PHYjVlOSIS and THE PflEPUGE 
OK 
A PLEA FOR CIRCUMCISION 
BY 
P. C. REMONDINO, M. D., 
President of«the Board of Health of the 
City of San Diego and Member of 
Council of Section on Climatol- 
ogy and Demography, Ninth 
International Medical 
Congress, 
ReprintedJrom Proceedings of Southern 
// California Medical Society. \ \ I PHYMOSIS AND THE PREPUCE, OR A PLEA FOR CIR- 
CUMCISION. 
BY P. C. REM0ND1N0, M. D., 
President of the Board of Health of the city of San Diego, Cal. 
HISTORICAL. 
Circumcision is not of Jewish origin, or a Mosaic invention, 
as generally imagined. The earliest mention is from ancient 
Egyptian sources. It was practiced by the Greeks, and was 
at one time a national practice which finally fell into disuse, 
and in the time of Pythagoras was only observed by the 
priests and philosophers. Moses, undoubtedly, learned its 
objects and benefits in the Egyptian temples from the priest- 
hood and incorporated it in his law. The founder of the Ma- 
hometan creed was as fully impressed with its advantages as 
a hygienic measure, which resulted in its becoming a marked 
necessity in their religion. The idea of uncleanliness associated 
with a prepuce, in the minds of the Saracens, was well seen 
in their expression of "uncircumcised dog", with which they 
jeered the Europeans. Whether the rite was at first a sacri- 
fice of what was dispensable of the body to pagan gods, or the 
natural prevalence to skin and cebaceous inflammations in 
warm countries led to its adoption as an hygienic necessity is 
unknown and a matter of speculation. 
DANGERS FROM A PREPUCE AND ADVANTAGES OF CIRCUMCISION. 
Phymosis in childhood is generally considered a physiologi- 
cal state, only to be taken as a pathological condition, under 
certain circumstances. Preputial adhesions may, according to 
many observers, also be classed as physiological at an early 
period of life, as it is by them considered as congenital, and 
common enough to warrant its being classed as normal. As 
to the first, or phymosis, it undoubtedly is a physiological 
condition during infancy, and it is also a fact that from birth 
to puberty it remains so in fully over one-half of the cases. 
Out of 98 children, from one week to 16 years of age, ex- 
amined by Dr. Packard, the prepuce was entirely unretract- 
able in 54; partly in 3, and wholly so in 36, while in 1 it only 
half covered the glands, and in 4 the glands were wholly un- 
covered, one of these 4 being an infant only five weeks old. 
(Am. Jour. Med. Sciences, Vol. LX.) 
Dr. Packard also gives the result of 172 examinations by 
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himself, of from 12 to 73 years of age, and 106 examinations 
by Dr. Maury, a total of 278; in whom 100 had a long pre- 
puce; 97 a partly covered gland, and 81 (of whom two had 
been circumcised) the glands were exposed. (Am. Jour. Med. 
Sciences, Vol. LX.) 
As to adhesions, there is an unaccountable diversity of 
opinion as to their constancy as a natural condition, being 
frequent enough to class them as physiological occurrences. 
Bokai, out of 100 children, found 8 who were over seven years 
of age who were perfectly free, while of the remaining 92 
under that age, 6 more showed no adhesions and 86 had vari- 
ous degrees of adhesion. Dr. Halgate, of the Outdoor De- 
partment of Bellevue, considered that all phymosic cases have 
adhesions, while Dr. Moses of New York, out of some fifty 
circumcisions performed at the eighth day, found only ad- 
hesions three times. (N. Y. Med. Jour., Vol. 26.) I have been 
present at a number of Hebrew circumcisions, performed 
from the eighth day up to the sixth month, and have never 
seen adhesions as a complication in any of the cases. I have 
more frequently met cases of adhesion from the second to the 
eighth year than during infancy, and in some cases I have 
seen the agglutination re-form during the second to the fourth 
year of life, after having been not only removed, but the sur- 
face where they existed had become perfectly healed. 
Another co-existing condition with phymosis, very often 
found, is a shortening of the frenum. Dr. Jansen out of 
3,700 soldiers of the Belgian army found 12.3 per cent with 
this pathological condition, and 2.5 per cent with a narrow 
prepuce. (Am. Jour. Med. Sciences, Vol. LX.) Take the three 
conditions named, phymosis, preputial adhesions and short 
frenum, all are but a departure from a normal, in a greater or 
less degree, and whether the resulting discomfort consists in 
mere mechanical impediment to urination or erection, or in 
any of the nervous derangements that may accompany these 
conditions, or in the more serious results, ending in positive 
deformity of body or limbs, or in the warping of moral senti- 
ments, or even further, in inducing insanity, I cannot see how 
the conditions that will certainly produce them, in a more or 
less degree, can ever, in any logical sense, be considered a 
physiological condition. 
