Pediatr Infect Dis J 1997; 16:727-34

PROPHYLACTIC NEONATAL SURGERY AND INFECTIOUS DISEASES

Gerald N. Weiss, M.D.
F.A.C.S., F.I.C.S., D.A.B.S., D.A.B.A.S., F.A.C.P.E.
E-mail: drgweiss@home.com

Former Appointments: Departments of Surgery at Tulane University School of Medicine, New Orleans, LA.; Louisiana State University School of Medicine, New Orleans and Shreveport, LA.,; Uniform Services University of the Health Sciences, Bethesda, MD.; Oklahoma University School of Medicine, Oklahoma City, OK.; University of Arkansas for Medical Sciences, Little Rock, AR.; Currently retired, Fort Collins, CO. Correspondence to: 5630 Wingfoot Drive, Fort Collins, CO 80525;


  One-third of the 16.5 million deaths worldwide in 1993, slightly more than cancer and heart disease combined, were due to infectious diseases (1). Globally some 1.8 billion suffer diarrheal diseases, 400 million are affected by debilitating malaria, 200 million have schistosomiasis and over 4 million died with acute respiratory infections. By 1994 more than 25 million were infected by the Human Immunodeficiency Virus. In the United States between 1980 and 1992 resurgence of infectious epidemic diseases rose 58%. The most common cause of death in the USA from age 25 to 44, over 30,000 during 1995, was due to HIV infection(2). The global resurgence of old familiar infectious diseases continues as newer ones take hold. In today's society the infectious diseases are crisis driven. Prevention, the most effective weapon against infections, remains an established unquestionable weapon. For millennia the male's preputial cavity has acted as a cesspool for infectious agents transmitting diseases though amenable to prophylactic surgery--i.e., neonatal circumcision, the most frequently performed surgery in childhood (3). More than half the people on this globe live in fear of plagues, often unaware of means of prevention.

  This study is an attempt to relate how surgery acting in its old, and perhaps now new, role can prevent many of the world's infectious diseases when the prepuce is removed neonatally. Furthermore the foreskin's removal does not compromise male genital function. Its effectiveness, unlike proven vaccination, may not be as absolute, but is of sufficient validity to seriously promote it as an option. As a measure of AIDS prevention in contemporary America an epidemiologist with the National Institute of Allergy and Infectious Diseases advocated circumcision (4) in 1986. By 1996 clinics advertised in Tanzanian newspapers offering adult male circumcision as a protection against AIDS (5). The viral infectious aspect of malignancy has been more clearly elaborated with contemporary research. Human papillomavirus studies (6,7,8,9) point to their role in the etiology of human genital cancer. Medical researchers are beginning to recognize what veterinarians call transmissible malignancy. The transmissible venereal tumors, i.e. "TVT", are common on the external genitalia of dogs (10). The viral etiology of papillomatosis in animals is akin to the infectious common wart. Established scientific proof of the absolute prevention of penile cancer by neonatal circumcision has been recognized for much more than a century (11,12). Research has shown the foreskin's smegma as a carcinogen (13). Cervical cancer in mice has been produced by horse and human smega. Some studies found that phimosis is even more contributory in cases of penile cancer (14). The surgical treatment of these diseases is well accepted, yet the concept of surgical prophylaxis of disease is as foreign today as it might have been four millennia ago in the Egyptian practice of circumcision. A classical example of malignancy prevention is penile cancer. No patient circumcised at birth in the United States has been reported to have developed carcinoma of the penis (15). It is the only cancer totally preventable when neonatal removal of the foreskin is done and this without compromising any of the organ's functions. Other diseases that may be prevented are urinary tract infections, penile infectious problems due to human parasitic helminth, protozoa, fungi, bacteria, viruses such as herpes and HIV, the transmissible malignant tumors and even simple mechanical or chemical irritation . Why has the safest, commonest and oldest of all surgical procedures failed to be accepted for prevention of disease? This article will explore the many reasons for the reluctance to circumcise.

