The old dilation vs circumcision debate gets interesting

Introduction

As the incidence of routine circumcision in Britain reached its peak in the early 1930s, a controversy in the correspondence columns of the British Medical Journal revealed that just about as many doctors were opposed to the procedure as in favour of it.  The correspondence is notable for the dismal quality of much of the argument, depressing lack of knowledge about male anatomy and sexuality, and blythe disregard for medical ethics. Anecdotes and "wise saws" were tossed around as though they were hard facts;  nobody was aware of existing research which showed infantile phimosis to be normal or that assumptions about the "greater erotic sensitivity" of the glans were erroneous; and there was no suggestion that boys might miss their foreskin or were entitled to a say in whether they were allowed to keep it. [1]  The dominant obsession – with the squeaky cleanliness of the glans – harks right back to William Acton's nervousness about the role of "secretions" in "premature sexual arousal" and masturbation.

Much of the discussion centred on such Victorian medical principles as the physical dangers of masturbation, and the necessity for instant action against "congenital phimosis". If these points in favour of circumcision did not impress, advocates trotted out their clinching argument: that it provided protection from, if not immunity, to syphilis. But the debate is also remarkable for an entirely new note in British medical discourse: the suggestion that doctors should not be concerned with moral issues like masturbation, and the revolutionary suggestion that phimosis in infants was not a disease or abnormality at all. Although most of the opponents of circumcision laboured under the delusion that "congenital phimosis" in infants had to be treated urgently, the provocative Dr Ainsworth dared to state that phimosis was an "imaginary disease" and even recommended that the infant foreskin be left entirely alone, thus pointing the way toward Douglas Gairdner's demolition of "congenital phimosis" the following decade.

The controversy was kicked off by a letter from D.I. Connolly, who deplored the high rate of injury and death arising from infant and childhood circumcision, and proposed his own patent method for separating and stretching the foreskin. Much of the resulting debate was the old circumcision vs. dilation argument which still gripped Alan Guttmacher in 1941. The zeal with which Connolly and his commentators recommended their patent methods for either cutting or stretching was not matched by the clarity of their exposition; most gave such a confused description of their technique that one wonders whether they could have given clear instructions for making a cup of tea, let alone for operating on one of the most complex sites of the male body.

The letters

The controversy is sparked off

Although circumcision is performed frequently in all parts of the world, yet I think that this minor operation is capable of causing much trepidation even to the most experienced of surgeons. Complications occur now and again, but the most dreaded sequel of all is haemorrhage. This latter has been known to be the cause of death. It is not necessary to stress this fact; it is known only too well to many amongst us. Shock also may be an immediate cause of death. Other complications such a sepsis and ulceration do arise, and the latter may have serious later consequences.

Hence the question arises: Is there any reliable, efficient method of treating severe phimosis other than by a cutting operation? In my opinion there is such a method, and one worthy of extensive trial. This method – or operation rather – should be performed as early as possible, say within the first week of the infant's life. No anaesthetic is needed.

After thoroughly cleansing all the parts, using any reliable antiseptic – for example, bichloride of mercury – and wiping with antiseptic spirit, the child's legs are held firmly by an assistant standing at the head of the infant and the latter lying on his back. Strict asepsis must be practised as in any major operation. The instruments necessary are: Spencer Wells forceps, dressing or sinus forceps, and a blunt probe. The operator should draw the prepuce downwards with the index finger and thumb of his left hand. Gently insert the closed blades of the Spencer Wells forceps into the prepuce, of course avoiding the urinary meatus. Using care, push the blades gently upwards and at the same time opening the blades and thoroughly stretching the outer layer of the prepuce. Keep the blades in this position and manoeuvre the prepuce back beyond the glans penis. Then separate the inner layer of the prepuce from the glans by means of the blunt probe. Apply the blades of the sinus or dressing forceps to the inner layer of the prepuce and repeat to it what has already been done to the outer layer – that is, manoeuvre it back to beyond the neck of the glans. Clean away all smegma and secretion that may have accumulated on the surface of the glans penis.

The next and important step is the dressing. It is absolutely necessary to keep the entire prepuce in the position as described for the next few days. To do this, I have devised a circumcision dressing shield made of fine rubber, perforated with holes to allow the passage of fine tapes. These latter can be carried  round the groins and tied off securely there. The shields are made up in sealed antiseptic cartons ready for use. They are impregnated with a zinc oxide cum boric powder. If necessary, some ribbon aseptic gauze may be first applied firmly around the retracted prepuce, and then the shield may be applied. Usually the mother is intelligent enough to be able to reapply the shield (if necessary). The child may be brought to the hospital or the surgery for redressing.

The whole procedure should not take more than five minutes. The points in favour of it are: (1) absolute efficiency; (2) no haemorrhage; (3) fouling of the wound is reduced to a minimum – the child is not able to kick off the shield dressing when efficiently applied and tied, hence sepsis is not so likely to occur; (4) if care and gentleness are used in the operation, shock is negligible; (5) anxiety and worry as to haemorrhage is removed from the surgeon's mind. The circumcision shields are made to my design by F. Whitehead and Co, Pickets Street, London S.W. 12.

