Canadian Medical Association Journal, Volume 95, Pages 576-581. Saturday, 10 September 1966.
Department of Pediatrics, 
Queen's University and the Kingston General Hospital, Kingston, On.
Clinical Fellow, The Hospital for Sick Children, Toronto, Present address: 4000 Yonge Street, Apt 321, Toronto 13, Ontario.
General Practice
One hundred male infants were studied at the Kingston General Hospital, Kingston, Ontario to determine the incidence and complications of routine circumcision. The parents were also interviewed concerning the cause of the operation.
In these 100 infants, complications, usually minor, were very common, and included hemorrhage (35), meatal ulcers (31), infection (eight), phimosis (one) and meatal stenosis.
The reasons given for operation were prophylactic - to avoid the psychological trauma of later operations for infection, phimosis and troubles
(40), cleanliness (11) and phimosis (four). The remaining cases were for social and other non-medical reasons. Attitudes of parents and physicians regarding circumcision varied from firm belief in its value to a casual approach. One half of the babies had partial circumcisions, confirming previous suspicions that non-Jewish males frequently had partial operations. Partial operations do not always guarantees cleanliness and probably do not eliminate the risk of penile carcinoma in all cases, if smegma is carcinogenic. Routine circumcision spare a few children psychologically traumatic operations at a later date and relieve parents of anxiety about the future of the uncircumcised child. This should be balanced against the complications, which, although usually minor, may occasionally be serious.
Between 1961 and 1962, at the Kingston General Hospital, 349 (48%) of 727 male infants were routinely circumcised.
Note:
A GREAT deal of controversy surrounds the subject of routine circumcision. Some have described the operation as a well-secured life annuity
while others regard it as shocking brutality.
The indications for doing it are generally ill defined, the benefits are often difficult to demonstrate, the complications may be significant, yet the operation is frequently performed and is usually regarded as a minor procedure.
Circumcision was discussed at length in 1949 by Gairdner1 in a classic paper entitled The Fate of the Foreskin.
The whole subject was reviewed again in 1951 by Hovsepian,2 later in 1953 by Speert3 and more recently by Weiss.4 Other papers have dealt with particular aspects of the operation.
The present communication describes the experience relative to circumcision in newborn babies in the Kingston General Hospital with particular reference to the incidence of complications of the operation and the reasons why it was performed.
The records of all male babies born in the Kingston General Hospital between December 1961 and November 1962 were reviewed in June 1963. One hundred consecutive male babies born in the latter half of this period, were chosen for further study because their parents were residing in Kingston and the immediate area. In each case the mother was interviewed in her home for 20 to 30 minutes. Both parents were seen whenever possible. The child was examined and the degree of circumcision was assessed by noting how much of the glans was covered by foreskin.
Incidence
In the Kingston General Hospital, between December 1, 1961 and November 30, 1962 circumcision was performed on 349 newborn babies, approximately 48% of all male babies born in this period. In 1952 this procedure was carried out on 50% of all male newborns, hence, the incidence over the 10-year period had not changed.
Except for three ritual circumcisions, all of the 349 operations were performed by 40 doctors, six of whom were pediatricians; one was as obstetrician and the remainder were general practitioners and hospital residents.
The operations were performed either with the Gomco clamp described by Manson5 or the Plastibell
used by Karther and Smith.6 The Gomco clamp is a metal cone which fits over the glans and lies between it and the prepuce. The distal foreskin is then removed. The Plastibell consists of a plastic cone which fits over the glans. The foreskin is stretched over this and a ligature is applied at the base. The distal foreskin is excised. The base of the Plastibell is left in situ; the rest of the cone is removed. This base falls off in a few days.
In the 100 infants selected for special study, 51 circumcisions were performed with the clamp and 47 with the Plastibell. Two operations were ritual procedures. In 25 of the 100 operations, the doctor performed the operation with full sterile precautions, using gloves. Most of the operations were performed when the child was 3 to 5 days old, while was in the newborn nursery. One doctor circumcised 10 babies at birth.
Degree of Circumcision
At follow-up examination wide variation was noted in the degree of circumcision in terms of the length of foreskin that remained after the operations. The degree of circumcision, depending on the length of foreskin covering the glans and exposure of the coronal sulcus, has been divided into four types (A, B, C and D) by Wynder and Licklider7 and into three grades (circumcised, partially circumcised, uncircumcised) by Dunn and Buell.8
TABLE I. DEGREE OF CIRCUMCISION AT FOLLOW UP
Examination Related to Method of Circumcision.
