History of Circumcision in the U.S.

A Short History of Circumcision in the U.S. In Physicians' Own Words

1860: 0.001% of the U.S. male population circumcised
"In cases of masturbation we must, I believe, break the habit by inducing such a condition of the parts as will cause too much local suffering to allow of the practice being continued. For this purpose, if the prepuce is long, we may circumcise the male patient with present and probably with future advantage; the operation, too, should not be performed under chloroform, so that the pain experienced may be associated with the habit we wish to eradicate." Athol A. W. Johnson, On An Injurious Habit Occasionally Met with in Infancy and Early Childhood, The Lancet, vol. 1 (7 April 1860): pp. 344-345.
1871: 1% of the U.S. male population circumcised
"I refer to masturbation as one of the effects of a long prepuce; not that this vice is entirely absent in those who have undergone circumcision, though I never saw an instance in a Jewish child of very tender years, except as the result of association with children whose covered glans have naturally impelled them to the habit." M. J. Moses, The Value of Circumcision as a Hygienic and Therapeutic Measure, NY Medical Journal, vol. 14 (1871): pp. 368-374. 1887: 10% of the U.S. male population circumcised
"Hip trouble is from falling down, an accident that children with tight foreskins are especially liable to owing to the weakening of the muscles produced by the condition of the genitals." Lewis L. Sayer, Circumcision For the Cure of Enuresis, Journal of the American Medical Association, vol. 7 (1887): pp. 631-633. "There can be no doubt of [masturbation's] injurious effect, and of the proneness to practice it on the part of children with defective brains. Circumcision should always be practiced. It may be necessary to make the genitals so sore by blistering fluids that pain results from attempts to rub the parts." Angel Money, Treatment of Disease in Children. Philadelphia: P. Blakiston. 1887, p. 421. 1888: 15% of the U.S. male population circumcised
"A remedy [for masturbation] which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment." John Harvey Kellogg [the breakfast cereal tycoon], Treatment for Self-Abuse and Its Effects, Plain Facts for Old and Young, Burlington, Iowa: P. Segner & Co. 1888, p. 295. 1891
"In consequence of circumcision the epithelial covering of the glans becomes dry, hard, less liable to excoriation and inflammation, and less pervious to venereal viruses. The sensitivity of the glans is diminished, but not sufficiently to interfere with the copulative function of the organ or to constitute an objection ... It is well authenticated that the foreskin ... is a fruitful cause of the habit of masturbation in children ... I conclude that the foreskin is detrimental to health, and that circumcision is a wise measure of hygiene." Jefferson C. Crossland, The Hygiene of Circumcision, NY Medical Journal, vol. 53 (1891): pp. 484-485. 1891
"Measures more radical than circumcision would, if public opinion permitted their adoption, be a true kindness to many patients of both sexes." Jonathan Hutchinson, On Circumcision as Preventive of Masturbation, Archives of Surgery, vol. 2 (1891): pp. 267-268. 1895
"In all cases in which male children are suffering nerve tension, confirmed derangement of the digestive organs, restlessness, irritability, and other disturbances of the nervous system, even to chorea, convulsions, and paralysis, or where through nerve waste the nutritive facilities of the general system are below par and structural diseases are occurring, circumcision should be considered as among the lines of treatment to be pursued." Charles E. Fisher, Circumcision, in A Hand-Book On the Diseases of Children and Their Homeopathic Treatment. Chicago: Medical Century Co., 1895. p. 875. 1895: 15% of the U.S. male population circumcised
"In all cases of masturbation circumcision is undoubtedly the physicians' closest friend and ally ... To obtain the best results one must cut away enough skin and mucous membrane to rather put it on the stretch when erections come later. There must be no play in the skin after the wound has thoroughly healed, but it must fit tightly over the penis, for should there be any play the patient will be found to readily resume his practice, not begrudging the time and extra energy required to produce the orgasm. It is true, however, that the longer it takes to have an orgasm, the less frequently it will be attempted, consequently the greater the benefit gained ... The younger the patient operated upon the more pronounced the benefit, though occasionally we find patients who were circumcised before puberty that require a resection of the skin, as it has grown loose and pliant after that epoch." E. J. Spratling, Masturbation in the Adult, Medical Record, vol. 24 (1895): pp. 442-443. 1896
"Local indications for circumcision: Hygienic, phimosis, paraphimosis, redundancy (where the prepuce more than covers the glans), adhesions, papillomata, eczema (acute and chronic), oedema, chancre, chancroid, cicatrices, inflammatory thickening, elephantiasis, naevus, epithelioma, gangrene, tuberculosis, preputial calculi, hip-joint disease, hernia. Systemic indications: Onanism [masturbation], seminal emissions, enuresis, dysuria, retention, general nervousness, impotence, convulsions, hystero-epilepsy." Editor, Medical Record, Circumscisus, Medical Record, vol. 49 (1896): p. 430. 1897
