|Sir Daniel Whiddon: Should baby be circumcised?|
The Lancet, 1953
In 1953 Dr W. B. St. C. Brewer, a family physician from New Zealand, asked Sir Daniel Whiddon, celebrated British surgeon, to see Mrs. T. C. who wanted to have her baby boy circumcised. Dr. Brewer’s request and Sir Daniel’s classic (and often cited) response were printed in the Lancet. The reference to Sidi Bou Ali is to the allied military campaign in North Africa during the Second World War, when both doctors served in the Medical Corps.
Dear Sir Daniel
Herewith Mrs. T. C. who wishes her firstborn circumcised.
I hope you remember me. The last time we met was at no. 4 New Zealand Field Ambulance at Sidi Bou Ali in April 1943. I have just entered a partnership of four in this town and, so far, enjoy the life of a G.P.
I remember you well, and am glad to hear that you are happily settled.
Baby C is a fine specimen. He has the long, non-retractile prepuce of the normal newborn male infant; that it is not worrying him or obstructing the flow of urine he demonstrated to his own satisfaction and the discomfiture of one of my dressers. He will be circumcised at Minor Operations on Saturday; and his mother will be satisfied. I am not; and since I have had a short morning and dealt with all letters but yours, I feel inclined to use the time, the opportunity, and the services of an expert stenographer, to send you an Essay on Circumcision. What is the prepuce and why is it there? Why does Man remove it? Does routine circumcision do any good? Does it do any harm? What should be the attitude of the doctor towards this first step in surgical handicraft? These are some of the questions I should like to answer.
The mammalian penis serves the double purpose of urination and generation. For the first purpose it remains flaccid, for the second it becomes rigid and elongated. Its shape, structure, and length vary widely in different species, but in all it is contained in a sheath, within which it remains while it is flaccid and from which it is protruded when erected for coitus. The human prepuce is the representative in Man of the sheath in other mammals - a covering protecting the glans penis, which is part of the mechanism of generation. The glans belongs to the group of special sense organs. It is almost insensitive to light touch, has no sense of tactile discrimination, and no appreciation of heat and cold, and it interprets painful stimuli (such as a pin prick) only as a vaguely unpleasant contact; but under appropriate stimulation it is capable of receiving pleasurable sensations that, when they have reached a certain pitch of intensity, take charge of the whole behaviour of the individual and lead to a series of uncontrollable actions that complete the important function of the life-cycle of the individual - the act of sexual union. The preservation, undulled and undiminished, of this special sense, and guarding of the mucous membrane in which it resides from long exposure and a dulling of its sensibility, is of paramount importance from the point of view of survival of the race. That then is the biological purpose of the prepuce.
A second less important purpose is in the act of coitus itself. The erect circumcised penis enters the vagina without effort or any rate without friction, the prepuce unfolding as the penis advances and each part of it remaining in contact with successive areas of the vaginal walls, till finally the uncovered glans lies at the cervix.
The circumcised penis, deprived of this self-tracking mechanism, is introduced to the accompaniment of friction between penile skin and vaginal mucous membrane. It is the difference between slipping the foot into a sock that has been rolled up and one that is held open at the top. The human foreskin, then, is neither vestigial nor useless. It is part of the normal mechanism of reproduction, and without it sexual desire is to some extent blunted, and the performance of the sexual act - at any rate the first act of coitus between the virgin male and the virgin female - made more difficult.
Why is the operation of circumcision practised? As well ask: why do races all over the world make symbols of the egg and hare in the spring, the bonfire in the autumn and the evergreen tree in midwinter? The origins of circumcision at least can be traced. It is part of the ritual of mutilation by which the young male, and less often the young female, is called upon to suffer and give proof of courage, by which they are admitted to the privileges of the tribe or the estate of manhood or womanhood. In this respect it must be grouped with the various forms of tribal markings by burning or incision, with piercing or slitting of other prominent folds of skin, the ears, the lips, the nostrils. It is also performed to reduce sexual desire, to make the man a better warrior for his tribe, a more faithful husband to his wife, a less frequent disturber of the harmony of the society in which he lives. In Africa female circumcision is widely practised with the intention of making the woman chaste, a faithful wife and servant to her husband. The distribution of circumcision over the surface of the globe is irregular, and can be traced to the influence of the race, the conqueror imposing the practice on his subjects.
