hope1' and unless perhaps in ,europe 7where comparatively slight traces of aboriginal manners and customs survive71 we find the ceremony characteristic not only of savage tribes1 but of nations ranking fairly high in the scale of civilisation2 for instance1 the ,mexicans1 and the ancient ,aztec races of ,central ,america4 ,the ,teanas and ,manaos on the ,amazon2 the ,salivos1 ,guamos1 ,otamocos1 on the ,orinoco2 the negroes of the ,congo1 with many other tribes on both the west and east coasts of ,africa1 notably the ,kaffirs1 ,bechuanas1 and ,hottentots2 the ,abyssinians 7,christian71 ,nubians and modern ,egyptians2 the natives of ,madagascar2 most of the ,australian aborigines2 the ,papuans1 ,new ,caledonians1 inhabitants of the ,new ,hebrides1 of ,java1 of the ,philippines1 and of ,fiji1 are only a few that may be indicated4 ,an approximation to the rite in the form of a slitting up of the prepuce was noticed among the ,friendly ,islanders by ,captain ,cook4 ,although not enjoined in the ,koran1 it is a universal practice among the ,mohammedans1 as a tradition from the ante-,mohammedan period4 ,a cognate operation upon females obtains among the modern ,egyptians1 the ,nubians1 the ,abyssinians1 as well as in many other parts of ,africa among the negro races2 also among the ,malays on the shores of the ,persian ,gulf 7,carsten ,niebuhr71 and on the banks of the ,orinoco4 ,as an ancient custom in ,arabia and ,egypt1 it is noticed by ,strabo4 ,local variations of detail are found2 as in the case of the ,friendly ,islanders just cited2 and of the ,madagascarians1 who cut the flesh at three several times2 the excised prepuce being eventually swallowed by some relative or other4 ,the date at which circumcision is performed varies considerably4 ,among the ,jews1 the eighth day is1 of course1 the selected period2 probably from consideration for the sacred number seven1 for the seven days of uncleanness prescribed for the parturient mother 7,lev4 xii4 #b71 and for an idea that with the second cycle of seven days the infant then properly commenced its earthly life4 ,among the ,arabs1 it is deferred till the thirteenth year2 the age at which their reputed ancestor1 ,ishmael1 was submitted to it4 ,and every race seems to have selected for itself what was considered the most suitable time4 ,the ,turks1 for example1 have chosen the seventh or eighth year2 the ,persians circumcise boys at thirteen1 girls1 between the ninth and the fifteenth year2 and so on4 ,it is thus evident1 not only that the rite is extremely ancient1 but that it is impossible to refer the practice of circumcision to any single source2 or to doubt that it originally arose among many widely-sundered peoples1 as the result of a certain stage in man's mental evolution4 ,the once widely-spread custom of the ,,couvade1 and other strange aboriginal practices1 afford an illustrative analogy4#d ,herodotus seems to have been the author1 or at least the introducer1 of the cleanliness theory2 according to which the ceremony was invented from motives of hygiene4 ,philo ,judus ascribes the custom to four causes3 #a4 ,cleanliness2 #b4 ,the avoidance of carbuncle 7,qu4 cancer872 #c4 ,the symbolisation of purity of heart2 #d4 ,the attainment of numerous offspring4 ,of these1 it need hardly be said that the last has no foundation in fact2 and the two preceding require no remark4 ,the idea1 however1 that circumcision was initiated for purposes of cleanliness has lasted to the present day1 and still appears to have considerable currency4 ,whatever may have been the social condition of the ancient ,egyptians and ,arabians1 on behalf of both which races1 as having been the source whence ,abraham derived his evident familiarity with the custom1 plausible pretensions have been put forth2 it is simply preposterous to imagine for a moment that the numerous savage tribes 7witness the ,hottentots and the ,australian aborigines7 who practise it1 could ever have been actuated by any such considerations4 ,its world-wide diffusion1 again1 totally forbids the supposition1 either of its introduction into these tribes by contact with other nations more highly civilised2 or of its adoption1 by the former1 while in a higher stage of sociology1 from which they have subsequently become degraded4 ,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 females4 ,in order1 therefore1 plausibly to account for the general prevalence of this strange mutilation1 we are compelled to look elsewhere2 and an examination of the religious ideas which are known to actuate primitive man1 will afford a clue4 ,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 ,testament2 and1 even in classical mythology1 although overlaid by the later developments of a high civilisation1 their influence is still not entirely effaced4 ,the principle of substitution was familiar to all the nations of antiquity1 to the ,israelites not the least4 ,witness the universal resort to sacrifices1 the theory of which is well indicated by that of ,isaac in ,genesis xxii4 ,further illustrative examples are afforded by the law of the scapegoat1 in ,leviticus xvi42 by the offering of children to ,molech 7,lev4 xx4 #b72 and by the legend of ,jephthah's daughter 7,judg4 xi474 ,with this1 various ceremonies1 involving either mutilation or the shedding of blood1 were in vogue--for example1 the priests of ,baal 7#a ,kings xviii4 #bh72 even cutting off the hair seems to have been in the nature of a representative sacrifice4#e ,hence many ,german authorities cited in ,keil's ,biblical ,archology 7vol4 i4 p4 #dae7 consider circumcision as a relic of ancient sacrifice3 the consecration of a part of the body for the whole4 ,the different grades in the process of humanisation may be assumed to have been successively attained as follows4 ,in the earliest periods1 human sacrifice was probably universal2 in the ,bible1 we have the episode of ,jephthah's daughter1 above referred to2 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 commands2 whence may be argued evident acquaintance with such deeds4 ,besides which1 we hear of human sacrifice among the tribes contiguous to the ,israelites1 until a much later date4 ,even the ,greeks and ,romans occasionally resorted to this during the historical period2 in the ,homeric age1 it appears to have been a not infrequent practice4 ,as1 however1 men progressed in culture and in humanity1 such barbarity became impossible4 ,instead of putting their firstborn children 7often by cruel methods1 as in the sacrifices to ,molech7 to death1 they propitiated the deity by an offer of the most precious member4 ,indeed1 in the ,genesis account of ,abraham's circumcision1 ,mr4 ,moncure ,conway considers 7,demonology and ,devil ,lore1 ii4 #hc7 that the legend1 subsequently obscured by later traditions1 originally points to the performance of a much more severe operation4 ,and when still more advanced1 even this became impossible2 the excision of a very small portion of the organ1 not of indispensable necessity to the fulfilment of its functions1 being substituted4 ,after many generations had then passed over1 the custom had become so firmly implanted in the mind and habits of the people1 that its eradication was rendered a matter of extreme difficulty2 even by new religious dispensations and more elevated modes of thought4 ,hence we find the rite among the ,israelites made an exception to the fierce denunciation of mutilations in general1 uttered by ,jahve or by his messengers2 and hence also1 we see it 7though not prescribed in the ,koran7 an ordinary modern custom throughout the whole of ,islam1 as well as among the ,christian ,abyssinians4 ,the practice of self-emasculation in honour of a divinity was a common feature in the worship of ,chronos1 of ,cybele1 and doubtless of many other among the earlier recipients of religious adoration2 it is referred to 7and not in terms of reprobation7 at ,matthew xix4 #ab4 ,it has descended to modern times--witness the fanatical sects in ,russia2 and even persons of high intellectual calibre 7as1 for instance1 ,origen7 have submitted to it4 ,what men regarded as honourable and meritorious in themselves1 they would be not unlikely to impose also on their children4 ,the existence of such ascetic practices among partially civilised nations must not be lost sight of in the present connection2 as helping us to comprehend the mental religious attitude of primval man4 ,there can be little question that here we find our correct explanation of the origin and wide prevalence of circumcision4 ,we are1 however1 no longer permitted to regard this as a hygienic custom1 but simply and solely as a relic of barbarism2 dating from an immemorial antiquity1 long anterior to the first historical records1 and when man was little1 if at all1 removed from savagery4 ,the venerable age of the prescriptive rite1 as well as the various social and religious phases through which the peoples adopting it have since successively passed1 have effectually spiritualised it and have shed around it a certain halo of sentimentalism2 but should not be suffered to obscure the only rational conception of its primary significance4 ,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 place2 that1 as we read in the third chapter of ,genesis1 being the allotted food of the serpent4 ,the practice seems to have continued down to a recent period1 but now to have fallen into disuse4 ,we thus clearly see that1 beside being the sign of the covenant with the tribal deity1 there was also involved the idea of a propitiatory sacrifice to the awful evil demons4 ,the most clear instance of circumcision as an act intended to conciliate an offended divinity1 or malignant spirit1 appears in the strange story of ,zipporah at ,exodus iv4 #bd2 where the vicarious nature of the rite is also plainly set forth4 ,there is no apparent reason for identifying the ,lord 7',adonai'72 who sought to slay ,moses1 with ,jahve2 from whom ,moses had just parted upon excellent terms4 ,and there can be little doubt that ,samael1 to whom the scapegoat was subsequently offered 7,lev4 xvi4 #bj71 or some similar dread power of darkness1 is here meant4#f ,if the writer is not greatly in error1 an impression prevails in some quarters that ,moses either instituted anew or effectually perpetuated the rite of circumcision among the ,israelites2 as a useful measure of sanitation4 ,however deservedly high the reputation of the great ,hebrew lawgiver as a sanitarian1 he does not seem entitled to credit in this connection2 and alludes but casually to the ceremony1 as to an already well-established custom1 among certain directions for the treatment of the parturient woman at ,leviticus xxii4 #c4 ,there is plainly no question of hygiene here involved4 ,dr4 ,asher 7,the ,jewish ,rite of ,circumcision7 considers that ,,chastity was the main purpose aimed at in the ,divine injunction to ,abraham2 but1 for reasons subsequently adduced1 such a theory will be seen to have no foundation in fact4#g ,as the present is not an antiquarian treatise1 only a very cursory historic or ethnic account of ritual circumcision is here inserted2 many other curious and interesting particulars may be found in the authorities cited at the end of this volume1 as well as in the copious ,german literature on the same subject4 ,all that has been attempted in the preceding pages is to exhibit the custom in its original character2 and 7in so far as the pretensions advanced upon its behalf as a surgical procedure are concerned71 divested of the traditional sanctity which is possibly largely answerable for some of the views promulgated by medical authors2 whereby the general habit and practice of the medical profession become also of necessity deeply tinged4#h ,,footnotes3 #a ,an account of the operation 7seemingly then not infrequently resorted to7 performed at a much later date for the above purpose1 is to be found in ,celsus1 lib4 vii4 cap4 xxv4 #b ,according to ,keating's ,cyclopdia of the ,diseases of ,children1 #ahij1 vol4 iii41 some of the rabbins now omit it2 in the teeth of a strong and growing popular prejudice4 ,i am informed1 however1 by the ,rev4 ,s4 ,singer1 to whom ,i am greatly indebted for a courteous reply to inquiry on the subject1 that these congregations would not be regarded as orthodox2 and that the innovation is unknown in the ,old ,world4 #c ,in the ,lancet of ,april #bj1 #ahhi1 is figured a curious circumcising ,instrument used by the ,malays1 who perform the rite upon boys at the age of eight years2 and also upon females1 about #a_/hth inch being nipped off the extremity of the clitoris4 ,in the ceremony performed on female children1 variations exist2 other tribes remove the nymph4 #d ,la ,couvade was the designation of the unwritten law1 according to which1 directly an infant was brought into the world1 the husband retired to bed and was sedulously nursed for a certain prescribed period2 the mother1 on the other hand1 getting up and attending to the affairs of the household4 ,tylor speaks of it as this once world-wide custom 7,primitive ,culture1 i4 #gf74 #e ,examples of the substitution principle among various modern races are to be found in ,tylor's ,primitive ,culture1 vol4 ii4 p4 #cf et seq4 #f ,the imposition of circumcision by the ,jews upon vanquished enemies1 as the ,idumeans and ,itureans 7,josephus1 ,antiq4 ,b4 #ac7 sounds the like note2 there could hardly be any question of proselytism4 ,at an earlier date these people would have been ruthlessly massacred en masse1 like the ,amalekites 7#a ,sam4 xv4 #h72 slaughtered in great part1 like the ,moabites 7#b ,sam4 viii472 or sacrificed1 like ,agag 7#a ,sam4 xv4 #c71 to the deity of the conquerors4 #g ,according to the same writer1 it is absolutely impossible to say1 in any given case among the ,mohammedans1 whether circumcision has been performed or not2 for1 as the muco-cutaneous membrane has not been divided1 'the soft elastic skin of the penis easily comes forward and re-covers the glans4' ,he states that the performance of that particular portion of the ceremony which consists in tearing and removing the membrane in question1 completely distinguishes the ,jews from all the other nations of the world who practise the operation as a religious rite4 #h ,two cases of interest in this connection may be here noticed4 ,dr4 ,levy1 a ,jew dentist of ,stettin1 states 7,medical ,record1 ,may #c1 #ahij7 that1 like his father before him1 he was born without a foreskin2 further1 that his four brothers1 who died in childhood1 were similarly circumstanced4 ,the late ,dr4 ,asher 7op4 cit471 who must be considered a high authority in such a matter 7so far at least as concerns his co-religionists71 says3 ',no part of the human body is subject to so many varieties and irregularities as the penis and foreskin4' ,he believes total absence of the prepuce to be extremely rare1 and doubts whether such a phenomenon has ever occurred2 but seems to regard a partial deficiency as nothing unusual4 ,he states that in most1 if not all1 instances of supposed congenital absence of this structure1 a small portion of the skin will be found prolonged to the glans across the intervening fossa2 which morsel1 however small1 must be excised by the ,mohel1 with the usual formalities4 ,a note informs us that1 according to ,jewish tradition1 the following personages never had foreskins3 ,adam1 ,seth1 ,noah1 ,shem1 ,melchizedek1 ,jacob1 ,joseph1 ,job1 ,moses1 ,balaam1 ,samuel1 ,david1 ,jeremiah1 ,zerubbabel4 ,the second case bears upon the very heterodox theory of maternal impressions1 and is reported in the same periodical1 of dates ,nov4 #c1 #ahhh1 and ,march #bc1 #ahhi4 ,it is that of a child born accurately circumcised1 seven months and twenty days after the like operation on his elder brother 7presumably in presence of the mother1 although this is not stated74 ,the local appearances in the two children are affirmed by ,dr4 ,harvey1 of ,illinois1 to have been exactly alike2 'the congenital case even showing the marks of the sutures4' ,both of the above cases1 together with ,dr4 ,asher's experiences1 may be respectfully commended to the notice of ,professor ,weismann4 ,,ii ,,nature ,,of ,,congenital ,,phimosis--,,physiological ,,importance ,,of ,,the ,,prepuce4 ,the word 'phimosis' 7,greek3 phimo1 ,i bind7 signifies that condition of the penis in which the prepuce cannot be retracted beyond the corona glandis2 and which may be either congenital or factitious4 ,the latter is a pathological phenomenon1 the product of injury or of disease4 ,to apply the term 'abnormal' to the former is1 however1 hardly permissible1 except when the difficulties in retraction are permanent and extreme2 when they cannot be overcome by judicious perseverance1 and by careful manipulation in the early weeks of infant life4 ,a certain amount of adhesion between the two contiguous surfaces of mucous membrane is almost constantly present at birth1 as a continuation of the normal intra-uterine agglutination 7,keating's ,cyclopdia of the ,diseases of ,children1 #ahij1 vol4 iii42 article by ,dr4 ,de ,forest ,willard74 ,the radical defect in congenital phimosis is thus the adhesion or imperfect separation of two muco-cutaneous surfaces1 normally developed in close contact4 ,as a rule1 these are so slightly connected that a very slight degree of force is sufficient to part them2 but in a considerable minority of instances the defect eventually becomes permanent2 with the natural growth of the organ more difficulty is experienced in procuring retraction2 and various disagreeable1 or even dangerous1 symptoms are prone then to make their appearance4 ,the complaint1 however1 is simply one of degree4 ,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 results2 and1 perhaps usefully1 serves to direct early attention to the state of the parts4 ,in rare cases1 no opening at all into the urethra has been discoverable2 and complete retention has necessarily ensued4 ,very often1 however1 nothing of this sort happens for several weeks1 months1 or even years2 and the existence1 or rather persistence1 of the disability may not be noticed at all until adolescence of adult life4 ,the majority of instances lie between these extremes2 not seldom unpleasant symptoms begin to be observed when the boy is a few months old2 but there is a wide range of variation4 ,the penile and preputial layers of mucous or quasi-mucous membrane being firmly adherent1 and growth of the glans penis proceeding apace1 certain consequences necessarily follow4 ,the prepuce being 7in extreme cases7 tightly fixed to the margins of the urethral orifice1 the meatus urinarius still retains the same calibre as when birth took place1 and becomes far too small for the needs of the rapidly growing child4 ,a difficulty in effectually voiding the bladder is experienced1 and may eventually result in complete retention4 ,the little patient tugs at the seat of unpleasant sensation2 and this elongates the folds of skin at the extremity of the penis1 normally somewhat redundant1 and extremely distensile4 ,the muscular force of the bladder being spent upon overcoming the obstruction at the narrow meatus1 the urine trickles out feebly1 and 'balloons' in the soft pouches beyond1 which continuously retain a few drops4 ,hence great local irritation and excoriation4 ,it is not warrantable1 however1 to speak of contraction of the penile mucous membrane4 ,no contraction takes place1 except as a consequence of inflammatory attacks2 and these1 in the infant1 are rarely sufficient to cause any material shrinking4 ,the phenomenon is simply one of natural development under a rigid restraining envelope2 and though eventually the aperture is found narrow enough1 the 'contraction' is relative only4 ,so also1 in every male child there is more or less seeming redundancy of skin at the end of the penis2--for natural physiological reasons4 ,the condition is apt1 as first stated1 to become factitiously enhanced under the pressure of urinary obstruction4 ,but there is seldom or never a real superfluity of integument in this locality ab initio2 in excess of what the subsequent needs of the full-developed organism may be reasonably supposed to warrant4 ,it is requisite to lay some stress on these two points1 as tending materially to influence our conceptions of the practice condemned in this pamphlet4 ,although plainly not absolutely essential to the due increase in bulk of the penis1 or to the subsequent performance of its functions1 it is prima facie obvious that the prepuce must be intended to subserve some useful purpose4 ,that1 according to ,dr4 ,willard 7,keating's ,cyclopdia71 'is to protect the head of the organ1 during the years when the penis is but a portion of the urinary apparatus2 and later1 by its friction over the sensitive corona1 to enhance the ejaculatory orgasm4' ,the latter half of this statement may fairly be questioned1 as the prepuce is completely retracted during coition2 and so no friction over 'the corona' can well take place under ordinary conditions4 ,the first part1 however1 is unimpugnable2 and to it may be added some consideration of the protection afforded during the first efforts at functional use4 ,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 appendage2 or in whom the latter is kept retracted for any length of time1 contrary to preceding habit4 ,extreme discomfort1 indeed considerable soreness and actual pain1 are complained of2 until tolerance becomes established1 and until the delicate membrane has by exposure and friction become so hardened