Why Circumcise?

A MEETING of the Melbourne Pædiatric Society was held at the Children's Hospital, Melbourne, on Wednesday, November 12, 1952.

DR. JOHN D. BEGG read a paper entitled Why Circumcise?. He said that the operation had been performed in many countries since time immemorial, but it was extraordinary how little was known of the origin and purpose of the ancient custom. It was performed in Egypt at least 4000 years. B.C., probably even earlier still, and was practised as a cult among the primitive peoples of such widely separated countries as Africa and the North American continent and among Australian aborigines. It had been a Jewish custom to circumcise on the eighth day after birth since early Biblical times, and although the Koran did not specifically ordain it, all Moslems were circumcised. It was a mystery why mankind, down the ages, should have shown such a strong aversion to the retention of a useful cutaneous appendage; for, despite the enormous literature on the subject, very fully dealt with in Hasting's Encyclopædia of Religion and Ethics, there was little real knowledge of the significance of the ancient rite.

It was tempting to ascribe a hygienic motive to the procedure, but a critical view analysis of the literature does not support such a view. Even if the view was found to be empirically correct, it could scarcely have been the original motive that prompted the Egyptians to circumcise their young. Gray, in the Encyclopædia of Religion and Ethics, concluded his summary by finding that in its inception, and late into its development, circumcision was essentially a religious custom, embracing in its broadest sense several concepts of an ideological nature. Thus, it might signify a sanctification of the reproductive organs, ensuring abundant fertility; it might be related to the ancient idea of human sacrifice-sacrifice of a small portion of the body as a propitiation of the Deity to protect the whole; or it might serve as initiation of the youth into the full manhood of the tribe.

With primitive peoples the operation was usually carried out to the accompaniment of various ceremonials, often of a cruel and revolting nature; but in contradistinction to these, one Australian tribe performed a mock ceremony before the candidate, flourishing a large wooden knife, but leaving him untouched. That it had a deeply religious significance to the Jews was, of course, a matter of common knowledge, but whilst one maintained ancient usages, it was reasonable to examine critically a procedure which although performed as a religious rite by one section of the community, was also carried out very frequently for supposedly surgical reasons by another.

Circumcision was performed on some 75% of male children born in Melbourne's private maternity homes, and although it was not performed routinely at the Women's or the Queen Victoria Hospital, many of the babies born in those institutions were later subjected to the operation at the Children's Hospital, or else at the pæ departments of the Alfred, Queen Victoria, Prince Henry's and Saint Vincent's Hospitals, as well as at the hands of private medical practitioners.

Figures revealed that in the hospitals mentioned nearly a thousand babies were circumcised annually; but as about six thousand boys were born annually in Melbourne's two major public maternity hospitals, even if allowance was made for circumcisions performed by private practitioners, the incidence of the operation was very much lower than in those of the higher income groups who attended the private institutions where three-quarters of the male babies were circumcised. Gairdner, in the British Medical Journal of December 24, 1949, in making a comparison between children attending the best known public schools and those attending state institutions, had stated that either the boys of well-to-do parents are suffering circumcision much too often or those of the poorer parents not often enough.

Dr. Begg then discussed the development and function of the prepuce, as described by Gairdner. He said it developed as a ring of thickened epidermis growing forward over the glans, and during its development, which was frequently incomplete at birth, the squamous epithelium lining the inner surface of the prepuce and the outer surface of the glans was fused into one single sheet. According to Deibert, a separation into two separate linings took place by the epithelium arranging itself into whorls, in the centres of which degeneration occurred. The fusion of these degenerate areas ultimately formed a continuous sub-preputial space. The process, which was seldom complete at birth, might be arrested at any stage of its development. Thus, again, according to Gairdner, only 4% of babies had a fully retractable foreskin at birth, only 25% at six months, and 50% at the end of the first year. At the end of the second year. At the end of the third year, however, 90% of children would have a retractable foreskin; so that it was obviously fallacious to regard non-retractability of the foreskin at birth as synonymous with phimosis. Even those which could not readily be retracted at the age of three years could usually be rendered easily retractable by the separation with a probe of the residual strands of undegenerated epithelium still persisting between the inner preputial layer and the outer layer of the glans. Dr. Begg said that he had no accurate figures with which to confirm the statistics, but eleven years of observation in a provincial town where very few babies were circumcised had convinced him that true phimosis must be a very rare condition.

Note:

The values regarding age of foreskin retractability provided by Gairdner in 1949 recently have been shown to be incorrect. See the recent  letter at the Medical Journal of Australia for more information.

The function of the prepuce seemed obviously to clothe and protect the sensitive glans, not only during the early years of incontinence when the organ was in contact with urine-soaked clothes, but throughout life as well.

Like other surgical operations, circumcision carried an operative risk. The risk was admittedly small, but hæmorrhage, sepsis, and anæsthetic accidents could occur, whilst, as the operation was frequently performed by practitioners of little surgical skill, mutilation of the organ was unfortunately by no means rare. The figures for Australia were not readily available, but for the five-year period from 1942 to 1947, an average of sixteen children died annually as a direct result of the operation in England and Wales. There was every reason to believe that a proportionate mortality would prevail in Australia.

