Why Circumcision?

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362

WHY CIRCUMCISION

ADDRESS FOR REPRINTS: (C.M.VI.) Department of

Pediatrics, Box 2951, Duke University Medical Center, Dur-ham, North Carolina 27710.

REFERENCES

1. Musher, D. M., and Schell, R. F.: False-positive gram

stains of cerebrospinal fluid. Ann. Intern. Med.,

79:6()3, 1973.

2. (;ibsI, T., and Norris, V. : Skin fragments removed by

in-jection needles. Lancet, 11:983, 1958.

:3. Shaywitz, B. A. : Epidermoid spinal cord tumors and pre-violls lumbar punctures. J. Pediat., 80:638, 1972.

Why

Circumcision?

Since the subject of this presentation is a query, let us follow with other questions. Why has

con-troversy developed among educated peoples

when discussing a procedure which has been per-formed for centuries? Why has circumcision

be-come a “hot issue”? One reason, we know, is that

health insurance carriers have asked the Amen-can Academy of Pediatrics, the American Urolog-ic Association and, we are sure, other concerned

groups or associations to determine whether or not

neonatal circumcisions should be covered. They have proposed an economic question; and we, as concerned physicians, must review the procedure from its inception and offer reasonable recom-mendations.

Is circumcision economically and medically in-dicated in the neonatal period, or should it be re-served for the “problem prepuce”? Review of the literature brings no formalized recommendations with regard to neonatal circumcision. We shall

at-tempt to do so.

The historical background of this procedure is quite interesting. In ancient Egypt captured

war-niors were often mutilated. At first an extremity

was amputated; but if the prisoner survived, he

was not usually fit for full labor. An alternative

procedure, castration, was tried. With total cas-tration of testicles and penis, the morbidity and

mortality were extremely high. As a result, or-chiectomy, and later circumcision, marked these

men as slaves. Eventually, all descendants of these

slaves were circumcised. That this custom was not

extended to those of royal blood is attested to by inspection of royal male mummies in all of whom the prepuces were found intact. The Phoenicians, and later the Jews who were largely slaves, adopt-ed the practice of circumcision and turned it into

a ritual. In time, ritualistic circumcision was

in-corporated into the Old Testament and consid-ered to be a covenant between God and man. The Moslem religion also advocates circumcision. The

male child is operated upon at the age of 12, a rite

of puberty not required by any writings in the Koran. 1.2

During the Roman occupation of Egypt, all priests were required to be circumcised; and they alone were allowed to perform these ritualistic

procedures.

Stone

implements

were

used.

Ritualistic

circumcision

also

sprang

up

inde-pendently in other parts of the world. Aboriginal tribes of Australia, Nicaraguan Indians, North and South American Indian tribes, and several of the

African

tribes

practiced

neonatal

circumcision.

In

other

of the

world’s

peoples,

circumcision

was

often performed as a test of the male’s ability to

withstand pain as he entered puberty and

eventual adult life in his community. In some cases, females were also circumcised as a tribal or communal rite.

Now we must evaluate neonatal circumcision

in our age and society from both a medical and an

economical

standpoint.

What

are

the

medical

considerations?

In 1942 Ravich postulated that circumcision de-creased the incidence of cervical and prostatic carcinoma.3 This postulation was restated in the

mid sixties by Aitken-Swan and others, who

showed that carcinoma of the cervix had an in-creased incidence in women whose husbands were not circumcised.’ This malignant disease was

shown to have an incidence of 2.2 per 100,000 in married Jewish women and as high as 44 per 100,000 in non-Jewish women married to

uncir-cumcised males. Penile hygiene appeared to be a

significant factor and correlated with the degree of coverage of the glans penis by the prepuce. The incidence of cervical carcinoma varied with cleanliness, increasing even in the wives of cm-cumcised men to 5.5 per 100,000 where partial preputial covering or poor hygiene was found. From these data, it can be concluded that circum-cision promotes cleanliness of the glans penis and thus decreases the incidence of cervical carcino-ma in wives or sexual partners.

Carcinoma of the penis has only been reported once when neonatal circumcision was performed. In this case, however, the skin edges separated postoperatively and the glans was still covered. In England there are over 200 deaths from penile

carcinoma

each

year.

The

United

States

records

over 300 such cases. In Brazil, where the perfor-mance of circumcision is low, deaths from penile

carcinoma

are

much

higher.

When

circumcision

is delayed until puberty, as in Moslems, the incidence of penile carcinoma is less than in the general population, although it does occur. It seems, then, that prevention of penile cancer

re-quires neonatal, not a later, circumcision.6 Medical practitioners-especially urologists,

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EXPERIENCE AND REASON 363

pediatricians, family doctors, dermatologists, and venerologists-are familiar with the conditions of the penis which occur in the uncircumcised male.

Balanitis and balanoposthitis, condylomata,

balanitic adhesions, frenular lacerations, phimosis and paraphimosis are not infrequently seen. My-cotic and parasitic infections thrive in hot humid climates; therefore, the moist anaerobic environ-ment tinder the prepuce favors these complica-tions. They can be avoided with neonatal circum-cision.