Degree of No of Plastibell Gomco Ritual
circumcision cases clamp
Uncircumcised
(type A)......... 4 __ 4
Partially circumcised
(types B and C)...... 46 23 23
Circumcised (type D). 50 24 24 2
In the present series, 50 children had almost complete removal of the foreskin (circumcised, type D) whereas the glans was almost completely covered by foreskin (type A, uncircumcised) in four cases. In the remaining 46 cases the glans was partially covered by the prepuce (types B and C, partially circumcised). The two ritual circumcisions showed the most complete removal of foreskin. In Table I the degree of circumcision is related to the method of operation. There was no significant difference in the amount of foreskin removed by the two methods of operation.
Complications of Circumcision
The following data on complications include those complications that occurred in hospital and those that occurred after the infant's return to the home.
(a) Bleeding
In 35 infants there was some postoperative bleeding (Table II). Slight bleeding, consisting mainly of oozing, occurred in 31 and in three of these bleeding occurred on the fifth to seventh postoperative day when the plastic ring fell off. In four there was moderate bleeding, sutures being necessary in one of them. Bleeding was more frequent following operations with the Gomco clamp. in no case was bleeding so severe as to require a blood transfusion.
TABLE II. INCIDENCE OF BLEEDING AS A COMPLICATION OF
CIRCUMCISION RELATED TO TYPE OF OPERATION.
Bleeding Gomco Plastibell Ritual Total
clamp
No bleeding. 27 36 2 65
Slight bleeding. 21 10 31
Moderate bleeding 3 1 4
(b) Infection
In eight of the cases, infection occurred at the circumcisional site. The infection was mild in most cases but one child had severe infection and was given antibiotics. In one case the infection was followed by fibrosis and phimosis. Seven of the eight infections developed after the child was discharged to the home.
(c) Meatal Ulcers
Meatal Ulcers were present at one time or another in 31 of the 100 babies, some children had recurrent ulceration. In most cases the ulceration was mild, but in one case it was severe and caused much discomfort to the child. No meatal ulcers were reported in the four babies in whom the foreskin covered the glans.
(d) Meatal Stenosis
Eight of the 100 babies had a pin-hole meatal orifice. Freud9 considers the meatal orifice to be abnormally small if the anteroposterior diameter is 3 mm. or less. Meatal stenosis was found to be commonly associated with meatal ulceration; half the cases of meatal stenosis occured in the 31 children with meatal ulceration. The association between these two lesions was noted in the younger babies (9 to 12 months) and in the older children (13 and 14 months) in this series.
(e) Phimosis
Phimosis occurred in one child who had very little foreskin removed at operation. He developed infection at the circumcisional site which healed by norosis giving rise to the acquired form of phimosis.
In this series the complications were severe infection, meatal ulceration, acquired phimosis requiring a second circumcision, and meatal stenosis. No deaths have been reported at the Kingston General Hospital in association with this procedure in the last 10 years. During this time, 6753 circumcisions were performed on newborn babies and 589 circumcisions were carried out on older children.
Reasons for circumcision
Various reasons were offered for circumcising the baby. (Table III). Forty babies were circumcised to avoid a later operation, while for 10 cases the procedure was performed for cleanliness.
In seven instances the parents thought it was desirable to match
(i.e., all boys should be circumcised) the child with siblings and with the condition of their friends and relatives.
TABLE III. - REASONS OFFERED BY PARENT FOR CIRCUMCISION OF
100 BABIES.
---------------------------------------------------------
Reasons offered for circumcision No of
cases
---------------------------------------------------------
Hygiene, cleanliness.......................... 10
Other people, i.e. friends, relatives and
their children,[17] father and sibling had
required the operation later in life.......... 15
The child may need the operation later for
infection,[1] phimosis[1] and other
"troubles"[9]................................. 15
Other circumcised people i.e. siblings,[4]
father,[1] relatives and friends are having
"trouble"..................................... 10
The child should "match" siblings and
other children................................ 7
Relatives advised the operation............... 8
It is "done automatically".................... 4
The doctor advised it for "tight skin"....... 4
The operation prevents masturbation........... 2
The operation prevents rupture................ 2
The woman's magazines advise it............... 2
Ritual........................................ 2
Other reasons................................. 10
--------------------------------------------------
Relatives were responsible for advising the operation in eight cases while in a further two children the mother was guided by the advice of women's magazines. Four mothers thought the operation was done automatically
and in a further four cases the doctor advised the operation for a tight skin.
Prevention of masturbation or rupture
was given as the reason for four operations. There were two ritual procedures.
