5 10 240 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>“No normal child needs to be circumcised”</h3> Parents can safely stop agonising over whether their baby boys need to be circumcised, thanks to a new medical policy statement. According to Australian and New Zealand child protection advocates, the revised policy on circumcision recently released by the Royal Australasian College of Physicians means that parents can simply forget about the idea of circumcising. “The circumcision decision is actually a fake dilemma”, said Sydney paediatrician and child heath specialist Dr George Williams. “No normal baby needs to be circumcised. Thanks to the new policy, parents can stop worrying about surgery and focus instead on the important things that a new baby needs – love, warm clothes and breast milk.” After a lengthy review of the medical evidence, the RACP concludes that routine infant circumcision is not warranted in Australia and New Zealand. This is because the diseases from which circumcision may give some protection are too rare or not a threat to children; because it does not protect enough; and because the resulting harm is too great and the complication rates are too high. “The authors of the policy have gone into great detail about those diseases and the levels of protection they may offer, but that’s the bottom line,” said Dr Williams “Circumcision is not medically necessary or even desirable, and is not recommended as a health precaution.” “They’ve gone into less detail about the harm, complications and risks of circumcision, but these go all the way up to death – for example, from unnoticed bleeding, or infection with diseases such as meningitis. That’s an unacceptable risk for a surgical operation that the RACP says is unnecessary.” Tasmania’s Children’s Commissioner, Paul Mason, praised the RACP for recognising the importance of ethical and human rights issues in the circumcision decision; for recognising that the foreskin has significant sexual functions and is actually the most sensitive part of the penis; and for pointing out that the operation is non-therapeutic (i.e. does not fix anything) and that the infant is unable to give consent. For these reasons it acknowledges that circumcision of minors has been under heavy fire from bioethics and human rights advocates for many years. “This is an untested area, but we believe it cannot be ethical for parents to decide to remove a healthy, functional body part from a baby, or for a doctor to perform a medically unnecessary surgery on a patient who has not given his consent. We doubt the law will continue to hold a parent’s consent to be valid”, Mr Mason said. The RACP also deserved praise for recognising that many men bitterly resent having being circumcised. “Thousands of men in previously circumcising countries (Australia, USA, Canada, UK) are using DIY methods to restore a semblance of their foreskins. Although some men might wish they had been circumcised as a baby, they are far fewer and have an easy remedy – to get circumcised now. It is not so simple for a man whose foreskin was surgically removed when he was too young to protest.” With fewer than one baby in five circumcised anywhere in Australia these days, and fewer than one in 20 in several states, and virtually no Pakeha or Maori babies circumcised in New Zealand, circumcising for conformity’s sake is a dead issue. “Indeed”, said Ken McGrath, Senior Lecturer in Pathology at Auckland University of Technology, “if parents are worried about peer acceptance, their best plan is to leave the boy’s penis alone.” Mr McGrath commended the RACP for rejecting the aggressive lobbying of a small pro-circumcision faction, who have been pushing hard for the introduction of near universal circumcision in Australia, supposedly as a public health measure. “Some of the reasons they give for circumcising – such as to prevent splashes on the toilet seat or to avoid zipper injuries – are simply absurd. “The fact is that the medical arguments for routine (medically unnecessary) circumcision are dead as a doornail.” Further information Paul Mason Commissioner for Children Tasmania, Australia +61 438 555 473 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New RACP policy welcomed by child protection advocates darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Morris is a man on a mission to rid the world of the male foreskin</h2> Since the mid-1990s Brian Morris, at that time a respected professor of molecular biology at the University of Sydney, has been waging a one-man war against the foreskin, and more particularly a relentless campaign in favour of circumcising baby boys. He started with a website, then managed to persuade a university press to publish a little booklet, In Favour of Circumcision (1999), in which he rehashed a mass of largely nineteenth century medical wisdom, as well as informing us that Abraham circumcised himself in order to cure a “foreskin problem” and that uncircumcised men needed three showers a day to keep down the smell. The book did not find favour with health experts, however: <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=64&Itemid=50" rel="noopener" target="_blank">reviewing it in Venereology</a>, Professor Basil Donovan described Morris as “a man on a mission to rid the world of the male foreskin”, and some of the claims so misleading that the publishers ought to withdraw the book. It was, he concluded, “a serious disservice to parents”; since Morris was not suggesting that adult men ought to get themselves circumcised as a health precaution, it is obvious that parents were the target audience. Undeterred, Professor Morris pressed on, hoping to influence the policy of the Royal Australasian College of Physicians, which had been anti-circumcision since the early 1970s. When this effort failed in 2002, 2004 and again 2010, and in response to his <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=category&sectionid=14&id=78&Itemid=71" rel="noopener" target="_blank">public disowning by the RACP,</a>, he set up his own organisation, the Circumcision Academy of Australia, with a small group of like-minded academics and medical practitioners, some of whom derive their income from performing circumcision procedures, and who thus have a vested financial interest in emphasising its benefits. During this period Professor Morris became a prolific contributor to medical journals, trotting out one article after the other on the sins of the RACP and other anti-circumcision activists, and insisting that he and his friends were the only people observing the principles of evidence-based medicine, and thus the true source of medical wisdom. In fact, most of the articles (despite a varying cast of co-authors) were pretty much the same, largely repeating the familiar litany of the benefits of circumcision that he had first set out in his booklet. Where all this frantic industry has led him can now be seen in a couple of articles that attempt to quantify the benefits of circumcision, and the results have been dramatic. <h2>Foreskin health risk doubles in 2 years</h2> A couple of years ago Brian Morris drew a certain amount of attention to himself with the claim that the benefits of circumcision outweighed the risks by 100 to 1. At the time child health authorities ridiculed the claim as scientifically baseless, exaggerated, implausible, absurd, frankly preposterous and just crazy. His additional suggestion that circumcision was just like vaccination and should be compulsory was described as the dumbest idea ever. Undeterred by these harsh words, our fearless anti-foreskin warrior has now published a further article in which he claims that the benefits of circumcision outweigh the risks by 200 to 1, and that 50 per cent of all uncircumcised men will experience medical problems as a direct result of their regrettable genital anatomy. This means that the danger to health posed by the foreskin has doubled in only 2 years, and should imply that boys and men all over the world (but especially in Europe, Britain and Australia) should be swarming into hospital emergency departments with crippling foreskin-related diseases. If the risk continues to soar at this rate, it will not be long before uncircumcised men are dropping like flies in the street. The fact that none of this is happening, however, does lend a certain air of unreality to Professor Morris’s alarmism, and perhaps explains the fact that, while his earlier (2014) claim met with ridicule and refutation, his latest anathema against the foreskin has left health authorities dumbfounded and speechless with amazement. The 100 to 1 claim was made in a respectable journal as an aside to an article that was really a speculation on the possible effects of the American Academy of Pediatrics 2012 circumcision policy on United States circumcision incidence. It is noteworthy that Professor Morris’s 200 to 1 claim appears in the very obscure Chinese-based World Journal of Clinical Pediatrics. Despite its grandiose title, this is a recently established, low-ranking organ that was included in Beale’s list of <a href="https://en.wikipedia.org/wiki/Predatory_open_access_publishing" rel="noopener" target="_blank">predatory open access publishers</a>. It had, in fact, already been the target of a <a href="http://retractionwatch.com/2016/11/22/journal-editor-resigns-over-firestorm-from-circumcision-article/" rel="noopener" target="_blank">speeding ticket from Retraction Watch</a> for dodgy publication practices – in this case, failure to ensure objective peer review. Still, one can’t blame Morris for that: if you are going to make claims as outlandish as those made by him and his coterie at the Circumcision Academy of Australia it is not surprising that you have to scrape the bottom of the barrel. <h2>The war of words</h2> Professor Morris seems to think that the war against the foreskin will be won by the weight of artillery and the number of shells that each side can fire – rather like the donkey generals of the First World War. If he can cite more articles in favour of circumcision than critics can cite articles against, the case for circumcision will be proved. Hence the bloated reference lists at the end of his numerous repetitive articles. But this is to overlook two vital factors: the quality of the articles and the burden of proof. It is one thing to cite dozens of papers, but if they turn out to be no more than letters to the editor, opinion pieces, viewpoints and literature reviews, and if they are published in obscure or low-ranking journals, they carry far less weight than if they are reports of real studies (i.e. of actual data), meta-analyses and other relevant literature. In the case of Morris’s most recent effort in the World Journal of Clinical Pediatrics, no fewer than 27 of the 160 references are to papers by Morris himself or close associates; at this rate it will not be long before he can prepare a “systematic review” consisting solely of his own work. Papers published in high-ranking journals carry more weight than those published in obscure or low-ranking journals, such as the World Journal of Clinical Pediatrics – a title cited in Beale’s list of predatory open access publishers, and already under criticism for failure to ensure objective peer review. Morris himself has stated that the only papers that need be taken seriously are “good research studies published in reputable journals” [1]. On that basis, there would seem to be no reason to pay any attention to his two most recent articles, neither of which is a “good research study”, and both of which are published in an obscure journal with no reputation at all. <h2>Peer review, or endorsement by mates?</h2> The quality of the peer review process is also an important factor to consider when judging the credibility of any paper or article. In fact, an earlier paper by Morris in the same journal was the target of a complaint to Retraction Watch because the sole peer reviewer was an associate and frequent collaborator with Morris. The editor agreed to retract the paper, and when this did not happen resigned. In the case of his most recent “systematic review”, the sole reviewer has been <a href="https://www.researchgate.net/profile/Webster_Mavhu" rel="noopener" target="_blank">named as Webster Mavhu</a> and his comments to the author made public; there is not much to them: COMMENTS TO AUTHORS: This a well-conducted and well-written systematic review of the current scientific evidence of the protection afforded by early infant male circumcision against infections and other adverse medical conditions. I have only a few minor comments: Suggest changing USA to Us throughout. p3 Core tip - insert 'of'. Our systematic review of... p8 Last paragraph, 2nd sentence - '...increased in... (not is). p10 Give a brief explanation of UTI and phimosis (as you do with paraphimosis) p10 References [33-46] and [47] - format different from the rest. pages 11,12 and Table 1, give full form of approx. p16 i.e., 6% - missing a point after e. Mr Mavhu, a health official from Zimbabwe, turns out to be an ardent believer in the efficacy and acceptability of non-therapeutic circumcision of minors, and is professionally involved in the “roll-out” of the African circumcision programs – hardly the sort of authority to give an objective and impartial assessment of Morris’s arguments. <h2>Burden of proof</h2> There is also the question of where the burden of proof lies. Since the foreskin is normal human anatomy (indeed, common to all mammals, male and female) it is not up to the circumsceptics to prove that circumcision is harmful, but up to the circumcision advocates to prove that it is so dangerous to health that it must be removed from as many boys as possible before it can do too much damage. In an article a few years ago Professor Morris claimed that the benefit/risk ratio was 100 to 1; in his most recent paper the ratio has increased to 200 to 1. According to him, in only a couple of years the danger of the foreskin to health has doubled. This news may come as a surprise to the 75 per cent of men worldwide who seem to be coping quite satisfactorily despite such a malevolent anatomical disadvantage and it would appear to be contradicted by “a good research study” (i.e. one using actual patient data) showing that <a href="https://www.circinfo.org/AAP_in_retreat.html" rel="noopener" target="_blank">95 per cent of boys never experience any foreskin problems</a>, and that only a tiny minority of these require circumcision to correct it. In relation to the burden of proof, the situation is analogous to a court of law where the foreskin is charged with the offence of being a menace to individual and public health – a situation where the accused is innocent until proved guilty. The prosecution can bring in as many witnesses as it likes, but as in a court of law the defence does not have to prove anything. It does not even have to produce witnesses of its own or require the foreskin to make any statement in its own defence. The outcome of the case depends on the credibility, consistency and force of the evidence presented by the prosecution, as judged by the jury, the members of which must assess its validity and relevance. Are the claims plausible? Could the prosecution witnesses be mistaken? Have they misinterpreted what they think they saw? Do they agree? Could they be motivated by personal malice or ideology? How credible are these authorities? How consistent are they? Has the case for a guilty verdict been made beyond reasonable doubt? In this situation it would not matter if there was not a single article n a medical or other journal contesting the claims of the circumcision advocates (though in fact there are a great many) – the prosecution would still have to prove its case to an impartial jury. In fact, the medical literature is as contested and inconclusive as it is vast; as when witnesses give contradictory accounts of “what happened,” it is thus difficult to draw firm conclusions. But if firm conclusions cannot be drawn the verdict arrived at must be “Not Guilty” (or as the Scots say, Not Proven), and the foreskin discharged. The real question is not whether it might have been guilty, but why a normal feature of human sexual anatomy should have to justify its existence to the likes of Professor Morris. <h2>Non-therapeutic circumcision like elephant repellent</h2> Recommending circumcision as a prophylactic of childhood diseases is reminiscent of the old joke about the fairground snake oil salesman flogging elephant repellent. Confronted by sceptical customers who point out that there are no elephants around, he has the compelling reply, “Proof of how effective it is!” The point is, that even if the repellent were effective, you do not need it in regions where elephants are not normally encountered, nor if elephants are not really very dangerous and can be scared away by saying “Shoo!” The key question, therefore, is not whether circumcision might have health benefits, or even if the benefits outweigh the risks, but whether the net benefits (i.e. after taking all harms into account) are great enough to justify performing the operation on children who cannot give informed consent. In making this assessment it is not enough to dredge through the vast accumulation of medical literature to find studies supporting some degree of risk reduction; nor is it enough when considering the cons to consider merely the risk of surgical complications, as the American Academy of Pediatrics and the Centers for Disease Control have done. The calculation required is far more complex. First you must consider the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection. Then (2) you must make a comprehensive study of the physical harms, including impact on sexual experience, surgical complications and other adverse outcomes, not merely in the immediate post-operative period, but long-term, until sexual maturity. Then (3) you must factor in the sexual, aesthetic, and personal value of the foreskin to the individual and the psychological impact of removing it. Next (4) you must assess the ethical harms and damage to human rights arising from operating without informed consent. Finally (5), you must find some widely acceptable formula for weighting all these disparate factors to produce a final judgement. <h2>Using a flame-thrower to swat a blowfly</h2> No circumcision advocate, and certainly not Professor Morris, for all their diligent labours, have ever come close to performing such an exercise. They have rather confined themselves to selective literature reviews, picking out studies that show, or appear to show, the foreskin increasing the risk of this or that disease, while ignoring or disparaging critiques of these, as well as dismissing studies that reach different conclusions. Despite his impressive productivity, Professor Morris’s own papers tend to repetition – a familiar litany of the benefits of circumcision, along with assurances that it carries a minimal risk of complications and makes no difference to sexual experience. They also ignore the frequency, severity, transmissibility and curability of the diseases etc to which circumcision is claimed to provide protection; in fact, most of them are rare, mild in effect, non-transmissible or of low virulence, and readily curable with antibiotics or other medications. Using circumcision to prevent or cure trivial penis problems such as inflammation (balanitis); or urinary tract or venereal infections that can be cured with antibiotics or prevented by behavioural strategies is like using a flame-thrower to swat a housefly. Nowhere in his extensive list of publications does Professor Morris tell us what material weighting he would give to the 5 factors listed above, most of which he simply ignores. How, then, can he arrive at the triumphant conclusion that the benefits of circumcision outweigh the risks by a factor of 200 to 1? One feels that the figure must have been plucked out of the air, having about as much scientific validity as phlogiston. <h2>Range of opinions on circumcision – but Morris and coterie at extreme edge</h2> Professor Morris would like us to believe that there are basically two positions on circumcision: the pro-circumcision position, represented by himself, the American Academy of Pediatrics, the United States Centers for Disease Control and many other responsible health authorities; and the anti-circumcision position, represented by a few misguided medical ethics wonks and some ratbag community activists. In fact, there are at least 6 major positions on circumcision, which may be summarised as follows: 1. Professor Morris and his coterie at the Circumcision Academy of Australia and the Early Infant Circumcision Advocacy Group who believe that parents should be strongly encouraged or compelled to get their baby boys circumcised. 2. The American Academy of Pediatrics and the US Centers for Disease Control, which do not recommend circumcision, but consider that the benefits of circumcision exceed the risk of surgical complications (though not by much). 3. Paediatric authorities such as the Royal Australasian College of Physicians and the Canada Paediatric Society which consider that the risks and harms of circumcision outweigh the benefits and that circumcision is neither warranted nor desirable, and certainly not necessary. 4. Medical authorities such as the Royal Dutch Medical Association, others in Europe and (marginally) the British Medical Association who consider that circumcision is both physically harmful and ethically unacceptable, and therefore that doctors and public health institutions should actively discourage the practice. A number of independent researchers, epidemiologists and paediatricians are also included in this group. 5. Legal authorities such as the Tasmania Law Reform Institute, the Cologne Court of Appeal and numerous legal, bioethical and human rights scholars who consider that non-therapeutic circumcision of minors violates accepted principles of bioethics and human rights, and should be treated in much the same way as female genital mutilation – that is partially prohibited or at least strictly regulated. 6. Community organisations and individuals who regard circumcision as genital mutilation and consider that it should be legally prohibited, and perpetrators prosecuted. As you can see, there is an extensive spectrum of opinion on circumcision from right to left, from compulsory at one end to legal prohibition outright at the other. It is also evident that by far the greater weight of opinion on a world scale is against circumcision, and that Professor Morris and friends are at the extremist end of the scale. The AAP must tremble at the thought of being defended by such fanatical allies – though in truth it is strange that no other supporters are speaking up in their favour, and that its own position is very much at variance from those of all other child health authorities. <h2>Does Professor Morris really matter?