that the absence of its former covering is no longer noticed1 a period occupying commonly several weeks4#i ,in the case of young children1 the unpleasant sensations involved must be relatively far greater2 considering their physical helplessness and their more impressionable nervous system4 ,according1 moreover1 to the authority previously cited1 early removal of the prepuce is apt to be followed by progressive sclerosis1 with attendant evils of contracted meatus1 balanitis1 c4 ,and1 failing this1 'the exposure of the tender skin to the friction of the clothing1 c4 tends to keep up a state of abnormal excitement during the early years of life4' ,it thus becomes apparent that1 apart from any risks involved by operative procedures1 ablation of the prepuce1 whether in infant or in adult1 is not a measure to be undertaken lightly1 or without satisfactory evidence of positive necessity4 ,,footnote3 #i ,the fact that many adults1 of not too sensitive organisation1 gradually acquire a habit of retaining the foreskin partially or even entirely retracted1 is of course not lost sight of4 ,but this in no way affects the question of its sudden removal1 or of the protection afforded by the structure in question to infants of tender years4 ,,iii ,,dangers ,,and ,,results ,,of ,,congenital ,,phimosis--,,acquired ,,phimosis4 ,a perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes4 ,so1 in the absence of this1 we encounter a number of ill consequences1 some local only2 some affecting the well-being1 and even the life1 of the entire organism4 ,the parts being extremely vascular1 and in very intimate relation with the central nervous system2 we very naturally find that congenital phimosis1 interfering with the normal growth of the glans penis1 is prone to develop various reflex neurotic disorders or diseases2 of which some have been minutely described by ,dr4 ,sayre4#aj ,thus forms of paralysis may ensue2 either confined to a single group of muscles1 and simulating club-foot1 or of a more general character4 ,epilepsy1 reflex cough1 convulsions1 choreic movements of the limbs1 are extreme examples2 but a milder instance of the same causes in operation shows itself in young infants1 as nocturnal restlessness with defective nutrition4 ,hip-joint disease and spinal caries may be simulated1 and the mal-assimilation of food may eventually produce such gross deformities as bowing of the legs4 ,chronic priapism is a not uncommon occurrence4 ,obstruction to the free discharge of urine may produce symptoms of severe vesical irritation1 occasionally supposed to indicate stone in the bladder4 ,the straining efforts at micturition may cause hernia or prolapse of the rectum2 the nocturnal incontinence of children is not unfrequently traceable to the same source4 ,epistaxis has been described4 ,retention of urine in the folds of the elongated foreskin1 together with the child's habit of pulling this1 induce a condition of soreness which causes great smarting whenever micturition takes place1 and induces the patient to defer that act as long as possible4 ,hence may in time result dilatation of the bladder1 cystic kidneys1 and death4 ,even eczema of the abdominal wall has been thus produced2 and has disappeared when the cause was removed1 as in a case cited by ,dr4 ,hayes ,agnew 7,principles of ,surgery1 #ahha74 ,when the patient is allowed to reach adult life with the disability unrelieved1 he becomes subject to attacks of balanitis2 and the parts may ulcerate or even slough4 ,in a case seen by the writer1 where at the time no symptoms of inflammation were present1 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 person4 ,in a unique case cited by ,erichsen1 ',dr4 ,wisham1 of ,fyzabad1 removed no fewer than #dbf calculi1 varying in size from a pin's head to a small bean1 from this situation1 in the person of a native of ,india1 sixty years of age1 who came under treatment for what appeared to be a large tumour at the end of the penis1 the true nature of which was not detected until1 on removing it1 the knife grated against the contained calculi4' ,the defect constitutes a serious impediment to impregnation2 in the event of an acquired local disorder1 its presence seriously hinders diagnosis1 and altogether precludes appropriate treatment4 ,it has been supposed1 and not without plausibility1 to predispose to epithelioma4 ,a case is given by ,mr4 ,oliver ,pemberton2 and others have been reported4 ,there can be no question that1 under such circumstances1 the presence of malignant disease about the glans would much longer remain undetected than in a normal state of the parts2 and that the prospects of cure by operative removal would be proportionately lessened4 ,only comparatively mild examples of phimosis1 in which the adhesions produced little or no constriction1 and did not at all interfere with urination1 could thus have been suffered to pass unrelieved until the subjects were far past maturity4 ,phimosis1 as an acquired condition1 is of frequent occurrence in an acute form2 as the result of inflammatory oedema of the prepuce in youths and adults4 ,this1 again1 may be a consequence of simple balanitis1 the result of want of cleanliness1 combined with disordered general health and a catarrhal state of all the mucous membranes2 in which event it usually yields to mild measures1 such as the injection of warm fluids under the foreskin4 ,in by far the greater number of instances it is produced by venereal infection2 and imperatively needs prompt operation1 usually in the guise of slitting up the structure on a director4 ,in a chronic form1 slowly and gradually coming on1 and very intractable to remedial measures1 it is not seldom seen in old men of gouty habit2 and of consequently unhealthy and irritable mucous membranes4 ,the pathology and treatment of ,,acquired phimosis do not fall within the scope of the present work1 but it is necessary to point out that these are essentially different from those of the congenital2 and that the latter needs consideration upon principles totally diverse4 ,in the congenital we have to deal with tissues perfectly healthy1 and with skin peculiarly elastic and distensile4 ,in the factitious1 all the parts are more or less altered by disease1 acute or chronic2 and as a sequel to the latter1 or to repeated attacks of the former1 true contraction takes place2 the prepuce often attaining a hard and gristly consistence1 under which condition simple dilatation is difficult or impossible4 ,the phenomenon is rarely1 if ever1 seen in association with congenital phimosis2 barring gout or venereal taint in addition4 ,,note4--,the infrequency of cancerous disease attacking the penis1 renders it unsafe to dogmatise upon any supposed causal relationship between that malady and the presence or absence of the foreskin1 and does not appear to warrant any stronger assertion on this point than that which is recorded on the previous page4 ,,footnote3 #aj ,orthopdic ,surgery1 p4 #ad4 ,see also ,hilton1 ,rest and ,pain1 p4 #bgf4 ,,iv ,,cutting ,,operations ,,for ,,the ,,relief ,,of ,,congenital ,,phimosis2 ,,their ,,supposed ,,advantages4 ,from the preceding1 the evils or dangers incurred by permitting a male child to reach adult life2 or1 in the event of pressing symptoms1 to pass even a few weeks or months with this disability unrelieved2 are sufficiently obvious4 ,although1 as ,dr4 ,willard 7op4 cit47 states1 the adhesions between prepuce and glans can nearly always be broken down with sufficient readiness during the first few weeks after birth1 there can be little doubt that1 without conspicuous necessity1 the medical practitioner will seldom care to 'make the baby cry1' and thus draw down upon himself vigorous maternal reproaches4 ,it seems1 moreover1 hardly judicious to encourage any tampering by nurses or midwives1 probably more or less ignorant and unskilled4 ,we may take it for granted1 therefore1 that nothing will usually be done until the child is several months old2 when some more energetic treatment will be requisite to remedy the condition in question4 ,in milder cases no notice will probably be taken of the abnormality for at least several years1 and its presence may be detected only by accident2 the adhesions in such are trivial1 and do not interfere with normal growth2 hence are1 as a rule1 easily overcome4#aa ,although less severe measures have been from time to time brought forward and advocated1 the operation of circumcision is1 to all intents and purposes1 the only procedure in general use for remedying congenital phimosis2 and as the latter is very common1 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 it4 ,there is a simplicity and thoroughness about the little amputation which may perhaps commend it to the surgical mind2 and there are unquestionably certain superficial advantages of a hygienic nature about the patient's subsequent condition2 though it may be doubted whether these are by any means so considerable as has been made to appear4 ,however this may be1 it goes without saying that no other curative proceeding has so far met with any wide favour in the medical profession2 and1 if one may judge from their published opinions1 the leading exponents of medical practice and opinion1 in this country at least1 are so pleased with circumcision and its results that they would willingly see the ,mosaic ,laws in this particular extended to the whole ,christian population1 whether affected by phimosis or not4 ,witness ,mr4 ,jonathan ,hutchinson3 ,it is surely not needful to seek any recondite motive for the origin of the practice of circumcision4 ,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 foreskin4 ,it constitutes a harbour for filth1 and is a constant source of irritation4 ,it conduces to masturbation1 and adds to the difficulties of sexual continence4 ,it increases the risk of syphilis in early life1 and of cancer in the aged4 ,i have never seen cancer of the penis in a ,jew1 and chancres are rare4--,archives of ,surgery4 ,arguments by this distinguished surgeon1 in favour of extension of the custom as a matter of ordinary routine to every male ,gentile1 are to be found in the ,medical ,times and ,gazette1 ,december #a1 #ahee2 together with a reference to previous utterances in an identical sense4 ,erichsen 7,surgery1 ,ninth ,edition1 #ahhh1 vol4 ii4 p4 #aahh7 says3 ,every child who has a congenital phimosis ought to be circumcised2 and even those who1 without having phimosis1 have an abnormally long and lax prepuce1 would be improved greatly in cleanliness1 health1 and morals by being subjected to the same operation4 ,it would be well if the custom of ,eastern nations1 whether it be regarded as a religious rite or only as a time-honoured observance1 were introduced amongst us4 ,in ,holmes's ,system of ,surgery1 #ahhc1 we read3 ,circumcision is the operation required in children2 and it is best adapted for adults also when the skin is redundant1 and the margins of the preputial opening are thickened4 ,mr4 ,w4 ,h4 ,jacobson 7,operations of ,surgery1 #ahhi7 says3 ,this operation is still not practised often enough1 especially among poorer patients2 amongst whom many practitioners still treat phimosis as a matter of but little importance4 ,some of the pretensions set forth above on behalf of circumcision will be subsequently referred to2 but on the plea for a general extension of the rite to nations not impelled thereto by special ,divine command1 it may be remarked that several ,jewish surgeons who have written upon the topic by no means regard this with an eye of favour2 and have1 in fact1 gone even so far as to denounce in the strongest terms its compulsory performance among their co-religionists4#ab ,for their dislike1 they advance what appear to be very adequate reasons2 and1 in such a matter they must have enjoyed a far wider special experience than any practitioner without the ,hebrew pale4 ,the following extract from ,erichsen's ,science and ,art of ,surgery 7,ninth ,edition1 #ahhh7 may be regarded as a typical account of the ordinary surgical operation in vogue at the present day4 ,the italics are the present writer's3 ,circumcision in boys or adults may be most conveniently performed in the following way4 ,the surgeon restrains hmorrhage during the operation by tying a tape tightly around the root of the penis1 or by compressing the organ in ,clover's circumcision tourniquet1 a most useful instrument1 which can be slackened or tightened at any time4 ,he next draws the elongated prepuce slightly forwards1 until the portion of it which corresponds to the back of the glans is brought just in front of that structure4 ,he then seizes the projecting prepuce immediately in front of the glans with a pair of narrow-bladed polypus-forceps1 which he gives to an assistant1 who must hold them tightly2 or he grasps it and protects the glans by means of a plate which ,i have had constructed for this purpose4 ,with one sweep of the bistoury he cuts off all that portion of the integument which projects beyond the forceps1 which are then taken away4 ,it will now be found that he has removed only a circle of skin1 but that the mucous membrane lining it still tightly embraces the glans2 this he slits up1 by introducing the point of a pair of scissors at the preputial orifice2 and then1 trimming off the angles of the flaps1 he turns back the mucous membrane and attaches it to the edge of the cutaneous incision by a sufficient number of fine catgut sutures4 ,before introducing these1 he will generally find it necessary to ligature a small artery on each side of the penis1 and one or two in the frnum4 ,the best dressing in children will be some simple ointment1 such as boracic acid ointment1 or the glans may be simply smeared with a little vaseline4 ,after every act of micturition the parts should be well sponged with boracic acid lotion or ,condy's fluid and water4 ,in the adult1 union by first intention may often be obtained by a dry dressing of iodoform-wool thickly covered with collodion1 so as to protect it from the urine4 ,this may be left unchanged for four or five days4 ,there is usually a good deal of swelling of the mucous membrane about the frnum1 and some solid oedema usually remains for some weeks after the operation4 ,this gradually subsides1 and a linear cicatrix remains1 which causes the patient no inconvenience4444 ,the chief points to be attended to in the performance of this operation1 and on which its after-success is most dependent1 are--#a4 ,that too much skin be not removed2 #b4 ,that the mucous membrane be slit up to the base of the glans2 #c4 ,that too much of it be not removed2 #d4 ,that all bleeding vessels be tied with catgut ligatures1 which must be cut short2 #e4 ,that the mucous membrane be well turned back1 so as to cover the gap left by the retracted skin2 #f4 ,that all sutures be of catgut1 which will be absorbed1 and thus save the pain of taking them out4 ,the modus operandi of different surgeons varies in particular details1 usually of a slight and unimportant character4 ,the pithy description contained in ,maunders ,operative ,surgery may be appropriately quoted3 ,the extremity of the foreskin being seized with forceps is drawn well forwards2 the whole prepuce is embraced with the blades of dressing-forceps1 immediately anterior to the glans penis1 and cut off in front of the latter instrument4 ,as soon as the forceps are removed1 the skin will become retracted1 leaving the mucous membrane still about the glans2 this is slit up longitudinally as far as the corona1 when it may be turned back1 and its edge will come into apposition with the circular wound in the skin4 ,the operation is now complete2 but in the adult it will be well to introduce a few interrupted sutures4 ,the prepuce has sometimes been slit up longitudinally on a director4 ,although well suited to cases of adventitious phimosis in the adult1 the method is in no way adapted to the congenital form1 and has never found general favour with the medical profession4 ,it has no advantages over circumcision2 although retaining the prepuce1 it still leaves the glans largely uncovered2 and the sharp corners of the divided skin1 unless trimmed and rounded off1 produce a very unsightly after-appearance4 ,in performing circumcision many surgeons hold the clamp or dressing forceps which protect the glans inclined obliquely downwards and forwards1 so as to leave a portion of the prepuce in the neighbourhood of the frnum unremoved4 ,as one of the main advantages claimed for the operation is the prevention of future infection by retention of morbid material in the preputial folds1 such a practice would seem to indicate a lurking disbelief in the validity of this pretension4 ,if it be reasonable and right to excise the structure on these grounds1 and if that proceeding be attended by such salutary effects2 it is only logical not to do things by halves1 but to make the excision as complete as possible4 ,thus ,liston made his section near the frnum1 'so as to retain the skin on the glans1 which is of advantage4' ,the use of the elastic ligature1 and of the craseurs1 both ordinary and galvanic1 for the performance of circumcision1 are cruel and fantastic modes of effecting that object1 which hardly need any expression of condemnation2 and which it is difficult to believe can ever have been seriously advocated4 ,keyes 7,diseases of the ,urinary ,organs1 #ahhh71 after breaking up adhesions with an oiled probe1 marks an aniline line around the foreskin1 and amputates the skin1 c41 in front of this mark2 thus previously estimating the amount of tissue to be removed4#ac ,for operations involving the amputation of the whole1 or nearly the whole prepuce1 the following advantages are claimed3-- 7a7 ,greatly enhanced local cleanliness throughout after-life4 7b7 ,greater chastity2 and the preclusion of immoral personal habits4 7c7 ,a smaller liability to venereal contagion in after-life4 7d7 ,a diminished proneness to eventual cancerous disease4 ,in respect of the first of these it may be conceded that1 among a people naturally of uncleanly habits1 abstraction of the prepuce would at any rate prevent mischief resulting from compulsory retention of the smegma4 ,whether it would lead to more frequent ablutions is perhaps doubtful2 as also whether the plea has any valid efficacy in regard of persons belonging to the better classes1 or to nations not specially distinguished 7like the ,oriental7 for their disregard of the most elementary laws of personal hygiene4 ,with savage tribes or with such races as the ,chinese 7many of whom are said to be completely washed from head to foot on two occasions only--when they enter the world1 and when they have quitted it71 anything conducing to more complete bodily cleanliness in after-life is certainly worthy of consideration2 and probably of approval1 even when it necessitates a surgical operation4 ,but to apply this reasoning to more civilised peoples seems hardly warrantable on the facts in view4 ,shaving the head1 or plucking out the nails would materially conduce to subsequent freedom from dirt2 but no one would seriously advocate either of these as habitual customs2 and the practice under discussion in no way differs from them1 so far as the principle involved is concerned4 ,the second of the reasons above assigned is one which has probably great weight in determining the practice of many surgeons2 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 continence4#ad ,this suggests the irrepressible commentary that1 whatever the case in bygone years1 the operation seems now to have wholly lost its salutary effects in the direction indicated1 as ,mr4 ,jonathan ,hutchinson 7,medical ,times and ,gazette1 loc4 cit47 himself testifies4 ,doubtless anything which might tend to enhance the chastity of many modern nations would be well worthy of serious consideration2 with a view to its universal adoption4 ,strange to say1 however1 certain of those medical men who have investigated the question with opportunities of special experience1 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 excitement1 and a corresponding disposition to onanism4 7,levit1 ,allg4 ,wiener med4 ,zeit41 ,november #ag1 #ahgd47 ,in the ,lancet of ,april #d1 #ahfi1 two cases materially bearing upon this point are reported4 ,one is that of a ,jew1 aged thirty-five1 suffering from 'spinal paralysis1' which he attributed to a habit of persistent masturbation in childhood or youth4 ,and allusion is made to a younger brother of the same patient2 who1 as a consequence of the same1 had acquired spermatorrhoea1 ,dr4 ,willard 7,keating's ,cyclopdia7 says3 ,i have failed to find any statistics proving that the circumcised masturbate less frequently1 or are more virtuous than others2 and the exposure of the tender skin to friction of clothing c41 tends to keep up a state of abnormal excitement during the early years of life4 ',where doctors differ1 who shall decide8' ,and in face1 therefore1 of such directly contradictory opinions from professional witnesses1 it is difficult to believe that ablation of the prepuce is of material avail1 either in precluding masturbation1 or in promoting the subsequent chastity of the adult individual4 ,on the third of the reasons assigned for advocating circumcision--the prevention of venereal disease when manhood is attained--,mr4 ,jonathan ,hutchinson1 whose testimony cannot but receive considerable weight1 remarks that chancres are rare in the ,jew4 ,the observation has not been controverted2 but must be received with a