"The prepuce is an important factor in the production of phthisis [tuberculosis]. This can be proven by the immunity of the Jewish race from tubercular affections." S. G. A. Brown, A Plea for Circumcision, Medical World, vol. 15 (1897): pp. 124-125. 1898
"Clarence B. was addicted to the secret vise practiced among boys. I performed an orificial operation, consisting of circumcision ... He needed the rightful punishment of cutting pains after his illicit pleasures." N. Bergman, Report of a Few Cases of Circumcision, Journal of Orificial Surgery, vol. 7 (1898): pp. 249-251. 1899
"Not infrequently marital unhappiness would be better relieved by circumcising the husband than by suing for divorce." A. W. Taylor, Circumcision - Its Moral and Physical Necessities and Advantages, Medical Record, vol. 56 (1899): p. 174. 1900: 25% of the U.S. male population circumcised
"Finally, circumcision probably tends to increase the power of sexual control. The only physiological advantages which the prepuce can be supposed to confer is that of maintaining the penis in a condition susceptible to more acute sensation than would otherwise exist. It may increase the pleasure of coition and the impulse to it: but these are advantages which in the present state of society can well be spared. If in their loss, increase in sexual control should result, one should be thankful." Editor, Medical News. (A Plea for Circumcision) Medical News, vol. 77 (1900): pp. 707-708. 1900
"It has been urged as an argument against the universal adoption of circumcision that the removal of the protective covering of the glans tends to dull the sensitivity of that exquisitely sensitive structure and thereby diminishes sexual appetite and the pleasurable effects of coitus. Granted that this be true, my answer is that, whatever may have been the case in days gone by, sensuality in our time needs neither whip nor spur, but would be all the better for a little more judicious use of curb and bearing-rein." E. Harding Freeland, Circumcision as a Preventive of Syphilis and Other Disorders, The Lancet, vol. 2 (29 Dec. 1900): pp. 1869-1871. 1901
"Another advantage of circumcision ... is the lessened liability to masturbation. A long foreskin is irritating per se, as it necessitates more manipulation of the parts in bathing ... This leads the child to handle the parts, and as a rule, pleasurable sensations are elicited from the extremely sensitive mucous membrane, with resultant manipulation and masturbation. The exposure of the glans penis following circumcision ... lessens the sensitiveness of the organ ... It therefore lies with the physician, the family adviser in affairs hygienic and medical, to urge its acceptance." Ernest G. Mark, Circumcision, American Practitioner and News, vol. 31 (1901): pp. 121-126. 1901
"Frequent micturition [urination], loss of flesh, convulsions, phosphatic calculus, hernia, nervous exhaustion, dyspepsia, diarrhea, prolapse of rectum, balanitis, acute phimosis and masturbation are all conditions induced by the constricted long prepuce, and all to be rapidly remedied by the simple operation of circumcision." H. G. H. Naylor, A Plea for Early Circumcision, Pediatrics, vol. 12 (1901): p. 231. 1902
"I have repeatedly seen such cases as convulsions, constant crying in infants, simulated hip joint diseases, backwardness in studies, enuresis, marasmus, muscular inco-ordination, paralysis, masturbation, neurasthenia, and even epilepsy, cured or greatly benefited by the proper performance of circumcision." W. G. Steele, Importance of Circumcision, Medical World, vol. 20 (1902): pp. 518-519. 1912: 35% of the U.S. male population circumcised
"The little sufferer lay in his mother's lap. The dropsy ... had taken the form of hydrocephalus ... I then circumcised the child ... The head diminished in size and in two weeks the condition of hydrocephalus had disappeared and the child was once more dismissed as cured." E. H. Pratt, Circumcision, Orificial Surgery: Its Philosophy, Application and Technique. Edited by B. E. Dawson. Newark: Physicians Drug News Co. 1912. pp. 396-398. 1912
"Circumcision promotes cleanliness, prevents disease, and by reducing oversensitiveness of the parts tends to relieve sexual irritability, thus correcting any tendency which may exist to improper manipulations of the genital organs and the consequent acquirement of evil sexual habits, such as masturbation." Lydston G. Frank, Sex Hygiene for the Male. Chicago: Riverton Press, 1912. 1914
"It is generally accepted that irritation derived from a tight prepuce may be followed by nervous phenomena, among these being convulsions and epilepsy. It is therefore not at all improbable that in many infants who die in convulsions the real cause of death is a long or tight prepuce. The foreskin is a frequent factor in the causation of masturbation ... Circumcision offers a diminished tendency to masturbation, nocturnal pollutions, convulsions and other nervous results of local irritation. It is the moral duty of every physician to encourage circumcision in the young." Abraham L. Wolbarst, Universal Circumcision, Journal of the American Medical Association, vol. 62 (1914): pp. 92-97. 1915