D.I. Connolly

BMJ, 24 August 1935, p. 359

Responses

I was interested in the technique described by Dr D.I. Connolly, as I endorse his view that circumcision can be followed by many unfortunate consequences. Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life. As the likelihood of such psychological trauma appears with the age of the child, it seems wise to deal with the condition at the earliest age possible, whether the prepuce is already adherent or the opening so small that adhesions are likely to occur.

I first learned from Mr Geoffrey Keynes about five years ago that stretching the foreskin was a useful alternative to circumcision, and  since that time I have not found it necessary to operate on any male child in my practice except in the case of orthodox Jews. My method is to stretch and free the foreskin daily, using a probe and sinus forceps, and doing it so gently that the child does not protest. This method will entail daily visits for one or two weeks, but after that the foreskin is quite free and can be pushed back by the mother when the child is washed as often as seems necessary to keep the glans clean. The stretching may be started soon after birth, and as a rough guide that a baby can stand this amount of interference, I usually wait until it has regained its birth weight. With adequate patience the whole thing can be done entirely without pain or risks, and to my mind the operation of circumcision in childhood is now seldom justifiable.

Cecile Booysen

Dr Connolly is to be congratulated on having taken a first step towards the treatment of phimosis. May I hope that he will soon take a second?

The cool assumption of some surgeons that they know better than providence how little boys should be made is laughable and irritating. it is quite time that this horrible mutilation should no longer be regarded as having any sanitary or therapeutic value, and phimosis should be relegated to the list of imaginary diseases. Circumcision is, and always was, a tribal rite, and has no place in surgery.

R. Ainsworth

Referring to Dr D.I Connolly's letter, I am glad to hear of someone at last who is opposed to unnecessary circumcision: the majority of doctors and most nurses are obsessed with the idea that 90 per cent of male infants should be circumcised. The prepuce has its definite uses, which need not be gone into here. I myself have practised a similar method to the one described by Dr Connolly for over thirty years – with success, but with this difference: I always use a local anaesthetic and no dressings or appliances.

After separation of the prepuce from the glans penis, the prepuce is completely retracted, a mild antiseptic ointment is applied, and the foreskin is replaced in its normal position. All that is necessary thereafter is that the prepuce should be completely retracted once daily and the ointment applied by the nurse or mother until it goes back easily and the mucous membrane, when abraded, is seen to be healed. This usually requires about seven to ten days. Subsequently the prepuce should, for purposes of cleanliness, be retracted in the daily bath and cleaned with a little wet cotton-wool.

D. Gordon Carmichael

Although severe phimosis in infants may occasionally require circumcision, I was once told by a surgeon with twenty years in general practice that he had almost entirely avoided the operation by completely stripping back the foreskin, aided by dilatation if necessary, in the newborn and others, and by instructing the mother to see that it would peel back and to clean behind it each time the child was bathed.

My own small experience is confirmatory. Every urologist would welcome the instilling of this particular habit of cleanliness into possible future patients.

Malcolm Baillie

Dr D.I. Connolly's very excellent procedure in the treatment of phimosis has one serious drawback – the prepuce still remains. The teaching that the male should be circumcised on the eighth day has stood the test of time, and still remains sound. That the prepuce should be removed, whether phimosis is present or not, is an opinion which deserves the careful consideration of every doctor practising midwifery. Circumcision becomes a gentle art if practised in accordance with this theory.

Joseph McAuley

BMJ, 7 September 1935, p. 472

More responses

Your correspondent Dr R. Ainsworth has apparently overlooked one important and well known fact when he writes that "circumcision is and always was a tribal rite and has no place in surgery", namely, the occurrence of carcinoma of the penis in the uncircumcised,  and the extreme rarity of its occurrence – if ever at all – in those who have been circumcised.

M.M. Posel

In India, where I practised for over twenty years, no Hindu is ever circumcised; it is the mark of the Mohammedan. (In the Moplah rising, the Mohammedans forcibly circumcised Hindus who fell into their hands.) Imagine the reception a European doctor would meet with who practised it on all and sundry! This being so, what was to be done with Hindu infants who, having phimosis, had well developed rupture due to straining? I asked a ell-known Brahmin doctor with a large practice in the Punjab – R.B. Balkishau Kaul of Lahore. He said that, whatever the difficulty, circumcision could never be done on a Hindu infant. All that was needed was to roll the prepuce sideways between finger and thumb, which broke down any adhesions, and then to push it back over the glans. This method was the same as that practised by Indian dais (midwives) when drawing milk from a woman's breasts. The nipple is gently trolled between finger and thumb. It is then easy to milk out any coagulum.

Kathleen Vaughan

Divergent views having been expressed on this subject, may I attempt to sum up and clarify the position?