certain amount of hesitancy1 in consequence of an evident bias in favour of radical measures of operative treatment4 ,it seems rather to need confirmation by surgeons of the ,jewish race1 practising especially among their co-religionists4 ,the present writer has been unable to discover any evidence in support from such a quarter4 ,the authority last cited points out that cicatricial tissue is of all others least resistent to infection2 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 small4 ,it is not improbable that a ,hunterian sore developed upon scar-tissue1 or upon the hardened integument of a denuded glans1 would be far more trivial in character1 more transient1 less productive of inconvenience1 and less easily recognisable1 than the same in a normal state of the parts2 the after-effects being1 of course1 identical4 ,such primary lesions in a people notoriously rather negligent of their person would seldom come under the notice of the medical practitioner4 ,so1 failing further evidence1 the provisional verdict upon this question must be the ,scotch one1 ',not proven4' ,but even if the above assertion be accepted in respect of true syphilis1 it assuredly fails to hold good with reference to other varieties of venereal disease4 ,thus ,mr4 ,jonathan ,hutchinson's oft-quoted statistics#ae 7,medical ,times and ,gazette1 ,december #a1 #ahhe71 in his own words1 'prove that1 though in proportion of nearly a third to the other patients1 they 7,jews7 furnish nearly half the cases of gonorrhoea4' ,the last-named motive for circumcision1 although1 in the passage quoted at the beginning of this section1 it has been stamped with the approval of the same high authority1 needs but transient allusion4 ,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 circumstanced2 the resulting attacks of inflammation and of unhealthy ulceration1 c41 may be naturally expected to lead to the growth of papillomata1 as well as to maintain a chronic condition of lowered vitality4 ,but the comparative rarity of epithelioma in this particular locality would deprive the allegation1 even if this were positively established as an indisputable fact1 of any weight as an argument for the removal of the prepuce4 ,moreover1 it is obviously a reason not for the routine performance of circumcision1 but for the relief of phimosis2 by whatever means attempted or proposed4 ,,footnotes3 #aa ,in ,druitt's ,surgeon's ,vade-,mecum1 #ith edition1 p4 #ffb1 are the notes of a case of 'congenital phimosis of the tightest kind' in an adult of twenty-three4 ,circumcision was threatened2 but the affection readily yielded to the injection of warm water daily4 ,there are probably many similar4 #ab ,dr4 ,asher 7op4 cit47 does not disapprove of circumcision1 but his evidently strong religious bias1 and the fact that his whole work is composed from an ecclesiastical point of view1 with the express sanction and co-operation of ecclesiastical dignitaries1 constitutes him a far from independent 7negative7 witness4 #ac ,an immense variety of operative procedures for phimosis1 or even of details in the performance of ordinary circumcision1 might be quoted4 ,quot homines1 tot operationes4 ,their multiplicity1 and the very contradictory nature of the advantages claimed for each1 strongly indicate that neither the results of slitting operations1 nor those of entire or partial excision of the prepuce1 are found uniformly satisfactory4 ,thus1 in addition to the methods described in the text1 it may be noted that ,jobert de ,lamballe and others divide the foreskin on both sides of the frnum without excision2 ,van ,buren makes two cuts1 one on the dorsum and one near the frnum1 subsequently removing the two flaps2 ,dr4 ,r4 ,w4 ,taylor 7,american ,journal of ,syphilis and ,dermatology1 ,october1 #ahgb7 makes two lateral incisions with scissors4 ,while1 as above stated1 some surgeons prefer to hold the forceps which guard the glans obliquely1 from above downwards and forwards1 so as to leave a certain portion of the skin about the frnum2 ,mr4 ,howse 7,guy's ,hospital ,reports7 advocates the careful removal of the frnum1 in order to prevent subsequent oedema4 ,simple incision on a director was formerly preferred by many1 though for congenital phimosis it has now probably fallen into disuse4 ,in contrast with the careful devices for retaining part of the prepuce1 or for ensuring that too much be not cut away1 ,sir ,w4 ,fergusson and ,professor ,humphrey find it best to amputate the structure as radically as possible4 ,on this point see cases by ,mr4 ,reginald ,harrison1 referred to at page #ci4 #ad ,see the ,lancet1 ,december #ab1 #ahgd4 ,dr4 ,asher 7op4 cit47 also takes the same view4 #ae ,the following is ,mr4 ,hutchinson's statistical table derived from his practice at the ,out-patient department of the ,metropolitan ,hospital3 ---------------------------------------- ---------------- ,cases ,gonorrhoea ,syphilis,proportion of gonorrhoea to syphilis ---------------------------------------- ---------------- ,not ,jews #bgb #ajg #afe #jf to #a ,jews #eh #dg #aa #dc #a ---------------------------------------- ---------------- ,on these figures a plausible inference might perhaps be founded1 that what the ,jew saves in immunity from syphilis he1 to a certain extent1 loses in increased proclivity to gonorrhoea2 certainly the least of the two evils4 ,mr4 ,hutchinson goes on to state that of #beb children under the age of five years1 #bg out of #agi ,christians exhibited symptoms of congenital syphilis in a well-marked form2 while only #c out of #gc ,jews were thus affected1 the proportion thus being #a in #f among the ,christians1 while only #a in #bd among the ,jews4 ,again1 of #ig women 7two-thirds being married71 of whom #ib were ,christians and #e ,jews1 #fa of the former were syphilised2 against a blank return among the latter4 ,upon the evidence of these statistics1 ,mr4 ,hutchinson advocates a general adoption of the rite of circumcision by ,western nations6 ,upon his own showing1 however1 the benefit to be derived from such a sweeping innovation1 supposing that this were practicable1 is not so very large2 for #aa syphilised ,jews out of a total of #eh with venereal disease1 is a tolerably respectable proportion4 ,the inferences here drawn1 moreover1 do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners2 among whom those of ,jewish birth should be able to give specially valuable testimony4 ,the field of inquiry was comparatively small2 statistics drawn from the out-patient department of a general hospital are1 for obvious reasons1 not always of the most reliable character2 and the conclusions may be vitiated by the facts suggested in the text4 ,hence1 although they refer to but one venereal malady1 it is hardly possible to acquiesce in them implicitly1 even in this limited respect2 without some confirmation drawn from a much more extended field of research4 ,v ,,disadvantages ,,and ,,dangers ,,of ,,circumcision4 ,as a surgical operation1 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 life2 and there can be no doubt that it is but seldom followed by a fatal result4 ,still1 with any breach of surface whatever1 there must be a chance of blood-poisoning and of the absorption of septic materials2 and1 in the case of a child liable to hmophilia1 it cannot be doubted that serious consequences might readily ensue4 ,thus1 in the third century it was enacted by the rabbins 7,talmud1 ,treatise ,jebamoth1 #fdf7 that1 after two deaths in the same family from this cause1 the ceremony was to be omitted2 and the prohibition has continued in force ever since4 ,maimonides inculcates the utmost caution in the performance of the rite1 and insists that 'in case of doubtful sickness1 a child must not be circumcised2 since danger to life overrides the whole ceremonial law4' 7,maimonides on ,circumcision1 ch4 i474 ,at the present date it is always effected by an expert 7,mohel71 who is not infrequently a qualified medical man2 and accidents are guarded against with jealous care4#af ,the ancient plan1 according to which the operator received in his mouth 7previously filled with wine7 the extremity of the lacerated member1 is now wholly or in great part abolished among the ,jewish community2 it being found that both syphilis and tuberculosis were thus communicated to the infant4#ag ,the ,lancet of ,october #a1 #ahgj1 quotes from the ,wiener ,med4 ,presse the particulars of two cases1 reported by ,dr4 ,schwartz1 of boys circumcised at the usual period2 who subsequently died from phlegmonous inflammation and sloughing of the part1 one five and the other twenty-five days subsequently to the operation4 ,in the same periodical for ,december #e1 #ahgd1 may be found allusion to the experience of ,dr4 ,kohn1 himself a ,jew2 who stated at a medical society in ,vienna1 that during a practice of thirty-five years he had known six deaths from this source 7,allg4 ,wiener ,med4 ,zeit4 ,november #ag1 #ahgd74 ,he himself had thus lost a child of his own4 ,however such fatality may be attributed to the neglect of all hygienic rules among the poorer classes of ,jews2 it can hardly be doubted that1 under even the most favourable conditions1 septic poisoning or uncontrollable hmorrhage must occasionally happen1 albeit extremely rare2 and this whether the operation has been performed from ritual or from surgical motives4 ,to the absence of such cases reported in medical literature1 too much weight must not be attributed4#ah ,it is rather upon the minor consequences1 immediate or subsequent1 that those who object to the practice have founded their opposition2 and of such there has been no lack1 especially among medical men who have been themselves ,jews1 and who have thus necessarily enjoyed the fullest experience of its effects4 ,thus the ,lancet of ,december #e1 #ahgd1 mentions a pamphlet by ,dr4 ,levit1 demonstrating the evils of the custom4 ,he speaks of the premature beginning of sexual excitement in boys deprived of their prepuce1 and the disposition to onanism so common to ,eastern nations2 he regards circumcision as a criminal manipulation2 and calls upon the medical profession to oppose the practice1 even at the risk of losing favour at the hands of the ,jewish families they attend4 ,and his arguments are effectually sustained by ,dr4 ,kohn4 ,dr4 ,schwartz1 in recording the fatal cases above quoted1 'deprecates the custom with great warmth1 and expresses the wish that it may be laid aside4' ,mr4 ,r4 ,w4 ,parker 7,british ,medical ,journal1 ,july #ai1 #ahgi7 refers to a child 7one of a family of bleeders7 who1 being circumcised1 nearly bled to death4 ,he also says3 ',diffuse cellulitis of the penis is not an uncommon complication after this operation in unhealthy1 ill-fed1 and badly-cared-for children4' ,dr4 ,mastin1 in ,gaillard's ,medical ,journal1 speaks of the great frequency with which he has been consulted by ,jews for chronic urethral discharges1 irritable urethra1 and other affections of the genito-urinary organs4 ,he describes 'the preternaturally small meatus which results from early removal of the prepuce by circumcision4' 7,medical ,record1 ,december #aj1 #ahhe47 ,elsewhere in the same periodical 7,medical ,record1 vol4 xxi47 we are informed that #ie per cent4 of young male ,jew adults have this contracted meatus4 ,shorn of its natural protective covering1 the muco-cutaneous covering of the glans soon becomes true dermoid tissue4 ,mr4 ,j4 ,hutchinson 7loc4 cit47 speaks of 'every one who is acquainted with the effects of circumcision in rendering the delicate mucous membrane of the glans hard and skin-like4' ,contact with the clothing1 c41 necessarily induces a chronic inflammatory condition of the part1 followed commonly by contraction and condensation4 ,we cannot with impunity rashly interfere with any of ,nature's dispositions1 however seemingly insignificant4 ,this hard skinlike condition of the integument upon the glans penis1 with its concomitant of narrowed urethral aperture1 may be regarded as the normal result of circumcision4 ,in the hands of bungling operators1 however1 far worse consequences may follow4 ,thus ,j4 ,bell 7,manual of ,operations in ,surgery1 #ahff7 'has known the glans penis included in the incision in at least one instance4' 7,the italics are his own47 ,mr4 ,reginald ,harrison 7,diseases of ,urinary ,organs1 #crd ,edition1 #ahhg7 has treated two varieties of urethral stricture after circumcision which have not turned out well2 in two cases1 the extremity of the glans penis1 including the meatus1 had been wounded in making the section of the prepuce2 in a third1 owing to 'oedema and difficulty of ascertaining where the glans was1 amputation had been performed1 and the end of the glans included4' ,the second variety of stricture was caused by the prepuce being divided too high up1 or1 what amounts to the same thing1 being drawn down too much over the glans penis1 before being included in the forceps for the purpose of making the necessary section4 ,on bringing together the parts with sutures1 the tension on them was so great as to cause ulceration1 and to leave behind a broad cicatrix1 capable of exercising a contractile pressure on the under surface of the urethra2 sufficient to impede micturition and to cause other discomfort4'#ai ,dr4 ,hyde 7,boston ,medical and ,surgical ,journal1 ,june #bf1 #ahij7 has seen disastrous results from circumcision2 and ,dr4 ,willard 7in ,keating's ,cyclopdia of the ,diseases of ,children7 says that1 after circumcision1 hardening of the glans occurs2 and the evils of contracted meatus1 balanitis1 c4 follow1 as pointed out by ,otis1 ,mastin and others4 ,so far1 therefore1 as the remote consequences of circumcision are concerned1 there is strong evidence that the operation is by no means an unmixed blessing to its recipient4#bj ,turning to the more immediate effects and consequences1 the italicised passages in ,mr4 ,erichsen's elaborate description concur with the experience since cited of other writers1 to show the need of considerable caution in the performance of this surgical procedure4 ,septic infection1 hmorrhage1 and subsequent sloughing of the part have to be sedulously guarded against2 and on the ,continent1 at least1 the resources of modern antiseptic surgery have been specially invoked4 ,without careful ligature of the arteries1 these may1 we are told1 give rise to troublesome and long unnoticed hmorrhage when the patient is put back to bed4 ,the examples above quoted1 and the varying practice of different surgeons1 show1 moreover1 that discrimination and judgment are essential as to the excision of either too much or too little of the foreskin2 both of which events may be disadvantageous4 ,mr4 ,w4 ,h4 ,jacobson 7,operations of ,surgery1 #ahhi7 says that after circumcision 'an adult should lie in bed for forty-eight hours1 and keep on the sofa for a week1 alternate stitches being removed at intervals4 ,if he insist on getting about too early1 he must run the risk of the parts remaining long oedematous and tender4 ,and for this reason1 with hospital patients1 who have to come backwards and forwards1 early and complete healing is not to be expected4 7,the italics are the present writer's47 ,it may be reasonably assumed that no sane man1 who possessed the advantages of a sound and entire prepuce1 would willingly sacrifice it without just and sufficient cause being shown4 ,and his natural repugnance to such a deprivation would probably be in no wise lessened by a perusal of the passage last cited4 ,it would be without doubt in the highest degree edifying in the present connection1 were the sensations of some educated adult of average sensitiveness1 who had submitted to the operation1 placed on record2 together with a statement of the time which elapsed before perfect tolerance became established2 and before the 'hard skinlike condition1' so much approved of by ,mr4 ,j4 ,hutchinson1 and the other more or less enthusiastic advocates of circumcision1 was satisfactorily attained4 ,in the absence of such a delineation1 however1 we can only surmise the feelings of the patient2 and conclude that1 as with catheterisation1 and other manipulations addressed to a delicate mucous membrane1 they would in some instances be almost nil2 but that in the man of highly sensitive organisation1 they would amount to keen and long-protracted torture4 ,infants of tender years must of necessity be classed in the latter of these two categories2 in their case1 there are also certain circumstances which tend to enhance the barbarity of the procedure2 and largely to aggravate the suffering involved4 ,thus an ,american operator 7at the association meeting of genito-urinary surgeons1 reported in the ,boston ,med4 and ,surg4 ,journal1 ,june #bf1 #ahij7 speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce1 and of the consequent torture to them4 ,even after healing1 contact with flannel napkins1 and other clothing1 must long be very painful4 ,there can be little doubt what would be the verdict--could they only give it utterance--upon the immediate results of the operation in question2 returned by these inarticulate 7if far from mute7 victims of hygienic orthodoxy4#ba ,,footnotes3 #af ,the most scrupulous and minute precautions for obviating any danger to life are enjoined by the ,talmud4 ,the ceremony is not permitted to take place at all unless the child is in perfectly sound health2 and that ,mohel1 whose conscience may convict him of having caused the death of an infant by his negligence1 is forbidden ever to officiate again4 #ag ,a case of tuberculosis thus contracted is reported in the ,british ,medical ,journal of ,march #e1 #ahhg2 and twelve other instances are also mentioned in the same paragraph4 #ah ,the writer has been unable to discover any mortality statistics of ritual circumcision1 and apparently none exist4 ,dr4 ,asher 7op4 cit47 makes a remark to the same effect4 #ai ,in the same work its author states that an unnatural smallness of the urethra is a not infrequent cause of incontinence of urine in children4 ,in some cases therefore ascribed to congenital phimosis1 may not the incontinence be merely a concomitant1 and not an effect1 of the latter condition8 #bj ,dr4 ,keyes 7,diseases of ,urinary ,organs1 #ahhh7 has been 'twice called upon to relieve by operation a phimosis resulting from a former operation4' #ba ,an objection to circumcision1 of wholly sentimental character1 yet not the less worthy of practical consideration1 may1 in addition to those set forth in the text1 be here noted4 ,the parents of any child1 in whom the necessity of some remedial measure for congenital phimosis has become apparent1 usually express considerable relief when told that it is not necessary to make the infant 'a little ,jew4' ,,vi ,,absence ,,of ,,necessity ,,for ,,circumcision ,,in ,,cases ,,of ,,congenital ,,phimosis--,,the ,,rational ,,treatment ,,of ,,the ,,latter4 ,from what has been already set forth1 it is sufficiently evident that no male should be suffered to reach adult life with this congenital disability unrelieved2 and that in the majority of instances radical treatment is requisite at a far earlier date4 ,there can be no doubt that it is infinitely better for an infant to be subjected to circumcision1 than to pass many months or years with the unpleasant or even dangerous symptoms previously detailed4 ,the point now to be considered1 therefore1 is whether these symptoms can be obviated by any less heroic measure1 and whether the suffering thus incurred is a matter of absolute necessity2 whether1 indeed1 it is right and proper to subject the child to mutilation for the benevolent purpose indicated4 ,for by no less term can the procedure in question be characterised4 ,it consists in the abstraction of a structure1 not indeed of paramount importance to the organism1 but obviously evolved by ,nature for wise ends as a protective covering4 ,were there no necessity for its presence1 it would not occur2 and without overwhelming evidence that such mutilation is unavoidable and beneficial1 it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ4 ,as indicated above1 congenital phimosis may be said in some slight degree to occur in every new-born male child4 ,two layers of muco-cutaneous membrane are developed in close contact1 and are commonly agglutinated in a measure2 but it is only when the separation is very incomplete that any defect producing consequences of importance is found4 ,there is no deformity or deficiency of parts2 and1 except as a consequence of long-continued inflammation1 no contraction occurs4 ,what is commonly spoken of as 'a contracted prepuce' simply signifies the natural growth of the glans under a rigid envelope1 primarily of normal proportions4 ,all1 then1 that is requisite to remedy this condition in the first instance1 is the due separation of the two contiguous layers of muco-cutaneous membranes1 which in the new-born may generally be effected with ease4 ,as the infant grows1 however1 there is apt to supervene relative disparity of size2 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 laceration4 ,and1 unless care be taken1 the wounds in the parietal layer of muco-cutaneous membrane again quickly heal2 the new cicatricial tissue undergoes1 perhaps1 a little real contraction2 and matters remain as they were before4 ,hence1 probably1 the disfavour with which procedures1 involving dilatation of the prepuce1 seem to have been hitherto regarded by most surgeons4#bb ,some amount of reunion between the two surfaces may also take place at