Circumcision is universal in the Semitic races, and has been taken by the Arab to all the seacoasts of Africa and by the Jew to all parts of the world. The age at which it is practised also varies. Among the Jews and Arabs the male infant is circumcised soon after birth; among the central African tribes that practice circumcision (and many do not), the rite is performed every three or four years on all males who have reached puberty since the last circumcision, and these young men pass though the various stages of tribal life - the warrior, the parent, the farmer, the statesman, the priest - as one group known by the year of their circumcision.
How often is circumcision necessary on surgical grounds? Here we must distinguish between circumcision in adult life, or at any rate after puberty, and circumcision in infancy. In the adult the unhealthy prepuce should be removed, and no sentimental embryological, racial or psychological arguments are strong enough to offset the general principle that unhealthy tissue should be removed. Circumcision in the adult should be performed for phimosis, for balanitis, for venereal or other preputial warts, and for early epithelioma as the first step in a course of treatment whose main plank is radiotherapy. True phimosis - that is a non-retractable and not mere a non-retracted prepuce - is seen only in adolescent and adult life. The infant prepuce cannot be retracted without force, and should not be retracted, but retraction comes normally in the years of childhood, without any maternal or medical assistance, and by puberty the non-retractable prepuce occurs in less than one in a hundred, and true phimosis - that is the prepuce with a fibrous stricture in the orifice - in perhaps one in a thousand.
The reasons advanced for circumcision in infancy are a strange mixture of taboos handed down from the dawn of history, of Bible training, of midwives' and other oldwives' medicine, and of the unthinking advice of those storehouses of unexpurgated tradition, the surgical textbooks. The baby sent to outpatients is usually accompanied by a note to say he has phimosis (I was glad to see that you did not perjure yourself to this extent). Is there such a thing as a baby with phimosis? I am old enough to have taught your father, and I have never seen one. The penis is developed as a solid bud, prepuce and all, and the urethra is formed as an infolding of its under surface. Only late in foetal life does a line of cleavage appear to mark off the future prepuce from the future glans, and at birth this plane is a visible distinction but not a free space, and the newborn baby has a prepuce projecting at least half an inch beyond the new glans and forming a little corrugated tube, like the empty oesophagus or anal canal. He passes water frequently and often. He may scream in doing so, but it does not follow that he has phimosis. Babies scream for all sorts of reasons, usually because they have a silly mother and “they know it teases”. They may scream in passing water because it hurts, as it may in the urine is highly acid, but not because the outflow is obstructed at the preputial orifice. The urinary apparatus may be congenitally obstructed at the lower ends of the ureters, in the prostatic urethra, at the meatus, but never at the prepuce.
The very shaky science of the arguments in favour of wholesale infant circumcision is often supported by the statement, itself unsupported by any by any scientific evidence, that the circumcised are less liable to disease, particularly that they are less likely to get venereal disease and cancer. The first statement is untrue. You were long enough in the Middle East to know that our circumcised allies were the most enthusiastic supporters of the VD departments. The second is true to the extent that cancer usually starts in the prepuce near the corona. But cancer of the penis is a rare disease. Five thousand men die every week in England, and only four of them die of penile cancer. The possible relation of the prepuce to the onset of venereal disease is that it may render the penis more liable to single or repeated trauma. But the penis protected by a normal retractile prepuce undergoes less trauma in coitus and less repeated irritation by exposure than the circumcised one. Disease is possibly commoner in the adult with phimosis than in the circumcised; but in the normal uncircumcised; it is if anything less common.
