Foreskin
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THE FATE OF THE FORESKIN
The British Medical Journal
December 24, 1949
It is a curious fact that one of the operations most commonly performed in
this country is also accorded the least critical consideration. In order to
this country is also accorded the least critical consideration. In order to
decide whether a child's foreskin should be ablated, the normal anatomy and
function of the structure at different ages should be understood; the danger
of conserving the foreskin must then be weighed against the hazards of the
operation, the mortality and the after-effects of which must be known. The
intention of this paper is to marshal the facts required by those concerned
with deciding the fate of the child's foreskin.
-----
Male circumcision, often associated with analogous sexual mutilations of the
female, such as clitoric circumcision and infibulation, is practised over a
wide area of the world by one-sixth the population. Over the Near East,
patchily thoughout tribal Africa, amongst the Moslem peoples of India and of
South-East Asia, and amongst the Australasian aborigines circumcision has
been regularly practised for as long as we can tell. The earliest Egyptian
nummies (2300 B.C.) were circumcised, and wall paintings to be seen in Egypt
show it was customary several thousand years earlier still.
-----
The Younger Child
The prepuce is still in the course of developing at the time of birth, and
the fact that its separation is usually still incomplete renders the normal
prepuce of the newborn non-retractable. (It will be seen that preputial
'adhesions' is an inapposite term to apply to the incompletely separated
prepuce, suggesting as it does that the prepuce and glans were formerly
separate structures.) The age at which complete separation of the prepuce
with full retractability spontaneously occurs, varies up to five years.
Function of the Prepuce
It is often stated that the prepuce is a vestigial structure devoid of
function. However, it seems to be no accident that during the years when in
child is incontinent the glans is completely clothed the the prepuce, for,
deprived of this protection, the glans becomes susceptible to injury from
contact with sodden clothes or diapers. Meatal ulcer is almost confined to
circumcised male infants, and is only occasionally seen in the uncircumcised
child when the prepuce happens to be unusually lax and the glans consequently
exposed.
Amongst the Western nations the circumcision of infants is a common practice
only with the English speaking peoples. It is, for the most part, not the
custom in continental Europe or Scandinavia, or in South America.
-----
Circumcision, like any other operation, is subject to the risks of
haemorrhage and sepsis, and, where a general anaesthetic is employed, to the
risk of anaisthetic death.
About 16 deaths in children under five years occur each year from
circumcision. In most of the fatalities which have come to my notice death
has occurred for no apparent reason under anaesthesia, but haemorrhage and
infection have sometimes proved fatal.
-----
Since in the newborn infant the prepuce is nearly always non-retractable,
remaining so generally for much of the first year at least, and since this
normal non-retractability is not due to tightness of the prepuce relative to
the glans but to incomplete separation of these two structures, it follows
that phimosis (which implies a pathological constriction of the prepuce)
cannot properly be applied to the infant. Further, the commonly performed
manipulation known as 'stretching the foreskin' by forcibly opening sinus
forceps inserted in the preputial orifice cannot be justified on anatomical
grounds, besides being painful and traumatizing. In spite of the fact that
the preputial orifice often appears minute-the so-called pin-hole meatus-its
effective lumen, when tested by noting whether or not a good stream of urine
is passed is almost invariably found to be adequate.
Infants with umbilical or inguinal hernia are particularly liable to suffer
circumcision on account of 'phimosis', but if this simple test is applied,
rarely will any obstruction to the urinary flow be found present.
Occasionally the preputial orifice is imperfectly related to the external
meatus, so that the urinary stream balloons out the subpreputial space; this
can be easily remedied by gently separating the prepuce from the glans in the
region of the meatus by means of a probe. True phimosis cauring urinary
obstruction is exceedingly rare: in the cases I have seen in which this
diagnosis has been made, simple separation of the prepuce has shown that
there was no constriction of the preputial tributable to operation rather
than to any pathological orifice.
-----
Through ignorance of the anatomy of the prepuce in infancy, mothers and
nurses are often instructed to draw the child's foreskin back regularly, on
the supposition that stretching of the foreskin is what is required. I have
on three occasions seen young boys with a paraphimosis caused by mothers or
nurses who have obediently carried out such instructions; for, although the
size of the prepuce does allow the glans to be delivered, the fit is often a
close one and slight swelling of the glans, such as may result from forceful
efforts at retraction, may make its reduction difficult.
-----
Summary
The development of the prepuce is incomplete in the newborn male child, and
separation from the glans, rendering it retractable, does not usually occur
until some time between 9 months and 3 years. True phimosis is extremely
rare in infancy.
During the first year or two of life, when the infant is incontinent, the
prepuce fulfils an essential function in protecting the glans. Its removal
predisposes to meatal ulceration.
The many and varied reasons commonly advanced for circumcising infants are
critically examined. None are convincing.
In the light of these facts a conservative attitude towards the prepuce is
proposed, and a routine for its hygiene is suggested. If adopted this would
eliminate the vast majority of the tens of thousands of circumcision
operations performed anually in this country, along with their yearly toll of
some 16 child deaths.