Other reasons included the following: it was necessary for fertility; it was a requirement for admission to the armed forces; it looks better
; it is a good and proper thing to do
; it was a routine procedure in the parents' country of origin; the woman's magazines informed the reader that carcinoma of the cervix was rare in the wives of circumcised men; it prevented excessive crying; it prevented urinary obstruction in old age; and it avoided difficulty with micturition in childhood.
Decisions and Attitudes to Circumcision
The role of the mother. In 74 cases the mother made the decision for operation. Mothers frequently had very firm views on the the subject; in 33 cases they would have insisted on the operation. Twenty-six mothers had not discussed the subject with their husbands, complaining that the latter were indifferent or insisting that it was a woman's business. They frequently discussed the subject with friends relatives and neighbours and sought information from baby books and women's magazines.
Two of the mothers were trained nurses who had witnessed adult circumcisions, while a third mother was taught at the nurses' training school that the operation should be done routinely.
Mothers seemed uncertain about their ability to teach cleanliness to the child and were doubtful of his cooperation. The mother who had not for some reason, had an older sibling circumcised, seemed anxious about the future of that child. She wanted to be reassured that he would not develop a rupture in childhood, masturbate later, become infertile in adulthood, or develop urinary obstruction in his old age.
The role of the father. Fifteen fathers made the decision for circumcision. Six of them were in some way connected with the army. Most of the fathers had witnessed adult circumcisions or had undergone the operation themselves as adults. In some cases the mother had been warned not to bring the boy home uncircumcised. In general, however, the role of the fathers was indifferent.
The role of the doctor. In 11 instances the doctor was responsible for the decision. Parents discussed the subject with their doctor in 84 cases. In a few instances the doctor disagreed with the parent, but generally he tended to go along with the parents decision; three doctors were firmly opposed to the operation. The doctors clearly influenced the incidence of circumcision, since those who opposed the operation circumcised 20% of their patients, those who favoured the procedure operated on 100% of their patients, and the doctors who thought that the decision was best left to the parents operated on 50% of their newborn patients.
The incidence of circumcision varies with different countries, year of birth, racial groups, social levels, and religious groups.
The operation is rarely performed in most European countries, China, and some other Far Eastern countries. It is very popular in the United States, where according to the medical literature the incidence varies from 60% to 97%.
Dunn and Buell8 have shown that the present high incidence of circumcision in the United States is a recent phenomenon; they found that 8% of males born before 1870 were circumcised, compared with 56% for those born after 1910. The effect of year of birth on the incidence of circumcision was also demonstrated by Doll and Hadley10 in Britain, who found that the incidence among merchant seamen was 19% for those born in 1914, whereas it was 22% and 30% for those born in 1924 and 1930 respectively. There seems to be a reversal of this trend in Britain, since at the present time few babies are circumcised in that country.
The incidence of the operation also varies with racial groups. Schrek and Lenowitz11 demonstrated that early circumcision is more frequently performed in Negroes than in white men; also that this high incidence was decreasing among Negroes, since fewer coloured veterans of World War II were circumcised than veterans of World War I.
The operation tends to be more popular in the higher socioeconomic groups. Carne12 in Britain, found that boys who attended grammar and public schools were far more likely to be circumcised than were those who attended private schools. Speert3 reported that 74% of private patients were circumcised, compared with 57% of staff patients.
The operation is common among Jews and Moslems for religious reasons.
In our series about 50% of newborn babies were circumcised; there has been no change in the incidence during the past decade. We also found that private patients were more likely to be circumcised than staff patients.3 The incidence of circumcision was influenced by the doctors' attitude to the operation.
An interesting finding in the present study was the variable degree of circumcision. Dunn and Buell8 observed that Jewish males probably had a maximum degree of anatomically complete circumcision. This degree was observed in less than half of non-Jewish males who considered themselves circumcised. Fifty per cent of babies in our study had complete circumcisions, as compared with 48% of men studied by Dunn and Buell.8 A recent study13 from Macedonia indicates that the operation tends to be more complete among Moslems in Macedonia, since 95.8% had complete circumcisions. The degree of circumcision may be some importance in relation to cleanliness and carcinoma of the penis. Wynder et al.14 found that 13 of 31 Moslems in Madras, most of whom had incomplete operations had slight smegma present on the glans. Some mothers in the present series expressed dissatisfaction with the operation, maintaining that they and their child had not been relieved of the bother of cleanliness.
