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                               The Surgery
                                   of
                                 Ritual
                              Circumcision,

                                   BY
                             JACOB SNOWMAN,

                     M.D., M.R.C.S., M.R.C.P., LOND.

          _Medical Officer of the Initiation Society, &c., &c._

                                 LONDON:
                   PUBLISHED UNDER THE AUSPICES OF THE
                MEDICAL BOARD OF THE INITIATION SOCIETY.
                                  1904.

          E. W. RABBINOWICZ, PRINTER, 48, COMMERCIAL STREET, E.




PREFACE.


_The object of the following few pages is to provide a basis of
instruction in the surgical aspect of the Jewish rite of circumcision.
The performance of this simple operation is not limited to medical men.
It is therefore essential that the lay Mohel should possess a scientific
knowledge of the important task he undertakes._

_The Initiation Society which controls the instruction of Mohelim has
arranged a Syllabus which guarantees such an acquaintance with the
subject. This little book is planned in accordance with that syllabus.
Its main object is to bring the principles of ASEPSIS within the
information of everyone acting as a Mohel, and to insist upon the urgent
need of carrying these principles into practice._

                                                              J. SNOWMAN.

    11, SHOOT-UP-HILL, BRONDESBURY, N.W.
    _July 1904._




CONTENTS.


                                                          PAGE.

      CHAPTER I.--_Causes of Infection of Wounds._           7

     CHAPTER II.--_Results of Infection of Wounds._         13

    CHAPTER III.--_Elements of the Antiseptic method._      17

     CHAPTER IV.--_Surgical Anatomy._                       23

      CHAPTER V.--_Technique of Operation._                 28
                      _The Dressing._
                      _Abnormalities._

     CHAPTER VI.--_Repair of the Wound._                    38

    CHAPTER VII.--_Hæmorrhage._                             44




CHAPTER I.

_Infection of Wounds._


The greatest advance in modern surgery has been to show how wounds become
infected and cause general blood poisoning. This applies both to wounds
made by the knife of the Surgeon as well as to accidental injuries. _The
principles concerned in this matter involve not only the arrangements
necessary for a severe and prolonged operation but also those required
for the simple circumcision of an infant._ It is therefore essential
that those who perform ritual circumcision should be familiar with the
elementary teachings of the _Antiseptic System of Surgery_ which is now
universally adopted even in the most trifling surgical proceedings.

Heavy responsibility lies upon the Mohel to carry out every case
strictly in accord with the lessons of surgical cleanliness. _Surgical
Cleanliness_ begins where ordinary cleanliness leaves off. Its object
is to destroy certain minute particles of matter which are invisible to
the naked eye, but which are _living organisms of a vegetable nature_,
able to grow very luxuriantly in blood, and wound discharges. Here they
produce a poison which gets absorbed into the body, causing serious
symptoms of disease; or they themselves enter the blood stream and
circulate in it with even more disastrous results. These organisms can
be observed under the microscope, but can only be seen by the naked eye
when growing together in colonies after being planted in such substances
as gelatine or broth, or on the surface of a slice of potato. They
correspond exactly to the growth of _mould or fungus_ on stale cheese
or meat, or to the growth of yeast in fermenting grape juice. When seen
separately under the microscope, or when growing in the mass they possess
very distinct characters so that the expert is able to distinguish
the one from the other, with the same confidence as a pear may be
distinguished from a fig.

A large number of diseases is due to the growth in the body of certain of
these organisms, and in many diseases we can be sure of always finding
the particular one responsible for the condition, either in the blood or
in the discharges from the body. This is notably the case in Consumption,
Typhoid Fever, and Malarial Fever. We often know how the organism has
obtained entrance into the body; it may be either by the lungs or the
stomach, or in other words through air or through food.

We are however only concerned just now with the _organisms which enter
the body by means of an open wound_.

These nearly all belong to one class--_micro-cocci_. They are minute
round bodies about 1/25000 inch in diameter. They possess the peculiarity
of growing together in clusters like grapes, or in chains. They are
responsible for the diseased conditions of wounds which delay healing,
for inflammation around wounds and for the general blood-poisoning which
may result.

These organisms are very abundant in the dust of rooms, on dirty clothes
and unclean general surroundings, and there can be no doubt that
everybody is often infected by them. But fortunately disease results only
rarely, because there are special powers resident in the vital tissues
which enable them successfully to resist the poisonous effects of these
organisms. There are however certain circumstances in which they are
liable to be more harmful than in others.

    _1_) _When they are absorbed in especially large numbers._

    _2_) _When absorbed in an especially active state._

    _3_) _When the body is in a condition of ill-health from whatever
    cause._

    _4_) _In the presence of cold._

Each one of these circumstances is of special importance in relation to
circumcision and may be commented on as follows.

1) The slightest departure from scrupulous cleanliness either on the
genitals of the infant, on the instruments or dressings used, or on the
hands of the Mohel enormously increases the number of microbes which may
possibly infect the wound. _Hence the necessity for absolute ordinary
cleanliness before resorting to antiseptic measures._

2) It is well known that these organisms exist in a very virulent form in
unhealthy wounds, in boils and in abscesses, and the worst cases of blood
poisoning have resulted from the direct infection of a healthy wound from
an unhealthy one. For this reason all the precautions in regard to the
disinfection of the hands, which will be referred to subsequently, must
be carried out with rigorous care, when there has been any possibility of
their having come in contact with such sources of infection.