</h2> For all his industry and zeal, however, Professor Morris cannot claim many victories. His efforts to influence the RACP have failed; his attempt to get the Australian and New Zealand Public Health Association to adopt a resolution in favour of circumcision got nowhere; the AAP has not recommended circumcision; the <a href="https://www.circinfo.org/CanadaCircumcisionPolicy.html" rel="noopener" target="_blank">Canada Pediatric Society</a> came out against circumcision; circumcision incidence in the United States and Australia continues to decline; legal, bioethical and human rights authoritie <a href="https://www.circinfo.org/Brit_judge_on_FGM_and_circumcision.html" rel="noopener" target="_blank">increasingly question the practice</a>. The increasing desperation of the circumcision lobby is shown in the escalating stridency and implausibility of its claims (200 to 1: really!), and its marginalisation by reliance on low-status, low-credibility publications. They really might as well pack up their gomcos and plastibels and devote their considerable energy to something more useful and productive than destroying foreskins. 1. “Circumcision facts trump anti-circ fiction”, Australian Skeptic 27 (4) Summer 2007. See also <a href="https://www.circinfo.org/Circumcision_and_sand.html" rel="noopener" target="_blank">reply by Robert Darby</a>, showing that Professor Morris’s respect for evidence is not all that it might be, and that he has trouble giving correct citations to sources. <h2>Further reading</h2> <a href="http://www.historyofcircumcision.net/index.php?option=com_content&task=view&id=64&Itemid=50" rel="noopener" target="_blank">Basil Donovan’s review of In Favour of Circumcision</a> Brian Earp & Robert Darby, <a href="https://www.skeptic.org.uk/magazine/onlinearticles/infant-circumcision/" rel="noopener" target="_blank">Does science support infant circumcision? A sceptical reply to Brian Morris</a> <a href="https://www.academia.edu/9872471/Does_science_support_infant_circumcision" rel="noopener" target="_blank">Expanded version of above</a> <a href="http://retractionwatch.com/2016/11/22/journal-editor-resigns-over-firestorm-from-circumcision-article" rel="noopener" target="_blank">Journal editor resigns over firestorm from circumcision article</a> Robert Darby, <a href="https://www.academia.edu/12035421/Risks_benefits_complications_and_harms_Neglected_factors_in_the_debate_on_non-therapeutic_circumcision" rel="noopener" target="_blank">Risks, benefits, complications and harms: Neglected factors in the debate on non-therapeutic circumcision</a> Robert Darby, <a href="http://journals.sagepub.com/doi/full/10.1177/2158244016649219" rel="noopener" target="_blank">Targeting patients who cannot object? Re-examining the case for non-therapeutic infant circumcision</a> <a href="http://www.circumstitions.com/morris.html" rel="noopener" target="_blank">Brian Morris fact check</a> <a href="http://www.circumstitions.com/news/news64.html#vernon9" rel="noopener" target="_blank">Is Professor Morris connected with Gilgal Society and convicted child molester Vernon Quaintance?</a> Morten Frisch and Brian Earp. <a href="http://www.tandfonline.com/doi/full/10.1080/17441692.2016.1184292" rel="noopener" target="_blank">Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence</a>. Global Public Health, on-line first, 16 May 2016. Brian Earp. <a href="http://quillette.com/2016/02/15/the-unbearable-asymmetry-of-bullshit/" rel="noopener" target="_blank">The unbearable asymmetry of bullshit</a>. Quillette, 15 February 2016. Robert Van Howe. Expertise or ideology? A response to Morris et al. 2016, ‘Circumcision is a primary preventive against HIV infection: Critique of a contrary metaregression analysis by Van Howe.’ <a href="http://www.tandfonline.com/doi/full/10.1080/17441692.2016.1272939" rel="noopener" target="_blank">Global Public Health, on-line first, January 2017</a> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Professor Brian Morris: relentless circumcision activist darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Britain</h2> <h3>Circumcision in Britain</h3> In Britain circumcision was not practised at all until the eighteenth century, and never as a routine or preventive procedure until the late nineteenth century. Men valued their foreskins as "the best of your property" and regarded circumcision as a humiliating disfigurement. In the eighteenth century surgeons started treating serious venereal infections of the penis by amputation of the diseased tissue. Since the venereal sores were usually on the foreskin, this was analogous to circumcision, but it was only done in advanced cases of disease, and only if the men agreed to it (which many did not). Such sores often caused phimosis by producing scabs which fused the foreskin to the glans, again requiring treatment; some surgeons treated the condition by amputating the foreskin (recommended by the English Robert James in his Medicinal Dictionary, published in the 1750s), others preferred conservative treatments and operated only if gangrene was present or threatened (such as recommended later by the French venereal disease expert, Philippe Ricord). The rise of extreme medical anxiety about masturbation in eighteenth century (the masturbation phobia) turned the normal fondling of the penis which all young boys and many babies did into a wicked and harmful vice which had to stamped out. This led to the gross medical error which characterised the normal phimotic condition of the infant and child penis as a pathological abnormality requiring immediate surgical correction. The main reason advanced for circumcision in Britain from 1840s onwards was to cure phimosis: that is surgically "correct" the natural condition of the penis. The later claims that circumcision could prevent cancer, epilepsy, paralysis, convulsions etc were all based on the original medical error that "phimosis" was pathological and had to be fixed. Various theories were advanced as to how, such as the tight foreskin pressing on the glans and causing imbalance of nerve force. Even those who did not support circumcision believed that the infant foreskin had to be separated from the glans and forced to retract within a few weeks of birth. It was not until the 1930s that this dogma was questioned, and not until Douglas Gairdner's article on 1949 that the error was dispelled (at least in Britain, though not for a while in Australia, and not for even longer in the USA). Circumcision in childhood was first introduced by French and English doctors as a treatment for masturbation in the 1830s and also recommended for spermatorrhoea (involuntary loss of semen) in adult men. Much of this was based on the crazy theories of <a href="http://www.whonamedit.com/">Claude-Francois Lallemand (1790-1853)</a>, whose vast treatise Les Pertes seminales involontaires (Involuntary seminal losses) was published in three volumes in the 1830s and translated into English in the 1850s. Circumcision as a treatment for phimosis had the same origin: nobody had worried about phimosis in childhood until masturbation became an issue, but once that was seen as a problem, phimosis also became a problem because the "secretions" it was supposed to trap caused irritation and led boys to fondle and scratch their penis (equals masturbation). Circumcision was not routine at this stage or even common, only done by a few over-anxious and highly punitive parents. It took nearly a century of advocacy and the invention of additional "health" reasons (the most important of which was the claim that it provided protection against syphilis, first raised in the 1850s, but not seriously pushed until the 1890s), and then various forms of cancer, before it became general. <h4>Circumcision folklore</h4> Various absurd stories are told about circumcision in the English royal family, among the British in India and in the case of Louis XV of France, who is supposed to have suffered from such severe phimosis that he was obliged to submit to circumcision before he could perform his most important royal duty. All these stories are nonsense. The story that Queen Victoria imagined she was descended from the biblical King David and had her own sons circumcised was invented by the British Israelites and given wider currency by a popular writer using the pen name Bud Berkeley. The story about Robert Clive getting circumcised by Indian Moslems is a fairy tale made up by Allen Edwardes in The rape of India, a work largely of fiction masquerading as a factual history book. He invented a whole sequence of scenes involving circumcision as a pornographic fantasy, and footnoted them to imaginary documents and records. His exposure and disgrace is mentioned by Ronald Hyam in Empire and sexuality: The British experience. It is true that some hundreds of British soldiers were captured, forcibly circumcised and enslaved by the Muslim Sultan Tipu of Mysore after their defeat in the Battle of Pollilur in 1780, but that is a different matter. (1) As for Louis XV, a recent article proves that he could not have been circumcised, but that he might have had a short frenulum (<a href="http://www.circumstitions.com/Frenbrev.html">frenulum breve</a>) that was quickly and simply fixed with a touch of the bistoury. (2) <h4>Semi-routine operation</h4> Circumcision became "routine" (i.e. done by adults to children showing no signs of disease or abnormality) and widespread among the rich at the end of the nineteenth century as a result of a combination of several factors, any one of which would not have been enough. It received an immense boost from the claim that it provided significant protection against syphilis, the AIDS of that era. The rate of infant circumcision in Australia doubled between 1910 and 1920, the decade which marked the height of the syphilis scare, and increased substantially in Britain. (There's a parallel here with AIDS today). Circumcision was recommended as a preventive of masturbation, nervous diseases, syphilis, and cancer, not to mention bed-wetting, epilepsy, pimples and hip joint disease, all of which were equally important in securing its widespread acceptance; by itself, none of these factors could have tipped the balance. The age at which circumcision was done in Britain varied. It was often done in infancy, but it was also common in childhood, particularly just before a boy started school, as a precaution against picking up the habit of masturbation there. Many boys were not circumcised as a routine thing, but because it was found that their foreskin was not retractable (as was perfectly normal in boys before puberty), or because they were caught masturbating: it was a treatment/punishment as much as a preventive. Where it was done to correct "congenital phimosis" it was on the basis of a serious medical error and failure to understand normal penile development. Nor was the style and technique of circumcision standardised until much later, probably with the invention of the Gomco clamp in the 1930s. In the late nineteenth century there was immense disagreement among doctors about how it should be done and how much tissue should be excised; some urged the maximum possible, others the minimum needed to free the glans, others a middle course. Jewish practice was often taken as a model, but it was the modern Jewish style, involving the tearing back of the foreskin and its radical removal which attracted the most support. In fact, English (and then American) circumcision techniques turned out to be significantly more severe than most ritual or tribal varieties. Little was known about Islamic circumcision techniques, but Moslems they did not enjoy the high status achieved by Jewish people, who came to be regarded as exemplars of sanitary wisdom in the late nineteenth century. <h4>Dissent</h4> Herbert Snow made much of these disagreements and used them to try to discredit circumcision in his attack on the practice (<a href="https://www.historyofcircumcision.com/templates/pages/the_barbarity_of_circumcision_1890.html">The barbarity of circumcision as a remedy for congenital abnormality</a>, 1890), but so deeply had the myth of phimosis as a congenital defect sunk in by the 1890s that even he conceded that something had to be done about non-retractability in early childhood, and he had little to offer on the functions and value of the foreskin. Circumcision was never classified as serious surgery (and thus reserved to qualified surgeons), but as a minor procedure (like scratching off a wart) which any GP, medical student or expert in women's health could do. The crude and ugly results bore witness to the fallacy of that assumption. Circumcision always had its critics in Britain. Parts of this vehement denunciation from Elizabeth Blackwell in 1894 still has relevance today: A serious warning against the unnatural practice of circumcision must here be given. A book of "Advice to mothers" by a Philadelphia doctor was lately sent to me. This treatise began by informing the mother that her first duty to her infant boy was to cause it to be circumcised! Her fears were worked upon by an elaborate statement but false statement of the evils which would result to the child were this mutilation not performed. I should have considered this mischievous instruction unworthy of serious consideration, did I not observe that it has lately become common among certain short-sighted but reputable physicians to laud this unnatural practice, and endeavour to introduce it into a Christian nation. Circumcision is based upon the erroneous principle that boys, i.e. one half of the human race, are so badly fashioned by Creative Power that they must be reformed by the surgeon; consequently that every male child must be mutilated by removing the natural covering with which nature has protected one of the most sensitive portions of the human body. The erroneous nature of such a practice is shown by the fact that although this custom (which originated amongst licentious nations in hot climates) has been carried out for many hundreds of generations (by Moslems and Jews), yet nature continues to protect her children by reproducing the valuable protection in man and all the higher animals, regardless of impotent surgical interference. Appeals to the fears of uninstructed parents on the grounds of cleanliness or of hardening the part are entirely fallacious and unsupported by evidence. It is a physiological fact that the natural lubricating secretion of every healthy part is beneficial, not injurious to the part thus protected, and that no attempt to render a sensitive part insensitive is either practicable or justifiable. The protection which nature affords to these parts is an aid to physical purity by affording necessary protection against constant external contact of a part which necessarily remains keenly sensitive; and bad habits in boys and girls cannot by prevented by surgical operations. Where no malformation exists, bad habits can only be forestalled by healthy moral and physical education. The plea that this unnatural practice will lessen the risk of infection to the sensualist in promiscuous intercourse is not one that our honourable profession will support. Parents, therefore, should be warned that this ugly mutilation of their children involves serious danger, both to their physical and moral health. Elizabeth Blackwell, The human element in sex: Being a medical enquiry into the relation of sexual physiology to Christian morality (1884; 2nd edition, London, 1894), pp. 35-6 Elizabeth Blackwell (1821-1910) was born in Britain and emigrated in childhood to the United States, where she became the first woman to take a medical degree. She later practised in both the USA and Britain, where she played a significant role in the campaign to repeal the Contagious Diseases Act during the 1880s. She also denounced masturbation and fornication but believed they should be controlled by moral willpower. See American National Biography (1999), Vol. 2. <h4>Statistics</h4> There are no reliable statistics on the circumcision rate in Britain, but it was overwhelmingly an upper class phenomenon. Circumcision was very common among the richer and better educated, but rare among the poor, labourers, farmers etc. The key was the respectable obsession with "cleanliness": the rich had baths and washed themselves, the poor and working class were the great unwashed, and their foreskins were the final proof of how filthy they were. As George Orwell pointed out, the middle class believed the working class smelled. The cleanliness of the circumcised boy was the guarantee of his superior social status, plus the fact that the scare over masturbation was most concentrated in the richer and better educated classes, and was an obsession at the public schools they attended. An example of how unpredictably the knife fell in Britain during the period when circumcision was common is given in the autobiography of the eminent classical scholar, <a href="https://en.wikipedia.org/wiki/Kenneth_Dover">Sir Kenneth Dover</a>, who also reveals that boys were more likely to resent the operation than to accept it. As he writes: I was born at a time when the craze for circumcision, which infected England in the latter part of the nineteenth century, was reaching its peak, and I was one of its millions of victims. Of the dozen boys I knew best at my school, at least five were circumcised, but at least five were not, and these included Alec and Martin, to whom I was closest. Each of us naturally championed his own kind of cock. One night, however, just before I went to sleep, a message which seemed to come from outside myself told me, with magisterial finality, that foreskins are good and circumcision is bad. This message was not articulated in words, but invaded me in two shock waves about a second apart: whoof! ... whoof! I felt that my whole system of values had been turned upside-down, and from that moment I have never been reconciled to my mutilation. [...] My dislike of circumcision did nothing to make me anti-Jewish, partly because I don't think anything could have done, and partly because I knew from my reading in anthropology and ancient history that it wasn't the fault of the Jews; it began independently in Egypt, from which it has spread into central and eastern Africa, over the whole Islamic world, and in some areas of the south-west Pacific. I am pretty sure, however, that it turned me off Semitic languages, in which I was beginning to be interested, and reinforced my loyalty to the Greeks and Romans, who rejected and ridiculed circumcision. Source: Marginal Comment: A Memoir (London: Duckworth, 1994) p. 20 Two surveys of army and airforce recruits in the early 1950s (i.e. men born in the 1930s) showed that about one third were circumcised, but these would have been mainly from the higher socio-economic groups. Before the 1950s the incidence of circumcision in Britain was strongly correlated with wealth: the rich generally had it done, the poor generally did not. A friend of mine who was a pupil at a (minor) public school in the early 1960s recalls that slightly less than half the boys (born late 1940s, early 50s) were circumcised even then. He was not, but his younger brother was - not as a routine thing, but because of a supposed phimotic problem in childhood. Circumcision had never been publicly financed in Britain and was already dying out in the 1940s, probably because hospital resources were stretched by the war, before Douglas Gairdner gave it the death blow. <h4>Notes</h4> 1. Robert Darby "Captivity and captivation: Gullivers in Brobdingnag", Eighteenth Century Life, Vol. 27, Fall 2003. 2. G. Androutsos, "Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?" Progres Urologique, 12 (1), 2002 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource History of circumcision - Britain darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> The crotchets of Sir Jonathan Hutchinson, father of routine male circumcision Anything may be proved by statistics, and ... anything may be seen by the aid of a microscope. ... Upon this subject of epidemics we want facts and faithful records -- Quaesitor, Lancet, 6 January 1855 For every problem there is a neat, simple solution, and it is always wrong -- H.L. Mencken Until very recently Jonathan Hutchinson was familiar only to a few medical historians as the surgeon who did not shrink from recommending castration in chronic cases of masturbation. If he was remembered by medical science it was as the closest thing to an authority on venereal disease nineteenth century England managed to produce: the Oxford Companion to Medicine pays tribute to him as a medical polymath who gave the world "Hutchinson's triad" â€“ three signs by which congenital syphilis could be recognised in young children. (1) At a time when no effective treatment was available the value of such a diagnosis to the child was slight, but it seemed evidence of the medical profession's insight into the mysterious world of disease, and at least warned parents that they should start saving for the funeral. It was not the sort of physiological discovery or therapeutic breakthrough on which enduring reputations are normally built. Surprisingly, however, the early work of Hutchinson has recently been cited by an international group of (mainly Hispanic, but largely US-trained) researchers, led by Dr Xavier Castellsague, who seem to be intent on reviving the old theory that the male foreskin is a major risk factor for cervical cancer in women. (2) This idea was first aired by enthusiasts for mass circumcision in the 1930s, when the natural preputial secretions were imagined to be the causative factor. The association was disproved for developed nations by many studies since the 1960s, (3) but this has not prevented Xavier's team from claiming that the link is valid for Third World countries, or at least among poor and ignorant populations with high birthrates, a lot of smoking and malnutrition, poor hygiene, a high incidence of sexual promiscuity (especially with prostitutes) and a low level of condom use â€“ all minor factors, however, compared with those troublesome foreskins which are the real cause of the problem, or a least a cause which is easily fixed. A virus (HPV) has been identified as the infectious agent, but the scent of quackery lingers. The researchers have hailed Hutchinson as their precursor on the basis of his report, in 1855, that circumcision might prevent syphilis â€“ and quite appropriately, for he did indeed claim this, and more. Among his many other gifts to medical understanding were the convictions that Jews were immune to syphilis; circumcision of male infants was necessary to discourage masturbation and promote continence; contraception was morally objectionable and physically harmful; and leprosy was a form of tuberculosis, caused by eating bad fish. (Sir) Jonathan Hutchinson (1828-1913) is an unlikely subject for positive revaluation. A reserved and gloomy Quaker whose watchword was self-denial, he was a puritanical workaholic even by Victorian standards. His youthful diary shows him rising before dawn each day to study his medical books and read the Bible: his text for 28 December 1848 was Hebrews XI, "a most eloquent and beautiful chapter", to which he responded: "My supplications were poured forth at the footstool of almighty power for an increase of faith, lest, privileged to live under a great and glorious covenant of mercy, I might by any