The advisability of routine circumcision has long been a subject of medical controversy. It is seldom however, that the discussions on the subject are based upon new factual observations. Since army experience provides an unusual opportunity to collect such data, it was decided to conduct the present investigation.
Before recording our observations on the incidence of circumcision amongst soldiers with venereal disease, some of the standard arguments for and against this operation will be reviewed. Those who advocate routine circumcision usually base their views upon the general consideration that the procedure renders subsequent cleanliness and hygiene of the penis so simple that no special attention or manipulation is ever necessary. They consider circumcision a justifiable method of rendering the delicate coronal membrane much more resistant to injury and infection. They argue that the future dangers of balanitis, painful erection, unsatisfactory coitus and paraphimosis can be removed by this simple prophylactic operation. If it is done with good judgment and reasonable surgical skill its dangers should be negligible.
On the other hand, the opponents of routine circumcision state that it is unwise to remove a protective covering which was obviously provided by nature for a purpose. They point out that the routine subjection of babies to an operation which has definite dangers is vicious and purposeless surgical interference. Frequently, good judgment and surgical skill are not exercised. The hazards of the operation then do not justify its routine or even frequent performance. They state that in practically all cases adequate instruction of the mother and stretching of the foreskin will render operation unnecessary. Another, less frequently voiced, yet very real objection of the operation, is the danger of meatal ulceration. This occurs not infrequently in circumcised infants who have ammoniacal diaper burns. This complication is preventable if precautions are taken.
Besides these valid arguments on medical grounds there is great discussion of the religious and personal aspects of the problem. For example some uncircumcised people claim that the toughening of the coronal membrane after circumcision reduces the sensory impulses from the region and renders coitus less pleasurable.
Material
- The V.D. group.?Information was collected regarding previous circumcision and final diagnosis on 1,304 consecutive patients at a Canadian Army V.D. treatment centre in the field.
- Control group.?1,000 recruits at an Army Reception Centre were examined to determine the incidence of circumcision amongst Canadian Army personnel.
Results
The detailed results are shown in Table I (a and b). From these figures it will be seen that 76.7% of the V.D. Group were uncircumcised whereas in the control group, 52% were uncircumcised. The most striking difference is in syphilis where 90% of the cases were uncircumcised. That these figures bear statistical analysis will be seen from the accompanying figures in Table I. In each instance except balanitis and venereal warts, the observed difference is highly significant. The number of cases in the latter two diseases are too small to be of significance. However, it is accepted that these diseases are very rare in circumcised people.
Discussion
The possibility must be considered that the higher proportion of uncircumcised soldiers amongst the venereal disease group may be due to a greater rate of promiscuous exposure amongst the uncircumcised. Selection may have taken place in this way. It is impossible to control this factor, but from general impressions it is considered unlikely that this group is significantly more promiscuous.
It is suggested from the present results that venereal disease is more prevalent amongst uncircumcised males. What are the possible explanations for this? In gonorrhoea it could be due to the fact that the foreskin, after coitus, retains infectious mucus. Here is an ideal environment of moisture and warmth, the organisms multiply and provide heavy contamination of the adjacent urethral mucosa.
That syphilis is more common in uncircumcised soldiers seems even more reasonable. Tears and abrasions of the foreskin itself are commonly seen on sick parade. Small abrasions of the delicate coronal membrane must be very common during brothel intercourse. Both provide a portal of entry for the spirochaete.
Army experience, in the light of the present results, leads one to the conclusion that the advantages of circumcision far outweigh the previously mentioned disadvantages. Frequent physical inspection of men reveals that cleanliness of these parts is commonly neglected. When bathing facilities are poor, neglect is almost universal. The area is then prone to infection. Venereal warts and balanitis are usually the result of such carelessness. Non-specific penile ulceration, chancroid and syphilis often result from tears in a tight foreskin. The latter also renders diagnosis more difficult. It is concluded that the presence of a foreskin is a distinct liability to the average soldier.