Most circumcisions are done with a preopera-tive diagnosis of phimosis. Gairdner states that 96% of newborn males have a physiologic phi-mosis and that 10% of these become pathologic by age of 3 It is impossible to tell which will be in the 10% of true phimotics when the infant is onig-inally seen. He feels, therefore, thaI circumcision should be delayed until these 10% make

them-selves evident. With them, however,

hospitaliza-tion and general anesthesia will surely be

re-quired, adding additional economic and

psycho-logical disadvantages.

There are several reasons why neonatal circum-cision should not be practiced routinely on the newborn. It should never occur without a com-plete physical examination by a competent physi-cian. The procedure is contraindicated when the infant shows evidence of exstrophy, epispadias, or

hypospadias. There is contraindication when

there is any question of ambiguous genitalia, a poor Apgar rating, or premature birth. We recom-mend that it not be done in any infant less than 24 hours of age since this lapse gives the physician an-other chance to examine the child after the heat of the delivery room and provides the child an op-portmity to cope with his new, hostile environ-ment. We feel it is contraindicated when there is any umbilical artery anomaly which might mdi-cate further urologic evaluation. Such an anomaly

is associated with a high degree of urologic con-genital problems. Urologic anomalies also occur when other teratogenic defects are noted at birth. We also feel that surgery is contraindicated when there is evidence of blood dyscrasia. When such infants are excluded, appropriate candidates for

circumcision remain.

Like any other surgical procedure, circumci-sion is not without complications; and the ques-tion arises as to whether or not the complications and even deaths outweigh the benefits. Most com-plications have been shown to be the result of inexperienced, incompetent, or careless surgeons. It is our feeling that every safeguard should be ob-served to prevent any but the experienced, trained, and skillful surgeon from performing this operation so important to the developing male.

Cautery burns, bivalving or amputation of the glans, urethral fistula, concealed penis, exploded penis or erysipeloid infections have been reported and, although few in number, are inexcusable.8 12

When a large series of circumcisions is looked at, the complication rate is extremely low. Spreet reported one death in 500,000 cases in New York City. This death occurred after a circumci-sion at home by a noncertified moel. Miller and Snyder’s 24,000 cases had no serious complica-tions and no deaths. In all studies, neonatal

cm-cumcision has been reported to have a lower

mor-bidity and mortality than the general complica-tions of general anesthesia and delayed

proce-u’#{176}

Meatal ulceration leading to meatal stenosis is the most frequent complication seen in neonatal circumcision. It is not related to iatrogenic incom-petence but is due to exposure of the uncovered glans and meatus to the diaper wet with urine. Oc-casionally, this ulceration can be prevented by frequent diaper changes or applications of oint-ments to the glans until keratinization protection develops. In those cases where meatal stenosis de-velops, a simple office procedure is all that is re-quired for correction.

Published articles have decried circumcision because of a reported diminution in glandular sen-sitivity after preputial excision. We do not argue with this assertion but theorize that such dimin-ished sensation might reduce the incidence of pre-mature ejaculations. Also, if one considers that tactile stimulus is diminished and is of such signifi-cance to the very large number of males who have been circumcised, then one must ask why these men are not lining up to have skin grafts or pre-puce plasties to replace this lost vestige?

Economically, the case for neonatal circumci-sion seems to be a reasonable one. The usual pro-cedure is performed during the neonatal hospital stay and does not require additional hospitaliza-tion. The surgical fee is minimal compared to that of a delayed childhood or adult procedure. It is, therefore, not unreasonable to recommend cover-age by insurance carriers.

In summary, the following recommendations are made:

1. Circumcision should never be referred to as routine or simple and should be performed only by a well-trained and experienced phy-sician.

2. This procedure should only be performed on

a healthy male neonate older than 24 hours of age with a good Apgar rating and without congenital or endocrine abnormalities.

3. Insurance carriers should cover this

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364 MOVEMENT DISORDER FROM DIPHENYLHYDANTOIN TOXICITY dune as any other elective surgical

proce-dune.

We conclude that the medical and economic advantages of neonatal circumcision far outweigh the disadvantages.

ROBERT BURGER, M.D.

THors H. GUTHRIE, M.D.

Roy and Lithe Cullen Department of Urologic Research

Division of Urology Baylor College of Medicine, and Urology Service of

Texas Children’s Hospital Houston, Texas

ADDRESS FOR REPRINTS: (R. B.) 1)ivision of Urology,

Baylor College of Medicine, Texas Medical Center,

Hous-ton, Texas 77025.

REFERENCES

1. Bitschai, J., and Brodney, M. L.: A history of Urology in Egypt. Calnbridge, Mass.: Riverside Press, 1956.

2. Wershub, L. P.: Urology From Antiquity to the 2()th

Century. St. Louis: Warren H. Green, 1970.

3. Ravich, A. : The relationship of circumcision to cancer of

the prostate. J. Urol., 48:298, 1942.