means fall short of the better things which God has provided for us". He was only twenty. (4) Other favourite readings were the sufferings of Job and St Paul's Epistle to the Galatians â€“ the one in which he reproaches them for continuing to practise circumcision, forgetful that Christ's sacrifice had made such fleshly signs of righteousness unnecessary. Hutchinson seems not to have approved of Paul, however, but to have agreed with the learned Dr Copland, author of the widely read Dictionary of practical medicine, that there would be much less masturbation among boys if the early Christians had not dropped the Judaic rite. (5) His own reasons for advocating routine circumcision owed more to moral sentiment than medical science, though he did his best to give them a statistical gloss. In his practice at the Metropolitan Free Hospital, Hutchinson recorded the incidence of venereal cases among his Jewish and non-Jewish patients during 1854 and came up with the following table: <table border="1"> <tbody> <tr> <td> </td> <td>Venereal cases</td> <td>Gonorrhoea</td> <td>Syphilis</td> </tr> <tr> <td>Non-Jews</td> <td>272</td> <td>107 (39.3%)</td> <td>165 (60.6%)</td> </tr> <tr> <td>Jews </td> <td>58</td> <td>47 (81%) </td> <td>11 (19%)</td> </tr> </tbody> </table> On the basis of these figures he claimed he had demonstrated a conclusion "long entertained by many surgeons of experience": that "the circumcised Jew is ... very much less liable to contract syphilis than an uncircumcised person", and the reason was obvious: circumcision rendered "the delicate mucous membrane of the glans hard and skin-like". Hutchinson provided no elaboration of his reasoning as to why a damaged ("hard and skin-like") glans should provide this protection, nor what non-injurious alternatives might be recommended if it really did, but he showed no such reticence when it came to the clinical implications. Given these facts, Hutchinson suggested that it was probable that circumcision was by Divine command made obligatory upon the Jews, not solely as a religious ordinance, but also with a view to the protection of health. ... One is led to ask, witnessing the frightful ravages of syphilis in the present day, whether it might not be worthwhile for Christians also to adopt the practice. (6) It was a flimsy foundation on which to erect such an ambitious therapeutic edifice. All his observations showed is that, while non-Jewish venereal cases had more syphilis than gonorrhoea (60.6 to 39.3 per cent), Jewish cases had more gonorrhoea than syphilis (81 to 19 per cent). Although Hutchinson insisted that the high level of gonorrhoea among the Jews proved that less promiscuity could not have been the reason for the difference, the statistics revealed nothing about the relative susceptibility of cut and normal men to venereal infection, and could as well be cited to show that circumcision increased the likelihood of getting gonorrhoea. By comparing the syphilis cases with the Jewish and non-Jewish population of London in the 1850s it is actually quite easy to manipulate these figures in such a way as to suggest a conclusion radically different from that reached by Hutchinson. In 1851 London held about 2,360,000 people, (7) and in 1858 there were about 36,000 Jews in England, of which two thirds (24,000) lived in the metropolis. (8) Taking Hutchinson's patients as a proportion of the respective populations, we arrive at the following table: <table border="1"> <tbody> <tr> <td> </td> <td>Syphilis cases</td> <td>London population</td> <td>Rate of syphilis</td> </tr> <tr> <td>Non-Jews</td> <td>165</td> <td>2,336,000</td> <td>0.007%</td> </tr> <tr> <td>Jews</td> <td>11</td> <td>24,000</td> <td>0.046%</td> </tr> </tbody> </table> It can readily be seen that circumcised Jews had a rate of syphilis many times higher than their gentile neighbours. The point is that you can make the rate of syphilis anything you like, depending how you select the catchment population against which to calculate the proportion. Nobody would take these extrapolations seriously, yet they are scarcely more illegitimate than the implications drawn from Hutchinson's own figures, which were taken so seriously that for the next century they were regarded as the "hard data" needed to prove the health-giving value of pre-emptive foreskin amputation. In 1900 E. Harding Freeland cited them to prove that "circumcision of every male in infancy" would reduce the incidence of syphilis by 49 per cent. (9) In 1914 Abraham Wolbarst relied on them to support his call for "Universal circumcision as a sanitary measure". (10) As late as 1947 Newsweek praised Hutchinson as the first to discover that "syphilis and gonorrhoea were uncommon among Jewish people" and asserted that circumcised men "are not likely to contract venereal disease". (11) That nobody until the 1890s even questioned Hutchinson's figures (12) is an indication of how strongly the tide of medical opinion was running in favour of circumcision: any evidence would apparently do. Hutchinson's enthusiasm for circumcision increased as he grew older. In 1890 he issued "A plea for circumcision" in which he insisted that "the superior cleanliness of a Hebrew penis" was in itself an argument for the amputation of the foreskin: "It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation and adds to the difficulties of sexual continence. It increase the risk of syphilis in early life, and of cancer in the aged." (13) Later that year he published a further article in which he urged circumcision as a disincentive to masturbation and regretted that public opinion would not permit the introduction of castration as a more radical approach to the problem. (14) Three years later he advised the circumcision of baby boys as "imperatively required whenever the prepuce is unusually long and contracted", but added that the surgeon should also "avail himself of every possible opportunity of inducing parents to have their male children circumcised", an operation with "great advantages" on which he provided detailed procedural instructions. Although he stated that the surgery had "no drawbacks whatever", he warned that haemorrhage was a danger and that "many children have died after the operation as a consequence of carelessness in this matter." (15) He seems to have felt it was better to die quickly from uncontrollable bleeding as an infant than to waste away slowly from the effects of masturbation or syphilis in adulthood. Hutchinson returned to the topic at the turn of the century with a lecture, "The advantages of circumcision", widely reported in British and US medical journals. His strongest argument in favour of "the general practice of circumcision" was that it "would reduce the prevalence of syphilis", in support of which opinion he recalled his statistics from 1854, "which proved" that, while gonorrhoea was as common among Jews as Christians, syphilis was "much less frequent". This fact showed that it was not superior morality which gave Jews their "comparative immunity", but some "adventitious advantage" which could only be "the absence of the prepuce"; and not surprisingly, for it would be "difficult to contrive an appendage more likely to facilitate the implantation of the syphilitic virus". Hutchinson assured the public that no measure for the prevention of syphilis was as efficient as circumcision, but he made no mention of condoms (mass produced and available since the 1880s), (16) probably because he "regarded with disgust artificial means to prevent having children. Such practices are prejudicial to both moral and physical health." (17) Indeed, he seems to have held a deeply puritanical objection to non-procreative sex: Measures, such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counterbalances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is no so with circumcision. Effected in early infancy, and with other avowed objects [that is, curbing masturbation] it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal. (18) In other words, in controlling syphilis circumcision was preferable to condoms or health checks because it would discourage pre- and extra-marital sex. The value of the operation would be enhanced by its effect in diminishing the sexual appetite: The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. (19) Such a frank acknowledgment of the effect of circumcision on sexual function showed a greater sense of realism than some of Hutchinson's other pronouncements on disease. Notable among these was his obstinate belief that leprosy was caused by eating rotten fish. He first wrote a paper on the subject in 1863, and even the discovery of the guilty bacillus in 1874 did not turn him from his path: Why was leprosy associated with coast-dwelling peoples? Why was it common in Europe in the Middle Ages, when everybody ate fish on Fridays, but rare today, when the practice was less strictly followed? Neither the public nor his colleagues were convinced, so in 1906 he wooed them with a book called On leprosy and fish eating, in which he not only amassed the statistical evidence, but demanded strict government regulation of the fish industry as the only effective means to address the problem. Among his scientific claims were that leprosy could be cured by abstention from fish and the use (both internally and externally) of "Chaulmoogra oil" (whatever that was); and that the bacilli of tuberculosis and leprosy were "differentiated forms of the same organism". (20) Hutchinson was not able to produce statistics as telling as those which proved that circumcision conferred protection against syphilis, and doctors had nothing to gain from closer supervision of the fish trade, so the "Fish â€“ control of leprosy regulations" did not emerge to complement the public health advantages of routine infant circumcision, and a startling epidemiological insight faded quietly away. As it turned out, Hutchinson's theories of syphilis prevention were as wrong as his ideas about leprosy. Gradually it was realised that any reduced incidence of venereal disease among Jews was the result of cultural and lifestyle factors: the quarantine effect of segregation and a low level of sexual promiscuity. The position was put clearly by Ephraim Epstein, a Russian Jew practising as a physician in Cincinnati, USA, who commented in 1874: In common with others ... once I believed that circumcision affords a protection against venereal [diseases], but my practice in Vienna ... and in this country since 1862 persuaded me fully to the contrary. The apparent immunity which the Jews of Russian and European Turkey ... seem to enjoy from venereal diseases arises from their greater chastity and the practice of early marriage. ... The singular pre-eminence of the Jews in health is a mere fiction, propounded either by those who are not acquainted with the Jewish race in this country, or by certain Jewish enthusiasts who have a special axe to grind. (21) It was also realised (as even Hutchinson had admitted) that the operation, in the days before aseptic surgery, actually infected many babies and children with syphilis, tuberculosis and other diseases, not to mention ordinary gangrene. (22) Circumcision played no role in the eventual conquest of syphilis, which was tamed by growing use of screening and early identification, condoms, Metchnikoff's ointment and Salvarsan, and defeated in the 1940s by penicillin. (23) Hutchinson's broad theory of disease causation belonged firmly to the eighteenth century: a mixture of divine providence and human error. He agreed with Thomas Sydenham (an English medical writer of the seventeenth century) that "of acute diseases, God is the cause; of chronic ones, ourselves". (24) Yet there is not such a yawning gulf between his approach and that of agenda-driven researchers like Dr Castellsague's team, both of which know what they want to find and are inclined to ignore contradictory or confounding data. Hutchinson all but admitted that he sought evidence only for what he already wanted to prove: as he confessed in 1890, "I had long ago adopted the rule, to believe only what I thought likely to be true". (25) Following this principle, it would be impossible to discover anything that would shake his opinions. His decision to collect statistics on the incidence of VD among his Jewish and non-Jewish patients arose from his certainty, "long entertained by many surgeons", as to the prophylactic value of an early circumcision; his aim was to support the opinion he had "long shared" with his friend Mr Forster that infants with tight foreskins should always be circumcised. (26) Commending Dr Castellsague's study, and welcoming the clinical implications, the editorial writers of the New England Journal of Medicine affirmed that it had merely verified what they had "long ... suspected": that (male) circumcision reduced the risk of cervical cancer. (27) The deeper truth is that the NEJM has been sniping at the foreskin for decades, deplores the decline of routine male circumcision in the USA and is very annoyed with the American Academy of Pediatrics for changing its policy in 1999. During the nineteenth century (as the Boston Medical and Surgical Journal) it regularly published articles like "Seminal weakness: Castration" (Vol. 29, 1843), "Insanity cured by excision of the external organs of generation" (Vol. 32, 1845), "Surgical treatment of hopeless cases of masturbation and nocturnal emissions" (Vol. 109, 1883), and "Excision of the clitoris as a cure for masturbation" (Vol. 66, 1862). Its latest attack on the male body is quite in accord with its finest traditions. Why, indeed, would you single out a certain part of the body for investigation unless you wanted to find evidence for its guilt in some wrongdoing? Reading the NEJM and its colourful press release, you would think that the cause of cancer was the foreskin, not a virus. And why the sex discrimination? Doctors are not blaming women for infecting men with HPV, but where else do they get it from? If the foreskin provides a nest for the virus, so does the clitoral hood and the folds of the labia in females; perhaps routine circumcision of women would reduce the incidence of HPV infection and penile cancer in men. Because western doctors now regard amputation of any part of the female genitals as mutilation, however, they no longer have any interest in exploring this intriguing therapeutic possibility, and they do not seek associations between normal female anatomy and risk of disease. It is different in the Islamic cultures which practise various forms of female circumcision, where doctors and religious leaders make similar claims about its benefits for women's health.(28) An Egyptian Muslim cleric who overturned a government ban on female circumcision in 1997 not only thanked God for preserving a religious requirement handed down by mothers and grandmothers for fourteen centuries, but stated that the operation protected the nation from AIDS by reducing promiscuity. (29) In explaining the link between circumcision and disease control in behavioural rather than anatomical terms, the priest showed a better understanding of the epidemiology of STDs than many medical researchers. It would seem that the agenda in 2002, as it was in 1855, is to find a scientific/medical rationale for a culturally-derived impulse to circumcise male infants. But why stop there? Think how much healthier the whole population would be if other troublesome body parts were amputated before they could get up to mischief. Mucous membranes seem to be a weak link in the body's defences, so off with the lips for a start; and perhaps we could revive the painful nineteenth century practice of cauterising the urethra with silver nitrate so as to reduce susceptibility down there. Excising a lung would cut down the surface area of treacherous pulmonary mucosa by 50 per cent, thus reducing vulnerability to airborne infections like tuberculosis and bronchitis. Amputation of the right hand in all men at birth would do much to protect women from the slaps, punches and beatings they routinely receive from abusive fathers, husbands and lovers, and give them a greater chance of resisting rape. One of the major sources of injury and disease in boys are cuts and fractures on the legs, arising from the fact that normal boys are born with two and are thus inclined to run about recklessly. Later they play rough sports and ride motorbikes, the accidents from which are a serious burden on the public health system. Jonathan Hutchinson's own omission with respect to such excess risk should be lesson to us. One of his sons died as a result of tetanus caught from a graze on his leg sustained in a fall. Had he been the beneficiary of a thoughtful pre-emptive leg amputation in infancy he would not have been running around so promiscuously, would not have fallen over, would not have cut his leg and caught a fatal disease, and he might well have lived long enough to make contributions to medical knowledge and human happiness as great as those of his father. <h3>References</h3> 1. Oxford Companion to Medicine, New York 1986, Vol. 1, p. 569 2. Xavier Castellsague et al, "Male circumcision and penile Human Papillomavirus infection and cervical cancer in female partners", New England Journal of Medicine, Vol. 346, 2002, pp. 1105-1112 3. For the connection: Handley WS. The prevention of cancer. Lancet 1936 May 2;1(5879):987-91; Wynder EL et al, A study of environmental factors in carcinoma of the cervix. Am J Obstet Gynecol 1954;68:1016-52. Against the connection: Aitken-Swan J, Baird D. Circumcision and cancer of the cervix. Br J Cancer 1965 Jun;19(2):217-27; Terris M, Wilson F, Nelson JH Jr. Relation of circumcision to cancer of the cervix. Am J Obstet Gynecol 1973 Dec 15;117(8):1056-66; Brinton LA, Reeves WC, Brenes MM, Herrero R, Gaitan E, Tenorio F, de-Britton RC, Garcia M, Rawls WE. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989 Aug. 15;44(2):199-203. See also George Denniston, "Tyranny of the victims: An analysis of circumcision advocacy", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999, pp. 226-7. It has recently (2003) been established by Israeli reserachers that the reduced susceptibility of Jewish women to cervical cancer is the effect of a protective genetic mutation: See Menczer J. The Low Incidence of Cervical Cancer in Jewish Women: Has the Puzzle Finally Been Solved? IMAJ 2003;5:120-3. <a href="http://www.cirp.org/library/disease/cancer/menczer1/" rel="noopener" target="_blank">Full text available here.</a> 4. Herbert Hutchinson, Jonathan Hutchinson: Life and letters, London, Heinemann, 1946, p. 30 5. James Copland, A dictionary of practical medicine, 4 vols, London, Longman, 1844-58, "Pollution", Vol. III, pp. 442, 445 6. Jonathan Hutchinson, "On the influence of circumcision in preventing syphilis", Medical Times and Gazette, NS Vol. II, December 1855, pp. 542-3 7. Ben Weinreb and Christopher Hibberd (eds),The London encyclopaedia, London, Macmillan, 1983, p. 614 8. V.D. Lipman, A history of the Jews in Britain since 1858, Leicester University Press, 1990, pp. 12, 14 9. E. Harding Freeland, "Circumcision as a preventive of syphilis and other disorders", Lancet 1900 (2), 29 December, pp. 1869-71 10. Abraham Wolbarst, "Universal circumcision as a sanitary measure", Journal of the American Medical Association, Vol. 62, 1914, pp. 93-4 11. "Circumcision and VD", Newsweek, 21 July 1947, p. 31 12. Herbert Snow, The barbarity of circumcision as a remedy for congenital abnormality, London, Churchill, 1890, p. 32-3 13. Jonathan Hutchinson, "A plea for circumcision", Archives of Surgery, Vol. II, 1890, p. 15 14. Jonathan Hutchinson, "On circumcision as a preventive of masturbation", Archives of Surgery, Vol. II, 1890, pp. 267-9 15. Jonathan Hutchinson, "On circumcision", Archives of Surgery, Vol. IV, 1893, pp. 379-80 16. Richard Davenport-Hines, Sex, death and punishment: Attitudes to sex and sexuality in Britain since the Renaissance, London, Collins, 1990, p. 194 17. Hutchinson, Life and letters, p. 200 18. "The advantages of circumcision", Medical Review, Vol. 3, 1900, p. 641 19. "The advantages of circumcision", pp. 641-2 20. Hutchinson, Life and letters, Chap. XXII, esp. p. 209 21. Ephraim Epstein, "Have the Jews any Immunity from Certain Diseases?", Medical and Surgical Reporter (Philadelphia), Vol. XXX, 1874, pp. 40-41, part quoted in Sander Gilman, Freud, race and gender, Princeton University Press, 1993, p. 64 22. Gilman, pp. 60-70; John M. Efron , Medicine and the German Jews: A history, New Haven, Yale University Press, 2001, pp. 177, 222-30 23. Milton Lewis, Thorns on the rose: The history of sexually transmitted diseases in Australia in international perspective, Canberra, AGPS, 1998 24. Hutchinson, Life and letters, p. 28 25. Hutchinson, Life and letters, p. 203 26. J. Cooper Forster, "A few remarks on the surgical diseases of children: Part 1, Congenital phimosis", Medical Times and Gazette, NS Vol. II, November 1855, pp. 491-2 27. Editorial "Cervical cancer and the elusive male factor", New England Journal of Medicine, Vol. 346, 2002, p. 1160 28. David Gollaher, Circumcision: A history of the world's most controversial surgery, New York, Basic Books, 2000, Chap. 8, esp. p. 199; Sami A. Aldeeb Abu-Sahlieh, Male and female circumcision among Jews, Christians and Muslims: Religious, medical, social and legal debate, Warren PA, Shangri-La Publications, 2001, pp. 185-7 29. Los Angeles Times, 25 June 1997 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The crotchets of Sir Jonathan Hutchinson darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Sir James Paget foreshadows modern research</h3> In recent times there has been a considerable effort to retrieve and restore the traditional knowledge about the <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">importance of the foreskin</a> for male sexual function (and <a href="http://www.cirp.org/library/anatomy/ohara/" rel="noopener" target="_blank">female sexual enjoyment</a>) that was common before the rise of the masturbation phobia and the consequent establishment of circumcision as a valid medical intervention. While several studies have shown that the presence of the foreskin makes a significant contribution to male sexual sensation, the Canadian pathologist John Taylor has gone further to suggest that the foreskin also plays an important role in the reflex actions that govern both erection and ejaculation. On these points, it is interesting to find that his hypotheses were anticipated by the prominent nineteenth century physiologist, James Paget, who recognised the role of the prepuce in reflex actions as early as the 1850s. Whether Paget's comments were ever published in a medical journal or in one of his own publications must await further research, but we do have a letter that he sent to William Acton, published in the first and second editions (1857 and 1858) of his best-selling treatise, The Functions and Disorders of the Reproductive Organs. Acton dropped Paget's comments from all subsequent editions of this book, and the reason is not far to seek. The decision had nothing to do with the scientific validity of Paget's suggestions, but was determined because Acton wanted to promote