Although experimental evidence has given conflicting results,15,16 many authors17-19 believe from their direct clinical observations, that smegma is an irritant agent, responsible for carcinoma of the penis. Jewish males who generally have complete circumcisions have almost complete immunity to this neoplasm; two cases of carcinoma of the penis in circumcised Jews have been reported in the literature. In the United States, Wolbarst17 was unable to find a case of carcinoma of the penis among 1103 Jewish men with neoplastic disease and similar findings have been observed in Israel. In contrast to Jewish males, Moslems not infrequently have incomplete circumcisions14 and they appear to be less protected from this disease. They do, however, have a lower incidence of this disease than the uncircumcised Hindu neighbour. Wolbarst,17 reporting on 1336 cases of carcinoma of the penis from Indian hospitals, found that 26 patients were Moslems whereas 1303 were Hindus, despite the fact that the average Moslem population in these hospitals was 21%. Similar observations were also noted by Kennaway.19 Degree of circumcision may not be the only factor responsible for these variations. The age at which circumcision is performed may be another factor responsible for the difference in the incidence of this neoplasm between Moslems and Jews; the former circumcise their children between 4 and 9 years, the latter on the eight day of life.
Note:
Complications of circumcision have occurred in almost all reported series but their incidence varies widely, partly because the different series have not been strictly comparable. Gairdner reported excessive hemorrhage in 3.8% of cases, whereas Moeller and Moss20 found not cases of severe hemorrhage in 2400 circumcisions performed immediately after delivery. Kariher and Smith6 found no bleeding in 600 babies operated on with Plastibell immediately after birth, yet Hovsepian,2 also operating at the same time in most of his 1878 cases, reported bleeding in 15% of cases. One child required sutures to control the hemorrhage; none needed a transfusion.
Postoperative infection occurred in 8% of our cases. Seven of these children developed the infection after discharge from the hospital. This may account for the discrepancy between our figures and those reported by other authors; Hovsepian2 and also Moeller and Moss20 reported no cases of infection in their series, while MacCarthy, Douglas and Mogford21 found nine cases of infection in 443 operations.
There was one child with postoperative phimosis in this study compared with seven out of 443 children reported by MacCarthy, Douglas and Mogford.21 Most authors regard meatal ulceration as a complication of circumcision. The lesion was surprisingly common, being present at one time or another in about one-third of the babies in this series.
Eight babies in the present series had meatal stenosis, the lesion being somewhat more common in the older than the younger babies. Berry and Cross22 found that severe meatal stenosis occurred more frequently in circumcised boys age 12 to 18 months than in uncircumcised boys in the same age group, the incidence being 10% and 3%, respectively. Innes-Williams23 and Berry and Cross regard the stenosis as secondary to the ulceration, whereas Campbell24 and Freud9 consider that meatal stenosis is the chief factor predisposing to meatal ulceration and a meatotomy may cure the ulceration.
In the present series, 55% of the children had some type of complications, varying from slight oozing of blood to phimosis needing recircumcision. This incidence of complications is considerably higher than reported by others. It may be due to the age at which the operation was performed (third to fifth day after delivery), the inclusion of all degrees of hemorrhage and all complications which occurred after the baby was discharged to the home, and the collection of data by personal interview rather than a mailed questionaire, telephone inquiry or outpatient records.
In addition to comparatively minor complications occurring in this series, other authors have reported more serious sequalae, such as urethral fistula, amputation of the penis, gangrene of the penis, avulsion of the scrotum, removal of material best suited for plastic repair of hypospadias, septicemia and death. Speert3 reported that approximately 566,483 babies had been circumcised in New York between 1939 and 1951, with one death. In Britain, Gairdner1 found 16 deaths attributable to circumcision among 90,000 children under the age of 5 years. The deaths were mainly due to anesthesia, hemorrhage and infection, while a few were unexplained.
Since the operation is not free of risk, it is understandable that the question arises why it is performed.
Forty operations were requested to avoid the need for later circumcision which parents considered was painful, psychologically traumatic and in older children and adults embarrassing. Some of the prophylactic operations were supposedly performed to preclude infection and phimosis, but a large number were done to forestall vague, unspecified future troubles.
True phimosis is a relatively rare condition, and paraphimosis is generally due to premature forceful retraction of the foreskin by the mother. Gairdner1 found that normally the foreskin was retractable in only 4% of newborns, but that by the age of 4 years 90% of boys had a fully retractable foreskin. There is no way of knowing in the newborn period who will need the operation later for true phimosis. Since true phimosis is rare and its early recognition virtually impossible, opponents of the routine use of this operation maintain that there is no justification for using this as a reason for operating on a large number of children who normally would not require this operation.