3) The natural protective power of the body against infection is
diminished when the general health is below the normal standard. This
occurs in infants mainly, when they are premature, or suffering from
jaundice, sickness or diarrhœa, congenital disease of the heart or other
organs. In these circumstances the circumcision must be delayed.

When the parts are unduly bruised, the local resistance is considerably
lowered; hence the paramount necessity of the operation being performed
neatly and dexterously.

If these micro-cocci have already found access to the body in other
parts, as evidenced by _purulent ophthalmia_ (i.e. matter discharging
from the eye lids) or _suppuration about the navel_, it is important that
these conditions be cured before the circumcision is undertaken, because
experience shows that in their presence the risks of a general blood
infection are increased.

4) There is a special liability for the skin of an infant, particularly
in the region of the scrotum, to become irritated by its excretions
and to present the eruption known as _eczema_. The folds of the groin
occasionally suffer in the same way, the skin becoming reddened and
peeling. These cases demand medical attention before operation, owing
to special risks of infection. _No infant presenting a rash of any kind
should be circumcised without previous examination by a doctor, because
it may indicate constitutional disease._

5) Cold always indicates that the bodily processes are deficient in
activity. Infants are especially liable to cold, and hence the necessity
to supply them with abundant artificial warmth. This is especially
required during the exposure which a circumcision involves, and therefore
due attention must be paid to the temperature of the room where the
operation takes place, draughts must be avoided, and adequate protection
of the infant when carried from and to the bedroom, must be ensured.

[Illustration]




CHAPTER II.

_Results of the Infection of Wounds._


The name usually given to the conditions which result from wound
infection is _Septic Disease_. This includes both the mild and the grave
troubles which may ensue.

The mild forms of infection usually appear as interference with the rapid
healing of the circumcision wound. The principal of these are:--

    1) Ulceration at the cut edge of the prepuce.

    2) Ulceration in the raw tissue left on the under surface of the
    penis between the reflected mucous membrane and the cut skin.

    3) Sloughing or mortification of the reflected mucous membrane.

These conditions are usually attended with some amount of swelling; and
the unhealthy state of the wound with the accompanying discharge afford a
fertile soil for the rapid growth and multiplication of micro-organisms
and their absorption into the system.

Of the more serious results of infection the principal is _Erysipelas_
in its various forms. Here we find that as the signs of unhealthy
inflammation around the wound occur, symptoms of constitutional illness
begin. The infant becomes feverish, there is loss of appetite, rapid
breathing and wasting supervene, with a profound alteration in the
general appearance. The signs evident, locally, are redness of the skin
increasing to a vivid blush which spreads on to the thighs, scrotum or
abdomen. The surface is tender, and the edge of the red patch is sharply
defined from the surrounding healthy skin. The disease is most active at
this sharp margin for it is there that the micro-cocci may be found in
abundance. The glands in the groin become swollen and tender, and the
circumcision wound, failing to heal will probably inflame and suppurate.
While this is going on, a poison is being manufactured by the microbes
in their growth, and this poison being absorbed into the circulation,
generally proves fatal to the infant.

The process is usually limited to the skin, and its uppermost layer is
often raised into blebs containing clear or discoloured blood serum.
But the morbid change may take place first in the tissues under the
skin, when there will be great swelling and dropsy of the part so that
the pressure of the finger will leave a pit in the skin before the
latter becomes itself inflamed. In these cases the organisms readily
enter the blood stream and being carried away to distant organs set up
infection in these. These are necessarily the most hopeless cases of
blood-poisoning.

So far we have briefly considered infection by the group of organisms
known as micro-cocci. It is necessary to point out here that at least two
of the organisms of the group of _Bacilli_ have been known to infect the
circumcision wound. The one is the Tetanus (lockjaw) Bacillus, the other
is the Tubercle Bacillus.

In _Tetanus_ the first symptom noticed is that the infant is unable to
suck, and on examination it will be found that this is due to cramp of
the muscles of the jaw, which become fixed and hard. The face assumes a
peculiar aspect which is quite characteristic of this disease, spasms of
the limbs and then convulsions of the whole body take place, the joints
become stiff and the case is almost invariably fatal.

In regard to the infection by the Tubercle Bacillus it may be said that
this occurrence is one of the rarest of the rare sequels of circumcision,
but it appears that _tubercular ulcers_ have arisen over the area of the
wound when the METZIZAH has been performed by mouth suction on the part
of a Mohel who was suffering from Tuberculosis. A number of these cases
have been reported from time to time, and in some of them it apparently
led to general Tuberculosis (_consumption_).

The foregoing brief statements exhaust most of the possibilities of wound
infection by means of micro-organisms. There is however another source of
infection, not yet definitely proved to be of microbic origin, which has
important relations to circumcision. This is the poison of _Syphilis_.
If the Mohel should be suffering from this disease the secretions of the
mouth are infective and the disease may easily be transmitted to the
infant by means of Metzizah. On the other hand, should the infant be born
with the disease--a circumstance of not infrequent occurrence--it must be
remembered that its blood is charged with the poison, and is capable of
infecting a healthy individual when it is brought into contact with any
wound, abrasion or other breach of surface.

