Don't Blame Your Grandparents:

Circumcision became routine without parents' permission.

Parents' Magazine, September 1941


By ALAN F. GUTTMACHER, M.D.
Associate Professor of Obstetrics,
Johns Hopkins University

An experienced doctor answers here the questions that almost every mother and father ask when a boy baby is born into their family

Should The Baby Be Circumcised?

"SHOULD MY BABY be circumcised?" Many a new mother asks her doctor this. At the same time a procession of thoughts march across her mind which lead to other questions she would like to ask her physician. What is the history of the operation? What are its advantages and disadvantages? What is the risk, if any? At what age is it best performed? How is it done? Who should do it and what aftercare does it require?

[No suggestion that any ethical questions are raised. This is still often the case.]

The first question, the history of the operation, is the most difficult to answer. The origin of circumcision is quite obscure, largely because its early performance antedated the dawn of recorded history. Circumcision is probably the second oldest operation in surgery; the most ancient is the cutting of the umbilical cord which joins the baby to the afterbirth. [The implication that these are in any way comparable is false.]

There are two main theories relating to the origin of circumcision. Some believe that circumcision first developed in one spot on the globe and then migrated from one people to another. Many of them probably abandoned it after a trial. The adherents of the theory of multiple origins feel that it sprang up quite independently in Asia, Africa, Australia and the Americas and at very different periods in world history. Be this as it may, the operation is still performed by widely scattered primitive peoples in all of these continents today. The age varies greatly from people to people, or even from tribe to tribe. No matter at what age it is done, the age is specific and unchangeable for each group and the operation is accompanied by an elaborate ceremony. 200,000,000 people still practice circumcision as part of religious dogma or tribal law. [This figure is far too high.]

Present day hygiene requires that the prepuce, the hoodlike fold of skin which covers the end of the penis (glans) be drawn back daily and the uncovered glans thoroughly washed. [Only after it is able to retract naturally, which may not occur till puberty.] Trouble occurs if this is neglected, for the secretion from the multiple glands lining the inside of the hood becomes caked, and within a few days the material may set up an inflammation. [This may (or may not) be true in adults. It is absolutely false in newborns.] Such inflammation may lead to the growth of slender, strandlike bands of tissue between the inside of the prepuce and the glans, gluing the two together, thus forming an adherent foreskin. [It is forcible retraction, tearing the synechia, which creates raw surfaces that heal together.] The second source of difficulty may arise when a child is born with too small an opening at the end of the foreskin so that attempts to draw it back are unsatisfactory. [The perfectly natural adherence of the foreskin to the glans may give the appearance of "too small an opening."] When the ringlike aperture is not large enough it either prevents the retraction of the foreskin completely (phimosis), or if it is retracted, the ring of foreskin may encircle the glans so tightly that it can not be drawn down again (para-phimosis) into its normal position. The constriction causes pain. Adherent prepuce or phimosis frequently causes difficulty in urination, and may cause sufficient pain to lead to impotence as in the case of hapless Louis XV, whose seven years of sterile marriage were cured by circumcision. [Louis married in 1725; the first of his 10 children was born in 1727.] In the light of these facts let us consider the advisability and inadvisability of circumcision.

All physicians are agreed that some thing must be done for the newborn infant who has so small an opening in the prepuce that the glans can not be readily exposed. [If this was ever true, they reached that agreement without any research. It has no basis in fact.] The baby must either be circumcised or attempts made to enlarge the tight ring by stretching its edges in all directions with a small, scissorslike, dull-bladed clamp. The doctor does this by introducing the point of the clamp within the ring of the prepuce and gently opening the handles. This may be tried daily for several days and if at the end of this time the opening is not sufficiently enlarged so that the foreskin retracts with ease, circumcision is necessary.

[A vast number of circumcisions will have been made "necessary" by this destructive interference.]

Now what about the infant whose foreskin goes back normally? Some physicians recommend routine circumcision, while others advise it only for a tight, unstretchable foreskin. What are the arguments for and against circumcision in these optional cases?

Those in favor of routine circumcision claim that:

(1) It makes care of the infant's genitals easier for the mother.
(2) It does not necessitate handling of the penis by the infant's mother, or the child himself in later years, and therefore does not focus the male's attention on his own genitals. Masturbation is considered less likely. [This is one reason no longer publicly offered.]
(3) Venereal disease is less easily contracted by the circumcised male and prophylaxis against it more efficient.
(4) Cancer of the penis, which to be sure is extremely rare, is even less frequent in the circumcised.
(5) A tight foreskin occasionally becomes tighter as the child grows older and may necessitate circumcision in adulthood. At this time the operation is very painful and requires several days for convalescence.
[Urinary Tract Infections, now considered the top reason for circumcising, are not mentioned.]