There are certain conditions peculiar to life, up to the time Phymosis and the Prepuce. 
103 
of birth, which, unless they then cease at once to exist, im- 
mediately become from a physiological into very serious 
pathological condition. These are well understood, and have 
their reasons for existing, but the prepiice has no function 
during uterine life or subsequently, and there being no valid 
reason for its existence, there are certainly no logical grounds 
for its being considered a physiological condition, especially 
when the serious results attending its most accentuated forms 
are considered; and its necessity in cases of its entire absence 
has not yet been demonstrated. 
It can well be said, that about two-thirds of mankind are 
affected, in a greater or less degree, with this pathological 
condition, causing them more or less annoyance. Of these a 
certain percentage suffer a life of continued misery as a direct 
or indirect result of these conditions. 
Of the more serious local results that I have seen resulting 
from the presence of the prepuce, strangely enough not one 
belonged to the class where a circumcision would have been 
considered necessary ; being in every case where the prepuce 
was retractible but too redundant. While in its remote effects 
it is, as a rule, a too narrow, tight and unretractible condition 
that causes the nervous disturbances. From these premises, 
and considering the little risk attending circumcision when 
intelligently performed, I have become an advocate of its 
more universal performance, being fully convinced of its 
necessity, both as a hygienic and a preventive measure. 
Such a proposal, I am well aware, will not meet with the 
universal approbation of the profession, to say nothing of the 
laity, as the operation is looked upon by many as barbarous, 
unnecessary and dangerous; and its observance by those of 
the Jewish faith, as the blind following of some traditional 
religious rite, evolved in the dark, remote and barbaric age of 
man's existence. 
Nothing is more unjust than to attribute the strict ob- 
servance of this rite by the Jews of the present day to such 
causes. That the rite still exists, and is observed, and is due 
to the enlightenment and intelligence of the present, is suf- 
ficiently evident from the fact that the ignorant and dangerous 
manner in which the operation was performed, and the result 
left to care for itself, did at a time so alarm and disgust a 
number of the faith, that in New York its abolishment formed 104 
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part of the ground-work for a schism in the synagogues. 
(See papers by Dr. Moses in Vol. XIV, New York Medical 
Journal, and by Dr. Cohen in Vol. XIX, of the same.) The 
resulting inquiry into the merits and demerits of the operation 
resulted in the operation, as an hygienic measure, being more 
insisted on even than, formerly, aside from any religious 
significance. 
To have charged its observance, by the Jewish faith, to 
ignorance, is not in keeping with our historical knowledge of the 
march of medicine, and the impress it received from Arabian 
teachings, which then comprised among its followers a number 
of learned Jews. During the dark periods of the Middle 
Ages, and in the more enlightened times that preceded the 
revival of the Hippocratic school, to which we belong, Jewish 
physicians and surgeons were for some centuries the only in- 
telligent exponents of our art; the mixture of superstition, 
religion and empiricism, followed by the monks of the period, 
then the only other practitioners, hardly deserving the name 
of medicine. So well was, even then, true merit self-asserting 
that even in Catholic Spain Jewish physicians held high 
places at court, as they did in the principal cities of Europe; 
and the blow that paralyzed medicine for over two centuries 
came when, with the Christian persecution, and the holy in- 
quisition, the Jews were driven from Europe; with them 
went what of medicine deserved the name of science. 
It is admitted that intelligent physicians have saved many 
from physical or mental wreckage, a life of misery, useless- 
ness and premature death, by the timely recognition, that 
certain neuroses, leading to serious organic changes, were due 
to causes easily removed by prompt circumcision; how many, 
then, are there not allowed to go to physical ruin, beyond the 
limit of help, simply because the true condition and its possi- 
ble remedy failed to have timely recognition. 
Objectors to circumcision have brought forward the plea of 
its danger to life, and certainly cases are not wanting where 
its bungling performance has been followed with fatal results. 
Baptism in Catholic Europe is the cause of considerable infant 
mortality. This is more observable in France, Italy and Spain. 
In France the mortality for infants, during the first month of 
life, is one-third more than that of England. (See Massachu- 
setts State Board of Health Report for 1873, and John Bell Phymosis and the Prepuce. 
105 
on Longevity.) How this affects infant life can easily be un- 
derstood, if the cold, damp, mephitic atmosphere of the 
churches is taken into account and its influence on infant 
vitality - James Henry Bennet being at one time overcome 
by the excess of carbonic acid on the lower levels of the 
Milan cathedral. (Bennet, Pulmonary Consumption.) The 
filth, ferment and pneumonia, and phthisis baccillus, are here 
in their elements, and with the great variations of tempera- 
ture, to which the child is subjected, and its sure return to an 
overheated home, it may be safely asserted, causes thousands 
of young Christian deaths where circumcision may cause a 
single one; and yet, not a voice has been raised to protect the 
Christain infant from an untimely end, save in the fact that 
its causes in regard have been pointed out by 
and Edwards. (Edwards, Influence of Physical Agents on 
Life.) 
