THE FATE OF THE FORESKIN
A STUDY OF CIRCUMCISION
DOUGLAS GAIRDNER, D.M., M.R.C.P.
Consultant Paediatrician, United
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 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 after-effects
of which must be known. Though tens of thousands of infants are circumcised
each year in this country, nowhere are these essential data assembled.
The intention of this paper is to marshal the facts required by those
concerned with deciding the fate of the child's foreskin.
Origins of Circumcision
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 some one-sixth of its population.
Over the Near East, patchily throughout 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. Many of the natives that Columbus found inhabiting the
American continent were circumcised. The earliest Egyptian mummies
(2300 B.C.) were circumcised, and wall paintings to be seen in Egypt
show that it was customary several thousand years earlier still.
to Elliot Smith circumcision is one of the characteristic features
of a "heliolithic" culture which, some 15,000 years ago, spread out
over much of the world; others believe that the practice must have
arisen independently among different peoples. In spite of the enormous
literature on the subject (well summarized in Hasting's Encyclopaedia
of Religion and Ethics), we remain profoundly ignorant of the
origins and significance of this presumably sacrificial rite. The
age at which boys are circumcised varies widely in different races,
from the Mosaic practice of circumcising at about the eighth day,
to the custom in many African tribes of making circumcision part of
an initiation ceremony near the age of puberty. Circumcision was introduced
into Roman Europe with Christianity; little is known about its status
in mediaeval Europe, but it was probably customary only amongst adherents
of the Jewish faith until, with the rise of modern surgery in the
nineteenth century, its status changed from a religious rite to that
of a common surgical procedure.
Development of the Prepuce
prepuce appears in the foetus at eight weeks as a ring of thickened
epidermis (Fig. 1, a) which grows forwards over the base of the glans
penis (Fig. 1, b). It grows more rapidly on the upper surface than
the lower, and so leaves the inferior aspect of the preputial ring
deficient (Hunter, 1935). At 12 weeks the urethra still opens on the
inferior aspect of the shaft of the penis and the terminal part of
the urethra has yet to be constructed. Arrest at this stage produces
the glandular type of hypospadias, with the "hooded" prepuce only
partially covering the glans.
Fig. 1. - Development of prepuce (a) Eight weeks;
(b) sagittal section and (c) coronal section, 12 weeks; (d) 16 weeks;
(e) at about term, compare Fig. 3.
the inferior aspect of the glans a pair of outgrowths are pushed out
and meet (the sulcus on the under aspect of the glans marks their
fusion), so enclosing a tube which, becoming continuous with the existing
urethra, advances the meatus to its final site. These outgrowths from
the glans carry with them the prepuce on each side (Fig. 1, c), thus
completing the prepuce inferiorly and forming the frenulum.
16 weeks the prepuce has grown forwards to the tip of the glans. At
this stage (Fig. 1, d) the epidermis of the deep surface of the prepuce
is continuous with the epidermis covering the glans, both consisting
of squamous epithelium. By a process of desquamation the preputial
space is now formed in the following manner (Deibert,
1933). In places the squamous cells arrange themselves in whorls,
forming epithelial cell nests. The centres of these degenerate, so
forming a series of spaces (Fig. 1, e); these, as they increase in
size, link up until finally a continuous preputial space is formed.
stage of development which has been reached by the time the child
is born varies greatly. Figs. 2, 3, and 4 show sections of the penis
in three full-term newborn infants; in Fig. 2 separation of the prepuce
has not yet begun; in Fig. 3 separation is partial; in Fig. 4 separation
is complete, though this, as will be shown, is uncommon at birth.
Fig. 2. - Separation of prepuce has not begun and
there is as yet no preputial space.
Fig. 3. - Foci of desquamation leading to partial
separation of prepuce.
Fig. 4. - Separation of prepuce completed to form
fully developed preputial space.
Anatomy of the Prepuce
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 is shown in Fig. 5, which has been constructed
from observations of the prepuce in a series of 100 newborns and about
200 boys of varying ages up to 5 years. Of the newborns, 4% had a
fully retractable prepuce, in 54% the glans could be uncovered enough
to reveal the external meatus, and in the remaining 42% even the tip
of the glans could not be uncovered. Of the older group 10% had been
circumcised and a few had at some time had their prepuce "stretched";
the figures from which the diagram is constructed are therefore not
precise, but they indicate with sufficient accuracy that the prepuce
is non-retractable in four out of five normal males of 6 months
and in half of normal males of 1 year. By 2 years about 20% and by
3 years about 10% of boys still have a non-retractable prepuce.