Cleanliness is frequently considered as an argument for routine circumcision. This has featured prominently in this study, as in other series. The following comment by Pugh,25 after he had interrogated 1000 men regarding instructions in penile hygiene, is worthy of note: The answers indicated that this was largely omitted from instructions regarding personal hygiene, one of the effects of taboo, down through the centuries, so that circumcision came to be recommended to overcome the ill consequences of precepts that certain parts must not be discussed.
The mothers of some patients in the present series thought that the operation would make it easier to maintain cleanliness but the majority of the believed that it would relieve them and the child of the bother of cleanliness.
It is evident that the operation as currently performed will hardly guarantee this. If circumcision is to provide cleanliness and not merely facilitate it, the operation should be complete. It is generally the lower social economic group who are notoriously reluctant to practise cleanliness, and Elliot26 has therefore suggested that an early and complete circumcision is best applied at this level where continued hygiene is unlikely to be obtained otherwise.
Some parents considered that there must be conformity among boys and thus had the baby circumcised so that he would match
with his siblings and other boys.
It was of interest that one boy was circumcised because of the low incidence of carcinoma of the cervix uteri in the partners of circumcised men. Medically the strongest argument for circumcision is the reduction in the incidence of carcinoma of the cervix uteri and carcinoma of the penis. Both of these neoplasms generally occur more frequently in the lower socioeconomic groups with poor penile hygiene. An earlier study by Wynder et al.14 and a more recent investigation reported by Terris and Oalmann27 suggested a relationship between carcinoma of the cervix and circumcision. Other studies,8,28 however, have not as yet confirmed that there is a direct relationship between circumcision and carcinoma of the cervix uteri. In a study of neoplastic diseases in Bombay,30 carcinoma of the cervix uteri was more frequently found in Moslem than in Parsee women, yet the latter have uncircumcised partners. It is known that Parsees are fastidious about personal hygiene. The role of circumcision and cleanliness in relation to carcinoma of the penis was carefully studied by Schrek and Lenowitz,11 who concluded that this neoplasm could be prevented by early circumcision or good penile hygiene.
The many other reasons that parents offered for having the operation scarcely reflect a proper medical need. Perhaps the most remarkable finding in the present study was the variety of attitudes to circumcision adopted by both parents and physicians. A few doctors were opposed to the operation, but in general the attitude varied from firm belief in the necessity for the operation to a completely casual approach. This agrees with recent findings of Shaw and Robertson,31 who circulated a questionnaire on reasons for circumcision to physicians and parents and concluded that their survey casts reasonable doubt on the belief that the decision -
These authors also found , as we have, that the majority of parents had never discussed the matter with their physicians and that their decisions were influenced more by social and cultural factors, often without foundation, than by medical advice. This situation is understandable, perhaps, in view of the lack of objective information about circumcision.pro
or con
- is reached in any scientific manner.
It seems that the routine removal of the foreskin in all newborn babies may spare a few children the possible psychological trauma of a late operation. It will also relieve a large number of parents of their anxiety, concerning not only cleanliness but a host of other conditions which they believe will apparently befall the uncircumcised boy. This has to be balanced against the complications of circumcision which are generally relatively minor but on rare occasions may be unpleasant and serious.
It is obvious from this study that there is a need for guidance of anxious, confused and misinformed parents. Information on most aspects of infant care and feeding is readily obtainable, yet little information is available on circumcision - an observation noted by some mothers.
Experience of circumcision in a general hospital has been reviewed. One hundred circumcised children were followed up and examined, and one or both parents were interviewed.
It was found that about 50% of all male babies born in the hospital were circumcised in the newborn period. The operation was performed by the Gomco clamp or the Plastibell technique, usually on the third to fifth day of life.
There was a wide variation in the amount of foreskin removed. After operation the foreskin partially or completely covered the glans in 50 cases.
A number of postoperative complications were encountered, including hemorrhage (35), infection (eight), meatal ulceration (31), phimosis (one) and meatal stenosis (eight). Most of the complications were minor.
Enquiry into the reasons for circumcision indicated that the operation was frequently performed to prevent the need for a later circumcision or for cleanliness. A large number of operations were carried out for reasons not based on medical facts.
Some physicians opposed the operation but in general the attitude of the physician and the parent varied from firm belief in the value of circumcision to a casual or indifferent approach.
The study revealed the need for guidance of confused or anxious parents.
I wish to thank Dr. M. W. Pattington for his constant advice and encouragement, also Drs. Alex. Bryans and D. Delahaye for their assistance. My appreciation is due to all the doctors who permitted me to study their patients and to all the patients who kindly co-operated in this study.
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