The effect of the presence of the prepuce, in different de- 
grees of tightness or redundancy, in producing reflex affec- 
tions, are too well known and admitted; having been ably 
pointed out by Sayres, Otis, Green, A. McLean Hamilton 
and others. This paper will, therefore, confine its remarks to 
the local derangements and dangers attending its presence, 
and to the preventive effects of circumcision in preserving from 
local contagion or infection. It may here be remarked that, 
although always favorably impresssed with the benefit result- 
ing from circumcision, it was the expression of voice and 
countenance of a professional brother, then dying of a cancer- 
ous affection, originating in the prepuce, whom I saw in con- 
sultation with Dr. Robert J. Gregg of San Diego, that first seri- 
ously opened my eyes to its importance and the dangers from the 
prepuce. He informed us that, when a youth, suffering from re- 
peated painful attacks of herpes preputiatis, he had called the at- 
tention of his father, also a physician, to the possible relief of 
his affliction by circumcision. "My father did not believe in it; 
if he had, I should not now be compelled to leave my poor 
family, after all this suffering, in the prime of my life.'' It 
was the same story that I have seen repeated in many cases 
since, when he arrived of age, occupation and business em- 
ployment prevented his giving the required time for the per- 
formance of the operation until too late. 
In general, the affections that a redundant or a tight prepuce 106 
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may cause are not sufficiently considered by those who do 
not deem circumcision necessary, unless for some immediate 
or imperative interference; these affections, pernicious in 
themselves, are often, if not directly, indirect cause of the 
abridgment of human life; for each period of life has its 
well marked preputial diseases - a class much more common 
than generally supposed, and that circumcision most em- 
phatically makes impossible. 
One of the objections to the operation has been the claim 
that it resulted in contraction and induration of the meatus. 
I find this in the majority of cases to be more apparent than 
real-and that, on the contrary, for an equal number ex- 
amined the proportion of this affection is in reality as four in 
the uncircumcised to one in the circumcised*. The condition 
being this, that although the meatus in the latter class is 
closed, it is in the majority of cases dilatable, and lacking that 
undilatability due to plastic deposit found in so many cases of 
the former-the natural results of inflammation and repeated 
herpetic attacks. 
Herpes, a vesicular skin disease, is one of the most common 
and frequent results of a redundant or tight prepuce, although 
itself innocent appearing it is a fruitful source of annoyance 
and danger, in the following ways : By causing plastic deposit, 
thickening and induration of the immediate tissues; by the 
production of vesical and renal irritability, that at times 
becomes a permanent condition, liable to aggravation on the 
least provocation by exposure or irregularity of diet; by lay- 
ing the foundation for urethral strictures, first on the anterior 
part of the canal, and latterly by the irritability induced, 
deeper-seated strictures. In treating strictures I have been 
surprised at the number that could be distinctly attributed to 
this cause-where an operation for the original irritative cause 
was necessary before resorting to an operation for the disease 
for which the patient applied to be relieved from. Psoriasis is 
another skin affection, induced by the same cause, and with 
very much the same results as the one previously mentioned. 
One result of these skin affections, not mentioned in connec- 
tion with preputial irritation by any writer-a condition far- 
reaching as regards its own results, and more annoying 
and serious than it appears at first sight - usually begins 
with a reflex irritability of the anal sphincter muscle, or Phymosis and the Prepuce. 
107 
a rectal irritation of the same order, which in time produces 
such organic change that an hypertrophied and irritable, 
indurated, unyielding muscle is the result. Agnew of Phila- 
delphia describes the condition, but does not mention this 
frequent cause, under the name of sphincterismus ; once this 
is established, the train of resulting pathological or diseased 
conditions that may follow are without end. This is no fancy 
sketch, nor will the student of the pedigree and origin of 
diseases feel that the case is exaggerated or imaginative. 
These are some of those cases that are always ailing, never 
well and never really sick, but are gradually breaking down, 
and finally die of what is termed a "complication of diseases" 
before living out half of their term of life. 
How this happens is simple enough-the straining required 
to produce an evacuation is out of all proportion with the 
character of the discharge; such patients often complain of 
being constipated when the evacuations are semi-fluid; this 
straining is followed by a dilatation and consequent loss of 
power of the rectum, which becomes pouched and its mucous 
membrane thickened; the whole intestinal tract sympathizes 
and digestion is interfered with, and the forcible expulsive 
efforts affects all the abdominal and thoracic organs in a more 
or less degree, laying the foundation for serious organic 
diseases. Now this condition, which may be said to be no 
more than one of obstinate constipation, is a more far-reaching 
condition, and afar more injurious state than imagined at first 
glance. Constipation is not, as a rule, always accompanied by 
the indigestion that goes with this condition-the contents of 
the intestine in simple constipation may simply lack fluidity 
without undergoing putrefactive fermentation, but in this 
condition the undigested and retained intestinal contents do 
undergo that change, resulting in the generation of material 
whose re-absorption produces a toxic condition of the blood, 
from whence begins a series of serious organic changes in the 
body. 