CONTEMPORARY SCIENTIFIC MEDICINE CONTRASTED WITH PRIMITIVE HEALTH CARE

  Scientific medicine is rooted in a critical attitude of study and research toward precise knowledge of cause and effect relationships in patient care and final results. Prior to our present scientific era folk medicine provided the only means of therapy. It was neither precise nor critical and was rooted in belief not knowledge. Yet it was well enough organized to meet the health needs of a population. Even today it is recognized that by far the majority of the world's health care is provided by healers using folk medicine (16). Requiring an occasional success to ensure its vigor, people today, as in the ancient world, often rely upon ritual and religion for their medical practices. At the height of the Egyptian civilization, a valid secular health measure was converted into a ritual. A succinct explanation is to be found by J.F. Allen in The Lancet (17): "There is an obvious means of protection, and one which must have been known in ages long past -- that is, circumcision. It is very probable that in ancient Egypt the presence of this little fluke (bilharzia haematobium) in the waters of the Nile suggested the adoption of the operation and that the Jews, who have faithfully preserved it, adopted the custom and carried it with them when they left Egypt, and it advanced from being a sanitary precaution to a religious rite." Medical literature even predated this statement when A.B. Arnold (18) stated in his review of circumcision that: "It should not be forgotten that among primitive peoples any traditional law and usage tends to assume a religious character in the course of time." American medicine in recent decades has come to recognize the validity of prophylaxis through the necessity of economic savings. Yet a surgical prophylaxis concept, over three millennia old, has yet to be recognized. Why? Considered devoid of scientific testing, with the strong injunction to separate church from state, Biblical lore continues to perpetuate the attitude of a ritualistic religious rite in the mind of both the average 20th century worldly citizen and researchers (19). The Hebraic Biblical covenant, whether a mandate from God or an idea of man (i.e., it has been said God created Man and Man returned the compliment), is not questioned as a religious mandate by Biblical fundamentalists. Abraham's message from God has been the eternal covenant which perpetuates this ceremonial rite among Jews. The Encyclopedia Judaica (20) states that it began as a ritualistic procedure, "for medical reasons only later" and "that man should perfect himself by the fulfillment of a divine covenant" (21). To fundamentalists of other faiths, the Holy Bible takes precedent and antedates all. Yet today, as in centuries gone by, neonatal circumcision also remains a strong health measure for prophylaxis of contemporary diseases (22). Even before Abraham┤s covenant with God there were unrecognized medical indications for the act of posthetomy. Long before the voluminous documentation of its scientific merit as it relates to cleanliness, reduction of penile and bodily diseases, prevention of diseases including malignancy and its mental, emotional and social benefits, documentation favored this operative procedure (12,17,23). Egyptians, who have been credited with the beginning of the Jewish circumcision ritual, had developed it in their highly refined civilization. For over 2000 years sages and fools have interpreted the reasons and results of circumcision at will, few with medical/surgical experience, and yet on occasion recognized in prominent American professional publications (24). Contradictory reports and interpretations have added to the confusion. In our country, founded out of religious persecution, came those with intense religious beliefs preserving the "word of God" that included the Biblical ritualistic dictums. The important concept of separation of Church and State by our country's founders further separated an ancient surgical procedure from intense scrutiny. This political recognition coupled with limited factual information available to historians and researchers is the reason for the chaos and confusion that exists in current understanding. World wide access to voluminous data (25,26,27), past and present, has brought a much clearer comprehension of the overall picture. However, misinformation continues to be promulgated. As to the prevailing American concept attributing the act of circumcision to religious ritual, history and medical historians bear out that the true reason for neonatal male circumcision is prophylactic surgery (17,28,29,30). Since 1993, when the government of Malaysia provided a sizable grant to develop the Tara KLamp Circumcision Device, attempts have been made to provide traditional circumcisers with a safe method. Recognizing that folk and traditional medicine healers are performing the operation "in the bush", Dr. T.Gurcharan Singh (31) has developed a simple device replacing some current methods employed throughout the majority of the world.

CIRCUMCISION FACTS OF ANCIENT HISTORY

  Egyptian hieroglyphics indicated high Priests and nobility were circumcised. By some accounts only the wealthy or those able to receive benefits of surgical care obtained circumcision. A Cairo museum statue depicts a circumcised Pharaoh dating from 3000 BC (32). Evidence of a circumcised mummy at a time the Hebrews inhabited the land has been discovered (28). Beginning with a literature analysis of the times it can be found that the "father of history", Herotodus, recognized the procedure as an old Egyptian custom. It also was performed among the Ethiopians and Copts (17) of the southern Nile and central Africa area. The Greek historian of the 5th century BCE in writing of the Egyptians said that "They practice circumcision for the sake of cleanliness, considering it to be better to be clean than comely" (33). Durant, the popular 20th century historian (34), cites the Hebrews as founders of prophylaxis in hygiene and their Code of Cleanliness as a factor that preserved the desert tribe after their expulsion from Egypt. They practiced no surgery beyond circumcision. One might say that the earliest and most widely documented history of the procedure was the Biblical record itself, but its scientific validity was not a consideration since medical science as we now know it had yet to be developed. In light of today's archeological finds, ancient literary antiquity, and growing scientific technology and knowledge, it has become apparent that: Biblical circumcision stories are compatible with the Hebrews' interest in health measures, particularly those that the Egyptians had established in their culture, The Hebraic code of disease prevention , even though surgery was required to preserve well being, was their modus operandi of the time, and The above facts are all clearly documented in the modern interpretation of the Holy Scriptures and subsequent writings (34).

