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Metcalfe and Elyas have produced a truly excellent paper1 that should become a classic. We would recommend it to anyone.
Having said that, we do have one quibble with this paper. The authors cited Wright2 when discussing complications of circumcision. Wright also said the following:
Gairdner’s otherwise masterly description contained one inaccuracy. He said that the foreskin should be fully retractable by three years of age. Clinical observation reveals that this is not true. It should be open and beginning to retract by three years of age but full retractability may not be achieved [until] many years later. Indeed nature will not permit the assignment of a strict timetable to this process.2
Inexplicably, Metcalfe and Elyas then quoted Gairdner’s inaccurate figures on the development of foreskin retractility.
Gairdner, for whom we generally have the very highest respect, reported in his classic paper that he used a probe to break the normal fusion between the inner surface of the foreskin and the underlying glans penis to create a retractable foreskin, and thus avoid a circumcision.3 But he also said that “it is inadvisable as a routine procedure.”
Gairdner’s bar graph shows a steep increase in retractility from birth to age 3 years. This does not occur in nature; it is possible that these values were obtained by the use of the probe. In any event, they have been disproved by later research. In actuality, development of retractility tends to be much slower.
Gairdner’s values for the development of foreskin retractility stood alone and unchallenged for decades, during which they were quoted by the authors of numerous textbooks.4 Unfortunately, thousands of physicians the world over have been trained with these false values. This undoubtedly has contributed to false diagnoses of pathological phimosis and large numbers of medically unnecessary amputations of healthy nonretractile foreskins in many nations.
Øster,5 Kayaba et al,6 Morales Concepción et al,7 Agarwal et al,8 and Ko et al9 all have demonstrated that the development of preputial retraction is a very gradual and variable event that occurs between birth and the completion of puberty. Moreover, Thorvaldsen and Meyhoff carried out a survey in Denmark and reported that the mean age of first foreskin retraction is 10.4 years.10 All of these authors provide evidence that refutes Gairdner’s 1949 data.
Gairdner’s values for foreskin retraction belong in a museum of medical history, but they should not be applied in current clinical practice.