To the practical physician these changes are evident, and 
their cause just as plain, and it is just here, where the laity 
lack the proper education, and where they should understand 
that the intelligent physician generalizes the disease and only 
individualizes the patient; and it is this ignorance on the part 
of the laity that gives to empiricism and quackery that ad- 108 
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vantage over them, as they look upon all disease as a distinct 
individual ailment, that should have an equally distinct and 
individual therepeutic agent to cope singly with it. 
A little digressive explanation will make this subject a little 
clearer. Sir Lionel Beale, in observing the immense import- 
ance he attaches to blood composition and blood change in 
diseases of various organs, truly remarks, that "blood change 
is the starting point, and may be looked upon as the cause of 
what follows." The other factor being the "'tendency' or in- 
herent weakness or developmental defect of the organ which 
is the subject of attack"; to which he adds that he feels con- 
vinced that if only the blood could be kept right, thousands of 
serious cases of illness would not occur, while the persistence 
of a healthy state of the blood is the explanation of the fact 
that many get through a long life without a single attack of 
illness, although they may have several weak organs, and that 
an altered state of the blood, a departure from the normal 
physiological condition often explains the first step in many 
forms of acute or chronic disease; Sir Lionel has been a pio- 
neer in the field of thought that looks for the cause of the 
disease, which, however remote it may be, should not be over- 
looked as a really primary affection. His extensive labor in 
the microscopic field has fully convinced him that many of 
the pathological changes in the different organs are due to 
what might be called some intercellular substance that is de- 
posited from the blood. (Bedie: Urinary and Renal Disor- 
ders.) 
Toxic elements in the blood affect the kidneys in a greater 
or less degree, and there produce changes at first unnoticed- 
at least as long as the kidney can perform its function-but 
the day arrives when, as described by Fothergill, blood de- 
puration is imperfect, and we get many diseases which are 
distinctly uremic in character, and ending in any of the so- 
called kidney diseases, Bright's disease being one of the most 
common. As observed by Fothergill, however, the kidney is 
not the starting point, the new departure only taking place 
when the structural change on the kidney has reached that 
point that it is no longer equal to its function-the "renal in- 
adequacy" of Sir Andrew Clarke. (J-. Milner Fothergill, in 
the Satellite, Fed)., 1889.) 
During the Bradshawe lecture Dr. William Carter made the Phymosis and the Prepuce. 
109 
following remarks: 11 According to Bonchard, one-fifth of the 
total toxicity of normal urines is due to the poisonous products 
re-absorbed into the blood from the intestines and resulting 
from putrefactive changes which the residue of the food 
undergoes there." In the course of the lecture Dr. Carter 
fully explains that one of the benefits derived from milk diet 
in Bright's disease is the small residuum deficient in toxic 
properties, and lays great stress on the employment of in- 
testinal disinfectants or antiseptics that exercise their influence 
throughout the whole tract, suggesting naphthalin as pecu- 
liarly efficacious, thereby cutting off one source of blood 
contamination a£ its source. Although these are recent de- 
velopments in medicine, Bouchard mentions that in the prac- 
tice of M. Tapret cases treated on this principle did well. 
(Braithwaite's Retrospect, January, 1889.) 
Persons laboring under this toxic condition of the blood, 
with a consequent deterioration in the texture and the 
physiological function of the vital organs, are of that class 
that easily succumb to injuries or serious sickness, and of that 
class to whom a surgical operation of even medium magnitude 
is equal to a death warrant. 
The above conditions are an almost constant attendant on 
that condition of the sphincter, described by Agnew as sphinc- 
terismus, which also is productive of hemorrhoids and fissure 
and often of fistula. That sphincterismus is caused in many 
cases by preputial irritation, is as evident as that the same 
affection, or hemorrhoids or any other rectal or anal affection, 
will in its turn produce vesical and urethral reflex actions, 
and primarily functional and secondarily organic changes in 
those parts. Besides the great number of cases wherein the 
gradual and progressive march of each pathological event 
could be traced with accuracy, has convinced me of the true 
cause of the difficulty being the result of reflex irritation. 
