Tuberculosis following Ritual Circumcision

Milton H. came to our notice at the Vanderbilt Clinic on November 1, 1916 at the age of nine weeks. On the eighth day he was circumcised 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 previously circumcised 2 other boys in the same family ; the boys are respectively seven and five years of age are both well.

Physical examination of the child was entirely negative; the spleen was not enlarged; the lungs were negative; the inginal glands in the right groin were enlarged; the whole mass being about the size of the small 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 scrutiny we could see four small tubercular masses (each separate and distinct—about one-eight 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 one obtained the feeling not unlike that of shot under the skin; they felt hard and indurated. We excised the largest of these tubercular masses, and microscopic examination by Dr. Willensky 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 (from 1011—119) and never had any fever. Excision of the tuberculous tissue of the penis and the inguinal glands on both sides was recommended. Tuberculidesof the skin were not present.

A review of the literature shows that there are reported 42 cases (including our case) of tuberculous infection following ritual circumcision. The incidence of such infection must have been greater and many cases have probably not been reported. It seems reasonable to suppose that the same operator (mohel) would probably infect a majority of the infants on whom he performed circumcision; because the tubercle bacilli is found fairly constantly in the mouths of tuberculous patients. We were anxious to follow up every infant who was circumcised by the mohel in the last year, but on inquiry we learned that our patient was the only one operated on by him in the last eighteen months; and this was done only at the urgent request of the mother.

 

 

In 37 cases the wound was sucked in the usual way; in 3 the wound was sprinkled with wine from the mouth of the operator; in one a dressing was applied to the wound on which wine from the mouth of the operator was poured on; in our case the wound was aspirated through a glass tube.

In two of the cases there was a history of tuberculosis in the family (mother and grandfather respectively); however, in every case the mohel presented evidence, clinical or bacteriological, of tuberculous infection. Tubercle bacilli were found in the sputa of four operators (cases of Elserberg, Debrovitz, Holt, Reuben).

The first symptom is infiltration and ulceration of the wound area; in the majority of cases ulceration and infiltration had developed after the circumcision wound had completely healed (Lehmann, Eve, Reuben). The infiltration takes place from seven to fourteen days after the operation in the form of small, hard, indurated tubercular masses, which gradually ulcerate; the ulceration usually begins at the frenum and is progressive; it may extend to the abdomen; in one case it led to total gangrene and destruction of the glans. The earliest ulceration was observed in the case of Holt (on the seventh day).

From two to eight weeks after operation, enlargement of the inguinal lymph glands takes place; the enlargement is usually greater on one side than the other; gradually these glands enlarge and soften; suppuration due to mixed infection takes place and in the majority of cases within two or three months after infection they break down.

Systemic infection rarely occurs before the fourth month after the circumcision. Without a single exception every case, whether it recovered or died showed tuberculous involvement of other tissues, glands or organs. The systemic manifestations of tuberculous infection infection were in the form of tuberculous spondylitis dorsalis, tuberculosis of radius, tuberculosis of hip and pelvis, tuberculous mastoiditis, pelvic abscess (cold), tuberculous cervical adenitis, cold abscess of abdomen, cold gluteal abscess, tuberculosis of knee, etc.

Of the 42 cases reported, 11 recovered, 16 died and of 15 the final outcome is not known. Death usually takes place at about one year of age; the earliest death reported is in the case of Holt, at the age of three and one-half months; the oldest death reported was at 3 years from a tuberculous spondylitis complicated by a compression myelitis.

The cases that apparently recover invariably show tuberculous manifestations of bones or glands in later life; in these cases the ulceration on the penis and the suppuration of the inguinal gland usually continue and do not heal for from four months to four years after circumcision.

The prognosis is best in those cases in which early suppuration of the inguinal glands takes place and which are operated on by curetting or excision.

In the days before the tubercle bacillus was isolated, the diagnosis was made on a clinical basis. In the cases of Elsenberg, Debrovitz, Meyer, Hofmokl, Ware, Kakles, Finney, Arluck, Holt and Reuben, sections or smears from involved tissues showed the tuberculous nature of the disease. In the case of Eve, pus from the wound was injected into a guinea pig which promptly died of tuberculosis. The von Pirquet reaction of the infant was positive in the cases of Kakles, Holt and Reuben; the von Pirquet reaction was negative in the case of Arluck (due to exhaustion of infant). Tubercle bacilli were isolated from tuberculides of the skin only in one case. (Holt).

Autopsies were performed on the cases of Arluck and Holt. In both cases general miliary tuberculosis of all the organs was found. There were found tuberculosis of the lungs, bronchial glands, the liver, the spleen, the mesenteric glands, tuberculous ulcers of the intestine, tuberculosis of the brain, mediastinal glands of the heart, of the coronary artery, of the peritoneum, of the bladder, etc.

The course of the disease may be described as follows: From seven to 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 the other; in the majority of cases these glands suppurate and break down. The majority of cases these infants die at from three and one-half months to three years after the infection; the most common causes of death are tuberculous meningitis or general miliary tuberculosis; those who recover invariably present other manifestations of tuberculosis in later life (tuberculosis of bones, lymph gland, cold abscesses). The treatment of these cases is early excision of the tuberculous tissue of the penis and the inguinal glands on both sides.

 

 

* Read at the New York Academy of Medicine, Section on Pediatrics, December 14, 1916.

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