"Circumcision not only reduces the irritability of the child's penis, but also the so-called passion of which so many married men are so extremely proud, to the detriment of their wives and their married life. Many youthful rapes could be prevented, many separations, and divorces also, and many an unhappy marriage improved if this unnatural passion was cut down by a timely circumcision." L. W. Wuesthoff, Benefits of Circumcision, Medical World, vol. 33 (1915): p. 434. 1915
"The prepuce is one of the great factors in causing masturbation in boys. Here is the dilemma we are in: If we do not teach the growing boy to pull the prepuce back and cleanse the glans there is the danger of smegma collecting and of adhesions and ulcerations forming, which in their turn will cause irritation likely to lead to masturbation. If we do teach the boy to pull the prepuce back and cleanse his glans, that handling alone is sufficient gradually and almost without the boy's knowledge to initiate him into the habit of masturbation ... Therefore, off with the prepuce!" William J. Robinson, Circumcision and Masturbation, Medical World, vol. 33 (1915): p. 390. 1920: 50% of the U.S. male population circumcised
"Circumcision is an excellent thing to do; it helps to prevent hernia due to straining, and later it helps in preventing masturbation. The ordinary schoolboy is not taught to keep himself clean, and if he is taught he thinks too much about the matter." I. Solomons, For and Against Circumcision, British Medical Journal, 5 June 1920, p. 768. 1928
"Phimosis may be a predisposing cause of masturbation in some cases ... Hemorrhage following circumcision at birth cannot be considered seriously as a contraindication. Meatal ulcer due to ammoniacal diapers in the circumcised is not a contraindication ... Routine circumcision at birth is warranted." Editor, Routine Circumcision at Birth?, Journal of the American Medical Association, vol. 91 (1928): p. 201. 1935: 55% of the U.S. male population circumcised
"I suggest that all male children should be circumcised. This is 'against nature', but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in view it does not seem apt to argue that 'God knows best how to make little boys.'" R. W. Cockshut, Circumcision, British Medical Journal, vol. 2 (1935): 764. 1941
"[Routine Circumcision] does not necessitate handling of the penis by the child himself and therefore does not focus the male's attention on his own genitals. Masturbation is considered less likely." Alan F. Guttmacher, Should the Baby Be Circumcised?, Parents Magazine, vol. 16 (1941): pp. 26, 76-78. 1971: 90% of the U.S. male population circumcised
"There are no valid medical indications for circumcision in the neonatal period." Committee On Fetus and Newborn. Standards and Recommendations for Hospital Care of Newborn Infants, 5th edition. Evanston, IL: American Academy of Pediatrics. 1971. p. 110. 1994: 60% of newborn males in the U.S. circumcised
"Circumcision causes pain, trauma, and a permanent loss of protective and erogenous tissue ... Removing normal, healthy, functioning tissue for no medical reason has ethical implications: circumcision violates the United Nations' Universal Declaration of Human Rights (Article 5) and the United Nations' Convention on the Rights of the Child (Article 13)." Leo Sorger, To ACOG [American College of Obstetrics and Gynecology]: Stop Circumcisions, Ob Gyn News, 1 Nov. 1994, p. 8. 1998
"Circumcision is not a medical decision. Preventing an improbable future infection is a spurious indication. The standard of care is antibiotics, not amputation." Eileen Marie Wayne, MD, Letters (Nothing to debate on circumcision), American Medical News, 27 July 1998, p. 27. "As editor of a newspaper dedicated to infectious diseases, you know that antibiotics are the standard of care for infection and that surgery is a last resort for body parts for which there is no other cure. Perpetrating sexual surgery on healthy non-consenting minors, under the legal age of informed consent or refusal, to purportedly prevent an unlikely and curable future infection, is unacceptable. Intentionally amputating healthy erogenous genital tissue from tethered, protesting infants is a surgical act of sexual sadism.
      "Kaiser Foundation's Edgar Schoen ignores the erogenous benefits of the foreskin and a man's birthright to the sexual fulfillment he was born to experience. He would do well to stop promoting and perpetrating sexual surgery. He withholds from parents, who have no ethical right to consent to unnecessary sexually disendowing surgery on their children, the fact that the foreskin has sexual and erogenous functions. He contends that circumcision protects against sexually transmitted disease!
      "Dr. Schoen's failed attempt to justify surgical genital abuse is a willful act of misrepresentation. It is a disgrace and discredit to the medical profession and Infectious Diseases in Children. It is imperative that you also remove this tainted material to minimize liability to this publication from harmed patients, especially circumcised victims who developed AIDS in spite of being circumcised. Beyond patient harm, beyond medical ethics, publishing misinformation is a licensing and disciplinary issue of grave import to all involved."
      Eileen Marie Wayne, MD, Letters (Circumcision -- sexual sadism?), Infectious Diseases in Children, Vol. 11, No. 2, February 1998.