Delafreld in his "Studies in Pathological Anatomy" gives 
as the first form of pneumonia, that from heart disease; in the 
days of Broussais this would have sounded absurd, but to-day 
some forms of heart disease are known to be the regular 
sequences of some particular form of kidney disease, just as 
some form of pneumonia attends an affected heart and that 
some forms of pneumonia degenerate into phthisis. When 
the blood change is an established fact it is only a question as 110 
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to which is the weak organ, and only question as to the 
organism of the individual whether it will be a simple 
sick headache or the beginning of a pneumonia ending in 
phthisis. 
I have purposely dwelt on this part of this subject, owing to 
the recent origin and publication of many of the views con- 
nected with it, also on account of the greater ease of making 
the subject plain by fully discussing each step of the process, 
and if the views of Sir Lionel will be recalled, that a toxic ele- 
ment in the blood is the starting point and that an irritable or 
weakened organ invites destruction-the induction of serious 
and fatal kidney disorder by the transmitted irritability and 
consequent injury to the kidney produced by preputial irrita- 
tion in the first instance, and the supplemental blood poisoning 
by intestinal absorption of septic matter, which soon brings 
about Sir Andrew Clarke's " inadequacy of kidney ", all will 
be readily understood. When this point is reached, a too 
hearty meal, exposure to variable weather, or a little extra 
care or anxiety, are sufficient as a determining cause to bring 
life into danger. 
As pointed out, many cases of Bright's disease or other 
renal difficulty have their origin in this distant but visible 
source, and although malarial poisoning and a great number 
of other causes will produce the same particular organic 
changes and diseases, this condition must be admitted as one 
of the frequent causes. The influence of the genito-urinary 
tract on the rest of the economy, and the importance of the 
sympathy it excites, or how quickly by its being irritated 
some apparently dormant pathological condition will be 
awakened to life and activity is not sufficiently appreciated. 
As observed by Hutchinson, a patient who has once been the 
subject of intermittent fever is more prone, on catherization, 
to have a urethral chill and fever than one who had never had 
the fever. (Hutchinson, Pedigree of Diseases J 
Returning now to the local effects of an elongated prepuce, 
we meet with a class of diseases of various degrees of severity 
which mainly affect adult life and old age; diseases that the 
circumcised are exempt from. The mildest of these are those 
fungous growths of nested epithelial cells which are generally 
called warts or excrescences. In elderly persons I have noticed 
a form of eczema attack the prepuce in its inner fold and the Phymosis and the Prepuce. 
111 
glans, at times extending over the whole member and even to 
the scrotum; some cases are attended by a very profuse 
and offensive discharge, and at times very rebellious to treat- 
ment. 
Gangrene is another disease affecting the prepuce; it is not 
so rare as to warrant the little notice paid to it in our text- 
books. M. Demarquay has collected the history of twenty-five 
cases; from him we learn that the prepuce is the most fre- 
quent seat of the start of the affection from whence, accord- 
ing to Astruc, it rapidly spreads to the skin of the whole 
organ, and then attacks the corpora cavernosa; it may even 
extend as high as the umbilicus. (Half-yearly Abst. Med. 
Sciences, Vol. 41.) This disease spares no age, it attacks old 
and young alike. 
Carcinoma attacks the prepuce and then the glans. This 
disease has been observed to attack subjects of phymosis. 
Amputation, if resorted to in time, may save the patient's life. 
According to Erichsen and Travers, epithelioma is unknown 
among the Jews. (Lancet, July 7, 1860.) Even where phy- 
mosis does not exist, but only the long, lax and retractible 
prepuce, that is considered a physiological condition, the pre- 
puce is liable to cause very distressing and complicating an- 
noyances, during the progress of other diseases. I have 
noticed that cases with a thick leathery prepuce are more 
liable to require the use of the catheter during the course of a 
continued fever. Such a condition is also a very frequent 
accompaniment of prostatic obstruction. So often has this 
been noticed that I am constrained to associate this condition 
as one that, by its irritation, tends to lay the foundation of 
prostatic troubles or disease in not a few cases. In elderly 
people the constant moisture from the urine on the inner fold 
and glans adds greatly to the irritation as well as to the dis- 
comfort of the patient. 
A number of affections are accompanied by edema, especi- 
ally toward the latter stages of the disease; such, for instance, 
as the ending of cases of mitral insufficiency. In these the 
distension of the prepuce is at times very great, and in some 
cases the resulting engorgement produces retention of urine. 
It was after an attendance on such a case, that required daily 
puncturing for its relief, but which, in spite of all care, finally 
became gangrenous, that a fellow-practitioner cheerfully sub- 112 
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mitted to circumcision, to avoid the possibility of any such 
complication occurring to embitter his closing illness. 
