Chapter V

DISADVANTAGES AND DANGERS OF CIRCUMCISION.

As a surgical operation, 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 life; and there can be no doubt that it is but seldom followed by a fatal result. Still, with any breach of surface whatever, there must be a chance of blood-poisoning and of the absorption of septic materials; and, in the case of a child liable to hæmophilia, it cannot be doubted that serious consequences might readily ensue.

Thus, in the third century it was enacted by the rabbins (_Talmud, Treatise Jebamoth_, 646) that, after two deaths in the same family from this cause, the ceremony was to be omitted; and the prohibition has continued in force ever since. Maimonides inculcates the utmost caution in the performance of the rite, and insists that 'in case of doubtful sickness, a child must not be circumcised; since danger to life overrides the whole ceremonial law.' (_Maimonides on Circumcision_, ch. i.). At the present date it is always effected by an expert (Mohel), who is not infrequently a qualified medical man; and accidents are guarded against with jealous care.[16]

The ancient plan, according to which the operator received in his mouth (previously filled with wine) the extremity of the lacerated member, is now wholly or in great part abolished among the Jewish community; it being found that both syphilis and tuberculosis were thus communicated to the infant.[17]

The _Lancet_ of October 1, 1870, quotes from the _Wiener Med. Presse_ the particulars of two cases, reported by Dr. Schwartz, of boys circumcised at the usual period; who subsequently died from phlegmonous inflammation and sloughing of the part, one five and the other twenty-five days subsequently to the operation. In the same periodical for December 5, 1874, may be found allusion to the experience of Dr. Kohn, himself a Jew; who stated at a medical society in Vienna, that during a practice of thirty-five years he had known six deaths from this source (_Allg. Wiener Med. Zeit._ November 17, 1874). He himself had thus lost a child of his own.

However such fatality may be attributed to the neglect of all hygienic rules among the poorer classes of Jews; it can hardly be doubted that, under even the most favourable conditions, septic poisoning or uncontrollable hæmorrhage _must_ occasionally happen, albeit extremely rare; and this whether the operation has been performed from ritual or from surgical motives. To the absence of such cases reported in medical literature, too much weight must not be attributed.[18]

It is rather upon the minor consequences, immediate or subsequent, that those who object to the practice have founded their opposition; and of such there has been no lack, especially among medical men who have been themselves Jews, and who have thus necessarily enjoyed the fullest experience of its effects. Thus the _Lancet_ of December 5, 1874, mentions a pamphlet by Dr. Levit, demonstrating the evils of the custom. He speaks of the premature beginning of sexual excitement in boys deprived of their prepuce, and the disposition to onanism so common to Eastern nations; he regards circumcision as a criminal manipulation; and calls upon the medical profession to oppose the practice, even at the risk of losing favour at the hands of the Jewish families they attend. And his arguments are effectually sustained by Dr. Kohn. Dr. Schwartz, in recording the fatal cases above quoted, 'deprecates the custom with great warmth, and expresses the wish that it may be laid aside.'

Mr. R. W. Parker (_British Medical Journal_, July 19, 1879) refers to a child (one of a family of bleeders) who, being circumcised, nearly bled to death. He also says: 'Diffuse cellulitis of the penis is not an uncommon complication after this operation in unhealthy, ill-fed, and badly-cared-for children.'

Dr. Mastin, in _Gaillard's Medical Journal_, speaks of the great frequency with which he has been consulted by Jews for chronic urethral discharges, irritable urethra, and other affections of the genito-urinary organs. He describes 'the preternaturally small meatus which results from early removal of the prepuce by circumcision.' (_Medical Record_, December 10, 1885.) Elsewhere in the same periodical (_Medical Record_, vol. xxi.) we are informed that 95 per cent. of young male Jew adults have this contracted meatus.

Shorn of its natural protective covering, the muco-cutaneous covering of the glans soon becomes true dermoid tissue. Mr. J. Hutchinson (_loc. cit._) speaks of 'every one who is acquainted with the effects of circumcision in rendering the delicate mucous membrane of the glans hard and skin-like.' Contact with the clothing, &c., necessarily induces a chronic inflammatory condition of the part, followed commonly by contraction and condensation. We cannot with impunity rashly interfere with any of Nature's dispositions, however seemingly insignificant.