Dr McAuley's letter raises the point which is the crux of the matter: Should the prepuce be removed whether phimosis is present or not? I suggest that phimosis, especially if extreme, demands circumcision for these reasons. (1) Many infants so affected cry excessively until the operation is done: thereby (2) they may develop hernia. (3) Various troubles – for example, nocturnal enuresis, "fits", and, in later life, epithelioma of the glans and paraphimosis – are associated with phimosis. (4) In patients with phimosis suffering from gonorrhoea, complications arise, and treatment is more difficult than in the circumcised. (5) The disadvantages in the event of marriage are obvious. Although difficult of proof, there is little doubt that the prepuce, especially a long one, renders boys more likely to acquire the habit of masturbation. For this very good reason alone I think circumcision desirable, phimosis apart, If the reasons given for circumcision are sound, then stretching operations find no place.

I venture to describe the method I use, as it is not the orthodox one. It is well to wait until the infant is 2 to 3 weeks old, and feeding is well established.

Local anaesthesia is  always used, novutox or locosthetic (P.D. & Co), being injected with a fine needle at the root of the penis on the dorsum and below at the peno-scrotal junction. This makes the operation entirely painless, as I have repeatedly proved. After thorough sterilising of all the parts with spirit and biniodide solution, the end of the prepuce is seized on the dorsum on each side of the middle line with small, narrow-bladed Spencer Wells forceps. Traction on these parts puts the prepuce on the stretch. A similar forceps is then passed down under the prepuce (dorsally), and opened widely, stretching the prepuce and freeing it from the glans, right down to the neck of the latter. The blade of a pair of straight, blunt-pointed scissors is then passed under the prepuce and the latter slit down dorsally to the neck of the glans. The prepuce is then separated, if necessary, from the glans on each side, and cut away, beginning at the fraenum and ending on the dorsum. The cutting is carried round close to the neck of the glans, leaving just enough skin and mucous membrane to be stitched together. During these various manoeuvres traction is made on the forceps originally applied, so as to steady and stretch the prepuce. Often no vessels need tying – at the most, one on the dorsum and one on the fraenum. The free edges of the skin and mucous membrane are united by a few sutures of fine iodised catgut, using a small, half-circle Hagedorn needle. A narrow strip of sterile gauze is  wrapped round and tied on. The operation takes very little longer than the usual one, and the skin edge left is almost a perfect "circle"; any after-trimming of the edges is rarely necessary.

The advantages of this method are two: (1) there is no possible risk of injury to the glans; and (2) seeing exactly what one is doing, it is possible to remove the whole of the prepuce, which is the main point. results are entirely satisfactory, and in my experience shock, sepsis, haemorrhage etc are unknown. Stitches absorb or work out, and healing is complete in five to ten days.

I hope I have shown, in reply to the flagrant statements of one of your correspondents, that "circumcision" is not a "horrible mutilation", that it "has a sanitary and therapeutic value", and, being ordained by Providence from very early times (doubtless for good reasons), it is not a "cool assumption" on the part of  surgeons doing this operation that they "know better how little boys should be made". And if phimosis is to be relegated to the list of imaginary diseases, why not make a clean sweep, and say that cancer, tuberculosis, and the rest do not exist?

G.W. Thomas

This subject, like  the big gooseberry, seem to crop up every few years, but nothing very fresh has been said on either side, and too often arguments are built up on irrelevant facts or theories. An example of this is given by Dr R. Ainsworth: "Circumcision was and is a tribal rite"; ergo, there is nothing more to be said in its favour. But was not fire itself at first an object of savage worship – yet we do not discard our kitchen stoves? Again, the argument is brought up that the prepuce "being a work of providence" (with a small p, however), must be perfect. This strange argument would seem to abolish all evolution from the present-day perfection of everything, and one wonders was the five-toed horse perfect in its day and, if so, why was our one-toed animal evolved?

But these are side issues. The crux of the whole matter is: Does removal of the prepuce lessen the incidence of syphilis? If this can be answered on the affirmative – and surely the Jewish practice can provide statistics to settle it – then circumcision is surely a duty in all cases.

F.G.

BMJ, 21 September 1935, p. 560

Another contribution

It is 42 years since I qualified. For many of these years I circumcised most of the boys. Latterly it is never done. Dr D.I. Connolly describes "unfortunate consequences", which I fully confirm – severe haemorrhage (one death from this cause), obstruction caused by sticky lymph at the urethral orifice, eczema round the scar, irritation of the glans penis. With firm determination the prepuce can always be pressed back. A few years ago Messrs C.H. Fagge and F. Steward of Guy's [Hospital] discontinued the operation, and there now exists a widespread objection to it, as shown by the correspondence in your columns. It may be worthy of record that I have been compelled to perform he little operation for a man of 80 years and, last year, for a man of 52 years, both with excellent results.

Vaughan Pendred

BMJ, 28 September 1935, p. 603

Yet further correspondence

To the other not negligible points in favour of circumcision already recorded by many of your correspondents, I hope you will permit me to add that all those whom Providence (with a capital P) has cast for the lot or doom, of working in a venereal disease clinic (and especially one for seafarers) can have only preference for the circumcised patient. He is cleaner, easier to handle and treat, and his condition is easier to diagnose.