[Illustration]




CHAPTER III.

_Elements of the Antiseptic Method._


_The purpose of Antiseptic Surgery is to avoid the occurrence of the
dangers of infection_ referred to in the preceding chapter. There are
many methods of carrying out the system, but the present description
being limited to the requirements of circumcision does not aim at being
exhaustive. The two objects aimed at are:

    1) _The prevention of any micro-organisms gaining entrance to the
    wound._ This end is attained by the disinfection of the hands and
    especially the thumbnails of the operator, of the instruments
    and dressings used; and by perfect cleanliness of the genitals
    of the infant. It may be said that the brief exposure of the
    parts during the performance of the circumcision carries with
    it no risk of infection, because the organisms we have been
    considering are not usually airborne.

    2) _The application of such dressings as will keep the wound in
    an aseptic condition._ Even the small amount of discharge from
    a circumcision wound forms a splendid soil for the growth of
    micro-organisms. It is necessary therefore to apply a dressing
    which has been saturated with such antiseptics as will destroy
    that constituent of the discharge which makes it a good culture
    material.

The most convenient antiseptic for general use is _Carbolic Acid_. This
is a clear, colourless liquid of rather oily consistence, which rapidly
becomes converted into solid crystals in cold weather. When required for
purposes of disinfection it should be mixed with 39 times its quantity of
water, or roughly one pint of water requires one tablespoonful of pure
Carbolic Acid to make a solution of 1 in 40.

This solution is required for soaking the hands after they have been
washed with soap and warm water, and the nails scrubbed with a nail
brush. This latter proceeding is one of _ordinary cleanliness_, the
soaking in the Carbolic Acid solution, which should be warm, is in order
to obtain _Surgical Cleanliness_. It will be readily understood, that if
the hands come in contact with any possible source of infection after
this soaking, then it must be repeated before beginning the operation.
The disinfection of the hands must be the last stage in all the
preparations for the circumcision. A similar solution of 1 in 40 Carbolic
Acid may be used for placing the instruments in before the operation.
They are to be taken directly out of the solution as required. A shallow
dish of a material easily cleaned, as metal, glass or porcelain should
be filled with 2½ ounces (5 tablespoons) of water which has been boiled,
and to this one half a teaspoonful of Carbolic Acid is added, taking care
that the acid is thoroughly well mixed up with the water and not allowed
to float about in droplets.

If the instruments are scrupulously clean, i.e., if they have been
washed thoroughly with soap and hot water, they require to remain for
_one hour_ in the Carbolic Acid solution to render them sufficiently
disinfected for operating purposes. It is therefore quicker, as it is
also more scientific, to _sterilize the instruments before using them_.
By sterilizing them we kill any micro-organisms that may be present on
them, and we are then confident that no living germs are carried to the
wound by means of the instruments. In other words they are _aseptic_.
Instruments are sterilized by boiling for about ten minutes in clean
water. It is useful to add washing soda in the proportion of 5 grains to
every two tablespoons of water. It is obvious that the instruments must
be of metal, as no other material will stand boiling. They must be made
in such a way as to prevent the accumulation of dust or dirt in joints or
crevices.

Compact apparatus for sterilization is supplied by every surgical
instrument maker. The instruments are usually placed on a wire gauze
tray with handles and then into the sterilizing dish, so that when the
boiling is completed, they are lifted out on this tray by means of hooks
supplied for the purpose. They are at once transferred to the shallow
dish containing the 1 in 40 Carbolic Acid solution detailed above. By
these means the instruments are cooled ready for use, for obviously they
cannot be taken directly out of the boiling water with the fingers; and
the fact that they are in an antiseptic solution, prevents the access of
any germs during the short interval before they are actually handled.

The _dressings_ used in Circumcision should consist only of _lint_ and
_gauze_. It is necessary that the dressing should be sterilized and also
impregnated with some antiseptic so as to render harmless any infective
material which may accidentally contaminate the wound after circumcision.
These dressings are supplied by manufacturers, already sterilized by
exposure to super-heated steam, and rendered antiseptic by various
chemical agents. Carbolic Acid used for the hands and the instruments,
is often employed for the dressings, the antiseptic being fixed in the
lint and the gauze by a special process. Most surgeons, however, prefer
“_double cyanide_” dressings, in which the antiseptic used is a salt
known as cyanide of zinc and mercury.

From the first dressing until the circumcision is absolutely healed
nothing but gauze need be used. In a normal case no other application
of any kind whatsoever is required. It is usual however in applying the
first dressing at the circumcision to use lint to surround the root of
the penis as it is firmer than gauze. When this is done a piece of tape
is twisted round the lint to retain it in position. The tape and the lint
must both be sterilized like the gauze.

The best course to adopt in regard to the dressings is to obtain them
from a reliable firm of manufacturers, who will supply them ready cut to
the pattern required, packed in small sealed aseptic tin cases ready for
use.