This hard skinlike condition of the integument upon the glans penis, with its concomitant of narrowed urethral aperture, may be regarded as the normal result of circumcision. In the hands of bungling operators, however, far worse consequences may follow. Thus J. Bell (_Manual of Operations in Surgery_, 1866) 'has known the glans penis included in the incision in _at least_ one instance.' (The italics are his own.) Mr. Reginald Harrison (_Diseases of Urinary Organs_, 3rd Edition, 1887) has treated two _varieties_ of urethral stricture after circumcision which have not turned out well; in two _cases_, the extremity of the glans penis, including the meatus, had been wounded in making the section of the prepuce; in a third, owing to 'oedema and difficulty of ascertaining where the glans was, amputation had been performed, and the end of the glans included.' The second variety of stricture was caused by the prepuce being divided too high up, or, what amounts to the same thing, being drawn down too much over the glans penis, before being included in the forceps for the purpose of making the necessary section. On bringing together the parts with sutures, the tension on them was so great as to cause ulceration, and to leave behind a broad cicatrix, capable of exercising a contractile pressure on the under surface of the urethra; sufficient to impede micturition and to cause other discomfort.'[19]

Dr. Hyde (_Boston Medical and Surgical Journal_, June 26, 1890) has seen disastrous results from circumcision; and Dr. Willard (in Keating's _Cyclopædia of the Diseases of Children_) says that, after circumcision, hardening of the glans occurs; and the evils of contracted meatus, balanitis, &c. follow, as pointed out by Otis, Mastin and others. So far, therefore, as the remote consequences of circumcision are concerned, there is strong evidence that the operation is by no means an unmixed blessing to its recipient.[20]

Turning to the more immediate effects and consequences, the italicised passages in Mr. Erichsen's elaborate description concur with the experience since cited of other writers, to show the need of considerable caution in the performance of this surgical procedure. Septic infection, hæmorrhage, and subsequent sloughing of the part have to be sedulously guarded against; and on the Continent, at least, the resources of modern antiseptic surgery have been specially invoked. Without careful ligature of the arteries, these may, we are told, give rise to troublesome and long unnoticed hæmorrhage when the patient is put back to bed. The examples above quoted, and the varying practice of different surgeons, show, moreover, that discrimination and judgment are essential as to the excision of either too much or too little of the foreskin; both of which events may be disadvantageous.

Mr. W. H. Jacobson (_Operations of Surgery_, 1889) says that after circumcision 'an adult should lie in bed for forty-eight hours, and keep on the sofa for a week, alternate stitches being removed at intervals. If he insist on getting about too early, he must run the risk of the parts remaining _long oedematous and tender_. And for this reason, with hospital patients, who have to come backwards and forwards, _early and complete healing is not to be expected_. (The italics are the present writer's.)

It may be reasonably assumed that no sane man, who possessed the advantages of a sound and entire prepuce, would willingly sacrifice it without just and sufficient cause being shown. And his natural repugnance to such a deprivation would probably be in no wise lessened by a perusal of the passage last cited. It would be without doubt in the highest degree edifying in the present connection, were the sensations of some educated adult of average sensitiveness, who had submitted to the operation, placed on record; together with a statement of the time which elapsed before perfect tolerance became established; and before the 'hard skinlike condition,' so much approved of by Mr. J. Hutchinson, and the other more or less enthusiastic advocates of circumcision, was satisfactorily attained. In the absence of such a delineation, however, we can only surmise the feelings of the patient; and conclude that, as with catheterisation, and other manipulations addressed to a delicate mucous membrane, they would in some instances be almost _nil_; but that in the man of highly sensitive organisation, they would amount to keen and long-protracted torture.

Infants of tender years must of necessity be classed in the latter of these two categories; in their case, there are also certain circumstances which tend to enhance the barbarity of the procedure; and largely to aggravate the suffering involved. Thus an American operator (at the association meeting of genito-urinary surgeons, reported in the _Boston Med. and Surg. Journal_, June 26, 1890) speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins, and other clothing, must long be very painful. There can be little doubt what would be the verdict--could they only give it utterance--upon the immediate results of the operation in question; returned by these inarticulate (if far from mute) victims of hygienic orthodoxy.[21]

FOOTNOTES:

[16] The most scrupulous and minute precautions for obviating any danger to life are enjoined by the Talmud. The ceremony is not permitted to take place at all unless the child is in perfectly sound health; and that Mohel, whose conscience may convict him of having caused the death of an infant by his negligence, is forbidden ever to officiate again.

[17] A case of tuberculosis thus contracted is reported in the _British Medical Journal_ of March 5, 1887; and twelve other instances are also mentioned in the same paragraph.

[18] The writer has been unable to discover any mortality statistics of ritual circumcision, and apparently none exist. Dr. Asher (_op. cit._) makes a remark to the same effect.

[19] In the same work its author states that an unnatural smallness of the urethra is a not infrequent cause of incontinence of urine in children. In some cases therefore ascribed to congenital phimosis, may not the incontinence be merely a concomitant, and not an effect, of the latter condition?

[20] Dr. Keyes (_Diseases of Urinary Organs_, 1888) has been 'twice called upon to relieve by operation a phimosis resulting from a former operation.'

[21] An objection to circumcision, of wholly sentimental character, yet not the less worthy of practical consideration, may, in addition to those set forth in the text, be here noted. The parents of any child, in whom the necessity of some remedial measure for congenital phimosis has become apparent, usually express considerable relief when told that it is not necessary to make the infant 'a little Jew.'