Uncircumcision: A Historical Review of Preputial Restoration Dirk Schultheiss, M.D., Michael C. Truss, M.D., Christian G. Stief, M.D., and Udo Jonas, M.D. Hannover, Germany

Throughout history, demands for restoration of the prepuce after circumcision were most commonly related to the political or religious persecution of the Jewish people. The first evidence for such a procedure is mentioned in the Bible: Under the reign of Antiochus IV (168 BC) Hellenistic ideals, such as public nakedness at athletic games or in public baths, emerged in Judea and forced Jews to stretch their shortened foreskins with a special weight, the Pondus Judaeus, to cover the glans (I. Maccabees 1). Similar efforts are reported in the Talmud during the time of Hadrian (132 AD).

Celsus (25 BC-50 AD) was the first to give a detailed description of two surgical techniques for uncircumcision in his De medicina libri octo. Subsequent works, for example by Galen (131-200 AD) and Paulus Aeginata in the seventh century, only contained a repetition of these methods without presenting any new aspects.

Ambroise Paré gave a new impetus in the sixteenth century, suggesting the insertion of a catheter into the distal urethra to guarantee free passage of urine during postoperative healing. In this past century, Johann Friedrich Dieffenbach was the first to dedicate a whole chapter to the problem of "posthioplastice" in a modern textbook of plastic surgery.

Almost no written documents exist of uncircumcision during the Nazi era; nevertheless, surgical treatment seemed to be widespread as every circumcised man was in danger of being denounced as a Jew. Personal reports of patients and doctors performing surgical restoration of the prepuce are presented.

Nowadays, reports on surgical foreskin restoration are still rare and alternative methods of nonsurgical skin-expansion have become more common. Several organizations were founded in America against routine infant circumcision and give advice to foreskin restoration seekers. (Plast. Reconstr. Surg. 101: 1990, 1998.)

 

Circumcision has been widespread since the beginning of civilization and was reported in the medical literature of the earliest cultures. It is not surprising, therefore, that the first illustration of a surgical procedure, a bas-relief from a tomb in Sakkara (Egypt; about 2200 BC), depicted a circumcision scene.)1

In most cases, this procedure was performed with a ritual or religious intention, e.g., as a sacrificial act for a god or as a token of the "covenant" as in Jewish religion. Furthermore, hygienic and medical reasons were of importance at all times. In ancient days, circumcision or even more extensive mutilation of the external genitalia was carried out on defeated enemies, captives, or slaves as a sign of subjugation.2,3

The demand for surgical or nonsurgical restoration of the prepuce after circumcision, the so-called uncircumcision, was usually associated with the persecution of the Jewish people. This association is documented from the times of the Old Testament until the darkest period of our century.

By some authors, the procedure of restoring the lost or missing foreskin was called decircumcision (e.g., Celsus) or posthioplasty (e.g., Dieffenbach). Because these terms were partly used for the same operative technique, there is no uniform definition for them; therefore, they are more or less exchangeable.

 

FIRST WRITTEN EVIDENCE FOR RESTORING THE PREPUCE

The first sign of evidence for uncircumcision among the Jews can be seen in a passage of the Old Testament (I Maccabees 1: 14-15): "Whereupon they built a place of exercise at Jerusalem according to the customs of the heathen. And made themselves uncircumcised (sibi praeputia fecerunt), and forsook the holy covenant, and joined themselves to the heathen, and were sold to do mischief."4,5 This passage was written at the time of the reign of Antiochus IV (168 BC), when the hellenization of Palestine and, therefore, the oppression of the Jewish religion and culture came to a first climax. Hellenistic ideals gained popularity, and it was, for example, common to exhibit the naked body at athletic games or at public baths. Jews were forced to hide their genitalia or restore their prepuces, so as not to be persecuted and to improve their social and economic position. This situation culminated in a law by Antiochius dictating that the act of circumcision was to be punished by death sentence (I Maccabees 1:63-64).

The restoration of the prepuce was either done operatively, as it will be described below, or bloodlessly with the help of the so-called Pondus Judaeus. Both methods took advantage of the common way of symbolic circumcision among Jews at that time, the milah. Only the distal part of the foreskin was cut off, leaving a short prepuce that partly covered the glans. The Pondus Judaeus was a special weight made of bronze, copper, or leather, which was fixed to this rudimentary preputial skin and pulled it downward. When it was applied for a longer period, the foreskin was lengthened and covered the glans totally as desired.3,6,7 This device could, therefore, be referred to as an ancient tissue expander, rather a tissue stretcher, keeping in mind that similar methods for uncircumcision are still offered in our days. Unfortunately, no detailed description or illustration of such a Jewish weight exists.

The successful Jewish revolt against Antiochus IV in 141 BC led to the establishment of the Hasmonean or Maccabean reign in Judea, making uncircumcision unnecessary for the following period. Later in 63 BC, the Romans took over the supreme authority and, together with the rise of Christianity, a new desire for hiding the state of circumcision appeared. Obviously, many Jews who converted to the Christian religion underwent uncircumcision to emphasize the break with their old religion and to be fully accepted in the Christian community. The Apostle Paul condemned this practice by saying: "Is any called being circumcised? Let him not be uncircumcised. Is any called being uncircumcised, let him not be circumcised" (I Corinthians 7:18).

The Roman tolerance toward circumcision among Jews came to an end with the hellenophilic emperor Hadrian, who was proclaimed emperor in 117 AD and once again urged a law forbidding circumcision. The Talmud gives proof that during his reign many of the circumcised turned to uncircumcision for obvious reasons.8 This habit was rejected by orthodox Jews and, therefore, after the law against circumcision was loosened again about 140 AD, they introduced radical circumcision to the Jewish community, the so-called periah. It left the glans totally uncovered and made it almost impossible to perform the above-mentioned methods of restoring the prepuce.3,7

In Greek terminology, a person who had undergone the procedure of stretching the prepuce was known as epispastikós, the stretched one (epispasmós = pull-over). Similarly, the Romans addressed him as recutitio, the reskinned (cutis = skin), not differentiating by this term whether it was done surgically or nonsurgically.3

Uncircumcision is also mentioned in Roman poetry of the first century. Petronius (died 66 AD) in Trimalchio's Dinner from his work Saturae told us of a slave who had "two defects, without which he would be priceless: he is reskinned and he snores (recutitus est et stertit)."3

In one of his epigrams (Epigrammaton Libri 7:30) Marcus Valerius Martialis (38/41-100 AD) portrayed a Roman prostitute named Caelia.3-5 She was never pleased by a Roman man but preferred to make love to Parthians, Germans, Dacians, Cilicians, Cappadocians, Egyptians, and Indians.3-5 This list is continued with the passage, "Nor do you shun the reskinned Jewish private parts (recutitorum inguina Judaeorum)." Martial also mentioned the Pondus Judaeus and gave a short description of it (Epigrammaton Libri 7:35).

