|Should he be circumcised? 1941|
Circumcise that baby!
The following article by Alan F. Guttmacher MD, associate professor of obstetrics at Johns Hopkins University, was published in the popular Parents Magazine in September 1941. This article was one of the first on the “advantages of circumcision” to appear in a mass-circulation magazine, and it represents a new phase in the medical campaign to enforce circumcision of infants throughout American society. It was very influential.
As you might expect, the article is a grotesque mix of woeful stupidity and wilful mendacity. Readers will particularly note Guttmacher’s fake even-handedness, his nonchalant attitude to the pain of the operation (“Naturally he wails …”), his abysmal ignorance of male genital anatomy and his quaint Victorian obsession with the perils of masturbation and the need for scrubbing. You might regard him as the missing link between William Acton and such modern luminaries as Edgar Schoen and Australia’s Brian Morris.
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?
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.
There are two main theories relating to the origin of circumcision. Some believe that circumcision first developed in one spot on the globe and ten 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 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 practise circumcision as part of religious dogma or tribal law. 
[Necessity for circumcision]
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. 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. 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. 
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. 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 cannot be drawn down again (paraphimosis) 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 the hapless Louis XV, whose seven years of sterile marriage were cured by circumcision.  In the light of these facts let us consider the advisability and inadvisability of circumcision.
All physicians are agreed that something must be done for the newborn infant who has so small an opening in the prepuce that the glans cannot be readily exposed. The baby must either be circumcised or attempts made to enlarge the tight ring by stretching its edges in all directions with a small, scissors-like, 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.
[For and against]
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 favour 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.
3. Venereal disease is less easily contracted by the circumcised male, and prophylaxis against it [is] 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 or convalescence.
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.
3. Circumcision causes some blunting of male sexual sensitivity because in the circumcised the skin of 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 75 per cent of all newborn males are routinely circumcised, although it may be necessary in only ten to fifteen per cent of the 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. When the obstetrician performs the operation he ordinarily adds 10 to 15 per cent 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, genito-urinary 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. [But deaths do occur, even today.]
The dangers following circumcision are infection and excessive bleeding. To prevent the latter complication some physicians study the blood on the day of the circumcision, especially its clotting ability. When deficient, it can be normalised in most cases by simply giving the child two thousand units (15 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 haemorrhage. 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 [sic] 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 discovered 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 weights 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 operation is deferred until later. In the last few years some brave 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 modelled 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 48 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 anaesthetic is used for an infant 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, five-eighths to three-quarters of an inch wide which weighs less than a quarter of an ounce. The wound heals quickly and requires little or no aftercare. 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 48 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.
Alan F. Guttmacher, “Should the baby be circumcised?”, Parents Magazine, Vol. 16 (September 1941), p. 26, 76-8
NOTESThe first question that strikes a reader today is why an obstetrician should be pontificating on male anatomy and physiology, subjects about which Guttmacher demonstrably knows very little. But it is a strange fact that it was the obstetricians and gynecologists who were the major force in promoting routine male circumcision in the USA from the 1930s onwards. Even more influential than Guttmacher was the article by Miller and Snyder, “Immediate circumcision of the newborn male”, published in the American Journal of Obstetrics and Gynecology in 1953. They seem to have regarded circumcision as the final phase of the birth process, and to have assumed that it was part of their job to tidy up boys’ penises in much the same way as they tied the umbilical cord. Symptomatic of their focus on women are the reasons Guttmacher gives in favour of circumcision; the first two have no connection with the health of the boy at all, but are entirely to do with the supposed convenience of the mother.
1. It is quite untrue that circumcision was practised in Asia before the arrival of the Moslems or in pre-Columbian America at any period. The only regions where it is known to have occurred in prehistoric times are parts of Africa, the Middle East and north-central Australia. A few Pacific peoples practised other (and milder) forms of penile mutilation, and it is possible that these were transformed into full circumcision under the influence of either Islam or nineteenth century Western medicine; Fiji and Samoa may be an example of the latter, while the horrible customs now prevalent in the Philippines may show the influence of both.
2. This is the myth of congenital phimosis, one of the great leaps backward in Anglophone anatomy. The infant penis is nearly always adherent and non-retractable, which is just how nature intends it to be. The claim that many boys were born with foreskin openings so small as to make urination impossible is another myth; there are no such cases known. The debate over “dilatation vs circumcision” goes back to the Orificial Surgery Society in the 1890s, as the contribution by Dr Beatty shows.
More up-to date information on phimosis available here.
Guttmacher cannot be blamed for repeating the medical wisdom of his period, but there is evidence that he had some acquaintance with medical history and should have known better, or at least to have wondered why "phimosis" in infants and boys had never been a problem until the 19th century. Some years after this article Guttmacher was the joint editor (with Owsei Temkin) of the most famous midwifery manual of the late ancient world, that by the Greek physician Soranus, and one which remained in use for hundreds of years. In this he might have read that medical authorities of that period considered a short or inadequate foreskin to be a defect requiring correction. The passage reads:
If the infant is male and it looks as though it has no foreskin, she
[the nurse of midwife] should gently draw the tip of the foreskin
forward or even hold it together with a strand of wool to fasten it.
For if gradually stretched and continuously drawn forward it easily
stretches and assumes its normal length, covers the glans and becomes
accustomed to keep the natural good shape.
Soranus's Gynecology, trans. and ed. Owsei Temkin and Alan F. Guttmacher (Johns Hopkins University Press, 1956), p. 107
Soranus advice is consistent with the view of Greek and
Roman physicians that a short or inadequate foreskin (one which did not
provide ample coverage of the glans) was a physiological defect known
as lipodermos. Their concern was to offer advice on how short foreskins
could be lengthened. None of them said a word about irritation, inflammation, secretions or any of the other perverse obsessions which agitated Victorian medicos.
3. The claim about Louis XV is nonsense. His only problem was a frenulum breve, corrected without circumcision. (See G. Androutsos, “Le phimosis de Louis XVI (1754-1793) aurait-il ete a l'origine de ses difficultes sexuelles et de sa fecundite retardee?” Progres Urologique, Vol. 12 (1), 2002)
4. Although the ancient Hebrews were heavily into blood (as in animal sacrifices etc), it is highly unlikely that they knew anything about its clotting properties in infants. Circumcision on the eighth day had a strictly ritual significance, connected with the seven days the Lord had taken to create and people the earth, and the time needed for the mother to purge the impurity induced by childbirth. The mother could be cleansed of her own polluted blood only by the shedding of purifying blood from her son’s penis. (For details see Laurence Hoffman, Covenant of blood: Circumcision and gender in rabbinic Judaism, Chicago University Press, 1996)
5. This is the notorious Gomco clamp, invented by Hiram S. Yellen and Aaron Goldstein in 1935, and promoted by (you guessed it), the American Journal of Obstetrics and Gynecology. It was certainly never bloodless, nor free from “complications”, but it marked the arrival of the “high and tight” American style of circumcision, in which every last shred of tissue was excised, leaving the remaining skin of the penis “tight as a drum”. Americans have become very attached to this flayed look; there are even fetishistic internet communities which celebrate it as a mark of manliness.
For further details, see the Gomco page on this site.