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.

Yours sincerely,

W.B.St.C.  BREWER

Dear Bill

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

Daniel Whiddon, "The Widdicombe file: Should baby be circumcised?", Lancet, 15 August 1953, pp. 337-8

Responses

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