 

CELSUS' METHODS OF OPERATIVE UNCIRCUMCISION

The first detailed description of an operative procedure for uncircumcision was given by the Roman medical writer Aulus Cornelius Celsus (25 BC-50 AD), seen on a later portrait in Figure 1. His comprehensive encyclopedic work De medicina libri octo was written during the reign of Tiberius (14-37 AD). It can be valued as the most important written document in the early history of medicine, which was not questioned until the scientific innovations of the Renaissance established modern medicine. In De medicina 7:25:1 he differentiated between two methods of prepuce reconstruction, which he referred to as "decircumcision."9

FIG. 1. Aulus Cornelius Celsus (25 BC-50AD) (from: Sambucus, Icones veterum aliquat ac recentium medicorum, 1574).

The first procedure he recommended mainly for children or for those with a congenitally shortened foreskin (Fig. 2). The skin of the penis was incised around the root and after mobilization, stretched over the glans. Ligation at the tip prevented any recession into the original position. Thus a physiologic double-layered prepuce was reconstructed, and the proximal skin impairment was reepithelialized during the course of the healing process.

FIG. 2. Celsus' first method of "Decircumcision" (after: Rubin, J.P. Celsus' Decircumcision Operation. Urology 16: 121, 1980).

If the patient had been circumcised after the customs of certain races (qui quarundam gentium more circumcisus est), mainly the Jewish milah, Celsus suggested the second method. A coronary incision was made, and the penile skin was mobilized along the whole length of the penis to the root (Fig. 3, above). The skin was thus stretched over the glans and recession was now prevented by means of a bandage fixed securely over the penile shaft from the pubis to the glans (Fig. 3, below). Only a single layer of skin was obtained over the glans, and adhesion was counteracted by the application of additional saturated dressings and plasters.

To avoid an erection during the healing period, Celsus advised a strict diet. The indication for the procedure of uncircumcision was described by him as decoris causa, an aesthetic reason without any medical necessity.8,9

FIG. 3 Celsus' second method of "Decircumcision" (after: Rubin, J.P. Celsus' Decircumcision Operation. Urology 16: 121, 1980).

Celsus did not point out the possible risks and failures of his methods. It is unlikely that he never experienced severe wound infection performing this kind of genital surgery and not knowing the principles of asepsis. Furthermore, both methods suggest a significant risk of postoperative failure, as, e.g., Dieffenbach pointed out in his comment on Celsus work.10 When the new prepuce is not permanently tightened at its tip, retraction of the scars may pull the skin backward with the glans remaining uncovered again. A simple dressing might not be able to prevent this effect until wound healing is completed.6

 

MEDICAL LITERATURE FROM GALEN TO DIEFFENBACH

A complete review on the medical literature dealing with uncircumcision is given in the remarkable Zeis Index of 1863, a detailed history of plastic surgery by the surgeon and historian Eduard Zeis from Dresden.4 He had also introduced the term plastic surgery (Plastische Chirurgie) into the medical terminology with the first textbook on this subject in 1838.11 The following text presents the important and relevant highlights of the history of uncircumcision; in addition Table I gives a more extensive overview of medical authors dealing with foreskin restoration between the second and the nineteenth century:

 

TABLE I

Overview of Medical Authors Dealing with Uncircumcision from the Second Century AD to the Nineteenth Century (According to the "Zeis Index")

 

Claudius Galenus 131-200 AD Methodus medendi; Lib. XIX
St. Epiphanius 4th century De ponderibus et mensuris liber
Paulus Aegineta 7th century Lib. VI; Ad tegendam glandem colis si nuda est
Gabriel Fallopius 1523-1562 De praeputii brevitate corrigenda
Ambroise Paré 1510/17-1590 Opera chirurgica; De curtiore praeputio, deque Recutitis
Fabricius ab Aquapendente 1537-1619 De chirurgicis operationibus; Ad tegendam colis glandem detectam
Johann von Jessen 1601 Institutiones chirurgicae; Sect. IV, Cap. IV
Marcus Aurelius Severinus 1643 De efficaci Medicina; De Lypoderma
Thomas Bartholin 1672 De morbis biblicis Miscellanea medica; De praeputio adducendo
Jobus Ludolfus 1691 De praeputio rursus superinducendo
Pierre Dionis 1708 Cours d'opérations de chirurgie; De l'opération des recutiti
Gabriel Groddeck 1733 De Judaeis praeputium attrahentibus
Eduard Zeis 1838 Handbuch der plastischen Chirurgie; Von der Posthioplastik
Johann Friedrich Dieffenbach 1845 Die operative Chirurgie; Posthioplastice
Antoine-Joseph Jobert 1849 Traité de chirurgie plastique; Autoplastic du prépuce
Aristide Verneuil 1858 L'histoire de l'atioplastie
Jean Louis Petit 1873 Oeuvres complètes; Du paraphimosis

 

Claudius Galenus (131-200 AD), the next great contributor to ancient medicine after Celsus, only reported his methods without modifications.12

The same is to be said about Paulus Aeginetas description: Ad tegendam glandem colis si nuda est (middle of the seventh century). He stated that there was almost no need for uncircumcision in his time and, therefore, it was hardly ever performed.13

This belief is also confirmed by most surgeons of the Renaissance: Gabriello Fallopio (1523-1562) commented on uncircumcision as follows: "I can testify that I have never cut nor found anyone so foolish as to be willing to suffer this torture."14

Fabricius ab Aquapendente (1537-1619) declared it "to be unnecessary and objectionable, as it is only carried out to improve the appearance, and this is a part which is not exposed."15

FIG. 4 Frontispiece from the first English translation of the work of Ambroise Paré (from Paré, A. The Workes of that famous Chirurgion Ambrose Parey. T. Johnson, trans. London, 1634).