The prepuce is the starting point of many of the cases of 
penitis and retention of urine that often accompany attacks 
of gonorrhea; especially can this result be anticipated in 
cases where the prepuce is long, pendulous and with its veins 
in a varicose state. This is plainly accountable for, anything 
that will add to the interference of the return circulation only 
exaggerates the tendency to penis engorgement; this increases 
the difficulty of urination, which, by the retention that results, 
in turn increases the constriction at the root of the penis, and 
adds to the already difficult return circulation. The bladder 
by its urine, and the penis by its blood, actually forming by 
their mutual pressures an impassable dam at the root of the 
organ. That this is the true condition, I am well satisfied, 
from the instant relief I have given to the whole condition, 
by the prompt employment of the suprapubic puncture or 
aspiration, as catheterization in such cases is altogether out of 
the question and should never be employed; 
The effect of a redundant prepuce in cases of continued 
fevers has already been mentioned; but it is proper that, 
under this head, it should be again referred to; as the condi- 
tion of retention spoken of may, if carried further, result in 
gangrene of the whole organ. A person laboring under a con- 
tinued fever has his blood in a condition to favor sphacelus, 
the slow moving current of vitiated blood, and its retention 
in such lax tissues as those of the penis, through the medium 
of the enlarged preputial veins, is a dangerous condition. 
H. Royes Bell, in Vol. VI of Ashurst Enc. of Int. Surg., 
mentions this gangrene as occurring in typhus or other low- 
grade fevers. 
I recently had a case of typho-malarial fever, that Dr. 
W. W. McKay of the U. S. Marine Hospital Service attended 
with me. The subject had a long, thick, leathery prepuce, 
and only the most careful and delicate use of the catheter for 
nearly three weeks saved the penis from certain gangrene, as 
the keeping the bladder empty prevented that stage of en- 
gorgement that would have prevented catheterization. As it 
was, the penis, although flaccid, was often dark and discolored 
from the passive engorgement. 
Of the diseases and results so far mentioned, it may be Phymosis and the Prepuce. 
113 
claimed that cleanliness, if properly attended to, would act 
as a preventive, and that where such precaution is impossi- 
ble, then that circumcision should be performed. The dif- 
ficulty here occurs as already pointed out in a previous part 
of this paper. Adults who run the greatest local risks hardly 
ever have the time to spare or the inclination to submit to the 
operation. 
I have seen a large number of unretractible and narrow 
prepuces, in four instances in persons past twenty years, where 
the prepuce after that age contracted at the juncture of the 
skin and mucous membrane, gradually contracting more, un- 
til it became impossible to uncover the glans. X have two 
cases who have been waiting "to have time" to be operated 
upon, who, up to the age of puberty, had a free and retracti- 
ble prepuce; one of these now has a. long and exceedingly 
thin prepuce, with a mere pin-hole aperture; during micturi- 
tion it balloons. This patient has mild uremic attacks, attacks 
of amblyopia, sick headaches, (disordered digestion, and, al- 
though a man of a wonderful physique and good development, 
he is slowly breaking down, while waiting for time to spare 
for an operation, which he puts off from month to month. 
Richardson, in his admirable work on Preventive Medicine, 
observing on the effects of syphilis, the deterioration of the 
organs of circulation and their degenerative changes, says 
that in his opinion syphilis is the progenitor of various dis- 
eases and that those who have given this opinion the greatest 
range are unfortunately nearest to the truth. The breathing 
organs, he remarks, are distinctly susceptible to injury from 
this hereditary cause. 
In 1854, at the Metropolitan Free Hospital, situated in 
the Jews' quarter in London, the proportion of Jews to 
Christians among the outpatients was as one to three; at 
the same time the proportion of cases of syphilis in the 
former to the latter was one to fifteen. Now, this result was 
not due to any extra morality on the part of the Jews, as 
fully one-half of the gonorrhea occurred among those of that 
faith. (Half Yearly Abst. Med. Sciences. Phila. Vol. LX.) 
In the conclusions to be reached I do not wish to give cir- 
cumcision any more credit as a preventive measure than it 
deserves, and I must here mention that the Jews owe in 
part their immunity to hereditary diseases due to syphilis, to 114 
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the chastity of their females, which shuts off one avenue of 
race infection. 
The statistics of illegitimacy by religious denomination, 
taken in Prussia, makes the Jewish women three times as 
chaste as the Catholic, and more than four times as chaste 
as the Evangelists; although the reverse must be said of the 
males. Considering, however, the less number of females 
born to the Jews, their being given in marriage earlier, and 
their known fecundity, the statistics given in relation to illegit- 
imacy as being competent to form an idea of their chastity 
may be fully accepted, and the immunity to syphilis from this 
source as fully credited. (Lancet and Observer, Cincinnati. 
Vol. XVI. 1873.) 
