Medical Societies

MELBOURNE  PAEDIATRIC SOCIETY

A MEETING of  the Melbourne Paediatric Society was held at the  Children's Hospital, Melbourne, on Wednesday, November 12, 1952.

Why Circumcise?

Dr. JOHN D. BEGG  read a paper entitled "Why Circumcise?". He said that  the operation had been performed in many countries  since time immemorial, but it was extraordinary how  little was known of the origin and purpose of the  ancient custom. It was performed in Egypt at least 4000 years. B.C., probably even earlier still, and was  practised as a cult among the primitive peoples of such  widely separated countries as Africa and the North  American continent and among Australian aborigines. It  had been a Jewish custom to circumcise on the eighth  day after birth since early Biblical times, and  although the Koran did not specifically ordain it, all  Moslems were circumcised. It was a mystery why mankind,  down the ages, should have shown such a strong aversion  to the retention of a useful cutaneous appendage; for,  despite the enormous literature on the subject, very  fully dealt with in Hasting's "Encyclopaedia of  Religion and Ethics", there was little real knowledge  of the significance of the ancient rite.

It was tempting to ascribe a hygienic  motive to the procedure, but a critical view analysis  of the literature does not support such a view. Even if  the view was found to be empirically correct, it could  scarcely have been the original motive that prompted  the Egyptians to circumcise their young. Gray, in the  Encyclopaedia of Religion and Ethics", concluded  his summary by finding that in its inception, and late  into its development, circumcision was essentially a  religious custom, embracing in its broadest sense  several concepts of an ideological nature. Thus, it  might signify a sanctification of the reproductive  organs, ensuring abundant fertility; it might be  related to the ancient idea of human  sacrifice-sacrifice of a small portion of the body as a  propitiation of the Deity to protect the whole; or it  might serve as initiation of the youth into the full  manhood of the tribe.

With primitive peoples the operation  was usually carried out to the accompaniment of various ceremonials, often of a cruel and revolting nature; but  in contradistinction to these, one Australian tribe  performed a mock ceremony before the candidate,  flourishing a large wooden knife, but leaving him  untouched. That it had a deeply religious significance  to the Jews was, of course, a matter of common  knowledge, but whilst one maintained ancient usages, it  was reasonable to examine critically a procedure which  although performed as a religious rite by one section  of the community, was also carried out very frequently  for supposedly surgical reasons by another.

Circumcision was performed on some 75%  of male children born in Melbourne's private maternity  homes, and although it was not performed routinely at  the Women's or the Queen Victoria Hospital, many of the  babies born in those institutions were later subjected  to the operation at the Children's Hospital, or else at  the paediatric departments of the Alfred, Queen Victoria, Prince Henry's and Saint Vincent's Hospitals, as well  as at the hands of private medical practitioners.

Figures revealed that in the hospitals  mentioned nearly a thousand babies were circumcised annually; but as about six thousand boys were born  annually in Melbourne's two major public maternity  hospitals, even if allowance was made for circumcisions  performed by private practitioners, the incidence of  the operation was very much lower than in those of the  higher income groups who attended the private  institutions where three-quarters of the male babies  were circumcised. Gairdner, in the  British Medical Journal of December 24, 1949, in  making a comparison between children attending the best  known public schools and those attending state institutions, had stated that "either the boys of  well-to-do parents are suffering circumcision much too  often or those of the poorer parents not often  enough".