Having adopted all these precautions the Mohel may be confident that
in regard to his own hands, the instruments, and the dressings he has
exercised every care which surgical science demands. The only other
important detail which demands attention is the part concerned in
circumcision. It is obvious that all the safeguards hitherto considered
are valueless unless the infant himself is in a perfectly clean
condition. The disinfection of the skin of an adult before an operation
is always a serious and difficult matter, because the skin harbours
so many micro-organisms, including the very micro-cocci referred to
previously. Elaborate measures are therefore employed for the skin
disinfection. But in the case of an infant the skin cannot be supposed to
be such a probable source of wound infection. It is sufficient that the
genitals be washed about half an hour before circumcision, with soap and
warm water, and subsequently a fomentation of Boracic lint applied. It
is as well to avoid the use of the various baby powders which nurses are
so fond of sprinkling freely on the folds of the skin. If it is thought
desirable to employ such a dusting powder, it should be a mixture of
equal parts of Boracic Acid and Starch.

The infant having been prepared as here stated, the circumcision may
proceed as soon as he is put in position. Should any soiling have taken
place, the infant must again be cleansed, and in this case the genitals
must be washed with the Carbolic Acid solution (1 in 40) by means of a
swab of cotton wool.

[Illustration]




CHAPTER IV.

_Surgical Anatomy._


It is essential for the Mohel to possess a knowledge of the structure of
the organ on which he operates.

The skin of the penis is continuous on the upper surface with the skin
of the abdomen, and on the under surface with that of the scrotum. On
drawing forward the prepuce or foreskin it is very easy to include the
skin of the scrotum in the grasp of the fingers unless due care is taken.
If the traction on the foreskin is too forcible and the skin of the
scrotum is therefore pulled up tightly, there is a danger of the scrotal
skin being slit up to some extent. The intimate connection of the skin of
the penis and scrotum must always be kept well in mind.

Under the foreskin and continuous with it at its free margin there is
a membrane which rising from the neck or constriction below the glans
envelops the latter entirely up to the opening of the urethra. Here
it leaves the glans and joins the outer skin. The name given to this
structure is _mucous membrane_, and the method of dealing with it
constitutes the principal portion of the art of circumcision.

This mucous membrane is the whitish glistening structure which appears
after the removal of the skin.

It is important to note the disposition of this mucous membrane, as
revealed after the amputation of the prepuce.

    1) It usually _covers over the glans right up to the orifice of
    the urethra_.

    2) It may be reflected off the glans before reaching this point,
    and become continuous with or adherent to the skin lining. In
    this case the glans will not be completely covered by the mucous
    membrane, because a small portion will have been cut off in the
    first stage of the operation. In those cases the membrane missing
    from the upper part of the glans will be found on the inside of
    the amputated foreskin.

    3) In other cases this inner mucous membrane is very deficient
    covering only three quarters or less of the surface of the glans,
    the remaining portion being adherent to the inner surface of the
    foreskin.

The _consistence of this membrane_ is such that it can be easily torn
through but,

    1) It may be elastic so that it stretches without tearing.

    2) It may be so thin that it is liable to be pushed down by the
    nails instead of being torn.

    3) It may be so thick as to necessitate the use of the scissors
    to cut it.

It may be loosely applied to the glans so that the thumb nails are easily
inserted beneath it, or it may be so adherent that great difficulty is
experienced in tearing it through and peeling it off the glans.

An important fold of this membrane, triangular in shape is attached to
the under surface of the glans below its base reaching almost up to the
opening of the urethra. This is called the _Frænum_, and it is fully
exposed during the second stage of the operation.

The body of the penis itself is composed of three parts. On the upper
surface behind the glans are the two _Corpora Cavernosa_, united firmly
together, but leaving a hollow on their under surface for the _Corpus
Spongiosum_ which is prolonged beyond them in an enlarged extremity known
as the _glans_. The constriction beneath the glans is called the _Cervix
or Neck_, while the projecting rim of the glans above this is called the
_Corona_. Occasionally there are found here small masses of soft creamy
material, which is the natural secretion of the part.

The canal of the urethra runs in the corpus spongiosum. Each of these
three corpora is firmly united to the pubic bone behind.

They are constructed of an outer sheath from the inner surface of which
numerous fine membranous partitions stretch, dividing the whole up into
numerous small compartments. These compartments are lined with a fine
network of veins, which are able to expand with blood and to distend and
fill up these spaces. When this occurs the whole organ swells and becomes
firm and the tension of the fibrous material forming the main structure
is called into play so that the process assumes the form of an erection.
The veins which should drain the penis of blood are compressed by the
action of certain muscles and this adds to the engorgement of the organ.

When the penis of an infant is in a state of erection the operation
of circumcision can be more easily performed and the dressing more
efficiently applied. The manipulation of the organ necessary to grasp the
prepuce is generally sufficient to stimulate the increased blood supply
requisite for an erection. The skin of the penis does not share with
the rest of the organ, a greater amount of blood during this state. It
stretches by its own elasticity.

All the arteries and veins of the penis run in the deep structures
previously alluded to, so that circumcision, in an infant at any
rate, can never wound a blood vessel. The _Frænum is freely supplied
with blood_, and if cut will produce troublesome hæmorrhage, but a
circumcision in no way interferes with this part.