circumcision â€“ as an aid to chastity, a preventive of masturbation, and a protection against syphilis â€“ and was well aware any evidence as to the physiological significance of the foreskin had to be suppressed. If people were aware that the foreskin made a difference to male sexual response, it would be much harder to convince them to cut it off. Although Acton wanted to assert that there is no difference in sexual sensation between the normal and the circumcised penis, he was at least honest enough to admit that the question is difficult, if not impossible, to answer. The same degree of honesty is not, sadly, apparent in some of his anti-foreskin disciples today. The relevant passages from Functions and Disorders of the Reproductive Organs (2nd edition, 1858) are reproduced below. <h4>Sexual congress, or the act of copulation</h4> In order to fulfil the purposes of the Creator, sexual congress is necessary. This is brought about by the influence of the sex-passion; and for its more certain fulfilment is attended with a considerable degree of pleasure. Mr Paget thinks that the prepuce is of importance in exciting the reflex action. He has kindly committed his opinion to paper. He says â€” "The function of the prepuce in the act of copulation is explicable on the principle that, other things being equal, the force of a reflex act is directly proportionate to the force of the incident impression which it follows. The contraction of the pupil is thus a measure of the intensity of light on the retina: the quantity and rapidity of secretion of saliva is proportionate to the quantity and strength of an irritant taken into the mouth; and so on, in numerous instances. "In like manner, the energy of the secretion and expulsion of the seminal fluid during copulation will (other things being equal) be proportionate to the quantity of highly excitable surface which is stimulated by the act. The mucous membrane of the prepuce, naturally reverted during copulation, supplies a large extent of highly-excitable surface; and the stimulus of its nerves, added to that of the nerves of the glans, increases the force of the incident impression on the spinal cord (and brain), and thus increases, in the same measure, the force of all the reflex acts. The importance of the prepuce, in this view, may be estimated by the difference between the sensibility of its mucous membrane and that of the common integument of the penis, or that of such a scar as may remain after circumcision." [The preceding passage is found only in the 1st and 2nd editions, 1857 and 1858; it was removed from all subsequent editions. The following paragraphs were substantially retained in subsequent editions, but heavily revised. Acton's following comments explain why.] Admitting, as I do, that this distinguished physiologist is right in the abstract, I still am of opinion that the prepuce in man (at least in civilized life) is the cause of much mischief, and that we could well spare that organ. As affording an additional surface for the excitement of the reflex action, this fold of membrane, in the present state of society, aggravates an instinct rather than supplies a want. The tenor of all I daily observe shows that, in the unmarried, it additionally excites the sexual desires, which it is our object to repress. In the act of sexual congress its existence may, I grant, give additional pleasure; and as age advances it may be necessary to copulation. Without it there may be a difficulty in exciting the flagging powers; but in the present state of society, all tends to prove that we require restraint, not excitement. In animals, the prepuce, I admit, not only protects the delicate glans penis from injury, but enables the intromittent organ of the male to be brought into an erect state by yielding to an extent that is not required in the human being. ... In monkeys there is no fraenum, [1] and this, doubtless, serves some good purpose, although we may fail to discover it. Man, in a state of nature, and the lower classes of civilized society, receive thorough protection from the foreskin; but to the sensitive, excitable, civilized individual the prepuce often becomes an additional source of mischief. In the East, the collection of the secretions between it and the glans causes irritation and its consequences; hence the origin of circumcision. That the existence of the foreskin predisposes to many forms of syphilis, no one can doubt; and, lastly, I am fully convinced that the excessive sensibility induced by a narrow foreskin, and the difficulty of withdrawing it, is often the cause of emissions, masturbation, or undue excitement of the sexual desires, which it becomes very difficult for the sufferer to endure. That Jews and those who have undergone circumcision enjoy as much pleasure in the copulative act as the uncircumcised admits of no decisive proof; but I am assured by those well able to speak upon the subject, that the former do not complain. Source: William Acton, The Functions and Disorders of the Reproductive Organs in Youth, in Adult Age and in Advanced Life. Considered in their Physiological, Social and Psychological Relations, 2nd edn (London: John Churchill, 1858), pages 23-24 <h4>Note</h4> 1. In fact, chimpanzees, the closest relative to humans, have a foreskin but no glans, suggesting that the former is the more important structure. It is conventionally assumed that the key element of the penis is the glans and often said that the main function of the foreskin is to "protect it", but the fact that the only penile features common to all primates are the prepuce and corpus cavernosum suggests the plausibility of John Taylor's contrary suggestion that the glans may well be there to protect and support the foreskin. See Cold and Taylor, "The prepuce", 1999; Chris Cold and Ken McGrath, "Anatomy and histology of the penile and clitoral prepuce in primates: Evolutionary perspective of specialised sensory tissue in the external genitalia", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice (New York: Kluwer Academic/Plenum Publishers, 1999), p. 23; and Taylor et al, The Prepuce, 1996. </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The reflex action of the foreskin darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h3>Athol Johnson discovers a new and hopeful treatment for masturbation</h3> The following article was published in The Lancet â€“ then, as now, one of the leading British medical journals â€“ in 1860. You will note that Mr Johnson also recommends clitoridectomy in serious cases of masturbation in girls, but considers that this will rarely be necessary, since they are less prone to the habit than boys. The subject of this communication is one of high importance in its relation to the physical as well as to the moral well-being of too large a number of persons in early life. Its repulsive nature, however, and the natural desire to ignore the existence of such a practice as onanism, have prevented the attention of our profession from being willingly turned to it, and have caused too frequently those who are actually suffering from its effects, or who can be terrified into the belief that such may be the case, to fall easy victims to the rapacity of advertising quacks and of ignorant extortioners. Even now, I shall gladly confine my observations to the disease (for such it really becomes) of onanism as we meet with it in infancy or early childhood. The following case, which I was lately urged to take charge of at the Hospital for Sick Children, will serve as a fair specimen of the course the affection takes, the origin from which it may spring, and the consequences it may induce. [The case of George A] George A--, six years of age, was admitted under my care in January of the present year. He had been in good heath till he was two years and ten months old, at which time he was sent from home into the country, where he was put to sleep with a girl fourteen or fifteen years of age. Soon after this his health appeared to fail, and he became weak and ailing, but without any definite malady. Under tonic treatment some improvement took place, followed, however, by frequent relapses, and five months ago a new symptom manifested itself in the shape of deafness. He was then removed to London, and again came under the care of his parents, who were distressed to find, in addition to his deafness, that his appearance was much changed, and that from being a fine, stout child he had the aspect of a little old man. It was soon noticed that his hand was frequently applied to his penis, which was often in a state of erection, and that the prepuce was somewhat elongated. He was taken to a dispensary, where he was sounded, under the impression that a calculus might be present, but no stone was detected, and in fact no irritation of the bladder really existed. Suspicion arising on the part of his parents, a close watch was set upon him, when it was discovered that he was nightly in the habit of practising onanism. To put a stop to this, various means were adopted, including severe punishments by his father, after which he would promise to abstain, but during sleep he would get restless and excited, and on waking up would continue the practice, emission taking place. His hands were then fastened out of bed, but he still effected his purpose by a peculiar convulsive or instinctive movement of the thighs. Repeated immersion in cold water at these times, and all other plans suggested having been employed ineffectually, as a last resource he was brought to the hospital. The child confesses readily that the practice began from the time of sleeping with the girl, and that it had been continued at least once nightly ever since. He promises and appears anxious to leave it off, but owns that he cannot restrain himself when he gets excited. He was directed to sleep with his hands out of bed, and under the immediate surveillance of the night nurse. After the first night or two, the restlessness and movements were resumed, but of course immediately arrested. He was then placed on bromide of potassium, and afterwards on belladonna. Perfect cleanliness was inculcated, especially with regard to any secretion between the foreskin and the glans; and bathing etc was ordered. At the same time he was informed that it would be necessary, on account of his health, to perform an operation, with the hope that the dread of this might prove effectual; but the nocturnal excitement still continued, and I have at last removed a portion of the foreskin, without placing him under chloroform. Since the operation he has been perfectly quiet, and he has now left the hospital, with instructions that he is to be brought back if any relapse occurs. [Discussion] This case shows us how deeply rooted the vicious habit may become even at a very early age, for it was probably commenced in this instance soon after the child attained his third year; it also points out the ill consequences which may arise from placing male children to sleep with young females, and the care which should be taken in this respect even in infancy. My attention has been more drawn to this danger from my having another case at the same time under my care at the Children's Hospital, in which a boy seven years old was admitted with severe gonorrhoea and buboes, apparently contracted from a servant girl fifteen years of age, with whom he had been in the habit of sleeping. [Literature review] It must not be thought that the case of onanism I have related is a very exceptional one, nor that it is confined to the male sex, for it prevails amongst very young girls much oftener than is generally supposed. Many writers have noticed the very early age at which children give themselves up to it. Barthez and Rilliet, for instance, in their celebrated work on the "Diseases of Children", state that it cannot be concealed that "it is often very young children who abandon themselves to it with fury;" and they place this among the causes which may give rise to tuberculosis. M. Marjolin is reported, in the Gazette des Hospitaux, to have stated that "the youngest children are not exempt from the vice; that it is observed at the Hopital des Enfans Malades, and even sometimes, which may appear almost incredible, in children still at the breast. Fournier and Bergin assert that they have several times observed it in infants, and detail the case of a girl four years of age, who gave herself up to masturbation, as it were instinctively. The real nature of the affection was not discovered for four years, and, notwithstanding the means adopted, the child ultimately expired in a state of frightful marasmus, carrying on the practice to the very last moment of her existence. Vogel, too, alludes to a little girl three years of age, in whom repeated attacks of epilepsy occurred, after onanism had been indulged in for six months. Zimmerman notices the frequency of the occurrence; and Dr Van Bambeke relates three cases in children from three to twenty months old, the first child being a male, the other two females. In infancy, and even at a slightly more advanced age, the attention of the parents is the less directed to the practice because the hand is commonly not employed, the irritation being effected by a kind of instinctive or convulsive movement of the thighs, as was seen in the boy at the Children's Hospital. These movements, when noticed, are naturally not attributed to their real cause, but referred to the irritation of worms, or to some other innocent origin, and allowed to go on unchecked. According to Dr Van Bambeke, who has written an interesting article on the subject in L'Union Medicale, the face of the infant at this time becomes injected and covered with sweat, the eyes are brilliant, and the child is abstracted from objects around. It generally lies down rather than sits, fixing itself against some object by way of fulcrum. The spasmodic condition, he continues, is followed by pallor and depression; and in one of the little girls, in whom the periods of excitement were very frequent, the erectile organs had acquired a pretty considerable development. [Evil consequences of masturbation] The consequences of this practice are probably more serious at an early age than at a later period. In infancy the nervous system, especially its excito-motory portion, is highly excitable, and its functions are performed with great activity; but reaction and subsequent exhaustion are keenly felt. It is probable, therefore, that the repeated and violent excitation of the system may lead to derangement as regards both its intellectual and organic functions. The irritability of the mind and body, the peevishness, the alteration of the habits and general tone, together with the deterioration of the mental faculties occasionally observed in children, may possibly, in some cases, be attributable to this cause, and be the less amenable to treatment as their origin is hardly likely to be suspected. The disturbance of the nervous system is attended, usually, with some derangement of digestion and nutrition â€“ functions of the highest importance at this age. The appetite becomes capricious, the muscles get weak and flabby, there is general wasting and, in some cases, a decided state of marasmus. I have already stated that Barthez and Rilliet place this vice amongst the causes which may lead to tuberculosis. The special senses, too, are occasionally impaired; that of hearing, for example, in the child whose case I have given; and of vision, as noticed by Mr Kane, who attributes some forms of night-blindness, as well as of amaurosis, to indulgences of this description. I may mention also that Marjolin asserts that "almost all children affected with Pott's disease" (of the spinal column) "give themselves up to onanism with a sort of fury"; though whether, supposing any connexion to exist between the two, the disease of the spine is the consequence or the cause of the practice may possibly admit of a question. As a predisposing cause we may possibly refer to the excitability of the nervous system in early life, which is much more marked â€“ at least as regards the generative organs â€“ in some children than in others, and varies, perhaps, in different nations; for I hope that in this country the habit in question is more uncommon than would appear to be the case in France. At the period of dentition, this irritability of the nervous system is more noticeable; and Dr Van Bambeke is inclined to assign the origin of the practice, in many cases, to this cause. [Treatment in infancy] Everything, however, which contributes to the excitation of he genitals may lead to the evil, for an act from which a pleasurable sensation is once experienced by the infant, may, unfortunately, degenerate into a habit. When any suspicion, therefore, exists great care should be taken with respect to the child's bed, which should be neither too soft nor too warm, whilst the custom should be early acquired of sleeping with the arms outside the clothes. In males, a deposit of sebaceous secretion under the prepuce, and around the corona glandis, frequently occasions considerable pruritis, especially when a tendency to phymosis is present; and in both sexes the irritation of the parts from the existence of herpetic or other slight inflammatory affections may induce masturbation. The genital organs, therefore, ought in all cases to be carefully examined, and any source of irritation at once removed. The existence of thread-worms in the rectum, or between the labia, where they may often insinuate themselves, should likewise be sought for, and means taken for their extirpation. The condition of the urine should also be attended to, for irritation of the neck of the bladder from certain conditions of this secretion, leads to great excitement of the genitals and, not unfrequently, to their being pulled about, as is seen so commonly in cases of actual or suspected stone. In infancy, if these points are looked to, and if care is taken instantly to check the movements as soon as the attention of the other is directed to their nature, a victory may soon be gained; for surveillance in these cases, as Dr Van Bambeke remarks, is easy, the infant seeking no concealment. Cleanliness, of course, is of the greatest importance, and the sudden dash of cold water over the parts, at the very time of the excitement, will perhaps produce such a shock as to arrest the practice at once and for ever. [Treatment in childhood] At a somewhat later age â€“ that is, in early childhood â€“ when the habit has been persevered in for some time, the cure becomes more difficult. Any appeal to the moral sense, of any description of the evil consequences which may ultimately ensue, though recommended by some authors, I believe to be not merely useless, but injurious. If the child has not already acquired the vice you run a great risk of teaching it to him; and if he has, an indefinite and unknown future evil will never lead such a child to abandon a present gratification. Great prudence, therefore, should be exercised in our investigations; and it may be desirable to be acquainted with a test which Dr Donne asserts will enable us occasionally to recognise the existence of the practice â€“ namely, the examination of the urine, which will present, shortly after the completion of the paroxysm, some mucus mixed with oxalate of lime. The same care should be exercised at this age as in infancy in the removal of any exciting cause which can be discovered; the greatest cleanliness should be enjoined, cold bathing ordered, and the condition of the urine carefully attended to. During the day, a full amount of muscular exercise should be enforced, so that at night the consequent fatigue should render sleep prompt and necessary. Careful surveillance should be employed, and the hands kept outside the bedclothes, or actually fastened down; in extreme cases, too, we may adapt a shield of gutta percha, or other suitable material, so constructed as to prevent friction of the parts either by the hand or in the manner already alluded to. I have made a short trial of bromide of potassium, in consequence of its asserted emasculating properties; and of belladonna, on account of its great power in relieving the irritation which leads to nocturnal enuresis; neither of these remedies, however, had much effect. [Benefits of circumcision] The means I have related will often fail of even temporary benefit, for the act can be accomplished simply by the muscular movements already alluded to. In such cases we must, I believe, break the habit by inducing such a condition of the parts as will cause too much local suffering to allow of the practice being continued. For this purpose, if the prepuce is long, we may circumcise the male patient with present and probably with future advantage; the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate. In the female, Dr Gros has advocated, in like manner, complete to partial amputation of the clitoris; this, however, would seldom be called for, except, perhaps, in those cases where furious masturbation is associated with congenital malformation of the organ. In both sexes, if the use of the knife should be considered unavoidable, and the practice be still continued after all obvious exciting causes have been removed, various irritating applications may be used locally, so as to render any movements of the parts painful. These are most likely to be called for in boys, for in female children, with the exception of the congenital cases I have alluded to, the practice seems to be more easily checked by surveillance than it is in males. [Conclusion] In conclusion, I have only again to call attention to the great care and caution to be exercised in the selection of those, whether of the same or of the opposite sex, with whom we allow children even of tender years to sleep or associate familiarly. Bad habits are easily acquired, but are lost with difficulty; ill health at the time and formidable disease in the future, mental impairment and moral degradation, may be the lamentable consequences of negligence in this respect on the part of the parents. Athol A.W. Johnson, FRCS,* "An injurious habit occasionally met with in infancy and early childhood", The Lancet, 7 April 1860, p. 344-5 * Surgeon to the Hospital for Sick Children and Lecturer on Physiology at St George's Hospital </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Masturbation and circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Editorial, Medical Times and Gazette, 13 April 1867</h2> <h2>Background</h2> Although this is one of the most hypocritical documents in British medical history, its is also one of the most useful for illuminating the origins and nature of the double standard on male and female genital mutilation which persists to this day in English speaking countries. While it seeks to quarantine "mere circumcision" from real mutilation, it nonetheless makes a cogent and powerful case against any form of genital alteration which is performed without informed consent. The editorial was a response to the disgrace of Isaac Baker Brown, a prominent gynaecologist and dextrous surgeon who had made a name for himself as an authority on the female genitals, and the advocate of a procedure intended (guaranteed!) to cure many obscure nervous diseases â€“ clitoridectomy. Brown claimed that conditions such as hysteria, epilepsy and catalepsy, as well as the masturbation which gave rise to them, could be prevented by the excision of the clitoris, and he insisted that he was merely following the lead of surgeons such as Jonathan Hutchinson, who had similarly asserted that masturbation in boys could be stopped by amputation of the foreskin. We should particularly note Brown's insistence that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. In his genius for self-promotion, as well as in his conviction that he had found the magic bullet for the most intractable diseases of his age, he might be regarded as the Roger Short of the mid-nineteenth century. During the early 1860s Brown enjoyed considerable celebrity, but his methods came under attack in 1866, and the following year he was disgraced and expelled from the Obstetrical Society. In this editorial the Medical Times and Gazette explains why clitoridectomy is both scientifically unsound as medical therapy and a violation of medical ethics in terms which are still relevant today. Although it tries to quarantine male circumcision from female genital mutilation in a manner all too familiar to us, its reasoning here is feeble and the discrimination fails. The foreskin is also "an organ of exquisite sensitiveness, well supplied with blood vessels and nerves"; like clitoridectomy, circumcision is also an operation "occasionally attended with serious bleeding".