Only the second method of Celsus is quoted by Ambroise Paré (1510/17-1590), who was the first to suggest the insertion of a catheter ("pipe") into the distal urethra to allow free passage of urine during postoperative healing. Figure 4 shows the frontispiece of the first English translation from 1634 with a portrait of Paré at the top. Figure 5 shows the chapter dealing with uncircumcision "Of the too short a Prapuce, and of such as have bin circumcised."16

FIG. 5. "Uncircumcision" from the first English translation of the work of Ambroise Paré (from Paré, A. The Workes of that Famous Chirugion Ambrose Parey. T. Johnson, trans. London, 1634).

The founder of modern plastic surgery, Johann Friedrich Dieffenbach (1795-1847, Berlin, see Fig. 6), dedicated a whole chapter in both of his surgical textbooks, from 1829 and 1845,10 on the problem of how to restore the prepuce. He entitled this operation "posthioplastice". After recapitulating Celsus methods, he offered technical improvements to prevent postoperative failure. In the first method of Celsus, for example, he suggested a distal narrowing of the new prepuce to avoid retraction over the glans. This method could be done by triangular excision of skin or by fixation of a metal clamp at the preputial tip. Dieffenbach quoted Celsus indications for posthioplastice such as "luxury, religion, shame or politics". On the other hand, he called it "a disgrace to the medical profession to perform it with the intention of creating a male virgin, comparable to the surgical restoration of a new hymen in women." He additionally described the closure of the divided prepuce in hypospadias and reconstruction in a totally cicatrized inner foreskin layer after balanitis. In the second case, he made a circular incision at the tip of the foreskin retracting the penile skin back to the shaft. The remaining inner layer of the prepuce cicatrized to the glans was then separated with the scalpel. Finally, the penile skin had to be inverted and kept in this position by sutures with the former outer layer now becoming the inner layer of the new prepuce.10

FIG. 6 Johann Friedrich Dieffenbach (1792-1847) (from: Meade, R. H. An Introduction to the History of General Surgery, Philadelphia: Saunders, 1968.)

 

UNCIRCUMCISION DURING THE NAZI ERA

The persecution of Jews under the Nazi regime made the state of being circumcised a life-threatening fact, making no difference whether the person had lost his foreskin for religious reasons or because of a congenital or acquired phimosis. So every circumcised man at that time was in danger of being denounced and, therefore, had to hide his genital state or have it uncircumcised. No description of a surgical technique can be found in the official medical literature of this time, but there exist several personal reports of patients undergoing and doctors performing uncircumcision during this time. One example is the work of Tenenbaum who knew several of these doctors and also examined some of the patients treated.17

From the memoirs of Jonas Turkow, a famous actor at that time, we hear the story of his nephew being uncircumcised twice without success. He pointed out that several "Aryan doctors" made a good living from this procedure by asking large sums of money for the treatment.18

Feriz performed several operations on circumcised patients in occupied Holland. After a circumferential incision at the base of the penis the penile skin was pulled over the glans, forming the new prepuce. The proximal skin defect was then covered by burying the penis under a tunnel of ventral scrotal skin. In a second stage operation about 10 days later he mobilized the penis and closed the new skin layer at the underside of the penis. The scrotal defect was easily closed in all cases. In his publication from 1962, Feriz reported no complications, and all of his patients were satisfied with the postoperative result; none of them requested a reversal of the surgery after the war.19

In 1965, Tushnet reported three different procedures to restore the prepuce depending on the age of the patient, the remaining preputial skin, and the skill of the surgeon.6 These facts were also investigated by interviewing patients and doctors who remained unnamed. The first and crudest method was to pull forward the penile skin over the glans, scarify the new prepuce edges, and avoid recession by suturing them together, thus producing a phimosis. This implied a high failure rate because the sutures were often extruded and the skin was retracted to the former position. The second method was quite similar to the second procedure of Celsus, resulting in a single-layered new prepuce. The main disadvantage of this way of foreskin restoration was the high infection rate. Finally, the last and most sophisticated method was performed by using a skin graft from the area over the iliac crest serving as the new prepuce.

 

MOTIVATION FOR PREPUCE RESTORATION IN OUR DAYS

During the past 30 years, a new movement of foreskin restoration has emerged mainly in the United States not originating from social, religious, or political demands. With routine male infant circumcision being established in America, more and more adult circumcised males are disturbed by the fact that the shape of their body had been altered after birth. Their main complaint is the loss of function; the prepuce is not just seen as a part of the human skin but referred to as a sensory organ of the body.20 Circumcision results in a lack of this organ and furthermore in a decrease of lubrication and sensibility of the glans because of increasing keratinization of the epithelium. That is why many circumcised men feel that their sexual pleasures are reduced. Others are more disturbed by the outer appearance of their circumcised penis and want to regain the natural status of a covered glans for physical and emotional wholeness and aesthetic body imaging. A minority is additionally irritated by the imagination that they had been mutilated as an infant without the chance to have a free choice of their genital status. A high percentage of these patients even resent their parents, doctors, or culture for their circumcision.7,21,22

On the one hand, this development has led to the organization of several movements against routine circumcision in America. NOCIRC (National Organization of Circumcision Information Resource Centers) and NOHARMM (National Organization to Halt the Abuse and Routine Mutilation of Males) were founded by "circumcision victims". Others were initiated by doctors or nurses who did no longer agree with the general attitude toward infant circumcision: D.O.C. (Doctors Opposing Circumcision) and Nurses for the Rights of the Child. Furthermore, NORM (National Organization of Restoring Man) provides information, literature, and material about nonsurgical and surgical methods of foreskin restoration. Most of these organizations have spread to other continents and are easily accessible by means of the Internet (see Internet references23).