[Illustration]




CHAPTER V.

_Technique of Operation._


A good light is essential for the performance of circumcision.

The instruments required are as follows:--

    1) _Knife_ of steel, to be made of one piece of metal without
    joints, crevices or any ornamentation whatsoever. The handle
    should be stout enough to permit a firm grasp upon it. The blade
    should be about 5 inches in length and fully half inch in width.

    2) _Shield._ This is a metal plate with a centre slit, the edges
    of which are made to grasp the prepuce at the level of the
    amputation. The Shield protects both the glans penis and the
    scrotum from injury by the knife.

    3) _Scissors._ These are required occasionally to cut through
    the mucous membrane. They should be of the pattern known as the
    “_blunt pointed_.” When it is evident that the mucous membrane
    is very adherent to the glans, the separation of these two
    structures may be effected by the use of a _Probe_. This is a
    thin metal rod which is easily inserted under the mucous membrane
    and swept round the glans so as to break through the adhesions.

The person who is to hold the infant, is seated on a chair with his feet
on the side rail of a second chair so as to keep the knees raised. The
latter must be kept close together. A firm pillow is placed on the knees
and the infant is laid thereon facing the Mohel. When the necessary
clothing has been loosened, the thighs and knees are bent up completely
(flexed) and then the thighs are in addition rotated outwards, and kept
in this position by the hands of the individual holding the infant.

The clothes should be displaced behind the buttocks of the infant so as
to raise the part.

The antiseptic preparations described in Chapter iii. having been carried
out, the operation is performed according to the following stages.

    _Stage I._ The root of the penis is taken between the index and
    middle fingers of the right hand palm downwards, and pressure
    is made firmly backwards, the index finger being against the
    scrotum, the middle finger against the lower portion of the
    abdomen. This steadies the penis, keeps away the skin of the
    scrotum, and helps towards producing an erection.

    _Stage II._ Keeping these fingers in this position, the _glans is
    grasped between the thumb and index finger of the left hand_. It
    is important not merely to take hold of the foreskin, the glans
    must be included between the fingers, and it must be examined
    by them so as to discover where it ends. This is determined by
    feeling the projecting rim of the Corona, and the neck beneath
    it. The skin overlying this marks the precise position where the
    shield is to be placed. When this position is accurately made
    out the whole of the skin in front of it is withdrawn beyond the
    glans by the fingers, and very firmly held upwards away from the
    scrotum.

    _Stage III._ The fingers are now to be removed from the root
    of the penis, and the shield is taken into the right hand and
    adjusted on the prepuce exactly at the level of the finger
    tips which are grasping it. The _direction of the shield is
    important_. It must _not_ be put on at right angles to the penis,
    but obliquely upwards, i.e., the part of the shield held in the
    hand must incline towards the abdomen of the infant, and the
    other part away from it. In this way the circumcision will take
    off the foreskin in a quill shape, and it will leave a sufficient
    amount of skin on the under surface of the penis. If this
    precaution is not observed there is a great risk of denuding the
    under surface of the skin almost as far as the scrotum.

    _Stage IV._ The knife is then taken in the right hand and with
    one sweep along the shield the foreskin is amputated. The knife
    must be handled firmly, and the cut made from the heel. The cut
    circular edge of the skin immediately retracts behind the corona,
    though on the under surface the amount of skin remaining may fall
    short of this level.

    _Stage V._ The amputated foreskin and the knife are now put
    aside, the shield having already fallen off. The Mohel will now,
    at a glance, observe the disposition of the mucous membrane
    covering the glans. He insinuates the nail of one thumb under
    its edge, and seizes it between the nail and the index finger.
    When this is grasped the manœuvre is repeated with the thumbnail
    and index finger of the other hand, keeping the two hands close
    together. Before proceeding further, the Mohel must be sure that
    he has a firm hold of the membrane.

    The next step is to tear the membrane down in the centre, until
    the prominent edge of the corona is exposed. This tearing may be
    completed with one movement of the hands, but if the membrane is
    long more than one movement may be required to tear it through
    completely.

    When the neck below the corona is seen, the flaps are reflected
    laterally backwards, so that the torn edges of the mucous
    membrane may join the cut edge of the skin. Care must be taken
    that the membrane is peeled off as far as possible (i.e. till its
    junction with the frænum) from the under surface of the glans and
    reflected directly backwards so as to unite with the cut edge of
    the skin.

    The essence of the operation consists in the proper performance
    of this stage. If not performed efficiently the resulting
    circumcision is very imperfect. The mistakes usually made by
    beginners are as follows:

    1) The mucous membrane is stretched without being torn through;
    the glans then projects completely giving the impression that it
    has been exposed by the proper method. 2) The membrane is rolled
    back over the glans instead of being torn back. 3) The membrane
    is cleared off from the upper surface of the glans, but is not
    sufficiently peeled off from the under surface.

    _Stage VI._ The operation is really completed with the preceding
    stage.[1]

    The practice of Metzizah may now be carried out by means of a
    swab of sterilized, cotton wool with which the penis is to be
    firmly compressed. This will effectually absorb the small amount
    of blood free in the tissues and at the same time helps to clean
    up the part.