* On the principle stated here â€“ that sensitive organs, well supplied with blood vessels and nerves should not be excised without the informed consent of their owner â€“ the editorial may be read as an attack on both clitoridectomy and circumcision, and a clear statement of why each procedure is an offence against both medical science and medical ethics. * Indeed, while there are numerous reports in nineteenth century medical journals of deaths and complications from circumcision, similar reports on clitoridectomy are very hard to find, suggesting that the latter was in fact the safer operation. <h4>Further reading:</h4> J.B. Fleming, "Clitoridectomy: The disastrous downfall of Isaac Baker Brown FRCS (1867)", Journal of Obstetrics and Gynaecology of the British Empire, Vol. 67, 1960, pp. 1017-34 Ornella Moscucci, "Clitoridectomy, circumcision and the politics of sexual pleasure in mid-Victorian Britain", in Andrew H. Miller and James Eli Adams (eds), Sexualities in Victorian Britain, Bloomington, Indiana University Press, 1996 Robert T. Morris, "Is evolution trying to do away with the clitoris?", Transactions of the American Association of Obstetricians and Gynaecologists, Vol. 5, 1892, pp. 288-30 <a href="http://www.cirp.org/library/ethics/" rel="noopener" target="_blank">CIRP ethics and human rights pages</a> Margaret Somerville, "<a href="http://www.intact.ca/canary.htm" rel="noopener" target="_blank">Altering baby boys' bodies: The ethics of infant male circumcision</a>" <h3>Clitoridectomy and Medical Ethics</h3> Medical Times and Gazette Saturday, April 13, 1867 THE operation of clitoridectomy, as performed under the conditions described in Mr. Baker Brown's writings and denounced in Dr. West's lectures, is an offence against Medical science and Medical ethics. 1. It is an offence against Medical science in the first place, that it should be described as a mere circumcision. (Note a) Instead of taking away a loose fold of skin, it removes a rudimentary organ of exquisite sensitiveness, well supplied with blood vessels and nerves, and the operation is described by the author as occasionally attended with serious bleeding ; in these respects it differs widely from circumcision. It is a second error to assume that if a woman desired to continue filthy habits this operation would stop her. The organ removed is but one amongst many susceptible of intense excitement. (Note b) In the third place, it is against all Medical science to remove such a part because "subject" (or subjected?â€”see note) "to unbearable irritation." Intense itching is a common malady, but this itching does not depend on local causes, and it may generally be relieved by proper measures. To cut off part of the body because it itches is monstrous. If indeed the clitoris be diseased, that is another thing ; but as clitoridectomy is practised, the part is cut off without any signs of disease in it. It is nothing to the purpose to affirm that clitoridectomy may have been successful in postponing epileptic fits or lengthening their interval. Any positive line of treatment will do that for a time. Many young men believe for three months that they have found a specific for epilepsy. An intimate friend lately thought he had found one in colchinum. Give enough of any potent drug to make the patient ill, break a leg, or cut off the clitoris, and the fits will probably be interrupted for a time. Neither is it to the purpose to accuse Mr. Brown of having performed an operation rashly, groundlessly, and unsuccessfully Many such operations have been performed in the best faith. Marshall Hall used to propose tracheotomy for epilepsy ; a living Surgeon once performed castration for the same malady ; each operation thoroughly unsuccessful, and not to be defended, save on the ground of the good faith of the proposers, and of an enthusiasm which had carried them beyond the bounds of sound discretion. Although, then, clitoridectomy must be condemned as an offence against Medical science, if that were all, it might let pass into oblivion without further notice. It is the offence against Medical ethics which it involves, which has secured for it the reprobation of the Profession. 2. It is an ethical offence, in the first place, if the Practitioner who is consulted for any common complaint, say hysteria, or fissure of the rectum, set himself to consider whether or not the patient is guilty of immoral practices, which have nothing to do with the case before him. Thus, as we said in our last number, and as we implied in the Med. Times and Gaz. June 4, 1864, if the clitoridectoral theory and practice were established, no parent who sent a daughter to any Medical man for any complaint whatever, could be sure that she might not return tainted with filthy inquiries, or branded by filthy suspicionsâ€”a thing incompatible with the honour of the Profession, and the possibility of that unrestrained frank intercourse between Practitioner and patient that happily exists now. As an illustration of this kind of breach of Professional honour and its consequences, we will mention a case which was shortly touched on in our first article in the number for June 4, 1864. A young lady was brought by her friends,* ten or twelve years ago, to a Surgeon practising specially on the rectum, for a fistula. He did not content himself with exploring the fistula, but ascertained that she had lost her virginity, and told her father so. The consequences were frightful, including a painful trial, and loss of honour, character, and position to the parties concerned. All this, because the Surgeon had gone out of the path of his duty, and, instead, of confining himself to the malady for which he was consulted, had gratuitously imported into it certain moral considerations with which he had nothing to do. If this were a habit with Medical men, there would be an end to the present free an honourable intercourse with their patients. We should be accused, and justly, of making prurient, or indecent, or degrading inquiries, and of bringing a knowledge of evil to minds from which it had been absent. Affirming then, in the first place, that the very entry of thoughts of pollution into the Practitioner's mind respecting his patients is an offence of the deepest dye, this offence is aggravated by the kind of evidence which the clitoridectomist is taught to accept as proof of his patient's guilt. That evidence consists, partly, in certain physical signs detailed in Mr. Baker Brown's bookâ€”a "peculiar straight and coarse hirsute growth," a peculiar follicular secretion, and other phenomena detected by inspection, which are as frivolous as they are disgusting. It is said by credible witnesses, that at a clitoridectomical operation nose as well as eyes were called into requisition, and that a respectable Practitioner was invited to apply his nose to the parts implicated, in order to satisfy his mind, by this test, that these parts had been subjected to abnormal irritation. The thing is almost too beastly to tell of, but we want to deal with this subject once for all, and to let our readers know why clitoridectomy does not stand in the same category as any other unsuccessful operation. But says Mr. Brown, "before commencing treatment, I have always made a point of having my diagnosis confirmed by the patient or her friends." And this brings us to what we may call the moral evidence on which the patient's guilt is assumed, the process of obtaining which is one of the most heinous offences against good sense and Professional ethics that can be conceived. We have heard of questions put (not by Mr. Brown) to female out-patients after the following fashion:â€”"Do you feel any irritation in certain organs?" "Is it very bad?" "Does it induce you to rub them?" "Does the rubbing ever make you feel faint?" And if the patient answers these questions affirmatively it is said that the evidence of unnaturally excitation is regarded as complete. Nervous young women, as it s well known, may be profoundly ignorant of the nature and drift of such questions. They delight to magnify their own sensations, they enjoy the Physician's sympathy and are sure to answer " yes " to any leading question whatever. But we say that if young women are subjected to such inquiries as these in out-patient rooms at Hospitals and Dispensaries, or by private Practitioners, the sooner the Profession speaks out the better. A Medical consultation may involve the worst contamination to the patient. We think we are justified in saying that the kind of evidence on which the guilt of the woman is assumed is itself an ethical offence. That the performance of clitoridectomy on a woman without her knowledge and consent, as detailed by Dr. West, is an offence against Medical ethics, needs not to be said. We suspect it is amenable to the criminal law of the land. It is an offence against Medical ethics, also, to obtain the woman's consent, nominally, while she is left in ignorance of the real scope and nature of the mutilation, and of the moral imputations which it involves. Consent to a thing whose nature is not known, is like the consent of an infant or lunaticâ€”null and void. Equally do we repudiate, as an offence against Medical ethics, the performance of such an operation, even with the consent, nominal or real, of the patient, but without the full knowledge and consent of the persons on whom she is dependent, as wife or daughter. As the woman's character affects theirs, they have a right to decide whether a female relative should undergo this operation, with the disgrace it involves, or whether relief shall be sought from other means. We may be pardoned for adding that not one of the supposititious cases alleged by Dr. Routh at the late meeting of the Obstetrical Society has the least bearing on or analogy with the performance of clitoridectomy without the knowledge of the patient or her friends. Dr. Routh argued that all the details of every operation cannot be described to patients. But it is not the detailsâ€”it is the moral questions involved in clitoridectomy, which ought not to be kept secret. Dr. Routh argued, also, that there are cases in which a Practitioner is bound to keep a patient's secrets from her husband ; but in cases before us, it is not secrets imparted by the patient, but dishonourable surmises and filthy imputations generated in the mind of the Practititionerâ€”the nature of the mutilation and its disgraceâ€”that are kept secret. Thus, then, we have shown, as shortly as possible, the real position of clitoridectomy as an offence against science and morality, and the reasons why the Medical Profession, as an honourable, moral Profession, whose members have free and familial access to families, must repudiate and utterly reject it. Note a: "Let it be known, once for all, that clitoridectomy is neither more nor less than circumcision of the female; and as certainly as that no man who has been circumcised has been injured in his natural functions, so it is equally certain that no woman who has undergone the operation of excision of the clitoris has lost one particle of the natural functions of her organs. I would here protest against the cruel insinuation made against me by my accusers, that my reasons for performing the operation are because women are subjected to immoral habits ; when, as I have distinctly again and again asserted, I operation because there is undue and unbearable irritation of the clitoris, and in such cases alone is the operation likely to be successful."â€” (Mr. Baker Brown's "Replies to the Remarks of the Council," Nos. 12 and 13.) Note B: For evidence, see Baker Brown on Curability, etc., pp. 12, 18, etc.** <h3>Notes</h3> * "Friends" means close relatives. ** Isaac Baker Brown, On the curability of certain forms of insanity, epilepsy, catalepsy and hysteria in females (London 1866) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clitoridectomy and medical ethics darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>Jonathan Hutchinson on the advantages of circumcision</h2> <h3>1. A plea for circumcision, 1890</h3> It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare". "A plea for circumcison", Archives of Surgery, Vol. II, 1890, p. 15; reprinted in British Medical Journal, 27 September 1890, p. 769 <h3>2. On circumcision as a preventive of masturbation, 1890</h3> The appended letter has been sent to me from the Refractory Gallery of a lunatic asylum. The patient who sends it is himself a surgeon. I venture to bring it before my readers because I believe that the subject to which it refers is an important one, and that my correspondent's views on it are worthy of consideration. The subject is not a novel one. My late colleague, Mr Curling, I know held the opinion that circumcision was of advantage as preventing the tendency to masturbation. At one time he tried to collect facts in order to institute a comparison between Jews and others in respect to that habit, but the distasteful nature of the inquiry I believe caused him to abandon it. It is indeed one upon which it is impossible to collect statistics. General impressions are all that can be had. I have myself, from considerable experience, formed a strong opinion that Jewish young men do not suffer nearly so frequently as others from the maladies which we associate more or less definitely with masturbation and nocturnal emissions. We must remember, however, that in their case we are dealing with the circumcision of infants as preventive, not with that of adults as curative. Under the latter conditions the operation is far less hopeful. Still, I am inclined to believe that it may often accomplish much, both in breaking the habit as an immediate result, and in diminishing the temptation to it subsequently. I know that the reply from specialists will be that the disorder is in the nervous system, and not in the organs, and this no doubt is in part true. The reiterated complaints and confessions of young men, however, force on me the conviction that he habit in question is very injurious to the nerve-tone, and that it frequently originates and keeps up maladies which but for it might have been avoided or cured. I confess I see no reason why a man admitted into an asylum for ailments associated with that vice should not be allowed such chance of relief as the operation offers. I may indeed go further than this and avow my conviction that measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to many patients of both sexes. [Letter quoted] The Hospital for the Insane, W â€”, E â€” Oct. 31, 1890 Dear Sir, â€” The British Medical Journal of the 27th of September, 1890, on p. 769, under the heading "A plea for circumcision", gives this quotation: "It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare". "I have been an inmate here, Sir, for more than seven years, and shall feel exceedingly obliged if you will kindly tell me whether you are aware of any reason why, if I am a confirmed masturbator, circumcision should not be performed upon me? "Will you kindly also tell me whether you think that any good reason can be advanced why Messrs L â€”, S â€”, H â€”, and D â€” (the first three quite young men), who have told me that they masturbate, should not also have circumcision performed upon them? "I mention these gentlemen's names because it seems necessary to establish the facts I mention, so that in the event of an inquiry into the truth of my statement being made, you will find that the above gentlemen have been locked up here for many months past, that they have been masturbators during nearly, if not quite, all that time, and that nothing worth calling efficient medical or surgical treatment has been given them, or been done to them, by either of the medical men, for the cure of this imperious habit." I trust it will not be supposed from what I have written above that I believe that the removal of the testes or ovaries will either completely or in all cases subdue the sexual passion. All that I contend for is that such operations are often and in most persons conducive to that end. "On circumcision as a preventive of masturbation", Archives of surgery, Vol. II, 1890, p. 267-9 <h3>3. On circumcision, 1893</h3> 1. Under what circumstances is the operation of circumcision in infancy desirable? 2. How should it be performed? 3. What special risks attend it? 1. It is imperatively required whenever the prepuce is unusually long and contracted at its orifice. The surgeon should, however, avail himself of every possible opportunity of inducing parents to have their male offspring circumcised. The operation confers great advantages in several different directions. If properly done it has no drawbacks whatever. 2. For the performance of circumcision the surgeon should be provided with two pairs of straight scissors â€“ one large, the other small. Drawing the prepuce a little forward, he should include all that is in front of the glans between the handles of his smaller scissors, and nipping it tightly, should then with the larger ones cut all the projecting part away. This will remove a broad ring of skin and leave the glans covered by only the mucous membrane. Next, with his smaller scissors, he should slit up the mucous membrane and cut it cleanly away level with the corona. Not more mucous membrane than a strip of about one eighth of an inch in width should be left. If any adhesions are present they should be carefully broken down. What remains of the fraenum should now be tied; no other vessels will need attention. Stitches are quite unnecessary, and generally inconvenient and injurious. 3. By far the most important risk is haemorrhage, and very careful attention should be given to the ligature of the fraenum. Many children have died after the operation in consequence of carelessness in this matter. The only other risks are poisoning of the wound by unclean instruments, and the introduction of syphilis by the dressings, etc. (Footnote: In my work on syphilis I have recorded a series of cases in which a Jewish circumciser communicated syphilis by unclean lint. I have recently been consulted in a case in which, in all probability, an operating surgeon did the same by his instruments.) "On circumcision", Archives of surgery, Vol. IV, 1893, pp. 379-80 <h3>4. The advantages of circumcision, 1900</h3> The first advantage of removal of the foreskin is cleanliness. In childhood this is important. In adults the habit of withdrawing the skin and washing the glans has usually been learned, though often it is not practised with sufficient frequency. In children it is, as a rule, never attempted; most boys would regard the attempt as indecent, and in many paraphymosis would result.. Apart from this risk, the practice would be injurious to the morals of the child. Yet the accumulation of smegma and its decomposition is a source of annoyance and irritation to many boys. Any irritation of the surface of the glans penis is liable to produce reflex excitement of an undesirable character. In middle life the possession of a prepuce is to many a source of more or less habitual annoyance. Seborrhoea, balanitis and herpes are common, and sometimes troublesome. As old age comes on the danger of cancer to those who suffer from phymosis is considerable. The number of middle-aged and senile persons who would be both more comfortable and more secure if they had been circumcised in infancy, is large. But the argument in favour of the general practice of circumcision which carries the most weight is that it would reduce the prevalence of syphilis. Mr Hutchinson [that is, yours truly!] many years ago collected statistics as to gonorrhoea and syphilis in Jews, which prove that whilst the former was quite as common [actually x times more common] amongst them as amongst Christians, the latter was much less frequent. This seems to show, what perhaps scarcely needed proof, that it is not to stricter morality but to some adventitious advantage that the comparative immunity of Jews from syphilis is due. The only advantage which can be alleged is the absence of the prepuce. It would, indeed, be difficult to contrive an appendage more likely to facilitate the implantation of the syphilitic virus than the prepuce. By it folds of delicate mucous membrane are kept constantly in a condition the most suitable for the retention and absorption of any virus which may be brought into contact with them. No other measure for the prevention of syphilis which has ever been proposed is so efficient as this. Its effects would be enormous. Most other measures, such as the inspection of prostitutes, have a collateral influence prejudicial to morality. Professedly making irregular sexual intercourse less dangerous, they possibly increase its amount to an extent which more than counter-balances their supposed advantages. They are also injurious to the sense of decency, to say nothing of modesty, and detrimental to the moral conscience of a community. It is not so with circumcision. Effected in early infancy, and with other avowed objects, it would silently become the means of preventing on a large scale the prevalence of a loathsome and misery-producing disease. The extent to which this diminution of risk might tend to increase sexual folly would probably be infinitesimal. The gain would be without any drawback. let it be remembered that a large proportion of the syphilis extant is contracted by young men who are by no means habitually incontinent. It is an open question whether the removal o the prepuce tends appreciably to increase the power of sexual control. Its influence, so far as it has any, must be in that direction. The only function which the prepuce can be supposed to have is that of maintaining the