The first report of uncircumcision for psychological reasons was reported by Penn in 1963.24 This article and the ones of the following years failed to give detailed information on the patient's motivation, and the authors were to a certain extent criticized for performing such a procedure at all.25

In 1981, Mohl presented the first detailed analysis of psychiatric aspects in a group of eight patients seeking prepuce restoration.26 He described several psychological disorders in these patients as narcissistic and exhibitionistic body image, depressions, major defects in early mothering, and ego pathology. Uncircumcision is compared with the request for augmentation mammoplasty in women. One of the main arguments of the modern uncircumcision movement, the loss of prepuce function in sexual activity, is not mentioned at all. Furthermore, all of the patients were currently or had in the past been exclusively homosexual.

Nowadays the understanding of the psychological motivations for uncircumcision is increasing, and the problem is dealt with more seriously. Actually, it is no longer only a matter of the homosexual community because the majority of the males performing skin-stretching is heterosexual.27

 

MODERN TECHNIQUES OF UNCIRCUMCISION

Skin Expansion

Despite the antique reports on the Pondus Judaeus, modern techniques of stretching penile skin have become famous only as lately as in the 1980s.7 Today, foreskin-stretching is estimated to be performed by over 10,000 individuals in the United States for the above-mentioned reasons.27 All methods depend on some kind of tape that is attached to the skin. The best overview with detailed instructions for skin-expansion is given in the work of Bigelow.7

The easiest way to start with is to pull the residual foreskin or the skin of the penile shaft over the glans as far as possible. The skin is fixed in this position by one or two tape straps that run from one side of the stretched penile skin over the tip of the glans to the other side of the shaft. If there is enough foreskin to cover the whole glans it is also possible to apply a tape ring around the distal skin of the new prepuce that makes it impossible to retract. The tape is either changed daily or in most cases left until it gets off the skin. In these simple methods simple pressure from the glans will start stretching the skin.

After sufficient skin has been obtained some kind of extension device can be attached to it to get more tension on the tissue. A simple weight might be fixed to the tape stretching by gravity but only works when the patient is in a standing position. Alternatively a stretched elastic strap is attached to the back of a garter belt under the knee or at the waist to perform permanent tension. Finally rubber cones in graduating sizes can be worn within the foreskin which is held in position by a tape ring.

The skin-expansion method is very time consuming. The period to regain a prepuce varies from about half a year to several years and depends on how much skin was left after circumcision, how persistently one is stretching, and what length of the new prepuce is desired. The problems of skin irritation through the tape can be diminished by correct hygiene and technique.

The natural narrowing of the tip of the prepuce, the so-called frenar band, can be additionally reconstructed by minor plastic surgery, e.g., tissue-removal techniques, transverse incision with vertical suturing or a circumferential purse-string suture.

Surgical reconstruction

The very first case report in modern medical literature about foreskin reconstruction was published in 1898.28 Mercier from Canada only performed construction of the frenulum and narrowing of the "new" foreskin in a patient 2 years after moderate circumcision that left enough skin at the penile shaft to cover the glans.

Several surgical procedures practiced during the Nazi era have been reported above.

In 1963 Penn from Johannesburg, after performing a proximal circular incision and pulling forward the penile skin to form a new prepuce, covered the denuded shaft with a "free graft", not indicating from where he took this graft.24

Goodwin29 covered the same defect in 1990 by implantation of the penis into the scrotum first and then liberating it in a second stage. This procedure is almost identical to the method of Feriz mentioned earlier19 and had been slightly modified before by Greer in 1982.30 A pedicled island scrotal flap was used for the same purpose by Lynch and Pryor in a one-stage procedure in 1993.31

All these publications are single case reports stating no severe complications, and it is not known whether the patients were fully satisfied with the result. Bigelow was able to reinvestigate a few patients operated on by the method of Greer and Goodwin.7 Some of them were extremely pleased with the result and others disliked their new genital status; there was even one patient who underwent recircumcision afterward.

Despite the possible complications of surgery and the inevitable presence of scars, the main disadvantage seems to be the different color and texture of the original penile skin and the graft. This outcome may not be what the patient had expected; therefore, most foreskin restoration seekers nowadays prefer skin expansion systems, which avoid these problems

FIG. 7 David (Michelangelo Buonarroti, 1501-1504, Accademia, Florence).

 

A CLOSING REMARK: UNCIRCUMCISION AND THE FINE ARTS

Lastly, another historic example dealing with the matter of circumcision and uncircumcision can be presented from the fine arts, surprising us that this problem is of any relevance in this field. From 1501 to 1504 Michelangelo Buonarroti created the statue of David (Fig. 7), which is today one of Florence’s main cultural and tourist attractions. One might be rather surprised that this representative of the Jewish people is shown with his penis not circumcised. Was Michelangelo just submitting to the aesthetic taste of his time, thereby making use of artistic liberty, as he had done before?32 Or did he fear any discredit of the Church or his customers by presenting such an obvious sign of Judaism as a circumcised penis? Some authors even postulated that Michelangelo had in mind to attach the face and weapons of David to the statue of Goliath.33 Because this question cannot be answered definitely, the reader is asked to make up his own mind.

Dirk Schultheiss, M. D.
Department of Urology
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover, Germany

 