Circoncisione

Circumcision 3-D view.

Circoncisione: Metodi & Strumenti

Mogen clamp

In 1954, Rabbi Harry Bronstein, a Brooklyn mohel who'd previously invented the Nutech clamp - that's the one that looks like a hacksaw - invented the Mogen clamp. Mogen means shield (and in fact what we call in English the Star of David is Mogen David in Hebrew, the Shield of David.) It resembles a barzel, but one whose two blades are hinged together, and brought together with a cam.



This is a step backward to straight-line cutting, but mohels like it because it's quick and resembles the traditional method. Unlike the barzel, it closes to crush the foreskin before it is cut. Described as "the least painful method" though there is no reason this should be so, and "able to be used without previous experience." With the glans below and completely out of sight, it can be trapped in the locked slit. And as Grossman points out, the meatal lips often project from the glans and into the clamp. It opens no wider than 3mm in order not to admit the glans - but it is not possible to see whether this has in fact happened: Varney's Midwifery - in a chapter written by a mohalet - says 'Using the Mogen clamp has the distinct disadvantage of making the circumcision a "blind" procedure. The glans of the penis cannot be seen (so anomalies may not be discovered until after the circumcision) and is thus at risk of being cut.'
This occurred in Florida in 2004, and the parents sued both the mohel and the Mogen company. They won $10.7 million, and the Mogen company went out of business.


Plastibell™

Come the 1950s, plastics and the age of disposables, and the Plastibell - developed out of the Ross Ring in 1950 - became the method of choice. Like the Gomco, it requires a dorsal slit and tearing of the foreskin from the glans before it can be fitted.



Then the foreskin is pulled up over the bell, and the ligature tied to crush it into the groove. Everything distal to the ligature dies, and to stop this upsetting parents too much, it may be cut off first.
A grooved plastic dome (with a handle, designed to be broken off) placed under the foreskin (which must be slit and forcibly separated from the glans to allow entry). A ligature (thread) is tied tightly around the foreskin, crushing it into the groove, causing it to become necrotic (to die) and drop off. Varney's Midwifery, citing Gee and Ansell, says "the Plastibell has a higher incidence of infection."

SPOILER (clicca per visualizzare)

Plastibell circumcision: A minor surgical procedure of major importance.