  For centuries, the art world has recognized that the renown heroic marble statue of nude David by Michelangelo is artistically and anatomically perfect. However, Bible scholars acknowledge that David, a Jew, would not have been portrayed with an unmistakable foreskin. It is a Biblical fact that David was circumcised but here the confusion is set in stone. Another issue to further confuse the Christian was St. Paul┤s failure to retain the covenant of circumcision as a religious sacrament (33). Then why should an ancient, primitive rite persist for millennia even among Christians? Because of the commandment to the Israelites, Jewish Rabbinic lore has attached to it such significance that it is said , "Circumcision is of such importance that heaven and earth are held only by the fulfillment of that covenant" (21). God is said to have commanded Abraham, father of the Hebrew as well as the subsequent Christian and Islamic faiths, in Genesis 17:10 (35) to perpetuate the act of circumcision. The American political and medical culture has for over 200 years treated the surgical act of circumcision as a religious genital ritual. In the society of today, as centuries past, it is another case of old labeling. A Judeo-Christian Biblical covenant brought over by the Pilgrims as they landed at Plymouth Rock set the stage for recognition of a singularly religious background for the procedure. To most of these fundamentalists, as with Orthodox Jews, the "word of God" is not to be questioned. Ignored is the fact that the operation itself existed centuries before Abraham┤s mandate as cited in the Biblical text (8). The Roman government prohibited the Hebraic practice which led Emperor Antiochus to declare war against the Jewish state. Jewish women of the time circumcised their sons at risk of loosing their own lives (21). Ritual sacrifice, tribal mark, blood bond, fertility initiation rite, mark of endurance, reason for increased or decreased sexual pleasure, or a religious covenant --all have contributed to it's perpetuation. Extensive modern research using the World Wide Web and Net (25,26) opens the way for an accurate scientific medical/surgical answer as we begin to "refashion information" (27). Lost through the ages in a body of religious literature is the real reason for posthetomy (28). One can speculate that such mundane health concerns, as bits of desert sand that cause irritation, annoyance and infection of an infant┤s foreskin as they played in the sand, without the cleanliness and diapers of modern civilization, would provoke action to prevent these diseases. It has been pointed out that prisoners of war and the Hebrew slaves were circumcised on their arrival in Egypt as a protective act to enhance their ability to work and avoid the debilitating illnesses of hematuria, dysuria, and further genitourinary complications that often meant death and loss of a slave (17). Surely the ancients saw bloody urine with obstructive uropathy and death from anuria. What was an unrecognized uremia associated with terminal obstructive uropathies focused attention on the genitourinary system. The solution of the times could reasonably have been removal of the foreskin unhindered by the scientific necessity of proof of an etiologic disease agent or its pathophysiology. Probably many of the genitourinary problems seen in the past were brought on by an unrecognized human parasite appearing as a gross disorder. The nature of the obstructing foreskin condition persists with a report here in the USA revealing an associated uremia and 5 fatalities (36). To uncover the true object of ancient prepucectomy with its lost meaning remains a part of the intent of this study.

CONTEMPORARY MEDICAL/SURGICAL INTERPRETATION OF BIBLICAL CIRCUMCISIONS

  A renown medical historian attributes to Judaism two of the greatest hygienic thoughts contributing to humanity's welfare, "the weekly day of rest and the direct prophylaxis of disease" (37). The primitive cultures in which the Hebraic faith was conceived were those of the Egyptians and Babylonians. These two nations sought to restore health through magic and idol worship in contrast to the Jewish Mosaic tradition of keeping healthy through preventing disease. Many other examples of health maintenance measures were incorporated into primitive Judaic rituals to assure compliance of the people for their own and the groups' benefit. Scholarly review of Biblical passages with a scientific surgical background reveals three fascinating findings regarding Abraham's, Moses's and Zipporah's actions that substantiate the thesis that circumcision emanated from the Hebrews' desire to prevent disease. In the very beginning of the Holy Scriptures it is recorded that Abraham at 99 years of age circumcised himself and Ishmael his 13 year old son. Subsequently, Sarah after many barren years with Abraham her husband became impregnated by him and bore their son Isaac. The significance of reproduction to the perpetuation of a group must have been part of the reason for his circumcision. As a surgeon in practice over half a century, it is logical to speculate that it was Abraham's foreskin that prevented conception with Sarah in his later life. We can suspect phimosis (38) with erection problems, or was it the frenulum breve with dysparunia leading to no or infrequent intercourse? Might it have been the foreskin adhesion problem causing a constriction over the glans that impaired erection and thus unsatisfactory intercourse after a desert life of repeated irritations and infections? The role of infections over the many years must be in the equation no matter what the specific reason. Scarcity of water in the desert and the endemic Schistosomiasis in infected waters of the region could further contribute to urinary tract disorders causing a sterility problem. More to the point of the infectious disease role in circumcision is the story of Moses in Egypt and his return. When Moses sojourned in Egypt, prior to his escape and moving to Medianite territory, he must have been well acquainted with the yet unexplained blood fluke infections causing genitourinary symptoms. Marrying Zipporah, whose Medianite tribe circumcised the adolescent male, but not the newborn, brought a conflict with the Biblical Abrahamic covenant for the Israelites. And so a strange intervention occurs in the Biblical tale when Moses on his way to Egypt to plead with the Pharaoh , is struck by God who "sought to kill him" (Exodus 4:24). Only by Zipporah circumcising their son was Moses spared death on his way to free the Israelites. Did the sages and scribes who created the Biblical message, as Allen speculates above, want to introduce a religious injunction to a secular health rite of Egyptian society? That there is a mandated covenant in circumcision is further emphasized in that no uncircumcised male may join in the annual Passover meal required of the descendants of the Israelites. Does the dread scourge of infectious disease and its prevention play a role? One can only speculate some 3000 years later but the evidence is in its favor. Another aspect brought forth in the tale is the woman's role as illustrated Biblically when Zipporah performs the procedure. The Midrashic stories emphasize the male's, i.e. Abraham, reluctance to do it (39). It is the female that makes the choice without question. Even scientific surveys today (40) show that centuries have not altered the female's preference for the circumcised penis in their mates and for their sons.

