( Originally Published 1940 )

THIS is an operation which is often required in males during early childhood in consequence of the smallness of the aperture in the above-mentioned fold of skin, which tends to impede the excretion of urine. Lack of hygiene is often the first cause.

As long as the contraction has not proceeded too far, one can always, before having recourse to an operation, thoroughly clean, disinfect and heal up the nearly closed space between prepuce and glans, by injecting a suitable fluid into the cavity. One should choose non-irritant and preferably astringent antiseptic lotions, e.g., lead water (Goulard's water) or a one per cent. solution of alum (one tablespoonful of alum to two pints of water) The injections are best performed with a bulbous syringe, having the canula slightly enlarged at its end. By introducing such a syringe between prepuce and glans and grasping the folds of skin round it with the hand, one can use the same liquid several times by injecting it between the prepuce and glans and letting it run back into the syringe. The action of the fluid may be reinforced by external massage. By this means, one may effectively clear the cavity: of course, one should avoid making fresh erosions.

Such local cleansing is all the more important because the collected dirt is liable to cause burning and itching, a fact which is possibly one of the most frequent causes of masturbation in children.

If the trouble has, however, gone too far, an operation will, in the end, be indispensable. The surgeon generally performs the operation as a real circumcision, by removing a circular portion, similar to the ritual circumcision among the Jews, for if the preputial ring is split lengthwise with the scissors, the desired widening of the lumen is at once obtained, but later on it will most likely grow together again in spite of any attempts to avoid it.

Circumcision is of great value as a surgical measure in pathological cases. It has a wide distribution ethnographically as religious ceremony among several tribes and races. Frequently it is devoid of any religious significance and is employed mainly as a means of beautifying or improving nature. We have mentioned some of the ceremonies of puberty above.

The ordinary circumcision of boys as a rite of puberty is not contrary to nature, as nature herself exposes the glans as puberty approaches. It must have been a device originally to help nature a little. An entirely uncovered glans was considered a sign of fertility and in Genesis XVII the promise of a numerous progeny is bound up with ritual circumcision.

While performing circumcision according to rule, the rabbi endeavours to produce as large an erection of the small penis as possible, while murmuring prayers and formulae. This is a necessary proceeding, as otherwise he could not be sure where the glans commences. If by mischance a portion of it should be removed, death through haemorrhage would almost certainly ensue.

By drawing the prepuce towards him, he then cuts it off with out damaging the glans. The latter he avoids by grasping the prepuce as close to the glans as possible with a forceps and by cutting along it. The glans is then further exposed and the whole bandaged, aseptically or better antiseptically, e.g., with iodoform gauze. In a few days' time the skin cut will have healed up.

There will be no loose fold of skin enveloping the glans. There will, however, be sufficient skin for an adult erection since only the outer portion of the foreskin which protrudes beyond the glans has been removed. The remainder will fold itself behind the margin of the glans.

The erection produced so soon after birth in all boys, and the permanent uncovering of the glans, whereby it is to a far greater extent exposed to touch, friction, and stimulus, together with a frugal and domesticated life, must have contributed very largely to the great increase and wide distribution of the Jews. In those days, when a high birthrate was a condition of existence on account of wars and as compensation for the high infantile mortality, they became by this means victorious in the struggle for existence. The prophecies linked up with circumcision have come true.

Circumcision entails other hygienic advantages of great importance in the struggle for existence. After this operation the collection of dirt in the preputial cavity is entirely impossible, for it no longer exists. It can therefore never become the site of venereal and other diseases which always menace the existence of the race. On the contrary the skin of the glans will now always be dry, a fact which ensures an adequate resistance against all harmful influences. May this serve as a warning for uncircumcised individuals to endeavour to obtain by cleanliness the advantages they have missed through not having had this operation performed.

In order to show the importance of this point in the hygiene of the race, I shall, as a practicing physician, add a chapter on hygiene.