Samad A, Khanzada TW, Kumar B. Department of Surgery, Isra University, Hyderabad, Pakistan.

J Pediatr Urol. 2009 Jun 12.

OBJECTIVE: To determine ... the Plastibell impaction rate in various age groups.

...

RESULTS: ... The overall complication rate was 7.4%. Plastibell impaction [the Plastibell™ ring trapped by the swollen penis] was the commonest complication, encountered after 6.1% of procedures, and was managed by cutting the Plastibell. The impaction rate was only 2.3% for babies under 3 months, but gradually increased to 26.9% for children over 5 years.

One study of 2000 PlastibellTM circumcisions found a complication rate of 2.8%, "the most frequent being minor infection and hemorrhage. Other complications included a tight Plastibell ring that can cause constriction of the glans penis, irregular skin margin, inadequate skin excision and migration proximally [up the penis] of the Plastibell ring as the glans swells with venous engorgement. There have been isolated cases of necrotizing fasciitis, ruptured bladder, retention of urine secondary to glandular prolapse, and retention of the Plastibell device.


Preputome

A cross between the Circumcision Forceps and the Gomco was the Preputome, invented in 1945 by a Brooklyn doctor called Al Akl.


(It was not actually a preputome, because it didn't cut. A better name would have been "prepustat".) It thoughtfully provided a hole through which the baby could urinate on the doctor. Since the bell pressed the glans downward, it could wedge some of the corona against the ring as the clamp was closed, allowing it to be cut along with the foreskin. The Preputome never became popular (especially not with babies).


Sheldon clamp II

The first of its two pairs of flat jaws grasps the acroposthion, the second set, the foreskin proper, ahead of the glans - if the boy is lucky. A straight cut is made between the two sets, resulting in a low circumcision similar to the tribal cut. Making the operator slice into a small aperture in the instrument almost guarantees an awkward cut. The Sheldon Clamp has reportedly been withdrawn because of lawsuits, but was still in use as late as 1994.



Sheldon Clamp (showing how glans can be damaged)
The design seems simply unfortunate; it's hard to understand how it ever left the drawing- board.


Tibone Clamp

Even simpler was the Tibone clamp of 1944 This lost the leverage provided by the Gomco, and was more awkward to fit. Also, says Grossman, the side arm of the C was too close to the bell, and got in the way of the scalpel. (You'd have thought that was easy to fix). The device never gained any popularity.




Improved Bloodless (Maryan) Clamp

Another variant on the Gomco was the Improved Bloodless Circumcision Clamp invented by a Dr H O Maryan in 1954:



This had three interchangable bells, and supported the screw on a tiny lintel, like an early printing press, that pulled instead of pushing.


Glansguard

A doctor called Melges invented the Glansguard as late as 1972. It resembles a kitchen bag-sealer. It has a built in knife. It doesn't guard the glans, especially when it's put on upside down, hence the clear message, "This Side Up".


Turner clamp

So did the Turner Clamp of 1952, but it is operates in the reverse direction, the bell crushing the prepuce down on the aperture.
Both had the problem of the Tibone times two, the supports of the bell getting in the way of the scalpel on both sides. Neither eclipsed the Gomco.




Leff clamp

Flat clamping continued with the Leff Clamp, invented in 1950, which looked like, and worked like, a large paper clip, used in conjuction with a barzel.




Kantor clamp

In 1953, a Texas physician called Kantor merged a haemostat with a barzel.
Its linear cuts, as with all linear devices, resulte in crushed "dog ears" at the front and back of the penis.


Ross Rings

The first of the tourniquet devices was the metal Ross ring.



In five sizes (reusable, as the handsome art deco walnut case implies), it included one groove for the ligature and one to catch the scalpel as it cut off the foreskin.



Its tiny handle was on an angle, perhaps to align with the axis of the penis and follow the line of the sulcus. But in that case the small notch on the outside is on the wrong side to accommodate the frenulum, as one commentary suggests. (Its purpose may actually be to facilitate the knot.) An enclosed leaflet reportedly "Says the device is to be left in place for 24 to 72 hours."