    _Stage VII._ The _dressing_ consists of a strip of sterilized and
    antiseptic lint or gauze long enough to encircle the penis below
    the glans two or three times, and wide enough to cover the whole
    space between the corona and the root of the penis, i.e. 4¼ in. ×
    ¾ in. The first layer of dressing is applied entirely below the
    glans and covers over the whole of the reflected mucous membrane.
    Care must be taken to apply this strip of lint at the very root
    of the penis and to begin on the under surface; otherwise there
    is a tendency for the dressing in this latter position only
    to just to reach the edge of the incision and to push it back
    towards the scrotum and thus increase the size of the raw area.

    The glans must be quite free of the dressing encircling the penis
    and must project completely beyond the strip of lint applied
    below it. This piece of lint or gauze adheres quite well by
    itself, but to ensure its remaining in position, it is better
    to secure it by surrounding it once or twice with a piece of
    sterilized tape and twisting up the ends. _If this is done too
    tightly it may obstruct the free flow of urine, or congest the
    glans._

    The dressing is completed by covering over the naked and
    projecting glans with a square piece of antiseptic gauze. A
    diaper folded in the ordinary triangular shape is then put on,
    and this is secured firmly by means of broad tape. Two or three
    turns must be given round the thighs so as to keep them fixed,
    and the ends are to be tied over the hip.

    During the after treatment the re-dressing may be regulated as
    follows. After about 10 or 12 hours, but at any rate within the
    first 24 hours, the piece of gauze covering the glans must be
    removed and the tape surrounding the dressing untwisted and also
    removed. If the circumcision has been properly and carefully
    performed, so that the whole of the mucous membrane and skin are
    kept back by the dressing, and the whole of the glans remains
    exposed, nothing further need be done but to replace some fresh
    gauze over the glans. On the following day the whole of the
    dressing should be removed, and gauze be re-applied around the
    penis leaving the end of the glans free. This dressing will fall
    off when the infant is in the bath, and may be renovated as often
    as necessary. As an alternative procedure the whole dressing may
    be removed after the first 24 hours, and the part re-dressed
    with gauze.

        [1] The performance of Metzizah according to statutory
        Jewish Law consists of suction by the mouth. The original
        sources of this practice indicate that it was considered
        an essential part of the operation in the same way as the
        dressing of the wound was. Failure to carry out this measure
        was regarded as constituting a serious risk to the infant.
        The possible dangers of this practice have become obvious
        during recent years and direct suction of the wound is, from
        every point of view, inadmissible. In order to carry out the
        ancient practice a device is used by some Mohelim by which
        the suction is performed through a small glass tube with a
        perforation at its end and containing a piece of absorbent
        wool in its interior.


_Circumcision in Abnormal Cases._

The penis is subject to many departures from its usual anatomy, but here
it will only be necessary to notice some of the more usual abnormalities.

    _1st._ In some cases the penis is sunken into the pubic skin, so
    that on grasping the prepuce the whole integument of the penis
    is pulled up leaving the organ itself buried in the skin behind.
    It will be found that in many of these cases the testicles have
    not descended into the scrotum. The first stage of the operation,
    in these instances, is all important. The root of the penis is
    embraced between the second and third fingers of the right hand
    as previously explained and firm pressure backwards is made until
    a definite erection is made. The amount of skin to be amputated
    must be very accurately estimated, the shield carefully adjusted
    in an oblique direction, as in these cases the inclusion of some
    of the skin of the scrotum is very easy. The mucous membrane
    often proves to be very thick, but whatever its consistence may
    be it should be cut away with scissors after reflection as this
    proceeding helps to prevent the glans sinking back into the skin.
    A careful examination of the infant must be made in these cases
    because they frequently denote immature development, and call for
    postponement of the performance of the circumcision.

    _2nd._ The prepuce is sometimes deficient. The upper portion of
    the glans may be exposed and project beyond the short prepuce.
    The amount of the latter which should be removed is so small,
    that on pulling it forward there is not sufficient in the small
    circle of skin for the fingers to obtain a firm grasp. In this
    case forceps should be employed to hold the foreskin.

    _3rd._ Some infants are born apparently circumcised. On
    examination it will be found that a considerable amount of
    prepuce still remains on the upper surface of the penis, while
    the under surface may be quite free. In these cases the whole
    of the remaining prepuce is grasped between the fingers and
    the operation is performed in the usual manner. Here also the
    underlying mucous membrane should be entirely cut away after it
    has been torn through.

[Illustration]




CHAPTER VI.

_Repair of the Wound._


As the whole difference between a scientific operator and a merely
mechanical Mohel lies in an appreciation of the process of repair in the
wound inflicted, it becomes necessary to consider this in detail.

The area of the circumcision wound extends between the corona of the
glans and the circular cut edge of the skin. The skin of the penis
always retracts, so that if the shield has been placed in the position
previously indicated, the skin will not after the circumcision reach
quite up to the corona; the neck of the glans will be well exposed. This
is the condition to be attained in ritual circumcision.