SCHISTOSOMIASIS AND CIRCUMCISION

  It is intriguing to speculate on the long term association of circumcision and infectious diseases. Research studies of this subject have been few until this century when the etiologies of infectious diseases began to be understood. Historically, prophylaxis for smallpox and treatments for syphilis and leprosy were begun prior to recognition of the etiologic agents. Vaccination, Ehrlich's heavy metal injection "606"Salvarsan,and isolation of leprous patients were all proposed before the infecting agents were identified. Even the ancient Egyptians' antimony therapy used for hematuria, no doubt due to the Schistosomia hematobium infection, was the treatment for this parasitic infection until 25 years ago (41)! Egyptian hieroglyphics depict painful and gross genitourinary conditions such as phimosis and bladder calculi. Reportedly some 5000 years ago a bas-relief on the tomb of the Egyptian King Ankh-Mahn depicted circumcision (42).

  Around 1900 BCE the Papyrus of Kahun, like other papyri, records many remedies for hematuria. Apparently it was a serious problem among Egyptians of that time (43). Confirmation of this human infection in the ancients was established in 1910 when large numbers of calcified ova and parasites were detected in kidneys of Egyptian mummies. In addition circulating schistosome antigens also have been detected in the mummy tissues from that time period (40). Lower urinary obstruction was recognized as a principle cause of bladder calculi with surgery attempted for its relief . The Hippocratic Oath refers to the "cutters for stone" recognizing them as specialists (44). Those infected with schistosome ova embedded in the bladder wall became victims besieged by urinary tract obstruction (45). Hematuria, the symptom most suggestive, is endemic in areas where this blood fluke parasite is present. Parasitologists report that the vesical type of infection has been common in the areas bordering headwaters of the Nile Valley for millennia, with extensive endemic areas still prevalent today (46). Since it was only the mid 19th century when the blood fluke, Schistosoma haematobium, was discovered, these ancients were apparently unaware of the etiologic agent causing their hematuria. Primitive people that commit things to traditional usage, as did the Egyptian circumcisionists would in the course of time, attach religious significance to the act. Other genitourinary problems might have coexisted once the individual had become infected by the ravages of urinary schistosomiasis. It is clear that the disease is more common in both the male child and adult than in females. The World Health Organization estimates 66 million children in 54 countries have urinary schistosomiasis (47). Children bathed in the contaminated waters of the Mid East oases (48) and rivers were more prone to infection, the foreskin allowing for a pooled pocket of infected water to harbor the cercaria and allow invasion of the body through the immunodeficient area (49) of the mucousal prepuce. Research with regard to the site of penetration of schistosomes remains wanting. Cort's (50) research on schistosome dermatitis in the USA showed that the non-human varieties of cercariae are prevalent in this country, however, the Egyptian infection, which is more virulent and infectious (51), has not had a scientific study related to a foreskin entry point. Interestingly, it is reported that British troops stationed in Egypt at the turn of this century were issued condoms when swimming in the Nile (52). It was thought at the time that schistosomal penetration was through the urethra but the cercarial stage was not recognized until several years later. Bilharz, who described the blood fluke disease in 1851, found it to be the cause of hematuria among the native Nile Valley workers. Oblivious of the cause, early medical authors and Biblical sages saw no reason to relate the act of circumcision to an epidemic infectious disease. The Hebrew word for uncircumcised is orla, translated as "obstruction" or "to impede" (21). From this comes the frequently quoted Biblical phrase the "uncircumcised heart", clearly inferring obstructionism. As ancient folk medicine therapies recorded, it appears that surgery was primarily for therapeutic purposes with prophylactic considerations perhaps secondary in cases of the obstructive genitourinary disease or penile granulomas of schistosomiasis (53). It seems that a primitive, but intelligent and discerning culture, could well have used circumcision to remove an obstructing or grossly diseased part -- the foreskin. By observing children's urinary signs and symptoms with schistosomiasis, it was a bold, calculated step by the discerning Hebraic sages and prophets who initiated the measure in the eight day old Jewish infants. This innovation, so medically significant to the Hebrew culture, became a mandatory health measure through its inclusion in the Bible. So paramount was this surgical procedure that it took the form of a religious covenant between Jews, and later Muslims, and their God.

CLINICAL HYPOTHESIS OF SCHISTOSOMIASIS AND HPV RELATIONSHIP

  Studies as cited above lead to the hypothesis of a possible relationship between old and newly detected transmissible diseases. An ancient AAA disease of Egyptian hieroglyphics has been thought by some to be associated with AIDS as we know it, but authorities have actually connected it with schistosomiasis (41). It appears that the schistosome infestation could be directly related to repeated exposure from infected waters retained in the prepucial sac. Why shouldn't the same be true of the herpes and papilloma viral infections? Taylor et al (54) have recommended removal of the prepuce routinely at birth "to reduce the risk of genital HSV (Herpes Simplex Virus) infection and hence the incidence of carcinoma of the cervix". Other clinical studies support the fact that carcinomas of the cervix and penis may have a common etiologic agent (55,56). Clearly penile malignancy rates in Uganda of circumcised males are much lower than rates in uncircumcised men, where cancer of the penis is the most common male malignancy. Such studies have led researchers Dodge et al (57) to recommend circumcision to "produce a large fall in the incidence of penile carcinoma in Uganda". Gynecological studies are reported wherein "the male cohort of a cervical cancer patient is at an increased risk of penile carcinoma" (58). Those who argue that circumcision is not the only relationship to these malignancies, or even HPV and HIV, may be right. It would appear that the repeated exposure to viruses, be it by different cohorts and/or the prolonged contact of infectious agents retained in the preputial sac encourage an infectious disease. Research in this regard would be informative. In the meantime, as was said of John Arderne, the father of English surgery, why not raise "expediency to the dignity of principle" (59) and proceed with Dodge's and others recommendations as an appropriate, pragmatic public health measure? More to the point is the research revealing the fact that the foreskin operates to increase susceptibility to the HIV(60,61,62,63). Although the number of exposures needed for the sexual transmission remains unknown, risk increases with more contacts and the efficacy of transmission is similar in either direction (64). Cocchi (65) has suggested transmission of the virus, found free in human milk, by absorption of infected cells through the feeding infant's mucous membrane. Why not transmission in a similar fashion when HIV infected cells contact the prepucial mucous membrane?