While there is no convincing evidence yet presented of less incidence of syphilis in the circumcised, our observation here is that in patients with primary syphilis presenting themselves for diagnosis and treatment, there is a higher proportion of sero-negative cases among the circumcised. Obviously the lesion has been the sooner noted by its circumcised bearer; and this is true of all the other lesions occurring on the glans or frenum or on under-surface of prepuce. The sooner noted the sooner is treatment sought. Venereal warts and buboes are rarer in the circumcised. Many adult males who have experienced sexual intercourse before and after circumcision have, on questioning, reported either "no difference" or "better"; none has said worse. Mr Havelock Ellis records the preference of the copulating woman for the circumcised male. And look you, Sir, providence (surely now with a small p) has contrived that gorilla and chimpanzee be born without prepuce. [2]

H.M. Hanschell

If your correspondent F.G. would refer to the Journal of January 27th, 1934, (p. 144) he would find reported some facts relevant to the question "Does the removal of the prepuce lessen the incidence of syphilis?" [3] An inquiry into the relation between presence or absence of the prepuce and acquired venereal disease in 400 consecutive patients attending the department for venereal diseases at Guy's Hospital failed to show any appreciable differences, and we were led to believe that as far as our own facts went, there was no lessened risk of acquired syphilis in the circumcised.

V.E. and N.L. Lloyd

No doubt more than enough has already been written in your columns on circumcision, and views have been expressed with almost religious fervour. I feel, however, that the letter of Dr Cecile Booysen should not go unchallenged. She writes:

Apart from the immediate physical effects, there is considerable evidence that an operation which is a perfect result from a surgical point of view may yet cause psychological trauma, which may either show itself at once, or become obvious only in adult life.

I do not know, nor does she tell us, on what evidence this assertion is based; but I am confident that the treatment she practises in place of circumcision will most certainly tend to bring about a most serious psychological trauma – namely, the habit of masturbation at a not very much later date. As I understand it, the treatment consists of stretching and freeing the foreskin daily for "one or two weeks", and when it is free the mother is instructed to carry on "when the child is washed as often as seems necessary to keep the glans clean". She adds, "with adequate patience the whole thing can be done entirely without pain or risks".

I have no doubt that the child exhibits no sign of pain, but rather of pleasure, for as every child's nurse knows, nothing quiets a child so much as gentle manipulation of his genitals. At the same time, nothing is more apt to start the habit of masturbation than regular and long-continued manipulation of the penis. We are many of us familiar of us with the melancholy sight of a child of 3 or 4, or even younger, masturbating, and most investigators in this field are satisfied that this practice in the very young is the result of unwise handling by parent or nurse, which has taught the child he possibility of pleasurable sensations from friction on those parts.

In a letter in he next column Dr Carmichael advocates much the same procedure. His treatment requires seven to ten days intensive manipulation, followed by occasional handling at bath time.

In my view, if the glans can only be kept clean by regular manipulation of the foreskin, then it had better be left dirty or its covering removed surgically. Whether it is any more necessary to cleanse the male glans than it is to wash out the virgin vagina I will leave to your readers, but in my view the increased liability to syphilis and cancer in the uncircumcised is sufficient justification for removing the foreskin.

C.E. Gautier-Smith

BMJ, 5 October 1935, p. 642

The debate continues

I am afraid that I must have earned, in my short time, the disapprobation of a number of your readers, for in my blundering ignorance I have assumed the mantle of a divinity and "shaped the ends" of some thousands of small boys. Yet I am unrepentant, for never have I had a complaint as regards ill after-effects. In view of my own slight experience I should unhesitatingly have any male children of my own circumcised within the first four weeks. The benefit conferred in respect of cleanliness alone is well worth any so-called risk of psychological trauma. I cannot convince myself of the reality of this phenomenon occurring in any child under, say, 5 years of age. I have a distinct recollection of my own circumcision at the age of 2, yet I altogether fail to perceive any gross mental lesion resultant therefrom. No person with any great experience of more or less routine circumcision  in all cases of even "tightness" of the prepuce, as distinct from real phimosis, can have failed to appreciate the resultant benefit in the general health and well-being of the children. This was not the case in children whose prepuce was merely "well stretched". In almost all cases when such was done it was later found necessary to circumcise the child, whereupon all trouble ceased. "Bad technique!" exclaim all the "stretching" experts. No doubt but the technique was exactly that employed by Dr D.I. Connolly.

Complications are, in my experience, due in almost all cases to poor nursing and careless mothers, and, even with the poorer classes in Glasgow as out-patients, were notable by their slight incidence. Haemorrhage need never occur with skill and  careful ligation, and in cases where there is any tendency to general oozing I always found that a touch of adrenaline upon the dressing was always quite sufficient. I am interested in the theory that the operation may lessen the liability to syphilitic infection. Your letter from the Drs Lloyd seems to negative this, but I do think it is worthy of full investigation. At present I have twelve continuous treatment cases under my care. Of these only four have been circumcised. one can form no valid conclusion from such small figures, but it would be interesting to hear from some hospital authorities or VD clinics whether circumcision does, apparently, lessen the risk.