Fig. 5. - Proportion of boys of varying ages from
birth to 5 years, in whom the prepuce has spontaneously become retractable.
Note that it is uncommon for this to occur in the first six months.
fact that at these ages non-retractability depends upon incomplete
separation of the prepuce can be easily demonstrated by running a
probe round the preputial space, gently completing its continuity.
It will then be found that, although the prepuce is often somewhat
tighter than in the adult, it is not tight enough to prevent retraction.
This test was applied to a series of 54 boys aged from 2 months to
3 years who had been referred to hospital for circumcision, generally
with a diagnosis of phimosis. In 53 of the 54 the prepuce became easily
retractable by this simple manipulation; in one 5-months-old infant
this manoeuvre failed because preputial separation had not advanced
far enough to enable manipulation to complete the process. Although
in this way the prepuce of nearly every infant can be rendered retractable,
the procedure, necessarily involving the tearing apart of two as yet
incompletely separated surfaces, causes some bleeding and opens the
way to possible infection. For these reasons it is inadvisable as
a routine procedure.
of the Older Child. - Of 200 uncircumcised boys aged 5-13 years
from three different schools, 6% had a non-retractable prepuce; in
a further 14% the prepuce could be only partially retracted. In the
majority of boys in this age group non-retractability depends upon
the persistence of a few strands of tissue between prepuce and glans,
so that minimal force is required to achieve retractability. In this
age group, however, retraction of a hitherto unretracted prepuce discovers
inspissated smegma, which, in contrast to that found in the younger
child, is in some cases malodorous. This, together with the facts
discussed under penile cancer, indicates that a different view ought
to be taken of the non-retractable prepuce in the child over about
5 years, and that, whereas a non-retractable prepuce in the young
child should be accepted with equanimity as normal, after about 3
years of age steps should be taken to render the prepuce of all boys
retractable and capable of being kept clean.
Function of the Prepuce
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 the child is incontinent the glans is completely clothed by the
prepuce, for, deprived of this protection, the glans becomes susceptible
to injury from contact with sodden clothes or napkin. 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 (Freud, 1947).
Incidence of Circumcision
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.
In England the collected data of various colleagues(* *) who have
kindly made observations on infants, school-children, and university
students reveal wide variations as between different districts and
between different social classes. For instance, in Newcastle-upon-Tyne
12% of 500 male infants aged 12 months were circumcised; in Cambridge
the comparable figure was 31% of 89 male infants aged 6 to 12 months.
Boys coming from the upper classes are more often circumcised, 67%
of 81 13-year-old boys entering a public school had been circumcised,
whereas only 50% of 154 boys aged 5 to 14 in primary and secondary
schools in the rural districts of Cambridgeshire, and 30% of 141 boys
aged 5 to 11 in primary schools in the town of Cambridge, had been
circumcised. The influence of social class is shown also by some figures
analysed by Sir Alan Rook from a group of university students. Whereas
84% of 73 students coming from the best-known public schools had been
circumcised, this was so of only 50% of 174 coming from grammar or
secondary schools. Either the boys of well-to-do parents are suffering
circumcision much too often, or those of poorer parents not often
view of the wide difference in the incidence of circumcised males
in different parts of the country, it is difficult to give an average
figure for the whole country. A conservative estimate of 20%, which
is above the rate for Newcastle-upon-Tyne but well below that for
all the other groups quoted, would mean that the number of circumcisions
performed on children in England and Wales is of the order of 90,000
Mortality and Sequelae of 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 anaesthetic death. The number of deaths presumed to be due to these
causes is shown in the accompanying Table. The Registrar-General groups
circumcision and phimosis together, but in view of the fact that "phimosis,"
as the term is commonly applied to infants, is physiological (see
below) it is probable that the great majority of these deaths were
attributable to operation rather than to any pathological condition
Table Showing Deaths in Children Attributed to Circumcision or
Phimosis in England and Wales
||Under 1 Year
||Total, Under 5 Years
16 deaths in children under 5 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.
is not uncommon after circumcision. F. J. W. Miller and S. D. Court
(1949, personal communication), who followed 1,000 infants in Newcastle-upon-Tyne
for their first year, found that 58 were circumcised, and two of these
bled sufficiently to require blood transfusion. In my own experience
about two out of every 100 children circumcised as hospital out-patients
will be admitted on account of haemorrhage or other untoward event.