the spots where the adhesions have been ruptured4 ,the principle to be aimed at1 however1 is simply the separation of two contiguous and adherent layers of mucous or muco-cutaneous membrane4 ,few medical men are probably aware of the natural distensibility of the parts2 of the ease with which 7when the patient is rendered passive and unconscious by means of an ansthetic7 the glans can be brought completely into view1 and the prepuce perfectly retracted behind the corona4 ,all that is then necessary is1 by the use of emollients and by daily retraction for a very brief period1 to prevent reunion of adhesions or of fissures in the muco-cutaneous membrane2 until a sufficient degree of dilatation has been secured to preclude all fear of any future difficulty4 ,certain precautions are1 of course1 necessary4 ,the patient should be ansthetised2 the tissues involved are extremely sensitive1 and the administration of ether 7or of chloroform in the case of a young child71 besides relaxing the parts1 enables the measure to be carried out much more efficiently than would otherwise be the case4 ,although the necessary dilatation can usually be very speedily effected1 it often takes some little time thoroughly to remove the adherent smegma1 not seldom of gritty and calcareous consistence4 ,this1 besides being the longest1 is the most painful part of the manipulation4 ,the use of cocaine as a local ansthetic for such a purpose1 precluding the administration of ether or chloroform1 is not to be recommended4 ,the wide surface involved renders its influence incomplete2 and it is of considerable advantage to have the patient1 particularly when of tender years1 oblivious to what is going on4#bc ,if the distension be too timidly effected1 so that the foreskin can be retracted over the glans only with difficulty2 an equal difficulty will be found in pulling it forwards again1 and temporary paraphimosis may result4 ,under ansthesia1 however1 this cannot but prove transient2 but if free dilatation be procured in the first instance1 there is not the least fear of its occurrence at all4 ,on the other hand1 care is requisite not to lacerate unnecessarily the delicate membrane2 after which more or less inflammatory trouble supervenes1 and the necessary daily retraction of the foreskin1 to be subsequently insisted on1 becomes difficult and painful4 ,should much oedema thus occur1 it is best to discontinue for a few days the retraction1 until the inflammation has subsided2 substituting the daily injection with a syringe under the prepuce of warm carbolised oil1 in such a manner that 7the orifice being closed71 the fluid is made to distend and 'balloon' that envelope as much as possible4 ,the ideal dilatation-procedure is how to effect the maximum of dilatation with the minimum of laceration4 ,in boys of seven or eight and upwards1 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 membrane1 and without the loss of a single drop of blood4 ,in younger children1 however1 this structure is necessarily much more delicate1 and easily torn1 especially if there be struggling4 ,in the latter case complete ansthesia1 plenty of deliberation1 and the use of not too large an instrument1 are elements of importance4 ,the following is the usual method of performing this manipulation--'operation' is much too grave a word3 ,the only instrument needed is an ordinary dressing-forceps of average size in the case of an adult or boy of age above indicated2 proportionately smaller with young infants1 in whom1 indeed1 a probe will sometimes effect all that is requisite4 ,the patient being well ansthetised1 the surgeon1 taking the organ in his left hand1 retracts as far as possible the foreskin4 ,with his right he introduces the closed dressing-forceps as far as it will enter2 making sure1 of course1 that he has not passed it into the meatus4 ,he then widely expands the two limbs of the handle1 holding these apart for a few seconds4 ,complete retraction of the foreskin behind the corona glandis is then usually at once easy2 adherent spots being separated with the thumb-nail4 ,should there be any difficulty the tissue is gradually peeled off by manipulation with the fingers2 and the collections of inspissated smegma scraped off with the nail or with an ear-scoop4 ,finally1 the operator pulls the prepuce backwards and forwards two or three times1 making sure that it is perfectly loose2 anoints the glans well with vaseline1 and leaves it covered by the foreskin as in the normal state4 ,subsequently1 complete retraction is necessary on each of the first four or five days2 after which it may be gradually intermitted1 being subsequently resorted to only for purposes of cleanliness4 ,the daily washing recommended by some ,american writers seems wholly unnecessary2 and1 as before remarked1 the less tampering with these organs 7except when absolutely unavoidable7 the better4 ,when free movement of the foreskin on the glans has been attained1 together with healing of any excoriation or sore1 there is no fear of subsequent contraction4 ,any seeming redundance of the prepuce is in no way detrimental2 it should only serve to induce a more careful habit of cleanliness1 and the habitual use of those ablutions to which every man naturally resorts upon attaining years of discretion4 ,dilatation thus effected can at the least do no harm1 and cannot possibly place the subject in a worse position than he was previously2--which the examples in previous chapters show to be far from the case1 with the operation of circumcision4 ,if carried out as here indicated1 it will be found thoroughly effectual2 the reasons why it appears to have failed in some hands apparently being3 7a7 neglect of after-treatment1 and of care to retract the prepuce daily throughout the first few days2 7b7 insufficient dilatation at the time1 so that retraction has never been perfectly easy2 7c7 avoidable and unnecessary laceration of the muco-cutaneous structures1 followed by inflammatory mischief4#bd ,the adoption of a special instrument for the above purpose has been advocated from time to time by several writers1 who speak in glowing terms of the favourable results they have thus attained4 ,a rather formidable-looking one1 used by ,nlaton1 is depicted in the ,gazette des ,hpitaux1 #ca1 #ahfh2 this has three blades at right angles to the stem1 and is somewhat on the model of an ordinary urethral dilator4 ,several successful cases are described1 with one of failure4 ,in the latter1 a youth of seventeen1 incision had to be resorted to1 as the prepuce could not be stretched sufficiently with the instrument2 and in this there was doubtless true contraction1 probably as a result of venereal infection4 ,in the ,dublin ,quarterly ,journal1 ,no4 xlviii4 p4 #dhb1 ,dr4 ,cruise1 of ,dublin1 figures a somewhat analogous instrument with two blades1 and speaks of numerous cases 7'in which with due care the result has been perfect'7 in his own hands and in those of his friends4 ,he1 however1 kept the foreskin subsequently retracted for twenty-four to forty-eight hours1 a proceeding which entails upon the patient very considerable discomfort1 and is unnecessary4 ,dr4 ,hayes ,agnew 7,principles of ,surgery7 figures a special 'phimosis-forceps1' which appears in no essential particular to differ from ordinary dressing-forceps2 the only noticeable peculiarity being that the blades are a little longer than usual4 ,levis's dilatation-instrument1 described in ,keating's ,cyclopdia1 vol4 iii4 p4 #fdc1 is worked by screw-power1 and is stated to be 'very effective2' it resembles an ordinary pair of dissecting-forceps1 with a screw placed close to the handle1 which effects separation of the two blades4 ,this is1 no doubt1 satisfactory in its results1 but seems to be unnecessarily severe for the purpose to which it is applied2 in which very little force is usually needed1 or1 indeed1 is desirable1 for obvious reasons4 ,mr4 ,r4 ,w4 ,parker's dilatation-instrument has been referred to on the previous page2 and there are doubtless many others4 ,dr4 ,f4 ,h4 ,stuart1 of ,brooklyn 7,medical ,record1 ,december #d1 #ahhf71 in advocating a manipulation very similar to the one here described 7he introduces first a probe to break down adhesions1 then the dressing-forceps1 turning the latter round72 comes to the conclusion that 'the number of cases which really require circumcision is extremely small4' ,and it may be generally remarked that no one who has really tried the dilatation plan with due care and without prejudice1 appears to have subsequently relinquished it2 or to have been otherwise than highly satisfied with its effects1 whatever the precise method adopted4 ,those surgeons who speak of having seen unsatisfactory results generally convey the idea that these have taken place in other hands2 and have never1 in any publication seen by the present writer1 condescended to details4#be ,to the case of boys past the early years of childhood1 and still more to that of adults1 the arguments in favour of the substitution of a simple dilatation-process for the unnecessarily severe operation of circumcision1 apply with redoubled force4 ,as in these no symptoms directing attention to the phimosis have previously existed for any length of time1 it may be taken at once for granted that1 however tight the so-called 'contraction' may seem on inspection1 the condition is present in only a minor degree2 that under an ansthetic the adhesions will yield to very slight force1 and satisfactory retraction1 with subsequent free mobility1 be procured without the slightest difficulty4 ,with adults1 moreover1 the avoidance of any need for confinement to bed1 of even to the house1 is an important consideration4 ,in such the tissues are necessarily more elastic and less fragile than in young infants2 there is much less prospect of laceration1 with consequent tenderness and swelling4 ,an operation for the relief of congenital phimosis advocated by ,mr4 ,furneaux ,jordan 7,british ,medical ,journal1 ,may #b1 #ahfc7 may be here alluded to4 ,mr4 ,jordan passes one blade of a small round-pointed scissors 7,critchett's strabismus-scissors answer well7 through the orifice2 skin and mucous membrane are divided to the length of a quarter of an inch on one side1 the same being repeated on the other4 ,the prepuce is now retracted as far as possible2 this exposes more lining membrane between the lips of the wound1 and this again is divided by a second incision on each side4 ,the operation is now complete1 and the foreskin may easily be retracted4 ,the incisions which were made in the long axis of the penis after retraction become linear in a vertical direction1 and almost imperceptible in the circular folds of retracted foreskin4 ,in the after-treatment the prepuce should be kept