became irritable and anorectic. The scrotum developed a purpuric discoloration and the base of the penile shaft became red and firm. There was no fever, however, and the mother telephoned her physician who recommended aspirin therapy. When marked lethargy developed, the infant was taken to a local hospital where he was noted to be moribund. After intubation and stabilization he was
transferred to Hermann Hospital, University of Texas Medical School at Houston. Initial physical exam re vealed an ashen gray, hypotonic infant with a pulse rate of 178 beats per minute, temperature of 34.7 C (rectally), and blood pressure of 103/58 mm Hg. He required a respirator to maintain ventilation. He was obtunded with occasional spontaneous limb movements. The only other pertinent findings involved the genitalia. The shaft of the penis and surrounding tissue were firm and erythematous and the scrotum had a bluish discoloration (Figure). Ampicilhin, methicillin, and gentamicin were begun. Ini tial laboratory data showed: hemoglobin, 8.6 gm/dl; he matocrit, 25.7%; white blood cell count 5,000/cu mm with 94% lymphocytes, 2% segmented neutrophils, 2% stab cells, 1% myelocytes, 1% eosinophils (the infant subse quently developed a brisk neutrophiic leukocytosis). The platelet count was 166,000/cu mm. The urinalysis showed proteinuria, hematuria, and pyuria. An initial arterial blood gas determination while the infant was receiving 100% oxygen revealed a pH of 6.87, Po2 of 266 mm Hg and PCO2 of 53 mm Hg. CSF contained 105 leukocytes/ cu mm, all of which were mononuclear. CSF glucose was 2 mg/dl; CSF protein was 1,210 mg/dl. The Gram strain showed bacteria. The infant's subsequent hospital course was complicated by shock, generalized seizures, hypocal cemia, renal failure, disseminated intravascular coagula tion, arrhythmias, and death. Blood, urine, and CSF cultures grew group B fl-hemolytic Streptococcus.
DISCUSSION
Because circumcision was delayed in this child until 6 weeks of age, the relationship between the operation and his subsequent infection was clear cut, unlike the situation in some previous reports. Estimates of the frequency of infection following
circumcision vary widely although it is generally stated that serious infection is a rare event. The
Reprint requests to (T.G.C.): The University of Texas Medical School, 6431 Fannin, 228 Freeman Building, Houston, TX 77030.
PEDIATRICS Vol. 64 No. 3 September 1979 301
EXPERIENCEANDREASON—Briefly
Recorded
. In Medicine one must pay attention not to plausible theorizing but to experience and reason
together. . . . I agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its deductions from what is observed. . . . But conclusions drawn from unaided reason can hardly be serviceable; only those drawn from observed fact.'@
Hippocrates: Precepts. (Short communications of factual material are published here. Comments and criticisms appear as Letters to the Editor.)
Overwhelming Infection with
Group B fl-Hemolytic
Streptococcus Associated
with Circumcision
The lack of valid medical indications has caused routine neonatal circumcision to fall into disrepute in recent years. ‘¿
@ However, despite the substantial
arguments against continuation of this therapy, it still ranks as one of the most common surgical procedures.'4
Significant infection is rarely solely attributed to circumcision because a clear-cut cause and effect relationship is difficult to establish. There have been reports@7 of newborns who have been circum cised and then developed life-threatening infection within several days of this procedure. However, the fact that in these infants infection has occurred at an age when the incidence of infection is high due to other factors complicates interpretation of these reports.
We report a 6-week-old infant in whom the rela tionship between circumcision and sepsis was un equivocal.
CASE REPORT
On admission T.H. was the 6-week-old product of a 32-week twin gestation born to a 26-year-old multiparous mother. Birth weight was 2,160 gm (4 lb, 12 oz). His early course was complicated by transient tachypnea requiring oxygen therapy for 2½days and hyperbiirubinemia re quiring phototherapy for four days. He was discharged from the nursery at 12 days of age with appropriate weight gain. At 6 weeks of age he was circumcised in the office of the mother's physician. Within 24@hours he
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Figure. Perineum of the infant shortly after admission.
interpretation of what constitutes an infected cir cumcision is problematic because the wound often has some exudate and erythema without other def mite signs of infection. Even if the wound looks uninfected, it is possible that it may serve as a portal of entry for bacteria. Tooth brushing, proc toscopy, and a variety of other “¿innocuous―proce dures causing a break in epithelial barriers have been documented to cause bacteremia. It would not be surprising if circumcision also caused bactere mia. This, coupled with the natural tendency of physicians not to ascribe a poor outcome to an elective procedure, may have led to gross underes timates of the frequency of life-threatening infec tious complications. In one retrospective series of more than 900,000 male births, there were no deaths attributed to infection.8 The incidence of neonatal sepsis is estimated at 1:300 to 1:1,600 live births. With the usual male predominance (approximately 2:1), one might have expected between 700 and 3,900 septic male infants in this large study. Since the rate of circumcision during the years of study was 61%, there must have been many male infants who were circumcised and who became septic but in whom the two events were not judged to have been related.