REFERENCES

  1. Hanafy, H. M., Sadd, S. M., and Al-Ghorab, M. M. Ancient Egyptian medicine. Urology 4: 114, 1974.
  2. Bolande, R. P. Ritualistic surgery-circumcision and tonsillectomy. N. Engl. J. Med. 280: 591, 1969.
  3. Edwardes, A. Erotica Judaica. New York: The Julian Press, 1967.
  4. Zeis, E. Die Literatur und Geschichte der Plastischen Chirurgie. Leipzig: Verlag von Wilhelm Engelmann, 1863.
  5. Zeis, E. The Zeis Index and History of Plastic Surgery. J. S. Patterson, trans. Baltimore: Williams & Wilkins, 1975.
  6. Tushnet, L. Uncircumcision. Medical Times 93: 588, 1965.
  7. Bigelow, J. The Joy of Uncircumcising! Aptos: Hourglass Book Publishing, 1995.
  8. Schneider, T. Circumcision and Uncircumcision. S. Afr. Med. J. 50: 556, 1976.
  9. Rubin, J. P. Celsus' decircumcision operation. Urology 16: 121, 1980.
  10. Dieffenbach, J. F. Die Operative Chirurgie. Leipzig: F. A. Brockhaus, 1845.
  11. Zeis, E. Handbuch der Plastischen Chirurgie. Berlin: G. Reimer, 1838.
  12. Galen, C. Methodus Medendi. Lib. XIV, Cap. 16: Editio Kuhniana. Vol. X. Lipsiae, 1825.
  13. Paulus Aegineta. Des besten Arztes sieben Bucher. Leiden: E. J. Brill, 1914.
  14. Fallopius, G. Operum Tomus II. Opera Johann. Frankfurt: Petri Maphaei, 1600.
  15. Fabricius ab Aquapendente. Opera chirurgica in Pentateuchum et operationes chirurgicas distincta. Patavii, 1666.
  16. Pare, A. The Workes of that Famous Chirurgion Ambrose Parey. T. Johnson, trans. London, 1634.
  17. Tenenbaum, J. In Search of a Lost People. New York: Beechhurst Press, 1948.
  18. Turkow, J. In Kamf farn Lebn. Buenos Aires: Tsentral-Farband fun Poylishe Yidn, 1949.
  19. Feriz, H. Eine einfache Methode zur Plastik des Praputiums nach radikaler (ritueller) Zirkumzision. Munch. Med. Wochenschr. 31: 1406, 1962.
  20. Taylor, J. R., Lockwood, A. P., and Taylor, A. J. The prepuce: Specialized mucosa of the penis and its loss to circum.... Br. J. Urol. 77: 291, 1996.
  21. Hammond, T. Awakenings: A preliminary poll of circumcised men. San Francisco: NOHARMM, 1994.
  22. NOCIRC Annual Report. 11(1), 1997.
  23. National Organization of Circumcision Information Resource Centers. Available at: NOCIRC http://www.nocirc.org/.
    National Organization to Halt the Abuse and Routine Mutilation of Males. Available at: NOHARMM http://eskimo.com/~gburlin/noharmm/
    Doctors Opposing Circumcision. Available at: D.O.C. http://weber.u.washington.edu/~gcd/DOC/
    National Organization of Restoring Man. Available at: NORM http://www.geocities.com/HotSprings/2100/.
  24. Penn, J. Penile reform. Br. J. Plast. Surg. 16: 287, 1963.
  25. Schoen, E.J. Uncircumcision technique for plastic reconstruction of a prepuce after circumcision (Letter). J. Urol. 146: 1619, 1991.
  26. Mohl, P. C., Adams, R., Greer, D. M., and Sheley, K. A. Prepuce restoration seekers: Psychiatric aspects. Arch. Sex. Behav. 10: 383, 1981.
  27. Hammond, T. Personal communication, 1997.
  28. Mercier, O. F. Restauration d'un Prepuce. L' Union Medicale du Canada 3: 264, 1898.
  29. Goodwin, W. E. Uncircumcision: A technique for plastic reconstruction of a prepuce.... J. Urol. 144: 1203, 1990.
  30. Greer, D. M., and Mohl, P. C. Foreskin reconstruction: A preliminary report. Sexual Medicine Today. April 17, 1982.
  31. Lynch, M. J., and Pryor, J. P. Uncircumcision: A one-stage procedure. Br. J. Urol. 72: 257, 1993.
  32. Crosby, W. H. Michelangelo's David (Letter). J.A.M.A. 219: 1212, 1972.
  33. Dock, W., and Crosby, W. H. Michelangelo's David (Letter). J.A.M.A. 219: 1212, 1972.



Citation:
  • Schultheiss D, Truss MC, Stief CG, Jonas U. Uncircumcision: a historical review of preputial restoration. Plast Reconstr Surg 1998;101(7): 1990-1998.

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Replies to This Discussion

History of Circumcision

This index page links to material relating to the origin and history of male circumcision. Material is indexed in chronological order of publication.

Introduction

The practice of male genital mutilation is far older than recorded history. Certainly, it is far older than the Biblical account of Abraham (Genesis 17). It seems to have originated in eastern Africa long before this time.6

Many theories have been advanced to explain the origin of genital mutilation. One theory postulates that circumcision began as a way of "purifying" individuals and society by reducing sexuality and sexual pleasure. Human sexuality was seen as dirty or impure in some societies; hence cutting off the pleasure-producing parts was the obvious way to "purify" someone.

It is now known that the male foreskin, or prepuce, is the principal location of erogenous sensation in the human male (see Anatomy.) Removal of the prepuce substantially reduces erogenous sensation.12,16 Therefore (in the appropriate cultural context), circumcision is revealed as a sacrifice of "sinful" human enjoyment (in this earthly life), for the sake of holiness in the afterlife.12

The Jews adopted circumcision as a religious ritual8,10,15,18 and preserved this prehistoric practice into modern times.10,16,18 The circumcision of Abraham removed only the very tip that extended beyond the glans penis.8,17,22,28 Moses and his sons were not circumcised. (Exodus 4:25) Although Moses apparently prohibited circumcision during the 40 years in the wilderness,15,18 (Joshua 5:5) Joshua reinstituted circumcision at Gilgal after the death of Moses.15,18 (Joshua 5:2-10) It is interesting to note that after the Israelites were circumcised, they immediately became soldiers in Joshua's army for the conquest of Palestine. (Joshua 6:1-3)

In contrast to the Jews, the Greeks and the Romans placed a high value on the prepuce.31 The Romans passed several laws to protect the prepuce by prohibiting circumcision.31

Much later in the Hellenic period, about 140 C.E., the circumcision procedure was modified to make it impossible for a Jew to appear to be an uncircumcised Greek.8,18,25 A radical new procedure called peri'ah was introduced by the priests and rabbis. In this procedure the foreskin was stripped away from the glans, with which it is fused in the infant (See Normal.) In a painful procedure known today as a synechotomy, more foreskin was removed than before and the injury was correspondingly greater. With the introduction of peri'ah, the glans could not easily be recovered, and so no Jewish male would easily be able to appear as an uncircumcised Greek.8,18,25

It may have been at this time that the Pondus Judaeus (also known as Judaeum Pondum), a bronze weight worn by Jews on the residual foreskin to stretch it back into a foreskin,8,18,23 gained popularity amongst Jewish males. This lessened the ugly appearance of the bare exposed circumcised penis.18 This restorative procedure was known by the Greek word epispasm,8 or "rolling inward."