The mucous membrane, after being torn through and reflected covers
over the area of the resulting wound. _The planning of the operation
should be so carried out that the torn edges of the mucous membrane may
unite with the cut edge of the skin._ This approximation is not usually
complete all round the wound. The tearing through of the mucous membrane
produces a narrow V shaped rent; this is widened out when the membrane
is reflected, and if carefully apposed to the cut skin, will unite with
it. But the edge of that portion of the membrane peeled off from the
under surface of the glans will often fail to unite with the exit edge
of the skin on the under surface of the penis. It frequently does not
reach as far back as the cut skin, especially when the foreskin has been
freely removed or when the mucous membrane has a tendency to curl up.
The result in the majority of circumcisions is that the upper portion of
the wound heals rapidly, where the lacerated edge of the mucous membrane
has united to the cut edge of the skin, while on the under surface, the
mucous membrane will adhere to the raw surface of the penis left by the
retracting skin, but there will probably be a gap where the membrane has
failed to reach the cut edge of the skin. This gap will necessarily be
very small when the reflection of the mucous membrane has been complete.
Where approximation of the two edges occurs union is rapid and healing by
“first intention” results. Where some loss of substance occurs the gap
becomes gradually filled by what is called _granulation tissue_, and the
term “second intention” is given to the healing process.


_Healing by first intention._

In amputating the foreskin a number of minute hair-like blood vessels
which permeate the skin are cut through. There is little or no bleeding,
because the blood immediately clots, and almost at once a rim of coagulum
is formed at the margin of the circumcision. Besides this the injury
destroys a minute amount of living tissue known as _connective tissue
cells_. The wound causes a special degree of activity in the adjacent
blood vessels, so that certain important constituents of the blood
flow out of the vessels and invade the cut margin where the blood has
coagulated.

This invasion consists of the fluid portion of the blood--or lymph, and
the solid elements called white corpuscles--or leucocytes. These latter
remove the cells which have been killed by the injury, and get rid of the
blood clot, probably by a process of digestion. When this is effected,
the way is paved for the healing, i.e. the formation of the scar.

The naked-eye evidence of all this is to be found in the moisture or
exudation on the surface of a wound. As this forms on both surfaces of
a wound, the exudation is the first bond of union. The fluid portion
of this exudation becomes absorbed, and what remains of it forms the
scaffolding on which the scar is built up. The scar consists of new
connective tissue cells which have grown into this framework, and
multiplied rapidly, causing firm cohesion of the two separate surfaces.

In order that these new cells should be properly nourished they require
a sufficient blood supply, and it is found that while their formation is
proceeding minute new blood vessels shoot forth from the existing ones,
and they grow into the soft newly developing scar tissue. Owing to this
fact, free oozing of blood takes place when a healing wound is disturbed.

In the operation of circumcision it is well seen how the circulation of
the blood re-acts to injury. When the mucous membrane covering the glans
is exposed it looks pale and translucent, because of its scanty blood
supply and its thinness. Very soon after it has been torn through, its
whole character changes. It becomes engorged with blood, it becomes red
and congested it loses its translucency, and at its lacerated edge the
process of healing takes place as detailed above.

All scars are at first pink in colour, because more new blood vessels are
formed than are required for the permanent nourishment of the part when
completely healed. In the course of time these blood vessels shrink and
waste away and the scar becomes whiter even than the adjacent skin. This
occurs also in the mucous membrane which remains pink for a considerable
time. The membrane in fact undergoes the first stage of inflammation
as a reaction to the injury it has sustained. The blood vessels become
enormously dilated, and its blood supply increased. It presents the best
conditions for healing along the edges where it has been torn, but the
whole of its outer surface also, which, after reflection becomes opposed
to the raw surface between the corona and the cut foreskin inferiorly,
becomes united by a similar process to this raw area.

In those cases where the reflection of the mucous membrane has not been
perfect a gap will be left between its margin and the cut foreskin, in
which healing takes place by _granulation or second intention_.

The details of this method of healing are similar to the first; the
discharge or exudation from the wound takes place in the same manner,
but as there are not two surfaces to unite to each other, this exudation
simply covers over the wound in the form of a whitish or pale yellow
layer of _lymph_. The fluid discharge should be tolerably clear; if it
tends to be thick or milk like in colour it indicates that there has been
some accidental contamination of the wound, or that the vital powers
necessary for normal healthy repair are below the average. It shows
that the inflammatory re-action of the tissues which is the essential
requisite for healing has been excessive. In this case not only has
the wound been invaded by the white blood cells, which as previously
explained, form the groundwork of the new tissue cells; but a further
step has taken place. These white cells have been thrown off the surface
of the wound and together with the exuded fluid go to form “_pus_” or
_matter_. All this causes delay in the healing. But eventually the wound
becomes filled up by the growth of new connective tissue cells; these
continue to multiply until the surface is reached, when the uppermost or
epithelial layer of the cut edge of the adjoining skin grows over it,
constituting a continuous skin covering.

The _defects in the healing process_ may therefore be briefly summed as
being due to some interference with the natural course of physiological
repair. They may be comprised under the following heads.

    1) Deficient vitality of the infant.

    2) Infection of wound.

    3) Imperfect performance of the operation especially when the
    tearing through and reflection of the mucous membrane has been
    incomplete.