back1 or frequently retracted4 ,in children retraction once daily for a week or ten days1 till the wounds have healed1 is quite sufficient4 ,the extent of the incisions should1 of course1 be a little less in children1 a little greater in the adult4 ,the present writer has seen this operation performed in one instance1 and the after-results were in the highest degree satisfactory4 ,as contrasted with circumcision1 the procedure merits warm commendation2 preserving the useful foreskin1 and followed by a much more speedy recovery than may be expected from the former4 ,for the lacerations which may result from forcible dilatation1 small nicks with a pair of scissors are substituted4 ,the only objection is that even this operation1 trivial as it appears1 is seldom necessary2 and that sufficient distension of the foreskin may often be procured without any breach of surface whatever4 ,moreover1 some confinement to bed or to the sofa is subsequently requisite2 whereas1 after the effects of the ansthetic have passed off1 the patient1 young or old1 whose foreskin has been dilated1 can behave exactly as usual4#bf ,mr4 ,jordan's operation is1 however1 a very useful corollary to the dilatation-method in the chronic phimosis 7often associated with gout7 of men in advanced life2 when the parts are usually in a very gristly condition2 and when1 if it be found impossible to procure retraction by stretching1 the contracted tissues may be advantageously nicked with scissors in the mode here indicated4 ,,footnotes3 #bb ,for instance1 ,mr4 ,erichsen 7op4 cit47 dismisses the measure with the cursory allusion of a brief paragraph2 against the long and elaborate account1 previously detailed1 of circumcision2 it is not mentioned at all in the earlier editions of his work4 ,ashby and ,wright speak of it with great disfavour4 ,mr4 ,jacobson 7,operations of ,surgery1 #ahij7 does not introduce it at all2 possibly because hardly worthy to be dignified by the title 'operation4' #bc ,in adults1 or in boys approaching manhood1 gradual dilatation by the daily introduction of a sponge tent has been recommended4 ,it might be resorted to in the case of an exceptionally timid and patient individual1 but hardly for any other4 #bd ,mr4 ,r4 ,w4 ,parker 7,brit4 ,med4 ,journal1 ,july #ai1 #ahgi7 recommends gradual dilatation with a special screw-forceps1 which he has used in a considerable number of cases at the ,children's ,hospital1 'always with good results4' #be ,in the paper above quoted1 by ,dr4 ,cruise1 of ,dublin 7#ahfh71 that surgeon speaks of ,dr4 ,hutton having used dressing-forceps for the cure of phimosis fifteen years previously4 ,very probably the adoption of that instrument for the same purpose would be found on inquiry to date back still further2 and no pretension of originality can be here put forth for the advocacy of a simple common-sense practice1 which must have been repeatedly resorted to by many practitioners of the past4 #bf ,m4 ,faure has also described a somewhat analogous 'nicking' operation4 ,,vii ,,summary4 ,i4 ,circumcision as a sacrificial rite has been practised by very numerous races of diverse origin1 and dates from an extremely remote antiquity2 probably from the ,stone ,age1 as suggested by the internal evidence of ,biblical records4 ,,ii4 ,this fact1 together with that of its application by many tribes to the persons of female children1 deprives the religious ceremony of any title to the hygienic character and purpose1 which have been frequently attributed to it4 ,,iii4 ,the surgical operation of circumcision1 especially where infants are concerned1 has therefore to be discussed solely on its own merits1 wholly apart from any theory of ,divine intentions1 based upon theological considerations4 ,it appears to be erroneous in principle4 ,,iv4 ,it consists in a mutilation2 in the removal of a perfectly normal structure1 with which1 for patent physiological reasons1 every male child is endowed by nature4 ,the morality of such a practice1 without grave necessity1 is open to question4 ,v4 ,unless as the result of subsequent disease1 no deformity1 and indeed no actual abnormality1 exist as factors productive of the condition designated ',congenital ,phimosis4' ,almost every male child suffers at birth from some degree of the same phenomenon--the imperfect separation of two muco-cutaneous surfaces1 developed in contiguity4#bg ,,vi4 ,symptoms ascribed to a 'contracted prepuce' are due to natural growth of the glans penis1 when this physiological separation is very incomplete1 and when1 therefore1 a rigid constricting envelope prevents development4 ,no true contraction exists1 except as the result of superadded inflammation2 and is rarely of much importance1 unless an element of contagion has been introduced4 ,,vii4 ,the rational treatment of congenital phimosis primarily consists in the efficient execution of the process originally intended by nature1 but imperfectly carried out4 ,and1 secondarily1 in precautions to ensure the permanently free mobility of the prepuce upon the glans penis4 ,,viii4 ,such complete separation of the two contiguous layers of membrane may almost invariably be effected by very simple means2 and1 with some slight attention to after-treatment1 will permanently secure all that is desired1 without risk and without even transient disability4 ,,ix4 ,the treatment of congenital phimosis by dilatation is the common-sense remedy for this condition4 ,it has been carried out by many practitioners with different instruments and variations of detail2 and all who have thus attempted it with ordinary care 7including the present writer7 seem eminently satisfied with the results4#bh ,x4 ,when diseased processes co-exist with congenital phimosis1 the case must necessarily be treated on its own merits4 ,simple dilatation1 even if practicable1 is not always sufficient1 but should be combined with incisions of as limited a nature as possible4 ,mr4 ,furneaux ,jordan's operation is then useful4 ,,xi4 ,in the event of disease1 the operation of circumcision is not devoid of risk1 and should be reserved as far as possible for extreme cases1 in which removal of the whole prepuce is obviously a matter of necessity4#bi ,,xii4 ,in healthy children the operation seems to be rarely fatal in this country4 ,many cases of death directly traceable to circumcision have1 however1 been reported on the ,continent4 ,,xiii4 ,the immediate effects of circumcision1 especially when performed on young infants1 involve considerable and protracted suffering4 ,,xiv4 ,the most conspicuous remote result is that of an extremely contracted meatus urinarius1 as the consequence of subsequent inflammatory processes1 due to the exposure and continual friction of the unprotected glans4 ,,xv4 ,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 hygiene2 and has little weight even in individual cases4 ,,xvi4 ,the superior chastity and purity of mind and body supposed to be procured for its recipients by ritual circumcision1 lie open to very considerable question1 in the face of abundant well-known facts4 ,,xvii4 ,the advantage of circumcision in obviating future venereal contagion is restricted by its principal advocate to one form 7albeit the most important7 of such disease4 ,even in this limited field the facts adduced appear open to dispute1 and greatly to need confirmation by independent observers4 ,,xviii4 ,in the hands of careless or inexperienced operators the surgical operation of circumcision has been followed by the most disastrous permanent consequences4 ,,xix4 ,in face of the facts here set forth1 it is ,,not advisable to apply the operation of circumcision1 as a remedy for congenital phimosis1 to ,christian infants2 much less to extend this1 as a routine custom1 to the whole male population4 ,,footnotes3 #bg ,the word 'adhesion' in the previous pages is employed solely as a term of convenience1 to denote this imperfect separation1 and does not imply any analogy to inflammatory processes4 #bh ,the writer first drew attention to the advantages of this method of treatment in the ,british ,medical ,journal1 ,nov4 #ae1 #ahgd4 ,having instituted a tolerably extensive search through the medical literature of the preceding three or four decades1 he is unable to find any account of a case in which the procedure failed to effect a permanent cure1 unless there had existed previous disease4 #bi ,a fatal case1 after circumcision for gonorrhoeal inflammation1 in a youth of #ag1 is reported in the ,lancet1 ,feb4 #be1 #ahhb4 ,death took place on the eighth day apparently from septicmic pneumonia4 ,,bibliography4 ,,published ,,works4 ,i4--,,medical4 ,erichsen's ,surgery1 ,ninth ,edition2 ,holmes's ,system of ,surgery1 ,third ,edition2 ,maunder's ,operative ,surgery2 ,joseph ,bell's ,manual of ,surgical ,operations2 ,jacobson's ,operations of ,surgery2 ,reginald ,harrison's ,diseases of ,urinary ,organs1 ,third ,edition2 ,keyes's ,diseases of ,urinary ,organs2 ,keating's ,cyclopdia of the ,diseases of ,children2 ,ashby and ,wright's ,diseases of ,children2 ,jaff's ,die rituelle ,circumcision im ,lichte der antiseptischen ,chirurgie2 ,asher's ,the ,jewish ,rite of ,circumcision2 ,wunderbar's ,biblisch-,talmudische ,medicin2 ,gideon ,bircher's ,die ,beschneidung der ,israeliten2 ,dr4 ,hayes ,agnew's ,principles of ,surgery2 ,sayre's ,orthopdic ,surgery2 ,hilton's ,rest and ,pain2 ,international ,encyclopdia of ,surgery1 #ahhf2 ,guy's ,hospital ,reports2 ,american ,journal of ,syphilis and ,dermatology1 ,october #ahgb2 ,walsham's ,theory and ,practice of ,surgery1 c4 c4 ,,ii4--,,historical ,,and ,,miscellaneous4 ,the ,testaments1 ,old and ,new2 ,the ,talmud2 ,maimonides on ,circumcision2 ,tylor's ,primitive ,culture2 ,moncure ,conway's ,demonology and ,devil ,lore2 ,keil's ,biblical ,archology2 ,smith's ,dictionary of the ,bible2 ,calmet1 ,dictionary of the ,bible1 ,encyclopdia ,americana1 ,encyclopdia ,britannica2 ,howard1 ,royal ,encyclopdia2 ,penny ,cyclopdia2 ,chambers's ,encyclopdia2 ,encyclopdia ,metropolitana2 ,winer's ,realwrth2 ,brewster1 ,edinburgh ,encyclopdia2 ,english ,cyclopdia2 ,wilkes's ,encyclopdia ,londinensis2 ,globe ,encyclopdia1 c4 ,,periodicals4 ,the ,lancet1 ,british ,medical ,journal1 ,medical ,times and ,gazette1 ,medical ,record1 ,dublin ,journal1 ,boston ,medical and ,surgical ,journal1 ,chicago ,medical ,standard1 ,gazette des ,hpitaux1 ,allgemeine ,wiener ,med4 ,zeitung1 ,wiener ,med4 ,presse1 c4 ,,by ,,the ,,same ,,author4 ,,the ,,palliative ,,treatment ,,of ,,incurable ,,cancer4 7,with ,appendix on the ,opium ,pipe47 #bs4 #f;d4 ,,the ,,reappearance ,,of ,,cancer ,,after ,,operation4 #es4 #f;d4 ,,the ,,general ,,theory ,,of ,,cancer-,,formation4 #as4 ,,clinical ,,notes ,,on ,,cancer4 #cs4 #f;d4 ,j4 ,a4 ,,churchill1 ,new ,burlington ,street4