OTHER INFECTIONS OF THE PREPUTIAL SAC AVOIDED BY NEONATAL CIRCUMCISION

  The very anatomy, gross and microscopic, of the preputial sac speaks of the nature of a cesspool. In this pocket, completely exposed only when the glans penis is revealed, by erection or mechanical manipulation and cleaning, reside all the secretions, excretions, sloughing debris and whatever else it accumulates at the terminal end of the male penis. Usually the mother as the caretaker of the infant's penis is confused whether to clean or not beneath the prepuce (30). The child, often left to his own care, manipulates the foreskin to clean it at undetermined, often delayed, intervals (66). Frequent preputial adhesions may prevent retraction and cause much discomfort. Teenage, the time of increased and intense sexual awareness, results in exposure of the penis to interest by the male and at times the female attendant. The secretions from Tyson's glands and infection from multiple sources make the need for cleanliness paramount especially if the foreskin is present. The married or working male has another set of demands on this organ, but cleanliness remains an imperative. During military service, or in other activities where the availability of water is uncertain, cleanliness may become compromised and disregarded which justifies those who call for "...ready access to circumcision from the military surgeon"(67,68). After intercourse, often because of fatigue and neglect, this sac harbors all type of pathogenic organisms transmitted from the female genital tract or other perineal areas depending on a given maleĂs sexual preference (69). In later life, if repeated infections take a toll on the glans or prepuce, often resulting in scarring, there may be a severe cleansing problem and paraphimosis requiring therapeutic prepucectomy (70). Uncircumcised diabetics readily develop balinoposthitis (71). The weakened, shrunken penis needs intense care and cleansing to avoid irritation or dysparunia related to frenulum problems at intercourse (72). In the event a voiding problem occurs, the use of an indwelling urethral catheter does best on a circumcised penis for ease of cleaning. A circumcised organ avoids all of the above in the greatest majority of cases. With neonatal circumcision, cancer of the penis is totally unknown (73). Roberts' et al (74) research cites the fact that the bacterial fimbriae (as in Proteus mirabilis and Serratia odoriferous) and hydrophobicity correlated with electrostatic charges causes prepucial adherence (as in Pseudomonas aeuroginosa and Klebsiella strains) resulting in more infections of the uncircumcised. Circumcision, they conclude, prevents UTI . The array of articles (75,76,77,78,79,80,81) and books (12,82) long before the AIDS epidemic pointed to an association of sexually transmitted diseases, including syphilis, gonorrhea, non-gonococcal urethritis, trichomoniasis, chlamydia, condylomata,etc., as more common in the uncircumcised. Besides the sexually transmitted neoplasias mentioned above even cancer of the prostate is suspect by researchers who report less than half its frequency in the circumcised males (83). From the view point of infections a whole liturgy of organisms have been found to infect and be transmitted from beneath the prepuce (75) and often entrapped in the sac. In spite of voluminous amounts and various types of medication applied to the foreskin for therapy, it has been pointed out that the simple act of neonatal circumcision would prevent the often delayed treatment for such disorders as Zoon's balanitis (84).

SURGICAL PROBLEMS WITH CIRCUMCISION

  American medicine has given preference to chemistry while down playing the surgical prophylaxis of disease. Particularly has this been true in the sphere of posthetomy. The surgical procedure- circumcision- has been assigned to junior staff and nurses since for centuries it has been considered a mere ˘ritual÷ that is quite simple surgically. Surgeons have been reluctant to enter the domain of a religious act that has been traditionally the role of a ritual, religious circumciser, the Mohel. Because of this consideration as a simple, religious procedure, the medical/surgical community has frequently delegated the ill informed and poorly surgically trained to perform the operation with, in occasional cases, devastating effects. Generally, American medical schools have avoided such training in their curriculum and despite individual efforts, this unhappy practice has not been corrected. Often the adage is "See one, do one, teach one" which has resulted in unwarranted complications(85) and an attitude resulting in vilification of the procedure. This must stop or the baby will be thrown out with the bath water as the saying goes. Complications can always occur in a surgical procedure but if there is a reduction in the untrained who do them there could be a negligible incidence of difficulties (86). As is, the current morbidity rate is less than 0.1% and no mortalities in trained hands (87). Many who can afford quality surgical care in this regard seek services of a Mohel as in the case of European Royalty. Qualified Mohelim, physicians or surgeons can do the job right--- with speed and dexterity. Speed is essential in eliminating pain, but most gadgets today require excessive time requirements. This leads to prolongation of the procedure with excessive restraint of the infant. An operation that takes 15 to 30 seconds has been extended to 15 or 30 minutes with contemporary devices currently used in the USA. One Mohel has written that he would not consider doing the procedure on a Jewish child with such "barbaric" methods now in use by most American practitioners (88). The extent of circumcision,i.e., how much foreskin should be removed is not within the scope of this paper but needs to be taught by qualified surgeons in the medical schools of all countries. Concerned doctors have encouraged this since the beginning of the century (89). Such is currently not the case and may well be the reason in part for maligning and misunderstanding of the purpose and technique for this potentially innocuous prophylactic surgery. Informed physicians, and indeed medical students or other practitioners, need proper instruction if quality surgical health measures are to prevail in the world where uncounted circumcisions have already been and will continue to be performed.