The third stage of ritual circumcision, the Messisa or Metzitzah, was not introduced until the Talmudic period (500-625 C.E).8,17,23 In Metzitzah, the mohel (ritual circumciser) sucks blood from the penis of the circumcised infant with his mouth.31 This procedure has been responsible for the death of many Jewish babies due to infection.13 In modern times, a glass tube is sometimes used instead.

The Reform movement within Judaism considered circumcision to be a cruel practice.17 The Reform movement at Frankfort declared in 1843 that circumcision was not necessary.17,21

The Christians took a strong stand against circumcision in the first century. Christians rejected circumcision at the Council at Jerusalem.17 (Acts 15) St. Paul, the apostle to the gentiles, taught parents that they should not circumcise their children. (Acts 21:25) In a reference to the old practices of genital mutilation, St. Paul warned Titus to beware of the "circumcision group." (Titus 1:10-16)

The modern use of Hebrew circumcision as a medicalized practice dates from about 1865 in England and about 1870 in the US.10 The procedure accepted for medical use essentially was the Jewish peri'ah. Moscucci reports that circumcision was imposed in an attempt to prevent masturbation.15 Gollaher further describes the history of medicalized circumcision.10 No scientific studies were carried out to determine the efficacy and safety of circumcision prior to its introduction into medical practice,10 nor were any studies conducted to determine the social effects of imposing genital alteration surgery on a large portion of the population.

South Koreans started to circumcise children during the American trusteeship following World War II. The American cultural practice of circumcision became nearly universal in South Korea after the Korean War of 1950-52.24

In 1949, Gairdner wrote that circumcision was medically unnecessary and non-beneficial,3 and contraindicated because of complications and deaths.3 The British National Health Service (NHS) deleted non-therapeutic neonatal circumcision from the schedule of covered procedures in 1950. The incidence of neonatal circumcision in the United Kingdom declined sharply to a very low level after publication of this article after the procedure was delisted by the NHS.

America waited another 20 years before addressing the problem of non-therapeutic circumcision. The Journal of the American Medical Association published an influential landmark article by Dr. E. Noel Preston, Captain, MC, USAF.4 Dr. Preston established that there is no therapeutic or prophylactic benefit to circumcision. He also cited "undesirable psychologic, sexual, and medico-legal difficulties."4

Influenced by Preston, the American Academy of Pediatrics (AAP), in 1971, issued a statement that "[t]here are no valid medical indications for circumcision in the neonatal period."10 This marked the beginning of the end of America's infatuation with male circumcision. The incidence of male neonatal circumcision in the U.S. peaked in 1971 and began a slow decline that continues to the present day.

Recent History

The AAP convened an "ad hoc Task Force" under the chair of Hugh C. Thompson, M.D., to review the issue of circumcision in 1975. The 1975 Task Force reaffirmed the 1971 AAP statement.10 The Canadian Paediatric Society (CPS) also took a position in 1975 that circumcision is medically unnecessary.

The matter rested there until 1985, when retrospective data collected from U.S. Army medical records by Thomas Wiswell, M.D. seemed to show a somewhat higher rate of urinary tract infection (UTI) in non-circumcised boys. Careful examination of Wiswell's methods and data revealed many methodological flaws which rendered his conclusions questionable and unreliable. This created new controversy about the value of neonatal circumcision. The Canadian Paediatric Society examined Wiswell's data in 1989 and found it to be "insufficiently compelling" to cause it to change its 1975 policy statement, which is against circumcision.

The National Organization of Circumcision Information Resource Centers (NOCIRC) was formed in 1986. The mandate of NOCIRC is to provide accurate information regarding male circumcision, to promote children's rights, and to shed light on the medical mistakes of the past. Professor George C. Denniston, M.D., M.P.H., founded Doctors Opposing Circumcision (DOC) in 1995 to promote the health advantages of genital integrity within the medical community.

The Circumcision Information and Resource Pages (CIRP) were created in 1995 to provide a source of accurate information about circumcision on the World Wide Web.

The development of new information in the medical literature since 1975 caused the AAP to revisit the matter of circumcision in 1989. A new Task Force under the chair of Edgar J. Schoen, M.D., examined new data about neonatal pain, behavior changes, and loss of sexual sensitivity secondary to neonatal circumcision. New data also conclusively established the role of the human papillomavirus (HPV) in the pathogenesis of genital cancers. This removed any lingering belief that the prepuce somehow caused cancer.

The Canadian Paediatric Society revisited the matter of neonatal circumcision in 1996. A new evidence-based policy statement was issued that strengthened its 1975 recommendation, stating that circumcision is medically unnecessary. The CPS recommended: "Circumcision should not be routinely performed."

The incidence of neonatal circumcision in the US has continued to decline, and stood at only 60% in 1996. In the same year, the Australian College of Paediatrics (ACP) reported that the incidence of neonatal circumcision in Australia has continued its decline to 10%. The ACP termed circumcision traumatic, a possible violation of human rights, and called for parents to be provided with full and complete information about circumcision before making a decision.

John R. Taylor and colleagues published a landmark article in 1996 that described original research into the anatomy and histology of the foreskin. The research showed that the foreskin is highly innervated tissue with the characteristics of a sensory organ designed to provide erogenous sensation.16

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), in a joint statement, reclassified neonatal circumcision from "routine" to "elective" in 1997.19 The change in policy was announced the year after the publication of Taylor's important article that describes in detail the injury inherent in every circumcision. This action removes any suggestion that circumcision is beneficial or that it is recommended by medical authorities. It may also be an attempt to shift legal liability for the injury that is inherent in every child circumcision from the doctor to the parents.