D.W. Walker

For many years I have been interested in circumcision as practised both in males and females in various parts of the world, and in my book to be published soon this essentially "tribal rite", as rightly described, will be fully investigated. When we come to inquire into the origin of this strange custom we meet many difficulties, but certain facts give support to the view that it originated from entirely different motives, such as (1) hygienic and prophylactic (useless, of course); (2) a possible association with phallic worship (and that, as we know it today, the remains of prehistoric human sacrifice connected with the cult); (3) a sacrifice  of a portion to the gods to preserve the rest from harm, a practice well illustrated in other parts of the body; (4) to promote chastity – history supplies examples of its total failure in this respect.

Where did the practice originate? It was not compulsory, except among the priesthood, in ancient Egypt, and there is strong evidence that it was introduced into that country by the Negroes. It has been practised in West Africa for over five thousand years, without variation, and today the circumcision societies are still in a flourishing condition. It is general among the Jews, who took the custom from either the Babylonians or the Negroes, probably the latter. It is untrue to say the spread of the custom in Africa is due to Islam; it existed, of course, thousands of years, before Islam. It is interesting to note that during the Roman occupation of Egypt any doctor performing the barbaric operation was executed – a harsh measure, but I believe some punishment should be reserved for those who waste valuable space in medical journals advocating the mutilation.

T. Gerald Garry

BMJ, 12 October 1935, p. 702-3

More arguments

While avoiding the pros and cons of circumcision of male infants and children, I should like to express my entire agreement with Dr C.E. Gautier-Smith – that manipulative surgery should find no place in the treatment of phimosis and allied conditions.

The operation of circumcision, anaesthetic apart, is attended with very few risks. Haemorrhage should be very rare if the fraenal vessels are first tied before any incision is made and a simple tourniquet applied at the root of the organ (inch jaconet folded in three and held firmly in Spencer Wells forceps); a clean cut with a scalpel is made, taking care not to remove too much foreskin – that is, flaying the glans penis. Redundant mucous membrane having been cut away, two lateral and one dorsal catgut sutures (Halstead) are inserted; a dressing applied, such as gauze impregnated with tinct. benz. co. does quite well. It is understood that the tourniquet is first released to make sure that there is no oozing before applying the gauze. Primary healing should be the rule, as soiling of the wound is prevented.

Some of my colleagues have informed me that where necessary they sometimes do a circumcision on a newborn infant while awaiting the arrival of the placenta, with gratifying results. Of this line of treatment I myself have no experience. It has the great merit, however, that there is no anaesthetic risk, and it is done at a time when an infant can best tolerate trauma; but personally I would consider it a somewhat hurried proceeding.

S.A. Montgomery

With regard to your correspondence on circumcision the following case may be of interest.

My son, now aged 6, was born with a long, tight foreskin. As I was against circumcision at the time, he was left uncircumcised. When he was 6 months old I noticed that he continually handled his penis. A colleague found adhesions, which he freed, and since then the foreskin has been pushed back every night at bath time and the parts thoroughly washed. There has been no recurrence of the handling on his part, except on one or two occasions when nightly washing has been omitted and there has been some slight inflammation. The boy now does the washing himself as a matter of routine, which falls into place with the cleaning of ears, teeth etc.

The points I wish to stress are: (a) it is really difficult to keep the parts clean in the uncircumcised, and (b) regular pushing back of the foreskin and washing does not always conduce to masturbation, whereas dirty, itching parts do. I hesitate to have the boy circumcised now because I think it quite likely that a psychological trauma may result from the operation at this age. I know of at least one case where a boy of 4 years, one of twins, was circumcised, in which the operation was undoubtedly a great shock, and this may have farreaching results.

With regard to what Dr H.M. Hanschell says of the preference of copulating women for the circumcised male: this may be due to the fact that the glans is less sensitive after circumcision in infancy and that therefore coitus can be prolonged. If this is the explanation it is an argument in favour of circumcision which should not be overlooked. Ejaculatio praecox with its concomitant unhappiness to both partners is common enough to call for investigation.

W.M.C.

My own personal experience leads me to echo Dr D.W. Walker's advice, although my experience is admittedly trivial in comparison.

My elder brother and myself both required this attention at school age; two of my friends required it when medical students; recently an official in my town hall, with two grown-up children, had to absent himself for circumcision – a very uncomfortable kind of operation for an adult, apart from the inevitable ribaldry as to change of faith and so on which ensues among the easily amused. I was foolish enough myself to listen to the advice of one of our maternity and child welfare staff, who stretched he prepuce of my elder son, with the result that he required at school age the operation he should have had as an infant.

It is too bad that boys should suffer discomfort or be subjected to an operation at school age or later which should be carried out in infancy.

M.D., D.P.H.

I suggest that all male children should be circumcised. This is "against nature", but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in mind it does not seem apt to argue that "God knows best how to make little boys".

R.W. Cockshutt

BMJ, 19 October 1935, p. 763-4

Will the letters never cease?

The question of circumcision seem to lead to a partisanship as violent as politics. I fancy that this enthusiasm for universality, apart from what has been called "tribal rites", is of fairly recent origin. I do not recall any clamour for it in the 1880s. At that time it was regarded as a tiresome minor operation, sometimes required on account of an objectionable and adherent prepuce.