Blood losses in the first year are particularly apt to lead to anaemia,
and several infants have been seen with severe iron-deficiency anaemia
following haemorrhages after circumcision.
has already been made to meatal ulcer, which, in so far as it is so
much more frequent in circumcised male infants, should be counted
a sequel of the operation.
Pathological Conditions of Prepuce for which Circumcision is Performed
surprising variety of reasons why different doctors advise circumcision
and other operations and manipulations on the prepuce can be found
described in the long correspondence on the subject which ran in the
British Medical Journal from August to November, 1935. Circumcision
is sometimes undertaken in order to cure existing pathological conditions,
sometimes in order to prevent various diseases from occurring at a
much later date.
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.
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 causing urinary obstruction has been described
(Campbell, l948), but must be 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.
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
Balanitis and Posthitis
of the glans is uncommon in childhood when the prepuce is performing
its protective function. Posthitis - inflammation of the prepuce -
is commoner, and it occurs in two forms. One form is a cellulitis
of the prepuce; this responds well to chemotherapy and does not seem
to have any tendency to recur; hence it is questionable whether circumcision
is indicated. More often inflammation of the prepuce is part of an
ammonia dermatitis affecting the napkin area. The nature of this condition
was firmly established by Cooke in 1921, bit is still not universally
known. The urea-splitting Bact. ammoniagenes (derived from
faecal flora) acts upon the urea in the urine and liberates ammonia.
This irritates the skin, which becomes peculiarly thickened, while
superficial desquamation produces a silvery sheen on the skin as if
it were covered with a film of tissue paper. Such appearances are
diagnostic of ammonia dermatitis, and inquiry will confirm that the
napkins, particularly those left on through the longer night interval,
smell powerfully of ammonia. Treatment consists in impregnating the
napkins with a mild antiseptic inhibiting the growth of the urea-splitting
organisms. For this purpose boric acid powder sprinkled over the napkins,
or a rinse of 1 in 4,000 mercuric chloride or of the recently introduced
non-toxic substance "diaparene" (Benson et al., 1949), are
involved in an ammonia dermatitis the prepuce shows the characteristic
thickening of the skin, and this is often labelled a "redundant prepuce"
- another misnomer which may serve as a reason for circumcision. The
importance of recognizing ammonia dermatitis lies in the danger that
if circumcision is performed the delicate glans, deprived of its proper
protection, is particularly apt to share in the inflammation and to
develop a meatal ulcer. Once formed, a meatal ulcer is often most
difficult to cure.
number of symptoms of obscure cause, such as enuresis, masturbation,
habit spasm, night terrors, or even convulsions, have from time to
time been attributed to phimosis, and circumcision has been advised.
No evidence exists that a prepuce whose only fault is that it has
not yet developed retractability can cause such symptoms.
may be apposite at this stage to quote the reasons given by the mother
for desiring her child's circumcision in a series of 54 infants referred
to hospital by a doctor. In 39 infants the reason was a symptomless
"phimosis" found on routine inspection by doctor, nurse, mother, or
neighbour. In nine cases it was said that "he cries when he wets":
five of these proved to be due to ammonia dermatitis; closer questioning
of the others revealed either no connexion between when the baby cried
and when he urinated, or merely that crying often started micturition.
In these three cases the foreskin was judged to be too long or redundant,
and in a further three the reason was even more frankly cosmetic ("it
looks funny") or was intangible ("we believe in it"). As has been
stated earlier, in all except one of this group of 54 infants, phimosis
was disproved, in so far as gentle manipulation enabled the prepuce
to be retracted.
