LETTER OF DR. W. B. LAING Bulletin of the Vancouver Medical Association October 1953, vol. 30, pp. 76-77. Sir: In the interests of all unborn sons of Vancouver and of not a few of their prospective parents, may I, as a humble observer, be permitted to voice a protest against the routine operation of circumcision? Any thoughtful person, especially if he believes that he is resident in “God’s own country,” must find it difficult to believe that the Creator would have made such a botch of the organ par excellence, that about 90% of these finished members should require correction, yet in Vancouver this percentage of circumcisions is being carried out on infant boys, not always with wholehearted parental approval. Gairdner (Brit. Med. J. 1949, 2, 1433) showed that the development of the prepuce continued for the first few years of life, and that only 10% of prepuces would fail to attain retractability by the age of three years, and that in most of the remainder correction could be obtained by gentle manipulation. Denis Browne (Brit. Med. J. 1950, 1, 181) in support of Gairdner’s teaching, said that for many years he had performed fewer straightforward circumcisions than operations designed to correct or mitigate the results of previous attacks on the foreskin. More recently a leading article in the British Medical Journal (1952, 2, 766) concluded as follows: “When the medical profession has realized that circumcision in the first three years of life is an unnecessary operation, the parents will soon be dissuaded from requesting it. The matter is not important enough for a national propaganda campaign addressed to the laity, who already suffer from a surfeit of exhortation. If those who teach paediatrics to medical students and those who lecture to midwives would remember to condemn the operation as a treatment for the non-retractable prepuce of the infant, routine circumcision would again be no more than a religious ritual and an anthropological curiosity.” If carcinoma of the penis were a common condition (according to Dean (1935) J. Urol., 33, 252, carcinoma of the penis forms 1.25 per cent of all malignant tumours found in the male) and if the essential precursor were a retractable foreskin, rather than filth, balanitis, or venereal disease, there might be a case for preventive routine circumcision. There appears to be no evidence however that carcinoma of the penis cannot be prevented by the liberal use of soap and water. The rarer, but similar, carcinoma of the umbilicus is said to be due to the irritation of retained umbilical sebaceous material and its calcified fragments or calculi, and it is probable that routine excision of the umbilicus, or even of the deep type only, would give absolute protection; again there is not the slightest reason for believing that soap and water would not be equally efficacious. As a preventive of cancer however, there certainly seems to be more justification for excision of a deep, and difficult to clean, umbilicus than of a normal retractable prepuce. I have spoken to numerous parents in Vancouver whose baby boys were circumcised, not because they wished this to be done, but because they were led to believe that it was desirable, and to a few who have incurred the displeasure of their doctors by refusing to allow the operation to be performed. Because of the frequency with which the operation is being carried out on the newborn, meatal ulcers are a commonplace at the Well Baby Clinics here. Gairdner, in the article already referred to, remarked that it second [sic] to be no accident that during the years when the child is incontinent the glans is completely clothed by foreskin, and that meatal ulcer is almost confined to circumcised male infants. Last week I examined a six-year-old boy who has become so embarrassed and unhappy about his normal foreskin, since acquiring two circumcised foster brothers, that his mother is giving serious consideration to the question of circumcision. If routine circumcision is, as it seems to be, an unnecessary operation, then, in a community where about 90% of boys are being circumcised, perhaps there is something to be said for removal of the embarrassing, if not tight, foreskins of the odd 10% or so who previously slipped through the net? I am sir,
CIRCUMCISION AND VENEREAL DISEASE* R. A. WILSON, M.D., M.R.C.P.(Lond.)**
Canadian Medical Association Journal January 1947, vol. 56, pp. 54-56. THE advisability of routine circumcision has long been a subject of medical controversy. It is seldom however, that the discussions on the subject are based upon new factual observations. Since army experience provides an unusual opportunity to collect such data, it was decided to conduct the present investigation. Before recording our observations on the incidence of circumcision amongst soldiers with venereal disease, some of the standard arguments for and against this operation will be reviewed. Those who advocate routine circumcision usually base their views upon the general consideration that the procedure renders subsequent cleanliness and hygiene of the penis so simple that no special attention or manipulation is ever necessary. They consider circumcision a justifiable method of rendering the delicate coronal membrane much more resistant to injury and infection. They argue that the future dangers of balanitis, painful erection, unsatisfactory coitus and paraphimosis can be removed by this simple prophylactic operation. If it is done with good judgment and reasonable surgical skill its dangers should be negligible. On the other hand, the opponents of routine circumcision state that it is unwise to remove a protective covering which was obviously provided by nature for a purpose. They point out that the routine subjection of babies to an operation which has definite dangers is vicious and purposeless surgical interference. Frequently, good judgment and surgical skill are not exercised. The hazards of the operation then do not justify its routine or even frequent performance. They state that in practically all cases adequate instruction of the mother and stretching of the foreskin will render operation unnecessary. Another, less frequently voiced, yet very real objection of the operation, is the danger of meatal ulceration. This occurs not infrequently in circumcised infants who have ammoniacal diaper burns. This complication is preventable if precautions are taken. Besides these valid arguments on medical grounds there is great discussion of the religious and personal aspects of the problem. For example some uncircumcised people claim that the toughening of the coronal membrane after circumcision reduces the sensory impulses from the region and renders coitus less pleasurable. Material
The detailed results are shown in Table I (a and b). From these figures it will be seen that 76.7% of the V.D. Group were uncircumcised whereas in the control group, 52% were uncircumcised. The most striking difference is in syphilis where 90% of the cases were uncircumcised. That these figures bear statistical analysis will be seen from the accompanying figures in Table I. In each instance except balanitis and venereal warts, the observed difference is highly significant. The number of cases in the latter two diseases are too small to be of significance. However, it is accepted that these diseases are very rare in circumcised people. Discussion The possibility must be considered that the higher proportion of uncircumcised soldiers amongst the venereal disease group may be due to a greater rate of promiscuous exposure amongst the uncircumcised. Selection may have taken place in this way. It is impossible to control this factor, but from general impressions it is considered unlikely that this group is significantly more promiscuous. It is suggested from the present results that venereal disease is more prevalent amongst uncircumcised males. What are the possible explanations for this? In gonorrhoea it could be due to the fact that the foreskin, after coitus, retains infectious mucus. Here is an ideal environment of moisture and warmth, the organisms multiply and provide heavy contamination of the adjacent urethral mucosa. That syphilis is more common in uncircumcised soldiers seems even more reasonable. Tears and abrasions of the foreskin itself are commonly seen on sick parade. Small abrasions of the delicate coronal membrane must be very common during brothel intercourse. Both provide a portal of entry for the spirochaete. Army experience, in the light of the present results, leads one to the conclusion that the advantages of circumcision far outweigh the previously mentioned disadvantages. Frequent physical inspection of men reveals that cleanliness of these parts is commonly neglected. When bathing facilities are poor, neglect is almost universal. The area is then prone to infection. Venereal warts and balanitis are usually the result of such carelessness. Non-specific penile ulceration, chancroid and syphilis often result from tears in a tight foreskin. The latter also renders diagnosis more difficult. It is concluded that the presence of a foreskin is a distinct liability to the average soldier.
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