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CIRCUMCISION
623 in a case of complicated multiple injuries involving also the chest and exhibiting this sign I was unwise enough not to do a laparotomy, and post-mortem examination showed the ruptured spleen to be a principal cause of death. I believe that unusual fixation of the spleen by congenital folds of peritoneum contributed to its rupture in the girl’s case by relatively minor violence, since nt,11P,rwi"e it might have slimmed out of the wav. G. J. FRAENKEL Radcliffe Infirmary, Surgical
Oxford.
tutor.
CIRCUMCISION
SiR,-As a, general practitioner I am grateful for "Sir Daniel Whiddon’s " advice (Aug. 15) on circumcision. It is strange how a really useful medical practice like vaccination tends to die out unless people are urged to have their children protected, while unnecessary operations like those for circumcision and tongue-tie remain
popular.
Mr. J. D. Hennessy (Sept. 12) has raised another very important issue-namely, that forcible retraction or stretching of the foreskin can be harmful procedures. Some mothers are most upset if they cannot push the Others prepuce right back so as to clean underneath it. perform the operation on someone else’s advice, but they dislike doing it. In my view this zeal for preputial hygiene is quite unnecessary or even harmful. More than once I have been called out to reduce an incipient paraphimosis, because the mother, having exposed the glans, is unable to replace the foreskin. After all, no-one ever thinks of inspecting the vulva of a small girl in order to
the smegma. It is eight years since I returned to the Forces, and in that time I have never circumcised a small baby. I have seen only 3 cases of balanitis, and they all cleared up readily on sulphonamides and caused no further trouble. Quite apart from the danger of physical damage to the child, I am quite sure that it cannot be good for a small boy to have his penis manipulated daily by his mother. When I examine all newborn babies immediately after birth to exclude congenital abnormalities, I always make a point of telling the mother that her son does not need circumcising. I advise her to wash and powder him well but to do no more. If then or at a later date she questions this advice, one must spend a little time explaining the protective function of the foreskin, and she must be In my assured that it will stretch as he gets older. for now ever arises. the circumcision hardly practice request C. A. H. WATTS. Ibstock, Leicester. remove
general practice from
sure that the large majority of doctors ritual and so welcome Sir Daniel’s barbaric this oppose frank exposition of views. But perhaps he should have made just one or two more points. Although Nature’s constancy is not to be denied, even if, on occasions, she has wondered whether the foreskin is really necessary,’I think that one or two of the complications of the unretracted foreskin should have been pointed out. Where the foreskin is left in situ (as it should be) by the family doctor he should ensure that at a suitable age, say over two years, a complete retraction of the prepuce is performed by himself. It is not at all uncommon for smegma to collect behind the corona in the boy whose foreskin is not retracted at intervals. This may become an irritant, and boys with such a collection often scratch about the genitalia. In front of this smegma the foreskin and glans are closely adherent. A further complication of this collection of smegma may be a subpreputial abscess which becomes apparent only when well advanced. These disturbances, while they do not justify circumcision in infancy, are the kind of things that help to maintain the belief that circumcision is a good thing " and will save a lot of trouble later." Until proper and
SiR,—I feel
1. J. Anat., Lond. 1951, 85, 370.
adequate education is given and controversy will continue to
this
1’inele,nds, (!ape Province.
acted upon
by parents,
recur.
THEODORE JAMES.
Sm,—In South Africa where we see hundreds of Bantus who are circumcised by their " witchdoctors," not according to laws of asepsis but according to the laws of the jungle, it is interesting to note that the uncircumciseci seldom present themselves with gonococcal warts. On the other hand, the " unclean " natives often have some form of balanitis, paraphimosis, or epithelioma ; and I once found actinomycosis of the prepuce in a native whose job was cleaning stables. Where cleanliness is a major consideration circumcision is, in my view, essential. The non-European races do not wash their sexual organs very often and the only means of cleaning the seminal secretions off the glans is to have an exposed coronal sulcus. SAMUEL MILLER. London, N.16. SENSITIVITY TO PHENOBARBITONE SIR,-In the belief that early recognition of phenobarbitone sensitivity was important because severe reactions might lead to death, Dr. Leishman and I described 4 such cases last year.1 It was our opinion that severe reactions to phenobarbitone were more common than was generally realised and that the diagnosis Our article does not seem to have was often missed. been read by your annotator (Sept. 12) or by McGeachy and Bloomer.2 Our findings were very much the same as those of McGeachy and Bloomer, though in 3 of our 4 cases, the patients were over the age of 50. A feature of the syndrome worth stressing is that improvement does not necessarily follow withdrawal of the phenobarbitone. The condition may continue for ten to fourteen days after withdrawal and, in fact, an irreversible state ending in death may occur. McGeachy and Bloomer suggest that corticotrophin (A.C.T.H.) or cortisone should be tried. We used intravenous corticotrophin on an apparently moribund woman suffering from
phenobarbitone sensitivity. Within twenty-four hours there was a dramatic improvement and despite the complication of staphylococcal pneumonia she recovered fully within a month. Corticotrophin would appear to be the treatment of choice in the very severe cases. With the widespread use of phenobarbitone it is likely that more and more examples of acquired sensitivity to the drug will be seen, and your annotation stresses quite rightly that the possibility of severe reactions to phenobarbitone should be more widely recognised, though fortunately they are at present rare. I. B. SNEDDON. Sheffield. GLUTAMIC ACID IN HEPATIC COMA
SiR,-In your last issue Dr. Gershon, Dr. Trautner, andDr. Trethewie report that patients can be aroused from hypoglycsemic coma by an intravenous injection of sodium succinate and suggest that this effect may be due to the same basic mechanism as the action of glutamic acid in hepatic coma. It has been shown3 that the arousal effect of intravenous succinate in hypoglycsemic coma is about equal to that of glycine, but much inferior to that of glutamate or arginine. On intravenous injection, all four substances induce a significant increase of the bloodadrenaline level. The intensity of this effect varies in the same order as the capacity of causing arousal. Other observations on the effects of intravenous or oral glucose administration,4of subconvulsive electrical stimulation of the brain 3 and of the iniection of adrenaline itself5 1. Sneddon, I. B., Leishman, A. W. D. Brit, med. J. 1952, i, 1276. 2. McGeachy, T. E., Bloomer, W. E. Amer. J. Med. 1953, 14, 600. 3. Well-Malherbe, H., Bone, A. D. J. ment. Sci. 1952, 98, 565. 4. Weil-Malherbe, H. Biochem. J. 1952, 52, xi. 5. Weil-Malherbe, H. J. ment. Sci. 1949, 95, 930.
Oxford.
tutor.
CIRCUMCISION
SiR,-As a, general practitioner I am grateful for "Sir Daniel Whiddon’s " advice (Aug. 15) on circumcision. It is strange how a really useful medical practice like vaccination tends to die out unless people are urged to have their children protected, while unnecessary operations like those for circumcision and tongue-tie remain
popular.
Mr. J. D. Hennessy (Sept. 12) has raised another very important issue-namely, that forcible retraction or stretching of the foreskin can be harmful procedures. Some mothers are most upset if they cannot push the Others prepuce right back so as to clean underneath it. perform the operation on someone else’s advice, but they dislike doing it. In my view this zeal for preputial hygiene is quite unnecessary or even harmful. More than once I have been called out to reduce an incipient paraphimosis, because the mother, having exposed the glans, is unable to replace the foreskin. After all, no-one ever thinks of inspecting the vulva of a small girl in order to
the smegma. It is eight years since I returned to the Forces, and in that time I have never circumcised a small baby. I have seen only 3 cases of balanitis, and they all cleared up readily on sulphonamides and caused no further trouble. Quite apart from the danger of physical damage to the child, I am quite sure that it cannot be good for a small boy to have his penis manipulated daily by his mother. When I examine all newborn babies immediately after birth to exclude congenital abnormalities, I always make a point of telling the mother that her son does not need circumcising. I advise her to wash and powder him well but to do no more. If then or at a later date she questions this advice, one must spend a little time explaining the protective function of the foreskin, and she must be In my assured that it will stretch as he gets older. for now ever arises. the circumcision hardly practice request C. A. H. WATTS. Ibstock, Leicester. remove
general practice from
sure that the large majority of doctors ritual and so welcome Sir Daniel’s barbaric this oppose frank exposition of views. But perhaps he should have made just one or two more points. Although Nature’s constancy is not to be denied, even if, on occasions, she has wondered whether the foreskin is really necessary,’I think that one or two of the complications of the unretracted foreskin should have been pointed out. Where the foreskin is left in situ (as it should be) by the family doctor he should ensure that at a suitable age, say over two years, a complete retraction of the prepuce is performed by himself. It is not at all uncommon for smegma to collect behind the corona in the boy whose foreskin is not retracted at intervals. This may become an irritant, and boys with such a collection often scratch about the genitalia. In front of this smegma the foreskin and glans are closely adherent. A further complication of this collection of smegma may be a subpreputial abscess which becomes apparent only when well advanced. These disturbances, while they do not justify circumcision in infancy, are the kind of things that help to maintain the belief that circumcision is a good thing " and will save a lot of trouble later." Until proper and
SiR,—I feel
1. J. Anat., Lond. 1951, 85, 370.
adequate education is given and controversy will continue to
this
1’inele,nds, (!ape Province.
acted upon
by parents,
recur.
THEODORE JAMES.
Sm,—In South Africa where we see hundreds of Bantus who are circumcised by their " witchdoctors," not according to laws of asepsis but according to the laws of the jungle, it is interesting to note that the uncircumciseci seldom present themselves with gonococcal warts. On the other hand, the " unclean " natives often have some form of balanitis, paraphimosis, or epithelioma ; and I once found actinomycosis of the prepuce in a native whose job was cleaning stables. Where cleanliness is a major consideration circumcision is, in my view, essential. The non-European races do not wash their sexual organs very often and the only means of cleaning the seminal secretions off the glans is to have an exposed coronal sulcus. SAMUEL MILLER. London, N.16. SENSITIVITY TO PHENOBARBITONE SIR,-In the belief that early recognition of phenobarbitone sensitivity was important because severe reactions might lead to death, Dr. Leishman and I described 4 such cases last year.1 It was our opinion that severe reactions to phenobarbitone were more common than was generally realised and that the diagnosis Our article does not seem to have was often missed. been read by your annotator (Sept. 12) or by McGeachy and Bloomer.2 Our findings were very much the same as those of McGeachy and Bloomer, though in 3 of our 4 cases, the patients were over the age of 50. A feature of the syndrome worth stressing is that improvement does not necessarily follow withdrawal of the phenobarbitone. The condition may continue for ten to fourteen days after withdrawal and, in fact, an irreversible state ending in death may occur. McGeachy and Bloomer suggest that corticotrophin (A.C.T.H.) or cortisone should be tried. We used intravenous corticotrophin on an apparently moribund woman suffering from
phenobarbitone sensitivity. Within twenty-four hours there was a dramatic improvement and despite the complication of staphylococcal pneumonia she recovered fully within a month. Corticotrophin would appear to be the treatment of choice in the very severe cases. With the widespread use of phenobarbitone it is likely that more and more examples of acquired sensitivity to the drug will be seen, and your annotation stresses quite rightly that the possibility of severe reactions to phenobarbitone should be more widely recognised, though fortunately they are at present rare. I. B. SNEDDON. Sheffield. GLUTAMIC ACID IN HEPATIC COMA
SiR,-In your last issue Dr. Gershon, Dr. Trautner, andDr. Trethewie report that patients can be aroused from hypoglycsemic coma by an intravenous injection of sodium succinate and suggest that this effect may be due to the same basic mechanism as the action of glutamic acid in hepatic coma. It has been shown3 that the arousal effect of intravenous succinate in hypoglycsemic coma is about equal to that of glycine, but much inferior to that of glutamate or arginine. On intravenous injection, all four substances induce a significant increase of the bloodadrenaline level. The intensity of this effect varies in the same order as the capacity of causing arousal. Other observations on the effects of intravenous or oral glucose administration,4of subconvulsive electrical stimulation of the brain 3 and of the iniection of adrenaline itself5 1. Sneddon, I. B., Leishman, A. W. D. Brit, med. J. 1952, i, 1276. 2. McGeachy, T. E., Bloomer, W. E. Amer. J. Med. 1953, 14, 600. 3. Well-Malherbe, H., Bone, A. D. J. ment. Sci. 1952, 98, 565. 4. Weil-Malherbe, H. Biochem. J. 1952, 52, xi. 5. Weil-Malherbe, H. J. ment. Sci. 1949, 95, 930.