|British Medical Journal: A ritual operation|
British Medical Journal, 1949
Editorial: A ritual operation
Little is known of the origin of circumcision, despite the very considerable literature on the subject. (1) At its inception the practice seems to have had an essentially religious connotation and to have arisen independently in the continents of Africa, America,* and Australia. Among the Semitic races it is probable that circumcision started as act of consecration to the goddess of fertility with the object of winning her favour and thus ensuring the birth of children. Circumcision in ancient Egypt was certainly not undertaken for hygienic reasons, and probably it served as a sanctification of the reproductive faculties and a ceremonial initiation. It is likely that the ancient Pharaohs were circumcised, the circumcised state being a necessary qualification for the priesthood. It is reported that Pythagoras had himself circumcised while in Egypt so he might be fully initiated into the esoteric religious rites of the Egyptians. Among others, notably the American Indians, circumcision was mainly adopted as an alternative to human sacrifice. Although circumcision is widespread in Moslem communities the Koran contains no specific ordinance on this subject. Mohammed is said to have been born without a prepuce, and the possession of a foreskin was regarded as a disgrace amongst the Arabs. It is reported that after one of the Prophet’s battles a slain Thaquafite tribesman was found uncircumcised, and great pains were taken to prove that he was a Christian and not truly a member of the tribe. In Arab communities the operation is performed with scissors, a razor, or a split reed, and there is a tradition that Abraham used an axe and was rebuked for his haste.
Some of the methods of disposal of the foreskin are more a matter for interest than emulation. The Levites during the Exodus piled their foreskins in the wilderness and covered them with earth; in parts of West Africa, where the operation is performed at about 8 years of age, the prepuce is dipped in brandy and eaten by the patient; in other districts the operator is enjoined to consume the fruits of his handiwork, and yet a further practice, in Madagascar, is to wrap the operation specifically in a banana leaf and feed it to a calf. In happy contrast to some of these macabre practices is the habit of the Bani Chams in Australia with a wooden knife and leave their victims unscathed.
In Britain, while the practice of circumcision is widespread, there are rather different reasons for its performance, and, though exact figures are difficult to obtain, it would seem that more than half the male members of the population are circumcised. Many doctors have for long rebelled against the wholesale and somewhat primitive lopping of the infant foreskin which goes on in some out-patient departments and surgeries. On these occasions the technique of the operation is frequently deplorable ; sacrifice of skin is often too generous, and attendant damage to the glans penis or fraenum is not unknown. If these criticisms are valid then it may well be asked why large numbers of doctors permit and encourage a practice which so savours of the barbaric. Religious considerations apart, it is not easy to find a rational argument for circumcision in most cases, and the operation is more often performed because it is de rigueur in certain districts or a habit in some families.
Dr. Douglas Gairdner’s valuable study, "The Fate of the Foreskin," which appears at page 1433 in this issue, will, we believe, make many readers pause for reflection. Though medical opinion about circumcision may be more conservative than it used to be, yet even to-day the attitude of the profession in general to the subject is too often based upon false ideas of the anatomy and physiology of what is a useful cutaneous appendage. Of the value of the prepuce in the first two or three years of life there is no doubt, for it has an important function in covering and protecting the glans penis. Contrary to widespread belief, non-retractability, a frequent finding, is not synonymous with phimosis. There can be little medical justification for routine circumcision of the infant, and the operation is only occasionally necessary under the age of 3. After this age operation is indicated for cases of non-retractability with true phimosis and for those with recurrent preputial inflammation or paraphimosis. Circumcision should be limited in extent: the fraenal region must not be damaged, and sufficient skin must be left to cover the very sensitive corona glandis. Although the operation of dorsal slit is unpopular with some, it is both satisfactory and simple to perform, and the ultimate cosmetic outcome is good.
Apart from the local reasons for circumcision it is argued by some that it will reduce the incidence of venereal disease, cancer of the penis, and cancer of the cervix uteri. The evidence supporting the first of these contentions is inconclusive ; the second is established beyond doubt ; while the available data on cancer of the cervix do not warrant the conclusions which have been drawn by some authorities. As Dr. Gairdner points out, it is likely that lack of cleanliness is more important than lack of circumcision in the case of venereal diseases and cancer of the penis. If the latter was not a very uncommon disease in this country it alone might provide justification for widespread emulation of the Jewish custom. The Mosaic law enjoins the practice of circumcision on the eighth day, and it appears certain that this ritual circumcision affords complete protection against carcinoma of the penis. Furthermore it has been shown that circumcision between the third and fourteenth years of life does not give complete protection against penile carcinoma.** (2) In the absence of more convincing evidence about carcinoma of the cervix it is difficult to describe its low incidence in Jewesses to the circumcision of their spouses. As Kennaway (3) has pointed out, the data are inadequate, and the low incidence in certain other races cannot be explained by circumcision. It seems safe to say that if Dr. Gairdner’s recommendations are accepted much circumcisional morbidity and mortality will be avoided and, further, that there is no good reason to fear increased incidence of venereal disease or genital cancer as a result of this policy.
* None of the indigenous societies in the Americas (north or south) ever practised circumcision, though there is some evidence that the Aztecs had a ritual which involved nicking the penis to draw blood.
** The statement that "ritual circumcision affords complete protection against carcinoma of the penis" was generally believed in 1949, but this is now known to be false. For more information see pages on circumcision and cancer
1 Hastings J., Encyclopaedia of Religion and Ethics, 1910, vol. 3
2 Kennaway, E.L., Brit. J. Cancer, 1947, 1, 335.
3 Ibid, 1948, 2, 177.
SOURCE: "A ritual operation" (Editorial), British Medical Journal, 24 December 1949, pp. 1458-9
EDITORIAL: The case against neonatal circumcision
British Medical Journal, 5 May 1979
1. Gee, W F, and Ansell, J S, Pediatrics, 1976; 58: 824.