Despite the marked male predominance, few re views of neonatal sepsis mention how many infants were circumcised. Although one series suggests that circumcision is a major cause of sepsis in newborn male infants9 most make no conclusion regarding a relationship. The marked excess of sepsis in male
infants has been assumed to reflect the biologic inferiority of a single dose of X chromosome. It has been noted that two X chromosomes cause greater genetic heterogeneity for X-linked genes involved in immunoglobulin synthesis,'° thymic function, and glucose-6-phosphate dehydrogenase related phagocytic cell function.― Although differences in infection susceptibility do exist in both man and experimental animals,'2 seldom is the female advan tage more exaggerated than in the neonatal period. It would seem that a reasonable explanation for some of these infections in male infants is that they routinely have the integrity of their integument violated in a moist, warm, contaminated area. Much has been made of the umbilicus as a portal of entry for bacteria, partly because of its proximity to the perineum. However, few fears have been voiced that an iatrogenic perineal wound may pose a risk of potentially greater importance.
THOMAS G. CLEARY, MD STEVE KOHL, MD
The University of Texas Medical School Houston
REFERENCES
1. American Academy of Pediatrics: Hospital Care of
Newborn Infants, ed 5. Evanston, IL, AAP, 1971, p 110
2. Ad Hoc Task Force on Circumcision: Report of the
Ad Hoc Task Force on Circumcision. Pediatrics 56: 610,1975
3. Grimes DA: Routine circumcision of the newborn infant: A reappraisal. Am J Obstet Gynecol 130:125,
1978
4. Schwark TE: Do edicts have any effect on circumci sion rate? Pediatrics 60:563, 1977
5. Sauer LW: Fatal Staphylococcus broncho-pneumonia following ritual circumcision. Am J Obstet Gynecol 46:583,1943
6. Kirkpatrick BV, Eitzman DV: Neonatal septicemia after circumcision. Clin Pediatr 13:767, 1974 7. Scurlock JM, Pemberton PJ: Neonatal meningitis
and circumcision. Med J Aust 1:332, 1977
8. Speert H: Circumcision of the newborn. Obstet Gyne
col 2:57, 1965
9. Reichelderfer TE, Fraga JR: Circumcision, in Shep ard KS (ed): Care ofthe Well Baby, Philadelphia, JB Lippincott Co, 1968, pp 293-307
10. Washburn TC, Medearis DN, Childs B: Sex differ ences in susceptibility to infections. Pediatrics 35:57, 1965
11. SchlegelRJ, BellantiJA: Increasedsusceptibilityof males to infection. Lancet 2:826, 1969
12. Goble FC, Konopka EA: Sex as a factor in infectious
disease. Trans NY Acad Sci 35:325, 1973
THE POET COLERIDGE RECALLS HIS CHILDHOOD
Samuel Taylor Coleridge (1772-1834) described himself as a precocious and imaginative child. Reading his recollection of himself as a child, one sees the emerging poet who was to become one of the most important and influential figures in the English Romantic movement.'
My father's sister kept an every-thing shop at Crediton—and there I read through all the gilt-cover little books that could be had at that time, and likewise all the uncovered tales of Tom Hickathrift, Jack the Giant-killer, etc. and etc. etc. etc.—and I used to lie by the wall, and mope—and my spirits used to come upon me suddenly, and in a flood and then I was accumstomed to run up and down the church-yard, and act over all I had been reading on the docks, the nettles, and the rank-grass. At six years old I remember
to have read Belisarius, Robinson Crusoe, and Philip Quarll—and then I found the
Arabian Nights' entertainments—one tale ofwhich (the tale ofa man who was compelled
to seek for a pure virgin) made so deep an impression on me (I had read it in the evening while my mother was mending stockings) that I was haunted by spectres whenever I was in the dark—and I distinctly remember the anxious and fearful eagerness with which I used to watch the window in which the books lay—and whenever the sun lay upon them, I would seize it, carry it by the wall, and bask, and read.
My father found out the effect which these books had produced—and burnt them. So I became a dreamer—and acquired an indisposition to all bodily activity—and I was fretful, and inordinately passionate, and as I could not play at any thing, and was slothful, I was despised and hated by the boys; and because I could read and spell, and had, I may truly say, a memory and understanding forced into almost an unnatural ripeness, I was flattered and wondered at by all the old women—and so I became very vain, and despised most of the boys that were at all near my own age, and before I was eight years old I was a character sensibility, imagination, vanity, sloth, and feelings of deep and bitter contempt for almost all who traversed the orbit of my understanding were even then prominent and manifest.
REFERENCE
Noted by T.E.C., Jr, MD
1. Sutherland J: The Oxford Book of Literary Anecdotes. Oxford, Clarendon Press, 1975, pp 153—154
EXPERIENCE AND REASON 303
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1979;64;301
Pediatrics
Thomas G. Cleary and Steve Kohl
Circumcision
Associated with
Streptococcus
-Hemolytic
β
Overwhelming Infection with Group B
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1979;64;301
Pediatrics
Thomas G. Cleary and Steve Kohl
Circumcision
Associated with
Streptococcus
-Hemolytic
β
Overwhelming Infection with Group B
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