-----
Dr. Douglas Gairdner, a British paediatrician, published this famous and now
classic paper in the British Medical Journal on December 24, 1949
This paper was found in The Compleat Mother magazine, Spring 2000
[Non-text portions of this message have been removed]
The British Medical Journal
December 24, 1949
It is a curious fact that one of the operations most commonly performed in
this country is also accorded the least critical consideration. In order to
this country is also accorded the least critical consideration. In order to
decide whether a child's foreskin should be ablated, the normal anatomy and
function of the structure at different ages should be understood; the danger
of conserving the foreskin must then be weighed against the hazards of the
operation, the mortality and the after-effects of which must be known. The
intention of this paper is to marshal the facts required by those concerned
with deciding the fate of the child's foreskin.
-----
Male circumcision, often associated with analogous sexual mutilations of the
female, such as clitoric circumcision and infibulation, is practised over a
wide area of the world by one-sixth the population. Over the Near East,
patchily thoughout tribal Africa, amongst the Moslem peoples of India and of
South-East Asia, and amongst the Australasian aborigines circumcision has
been regularly practised for as long as we can tell. The earliest Egyptian
nummies (2300 B.C.) were circumcised, and wall paintings to be seen in Egypt
show it was customary several thousand years earlier still.
-----
The Younger Child
The prepuce is still in the course of developing at the time of birth, and
the fact that its separation is usually still incomplete renders the normal
prepuce of the newborn non-retractable. (It will be seen that preputial
'adhesions' is an inapposite term to apply to the incompletely separated
prepuce, suggesting as it does that the prepuce and glans were formerly
separate structures.) The age at which complete separation of the prepuce
with full retractability spontaneously occurs, varies up to five years.
Function of the Prepuce
It is often stated that the prepuce is a vestigial structure devoid of
function. However, it seems to be no accident that during the years when in
child is incontinent the glans is completely clothed the the prepuce, for,
deprived of this protection, the glans becomes susceptible to injury from
contact with sodden clothes or diapers. Meatal ulcer is almost confined to
circumcised male infants, and is only occasionally seen in the uncircumcised
child when the prepuce happens to be unusually lax and the glans consequently
exposed.
Amongst the Western nations the circumcision of infants is a common practice
only with the English speaking peoples. It is, for the most part, not the
custom in continental Europe or Scandinavia, or in South America.
-----
Circumcision, like any other operation, is subject to the risks of
haemorrhage and sepsis, and, where a general anaesthetic is employed, to the
risk of anaisthetic death.
About 16 deaths in children under five years occur each year from
circumcision. In most of the fatalities which have come to my notice death
has occurred for no apparent reason under anaesthesia, but haemorrhage and
infection have sometimes proved fatal.
-----
Since in the newborn infant the prepuce is nearly always non-retractable,
remaining so generally for much of the first year at least, and since this
normal non-retractability is not due to tightness of the prepuce relative to
the glans but to incomplete separation of these two structures, it follows
that phimosis (which implies a pathological constriction of the prepuce)
cannot properly be applied to the infant. Further, the commonly performed
manipulation known as 'stretching the foreskin' by forcibly opening sinus
forceps inserted in the preputial orifice cannot be justified on anatomical
grounds, besides being painful and traumatizing. In spite of the fact that
the preputial orifice often appears minute-the so-called pin-hole meatus-its
effective lumen, when tested by noting whether or not a good stream of urine
is passed is almost invariably found to be adequate.
Infants with umbilical or inguinal hernia are particularly liable to suffer
circumcision on account of 'phimosis', but if this simple test is applied,
rarely will any obstruction to the urinary flow be found present.
Occasionally the preputial orifice is imperfectly related to the external
meatus, so that the urinary stream balloons out the subpreputial space; this
can be easily remedied by gently separating the prepuce from the glans in the
region of the meatus by means of a probe. True phimosis cauring urinary
obstruction is exceedingly rare: in the cases I have seen in which this
diagnosis has been made, simple separation of the prepuce has shown that
there was no constriction of the preputial tributable to operation rather
than to any pathological orifice.
-----
Through ignorance of the anatomy of the prepuce in infancy, mothers and
nurses are often instructed to draw the child's foreskin back regularly, on
the supposition that stretching of the foreskin is what is required. I have
on three occasions seen young boys with a paraphimosis caused by mothers or
nurses who have obediently carried out such instructions; for, although the
size of the prepuce does allow the glans to be delivered, the fit is often a
close one and slight swelling of the glans, such as may result from forceful
efforts at retraction, may make its reduction difficult.
-----
Summary
The development of the prepuce is incomplete in the newborn male child, and
separation from the glans, rendering it retractable, does not usually occur
until some time between 9 months and 3 years. True phimosis is extremely
rare in infancy.
During the first year or two of life, when the infant is incontinent, the
prepuce fulfils an essential function in protecting the glans. Its removal
predisposes to meatal ulceration.
The many and varied reasons commonly advanced for circumcising infants are
critically examined. None are convincing.
In the light of these facts a conservative attitude towards the prepuce is
proposed, and a routine for its hygiene is suggested. If adopted this would
eliminate the vast majority of the tens of thousands of circumcision
operations performed anually in this country, along with their yearly toll of
some 16 child deaths.
-----
Dr. Douglas Gairdner, a British paediatrician, published this famous and now
classic paper in the British Medical Journal on December 24, 1949
This paper was found in The Compleat Mother magazine, Spring 2000
[Non-text portions of this message have been removed]