The fate of the foreskin (letter)

CORRESPONDENCE

SIR,—I am grateful to the many correspondents who have commented on my article (December 24, 1949, p. 1433), particularly to those who have added further facts to a subject the discussion of which in the past has too often engendered heat rather than light. A number of pertinent questions have been asked.

Phimosis. Dr. C. A. Royde (January 21, p. 181) doubts my contention that true phimosis causing urinary obstruction virtually never occurs and so cannot be responsible for many of the child deaths registered as due to circumcision or phimosis. The facts are : (1) I have long searched for such a case without finding one ; (2) two experienced paediatric surgeons, Mr. Twistington Higgins and Mr. Dennis Browne, both interested in urology, inform me that they have never met such a case ; and (3) the only reference I know is that of Campbell,¹ who writes, I know of four infant deaths in New York City from this cause, without giving further details-but this authors account of the anatomy of the prepuce is so at variance with my own that I feel bound to question his explanation of these deaths.

Drs. H. M. Rose and A. M. Gould (January 28, p. 247) find true phimosis present in one-sixth of the infants referred for circumcision.. I am well aware of the appearances they describe, and if they will try the effect of simply completing the separation of the prepuce from the glans they will be surprised to see that the preputial constriction is an illusion. In this context, Dr. B. Webbers experience (January 28, p. 247 is valuable : in circumcising some 200 infants he found none in which the prepuce was not easily retractable after separation.

Venereal disease. Limitation of space caused me to deal summarily with the evidence, bt my conclusion that it seems scarcely to warrant universal circumcision as a prophylactic against venereal disease was based on a critical reading of the literature, including most of the authors listed by Dr. C. A. Royde when he affirms that it has been well established that circumcision reduces the risk of syphilis. In fact the existing evidence bearing on this matter proves disappointingly poor. For instance Wolbarsts² figures, which are much quoted, do not distinguish between chancre and chancroid ; as chancroid is the one venereal disease which all agree is uncommon in the circumcised his figures fail to prove that syphilis is less common in the circumcised. Comparable deficiencies vitiate the value of the statistical evidence of other older authorities, as Lloyd and Lloyd³ showed in their review of the subject in 1934. Since then little further matter has been published except for a study by Wilson⁴ of venereal disease as seen in the Canadian army. His results are difficult to assess because although both chancre and chancroid were shown to be much less common in the circumcised, so also was gonorrhoea, although there has been general agreement that gonorrhoea is in no way prevented by circumcision. The only careful study of the value of circumcision in preventing syphilis remains that of Lloyd and Lloyd, whose results from Guys Hospital V.D. department showed that the proportion of circumcised men was 22% (of 118) with genital syphilis, compared with 27% (of 278) with gonorrhoea-i.e., there was no great difference which would favour the idea that circumcision prevented syphilis. A fair summary of the evidence would be that circumcision does not prevent gonorrhoea, greatly reduces the chance of chancroid, and possibly may have some small effect in reducing the risk of syphilis, though this is unproved.

Penile cancer. Dr. J. B. Peck (January 14, p. 122), among others, considers as this disease can be prevented by circumcision it should be, since even (as I think likely) rational local hygiene were equally effective a number of men will never maintain the requisite level of hygiene. A corollary of this view is that all males should be circumcised in infancy, and that if this is done in the first month, the risk of an anaesthetic can be avoided. Deaths per year from circumcision or phimosis in England and Wales between 1940 and 1947 have averaged 3 in the first month of life and 12 in the first year, and it seems certain that if all the 400,000 males born each year in this country were circumcised a certain number of disasters must inevitably occur from infection, if not from the horrible surgical bloomers listed by Mr. Denis Browne. The question comes down to this: Is it justifiable to sacrifice a few infants in order to save a probable larger number of elderly and (as I have shown) low-grade men from cancer ? Some may consider it is.

The supposed aesthetic or erotic superiority of the shorn member. Dr. Dermod MacCarthy (February 4, p. 304) elegantly shown us that Michelangelo would have voted conservative on the first of these issues, while Dr. R. C. MacKeith (January 14, p. 122) strikes a blow for unsatisfied English womanhood and asks for more information about the second. To the evidence, sketchy and circumstantial, I have already adduced only this can be added : outside the English-speaking people of the West circumcision is not customary, and Frenchmen, Swedes, and South Americans, to name three different races who are said to take these matters quite seriously, seem to have felt no need to employ circumcision to further their ends.

Finally, I believe that this controversial issue can be simplified to a choice between two possible views, either of which accords with the facts. Some may hold that all male infants should be circumcised, irrespective of the state of the prepuce, in order possibly to prevent certain late stage disease-paraphimosis, cancer, and venereal disease. The operation should then probably be done in the first month, and in the full knowledge that an occasional accident may cause the loss of an infants life. This is rational prophylaxis. Others will reserve circumcision for the occasional case where disease of the prepuce requires this treatment, having in mind that the prepuce cannot be retracted during the first few years. This is rationaltherapeutics.

There is a third policy-that which largely obtains to-day-whereby a proportion of infants, varying from 12 to 84% in different sections of the community, are almost invariably selected for circumcision on the grounds of supposed phimosis. The burden of my argument has been to show that this practice fails utterly to accord with anatomical facts. I still have hopes that Mr. Geoffrey Parker's (January 21, p. 181) sorrowful comment on my article— that no one will take the slightest notice of what he says —may prove an overstatement.—I am, etc.

Cambridge, DOUGLAS GAIRDNER

*** Correspondence on this subject was closed in last week's Journal, which went to press before Dr. Gairdners letter was received, but as the author of the article, he should have a right of reply.—ED., B.M.J.

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