Dr. Begg then discussed the development  and function of the prepuce, as described by Gairdner.  He said it developed as a ring of thickened epidermis  growing forward over the glans, and during its  development, which was frequently incomplete at birth,  the squamous epithelium lining the inner surface of the  prepuce and the outer surface of the glans was fused  into one single sheet. According to Deibert, a  separation into two separate linings took place by the  epithelium arranging itself into whorls, in the centres  of which degeneration occurred. The fusion of these degenerate areas ultimately formed a continuous  sub-preputial space. The process, which was seldom  complete at birth, might be arrested at any stage of  its development. Thus, again, according to Gairdner,  only 4% of babies had a fully retractable foreskin at  birth, only 25% at six months, and 50% at the end of  the first year. At the end of the second year. At the  end of the third year, however, 90% of children would  have a retractable foreskin; so that it was obviously fallacious to regard non-retractability of the foreskin  at birth as synonymous with phimosis. Even those which  could not readily be retracted at the age of three  years could usually be rendered easily retractable by  the separation with a probe of the residual strands of  undegenerated epithelium still persisting between the  inner preputial layer and the outer layer of the glans.  Dr. Begg said that he had no accurate figures with  which to confirm the statistics, but eleven years of observation in a provincial town where very few babies  were circumcised had convinced him that true phimosis  must be a very rare condition.

(Note: The values regarding age of  foreskin retractability provided by Gairdner in 1949 have since been shown to be incorrect. See the letter in the Medical Journal of Australia for more information.)

The function of the prepuce seemed  obviously to clothe and protect the sensitive glans,  not only during the early years of incontinence when  the organ was in contact with urine-soaked clothes, but  throughout life as well.

Like other surgical operations,  circumcision carried an operative risk. The risk was  admittedly small, but haemorrhage, sepsis, and  anaesthetic accidents could occur, whilst, as the  operation was frequently performed by practitioners of  little surgical skill, mutilation of the organ was unfortunately by no means rare. The figures for  Australia were not readily available, but for the five-year period from 1942 to 1947, an average of  sixteen children died annually as a direct result of  the operation in England and Wales. There was every  reason to believe that a proportionate mortality would  prevail in Australia.

Contact of the delicate tip of the  glans with ammonia-soaked clothes not infrequently led  to ulceration of the urethral meatus, and that, apart  from being exceedingly painful, was at times difficult  to heal and could even lead to a meatal stricture. That  complication of circumcision was particularly likely to  occur in a child whose prepuce had become redundant  from ammonia irritation-an appearance which  unfortunately was regarded by some doctors as a  particular indication for circumcision. Removal of the  foreskin in such circumstances had been likened by a contributor to the British Medical Journal some  years previously to "a soldier taking off his tin hat when the shrapnel was falling"; the irritation was  transferred to the meatus with the inevitable result.

Dr. Begg then proceeded to examine the  reasons given by parents for requesting that their child be subjected to the operation, and mentioned that  inquiries from the nursing staffs of maternity  hospitals revealed that the majority of babies were  circumcised at the request of their parents and not at  the advice of their doctors. Dr. Begg said that in his  experience in questioning mothers of newborn babies on  the reason for requesting circumcision, by far the most  common reason given-and this was confirmed by nursing  staffs-was that the father wanted it done. The information was imparted by the mother with a slightly  mysterious air as if questioning that anyone should  doubt the paternal wisdom. On being further questioned,  most would volunteer that they thought it prevented the  child from wetting the bed or that it prevented in some mysterious way the development of venereal disease or  the habit of masturbation. No doctor these days would  seriously regard circumcision as a cure of enuresis,  whilst, if the psychiatrists were to be believed,  masturbation occurred in both sexes, and appeared to  have no relation to the presence or absence of the  prepuce. Venereologists agreed that the circumcised man  who contracted syphilis or gonorrhoea was easier  to manage, but there was no real evidence that the operation in any way lessened the incidence of those  diseases. The matter was of still less importance at  the present time, with chemotherapy and the greatly  lessened incidence of venereal disease in general.

Cleanliness was another reason given by parents, and it  was in regard to that that a considerable misconception  existed amongst both medical and non-medical people. It  was true that smegma, the main source of which was  generated epithelium lining the glans and prepuce,  together with a variable amount from minute secretory  glands near the fraenum, did collect in the  retro-coronal sulcus, but in the young child it was  non-odorous and entirely harmless. Later, as mild  decomposition of the smegma might occur, and as  infection might then be added, it was wise to take  steps to remove it. At the stage when that was likely  to happen, however, separation of the two layers had  taken place, and the foreskin, if not readily  retractable, could easily be made so. Miscellaneous  reasons, such as "we believe in it" and the frankly  feminine one, "it looks nicer," were occasionally  given.