It was. I think, in the naughty nineties that the idea of promiscuous circumcision began to gain ground. For a time I fell in with the fashion. But it annoyed me to see the healthy progress of the infant sometimes even temporarily interrupted; and in still more to see occasionally the lactation of the mother interfered with by her worrying over the child. Still more was I upset by two unusual cases which occurred in the practice of a friend (who was, by the way, a very capable surgeon, priding himself particularly on his thoroughness in this minor operation). In each of these the cicatrix contracted and drew the loose skin of the penis up over the glans to form a fresh false prepuce. In one case the operation had to be done three times. In the other the difficulty was obviated by slitting the false prepuce longitudinally, so that any subsequent contraction would tend to pull the skin off the glans instead of over it.

On discussing these cases with a well-known gynaecologist, I was surprised when he gave his opinion that it was very seldom necessary to resort to circumcision. From that time I reverted to "detachment and dilatation", with careful instruction as to subsequent daily cleansing of the parts beneath the prepuce. I never had any reason to be dissatisfied with the result of this method as a substitute for circumcision.  Of course, neglect of such regular cleansing may lead to minor troubles later on. But the ill results of uncleanliness are not confined to the penile region.

I do not know of any statistics which suggest that the circumcised are less liable to venereal disease. Nor have I any reason to believe that the uncircumcised are more prone to masturbation; on the contrary, I can recall the cases of two mothers, who each had one sone circumcised and the other not. The complaint of each of these mothers was that the circumcised boy was always "playing with his penis"; but the uncircumcised boy did not do so. I have no use for the argument that was once used to me – that I was throwing away fees for operation.

A.H. Williams

Brevity is the soul of wit: I will be brief. If the technique I have described is followed closely and the dressing shield applied to the retracted prepuce, there will be no need for any other operation. But – and this is most important – the prepuce must be kept back for at least four to five days after the stretching etc. I have a long experience of the older radical method of circumcision. I would not think of doing it any more. My object in writing to the Journal was to advocate an extensive trial of the method of stretching plus dressing shield pressure; also, I started on the assumption that something must be done to overcome the severe phimosis. I am grateful to all those who have stated their experiences. it was not my intention to enter into the question of the functions of the prepuce, nor into any abstruse problems concerning the origins of circumcision. These are, however, of great interest. Has it ever occurred to anyone that a vaccine prepared from the smegma bacillus may possibly be of practical use – for example, in connexion with tuberculosis therapy?

D.I. Connolly

I have been waiting in vain to see someone mention what I consider to be by far the best treatment for phimosis, and which I have used for thirty years.

When a male child is born the penis is at once examined, and if the glans cannot be properly exposed I ask the mother and father whether they will have the child circumcised.  I make arrangements with the nurse (usually the district nurse) for the next day. having seen the mother we go into the next room, and the nurse holds the child between her knees. A probe and a blunt pair of scissors are probably all that is necessary. Having separated all the foreskin from the glans a straight cut is made down the dorsum to the base of the glans. The foreskin is rolled back to form a scar around the penis on a level with the base of the glans. Occasionally one or two stitches are put in. A small piece of gauze is wrapped round it, to be renewed if it gets washed off. I explain that the penis may appear rather swollen on the second or third day, but that [this] need not be worried about. On the tenth day it has healed, and the foreskin has entirely disappeared.

I have never had the slightest trouble over bleeding, as the fraenal artery is not approached, and the dressing has never given any trouble. I have done this on a few occasions to adults, under local anaesthesia, with the result that after a few months the foreskin has entirely disappeared. Of course, a few stitches have to be used.

Norman H. Joy

I have been watching the correspondence regarding this operation to see if any improvements on the technique of the late Mr A. Richardson of Leeds emerged, but so far have been disappointed. There is no question that the instruments used by the Jews, fashioned after the style of an Army button stick, which is slipped over the prepuce before section, is far and away the safest protection for the glans, and causes no trauma to the foreskin remaining. The key to the reconstruction is a stitch introduced on the left of the median raphe and passed obliquely to the right of the fraenum; it acts as a ligature to the fraenal artery; moreover, it puts the whole in position and avoids a knot of tissue beneath the penis. It is essential to ligature the two dorsal arteries, which can be done by passing a needle through the skin and mucosal cuff, and throwing the Spencer Wells forceps (already applied) over the ligature, thus serving two purposes.  [4]

Those who deny the existence of phimosis remind me of the old lady who, on visiting the zoo, was shown a giraffe. "There is no such animal", she exclaimed.

A.P. Bertwhistle

BMJ, 26 October 1935, p. 822-23

The discussion brought to a close

I have been very much interested in the correspondence on circumcision. What it all comes to is this. Are doctors to be governed by purely medical reasons or not? Such arguments as those put forward that it lessens the likelihood of masturbation and the sensitivity of the penis, that it increases the pleasure of the partner in copulation etc, are scarcely in the realm of medicine, but of morality.

Masturbation is a normal and harmless manifestation, except where it occurs in excess as a symptom of mental ill-health, and it savours if Jovian omniscience to interfere with the naturally provided erotic mechanism, although, of course, the untutored savage does not hesitate to do so, and could no doubt give many reasons for excising the clitoris or rupturing the perineum or ripping open the male urethra.