Conditions Prevented by Circumcision
circumcision of male infants has been urged as a means of preventing
the later development of a variety of conditions - paraphimosis, venereal
diseases, penile cancer, and cervical cancer of women.
idea of the importance of paraphimosis can be gained from figures
from the royal Victoria Infirmary, Newcastle-upon-Tyne, a hospital
serving a large population in which, as has been mentioned, infants
are circumcised less often than in the country generally. In the children's
wards paraphimosis accounts for about seven out of a total of 800
male child admissions each year (0.9%); an appreciable number of these
are found to be the result of the mother's obeying misguided instructions
to retract her infant's prepuce forcibly. In the adult wards it accounts
for about 10 out of a total of 5,000 male surgical admissions (0.1%),
so that paraphimosis scarcely constitutes an important hazard to the
there is a common belief that the circumcised man runs a lessened
risk of venereal infection, particularly syphilitic, there are few
figures to support this. Lloyd and Lloyd (1934), who reviewed the
published evidence and analysed their own figures, concluded that
circumcision did not diminish the chance of a syphilitic chancre.
Schrek and Lenowitz (1947) found that hospital patients gave a history
of venereal disease equally often whether circumcised or not. Wilson
(1947) has published figures showing that, of the men attending a
Canadian Army venereal disease centre, the proportion of uncircumcised
solders (77%) was higher than in the Canadian Army generally (52%),
and concluded that the uncircumcised soldier is more prone to venereal
infection. It may be, however, that since circumcision of infants
is de rigueur in Canada, the uncircumcised man will tend to
come from a lower social grade and thus to be more likely to expose
himself to infection. The evidence seems scarcely to warrant universal
circumcision as a prophylactic against venereal infection.
subject merits careful appraisal, for it alone, of the medical reasons
commonly advanced for the universal circumcision of infants is capable
of withstanding critical scrutiny. In England and Wales deaths from
penile cancer number about 150 a year. The relation between this disease
and antecedent circumcision has recently been reviewed by Kennaway
(1947). All observers agree that circumcision in the first five years
of life protects absolutely from penile cancer, and this applies not
only to one group such as the Jewish but equally to the mixed races
of the U.S.A. The reason for this preventive effect of early circumcision
is not known: it is not due to removal of the cancer-bearing area
since the usual site of penile cancer, the sulcus behind the glans,
is retained. If it is due to retained smegma or its decomposition
products being carcinogenic, this effect must be of startling potency,
since circumcision after the fifth year fails to prevent cancer occurring
several decades later.
clue to the problem may lie in the exceptionally low hygienic standards
of patients with penile cancer, which has struck several observers.
Dean (1935), reviewing 120 cases, writes: "Men with penis cancers
gave the impression of being less intelligent, as a class, than other
cancer patients. Not only had the majority ignored for long periods
the precancerous state of physical annoyance, filth, and odoriferous
discharges, but also it was not unusual for many to delay seeking
advice until a large part of the penis bad become affected with an
ulcerating growth." The unusual frequency with which patients with
penile cancer have had venereal disease has been demonstrated by Dean
(1935) and by Schrek and Lenowitz (1947), these authors having come
to the conclusion that this fact indicates again the significantly
low standard of social hygiene of these patients. A further factor
frequently present in patients with penile cancer is phimosis; although
this is often the result of the growth, in many patients the prepuce
has never been retractable (Lewis, 1931).
these facts it may reasonably be contended that, if the uncircumcised
male has a prepuce which he can retract and which he keeps clean,
he is likely to enjoy the same immunity from penile cancer as his
Cervical Cancer In Women
low incidence of cervical cancer among Jewesses has led Handley (1947)
to the conclusion that this disease is mainly caused by the introduction
of irritant material by the uncircumcised husband during coitus. It
should be a simple matter to put this theory to the test by noting
whether the husbands of women with cervical cancer are more frequently
uncircumcised than others. Meanwhile the evidence seems insufficient
to warrant universal circumcision or preputiotomy, such as Handley
Minor Advantages of Circumcision
remain a number of more or less trivial factors which are sometimes
mentioned as reasons why infant circumcision is desirable: difficulties
in keeping the uncircumcised parts clean, or the supposed aesthetic
or erotic superiority of the shorn member. In order to fulfil the
intention of this paper an inquiry on these points should have been
made amongst a group of uncircumcised men. This was not attempted,
although with regard to the last two of the factors mentioned it should
be stated that whenever the subject has been broached in male company
those still in possession of their foreskin have been forward in their
insistence that any differences which may exist in such matters operate
emphatically to their own advantage.