THOSE who oppose routine circumcision claim that:

(1) An unnecessary operation is never justified, because no surgical procedure is without risk.
(2) A circumcised boy may feel self-conscious when unclothed in the presence of boys who are uncircumcised. [And he'll feel worse when he learns what has been done to him.]
(3) Circumcision causes some blunting of male-sexual sensitivity because in the circumcised the skin on the glans becomes thicker. However, this supposed disadvantage is often listed as an advantage.

In the United States most doctors support the affirmative side of the circumcision debate and in urban hospitals well over seventy-five percent of all newborn males are routinely circumcised, although it may be necessary in only ten to fifteen percent of the cases. [In Scandinavia it proves necessary in about one percent of cases.] Some doctors make a practice of routine circumcision unless specific objection is raised by the parents, while others first consult the parents in order to discover their wishes.

[Even for 1941, this seems extraordinary. Medical ethics have come a long way. They have a long way to go.]

When the obstetrician performs the operation he ordinarily adds 10 to 15 percent to his bill, although some include it in their original fee. A surgeon usually charges 25 to 50 dollars.

The risk of circumcision in the infant male is very small. In a safe hospital in the hands of a competent obstetrician, genitourinary specialist, or surgeon it is almost negligible. I have never known a child to die as the result of a medical circumcision in any of the several hospitals with which I am connected.

The dangers following any circumcision are infection and excessive bleeding. To prevent the latter complication some physicians study the blood on the day of circumcision, especially its clotting ability. When deficient, it can be normalized in most cases by simply giving the child two thousand units (fifteen drops) of vitamin K by mouth. Infection is guarded against by performing the operation in an operating room, with scrupulous surgical technique.

ACCORDING to Jewish law, of which ritualistic circumcision is a part, it should be done on the eighth day of life. This particular day was probably selected after centuries of experimentation through trial and error. No doubt the Jews found, as we have, that when circumcision was done earlier the child had a greater tendency to hemorrhage. According to Dr. Quick of Marquette University, the answer to this riddle is now known. He claims that a full-term child is born with a relatively high prothrombin level of its blood. Prothrombin is a substance which plays a significant role in the clotting of blood and its quantity in the body is directly affected by the newly isolated chemical, vitamin K. Dr. Quick states that the prothrombin level drops rapidly after birth and does not start to rise until the child is several days old, not reaching satisfactory levels again until about the seventh day. This he believes is the reason that a circumcision done. before the eighth day, unless within the first several hours after birth, is more likely to bleed excessively than a circumcision done the eighth day or later. Usually when the child weighs six pounds or more, and is strong and well, the operation is done between the eighth and tenth days; but if the child is puny or weak the procedure is deferred until later. In the last few years some brave new spirits have been circumcising the child as soon as it is born, taking advantage of the temporary high prothrombin level. I have seen several of these cases and they seem to do just as well as children circumcised at the later time.

Several different operative techniques may be employed in doing circumcisions. A common one is modeled after the method of the Jewish ritualistic circumcision. The elastic foreskin is stretched forward beyond the glans and a clamp applied across it, just in front of the glans. A knife cut is made just behind the clamp and in front of the glans. When the severed skin retracts through its own elasticity it is sufficiently shortened so that its forward edge is now even with the base of the glans. A few key stitches are used to control bleeding and a dressing applied. If the stitches are catgut they dissolve and drop out in a few days of their own accord. If silk stitches are used they must be removed forty-eight hours after the operation.

The second type of operation is termed the dorsal-slit. In this, a slit is made in the foreskin with a scissors, the incision being carried back until it is flush with the base of the glans. Then a circular cut is made with the scissors amputating a strip of foreskin. The wound is stitched and dressed.

A third and increasingly popular method is the use of the clamp, a gadget which squeezes a circular groove in the foreskin at the proper distance from the end. It squeezes the skin so hard that after being severed with a knife along this compressed tract there is virtually no bleeding and no stitches have to be used. Any one of these three methods in the hands of a surgically trained operator produces excellent results.

No anesthetic is used for an infant's circumcision. The baby is merely given a piece of gauze to suck which has been dipped in plain water, sugar water, or sugar water plus whiskey. Naturally he wails during the more painful stages, but as soon as the operation is over all appears forgotten and forgiven in slumber.

The amount of tissue removed is very little. It is simply a circular band of skin 1/2 to 3/4 of an inch wide which weighs less than a quarter of an ounce. [As usual, ignoring the fact that if left alone it grows much bigger.] The wound heals quickly and requires little or no aftercare. [False.] The site of the incision is usually encircled with a small vaselined bandage and then a small, sterile gauze sponge is wrapped around the end of the penis. The sponge is changed whenever the infant is rediapered, but the Vaseline bandage is allowed to remain in place for forty-eight hours, when it is removed. If the wound is well healed nothing more need be done; but if some raw areas remain these are usually touched up by a nurse or doctor with a mild antiseptic. The infant is usually given only an oil bath until both the cord stump and circumcision are healed.

One nice thing about circumcision is that when it is done it is finished. The foreskin never grows back. [False. A significant number of boys are brought back for further surgery.]

September, 1941

 

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