To those who instance the occurrence of preputial lesions necessitating amputation in later life as a reason for preventive circumcision in infancy, one would say – Why not eradicate the appendix, the tonsils? Why not expose the child to measles, mumps, whooping cough, and chicken pox? Or is the doctor supposed to be a prophet?

Circumcision of the male prepuce, except when done in the presence of a definite physical lesion, as is the case with all the other bodily organs which are liable to disease, is a propitiatory gesture, incapable of justification on surgical grounds.

J.L. Faull

The description of a method of treating phimosis by the dorsal slit of the foreskin urges me to add yet another to the numerous letters on this matter. I too tried this as a substitute for the usual circumcision, but found the results far from satisfactory. With a lengthy foreskin, two flaps resulted, which hung down like miniature elephant's ears, and frequently became irritated from contact with urine. In more than one case a subsequent operation of  circumcision was necessary to remedy this condition. I have now for many years used the following simple technique, which has given entire satisfaction.

The foreskin is retracted, and after separation from the glans the preputial orifice is snipped at three points, one on the dorsum, the other two on each side of the fraenum, so that the three incisions are equidistant from each other. The foreskin is then fully retracted, and if the three snips have been accurately judged the foreskin should remain in this position. If too tight it is a simple matter to enlarge the incisions somewhat and secure an easy fit. The incisions made in the long axis of the penis become stretched to form three segments of a circle, and heal without producing any deformity such as that described above.

The usual dressing is a strip of gauze soaked in sterile Vaseline, which effectually prevents soiling with urine. Should the opening be too wide the foreskin may slip forward, but it is not a difficult task for the nurse to push it back daily, and healing occurs perhaps more slowly, but equally satisfactorily.

J.A. Pottinger

The simplest method of relieving a phimosis in the newborn has not so far been mentioned in the discussion. This consists in simply splitting the foreskin with scissors, putting in three stitches, one at the corona and one at each anterior corner. Practically no interference with either the nerve or blood supply happens, and cosmetically the result is excellent.

W.L. English

I do not agree with Dr R.W. Cockshut that the less sensitive glans of the circumcised is conducive to chastity and forms a shield against sexual perversions. The Mohammedan is not any more chaste than the non-Mohammedan, nor is he free from sexual perversions. I should also have thought that the exposed glans would have attracted the adolescent's attention more than the  covered one. As regards manipulative surgery in phimosis, I fail to see the objections raised by some of your correspondents. It has its place wherever practicable, and I have seen no ill effects follow its practice.

Circumcision is the last resource, and it is possible that there is a certain amount of "psychic trauma" attending its performance on an introspective boy. Can it be that the circumcision of a highly sensitive and gifted boy made him inflict on the world his "castration complex"?

M.P.K. Menon

It seems that the opinion of the majority of your recent correspondents on the subject of circumcision in childhood for phimosis is that (1) it should be done when required; (2) the risk of operation and its consequences are small; (3) the manipulative stretching method has its drawbacks; (4) from a psychological point of view, it is undesirable and even embarrassing for the mother, nurse or, later on, the child himself, to pay so much and constant attention etc to his genital organs; (5) if venereal disease is contracted, the circumcised are in a cleaner and more hygienic state; and finally (6) some uncircumcised people fail to keep themselves clean, as is well illustrated in the following case.

Some six or seven years ago a young Englishman, who acted as a representative for a British firm in Germany, came to me while on holiday in London on account of some white discharge from his penis. As he had been exposed to possible infection he was sure that he suffered from gonorrhoea. On examination, however, I found that his foreskin was adherent to the glans, and that between the two there was a thick layer of yellow-white cheesy smegma or concretion. It was very adherent, and owing to some inflammation it took me a few days to remove it gradually with warm alkaline lotion, and so separate  the adhesions etc. The patient was, however, greatly surprised when I told him he did not suffer from gonorrhoea, but from the effects of local uncleanliness.

L.B. Sheinkin

A somewhat provocative letter which I wrote as a soporific in the hot hours of an early August morning has been followed by such a long correspondence that I wonder if you will allow me to thank those who have tried to point out my errors and to lead me into the right way.

Many of the writers are so lost in admiration of their own techniques that reasons for their procedure are obviously of secondary consideration with them. But the one with whom I am most in sympathy is Dr H.M. Hanschell. He says that with universal circumcision his patients in a venereal disease clinic would be cleaner and easier to handle and treat. Not, be it noted, that the incidence of such disease would be lessened, or that treatment would be more efficient, but that Dr Hanschell would have an easier time. And if I were in his place I have no doubt that I should be of the same opinion.

Now with regard to the condition known as phimosis, may I point out the elementary fact that the preputial orifice is surrounded by a fibro-elastic ring, and that fibro-elastic tissue stretches with varying degrees of ease and rapidity in different individuals. Anyone who as patiently watched the slow stretching of the perineal region in a primipara must realize this; and also that a very small opening can be gradually dilated to a great size without injury, provided that ample time is taken and the force exerted is not too great. Similarly, a small preputial orifice which cannot be stretched to the size of a threepenny bit in half a minute is not a pathological  condition; and there is no justification whatever for losing one's patience and forcibly cutting or stretching it. If I innocently ask why it is so necessary that a baby's prepuce should be retracted at the earliest possible moment I know I shall be met with a sniff and a snort, and be shrivelled up by the magic word "cleanliness".