  A final comment to this study relates to the axiom, "An ounce of prevention is worth a pound of cure". In the cost conscious health world today, it has been shown that myopic planning only increases expenses in the long run. Over a century ago, Remandino commented , "Life insurance companies should class wearers of the prepuce under the head of a hazardous risk"(12). There are no longitudinal studies indicating the extent of pain, disease and expense that the human prepuce has caused during the lifespan of a generation of uncircumcised. Yet for at least three millennia neonatal circumcision has been performed on millions of males. The surgery in infancy when compared to the same operation in later life has less mortality, morbidity and cost while being technically easier(30,42,90,91,92).

SUMMARY AND CONCLUSION

  Infections worldwide are the primary cause of morbidity and mortality today. The need for prevention is essential. Prophylactic surgery with the reduction of infectious disease has been available for many millenia, but its recognition has been questionably accepted. This article presents evidence of former times when circumcision was performed in the ancient Egyptian, Coptic and Ethiopian cultures probably as a therapeutic measure to combat the ravages of schistosomal infectious symptomatology. How this health measure was converted to a religious rite and the confusion caused by this misunderstanding is fully explored. The association of an operative procedure as a religious ritual among Jews, and Christian Biblical ambiguity toward it, has further clouded the issue. Neonatal circumcision has been perpetuated in many societies and cultures, not because of the Jews and their Covenant of Circumcision, but because of its merit as a secular surgical prophylactic health measure. This article explores this interesting issue from its beginning to contemporary research and findings that justify the procedure as a viable option in maintaining and promoting quality genital health care for males of all ages.

REFERENCES

1. Platt AE. Infecting Ourselves: How Environmental and Social Disruptions Trigger Disease. Worldwide Watch Paper 129. Washington, DC.: Worldwide Watch Institute;1996.

2. Rosenberg HM, Ventura SJ, Maurer JD, et al. Births and deaths: United States, 1995. Monthly vital statistic report; vol 45 no 3, supp 2, p.31. Hyattsville, MD: National Center for Health Statistics. 1996.

3. Wiswell TE, Tence, HL, Welch CA, et al. Circumcision in Children Beyond the Neonatal Period. Pediatrics. 1993; 92:791-793.

4. Marx JL. Circumcision May Protect Against the AIDS Virus. Science. 1989; 245:470-471.

5. Caldwell JC, Caldwell P. The African AIDS Epidemic. Scientific American. 1996; March:62-68.

6. Syrjanen KJ. Biology of Human Papillomavirus (HPV) Infections and Their Role in Squamous Cell Carcinogenesis. Med. Biology. 1987;65:21-39.

7. zur Hausen H, Gissmann L, Schlehofer JR. Viruses in the Etiology of Human Genital Cancer. Prog. med.Virol. 1984;30:170-186.

8. Reid R. HPV Infection Tied to Cervical, Vulvar Cancer. Advances in the Treatment of Lower Genital Tract Infections in Women. Snowbird, Utah; Academy of Professional Information Services, Inc.; 1988.

9. Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J. Natl Cancer Inst. 1993;85(1): 19-24.

10. Stone EA. Urogenital tumors - canine transmissible veneral tumor of the penis, vagina, and vulva. Vet Clin North Am. 1985;15:603.

11. Paymaster JC, Gangadharan P. Cancer of the Penis in India. J.Urol. 1967; 97:110-113.

12. Remandino PC. History of Circumcision. Philadelphia: FA Davis Co.; 1891.

13. Plaut A, Kohn-Speyer AC. The Carcinogenic Action of Smegma. Science. 1947; 105:391-392.

14. Reddy CRRM, Gopal R, Venkatarathnam G, et al. A Study of 80 Patients with Penile Carcinoma Combined with Cervical Biopsy Study of Their Wives. Inter Surg. 1977;62:549-552.

15. Skinner DG, deKernion JB. Genitourinary Cancer. Philadelphia: WB Saunders; 1978.

16. Hodgdon L. Perspectives on Third World Development, A Systems Analysis. Fort Collins, Colorado: Colorado State University; (unpublished); 1990.

17. Allen JF. Bilharzia Haematobia and Circumcision. The Lancet. May 8, l909; 1317-1320.

18. Arnold AB. Circumcision. N.Y. Medical J. February 13,1886;173-179.

19. Zimmermann F. Origin and Significance of the Jewish Rite of Circumcision. Psychoanalytic Rev. 1951;38 (2):103-112.

20. Snowman LV. Circumcision. Encyclopaedia Judaica. Jerusalem: Keter Publishing House Ltd; 1971.

21. Singer I. Circumcision. Jewish Encyclopedia. New York: KTAV Publishing House, Inc.; 1901.

22. Wiswell TE. Neonatal Circumcision: A Current Appraisal. Pediatrics. 1995;1(2): 93-99.

23. Barth LM. Brit Mila in the Reform Context. New York: Mila Board of Reform Judaism; 1990:93.

24. Wallerstein E. Circumcision: The Unique American Medical Enigma. Uro Clin North Am. 1985;12(1):123-132.

25. Quaintance V. International Circumcision Information Reference Centre (ICIRC). http://www.users.dircon.co.uk/~vernon/ICIRC/index.html; March1997.

26. Morris B. Medical Benefits from Circumcision. http://www.physiol.su.oz.au/ brianm/circumcision.htm; March1997.

27. Gates B. The Road Ahead. New York: Penguin Books: 1996:23.

28. Read HL. Posthectomy. Int J. Surgery. May1915:168-172.

29. Wolbarst AL. Does Circumcision in Infancy Protect against Disease? Virginia Med Monthly. March1934:723-728.

30. Weiss GN. Neonatal Circumcision is Necessary. Fort Collins,CO: Personal brochure; 1985.

31. Singh TG. Disposable Circumcision Device-Tara Klamp. http://www.mol.com. my/corp/tara/default2.htm.

32. Murphy LJT. The History of Urology,Part I: The History of Urology to the Latter Part of the Nineteenth Century. Springfield: Charles C. Thomas: 1972.

33. Weiss GN, Weiss EB. A Perspective on Controversies over Neonatal Circumcision. Clin Ped. 1995;33:726-730.

34. Durant W. The Story of Civilization: Part I: Our Oriental Heritage. New York: Simon and Schuster; 1954;328-339.

35. The Torah: The Five Books of Moses. Philadelphia: Jewish Publication Society of America; 1962.

36. Barnett HL, Einhorn AH. Pediatrics. New York: Appleton-Century-Crofts: 1958;1553.

37. Weiss GN. The Jews Contribution to Medicine. Medical Times. 1968;96:797-802.

38. Weiss C. Motives for Male Circumcision Among Preliterate and Literate People. J. Sex Research. 1996;2:69-88.

39. Weissman M. The Midrash Says, The Book of Beraishis. Brooklyn,NY: Benei Yakov Publications. 1980;153-156.

40. Williamson ML, Williamson PS. WomenĂs Preference for Penile Circumcision in Sexual Partners. J. Sex Educ and Therapy. 1988;14:8-12.

41. Cooley DG. Ancient Egypt and Today: Enough Scourges to Go Around. Emerging Infectious Diseases. 1996;2:362.

42. Warner E, Strashin E. Benefits and Risks of Circumcision. CMA Journal. 1981; 125:967-992.

43. Jordan P, Webbe G. Human Schistomiasis. Springfield: Charles C. Thomas; l969.

44. Sabiston DC. Davis-Christopher Textbook of Surgery. Philadelphia: WB Saunders; 1977;1758.

45. Beeson PB, McDermott W. Cecil-Loeb Textbook of Medicine. Philadelphia: WB Saunders; 1971;745-752.

46. Faust EG, Russell PF, Jung RC. Craig and FaustĂs Clinical Parasitology. Philadelphia: Lea and Febiger; 1970;442-445.

47. Nuttall I. World Health Organization, Division of Control of Tropical Disease. http://www.who.ch:80/programmes/ctd/diseases/shis/shisdat.htm; January1997.

48. Kuntz RE. Schistosoma Mansoni and S. Haematobium in the Yemen, Southwest Arabia: with a Report of an Unusual Factor in the Epidemiology of Schistosomiasis Mansoni. J. Parasitology. 1952;38:24-28.

49. Weiss GN, Westbrook KC, Sanders M. The Distribution and Density of Langer- hans Cells in the Human Prepuce: Site of a Diminished Immune Response? Israel J. Med Sci. 1993;29:42-43.

50. Cort WW. Studies on Schistosome Dermatitis, Status of Knowledge after More than Twenty Years. Am J. Hygiene. 1950;52:251-295.

51. Thompson G, Walker L. Other Infections of the Bladder, Bilharziosis. Genito- Urinary Surgery. Philadelphia: WB Saunders; 1950;467-474.

52. Cline B. Schistosomiasis and Its Relation to Circumcision. Tulane University. New Orleans: Personal e-mail correspondence; 1997; bcline@mailhost.tcs.tulane.edu.

53. Cahill KM, Moneim El Mofty A. Extra-Genital Cutaneous Lesions in Schistosomiasis. Am J. Trop Med Hyg. 1960;13:800-803. 54. Taylor PK, Rodin P. Herpes genitalis and circumcision. Brit J. vener Dis. 1975; 51:274-277.

55. Martinez I. Relationship of Squamous Cell Carcinoma of the Cervix Uteri to Squamous Cell Carcinoma of the Penis. Cancer. 1969;24:777-780. 56. Campion MJ, Singer A, Clarkson PK, et al. Increased Risk of Cervical Neoplasia in Consorts of Men with Penile Condylomata Acuminata. Lancet. April 27, 1985;943-946.