Circumcision, therefore, though  sometimes advised by the obstetrician, was more often performed by him to satisfy the parental wish. If  non-retractability of the foreskin at birth was regarded with equanimity, it would be found that in  time the vast majority of foreskins were so easily  retracted as to fall within the scope of all but the  most incapable.

It appeared to be an indisputable fact  that carcinoma of the penis was virtually unknown in those circumcised before the age of five. It did,  however, occur occasionally in Moslems who were  circumcised between the sixth and the fourteenth years,  but less commonly than in the uncircumcised. Thus  Kennaway, in the British Journal of Cancer,  comparing the incidence of the disease in Moslems with  that of Hindus, among whom the operation was taboo, in  fourteen hospitals in India, showed that the ratio of  penile cancer to male cancer in Hindus was a high as 1:3.9, while that in Moslems was only  1:34.3. He suggested that failure of the  operation until the fourteenth year to confer the  immunity produced by that performed in infancy, was due  to carcinogens retained in the coronal sulcus, and if  carcinoma of the penis was a common disease, there  could be a very potent argument in favour of universal  circumcision at an early age. The disease, however, was  not a common one, particularly in western countries. An  average of 6.3 cases annually were met with in  Melbourne's public hospitals over a five-year period,  representing only 0.3% of male carcinomata in  general. Furthermore, it usually occurred in persons  with a low standard of personal hygiene, and was almost  always associated with true organic phimosis. Accordingly, a disease whose main incidence was after  the sixth decade of life, and which was probably as  easily prevented by simple attention to cleanliness as  by circumcision, could not be cited as a convincing  argument for subjecting every baby boy to the  operation.

In conclusion, Dr.  Begg summarized his paper by saying that circumcision,  commencing as an expression of primitive man's  religious emotions, was carried on largely as a  response to a widespread public demand. That demand was  based on a misconception of the benefits conferred by  the operation, which in the great majority of children  is unnecessary. As unnecessary surgery was bad surgery,  the time has come when the profession should deprecate  its widespread performance in infancy except for  religious reasons. Indications for the operation  existed only if, after the first few years, true  phimosis was found to be present.

In short, the answer to the question  which formed the title of the paper, "Why Circumcise?", must be found in many cases "Why indeed?".

DR. F. STONEHAM said he agreed with Dr. Begg.  Phimosis could be corrected by dilatation of the  foreskin with sinus forceps in most cases and  circumcision was not necessary.

DR. J. FARBER said that at birth the prepuce  could be retracted in certain infants but not in others. He had been surprised at the number of infants  whose prepuce was not retractable at birth, but was  easily retractable two to three months later.

DR. M. L.  POWELL referred to the  advisability of circumcision in some cases in the  tropics as a means to reducing dermatitis of the  prepuce and glans penis. He wondered if that  fact had any significance with regard to religious  rites amongst Moslems.

Dr. Begg replied that during the last  war circumcised serviceman had certainly suffered less dermatitis of the penis, and he agreed with Dr. Powell  that might have been the basis of circumcision in some religions.

Medical Journal of Australia, 1953 (1), pp. 603-4

NOTE

This paper was an antipodean response to Douglas Gairdner's famous article, "The fate of the foreskin"  (British Medical Journal, December 1949), and it shows that Australian paediatricians were already sceptical of the benefits of indiscriminate circumcision. What is interesting, however, is how little influence this paper seems to have exercised, or at least how long it took to have an effect: what we know of the figures suggests that the incidence of neonatal circumcision continued to increase until the mid-1950s or even the early 1960s, and then began to decline only slowly. Still, the paper is of great historic interest, showing how little the debate on the so called pros and cons of circumcision has changed over the past half-century.