if there were sensible disadvantages in being uncircumcised, one would
expect that the fathers of candidates for circumcision would sometimes
register their feelings in the matter. Yet in interviewing the parents
of several hundred infants referred for circumcision I have met but
one father who wished his son circumcised because of his disagreeable
experience of the uncircumcised state. The rest of the fathers were
equally indifferent about the matter whether they themselves had been
circumcised or not. Indeed, so little did the father's personal experience
seem important that one-quarter of the mothers did not even know whether
their husbands were or were not circumcised. These facts provide some
evidence that few uncircumcised men have cause to regret their state.
has been shown that, since during the first few year of life the prepuce
is still in process of developing, it is impossible at this period
to determine in which infants the prepuce will attain normal retractability.
In fact, only about 10% will fail to attain this by the age of 3 years.
Of this 10% of 3-year-old boys, in most it will be found a simple
matter to render the prepuce retractable by completing its separation
from the glans by gentle manipulation. In a very few this may prove
impossible and circumcision might then be considered a justifiable
precaution. Higgins (1949), with long experience of paediatric urology,
also concludes that circumcision should not be considered until "after
the age of, say, 2 to 3 years."
prepuce of the young infant should therefore be left in its natural
state. As soon as it becomes retractable, which will generally occur
some time between 9 months and 3 years, its toilet should be included
in the routine of bath time, and soap and water applied to it in the
same fashion as to other structures, such as the ears, which are customarily
treated with special assiduousness on account of their propensity
to retain dirt. As the boy grows up he should be taught to keep his
prepuce clean himself, just as he is taught to wash his ears. If such
a procedure became customary the circumcision of children would become
an uncommon operation. This would result in the saving of about 16
children's lives lost from circumcision each year in this country,
besides saving much parental anxiety and an appreciable amount of
the time of doctors and nurses.
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.
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.
and varied reasons commonly advanced for circumcising infants are
critically examined. None are convincing.
early circumcision will prevent penile cancer, there is reason to
suppose that keeping the prepuce clean would have a like effect in
preventing this disease.
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 annually in this country, along with their yearly
toll of some 16 child deaths.
are due to Dr. A. M. Barrett for pathological facilities.
Benson, R. A., Slobody, L. B., Lillick, L., Maffia, A., and Sullivan,
N. (1949). J. Pediat., 34, 49.
Campbell, M. F. (1948). In Brennemann's Practice of Pediatrics,
vol. 3, chap. 30, p. 34. Hagerstown.
Cooke, J. V. (1921). Amer. J. Dis. Child., 22, 481.
Dean, A. L. (1935). J. Urol., 33, 252.
A. (1933). Anat. Rec., 57, 387.
Freud, P. (1947). J. Pediat., 31, 131.
Handley, W. S. (1947). British Medical Journal, 2, 841.
Higgins, T. T. (1949). In Garrod, Batten, and Thursfield's Diseases
of Children, 2, 462. London.
Hunter, R. H. (1935). J. Anat., 70, 68.
Kennaway, E. L. (1947). Brit. J. Cancer, 1, 335.
Lewis, L. G. (1931). J. Urol., 26, 295.
Lloyd, V. E., and Lloyd, N. L. (1934). British Medical Journal,
Schrek, R., and Lenowitz, H. (1947). Cancer Res., 7,
Wilson, R. A. (1947). Canad. med. Ass. J., 56, 54.
(* *)Dr. H. P. Broda, assistant
school M.O., Cambridge; Dr. Eileen Brereton, assistant school M.O.,
Cambridgeshire; Drs. F. J. W. Miller and S. D. Court, Child Health
Department, King's College, Newcastle-upon-Tyne; Dr. Margaret Patterson,
assistant M.O.H., Cambridge; Sir Alan Rook, senior health officer,
Cambridge University; Dr. R. E. Smith, medical officer to Rugby School.
It is a pleasure to record my thanks to all these colleagues for their
ready co-operation and many painstaking observations, and for generously
allowing me to quote their findings.