CIRCUMCISION - An Overview by Geoffrey Francis CIRCUMCISION - the surgical removal of the prepuce, or foreskin, from the penis - is one of the oldest operations known to man and, worldwide, is the most commonly performed operation. It has been practiced through all ages by both primitive tribes and great civilisations and is widespread across most of the globe. Nobody is able to give conclusive reasons for the origins and the widespread nature of this custom. Many theories have been propounded, of which at least parts must be correct, but as yet there is no real explanation for the desire by so many peoples to modify the natural appearance of the male genital organ. The one thing on which all serious anthropologists are agreed is that the practice of Circumcision grew up totally independently in many different places. Some tribes are known to have adopted it from others, but there is no one common source of the practice. In the modern world Circumcision is the norm amongst all Jewish and Moslem religious groups; most African tribes; the Australian Aborigines; Polynesians; and all English speaking peoples except the United Kingdom. It has gained no stronghold amongst Germanic; Hispanic and Nordic peoples; nor in Asia except amongst Moslems and Jews. Circumcision has been used variously as a mark of a slave (or captured people); as a royal badge; as a tribal or religious initiation; as a medical prophylactic; and as a punishment for various wrongdoing. It is well known that the ancient Egyptians performed Circumcision initially as a mark of Royal status. Pictures in the Pyramids clearly show Royal teenagers submitting to the operation. Over a period of time the upper classes and then eventually the common people adopted the Royal custom and had their sons Circumcised. Informed scholars now accept that the Jewish prescription of universal infant Circumcision is based on having learnt the practice from their Egyptian neighbours. It is interesting to note that both Jews and Moslems hold two common tenets in their religions, both of which actually are based on sound medical reasoning. Both practice Circumcision and both prohibit the eating of Pork meat. In the desert conditions where these great religions started, both practices are desirable. Pork deteriorates fastest of all meats in desert conditions and so a ban on eating it prevents much unnecessary food poisoning. Water is scarce in the desert and cannot be wasted on frequent washing of the genitals. A foreskin tends to harbour not only smegma, but also sand which gives rise to irritation and inflammation of the penis. Thus Circumcision is a desirable action to prevent problems. Many British troops found this out the hard way during the North African desert campaigns in World War 2. Circumcision is performed at widely varying ages in different parts of the world. Naturally, those operations which are performed as a result of serious medical necessity will be done at whatever age the problem shows itself - from a few months to old age. The Jews, in accordance with the Covenant, perform the operation on the eighth day of a boy's life. The strictest Moslem groups wait until a boy's thirteenth birthday before Circumcising him; whilst other Moslems perform the operation variously during the first; sixth; eighth and eleventh years of a boy's life, or at any other convenient time in between. In general the age for 'tribal' Circumcision is at or around puberty. In most cases it acts as a test of courage as a lad passes from being a mere boy to being a man with the obligations of hunting and fighting to feed and protect the tribe. There are numerous methods used to perform Circumcision - most of them developed in Western nations within the last hundred years. The ancient Egyptians tied a cord around the outstretched foreskin and then sliced it off with a knife. The traditional Jewish method involves pulling the foreskin through a slit in a lyre shaped metal shield and then slicing off the protruding skin using the shield as a cutting guide. A relatively late addition to the Jewish rite makes it necessary to then tear the inner lining along its dorsal (upper) surface so as to make any form of foreskin restoration virtually impossible. A modern device, much favoured by American pediatricians for neo-natal Circumcision, is the Plastibell. This is a clear plastic bell with a groove around its rim and a large hole at the top. A snap-off handle initially protrudes from the top of the bell. In use, the foreskin is first slit along its dorsal surface and folded back to expose the glans. The bell is placed over the glans, which is positioned so that the meatus (piss slit) protrudes through the hole in the top of the bell. The foreskin is folded back over the bell and temporarily clamped to the handle whilst surgical thread is placed over the foreskin above the rim of the bell and tied very tightly into the groove. The loose flaps of foreskin are roughly cut off and the handle of the bell snapped off, leaving the bell clamped to the glans by the constricted foreskin. The tight thread causes the blood supply to the remaining foreskin to be stopped, thus the remnant dies and falls off. The tight thread kills nerve endings immediately below it, seals the blood vessels and causes the edges of skin to fuse together. Thus no stitching is needed and the boy feels little or no pain from having the bell clamped on his penis. The Plastibell is so easy to use that the operator doesn't have to acquire much by way of surgical skill - all one needs to be able to do is tie a secure surgical knot - even a nurse can perform a Plastibell Circumcision. The major disadvantage is that the bell must not be pulled to tightly onto the glans and hence the final Circumcision usually leaves a considerable amount of untidy loose skin on the penis. Plastibells are available in several sizes and can be used on most boys up to the age of 12, but are best used only on infants and toddlers. For older children and adults the two preferred methods are totally freehand cutting and the Gomco Clamp. Freehand cutting can give the most perfect aesthetic and practical results since the surgeon has total control of the operation at all times. However, it does presuppose that the surgeon is highly skilled in performing Circumcisions and that the patient is either totally unconscious or totally relaxed and cooperative. With a less than perfect surgeon, the results of freehand cutting can be the most ugly and awful mess imaginable. The Gomco clamp is a good compromise solution and can be used on young boys, teenagers and adults with equal ease. There are no problems like those posed by a tightly fitted Plastibell since the clamp is in place for only a few minutes whilst the actual surgery takes place. The Gomco Clamp consists of four stainless steel parts, which are deceptively simple in practice but considerably harder to describe. Firstly there is a baseplate which has a tapered hole at one end, a threaded stud at the other and, near the hole, a transverse groove with a rounded bottom. The second major part is a bell, available in different internal sizes to suit the size of the glans, which fits through the hole in the baseplate. On top of the bell is a 'T' shaped extension under which the third portion can hook. The third part of the clamp is a bar with a semi-arch at one end. This arch has a pair of hooks to fit under the 'T' piece of the bell. At the base of the arch, the underside of this part has a half-round protrusion which will fit into the groove of the baseplate and allow it to rock about that axis. The far end has a hole which fits over the threaded stud of the baseplate. The final part is a circular nut which fit over the 'hook' part and screws down on the stud. In use, the foreskin is slit dorsally and the bell placed over the glans. The foreskin is pulled forward again and the bell and foreskin passed through the hole in the baseplate. The hook part is placed under the 'T' piece of the bell and clamped gently with the nut. The foreskin is now pulled forward between the bell and baseplate until the point at which the cutting is to take place has come in front of the baseplate. The nut is then tightened to clamp the foreskin there. The surgeon waits for the clamping action to seal the blood vessels and then slices the foreskin off with a scalpel, using the baseplate as a cutting guide. The clamp falls off and the resulting cut edges are stitched together. Although the Gomco clamp requires considerable surgical skill for successful use, most surgeons can produce consistently better results with it than they would with freehand operations. This article has necessarily been a brief overview only and has left many matters untouched. If there is sufficient interest then further articles may appear in future newsletters. The author welcomes discussion, facts and statistics relating to circumcision in all parts of the world. Feedback can be via the newsletter or in the form of articles on STUDS or personal mail to the author. Copyright (C) 1989 Geoffrey Francis and STUDS Newsletter les on