penis in a condition susceptible of more acute sensation than would otherwise exist. It may be supposed to increase the pleasure of the act and the impulse to it. These are advantages, however, which in the present state of society can well be spared, and if in their loss some degree of increased sexual control should result, one should be thankful. "The advantages of circumcision", Medical Review, Vol. 3, 1900, p. 641-2 <h4>Note</h4> Hutchinson was convinced that circumcision reduced the risk of contracting syphilis, but he had no proof of this, only dubious statistical correlations and impressions derived from the reportedly low incidence of syphilis among the Jewish population of east London. On the other hand, as this article and numerous others in the British Medical Journal from this period show, there was incontrovertible proof that circumcision itself was the cause of syphilis, tuberculosis and other diseases in an unknown number of cases (dozens reported, many more likely), as well as deaths arising from the operation itself. Given two sets of facts to choose from, one dubious, the other certain, Hutchinson's prior inclination towards circumcision is proved by his plumping for the former. His procedure is rather like those tunnel-visioned researchers today who, on the basis of some equally suspicious statistical correlations, say that little African boys should be forcibly circumcised to save them from AIDS; yet who, like Hutchinson, ignore the fact that circumcision itself is a significant cause of death among African boys. (Indeed, it is likely that more <a href="http://www.cirp.org/library/death" rel="noopener" target="_blank">African teenagers die as a "complication" of circumcision</a> than from <a href="http://www.cirp.org/library/disease/HIV/" rel="noopener" target="_blank">sexually acquired AIDS</a>.) </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hutchinson on circumcision darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h4>Herbert Snow's attempt to turn the tide</h4> One of the reasons why circumcision remained a minority practice in Britain is that it never commanded the unanimous assent of the medical profession and, unlike in the USA, there were always vocal critics from within the medical fraternity itself. One of the earliest of these was Herbert Snow, who wrote a short book against the rising tide as early as 1890, and which he called The barbarity of circumcision as a remedy for congenital abnormality. <h3> <a name="the"></a>The context</h3> It is not possible to hail Snow's text as a model for today's critics of routine circumcision, much less as a source of reliable anthropological or biological knowledge; what is interesting is not that Snow was ahead of his time, but the extent to which he was bound by the limited and erroneous knowledge of his place and period. The most serious instance of this is his acceptance of the theory of congenital phimosis and consequent belief that the infant's foreskin should be mobile and retractable within a few days of birth. His argument was not that this theory was wrong, but that circumcision was an inhumane and barbaric way to deal with the problem; the right way was by dilation of the foreskin. He thus became one of the founders of the "dilatation vs circumcision" debate, which dominated the discussion of the issue until Douglas Gairdner disproved the theory of congenital phimosis in 1949. Snow's discussion of the historical evolution of circumcision as a religious rite is less off the track, but even there he was often misled by the limitations of the anthropological research available to him. <h4>Snow's argument</h4> In his booklet, The barbarity of circumcision as a remedy for congenital abnormality, Snow's stated aim was "the abolition of an antiquated practice involving the infliction of very considerable suffering upon helpless infants; and sanctioned, on very questionable grounds, by men of eminent authority". This statement concisely set out the terms of his opposition: circumcision was an antiquated religious custom, not a modern medical therapy; it meant suffering and harm to a class of patient who had not given consent; and the grounds advanced to justify it were spurious. He also implied that the advance of circumcision was an effect of the authority of its promoters, not of the quality of their scientific reasoning. On the first point, Snow rejected hygienic explanations for the origin of ritual circumcision and accepted the argument of anthropologists that it was a sacrifice intended for a deity which obviously required appeasement, and probably an attenuated form of what had once been the sacrifice of something yet more precious, such as the entire genitalia or living children. He took the view that the tribes who practised circumcision were barbarians whose customs did not warrant emulation by modern Britons. On the second point Snow made the reasonable suggestion that "no sane man who possessed the advantages of a sound and entire prepuce would willingly sacrifice it without just and sufficient cause being shown". He described circumcision as the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were there no necessity for its presence it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ. Snow then argued that the four advantages claimed by the proponents of circumcision did not stand up to scrutiny. He dismissed "enhanced local cleanliness" as trivial and irrelevant in modern conditions, commenting that nobody advocated similar tactics like shaving the head or pulling out the toenails. On the argument for greater chastity and "preclusion of immoral personal habits", he agreed about the importance of chastity but considered the evidence to be inconclusive; he countered that plenty of Jewish and other circumcised men were known to masturbate, and made the desperate and improbable claim that early removal of the prepuce encouraged infantile fondling. On the argument for protection from venereal disease, he found the case "not proven", and he pointed out that even Hutchinson's statistics showed that (circumcised) Jews were more prone to gonorrhoea. On the claim for protection against cancer of the penis, Snow replied that this was a rare disease of adults, more likely caused by phimosis and poor hygiene than the foreskin per se. Disadvantages of circumcision Turning to the offensive, Snow then listed the "disadvantages and dangers of circumcision", and devoted several pages to a discussion of what are now called "risks and complications": the most common injuries inflicted during the procedure and some of the longer term side effects. He commented that the traditional Jewish practice of metsitsah (the sucking of the penis following the cutting of the foreskin) had been largely discontinued among modern communities because of its role in transmitting syphilis and tuberculosis. He also warned that infection, haemorrhage, ulceration and damage to glans, meatus and shaft were regular occurrences when circumcision was performed in surgical settings, but his case lacked force because he could not produce figures: nobody was recording instances even of immediate injury and death, let alone the longer term problems (such as excessive tissue loss) which might not become apparent until puberty brought the penis to its full size. If official statistics in the 1940s showed 16 deaths each year from surgical complications, it seems likely that the number of fatalities before antibiotics must have been considerably higher. Snow was rare among medical commentators in showing some regard for the boy being operated on as a subject with his own feelings and opinions, rather than a mere object at the mercy of guardians and doctors: An American operator ... speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins and other clothing must long be very painful. There can be little doubt what would be the verdict â€“ could they only give it utterance â€“ upon the immediate results of the operation in question, returned by these inarticulate (if far from mute) victims of hygienic orthodoxy. If Snow was unusual in showing scruples about consent, he was even more radical in admitting that "an objection to circumcision of wholly sentimental character [is] not the less worthy of practical consideration". Why shouldn't boys be emotional about their penis? <h4>Its reception</h4> The barbarity of circumcision was reviewed cautiously by the British Medical Journal, which had reservations about Snow's sweeping rejection of circumcision; and sympathetically by the Lancet, which was "inclined to endorse most of what he says". It agreed that circumcision was a relic of primitive man, pointing out that the peoples which still practised it were "many of the least civilized peoples on the face of the globe". More significantly, it accepted Snow's argument that an operation was rarely necessary "for the relief of congenital phimosis", and it actually proposed that "the prepuce is not the valueless or mischievous appendage that some would have us believe"; although "non-separation of the prepuce from the glans penis is constantly mistaken for phimosis", only genuine cases of the latter required operative treatment. The reviewer did not go so far as to suggest that an adherent prepuce needed to treatment at all, but he supported Snow's view that "forcible retraction" and its "daily repetition for a short time" was all that was required. It is thus clear that Snow was not an isolated voice, but equally apparent that the misconceptions about genital anatomy and preputial development which had originally led to the craze for widespread circumcision were very deeply ingrained. The full text of the reviews in the BMJ and the Lancet are below. <h4>Limitations of Snow's argument</h4> The effectiveness of Snow's intervention was limited by two serious weaknesses. First, he accepted the current medical wisdom that the adherent and non-retractable foreskin was indeed a pathological defect which required speedy correction. he went so far as to write that "a perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the glans", and further conceded that it was "universally agreed" that "the adhesions between the prepuce and the glans can nearly always be broken down ... during the first few weeks after birth". Where he differed from most of his colleagues was in his insistence that this could be achieved by manipulation and dressing, rather than amputation. It was, however, very hard to defend the foreskin by thus conceding the major complaint of its enemies, for it was this very "phimosis" which formed the basis of their charge that it led to childhood masturbation, nervous diseases and increased susceptibility to syphilis and cancer. Snow argued that all these risks could be managed conservatively, but his methods were a lot of bother, and it is little wonder that many doctors and parents preferred the quick snip. Secondly, for all the depth of his conviction that possession of one's foreskin was advantageous, Snow was hard-pressed to articulate what those advantages were. The best he could do was cite Dr Willard (from Keating's Cyclopaedia of diseases of children) that its functions were "to protect the head of the organ during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm". He actually rejected Willard's largely correct echo of Aristotle's master-piece, that foreskin and glans worked in tandem to generate sexual sensation (though even he emphasised the final orgasm at the expense of the pleasures of getting there). Snow replied with the ignorant majority that "since the prepuce is completely retracted during coition ... no friction over the corona can well take place". But even if this were true (and there is obviously much variation from one individual to another), the foreskin would still increase sensation by the mere fact that its nerve-rich surfaces were now redeployed along the shaft of the erect penis. All Snow was left with was the rather lame protestation that the foreskin was necessary to protect the glans â€“ a plea which fell easy prey to the sallies of Clifford and Remondino, who simply countered that the protection needed by naked savages leaping over thornbushes was no longer essential for civilized men wearing underpants. Without appreciation of the complex innervation and physiological role of the foreskin, and thus awareness that it had significant value in its own right, it was difficult to argue effectively against its dismissal as a redundant scrap of skin. <a name="dow"></a>This title page is taken from an interesting copy of Snow's book. It shows that this copy was owned by Ernest Hart, editor of the British Medical Journal, and that he presented it to the library of the British Medical Association. It may well be the very copy that Snow sent for review to the journal, in which case it is also possible that Hart himself was the reviewer. <h3> <a name="rev"></a>Reviews of The barbarity of circumcision</h3> The Lancet The barbarity of circumcision as a remedy for congenital abnormality, by Herbert Snow, MD, Surgeon to the Cancer Hospital We must confess to sympathy with the main contention of this brochure, which is that circumcision is a relic of barbarism which has survived in certain races because elevated into a religious rite. Its origin in barbarism is seen by its being practised by many of the least civilized peoples on the face of the globe. But it is the surgical argument which is of most interest, and while we cannot go with Dr Snow to the extreme to which the zeal of the advocate has led him, we are inclined to endorse most of what he says. The prepuce is not the valueless or mischievous appendage that some would represent it to be, nor its removal so entirely harmless as some would have us believe. The great fact, however, on which we would lay stress is the rarity of any necessity for circumcision for the relief of congenital phimosis. Non-separation of the prepuce from the glans penis is constantly mistaken for phimosis, and while the latter requires some kind of operative treatment, the former never does in infant and little boys. The forcible retraction of the prepuce (very slight force is really needed), and the daily repetition of this for a short time, brings about in a perfectly harmless and only slightly painful manner a better result than the operation of circumcision effects. The Lancet, 20 June 1891, p. 1386 British Medical Journal Dr Snow has a strong objection to circumcision as a remedy for congenital phimosis, and brings forward facts and arguments in this little book in order to prove that the operation, whilst causing much suffering to helpless children, is as a rule quite unnecessary. Although, as is acknowledged in the preface, no one could expect without presumption to abolish this practice altogether, it is probable that many of those who peruse this book will be induced to question the propriety of resorting very frequently to circumcision in the treatment of certain abnormal conditions of the prepuce. The first chapter is devoted to an historical sketch of circumcision as a religious rite. Dr Snow's work is too small for a satisfactory discussion of so large a subject, but he has collected many interesting facts, and presents good grounds for the view he holds that circumcision , as regularly practised by very numerous races of diverse origin, is essentially a sacrificial and religious act, and has no title to any hygienic character or purpose. In a subsequent section there is a full discussion of the arguments in favour of the removal of the prepuce in cases of supposed congenital abnormality. The author holds that the operation does not conduce to local cleanliness in after-life, or to greater chastity and, moreover, that it does not serve to protect the subject from venereal disease or render him less prone to cancer. In many cases, it is asserted, death has been caused by circumcision, and the operation in most instances entails as an immediate result much suffering, and as a remote result contraction of the meatus urinarius. Even in cases of acquired phimosis and in adult subjects circumcision, it seems, is not free from risk. Indeed, Dr Snow would reserve the operation for some few exceptional cases of chronic acquired phimosis. With regard to the congenital form, he holds that the common-sense and most satisfactory treatment is dilatation, associated in complicated cases with limited incisions. With the results of such treatment the author states that he is entirely satisfied. There can be little doubt, we think, that circumcision has frequently been performed in cases in which [a] careful and prolonged bloodless plan of treatment might have effected a cure. Dilatation, however, is by no means a novel plan of treatment, and, as Dr Snow tells us, it "must have been repeatedly resorted to by many practitioners of the past." many and varied forms of instruments have been devised for carrying out such treatment, some of which are described in this book. This fact, together with that of the advocacy of circumcision in cases of congenital phimosis by many very cautious and experienced surgeons, would seem to us to suggest that the dilatation method may not be invariably satisfactory, and that a certain number of cases may remain in which operative treatment will be found necessary. British Medical Journal, 16 May 1891, p. 1078 </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The barbarity of circumcision (1890) darby Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Robert Darby Subject The topic of the resource Circumcision history Description An account of the resource Archive of the work published by Robert Darby Creator An entity primarily responsible for making the resource Robert Darby Source A related resource from which the described resource is derived circinfo.org historyofcircumcsion.org Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Text Any textual data included in the document <div class="intro" id="intro"> <h2>The old dilation vs circumcision debate gets interesting</h2> <h3>Introduction</h3> As the incidence of routine circumcision in Britain reached its peak in the early 1930s, a controversy in the correspondence columns of the British Medical Journal revealed that just about as many doctors were opposed to the procedure as in favour of it. The correspondence is notable for the dismal quality of much of the argument, depressing lack of knowledge about male anatomy and sexuality, and blythe disregard for medical ethics. Anecdotes and "wise saws" were tossed around as though they were hard facts; nobody was aware of existing research which showed infantile phimosis to be normal or that assumptions about the "greater erotic sensitivity" of the glans were erroneous; and there was no suggestion that boys might miss their foreskin or were entitled to a say in whether they were allowed to keep it. [1] The dominant obsession â€“ with the squeaky cleanliness of the glans â€“ harks right back to William Acton's nervousness about the role of "secretions" in "premature sexual arousal" and masturbation. Much of the discussion centred on such Victorian medical principles as the physical dangers of masturbation, and the necessity for instant action against "congenital phimosis". If these points in favour of circumcision did not impress, advocates trotted out their clinching argument: that it provided protection from, if not immunity, to syphilis. But the debate is also remarkable for an entirely new note in British medical discourse: the suggestion that doctors should not be concerned with moral issues like masturbation, and the revolutionary suggestion that phimosis in infants was not a disease or abnormality at all. Although most of the opponents of circumcision laboured under the delusion that "congenital phimosis" in infants had to be treated urgently, the provocative Dr Ainsworth dared to state that phimosis was an "imaginary disease" and even recommended that the infant foreskin be left entirely alone, thus pointing the way toward <a href="http://www.cirp.org/library/general/gairdner/" rel="noopener" target="_blank">Douglas Gairdner's demolition</a> of "congenital phimosis" the following decade. The controversy was kicked off by a letter from D.I. Connolly, who deplored the high rate of injury and death arising from infant and childhood circumcision, and proposed his own patent method for separating and stretching the foreskin. Much of the resulting debate was the old circumcision vs. dilation argument which still gripped <a href="http://www.historyofcircumcision.net./templates/pages/should_he_be_circumcised_1941.html">Alan Guttmacher in 1941</a>. The zeal with which Connolly and his commentators recommended their patent methods for either cutting or stretching was not matched by the clarity of their exposition; most gave such a confused description of their technique that one wonders whether they could have given clear instructions for making a cup of tea, let alone for operating on one of the most complex sites of the male body. <h3>The letters</h3> <h4>The controversy is sparked off</h4> Although circumcision is performed frequently in all parts of the world, yet I think that this minor operation is capable of causing much trepidation even to the most experienced of surgeons. Complications occur now and again, but the most dreaded sequel of all is haemorrhage. This latter has been known to be the cause of death. It is not necessary to stress this fact; it is known only too well to many amongst us. Shock also may be an immediate cause of death. Other complications such a sepsis and ulceration do arise, and the latter may have serious later consequences. Hence the question arises: Is there any reliable, efficient method of treating severe phimosis other than by a cutting operation? In my opinion there is such a method, and one worthy of extensive trial. This method â€“ or operation rather â€“ should be performed as early as possible, say within the first week of the infant's life. No anaesthetic is needed. After thoroughly cleansing all the parts, using any reliable antiseptic â€“ for example, bichloride of mercury â€“ and wiping with antiseptic spirit, the child's legs are held firmly by an assistant standing at the head of the infant and the latter lying on his back. Strict asepsis must be practised as in any major operation. The instruments necessary are: Spencer Wells forceps, dressing or sinus forceps, and a blunt probe. The operator should draw the prepuce downwards with the index finger and thumb of his left hand. Gently insert the closed blades of the Spencer Wells forceps into the prepuce, of course avoiding the urinary meatus. Using care, push the blades gently upwards and at the same time opening the blades and thoroughly stretching the outer layer of the prepuce. Keep the blades in this position and manoeuvre the prepuce back beyond the glans penis. Then separate the inner layer of the prepuce from the glans by means of the blunt probe. Apply the blades of the sinus or dressing forceps to the inner layer of the prepuce and repeat to it what has already been done to the outer layer â€“ that is, manoeuvre it back to beyond the neck of the glans. Clean away all smegma and secretion that may have accumulated on the surface of the glans penis. The next and important step is the dressing. It is absolutely necessary to keep the entire prepuce in the position as described for the next few days. To do this, I have devised a circumcision dressing shield made of fine rubber, perforated with holes to allow the passage of fine tapes. These latter can be carried round the groins and tied off securely there. The shields are made up in sealed antiseptic cartons ready for use. They are impregnated with a zinc oxide cum boric powder. If necessary, some ribbon aseptic gauze may be first applied firmly around the retracted prepuce, and then the shield may be applied. Usually the mother is intelligent enough to be able to reapply the shield (if necessary). The child may be brought to the hospital or the surgery for redressing. The whole procedure should not take more than five minutes. The points in favour of it are: (1) absolute efficiency; (2) no haemorrhage; (3) fouling of the wound is reduced to a minimum â€“ the child is not able to kick off the shield dressing when efficiently applied and tied, hence sepsis is not so likely to occur; (4) if care and gentleness are used in the operation, shock is negligible; (5) anxiety and worry as to haemorrhage is removed from the surgeon's mind. The circumcision shields are made to my design by F. Whitehead and Co, Pickets Street, London S.W. 12. D.I. Connolly BMJ, 24 August 1935, p. 359 <h4>Responses</h4> I was interested in the technique described by Dr D.I. Connolly, as I endorse his view that circumcision can be followed by many unfortunate consequences. Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. As the likelihood of such psychological trauma appears with the age of the child, it seems wise to deal with the condition at the earliest age possible, whether the prepuce is already adherent or the opening so small that adhesions are likely to occur. I first learned from Mr Geoffrey Keynes about five years ago that stretching the foreskin was a useful alternative to circumcision, and since that time I have not found it necessary to operate on any male child in my practice except in the case of orthodox Jews. My method is to stretch and free the foreskin daily, using a probe and sinus forceps, and doing it so gently that the child does not protest. This method will entail daily visits for one or two weeks, but after that the foreskin is quite free and can be pushed back by the mother when the child is washed as often as seems necessary to keep the glans clean. The stretching may be started soon after birth, and as a rough guide that a baby can stand this amount of interference, I usually wait until it has regained its birth weight. With adequate patience the whole thing can be done entirely without pain or risks, and to my mind the operation of circumcision in childhood is now seldom justifiable. Cecile Booysen Dr Connolly is to be congratulated on having taken a first step towards the treatment of phimosis. May I hope that he will soon take a second? The cool assumption of some surgeons that they know better than providence how little boys should be made is laughable and irritating. it is quite time that this horrible mutilation should no longer be regarded as having any sanitary or therapeutic value, and phimosis should be relegated to the list of imaginary diseases. Circumcision is, and always was, a tribal rite, and has no place in surgery. R. Ainsworth Referring to Dr D.I Connolly's letter, I am glad to hear of someone at last who is opposed to unnecessary circumcision: the majority of doctors and most nurses are obsessed with the idea that 90 per cent of male infants should be circumcised. The prepuce has its definite uses, which need not be gone into here. I myself have practised a similar method to the one described by Dr Connolly for over thirty years â€“ with success, but with this difference: I always use a local anaesthetic and no dressings or appliances. After separation of the prepuce from the glans penis, the prepuce is completely retracted, a mild antiseptic ointment is applied, and the foreskin is replaced in its normal position. All that is necessary thereafter is that the prepuce should be completely retracted once daily and the ointment applied by the nurse or mother until it goes back easily and the mucous membrane, when abraded, is seen to be healed. This usually requires about seven to ten days. Subsequently the prepuce should, for purposes of cleanliness, be retracted in the daily bath and cleaned with a little wet cotton-wool. D. Gordon Carmichael Although severe phimosis in infants may occasionally require circumcision, I was once told by a surgeon with twenty years in general practice that he had almost entirely avoided the operation by completely stripping back the foreskin, aided by dilatation if necessary, in the newborn and others, and by instructing the mother to see that it would peel back and to clean behind it each time the child was bathed. My own small experience is confirmatory. Every urologist would welcome the instilling of this particular habit of cleanliness into possible future patients. Malcolm Baillie Dr D.I. Connolly's very excellent procedure in the treatment of phimosis has one serious drawback â€“ the prepuce still remains. The teaching that the male should be circumcised on the eighth day has stood the test of time, and still remains sound. That the prepuce should be removed, whether phimosis is present or not, is an opinion which deserves the careful consideration of every doctor practising midwifery. Circumcision becomes a gentle art if practised in accordance with this theory. Joseph McAuley BMJ, 7 September 1935, p. 472 <h4>More responses</h4> Your correspondent Dr R. Ainsworth has apparently overlooked one important and well known fact when he writes that "circumcision is and always was a tribal rite and has no place in surgery", namely, the occurrence of carcinoma of the penis in the uncircumcised, and the extreme rarity of its occurrence â€“ if ever at all â€“ in those who have been circumcised. M.M. Posel In India, where I practised for over twenty years, no Hindu is ever circumcised; it is the mark of the Mohammedan. (In the Moplah rising, the Mohammedans forcibly circumcised Hindus who fell into their hands.) Imagine the reception a European doctor would meet with who practised it on all and sundry! This being so, what was to be done with Hindu infants who, having phimosis, had well developed rupture due to straining? I asked a ell-known Brahmin doctor with a large practice in the Punjab â€“ R.B. Balkishau Kaul of Lahore. He said that, whatever the difficulty, circumcision could never be done on a Hindu infant. All that was needed was to roll the prepuce sideways between finger and thumb, which broke down any adhesions, and then to push it back over the glans. This method was the same as that practised by Indian dais (midwives) when drawing milk from a woman's breasts. The nipple is gently trolled between finger and thumb. It is then easy to milk out any coagulum. Kathleen Vaughan Divergent views having been expressed on this subject, may I attempt to sum up and clarify the position? Dr McAuley's letter raises the point which is the crux of the matter: Should the prepuce be removed whether phimosis is present or not? I suggest that phimosis, especially if extreme, demands circumcision for these reasons. (1) Many infants so affected cry excessively until the operation is done: thereby (2) they may develop hernia. (3) Various troubles â€“ for example, nocturnal enuresis, "fits", and, in later life, epithelioma of the glans and paraphimosis â€“ are associated with phimosis. (4) In patients with phimosis suffering from gonorrhoea, complications arise, and treatment is more difficult than in the circumcised. (5) The disadvantages in the event of marriage are obvious. Although difficult of proof, there is little doubt that the prepuce, especially a long one, renders boys more likely to acquire the habit of masturbation. For this very good reason alone I think circumcision desirable, phimosis apart, If the reasons given for circumcision are sound, then stretching operations find no place. I venture to describe the method I use, as it is not the orthodox one. It is well to wait until the infant is 2 to 3 weeks old, and feeding is well established. Local anaesthesia is always used, novutox or locosthetic (P.D. & Co), being injected with a fine needle at the root of the penis on the dorsum and below at the peno-scrotal junction. This makes the operation entirely painless, as I have repeatedly proved. After thorough sterilising of all the parts with spirit and biniodide solution, the end of the prepuce is seized on the dorsum on each side of the middle line with small, narrow-bladed Spencer Wells forceps. Traction on these parts puts the prepuce on the stretch. A similar forceps is then passed down under the prepuce (dorsally), and opened widely, stretching the prepuce and freeing it from the glans, right down to the neck of the latter. The blade of a pair of straight, blunt-pointed scissors is then passed under the prepuce and the latter slit down dorsally to the neck of the glans. The prepuce is then separated, if necessary, from the glans on each side, and cut away, beginning at the fraenum and ending on the dorsum. The cutting is carried round close to the neck of the glans, leaving just enough skin and mucous membrane to be stitched together. During these various manoeuvres traction is made on the forceps originally applied, so as to steady and stretch the prepuce. Often no vessels need tying â€“ at the most, one on the dorsum and one on the fraenum. The free edges of the skin and mucous membrane are united by a few sutures of fine iodised catgut, using a small, half-circle Hagedorn needle. A narrow strip of sterile gauze is wrapped round and tied on. The operation takes very little longer than the usual one, and the skin edge left is almost a perfect "circle"; any after-trimming of the edges is rarely necessary. The advantages of this method are two: (1) there is no possible risk of injury to the glans; and (2) seeing exactly what one is doing, it is possible to remove the whole of the prepuce, which is the main point. results are entirely satisfactory, and in my experience shock, sepsis, haemorrhage etc are unknown. Stitches absorb or work out, and healing is complete in five to ten days. I hope I have shown, in reply to the flagrant statements of one of your correspondents, that "circumcision" is not a "horrible mutilation", that it "has a sanitary and therapeutic value", and, being ordained by Providence from very early times (doubtless for good reasons), it is not a "cool assumption" on the part of surgeons doing this operation that they "know better how little boys should be made". And if phimosis is to be relegated to the list of imaginary diseases, why not make a clean sweep, and say that cancer, tuberculosis, and the rest do not exist? G.W. Thomas This subject, like the big gooseberry, seem to crop up every few years, but nothing very fresh has been said on either side, and too often arguments are built up on irrelevant facts or theories. An example of this is given by Dr R. Ainsworth: "Circumcision was and is a tribal rite"; ergo, there is nothing more to be said in its favour. But was not fire itself at first an object of savage worship â€“ yet we do not discard our kitchen stoves? Again, the argument is brought up that the prepuce "being a work of providence" (with a small p, however), must be perfect. This strange argument would seem to abolish all evolution from the present-day perfection of everything, and one wonders was the five-toed horse perfect in its day and, if so, why was our one-toed animal evolved? But these are side issues. The crux of the whole matter is: Does removal of the prepuce lessen the incidence of syphilis? If this can be answered on the affirmative â€“ and surely the Jewish practice can provide statistics to settle it â€“ then circumcision is surely a duty in all cases. F.G. BMJ, 21 September 1935, p. 560 <h4>Another contribution</h4> It is 42 years since I qualified. For many of these years I circumcised most of the boys. Latterly it is never done. Dr D.I. Connolly describes "unfortunate consequences", which I fully confirm â€“ severe haemorrhage (one death from this cause), obstruction caused by sticky lymph at the urethral orifice, eczema round the scar, irritation of the glans penis. With firm determination the prepuce can always be pressed back. A few years ago Messrs C.H. Fagge and F. Steward of Guy's [Hospital] discontinued the operation, and there now exists a widespread objection to it, as shown by the correspondence in your columns. It may be worthy of record that I have been compelled to perform he little operation for a man of 80 years and, last year, for a man of 52 years, both with excellent results. Vaughan Pendred BMJ, 28 September 1935, p. 603 <h4>Yet further correspondence</h4> To the other not negligible points in favour of circumcision already recorded by many of your correspondents, I hope you will permit me to add that all those whom Providence (with a capital P) has cast for the lot or doom, of working in a venereal disease clinic (and especially one for seafarers) can have only preference for the circumcised patient. He is cleaner, easier to handle and treat, and his condition is easier to diagnose. While there is no convincing evidence yet presented of less incidence of syphilis in the circumcised, our observation here is that in patients with primary syphilis presenting themselves for diagnosis and treatment, there is a higher proportion of sero-negative cases among the circumcised. Obviously the lesion has been the sooner noted by its circumcised bearer; and this is true of all the other lesions occurring on the glans or frenum or on under-surface of prepuce. The sooner noted the sooner is treatment sought. Venereal warts and buboes are rarer in the circumcised. Many adult males who have experienced sexual intercourse before and after circumcision have, on questioning, reported either "no difference" or "better"; none has said worse. Mr Havelock Ellis records the preference of the copulating woman for the circumcised male. And look you, Sir, providence (surely now with a small p) has contrived that gorilla and chimpanzee be born without prepuce. [2] H.M. Hanschell If your correspondent F.G. would refer to the Journal of January 27th, 1934, (p. 144) he would find reported some facts relevant to the question "Does the removal of the prepuce lessen the incidence of syphilis?" [3] An inquiry into the relation between presence or absence of the prepuce and acquired venereal disease in 400 consecutive patients attending the department for venereal diseases at Guy's Hospital failed to show any appreciable differences, and we were led to believe that as far as our own facts went, there was no lessened risk of acquired syphilis in the circumcised. V.E. and N.L. Lloyd No doubt more than enough has already been written in your columns on circumcision, and views have been expressed with almost religious fervour. I feel, however, that the letter of Dr Cecile Booysen should not go unchallenged. She writes: Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. I do not know, nor does she tell us, on what evidence this assertion is based; but I am confident that the treatment she practises in place of circumcision will most certainly tend to bring about a most serious psychological trauma â€“ namely, the habit of masturbation at a not very much later date. As I understand it, the treatment consists of stretching and freeing the foreskin daily for "one or two weeks", and when it is free the mother is instructed to carry on "when the child is washed as often as seems necessary to keep the glans clean". She adds, "with adequate patience the whole thing can be done entirely without pain or risks". I have no doubt that the child exhibits no sign of pain, but rather of pleasure, for as every child's nurse knows, nothing quiets a child so much as gentle manipulation of his genitals. At the same time, nothing is more apt to start the habit of masturbation than regular and long-continued manipulation of the penis. We are many of us familiar of us with the melancholy sight of a child of 3 or 4, or even younger, masturbating, and most investigators in this field are satisfied that this practice in the very young is the result of unwise handling by parent or nurse, which has taught the child he possibility of pleasurable sensations from friction on those parts. In a letter in he next column Dr Carmichael advocates much the same procedure. His treatment requires seven to ten days intensive manipulation, followed by occasional handling at bath time. In my view, if the glans can only be kept clean by regular manipulation of the foreskin, then it had better be left dirty or its covering removed surgically. Whether it is any more necessary to cleanse the male glans than it is to wash out the virgin vagina I will leave to your readers, but in my view the increased liability to syphilis and cancer in the uncircumcised is sufficient justification for removing the foreskin. C.E. Gautier-Smith BMJ, 5 October 1935, p. 642 <h4>The debate continues</h4> I am afraid that I must have earned, in my short time, the disapprobation of a number of your readers, for in my blundering ignorance I have assumed the mantle of a divinity and "shaped the ends" of some thousands of small boys. Yet I am unrepentant, for never have I had a complaint as regards ill after-effects. In view of my own slight experience I should unhesitatingly have any male children of my own circumcised within the first four weeks. The benefit conferred in respect of cleanliness alone is well worth any so-called risk of psychological trauma. I cannot convince myself of the reality of this phenomenon occurring in any child under, say, 5 years of age. I have a distinct recollection of my own circumcision at the age of 2, yet I altogether fail to perceive any gross mental lesion resultant therefrom. No person with any great experience of more or less routine circumcision in all cases of even "tightness" of the prepuce, as distinct from real phimosis, can have failed to appreciate the resultant benefit in the general health and well-being of the children. This was not the case in children whose prepuce was merely "well stretched". In almost all cases when such was done it was later found necessary to circumcise the child, whereupon all trouble ceased. "Bad technique!" exclaim all the "stretching" experts. No doubt but the technique was exactly that employed by Dr D.I. Connolly. Complications are, in my experience, due in almost all cases to poor nursing and careless mothers, and, even with the poorer classes in Glasgow as out-patients, were notable by their slight incidence. Haemorrhage need never occur with skill and careful ligation, and in cases where there is any tendency to general oozing I always found that a touch of adrenaline upon the dressing was always quite sufficient. I am interested in the theory that the operation may lessen the liability to syphilitic infection. Your letter from the Drs Lloyd seems to negative this, but I do think it is worthy of full investigation. At present I have twelve continuous treatment cases under my care. Of these only four have been circumcised. one can form no valid conclusion from such small figures, but it would be interesting to hear from some hospital authorities or VD clinics whether circumcision does, apparently, lessen the risk. D.W. Walker For many years I have been interested in circumcision as practised both in males and females in various parts of the world, and in my book to be published soon this essentially "tribal rite", as rightly described, will be fully investigated. When we come to inquire into the origin of this strange custom we meet many difficulties, but certain facts give support to the view that it originated from entirely different motives, such as (1) hygienic and prophylactic (useless, of course); (2) a possible association with phallic worship (and that, as we know it today, the remains of prehistoric human sacrifice connected with the cult); (3) a sacrifice of a portion to the gods to preserve the rest from harm, a practice well illustrated in other parts of the body; (4) to promote chastity â€“ history supplies examples of its total failure in this respect. Where did the practice originate? It was not compulsory, except among the priesthood, in ancient Egypt, and there is strong evidence that it was introduced into that country by the Negroes. It has been practised in West Africa for over five thousand years, without variation, and today the circumcision societies are still in a flourishing condition. It is general among the Jews, who took the custom from either the Babylonians or the Negroes, probably the latter. It is untrue to say the spread of the custom in Africa is due to Islam; it existed, of course, thousands of years, before Islam. It is interesting to note that during the Roman occupation of Egypt any doctor performing the barbaric operation was executed â€“ a harsh measure, but I believe some punishment should be reserved for those who waste valuable space in medical journals advocating the mutilation. T. Gerald Garry BMJ, 12 October 1935, p. 702-3 <h4>More arguments</h4> While avoiding the pros and cons of circumcision of male infants and children, I should like to express my entire agreement with Dr C.E. Gautier-Smith â€“ that manipulative surgery should find no place in the treatment of phimosis and allied conditions. The operation of circumcision, anaesthetic apart, is attended with very few risks. Haemorrhage should be very rare if the fraenal vessels are first tied before any incision is made and a simple tourniquet applied at the root of the organ (inch jaconet folded in three and held firmly in Spencer Wells forceps); a clean cut with a scalpel is made, taking care not to remove too much foreskin â€“ that is, flaying the glans penis. Redundant mucous membrane having been cut away, two lateral and one dorsal catgut sutures (Halstead) are inserted; a dressing applied, such as gauze impregnated with tinct. benz. co. does quite well. It is understood that the tourniquet is first released to make sure that there is no oozing before applying the gauze. Primary healing should be the rule, as soiling of the wound is prevented. Some of my colleagues have informed me that where necessary they sometimes do a circumcision on a newborn infant while awaiting the arrival of the placenta, with gratifying results. Of this line of treatment I myself have no experience. It has the great merit, however, that there is no anaesthetic risk, and it is done at a time when an infant can best tolerate trauma; but personally I would consider it a somewhat hurried proceeding. S.A. Montgomery With regard to your correspondence on circumcision the following case may be of interest. My son, now aged 6, was born with a long, tight foreskin. As I was against circumcision at the time, he was left uncircumcised. When he was 6 months old I noticed that he continually handled his penis. A colleague found adhesions, which he freed, and since then the foreskin has been pushed back every night at bath time and the parts thoroughly washed. There has been no recurrence of the handling on his part, except on one or two occasions when nightly washing has been omitted and there has been some slight inflammation. The boy now does the washing himself as a matter of routine, which falls into place with the cleaning of ears, teeth etc. The points I wish to stress are: (a) it is really difficult to keep the parts clean in the uncircumcised, and (b) regular pushing back of the foreskin and washing does not always conduce to masturbation, whereas dirty, itching parts do. I hesitate to have the boy circumcised now because I think it quite likely that a psychological trauma may result from the operation at this age. I know of at least one case where a boy of 4 years, one of twins, was circumcised, in which the operation was undoubtedly a great shock, and this may have farreaching results. With regard to what Dr H.M. Hanschell says of the preference of copulating women for the circumcised male: this may be due to the fact that the glans is less sensitive after circumcision in infancy and that therefore coitus can be prolonged. If this is the explanation it is an argument in favour of circumcision which should not be overlooked. Ejaculatio praecox with its concomitant unhappiness to both partners is common enough to call for investigation. W.M.C. My own personal experience leads me to echo Dr D.W. Walker's advice, although my experience is admittedly trivial in comparison. My elder brother and myself both required this attention at school age; two of my friends required it when medical students; recently an official in my town hall, with two grown-up children, had to absent himself for circumcision â€“ a very uncomfortable kind of operation for an adult, apart from the inevitable ribaldry as to change of faith and so on which ensues among the easily amused. I was foolish enough myself to listen to the advice of one of our maternity and child welfare staff, who stretched he prepuce of my elder son, with the result that he required at school age the operation he should have had as an infant. It is too bad that boys should suffer discomfort or be subjected to an operation at school age or later which should be carried out in infancy. M.D., D.P.H. I suggest that all male children should be circumcised. This is "against nature", but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in mind it does not seem apt to argue that "God knows best how to make little boys". R.W. Cockshutt BMJ, 19 October 1935, p. 763-4 <h4>Will the letters never cease?