Reference:(For instruments from 1920-1980) Grossman E. The Evolution of Circumcision Technique. In Circumcision: A Pictorial Atlas of its History, Instrument Development and Operating Techniques. Great Neck: Todd & Honeywell 1982]

Circoncisione: Metodi & Strumenti

Methods of circumcision

Tribal



Tribal circumcision has common in Africa. The commonest method is to pull out the foreskin and chop with a spear or slice with a knife against some hard substrate. The terror and pain of this seems to be part of its appeal (to the adults).


Barzel and Izmel



The izmel (Hebrew for scalpel) is a double-bladed knife, to ensure that a nervous mohel can not choose the wrong side and thereby cause (additional) pain to the baby. You might think that the wrong side could be marked, coloured or otherwise indicated quite easily, reducing both that risk and the risk of cutting some other part of the baby or the mohel himself with the back blade.



The barzel (Hebrew for iron) also known as a mogen (Hebrew for shield) s a slotted shield to protect the glans, which it may or may not do, depending on the glans' size and conformation. This one is gold-plated silver.


Forceps guided



A basic surgical method before the invention of the various medical clamps - widespread in the British Commonwealth when it was still believed to do some good. The foreskin was pulled through a pair of bonecutters, which (usually) protected the glans, and the exposed foreskin cut along the clamp's edge.


Sleeve resection

Two circular cuts and one lengthwise one are made in the shaft and a cylinder of skin is removed, then the cut ends pulled together and stitched. The outcome depends on where along the penis the cuts are made, and how far apart they are. In Japan, though it is rarely done at all, proximal cuts (close to the body, are reportedly favoured, keeping the inner mucosa and ridged band, but possibly interfering with their innervation.



This image is from a study that found 10 immediate and 8 late complications, and 20 adhesions, in 68 sleeve circumcisions.


Scissors

When non-religious circumcision of adults became a commonplace, Sir Frederick Treves used scissors.



The problem with using no clamping method was, how to keep even tension on the foreskin to give a straight cut? As the cut proceeds, the same amount of tension is concentrated in less and less skin, "so the incision at the frenulum was often deeper and uneven." (Grossman)


Smartklamp™

A non-reusable circumcision device made of plastic, similar to the Tara KLamp. Works by cutting off circulation to the foreskin, using a plastic ring clamped in place over a tube. Available in sizes up to adult.




Tara KLamp™

A non-reusable circumcision device made of plastic. Works by cutting off circulation to the foreskin, using a plastic ring clamped in place over a tube (to allow urination). Available in sizes up to adult, recently developed in Malaysia. (Capital, Kuala Lumpur = K.L., hence KLamp)

SPOILER (clicca per visualizzare)

S Afr Med J. 2009 Mar;99(3):163-9,
High rate of adverse events following circumcision of young male adults with the Tara KLamp technique: a randomised trial in South Africa.

Lagarde E, Taljaard D, Puren A, Auvert B.

Abstract

BACKGROUND: The Tara KLamp (TK) device has been claimed to enable circumcisions to be performed safely and easily in medical and non-medical environments. Published evaluation studies have been conducted among young children only.

METHODS: Following a randomised controlled trial (RCT) on 3 274 participants on the impact of male circumcision on HIV transmission, 69 control group members participated in this male circumcision methods trial and were randomised to a forceps-guided (FG) group and a TK group, and circumcised.

RESULTS: Of the 166 men asked to participate, 97 declined, most (94) refusing circumcision by the TK technique; 34 men were randomised to the FG group and 35 to the TK group, and 32 and 24 patients were circumcised by the FG and TK methods respectively, of whom 29 and 19 respectively attended the post-circumcision visit. All 12 adverse event sheets corresponded to the TK group (p<0.001) and circumcisions by the TK method. Less favourable outcomes were associated with the TK method, including any sign of an adverse event (37% v. 3%; p=0.004), delayed wound healing (21% v. 3%; p=0.004) and problems with penis appearance (31% v. 3%; p=0.001). Participants randomised to the TK method were significantly more likely to report bleeding (21% v. 0%; p=0.02), injury to the penis (21% v. 0%; p=0.02), infection (32% v. 0%; p=0.002), swelling (83%/ v. 0%; p<0.001), and problems with urinating (16% v. 0%; p=0.056). The mean score of self-estimated pain was 9.5 for participants circumcised by TK compared with 6.1 for other participants (adjusted p=0.003).

