Divergent views having been expressed on this subject, may I attempt to sum up and clarify the position?
Dr McAuley’s letter raises the point which is the crux of the matter: Should the prepuce be removed whether phimosis is present or not? I suggest that phimosis, especially if extreme, demands circumcision for these reasons. (1) Many infants so affected cry excessively until the operation is done: thereby (2) they may develop hernia. (3) Various troubles – for example, nocturnal enuresis, “fits”, and, in later life, epithelioma of the glans and paraphimosis – are associated with phimosis. (4) In patients with phimosis suffering from gonorrhoea, complications arise, and treatment is more difficult than in the circumcised. (5) The disadvantages in the event of marriage are obvious. Although difficult of proof, there is little doubt that the prepuce, especially a long one, renders boys more likely to acquire the habit of masturbation. For this very good reason alone I think circumcision desirable, phimosis apart, If the reasons given for circumcision are sound, then stretching operations find no place.
I venture to describe the method I use, as it is not the orthodox one. It is well to wait until the infant is 2 to 3 weeks old, and feeding is well established.
Local anaesthesia is always used, novutox or locosthetic (P.D. & Co), being injected with a fine needle at the root of the penis on the dorsum and below at the peno-scrotal junction. This makes the operation entirely painless, as I have repeatedly proved. After thorough sterilising of all the parts with spirit and biniodide solution, the end of the prepuce is seized on the dorsum on each side of the middle line with small, narrow-bladed Spencer Wells forceps. Traction on these parts puts the prepuce on the stretch. A similar forceps is then passed down under the prepuce (dorsally), and opened widely, stretching the prepuce and freeing it from the glans, right down to the neck of the latter. The blade of a pair of straight, blunt-pointed scissors is then passed under the prepuce and the latter slit down dorsally to the neck of the glans. The prepuce is then separated, if necessary, from the glans on each side, and cut away, beginning at the fraenum and ending on the dorsum. The cutting is carried round close to the neck of the glans, leaving just enough skin and mucous membrane to be stitched together. During these various manoeuvres traction is made on the forceps originally applied, so as to steady and stretch the prepuce. Often no vessels need tying – at the most, one on the dorsum and one on the fraenum. The free edges of the skin and mucous membrane are united by a few sutures of fine iodised catgut, using a small, half-circle Hagedorn needle. A narrow strip of sterile gauze is wrapped round and tied on. The operation takes very little longer than the usual one, and the skin edge left is almost a perfect “circle”; any after-trimming of the edges is rarely necessary.
The advantages of this method are two: (1) there is no possible risk of injury to the glans; and (2) seeing exactly what one is doing, it is possible to remove the whole of the prepuce, which is the main point. results are entirely satisfactory, and in my experience shock, sepsis, haemorrhage etc are unknown. Stitches absorb or work out, and healing is complete in five to ten days.
I hope I have shown, in reply to the flagrant statements of one of your correspondents, that “circumcision” is not a “horrible mutilation”, that it “has a sanitary and therapeutic value”, and, being ordained by Providence from very early times (doubtless for good reasons), it is not a “cool assumption” on the part of surgeons doing this operation that they “know better how little boys should be made”. And if phimosis is to be relegated to the list of imaginary diseases, why not make a clean sweep, and say that cancer, tuberculosis, and the rest do not exist?
With regard to your correspondence on circumcision the following case may be of interest.
My son, now aged 6, was born with a long, tight foreskin. As I was against circumcision at the time, he was left uncircumcised. When he was 6 months old I noticed that he continually handled his penis. A colleague found adhesions, which he freed, and since then the foreskin has been pushed back every night at bath time and the parts thoroughly washed. There has been no recurrence of the handling on his part, except on one or two occasions when nightly washing has been omitted and there has been some slight inflammation. The boy now does the washing himself as a matter of routine, which falls into place with the cleaning of ears, teeth etc.
The points I wish to stress are: (a) it is really difficult to keep the parts clean in the uncircumcised, and (b) regular pushing back of the foreskin and washing does not always conduce to masturbation, whereas dirty, itching parts do. I hesitate to have the boy circumcised now because I think it quite likely that a psychological trauma may result from the operation at this age. I know of at least one case where a boy of 4 years, one of twins, was circumcised, in which the operation was undoubtedly a great shock, and this may have farreaching results.
With regard to what Dr H.M. Hanschell says of the preference of copulating women for the circumcised male: this may be due to the fact that the glans is less sensitive after circumcision in infancy and that therefore coitus can be prolonged. If this is the explanation it is an argument in favour of circumcision which should not be overlooked. Ejaculatio praecox with its concomitant unhappiness to both partners is common enough to call for investigation.
Comment: These quotes give a very interesting perspective to a time period generally considered to be patriarchal and prudish.