Richardson mentions the immunity of the race from tuber- 
cular disease, and notices the well known relation existing 
between a syphilitic taint and a phthisical tendency. How 
much circumcision contributes to this immunity may be judged 
by the following statistical comparison made between two 
circumcised and one uncircumcised people. In the year 1839- 
40-41, the recorded deaths from phthisis gave the following 
percentages: In Algiers, the records being from the reports 
of the French minister of war, among the Christians there 
was one death in 9.3; Musselmen, one in 40.7; and among the 
Jews, one in 36.9; the additional abstemious habits of the 
Moors giving them nearly 4 per cent advantage over their 
circumcised Jewish brethren. (Millard, Statistics and Climate 
of Consumption.') 
The longevity of circumcised races, as exemplified in the 
Jewish people, is well shown in the statistics returned from 
the French war office. In Algeria the deaths per 1000 of 
each class, during two years, was as follows: 
YEARS -1844 
1845 
Jews 
21 
36 
Moors 
32 
40 
Europeans 
43 
45 
In London, according to Dr. Stallard, the mortality among 
Jewish children, from one to five years, is only 10 per cent, 
while among Christians it is 14 per cent; the average dura- 
tion of life among the Jews being forty-nine and among the 
Christians, in London, only thirty-seven Phymosis and the Prepuce. 
115 
In Germany, according to M. Mayer, the same rate as to 
small children holds good as in London, and the average for 
all ages gives the Christian eleven less years of life than the 
Jew. In France, Dr. Neufville has found that the mortality, 
from 1 to 5 years, gives the Jew a greater hold on life than 
the Christian; the death rate among the latter being 24.1, as 
against 12.9 per cent of the former. The general result being 
among all ages that the Jew lives 8 years and 2 months longer 
than the other race. {Lancet and Observer, Cinn., Vol. XVI., 
'73.) As to general immunity to disease from circumcision, it 
will be logical to conclude that it is as proportionate as the 
presence of the prepuce in different degrees of pathological 
existence is liable to induce them. There is here a very in- 
teresting field of study. Preputial irritation is noted for the 
number and extent of reflex neuroses it induces, and the 
Jewish people are as remarkable for their exemption from 
acute nervous and convulsive diseases. I have also noted, 
during the course of a long practice in genito-urinary surgery, 
that in proportion as the prepuce is liable to act as an irritant 
just in that proportion is usually the patient liable to be sub- 
ject to urethral chill, and investigation has convinced me that 
the disposition to chill on the access of any disease, or mental 
or nervous impression, is as greatly influenced by the pre- 
putial condition, and, strangely enough, Glatter of Vienna 
finds that intermittent fever is one of the forms of diseases to 
which the Jews are not as liable as the Christians. Epidemic 
influences do not affect the Jewish race as they do the other 
races. The plague of 1346 did not affect them; according to 
Fracastor they escaped the typhus of 1505; Ran remarks 
their immunity to the typhus of 1824; Ramazzini noticed 
their exemption to the intermittent at Rome of 1691, and 
Degner says that they escaped the epidemic of dysentery at 
Nimegue in 1736. {Lancet and Obs., Cinn., Vol. XVI., l13.) 
Richardson truly remarks that "From epidemics the Jews have 
often escaped, as if they possessed a charmed life"; he also 
notices the relatively less tendency to suicide among the race. 
Glatter, in his statistical tables, giving to the Semitic race one 
suicide to four in the Germanic and Sclavonic races. (Dis- 
eases of Modern Life.) 
The evidence given by the Moorish race as to phthisis and 
general disease liability, as compared to uncircumcised races, 116 
Southern California Medical Society. 
which in some instances surpasses that of the Jew, shows that 
the exemption is not wholly due, as has been believed, to race 
peculiarity independently. The influence that is exercised by 
circumcision in the immunity to disease, better health and 
longer life among these people, must go for something. In 
the matter of syphilis it does count considerable in protecting 
the individual primarily and the race from heredity second, 
arily. From the careful tables of Glatter of Vienna, the Jews 
are shown to be less liable to diseases; in other words, to have 
more resistance. Every physician who has recognized the 
benefits of and advocated and performed the operation, knows 
full well that he has brought about the same condition of 
resistance to disease in individuals formerly liable to all forms 
and manner of derangement of health by its simple perform- 
ance. Dyspepsia, functional heart and kidney disorders, 
tendency to catarrhal diseases, have often been made to dis- 
appear, and their recurrence averted. That the system being 
continually subject to debilitating influences would be more 
liable to the inception of other diseases must certainly be 
admitted, and it must be equally admitted that when by the 
removal of what Ricord calls " a superfluous bit of skin and 
mucous membrane whose object he could never divine" all 
these deteriorating conditions of health are removed and the 
system brought back to as normal position as possible from 
all departures from healthy physiological conditions, that our 
standard of resistance to diseases is increased and its status 
approximated to that resistance to disease inherent in circum- 
cised races. As before remarked, there are other conditions 
that in the Semitic race assist in giving the wonderful hygienic 
results observable; but circumcision as a powerful factor in 
this condition cannot be ignored. As a last evidence, let us 
look at croup, which generally affects boys. According to M. 