CONCLUSION: This study provides compelling evidence that strongly cautions against use of the TK method on young adults.

Sunathrone



The Sunathrone, made in Malaysia, described as "the Superb Bio-Engineering Innovation Envisioned and Derived from Aerospace Technology" offers "non-invasive circumcisions" - which would be quite a feat. It replaces the suture of the Plastibell with a hard outer clamp that is applied with a plier-like device called a Sunalever and locks shut like a handcuff. The chess-queen-like cone is broken off after the foreskin has been cut away.


Kirve Clamp

The Kirve clamp resembles the Shang ring, but with a placement device with a handle and a bayonet fitting so that it can be removed from the inner ring after placement and cutting.



Kirve is Turkish for "uncle".


PrePex

Very similar to an Elastrator, the PrePex system cuts off circulation and kills the foreskin with an elastic ring that crushes it into a grooved ring. Claimed to be bloodless and not to require anaesthetic or a sterile environment. Being tested in Rwanda in 2011.




Ismail Clamp

The Ismail clamp uses a screw to apply pressure instead of levers.



It claims to be "readily removable" which means it can be re-used, with a risk of cross-contamination.


Ali's Clamp

Ali's clamp is the only devide to recognise that the cut is on an angle to the axis of the penis, and hence not circular.



It makes the slightly less inaccurate simplifying assumption that the penis then has an elliptical cross-section.


Ecraseur



In Paris in 1920, Doyen used what he called an écraseur or crusher on both adults and babies.


Circumcision forceps

Invented by a Dr Moskovich in 1920, apparently for adult circumcision, but they look more as though they should be used to blow bubbles.



The top ring was introduced into the preputial cavity - somehow - and the foreskin fanned out between the two rings. After cutting round it, seven sutures could be made in the notches. It had the obvious problem of the place where the forceps attach to the rings. The rings also left a collar of skin round the glans. Less obvious, it can't apply much pressure over so large an area, but it was the first circumcision device to acknowledge that the prepuce is, more or less, circular.


Harris Clamp

The Harris Clamp (1932) certainly didn't consider the actual shape of the foreskin. It looks as though you'd need two thumbs to work it.



The third arm, C, drives a blade up through a slit in both the haemostat arms. The problem with that is that the blade gets blunt with repeated use.


Gomco™ clamp

A device invented in 1934 by Hiram S. ("Inch") Yellen, M.D. and Aaron A. Goldstein (and reportedly based on the tyre-lever used for Model T Fords, according to Julian Wan's sickeningly worshipful history of the device). It consists of a metal bell placed over the glans (requiring a slit in the foreskin first) and a flat plate with a hole in it placed over both, to define the position of the cut. They are brought together by a screw to apply circular crushing and fusing force (of 8000 to 20,000 pounds, according to Wan) at the position of excision. It leaves a characteristic dark line at the excision scar.



Varney's Midwifery says its disadvantages are that "it involves more parts, requires more steps in the procedure, and it takes more time." Under that enormous pressure, a groove wears in the bell with prolonged use, making it ineffective. The clamp is made in a set with different-sized bells and rings and there is a danger of mixing parts of different sizes. In 2001, the FDA issued a warning against clamp injuries. A video for the rival Accu-circ demonstrates how these injuries can occur.

In 2009, Dr David Tomlinson endeavoured to reduce this risk by adding coded holes to the lever and corresponding studs on the plate, and differently sized shafts on the bells, matched to differently sized notches on the lever.



The bell has been found to develop grooves and nicks following repeated use with surgical blades. There have been reports of the bell breaking where it presses against the baseplate as pressure is applied. A ring of metal breaks off and is left inside the preputial cavity and the clamp is rendered useless. There have also been reports of glans injury if the scalpel cuts through the bell.
The Gomco can obviously not be left on the penis, in fact it is removed as soon as the skin is cut off, giving a risk of bleeding.


Nutech Clamp
This is even more true of its offspring, the Nutech Clamp invented by Rabbi Harry Bronstein, which looks like a hacksaw, but is actually held the other way around:




Circumstat

A more obvious descendent of the Gomco is the Circumstat, invented by Rabbi Irving Grossman in 1962.



The cam is apparently quicker and simpler than the screw of the Gomco.