These defects are to be prevented by a careful examination of the health
of the infant previously to the circumcision, by the employment of
Antiseptic measures, and by carefully carrying out the technique of the
operation.

[Illustration]




CHAPTER VII.

_Hæmorrhage._


Trouble from bleeding is an exceedingly rare occurrence at the
circumcision of an infant, because no arteries or veins are cut through.
But the possibility of its occurrence, however, remains, and therefore
some points regarding it should come within the information of every
Mohel. It will be his duty to apply first aid, and consequently a
knowledge of the principles of the treatment of hæmorrhage should be
familiar to him.

There are _three varieties of bleeding_.

    1st. _Capillary._ This consists of the oozing of blood from
    various points on a cut surface. The vessels are minute hair-like
    structures, and bleeding from them is invariably stopped by firm
    pressure. This loss of blood occurs in more or less degree at
    every circumcision, and in the vast majority of cases is arrested
    by the natural process previously explained.

    2nd. _Arterial._ The distinctive sign of this kind of bleeding
    is that it issues forth from the wound in spurts, and not in a
    continuous stream. Each spurt corresponds to a heart beat. This
    variety of hæmorrhage can only occur if an artery is cut through,
    i.e., a vessel which carries blood away from the heart to supply
    the tissues of the body.

    3rd. _Venous._ This bleeding is due to the wound of a vessel
    which returns blood to the heart after it has circulated through
    the tissues. These vessels are called veins. The blood is dark in
    colour and issues from one definite spot in a continuous stream.

_Treatment._ For practical purposes only the first variety of hæmorrhage
need be considered here. Circumcision in an infant should never interfere
with an artery or vein; but in the event of this accident occurring a
pledget of cotton-wool or lint must be firmly compressed with bandage
around the bleeding point until the proper method can be adopted to deal
with it. This consists of seizing the bleeding point with an instrument
constructed for the purpose (artery forceps) and then twisting up the
tissue caught in the forceps, or applying a ligature. This is a purely
surgical proceeding, and as every case of hæmorrhage should without delay
receive qualified medical attention nothing further need be said on this
matter here.

In most cases the application of the dressing with very firm pressure
suffices to arrest the inevitable bleeding of every circumcision. _The
bandaging cannot be considered satisfactory until the blood ceases to
ooze through the dressing._ In adjusting the diapers it must be seen that
the thighs are tied together so that they are immovable, perfect rest
being indispensable for the control of hæmorrhage. This treatment is
merely a mechanical aid to the natural processes which arrest bleeding,
and in the vast majority of cases is perfectly successful.

There are however certain drugs which may be applied to a bleeding
surface to hasten the coagulation of the blood. These are called
_astringents_. These are not to be used indiscriminately as many of
them injure the tissues and interfere with the healing of the wound.
If pressure alone is insufficient to stop the hæmorrhage and the local
application of an astringent is to be tried, the part must first be
carefully washed with an antiseptic solution, so as to see precisely
where the bleeding is actually coming from. Strips of lint soaked in the
astringent solution are then carefully applied and retained in position
by the firm pressure of a bandage.

The following are the principal drugs which may be used in this way.

    1.) Compound Tincture of Benzoin.

    2.) Tincture of Hazeline.

    3.) Strong solution of Alum in hot water.

    4.) Solution of Tannic Acid (4 grains to the ounce.)

    5.) Solution of Adrenalin Chloride.

The last of these has the reputation of being the most powerful
astringent known.

A solution of Perchloride of Iron is often used, but this is open to the
objection of injuring the delicate living tissues.


_Secondary Hæmorrhage._

Besides the bleeding which may occur immediately on the infliction of a
wound, there is another variety which may take place subsequently, known
as Secondary Hæmorrhage. This occurs when there is some failure in the
process previously described, by which the wound heals. The coagulum is
disturbed and the vessels are practically re-opened, or the coagulum
_becomes softened through the action of an infective agent_. As a rule
secondary hæmorrhage indicates some form of infection.

Often in changing the dressing there is a minute amount of hæmorrhage.
This is due to injuring the developing blood vessels in the newly growing
scar tissue.


_Hæmorrhage due to constitutional conditions._

Some infants are born with a tendency to bleed, without any evident
cause, either from the nose, bowels, or in the skin. The separation of
the navel may be followed by bleeding. Many of these cases are due
to hereditary disease of one character or another. Of these, there is
one which requires special mention, because when fatal hæmorrhage has
occurred after circumcision it has been due to it. This is _Hæmophilia_.
Subjects of this disease are called _Bleeders_, and it usually only
affects males. It runs in families, one or two members may be affected
while the rest are free. The females in a family of “bleeders”, though
they may not suffer themselves, transmit the disease to their children.
In this condition the slightest injury will start profuse hæmorrhage. The
use of a toothbrush may be sufficient to cause severe bleeding from the
gums. If the family history of any child reveals the presence of this
disease circumcision must not be performed. Should the operation have
taken place in ignorance of the condition the difficulty in controlling
the hæmorrhage, and its recurrence if at all relieved will at once
confirm the presence of Hæmophilia. The nature of the bleeding in this
condition is that referred to before as _Capillary_.

[Illustration]