4. Aitken-Swan, J., and Baird, D.: Circumcision and

carci-noma of the cervix. Brit. J. Cancer, 19:217, 1965.

5. Bolande, R. P.: Ritualistic surgery. New Eng. J. Med.,

280:591, 1968.

6. Miller, R. L., Snyder, 1). C.: Immediate circumcision of

the newborn male. Amer. J. Obstet. Gynec., 65:1,

1953.

7. Gairdner, D.: The fate of the foreskin. Brit. Med. J.,

2:1433, 1949.

8. Lackey, J.T., Mannion, R. A., and Kerr, J.F.:

Suhglandu-lar urethral fistula from infant circumcision.

mdi-ana State Med. Assoc. J., 62: 13()5, 1969.

9. McGowan, A. J.,Jr.: Complications of

circumcision-Bi-valve penis. JAMA, 207:2104, 1969.

10. Spreet, H. : Circumcision of the newbom: An appraisal

of present status. Obstet. Gynec., 2:164, 1953.

11. Trier, W. C., and Drach, G. W.: Concealed penis. Amer.

J. Dis. Child., 125:276, 1973.

12. Yellen, H. S. : Bloodless circulncision of the newborn.

Amer. J. Obstet. Gynec., 30: 146, 1935.

Movement

Disorder as a Manifestation

of

Diphenyihydantoin

Toxicity

Transient toxic central nervous system (CNS) reactions to diphenyihydantoin (DPH) from acci-dental single or cumulative overdoses or from un-usual sensitivity to the drug have been

These include ataxia, hyperactive deep tendon ne-flexes, nystagmus, vertigo and diplopia, increased seizures, hyperactivity, hallucinations, silliness,

confusion and slurred speech.1 These manifesta-tions appear to be dose-dependent2 and clear promptly upon withdrawal of the drug. In addi-tion, parenchymatous cerebellar degeneration

questionably secondary to DPH toxicity has been reported.3 A peripheral neuropathy has been de-scnibed following prolonged administration of the

drug.4

We have observed a child with bizarre involun-tary movements concomitant with documented diphenyihydantoin (Dilantin) toxicity. The move-ments disappeared when the drug was withdrawn.

A similar movement disorder has recently been

recognized as a possible manifestation of Dilantin

toxicity in adults,5 but is hitherto unreported in children.

CASE REPORT

The patient, W. S., is a 9-year-old white boy who had his

first seizure, nonfocal tonic-clonic in type, associated with a febrile illness at the age of 7#{189}months. Tonic-clonic

general-ized seizures subsequently recurred in association with fever

and began to dtcur independent of fever at the age of 2#{189}

years. Episodes of staring began at 8 years of age and were

correlated with typical, three cycle per second, spike-wave

complexes on the EEG.

The past medical history was unremarkable except for

pneumonia at age 2. Neurodevelopmental progress and

per-formance in school were always found to be within the

nor-mal range. Neurologic examination on several occasions was

unremarkable.

Several maternal relatives are being treated for seizure

disorder. There is no family history of movement disorders,

ataxia or mental deterioration.

In December 1972 the patient was treated with increasing

doses of phenobarbital, diphenylhydantoin and

ethosuccini-Inide because of poor seizure control. When seen

approxi-mately one month prior to admission he had been having

ap-proximately two generalized motor seizures per week an#{231}l

many absence attacks. At that time the following

medica-tions were prescribed: phenobarbital, 60 mg orally bid (3.82

mg/kg/day); diphenylhydantoin, 150 mg bid (9.55

mg/kg/day); and ethosuccinimide, 250 mg tid (23.9

mg/kg/day). Three weeks later he was noticed to have a

“staggering” gait with frequent collisions and falls. He

de-veloped such difficulty with coordination of the hands and

arms that he could not feed himself. At the same time his

speech became slurred. These symptoms remained stable

over the next few days until two days prior to admission

when the family noticed the onset of writhing movements of

the face, trunk and arms. There was no known history of sore

throat, joint pain or skin rash over the preceding months.

Examination revealed an alert, cooperative and rather

fid-gety patient with choreo-athetoid movements involving the

face, neck and upper extremities both proximally and

distal-ly. The tongue could not be maintained protruded for more

than five seconds. A “milkmaid’s grip” was felt bilaterally.

Speech was slurred and somewhat “explosive.” There was

mild terminal tremor on finger to nose testing. Heel to shin

maneuver was well performed. The gait was wide based. He

could not maintain station even with eyes open. There was

gross horizontal nystagmus on lateral gaze. The remainder of

the neurological examination was unremarkable, as was the

general physical examination. No evidence of rheumatic

cbs-ease was noted.

Results following laboratory studies were within normal

limits: complete blood cell count, sedimentation rate (1

mm/hr), urinalysis, electrolytes, BUN, blood glucose, total

protein, serum calcium, serum creatinine, LDH, CPK, and

SCOT. An x-ray film of the chest and ECG were normal. An

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1974;54;362

Pediatrics

Robert Burger and Thomas H. Guthrie