Contact of the delicate tip of the glans with ammonia-soaked clothes not infrequently led to ulceration of the urethral meatus, and that, apart from being exceedingly painful, was at times difficult to heal and could even lead to a meatal stricture. That complication of circumcision was particularly likely to occur in a child whose prepuce had become redundant from ammonia irritation-an appearance which unfortunately was regarded by some doctors as a particular indication for circumcision. Removal of the foreskin in such circumstances had been likened by a contributor to the British Medical Journal some years previously to a soldier taking off his tin hat when the shrapnel was falling; the irritation was transferred to the meatus with the inevitable result.

Dr. Begg then proceeded to examine the reasons given by parents for requesting that their child be subjected to the operation, and mentioned that inquiries from the nursing staffs of maternity hospitals revealed that the majority of babies were circumcised at the request of their parents and not at the advice of their doctors. Dr. Begg said that in his experience in questioning mothers of newborn babies on the reason for requesting circumcision, by far the most common reason given-and this was confirmed by nursing staffs-was that the father wanted it done. The information was imparted by the mother with a slightly mysterious air as if questioning that anyone should doubt the paternal wisdom. On being further questioned, most would volunteer that they thought it prevented the child from wetting the bed or that it prevented in some mysterious way the development of venereal disease or the habit of masturbation. No doctor these days would seriously regard circumcision as a cure of enuresis, whilst, if the psychiatrists were to be believed, masturbation occurred in both sexes, and appeared to have no relation to the presence or absence of the prepuce. Venerologists agreed that the circumcised man who contracted syphilis or gonorrhœa was easier to manage, but there was no real evidence that the operation in any way lessened the incidence of those diseases. The matter was of still less importance at the present time, with chemotherapy and the greatly lessened incidence of venereal disease in general. Cleanliness was another reason given by parents, and it was in regard to that that a considerable misconception existed amongst both medical and non-medical people. It was true that smegma, the main source of which was generated epithelium lining the glans and prepuce, together with a variable amount from minute secretory glands near the frænum, did collect in the retrocoronal sulcus, but in the young child it was non-odorous and entirely harmless. Later, as mild decomposition of the smegma might occur, and as infection might then be added, it was wise to take steps to remove it. At the stage when that was likely to happen, however, separation of the two layers had taken place, and the foreskin, if not readily retractable, could easily be made so. Miscellaneous reasons, such as we believe in it and the frankly feminine one, it looks nicer, were occasionally given.

Circumcision, therefore, though sometimes advised by the obstetrician, was more often performed by him to satisfy the parental wish. If non-retractability of the foreskin at birth was regarded with equanimity, it would be found that in time the vast majority of foreskins were so easily retracted as to fall within the scope of all but the most incapable.

It appeared to be an indisputable fact that carcinoma of the penis was virtually unknown in those circumcised before the age of five. It did, however, occur occasionally in Moslems who were circumcised between the sixth and the fourteenth years, but less commonly than in the uncircumcised. Thus Kennaway, in the British Journal of Cancer, comparing the incidence of the disease in Moslems with that of Hindus, among whom the operation was taboo, in fourteen hospitals in India, showed that the ratio of penile cancer to male cancer in Hindus was a high as 1:3.9, while that in Moslems was only 1:34.3. He suggested that failure of the operation until the fourteenth year to confer the immunity produced by that performed in infancy, was due to carcinogens retained in the coronal sulcus, and if carcinoma of the penis was a common disease, there could be a very potent argument in favour of universal circumcision at an early age. The disease, however, was not a common one, particularly in western countries. An average of 6.3 cases annually were met with in Melbourne's public hospitals over a five-year period, representing only 0.3% of male carcinomata in general. Furthermore, it usually occurred in persons with a low standard of personal hygiene, and was almost always associated with true organic phimosis. Accordingly, a disease whose main incidence was after the sixth decade of life, and which was probably as easily prevented by simple attention to cleanliness as by circumcision, could not be cited as a convincing argument for subjecting every baby boy to the operation.

In conclusion, Dr. Begg summarized his paper by saying that circumcision, commencing as an expression of primitive man's religious emotions, was carried on largely as a response to a widespread public demand. That demand was based on a misconception of the benefits conferred by the operation, which in the great majority of children is unnecessary. As unnecessary surgery was bad surgery, the time has come when the profession should deprecate its widespread performance in infancy except for religious reasons. Indications for the operation existed only if, after the first few years, true phimosis was found to be present.

In short, the answer to the question which formed the title of the paper, Why Circumcise?, must be found in many cases Why indeed?.

DR. F. STONEHAM said he agreed with Dr. Begg. Phimosis could be corrected by dilatation of the foreskin with sinus forceps in most cases and circumcision was not necessary.

DR. J. FARBER said that at birth the prepuce could be retracted in certain infants but not in others. He had been surprised at the number of infants whose prepuce was not retractable at birth, but was easily retractable two to three months later.

DR. M. L. POWELL referred to the advisability of circumcision in some cases in the tropics as a means to reducing dermatitis of the prepuce and glans penis. He wondered if that fact had any significance with regard to religious rites amongst Moslems.

Dr. Begg replied that during the last war circumcised serviceman had certainly suffered less dermatitis of the penis, and he agreed with Dr. Powell that might have been the basis of circumcision in some religions.

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