Persistent criticism of the obvious flaws of the supplemental 1989 Report of the Task Force on Circumcision has caused the AAP to distance itself from its own report. The AAP has removed its policy statement from its website. The AAP convened a new Task Force under the chair of Carole Marie Lannon, MD, in 1997 to develop a new evidence-based policy statement which was released in March 1999. After fully reviewing the medical evidence, the Task Force concluded that routine neonatal circumcision cannot be recommended because of lack of any proved benefit. It said that the benefits are "potential" (i.e. they are unproven).

The Council on Scientific Affairs of the American Medical Association issued a policy report in December 1999 that re-classified neonatal circumcision as a "non-therapeutic" procedure.30 This may have a medico-legal impact.

The ratio of boys circumcised to boys preserved intact continues to decline in America. In 2001, it had further declined to a ratio of 55 percent circumcised, while the percentage of boys preserved intact had risen to 45 percent.36

Highlights

The Encyclopædia Britannica article from the 9th edition (1876) provides us with a Victorian view of circumcision. Interestingly, it does not mention any alleged medical purposes.2

Gairdner's historic world famous landmark classic medical article (1949) is presented.3

Preston's historic influential medical article (1970) is presented.4

Paige (1978) provides us with a history of cirumcision in the US. She discusses the fear of masturbation that lead to the commencement of the circumcision of boys.5

DeMeo (1989) says geographical patterns of global distributions of the male and female genital mutilations among native, non-Western peoples, along with history and archaeology, suggest their genesis in the deserts of Northeast Africa and the near East, with a subsequent diffusion outward into sub-Saharan, Oceania and possibly even into parts of the New World.6

Montagu (1991) uses anthropological knowledge to give insight into the origins of genital mutilation.7

Bigelow (1992) traces the development of various forms of circumcision within Judaism through the centuries and into modern times.8

Voskuil (1994) suggests that the identical 28 day lunar month and the monthly menstruation cycle of the woman are linked to the origin of circumcision.9

Gollaher (1994) describes the transformation of ritual circumcision into a medical procedure.10

McLaren gives us a not very complimentary portrait of Dr. John Harvey Kellogg who promoted circumcision and corn flakes as a cure for masturbation.11

Warren and Bigelow (1994) discuss the sacrificial origin of circumcision.12

Frederick M. Hodges, Jerry W. Warner. The Right to Our Own Bodies: The History of Male Circumcision in th.... M.E.N. Magazine 1995 (November).14

Moscucci reports the results of her research into the introduction of male circumcision to prevent masturbation in the late 19th century.15

The Oxford Dictionary of the Jewish Religion (1997) reviews the history of Jewish circumcision.16

DeMeo (1996) revisits his earlier work and discusses several theories regarding the origin of male and female circumcision. DeMeo identifies anxiety about sexual pleasure as the underlying psychological reason for both male and female circumcision.17

Schultheiss and others (1998) provide an account of the long history of man's attempts to restore the prepuce after unwanted circumcision.21

Dunsmuir and Gordon (1999) provide a good general history of circumcision with particular attention paid to the history of the development of surgical technique.22

Kim and colleagues provide a history of circumcision in South Korea.23

Brandes and McAninch review the history of efforts to undo the effects of male circumcision.24

Frederick Mansfield Hodges (1999) unveils the medical treatment of phimosis and paraphimosis in the classical medical literature.26

James E. Peron illuminates the development of circumcision in Jewish history from a minor procedure into a major mutilation, and how this most mutilating and injurious form of circumcision was accepted into medical practice.27

Frederick Mansfield Hodges, D. Phil., has researched the Greek and Roman attitudes toward the prepuce. He reports in this profusely illustrated document that the Greeks and Romans placed a high value on the prepuce, preferred long tapering prepuces, and later the Romans protected the prepuce by law.30

John M. Ephron reports that German Jews used medical arguments to justify and promote the practice of male circumcision to Gentiles during the 19th and early 20th centuries.31

John Evelyn observed a Jewish circumcision at Rome in 1645 and recorded it in his diary.32