Does circumcision in infancy do any harm? Undoubtedly. Firstly, like all operations that are looked on as easy, it is often very badly done. The Rabbinical method in the hands of the rabbi is safe, speedy and satisfactory; done by the Gentile working from a textbook description, it is one of the worst. Ritual circumcision depends on cutting off both layers in one sweep, and turning the cuff of mucous membrane down, when it is bandaged without sutures and allowed to unite. If the removal of skin has been inadequate, if the cuff of mucous membrane comes forward again as it often does and the two unite by granulation, the result is appalling, a half-length prepuce ending in a fibrotic ring attached to the glans half-way up.
Circumcision by proper surgical technique with trimming of the surfaces to the exact length and slope required, careful arrest of all haemorrhage, and suture of the cut edges with careful delicacy gives much better results; but may be disastrous in the hands of those who are not surgeons and know no technique. Unless the prepuce is freed completely from the glans before division, the meatus can be sliced off in the cut and a stricture that can never be overcome is produced.
Apart from those evil results which are due to imperfect workmanship, there are the fairly common minor troubles that follow because a stupid and unnecessary operation has been done, a normal mechanism has been destroyed, and a delicate surface exposed to air and to friction four or five years before it should be exposed. Eczema of the glans and meatus is not rare in the newly circumcised infant; it needs careful treatment with ointment and sometimes leads to scarring and narrowing of the meatus.
Those are the facts. But we must not break our hearts by putting two much of them into a fruitless crusade against infant circumcision. Fruitless it will be, for the medicine of the jungle and the witch doctor, the teaching of the Bible and Koran, the traditional science of the midwife, the health visitor, and the home medical dictionary are all against us. None the less, let us keep our own sanity. When we met those who advocate this mutilation, let us ask them why they do it and why: they have seldom asked themselves. When we meet a young mother whose mind is her own and not someone else's gramophone record, let us ask her if she thinks it likely that nature would bring 1000 English children into the world every day, well formed in all respects save this one; if it is no more likely that Nature is right and the folk-medicine that tries to improve on her is wrong. And when, as we often must, we have to give way to folly for the sake of peace and mind - our own, that of the mother, that of the school doctor - let us not commit the sin against the Holy Ghost by concealing from ourselves that it is foolish.
Your old friend,
Daniel Whiddon, “The Widdicombe file: Should baby be circumcised?”, Lancet, 15 August 1953, pp. 337-8
There were a number of letters in response to Sir Daniel’s article in subsequent issues of the Lancet, including this one from a general practitioner.
As a general practitioner I am grateful for Sir Daniel Whiddon’s advice on circumcision. It is strange how a really useful medical practice like vaccination tends to die out unless people are urged to have their children protected, while unnecessary operations like those for circumcision and tongue-tie remain popular.
Mr J.D. Hennessy has raised another very important issue – namely, that forcible retraction or stretching of the foreskin can be harmful procedures. Some mothers are most upset if they cannot push the prepuce right back so as to clean underneath it. Others perform the operation on someone else’s advice, but they dislike doing it. In my view this zeal for preputial hygiene is quite unnecessary or even harmful. More than once I have been called out to reduce an incipient paraphimosis because the mother, having exposed the glans, is unable to replace the foreskin. After all, no one ever thinks of inspecting the vulva of a small girl in order to remove the smegma.
It is eight years since I returned to general practice from the Forces, and in that time I have never circumcised a small baby. I have seen only 3 cases of balanitis, and they all cleared up readily on sulphonamides and caused no further trouble. Quite apart from the danger of physical damage, I am quite sure that it cannot be good for a small boy to have his penis manipulated daily by his mother.
When I examine all newborn babies immediately after birth to exclude congenital abnormalities, I always make a point of telling the mother that her son does not need circumcising. I advise her to wash and powder him well but to do no more. If then or at a later date she questions this advice, one must spend a little time explaining the protective function of the foreskin, and she must be assured that it will stretch as he gets older. In my practice the request for circumcision now hardly ever arises.
C.A.H. Watts, letter, Lancet, 19 September 1953, p. 623