Eisenmann, croup is extremely rare among the Hebrew race. 
Some forms of croup attack children when broken down and 
ill nourished, and will disappear on a proper course of cod 
liver oil, showing its general origin. In some cases I have 
found preputial irritation to have been the cause, as I have 
found asthma at times to depend on the same cause, and the 
tendency removed by an operation. 
In some families phymosis, or an extremely long and narrow 
prepuce, with all its annoyances, is an heredity, and I find 
many such families who regularly practice circumcision. Phymosis and the Prepuce. 
117 
During the discussion at the Ninth International Medical Con- 
gress, on a paper by Dr. Sayre on this subject, a gentleman 
argued that it was wrong and cruel to take an advantage of a 
poor helpless infant in subjecting him to this operation, unless 
there was the most imperative demand. I think it more cruel 
to send the child into the world handicapped in the manner 
that statistics and the present state of medical science teaches 
us that he is. From the first month of life to the end the 
Semitic or Moor has every advantage, not only as to tenacity 
to life but in the enjoyment of health and faculty for occupa- 
tion. The Christian's chances for leaving his children to the 
world's charity by his early death are much greater than those 
of the Hebrew's. As observed by Richardson in his Modern 
Diseases, " that race which presents the strongest vitality, the 
greatest increase of life and the longest resistance to death, 
must in course of time become, under the influence of civiliza- 
tion, dominant; and to-day the Semitic race rule more potently 
than when Solomon in all his glory reigned in Jerusalem." If 
circumcision confers any immunities from immediate ills or 
widely extended dangers, man should certainly have that bene- 
fit, be he Jew or Gentile, and it is certainly a wrong to with- 
hold it. The struggle for existence is a hard one at best, and 
is only made harder for him who is the victim of physical 
infirmities. A man would not for a moment think of letting 
his child go through life with a clubfoot or a strabismus if 
capable of relief by an operation, although these predispose to 
no other troubles; but will strangely shrink from the contem- 
plation of one just as slight but tar more important and more 
far-reaching in its results. Probably superfluous in some 
individual case, but greatly telling in the aggregate as a factor 
in racial health, prosperity and longevity. 
Some years ago the Massachusetts State Board of Health 
instituted a series of investigations tending to solve the prob- 
lem of the causes and nature of the prevalence of inebriety, 
which developed the fact that the use and abuse of intoxicat- 
ing liquors is more or less influenced by geographical limits 
and racial habits and peculiarities. I have, in my own prac- 
tice, noticed the natural or supposed need of stimulants in 
reflex neuroses removed with the disappearance of their cause. 
It is to be regretted that the inquiry was not pushed further 
in the direction of why the Hebrew race, although proverbi- 118 
Southern California Medical Society. 
ally good livers, are noted for their sobriety, whether nationed 
for generations with the convivial Celt, the reserved Goth, or 
the more staid German, their sobriety remains the same. 
That circumcision as a factor must figure in a certain percent- 
age in this respect, cannot be denied, unless we take the 
ground that physical weakness and suffering are not one of 
the causes that lead to the abuse of liquors, a position that is 
untenable. The factors that exempt one class from becoming 
victims to alcoholic or narcotic habits; that makes them in- 
crease in a numerical proportion faster than any other race; 
that gives them immunity from disease, and the strongest and 
longest resistance to death, are well worthy of the study and 
attention of the hygienist. Is circumcision one of these fac- 
tors? What are the other agents that give this race such an 
advantage over all the others? These are questions to be an- 
swered. In the United States we only have one circumcised 
race for study and comparison, but our inquiry can be ex- 
tended to other races who also practice the rite, and thereby 
reach some tangible conclusion. The question should not be 
discussed from a surgical point of view, or from that of mere 
cleanliness, or that of simple protection from venereal disease, 
but on the broad ground of all points of view, as observed at 
the beginning of this paper. With the Hebrew of the nine- 
teenth century circumcision has more significance than a 
simple religious rite, or that of simple cleanliness. It is to be 
regretted that in the United States there is no authentic sys- 
tem of vital statistics, as from the detached observations I 
have been able to make-but all coinciding in results-I am 
convinced that the divergence in hygienic results between 
Jew and Gentile in the United States is far greater than that 
observed in either England, France or Germany. Were our 
vital statistics in any authentic shape a possibility, their 
tabulated results in this regard would create some surprise. 
In the past and ignorant centuries the evident immunity of 
the Jews to epidemics, being ascribed to their compact with 
and protection from the powers of darkness, has more than 
once subjected them to the ignorant fury of their less fortu- 
nate fellow-citizens of other creeds. The enlightenment of to- 
day would, in the face of such glaring difference in results, 
point to the proper source of their better condition, and stim- 
ulate a spirit of inquiry from which mankind could receive 
but good results.