THE CIRCUMCISION REFERENCE LIBRARY
Meeting of December 15, 1916.
ROYAL STORRS HAYNES, M. D., in the Chair.
DR. MARK S. REUBEN reported a case of
This patient came to our notice at the Vanderbilt Clinic on November 11, 1916, when he was nine weeks old. He had been circumcised on the eighth day by a mohel who aspirated the wound by means of a glass tube. Within a week the entire wound of the circumcision had healed. Five weeks after the circumcision had been performed the mother noticed a swelling in the right groin and it was for treatment of this swelling that the infant was brought to the clinic. The same mohel who circumcised the patient had circumcised two other boys in the same family; these are respectively seven and five years of age and are both well.
Physical examination of the patient was entirely negative; the spleen was not enlarged; the lungs were negative. The inguinal glands on the right side was enlarged; the whole mass being about the size of the little finger. There was also swelling of the left inguinal glands but not to the same extent as on the right side. Examination of the penis on casual observation, presented nothing abnormal; the circumcision wound had completely healed; there was no ulceration. On closer inspection we could see four small tubercular masses, each one separate and distinct and about one-eighth of an inch in diameter, on the anterior surface of the circumcision scar; the frenum was entirely free of any infiltration. On palpation of these little masses, not unlike that of buckshot under the skin, they felt hard and indurated. We excised the largest of these masses and microscopical examination by Dr. Wilensky showed that the tissue was infiltrated with numerous tubercles and diffuse tuberculous inflammatory tissue. The von Pirquet reaction of the infant was positive. Examination of the mohel showed that he was suffering from advanced tuberculosis and his sputum was loaded with tubercle bacilli. In the two weeks after we had first seen the infant it had gained about one pound in weight (10 pounds 11 ounces to 11 pounds, 9 ounces) and never had any fever. Excision of the tuberculous tissue of the penis and the inguinal glands on both sides was advised and will soon be carried out. Tuberculides of the skin were never present though they were looked for.
In the literature there are reported forty-two cases of tuberculous infection following ritual circumcision; of these twelve recovered and sixteen died, and of fourteen the results are not known. The most common cause of death in these cases is tuberculous meningitis or general miliary tuberculosis; those that die usually do so in six to twelve months after infection. The most rapid course was observed in a case of Holt's, in which the child died three and one-half months after infection. Those that recover invariably show other tuberculous manifestations in later life.
The course of the disease may be described as follows: From fourteen days after circumcision, the wound, which in the majority of cases does not heal, ulcerates and begins to discharge pus; from two and one-half to eight weeks after the circumcision the inguinal glands become enlarged on one side usually more than on the other. In the majority of these cases the glands suppurate and break down. The majority of these infants die in from three and one-half months to three years after infection, from tuberculous meningitis or general miliary tuberculosis. Those that recover invariably present other manifestations of tuberculosis in later life (tuberculosis of bones, glands, cold abscesses). The treatment of these cases is early excision of the tuberculous tissue of the penis and the inguinal glands on both sides.