</h4> The question of circumcision seem to lead to a partisanship as violent as politics. I fancy that this enthusiasm for universality, apart from what has been called "tribal rites", is of fairly recent origin. I do not recall any clamour for it in the 1880s. At that time it was regarded as a tiresome minor operation, sometimes required on account of an objectionable and adherent prepuce. It was. I think, in the naughty nineties that the idea of promiscuous circumcision began to gain ground. For a time I fell in with the fashion. But it annoyed me to see the healthy progress of the infant sometimes even temporarily interrupted; and in still more to see occasionally the lactation of the mother interfered with by her worrying over the child. Still more was I upset by two unusual cases which occurred in the practice of a friend (who was, by the way, a very capable surgeon, priding himself particularly on his thoroughness in this minor operation). In each of these the cicatrix contracted and drew the loose skin of the penis up over the glans to form a fresh false prepuce. In one case the operation had to be done three times. In the other the difficulty was obviated by slitting the false prepuce longitudinally, so that any subsequent contraction would tend to pull the skin off the glans instead of over it. On discussing these cases with a well-known gynaecologist, I was surprised when he gave his opinion that it was very seldom necessary to resort to circumcision. From that time I reverted to "detachment and dilatation", with careful instruction as to subsequent daily cleansing of the parts beneath the prepuce. I never had any reason to be dissatisfied with the result of this method as a substitute for circumcision. Of course, neglect of such regular cleansing may lead to minor troubles later on. But the ill results of uncleanliness are not confined to the penile region. I do not know of any statistics which suggest that the circumcised are less liable to venereal disease. Nor have I any reason to believe that the uncircumcised are more prone to masturbation; on the contrary, I can recall the cases of two mothers, who each had one sone circumcised and the other not. The complaint of each of these mothers was that the circumcised boy was always "playing with his penis"; but the uncircumcised boy did not do so. I have no use for the argument that was once used to me â€“ that I was throwing away fees for operation. A.H. Williams Brevity is the soul of wit: I will be brief. If the technique I have described is followed closely and the dressing shield applied to the retracted prepuce, there will be no need for any other operation. But â€“ and this is most important â€“ the prepuce must be kept back for at least four to five days after the stretching etc. I have a long experience of the older radical method of circumcision. I would not think of doing it any more. My object in writing to the Journal was to advocate an extensive trial of the method of stretching plus dressing shield pressure; also, I started on the assumption that something must be done to overcome the severe phimosis. I am grateful to all those who have stated their experiences. it was not my intention to enter into the question of the functions of the prepuce, nor into any abstruse problems concerning the origins of circumcision. These are, however, of great interest. Has it ever occurred to anyone that a vaccine prepared from the smegma bacillus may possibly be of practical use â€“ for example, in connexion with tuberculosis therapy? D.I. Connolly I have been waiting in vain to see someone mention what I consider to be by far the best treatment for phimosis, and which I have used for thirty years. When a male child is born the penis is at once examined, and if the glans cannot be properly exposed I ask the mother and father whether they will have the child circumcised. I make arrangements with the nurse (usually the district nurse) for the next day. having seen the mother we go into the next room, and the nurse holds the child between her knees. A probe and a blunt pair of scissors are probably all that is necessary. Having separated all the foreskin from the glans a straight cut is made down the dorsum to the base of the glans. The foreskin is rolled back to form a scar around the penis on a level with the base of the glans. Occasionally one or two stitches are put in. A small piece of gauze is wrapped round it, to be renewed if it gets washed off. I explain that the penis may appear rather swollen on the second or third day, but that [this] need not be worried about. On the tenth day it has healed, and the foreskin has entirely disappeared. I have never had the slightest trouble over bleeding, as the fraenal artery is not approached, and the dressing has never given any trouble. I have done this on a few occasions to adults, under local anaesthesia, with the result that after a few months the foreskin has entirely disappeared. Of course, a few stitches have to be used. Norman H. Joy I have been watching the correspondence regarding this operation to see if any improvements on the technique of the late Mr A. Richardson of Leeds emerged, but so far have been disappointed. There is no question that the instruments used by the Jews, fashioned after the style of an Army button stick, which is slipped over the prepuce before section, is far and away the safest protection for the glans, and causes no trauma to the foreskin remaining. The key to the reconstruction is a stitch introduced on the left of the median raphe and passed obliquely to the right of the fraenum; it acts as a ligature to the fraenal artery; moreover, it puts the whole in position and avoids a knot of tissue beneath the penis. It is essential to ligature the two dorsal arteries, which can be done by passing a needle through the skin and mucosal cuff, and throwing the Spencer Wells forceps (already applied) over the ligature, thus serving two purposes. [4] Those who deny the existence of phimosis remind me of the old lady who, on visiting the zoo, was shown a giraffe. "There is no such animal", she exclaimed. A.P. Bertwhistle BMJ, 26 October 1935, p. 822-23 <h4>The discussion brought to a close</h4> I have been very much interested in the correspondence on circumcision. What it all comes to is this. Are doctors to be governed by purely medical reasons or not? Such arguments as those put forward that it lessens the likelihood of masturbation and the sensitivity of the penis, that it increases the pleasure of the partner in copulation etc, are scarcely in the realm of medicine, but of morality. Masturbation is a normal and harmless manifestation, except where it occurs in excess as a symptom of mental ill-health, and it savours if Jovian omniscience to interfere with the naturally provided erotic mechanism, although, of course, the untutored savage does not hesitate to do so, and could no doubt give many reasons for excising the clitoris or rupturing the perineum or ripping open the male urethra. To those who instance the occurrence of preputial lesions necessitating amputation in later life as a reason for preventive circumcision in infancy, one would say â€“ Why not eradicate the appendix, the tonsils? Why not expose the child to measles, mumps, whooping cough, and chicken pox? Or is the doctor supposed to be a prophet? Circumcision of the male prepuce, except when done in the presence of a definite physical lesion, as is the case with all the other bodily organs which are liable to disease, is a propitiatory gesture, incapable of justification on surgical grounds. J.L. Faull The description of a method of treating phimosis by the dorsal slit of the foreskin urges me to add yet another to the numerous letters on this matter. I too tried this as a substitute for the usual circumcision, but found the results far from satisfactory. With a lengthy foreskin, two flaps resulted, which hung down like miniature elephant's ears, and frequently became irritated from contact with urine. In more than one case a subsequent operation of circumcision was necessary to remedy this condition. I have now for many years used the following simple technique, which has given entire satisfaction. The foreskin is retracted, and after separation from the glans the preputial orifice is snipped at three points, one on the dorsum, the other two on each side of the fraenum, so that the three incisions are equidistant from each other. The foreskin is then fully retracted, and if the three snips have been accurately judged the foreskin should remain in this position. If too tight it is a simple matter to enlarge the incisions somewhat and secure an easy fit. The incisions made in the long axis of the penis become stretched to form three segments of a circle, and heal without producing any deformity such as that described above. The usual dressing is a strip of gauze soaked in sterile Vaseline, which effectually prevents soiling with urine. Should the opening be too wide the foreskin may slip forward, but it is not a difficult task for the nurse to push it back daily, and healing occurs perhaps more slowly, but equally satisfactorily. J.A. Pottinger The simplest method of relieving a phimosis in the newborn has not so far been mentioned in the discussion. This consists in simply splitting the foreskin with scissors, putting in three stitches, one at the corona and one at each anterior corner. Practically no interference with either the nerve or blood supply happens, and cosmetically the result is excellent. W.L. English I do not agree with Dr R.W. Cockshut that the less sensitive glans of the circumcised is conducive to chastity and forms a shield against sexual perversions. The Mohammedan is not any more chaste than the non-Mohammedan, nor is he free from sexual perversions. I should also have thought that the exposed glans would have attracted the adolescent's attention more than the covered one. As regards manipulative surgery in phimosis, I fail to see the objections raised by some of your correspondents. It has its place wherever practicable, and I have seen no ill effects follow its practice. Circumcision is the last resource, and it is possible that there is a certain amount of "psychic trauma" attending its performance on an introspective boy. Can it be that the circumcision of a highly sensitive and gifted boy made him inflict on the world his "castration complex"? M.P.K. Menon It seems that the opinion of the majority of your recent correspondents on the subject of circumcision in childhood for phimosis is that (1) it should be done when required; (2) the risk of operation and its consequences are small; (3) the manipulative stretching method has its drawbacks; (4) from a psychological point of view, it is undesirable and even embarrassing for the mother, nurse or, later on, the child himself, to pay so much and constant attention etc to his genital organs; (5) if venereal disease is contracted, the circumcised are in a cleaner and more hygienic state; and finally (6) some uncircumcised people fail to keep themselves clean, as is well illustrated in the following case. Some six or seven years ago a young Englishman, who acted as a representative for a British firm in Germany, came to me while on holiday in London on account of some white discharge from his penis. As he had been exposed to possible infection he was sure that he suffered from gonorrhoea. On examination, however, I found that his foreskin was adherent to the glans, and that between the two there was a thick layer of yellow-white cheesy smegma or concretion. It was very adherent, and owing to some inflammation it took me a few days to remove it gradually with warm alkaline lotion, and so separate the adhesions etc. The patient was, however, greatly surprised when I told him he did not suffer from gonorrhoea, but from the effects of local uncleanliness. L.B. Sheinkin A somewhat provocative letter which I wrote as a soporific in the hot hours of an early August morning has been followed by such a long correspondence that I wonder if you will allow me to thank those who have tried to point out my errors and to lead me into the right way. Many of the writers are so lost in admiration of their own techniques that reasons for their procedure are obviously of secondary consideration with them. But the one with whom I am most in sympathy is Dr H.M. Hanschell. He says that with universal circumcision his patients in a venereal disease clinic would be cleaner and easier to handle and treat. Not, be it noted, that the incidence of such disease would be lessened, or that treatment would be more efficient, but that Dr Hanschell would have an easier time. And if I were in his place I have no doubt that I should be of the same opinion. Now with regard to the condition known as phimosis, may I point out the elementary fact that the preputial orifice is surrounded by a fibro-elastic ring, and that fibro-elastic tissue stretches with varying degrees of ease and rapidity in different individuals. Anyone who as patiently watched the slow stretching of the perineal region in a primipara must realize this; and also that a very small opening can be gradually dilated to a great size without injury, provided that ample time is taken and the force exerted is not too great. Similarly, a small preputial orifice which cannot be stretched to the size of a threepenny bit in half a minute is not a pathological condition; and there is no justification whatever for losing one's patience and forcibly cutting or stretching it. If I innocently ask why it is so necessary that a baby's prepuce should be retracted at the earliest possible moment I know I shall be met with a sniff and a snort, and be shrivelled up by the magic word "cleanliness". So to those of the profession who have time to think, may I leave a few questions for consideration? What is the use of Tyson's glands, [5] and at what age do they begin to function; when does a natural secretion become dirt; and what dreadful thing will happen if a baby's prepuce is left entirely alone? R.W. Ainsworth This corespondence is now closed. - Ed. BMJ, 2 November 1935, p. 876-77 <h3>NOTES</h3> 1. In 1894 German researchers using the newly invented aesthesiometer discovered that the glans was quite insensitive, and their findings were confirmed by the English neurologist Henry Head in 1908. In his Studies in neurology (1920) he reported that the glans was about as sensitive as the heel of the foot. Other German researchers had established the rich and complex innervation of the prepuce in a study published in 1893, but there was no further work on the subject until the 1930s. The denser innervation of the foreskin was confirmed by R.K. Winkelmann in the 1950s, and again (quite decisively) by Chris Cold and John Taylor in the 1990s. A good summary and the full text of most of the key articles <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">is available at the CIRP</a>. On the normality of infantile phimosis, it is interesting to note that this had been written as early as 1916: <div>It is not widely enough realized, particularly by the lay public, that a condition of phimosis is normal at birth. It is inconceivable that children are born with actual deformities in this region as often as the statistics of circumcision would lead an observer to suppose. It is not until the penis undergoes its final development at puberty that the proper balance between the prepuce and the glans is struck.</div> Geoffrey Jefferson, "<a href="http://www.cirp.org/library/anatomy/jefferson/" rel="noopener" target="_blank">The peripenic muscle; some observations on the anatomy of phimosis</a>", Surgery, Gynecology, and Obstetrics (Chicago), Vol. 23, 1916, pp. 177-81 2. The truth about apes is quite the reverse: chimpanzees have a foreskin but no glans. This was observed as early as the 1690s in the first-ever anatomical description of a young chimp by Edward Tyson (1651-1708), who reported: "Whether there was any Balanus or Glans in the Penis of our Pygmie, or what it was, I am uncertain: I do not remember I observed any". (Orang-Outang, sive Homo Sylvestris, or the Anatomy of a Pygmie, London 1699, facsimile reprint, with introduction by Ashley Montague [London: Dawsons, 1966], p. 45). This has been confirmed by <a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">Cold and Taylor 1999</a>, and in Chris Cold and Ken McGrath, "<a href="http://www.cirp.org/library/anatomy/cold-mcgrath/" rel="noopener" target="_blank">Anatomy and histology of the penile and clitoral prepuce in primates</a>", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999. For further information on Tyson, see Ashley Montagu, Edward Tyson MD and the rise of human and comparative anatomy in England (Memoirs of the American Philosophical Society, Vol. 20, 1943), and Stephen Jay Gould "To show an ape", in The Flamingo's smile (Penguin 1986), pp. 263-80. Although both Montagu and Gould praise Tyson's skill as an anatomist, he did sow the seeds of much future confusion by claiming to discover glands under the foreskin which were supposed to secrete "smegma", thus giving rise to the mythical "Tyson's glands", which have proved such a stand-by for posthephobes and others who imagine the foreskin to be unclean. See also Note 5. Montagu later wrote a <a href="http://www.nocirc.org/symposia/second/montagu.html" rel="noopener" target="_blank">powerful essay against routine circumcision</a>, "Mutilated Humanity", given at the Second International Symposium on Circumcision, San Francisco, California, April 30-May 3, 1991. 3. The reference is to V.E. and N.L. Lloyd, "Circumcision and syphilis", British Medical Journal, 27 January 1934, pp. 144-6. For further discussion see Robert Van Howe, "<a href="http://www.cirp.org/library/disease/STD/vanhowe6/" rel="noopener" target="_blank">Does circumcision influence sexually transmitted diseases? A literature review</a>", BJU International, Vol. 83, Supplement 1 (January) 1999, pp. 52-62; and Robert Darby, "Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914", Social History of Medicine, Vol. 16, 2003, pp. 57-78 4. In his article, "Juvenile circumcision: A plea for a standardised technique", (Lancet, 12 January 1936, pp. 85-6), Bertwhistle expressed surprise that every modern textbook described a different method of circumcision, and also concern that the results were "by no means uniformly good". He commented that a repeat operation was often necessary "because of cicatrization of a foreskin left unduly long, and an objectionable lump [near] ... the frenum". Despite the pleas, <a href="http://www.cirp.org/library/complications/" rel="noopener" target="_blank">complications remained common</a>, and Gairdner reported <a href="http://www.cirp.org/library/death/" rel="noopener" target="_blank">16 deaths per year</a> in the 1940s. 5. Although one finds references to them everywhere (from new baby bulletin boards and circum-fetishist/posthe-phobic Yahoo groups to serious works of reference such as Wiley's International Dictionary of Medicine and Biology (1986, Vol. 3, p. 1207) and the new Oxford Dictionary of National Biography (entry for Edward Tyson, Vol. 55, p. 819), there is no such thing as Tyson's glands. The moisture beneath the prepuce consists simply of water, shed skin cells, secretions from the prostate, seminal vesicle and urethral glands, various sterols and fatty acids which normally protect skin surfaces, and a variety of benign bacteria. Very few men, and even fewer boys, generate any visible smegma. (See articles by Satya Parkash et al 1980 and 1982, and by Cold and Taylor 1999, <a href="http://www.cirp.org/library/sex_function/" rel="noopener" target="_blank">all available at CIRP</a>.) Cold and Taylor comment: <div>Even in modern textbooks, Tyson's glands are often described as the source of smegma; however, no evidence of Tyson's glands has ever been described outside of Cowper's macroscopic description of these glands in 1694. This may be one of the longest held myths in medicine. Cowper's description of Tyson's glands in the human is actually of hirsutoid papillomas of the glans penis, which are fibroepithelial structures and not glandular structures. Although other mammals have true clitoral and penile preputial glands which secrete sex pheromones, there is no current evidence of these glands in humans. (<a href="http://www.cirp.org/library/anatomy/cold-taylor/" rel="noopener" target="_blank">See CIRP web version for references</a>.)</div> </div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource For and against circumcision darby