57. Dodge OG, Linsell CA. Carcinoma of the Penis in Uganda and Kenya Africans.Cancer. 1963;18:1255-1263.

58. Sand PK, Bowen LW, Blischke SO, et al. Evaluation of Male Consorts of Women with Genital Human Papilloma Virus Infection. Ob Gyn. 1986;86: 679-681.

59. Weiss GN. John Arderne, Father of English Surgery. J. Intl Col Surg. 1956; 25:247-260.

60. Tyndall MW, Ronald AR, Agoki E, et al. Increased Risk of Infestion with Human Immunodeficiency Virus Type 1 Among Uncircumcised Men Presenting with Genital Ulcer Disease in Kenya. Clin Inf Dis. 1996;23:449-53.

61. Simonsen JN, Cameron DW, Gakinya MN, et al. Human Immunodeficiency Virus Infection among Men with Sexually Transmitted Diseases. N Engl J. Med. 1988; 319:274-278.

62. Bongaarts J, Reining P, Way P, et al. The Relationship between Male Circumcision and HIV Infection in African Populations. AIDS. 1989;3:373-377.

63. XI International Conference on AIDS. Abstracts Available on the Net. Vancouver, Canada; 1996; http://www.interchg.ubc.ca/aids11/AIDS96.html.

64. Pan American Health Organization WHO. AIDS Profile of an Epidemic, Sexual Transmission of AIDS. 1989; 514: 265-268.

65. Cocchi P., Cocchi C. Letters to the Editor. JAMA. 1988;260:3586-3587.

66. St.John-Hunt D, Newell RGD, Gibson OB.Three Englishman Favor Circumcision and Why They Do. Pediatrics. 1977;60:363.

67. Nixon SA. Letters to the Editor, Southern Med J. 1987;80:538.

68. Pienkos EJ. Circumcision at the 121st Evacuation Hospital: Report of a Questionnaire with Cross-Cultural Observations. Military Medicine. 1989;154:169-171.

69. Spach DH, Stapleton AE, Stamm WE. Lack of Circumcision Increases the Risk of Urinary Tract Infection in Young Men. JAMA. 1992;267:679-681.

70. Williams JC, Morrison PM, Richardson JR. Paraphimosis in Elderly Men. Am J. Emerg Med. 1995;13:351-353.

71. Fakjian N, Hunter S, Cole GW, et al. An Argument for Circumcision. Arch Dermatol. 1990;126:1046-1047.

72. Smith J. Circumcision, A Guide to a Decision. London: Gilgal Society: 1995.

73. Bleich AR. Prophylaxis of Penile Cancer. JAMA. 1950;143:1054-1057.

74. Roberts JA. Does Circumcision Prevent Urinary Tract Infections? J Urol. 1986; 135:991-992.

75. Nickel WR, Plumb RT. Cutaneous Diseases of the External Genitalia. CampbellĂs Urology. New York: WB Saunders. 1986;963-967.

76. Newell J, Senkoro K, Mosha F, et al. A Population-based Study of Syphilis and Sexually Transmitted Disease Syndromes in North-Western Tanzania. Genitourin Med. 1993;69:421-426.

77. Ginsburg CM, McCracken GH. Urinary Tract Infections in Young Infants. Pediatrics. 1982;69:409-412.

78. Wiswell TE. Routine Neonatal Circumcision: A Reappraisal. Am Fam Practice. 1990;41:859-863.

79. Wiswell TE, Hachey WE. Urinary Tract Infections and the Uncircumcised State: An Update. Clin Ped. 1993;32:130-134.

80. Smith GL, Greenup R, Takafuji ET. Circumcision as a Risk Factor for Urethritis in Racial Groups. AJPH. 1987;77:452-454.

81. Maymon R, Bekerman A, Werchow M, et al. Clinical and Subclinical Condyloma J. Reprod Med. 1995;40:31-36.

82. Ravich A. Preventing V.D. and Cancer by Circumcision. New York: Philosophical Library; 1973.

83. Apt A. Circumcision and Prostatic Cancer. Acta Medica Scandinavica. 1965; 178:493-504.

84. Sonnex TS, Dawber RPR, Ryan TJ, et al. ZoonĂs (plasma-cell) Balantitis: Treat- ment by Circumcision. Brit J Dermatol. 1982;106:585-588.

85. Lupo V. Family gets $2.75 million in wrongful surgery suit. Lake Charles Amer- ican Press. Lake Charles, LA. May 28, 1986.

86. Kaplan GW. Complications of Circumcision. Urol Clin NA. 1983;10:543-549.

87. Shulman J, Ben-Hur N, Newman Z. Surgical Complications of Circumcision. Am J Dis Child. 1978;107:149-154.

88. Barrineau M. Rebirth of a Ritual, Rabbi brings back circumcision ceremony for Dallas Jews. Dallas Times Herald. July 7, 1987;E-1-5.

89. Bousfield P. Notes on Minor Surgery, The Circumcision of Children. St. Bartho- lomewĂs Hosp J. October,1916;5-7.

90. Weiss GN. Current Concepts of Neonatal Circumcision in the United States. Int Surg. 1986;71:62.

91. Weiss GN. Neonatal Circumcision. South Med J. 1985;78:1198-1200.

92. Roberts JA. Neonatal Circumcision: An End to the Controversy. South Med J. 1996;89:167-171.