redline

See also

Holdings

  1. Anonymous. Clitoridectomy and Medical Ethics. Medical Times and Gazette (London) 1867:(1):391-2.
  2. Encyclopædia Britannica, 9th Ed. s.v. "Circumcision," by Rev. T. K. Cheyne.
  3. Gairdner DA. The fate of the foreskin: a study of circumcision.. BMJ 1949;2:1433-1437.
  4. Preston EN. Whither the foreskin? A consideration of routine neonatal circumcision. JAMA 1970;213:1853-1858.
  5. Paige, Karen Eriksen. The ritual of circumcision. Human Nature, pp 40-48, May 1978. (Link to www.noharmm.org)
  6. James deMeo. The Geography of Genital Mutilations. The Truth Seeker, pp 9-13, July/August 1989. (Link to www.noharmm.org)
  7. Montagu, Ashley. Mutilated Humanity. Presented at the Second International Symposium on Circumcision. San Francisco, California. April 30-May 3, 1991. (Link to www.nocirc.org)
  8. Bigelow J, Ph.D., The Development of Circumcision in Judaism. In: Bigelow J., The Joy of Uncircumcising! Hourglass Book Publishing, Aptos, California 95001, 1992, 1995. (ISBN 0-934061-22-X) (out of print)
  9. Voskuil, D, Ph.D. From Genetic Cosmology to Genital Cosmetics: Origin Theories of the Righting Rites of Male Circumcision. Presented at the Third International Symposium on Circumcision. University of Maryland, College Park, Maryland, May 22-25, 1994. (Link to www.nocirc.org)
  10. Gollaher, David L. From ritual to science: The medical transformation of circumcision .... Journal of Social History Volume 28 Number 1, p. 5-36 (Fall 1994).
  11. McLaren, Carrie. Porn Flakes: Kellogg, Graham and the Crusade for Moral Fiber. (courtesy of STAYFREE! Homepage)
  12. Warren J, Bigelow J. The case against circumcision. British Journal of Sexual Medicine, September/October 1994:6-8.
  13. John J. Tierney. Circumcision. In: The Catholic Encyclopedia, 1913, 1997.
  14. Frederick M. Hodges, Jerry W. Warner. The Right to Our Own Bodies: The History of Male Circumcision in th.... M.E.N. Magazine 1995 (November)
  15. Moscucci, Ornella. Clitordectomy, Circumcision, and the Politics of Sexual Pleasure in Mid-Victorian Britain. Sexualities in Victorian Britain. Indiana University Press, Bloomington and Indianapolis, 1996.
  16. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circum.... Br J Urol 1996;77:291-295.
  17. Circumcision. In: The Oxford Dictionary of the Jewish Religion, Oxford University Press, New York & Oxford 1997.
  18. DeMeo, James. The Geography of Genital Mutilations. (Presented at the Fourth Symposium on Sexual Mutilations, University of Lausanne, Lausanne, Switzerland. August 9-11, 1996.) Published in: Sexual Mutilations, A Human Tragedy, Plenum Press, New York, 1997 (ISBN 0-306-45589-7). (link to www.nocirc.org)
  19. Hodges FM. A short history of the institutionalization of involuntary sexual mutilations in the United States. in: Denniston GC, Milos MF (eds.), Sexual Mutilations: A Human Tragedy (New York: Plenum Publishing, 1997), pp. 17-40. (ISBN 0-306-45589-7)
  20. Oh W, Merenstein G. Fourth Edition of the Guidelines for Perinatal Care: Summary of Changes. Pediatrics 1997;100(6)1021-1027.
  21. Goldman Ronald, Ph.D., Origins and Background. In: Questioning Circumcision: A Jewish Perspective. Vanguard Publications, Boston, 1998. (ISBN 0-9644895-6-2)
  22. Schultheiss D, Truss MC, Stief CG, Jonas U. Uncircumcision: a historical review of preputial restoration. Plast Reconstr Surg 1998;101(7): 1990-1998.
  23. Dunsmuir WD, Gordon EM. The history of circumcision. BJU Int 1999; 83, Suppl. 1: 1-12.
  24. Kim DS, Lee JY, Pang MG. Male circumcision: a Korean perspective. BJU Int 1999; 83 Suppl. 1:28-33.
  25. Brandes SB, McAninch. Surgical methods of restoring the prepuce: a critical review. BJU Int 1999; 83 Suppl. 1:109-113.
  26. Hodges FM. The history of phimosis from antiquity to the present. in: Denniston GC, Hodges MF, Milos MF (eds.), Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice (New York/London: Kluwer Academic/Plenum Publishing, 1999), pp. 37-62.
  27. Hodges FM. Phimosis in antiquity. World Journal of Urology 1999; 17(3):133-136.
  28. Peron, James E. Circumcision: Then and Now. Many Blessings 2000;III:41-42.
  29. Gollaher, David A., Circumcision: A History of the World's Most Controversial Surgery. New York: Basic Books, 2000. 253 pages. (ISBN: 0-465-04397-6)
  30. Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. July 6, 2000.
  31. Hodges FM. The Ideal Prepuce in Ancient Greece and Rome: Male Genital Aesthetics and Their Relation to Lipodermos, Circumcision, Foreskin Restoration, and the Kynodesme. Bull Hist Med 2001 Fall;75(3):375-405.
  32. John M. Ephron. Medicine and the German Jews. New Haven: Yale University Press, 2001: 222-233. (ISBN 0-300-08377-7)
  33. John Evelyn. Diary, January 15, 1645. In: The Times, London, 15 January 2003.
  34. Robert Darby. `Where doctors differ:' The debate on circumcision as a protection .... Social History of Medicine 2003;16(1):57-78.
  35. Robert Darby. The masturbation taboo and the rise of routine male circumcision: a.... J Soc Hist 2003;36:737-57.
  36. Robert J L Darby. Medical history and medical practice: persistent myths about the fo.... Med J Aust 2003; 178(4):178-9.
  37. Bollinger D. (2003) Intact Versus Circumcised: Normal versus Circumcised: U.S. Neonatal.... Circumcision Reference Library (an original online publication), 22 April 2003.
  38. Darby R. The riddle of the sands: circumcision, history, and myth. N Z Med J 2005;118(1218):U1564.
  39. Androutsos G. The truth about Louis XVI's marital difficulties. Prog Urol 2002;12:132-7. (Translated from the French by Dennis Harrison.)

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Patchwork Merchant Mercenaries had its humble beginnings as an idea of a few artisans and craftsmen who enjoy performing with live steel fighting. As well as a patchwork quilt tent canvas. Most had prior military experience hence the name.

 

Patchwork Merchant Mercenaries.

 

Vendertainers that brought many things to a show and are know for helping out where ever they can.

As well as being a place where the older hand made items could be found made by them and enjoyed by all.

We expanded over the years to become well known at what we do. Now we represent over 100 artisans and craftsman that are well known in their venues and some just starting out. Some of their works have been premiered in TV, stage and movies on a regular basis.

Specializing in Medieval, Goth , Stage Film, BDFSM and Practitioner.

Patchwork Merchant Mercenaries a Dept of, Ask For IT was started by artists and former military veterans, and sword fighters, representing over 100 artisans, one who made his living traveling from fair to festival vending medieval wares. The majority of his customers are re-enactors, SCAdians and the like, looking to build their kit with period clothing, feast gear, adornments, etc.

Likewise, it is typical for these history-lovers to peruse the tent (aka mobile store front) and, upon finding something that pleases the eye, ask "Is this period?"

A deceitful query!! This is not a yes or no question. One must have a damn good understanding of European history (at least) from the fall of Rome to the mid-1600's to properly answer. Taking into account, also, the culture in which the querent is dressed is vitally important. You see, though it may be well within medieval period, it would be strange to see a Viking wearing a Caftan...or is it?

After a festival's time of answering weighty questions such as these, I'd sleep like a log! Only a mad man could possibly remember the place and time for each piece of kitchen ware, weaponry, cloth, and chain within a span of 1,000 years!! Surely there must be an easier way, a place where he could post all this knowledge...

Traveling Within The World is meant to be such a place. A place for all of these artists to keep in touch and directly interact with their fellow geeks and re-enactment hobbyists, their clientele.

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