So to those of the profession who have time to think, may I leave a few questions for consideration? What is the use of Tyson's glands, [5] and at what age do they begin to function; when does a natural secretion become dirt; and what dreadful thing will happen if a baby's prepuce is left entirely alone?

R.W. Ainsworth
This corespondence is now closed. - Ed.
BMJ, 2 November 1935, p. 876-77

NOTES

1. In 1894 German researchers using the newly invented aesthesiometer discovered that the glans was quite insensitive, and their findings were confirmed by the English neurologist Henry Head in 1908. In his Studies in neurology (1920) he reported that the glans was about as sensitive as the heel of the foot. Other German researchers had established the rich and complex innervation of the prepuce in a study published in 1893, but there was no further work on the subject until the 1930s. The denser innervation of the foreskin was confirmed by R.K. Winkelmann in the 1950s, and again (quite decisively) by Chris Cold and John Taylor in the 1990s. A good summary and the full text of most of the key articles is available at the CIRP.

On the normality of infantile phimosis, it is interesting to note that this had been written as early as 1916:

Geoffrey Jefferson, "The peripenic muscle; some observations on the anatomy of phimosis", Surgery, Gynecology, and Obstetrics (Chicago), Vol. 23, 1916, pp. 177-81

2.  The truth about apes is quite the reverse: chimpanzees have a foreskin but no glans. This was observed as early as the 1690s in the first-ever anatomical description of a young chimp by Edward Tyson (1651-1708), who reported: "Whether there was any Balanus or Glans in the Penis of our Pygmie, or what it was, I am uncertain: I do not remember I observed any". (Orang-Outang, sive Homo Sylvestris, or the Anatomy of a Pygmie, London 1699, facsimile reprint, with introduction by Ashley Montague [London: Dawsons, 1966], p. 45). This has been confirmed by Cold and Taylor 1999, and in Chris Cold and Ken McGrath, "Anatomy and histology of the penile and clitoral prepuce in primates", in George C. Denniston, Frederick Hodges and Marilyn Milos (eds), Male and female circumcision: Medical, legal and ethical considerations in pediatric practice, New York, Kluwer Academic/Plenum Publishers, 1999.

For further information on Tyson, see Ashley Montagu, Edward Tyson MD and the rise of human and comparative anatomy in England (Memoirs of the American Philosophical Society, Vol. 20, 1943),  and Stephen Jay Gould "To show an ape", in The Flamingo's smile (Penguin 1986), pp. 263-80.  Although both Montagu and Gould praise Tyson's skill as an anatomist, he did sow the seeds of much future confusion by claiming to discover glands under the foreskin which were supposed to secrete "smegma", thus giving rise to the mythical "Tyson's glands", which have proved such a stand-by for posthephobes and others who imagine the foreskin to be unclean. See also Note 5.

Montagu later wrote a powerful essay against routine circumcision, "Mutilated Humanity", given at the Second International Symposium on Circumcision, San Francisco, California, April 30-May 3, 1991.

3.  The reference is to V.E. and N.L. Lloyd, "Circumcision and syphilis", British Medical Journal, 27 January 1934, pp. 144-6. For further discussion see Robert Van Howe, "Does circumcision influence sexually transmitted diseases? A literature review", BJU International, Vol. 83, Supplement 1 (January) 1999, pp. 52-62; and Robert Darby, "Where doctors differ: The debate on circumcision as a preventive of syphilis, 1855-1914", Social History of Medicine, Vol. 16, 2003, pp. 57-78

4.  In his article, "Juvenile circumcision: A plea for a standardised technique", (Lancet, 12 January 1936, pp. 85-6),  Bertwhistle expressed surprise that every modern textbook described a different method of circumcision, and also concern that the results were "by no means uniformly good". He commented that a repeat operation was often necessary "because of cicatrization of a foreskin left unduly long, and an objectionable lump [near] ... the frenum". Despite the pleas, complications remained common, and Gairdner reported 16 deaths per year in the 1940s.

5.  Although one finds references to them everywhere (from new baby bulletin boards and circum-fetishist/posthe-phobic Yahoo groups to serious works of reference such as Wiley's International Dictionary of Medicine and Biology (1986, Vol. 3, p. 1207) and the new Oxford Dictionary of National Biography (entry for Edward Tyson, Vol. 55, p. 819), there is no such thing as Tyson's glands. The moisture beneath the prepuce consists simply of water, shed skin cells, secretions from the prostate, seminal vesicle and urethral glands, various sterols and fatty acids which normally protect skin surfaces, and a variety of benign bacteria. Very few men, and even fewer boys, generate any visible smegma.  (See articles by Satya Parkash et al 1980 and 1982, and by Cold and Taylor 1999, all available at CIRP.)  Cold and Taylor comment: