{"collection":"scripture-revelation","full_text_available":true,"graph_url":"https://unchartedknowledge.5gfusion.net/v2/api/page/gutenberg_55692/graph","html_url":"https://unchartedknowledge.5gfusion.net/v2/page/gutenberg_55692","id":"gutenberg_55692","license":"Public Domain (US)","rights_basis":"gutenberg_metadata_copyright_false","source":"gutenberg","source_url":"https://www.gutenberg.org/ebooks/55692","summary":null,"tags":["Category: Health & Medicine","Category: How To ...","Category: Religion/Spirituality","Circumcision"],"text":"The Surgery\n                                   of\n                                 Ritual\n                              Circumcision,\n\n                                   BY\n                             JACOB SNOWMAN,\n\n                     M.D., M.R.C.S., M.R.C.P., LOND.\n\n          _Medical Officer of the Initiation Society, &c., &c._\n\n                                 LONDON:\n                   PUBLISHED UNDER THE AUSPICES OF THE\n                MEDICAL BOARD OF THE INITIATION SOCIETY.\n                                  1904.\n\n          E. W. RABBINOWICZ, PRINTER, 48, COMMERCIAL STREET, E.\n\n\n\n\nPREFACE.\n\n\n_The object of the following few pages is to provide a basis of\ninstruction in the surgical aspect of the Jewish rite of circumcision.\nThe performance of this simple operation is not limited to medical men.\nIt is therefore essential that the lay Mohel should possess a scientific\nknowledge of the important task he undertakes._\n\n_The Initiation Society which controls the instruction of Mohelim has\narranged a Syllabus which guarantees such an acquaintance with the\nsubject. This little book is planned in accordance with that syllabus.\nIts main object is to bring the principles of ASEPSIS within the\ninformation of everyone acting as a Mohel, and to insist upon the urgent\nneed of carrying these principles into practice._\n\n                                                              J. SNOWMAN.\n\n    11, SHOOT-UP-HILL, BRONDESBURY, N.W.\n    _July 1904._\n\n\n\n\nCONTENTS.\n\n\n                                                          PAGE.\n\n      CHAPTER I.--_Causes of Infection of Wounds._           7\n\n     CHAPTER II.--_Results of Infection of Wounds._         13\n\n    CHAPTER III.--_Elements of the Antiseptic method._      17\n\n     CHAPTER IV.--_Surgical Anatomy._                       23\n\n      CHAPTER V.--_Technique of Operation._                 28\n                      _The Dressing._\n                      _Abnormalities._\n\n     CHAPTER VI.--_Repair of the Wound._                    38\n\n    CHAPTER VII.--_H\u00e6morrhage._                             44\n\n\n\n\nCHAPTER I.\n\n_Infection of Wounds._\n\n\nThe greatest advance in modern surgery has been to show how wounds become\ninfected and cause general blood poisoning. This applies both to wounds\nmade by the knife of the Surgeon as well as to accidental injuries. _The\nprinciples concerned in this matter involve not only the arrangements\nnecessary for a severe and prolonged operation but also those required\nfor the simple circumcision of an infant._ It is therefore essential\nthat those who perform ritual circumcision should be familiar with the\nelementary teachings of the _Antiseptic System of Surgery_ which is now\nuniversally adopted even in the most trifling surgical proceedings.\n\nHeavy responsibility lies upon the Mohel to carry out every case\nstrictly in accord with the lessons of surgical cleanliness. _Surgical\nCleanliness_ begins where ordinary cleanliness leaves off. Its object\nis to destroy certain minute particles of matter which are invisible to\nthe naked eye, but which are _living organisms of a vegetable nature_,\nable to grow very luxuriantly in blood, and wound discharges. Here they\nproduce a poison which gets absorbed into the body, causing serious\nsymptoms of disease; or they themselves enter the blood stream and\ncirculate in it with even more disastrous results. These organisms can\nbe observed under the microscope, but can only be seen by the naked eye\nwhen growing together in colonies after being planted in such substances\nas gelatine or broth, or on the surface of a slice of potato. They\ncorrespond exactly to the growth of _mould or fungus_ on stale cheese\nor meat, or to the growth of yeast in fermenting grape juice. When seen\nseparately under the microscope, or when growing in the mass they possess\nvery distinct characters so that the expert is able to distinguish\nthe one from the other, with the same confidence as a pear may be\ndistinguished from a fig.\n\nA large number of diseases is due to the growth in the body of certain of\nthese organisms, and in many diseases we can be sure of always finding\nthe particular one responsible for the condition, either in the blood or\nin the discharges from the body. This is notably the case in Consumption,\nTyphoid Fever, and Malarial Fever. We often know how the organism has\nobtained entrance into the body; it may be either by the lungs or the\nstomach, or in other words through air or through food.\n\nWe are however only concerned just now with the _organisms which enter\nthe body by means of an open wound_.\n\nThese nearly all belong to one class--_micro-cocci_. They are minute\nround bodies about 1/25000 inch in diameter. They possess the peculiarity\nof growing together in clusters like grapes, or in chains. They are\nresponsible for the diseased conditions of wounds which delay healing,\nfor inflammation around wounds and for the general blood-poisoning which\nmay result.\n\nThese organisms are very abundant in the dust of rooms, on dirty clothes\nand unclean general surroundings, and there can be no doubt that\neverybody is often infected by them. But fortunately disease results only\nrarely, because there are special powers resident in the vital tissues\nwhich enable them successfully to resist the poisonous effects of these\norganisms. There are however certain circumstances in which they are\nliable to be more harmful than in others.\n\n    _1_) _When they are absorbed in especially large numbers._\n\n    _2_) _When absorbed in an especially active state._\n\n    _3_) _When the body is in a condition of ill-health from whatever\n    cause._\n\n    _4_) _In the presence of cold._\n\nEach one of these circumstances is of special importance in relation to\ncircumcision and may be commented on as follows.\n\n1) The slightest departure from scrupulous cleanliness either on the\ngenitals of the infant, on the instruments or dressings used, or on the\nhands of the Mohel enormously increases the number of microbes which may\npossibly infect the wound. _Hence the necessity for absolute ordinary\ncleanliness before resorting to antiseptic measures._\n\n2) It is well known that these organisms exist in a very virulent form in\nunhealthy wounds, in boils and in abscesses, and the worst cases of blood\npoisoning have resulted from the direct infection of a healthy wound from\nan unhealthy one. For this reason all the precautions in regard to the\ndisinfection of the hands, which will be referred to subsequently, must\nbe carried out with rigorous care, when there has been any possibility of\ntheir having come in contact with such sources of infection.\n\n3) The natural protective power of the body against infection is\ndiminished when the general health is below the normal standard. This\noccurs in infants mainly, when they are premature, or suffering from\njaundice, sickness or diarrh\u0153a, congenital disease of the heart or other\norgans. In these circumstances the circumcision must be delayed.\n\nWhen the parts are unduly bruised, the local resistance is considerably\nlowered; hence the paramount necessity of the operation being performed\nneatly and dexterously.\n\nIf these micro-cocci have already found access to the body in other\nparts, as evidenced by _purulent ophthalmia_ (i.e. matter discharging\nfrom the eye lids) or _suppuration about the navel_, it is important that\nthese conditions be cured before the circumcision is undertaken, because\nexperience shows that in their presence the risks of a general blood\ninfection are increased.\n\n4) There is a special liability for the skin of an infant, particularly\nin the region of the scrotum, to become irritated by its excretions\nand to present the eruption known as _eczema_. The folds of the groin\noccasionally suffer in the same way, the skin becoming reddened and\npeeling. These cases demand medical attention before operation, owing\nto special risks of infection. _No infant presenting a rash of any kind\nshould be circumcised without previous examination by a doctor, because\nit may indicate constitutional disease._\n\n5) Cold always indicates that the bodily processes are deficient in\nactivity. Infants are especially liable to cold, and hence the necessity\nto supply them with abundant artificial warmth. This is especially\nrequired during the exposure which a circumcision involves, and therefore\ndue attention must be paid to the temperature of the room where the\noperation takes place, draughts must be avoided, and adequate protection\nof the infant when carried from and to the bedroom, must be ensured.\n\n[Illustration]\n\n\n\n\nCHAPTER II.\n\n_Results of the Infection of Wounds._\n\n\nThe name usually given to the conditions which result from wound\ninfection is _Septic Disease_. This includes both the mild and the grave\ntroubles which may ensue.\n\nThe mild forms of infection usually appear as interference with the rapid\nhealing of the circumcision wound. The principal of these are:--\n\n    1) Ulceration at the cut edge of the prepuce.\n\n    2) Ulceration in the raw tissue left on the under surface of the\n    penis between the reflected mucous membrane and the cut skin.\n\n    3) Sloughing or mortification of the reflected mucous membrane.\n\nThese conditions are usually attended with some amount of swelling; and\nthe unhealthy state of the wound with the accompanying discharge afford a\nfertile soil for the rapid growth and multiplication of micro-organisms\nand their absorption into the system.\n\nOf the more serious results of infection the principal is _Erysipelas_\nin its various forms. Here we find that as the signs of unhealthy\ninflammation around the wound occur, symptoms of constitutional illness\nbegin. The infant becomes feverish, there is loss of appetite, rapid\nbreathing and wasting supervene, with a profound alteration in the\ngeneral appearance. The signs evident, locally, are redness of the skin\nincreasing to a vivid blush which spreads on to the thighs, scrotum or\nabdomen. The surface is tender, and the edge of the red patch is sharply\ndefined from the surrounding healthy skin. The disease is most active at\nthis sharp margin for it is there that the micro-cocci may be found in\nabundance. The glands in the groin become swollen and tender, and the\ncircumcision wound, failing to heal will probably inflame and suppurate.\nWhile this is going on, a poison is being manufactured by the microbes\nin their growth, and this poison being absorbed into the circulation,\ngenerally proves fatal to the infant.\n\nThe process is usually limited to the skin, and its uppermost layer is\noften raised into blebs containing clear or discoloured blood serum.\nBut the morbid change may take place first in the tissues under the\nskin, when there will be great swelling and dropsy of the part so that\nthe pressure of the finger will leave a pit in the skin before the\nlatter becomes itself inflamed. In these cases the organisms readily\nenter the blood stream and being carried away to distant organs set up\ninfection in these. These are necessarily the most hopeless cases of\nblood-poisoning.\n\nSo far we have briefly considered infection by the group of organisms\nknown as micro-cocci. It is necessary to point out here that at least two\nof the organisms of the group of _Bacilli_ have been known to infect the\ncircumcision wound. The one is the Tetanus (lockjaw) Bacillus, the other\nis the Tubercle Bacillus.\n\nIn _Tetanus_ the first symptom noticed is that the infant is unable to\nsuck, and on examination it will be found that this is due to cramp of\nthe muscles of the jaw, which become fixed and hard. The face assumes a\npeculiar aspect which is quite characteristic of this disease, spasms of\nthe limbs and then convulsions of the whole body take place, the joints\nbecome stiff and the case is almost invariably fatal.\n\nIn regard to the infection by the Tubercle Bacillus it may be said that\nthis occurrence is one of the rarest of the rare sequels of circumcision,\nbut it appears that _tubercular ulcers_ have arisen over the area of the\nwound when the METZIZAH has been performed by mouth suction on the part\nof a Mohel who was suffering from Tuberculosis. A number of these cases\nhave been reported from time to time, and in some of them it apparently\nled to general Tuberculosis (_consumption_).\n\nThe foregoing brief statements exhaust most of the possibilities of wound\ninfection by means of micro-organisms. There is however another source of\ninfection, not yet definitely proved to be of microbic origin, which has\nimportant relations to circumcision. This is the poison of _Syphilis_.\nIf the Mohel should be suffering from this disease the secretions of the\nmouth are infective and the disease may easily be transmitted to the\ninfant by means of Metzizah. On the other hand, should the infant be born\nwith the disease--a circumstance of not infrequent occurrence--it must be\nremembered that its blood is charged with the poison, and is capable of\ninfecting a healthy individual when it is brought into contact with any\nwound, abrasion or other breach of surface.\n\n[Illustration]\n\n\n\n\nCHAPTER III.\n\n_Elements of the Antiseptic Method._\n\n\n_The purpose of Antiseptic Surgery is to avoid the occurrence of the\ndangers of infection_ referred to in the preceding chapter. There are\nmany methods of carrying out the system, but the present description\nbeing limited to the requirements of circumcision does not aim at being\nexhaustive. The two objects aimed at are:\n\n    1) _The prevention of any micro-organisms gaining entrance to the\n    wound._ This end is attained by the disinfection of the hands and\n    especially the thumbnails of the operator, of the instruments\n    and dressings used; and by perfect cleanliness of the genitals\n    of the infant. It may be said that the brief exposure of the\n    parts during the performance of the circumcision carries with\n    it no risk of infection, because the organisms we have been\n    considering are not usually airborne.\n\n    2) _The application of such dressings as will keep the wound in\n    an aseptic condition._ Even the small amount of discharge from\n    a circumcision wound forms a splendid soil for the growth of\n    micro-organisms. It is necessary therefore to apply a dressing\n    which has been saturated with such antiseptics as will destroy\n    that constituent of the discharge which makes it a good culture\n    material.\n\nThe most convenient antiseptic for general use is _Carbolic Acid_. This\nis a clear, colourless liquid of rather oily consistence, which rapidly\nbecomes converted into solid crystals in cold weather. When required for\npurposes of disinfection it should be mixed with 39 times its quantity of\nwater, or roughly one pint of water requires one tablespoonful of pure\nCarbolic Acid to make a solution of 1 in 40.\n\nThis solution is required for soaking the hands after they have been\nwashed with soap and warm water, and the nails scrubbed with a nail\nbrush. This latter proceeding is one of _ordinary cleanliness_, the\nsoaking in the Carbolic Acid solution, which should be warm, is in order\nto obtain _Surgical Cleanliness_. It will be readily understood, that if\nthe hands come in contact with any possible source of infection after\nthis soaking, then it must be repeated before beginning the operation.\nThe disinfection of the hands must be the last stage in all the\npreparations for the circumcision. A similar solution of 1 in 40 Carbolic\nAcid may be used for placing the instruments in before the operation.\nThey are to be taken directly out of the solution as required. A shallow\ndish of a material easily cleaned, as metal, glass or porcelain should\nbe filled with 2\u00bd ounces (5 tablespoons) of water which has been boiled,\nand to this one half a teaspoonful of Carbolic Acid is added, taking care\nthat the acid is thoroughly well mixed up with the water and not allowed\nto float about in droplets.\n\nIf the instruments are scrupulously clean, i.e., if they have been\nwashed thoroughly with soap and hot water, they require to remain for\n_one hour_ in the Carbolic Acid solution to render them sufficiently\ndisinfected for operating purposes. It is therefore quicker, as it is\nalso more scientific, to _sterilize the instruments before using them_.\nBy sterilizing them we kill any micro-organisms that may be present on\nthem, and we are then confident that no living germs are carried to the\nwound by means of the instruments. In other words they are _aseptic_.\nInstruments are sterilized by boiling for about ten minutes in clean\nwater. It is useful to add washing soda in the proportion of 5 grains to\nevery two tablespoons of water. It is obvious that the instruments must\nbe of metal, as no other material will stand boiling. They must be made\nin such a way as to prevent the accumulation of dust or dirt in joints or\ncrevices.\n\nCompact apparatus for sterilization is supplied by every surgical\ninstrument maker. The instruments are usually placed on a wire gauze\ntray with handles and then into the sterilizing dish, so that when the\nboiling is completed, they are lifted out on this tray by means of hooks\nsupplied for the purpose. They are at once transferred to the shallow\ndish containing the 1 in 40 Carbolic Acid solution detailed above. By\nthese means the instruments are cooled ready for use, for obviously they\ncannot be taken directly out of the boiling water with the fingers; and\nthe fact that they are in an antiseptic solution, prevents the access of\nany germs during the short interval before they are actually handled.\n\nThe _dressings_ used in Circumcision should consist only of _lint_ and\n_gauze_. It is necessary that the dressing should be sterilized and also\nimpregnated with some antiseptic so as to render harmless any infective\nmaterial which may accidentally contaminate the wound after circumcision.\nThese dressings are supplied by manufacturers, already sterilized by\nexposure to super-heated steam, and rendered antiseptic by various\nchemical agents. Carbolic Acid used for the hands and the instruments,\nis often employed for the dressings, the antiseptic being fixed in the\nlint and the gauze by a special process. Most surgeons, however, prefer\n\u201c_double cyanide_\u201d dressings, in which the antiseptic used is a salt\nknown as cyanide of zinc and mercury.\n\nFrom the first dressing until the circumcision is absolutely healed\nnothing but gauze need be used. In a normal case no other application\nof any kind whatsoever is required. It is usual however in applying the\nfirst dressing at the circumcision to use lint to surround the root of\nthe penis as it is firmer than gauze. When this is done a piece of tape\nis twisted round the lint to retain it in position. The tape and the lint\nmust both be sterilized like the gauze.\n\nThe best course to adopt in regard to the dressings is to obtain them\nfrom a reliable firm of manufacturers, who will supply them ready cut to\nthe pattern required, packed in small sealed aseptic tin cases ready for\nuse.\n\nHaving adopted all these precautions the Mohel may be confident that\nin regard to his own hands, the instruments, and the dressings he has\nexercised every care which surgical science demands. The only other\nimportant detail which demands attention is the part concerned in\ncircumcision. It is obvious that all the safeguards hitherto considered\nare valueless unless the infant himself is in a perfectly clean\ncondition. The disinfection of the skin of an adult before an operation\nis always a serious and difficult matter, because the skin harbours\nso many micro-organisms, including the very micro-cocci referred to\npreviously. Elaborate measures are therefore employed for the skin\ndisinfection. But in the case of an infant the skin cannot be supposed to\nbe such a probable source of wound infection. It is sufficient that the\ngenitals be washed about half an hour before circumcision, with soap and\nwarm water, and subsequently a fomentation of Boracic lint applied. It\nis as well to avoid the use of the various baby powders which nurses are\nso fond of sprinkling freely on the folds of the skin. If it is thought\ndesirable to employ such a dusting powder, it should be a mixture of\nequal parts of Boracic Acid and Starch.\n\nThe infant having been prepared as here stated, the circumcision may\nproceed as soon as he is put in position. Should any soiling have taken\nplace, the infant must again be cleansed, and in this case the genitals\nmust be washed with the Carbolic Acid solution (1 in 40) by means of a\nswab of cotton wool.\n\n[Illustration]\n\n\n\n\nCHAPTER IV.\n\n_Surgical Anatomy._\n\n\nIt is essential for the Mohel to possess a knowledge of the structure of\nthe organ on which he operates.\n\nThe skin of the penis is continuous on the upper surface with the skin\nof the abdomen, and on the under surface with that of the scrotum. On\ndrawing forward the prepuce or foreskin it is very easy to include the\nskin of the scrotum in the grasp of the fingers unless due care is taken.\nIf the traction on the foreskin is too forcible and the skin of the\nscrotum is therefore pulled up tightly, there is a danger of the scrotal\nskin being slit up to some extent. The intimate connection of the skin of\nthe penis and scrotum must always be kept well in mind.\n\nUnder the foreskin and continuous with it at its free margin there is\na membrane which rising from the neck or constriction below the glans\nenvelops the latter entirely up to the opening of the urethra. Here\nit leaves the glans and joins the outer skin. The name given to this\nstructure is _mucous membrane_, and the method of dealing with it\nconstitutes the principal portion of the art of circumcision.\n\nThis mucous membrane is the whitish glistening structure which appears\nafter the removal of the skin.\n\nIt is important to note the disposition of this mucous membrane, as\nrevealed after the amputation of the prepuce.\n\n    1) It usually _covers over the glans right up to the orifice of\n    the urethra_.\n\n    2) It may be reflected off the glans before reaching this point,\n    and become continuous with or adherent to the skin lining. In\n    this case the glans will not be completely covered by the mucous\n    membrane, because a small portion will have been cut off in the\n    first stage of the operation. In those cases the membrane missing\n    from the upper part of the glans will be found on the inside of\n    the amputated foreskin.\n\n    3) In other cases this inner mucous membrane is very deficient\n    covering only three quarters or less of the surface of the glans,\n    the remaining portion being adherent to the inner surface of the\n    foreskin.\n\nThe _consistence of this membrane_ is such that it can be easily torn\nthrough but,\n\n    1) It may be elastic so that it stretches without tearing.\n\n    2) It may be so thin that it is liable to be pushed down by the\n    nails instead of being torn.\n\n    3) It may be so thick as to necessitate the use of the scissors\n    to cut it.\n\nIt may be loosely applied to the glans so that the thumb nails are easily\ninserted beneath it, or it may be so adherent that great difficulty is\nexperienced in tearing it through and peeling it off the glans.\n\nAn important fold of this membrane, triangular in shape is attached to\nthe under surface of the glans below its base reaching almost up to the\nopening of the urethra. This is called the _Fr\u00e6num_, and it is fully\nexposed during the second stage of the operation.\n\nThe body of the penis itself is composed of three parts. On the upper\nsurface behind the glans are the two _Corpora Cavernosa_, united firmly\ntogether, but leaving a hollow on their under surface for the _Corpus\nSpongiosum_ which is prolonged beyond them in an enlarged extremity known\nas the _glans_. The constriction beneath the glans is called the _Cervix\nor Neck_, while the projecting rim of the glans above this is called the\n_Corona_. Occasionally there are found here small masses of soft creamy\nmaterial, which is the natural secretion of the part.\n\nThe canal of the urethra runs in the corpus spongiosum. Each of these\nthree corpora is firmly united to the pubic bone behind.\n\nThey are constructed of an outer sheath from the inner surface of which\nnumerous fine membranous partitions stretch, dividing the whole up into\nnumerous small compartments. These compartments are lined with a fine\nnetwork of veins, which are able to expand with blood and to distend and\nfill up these spaces. When this occurs the whole organ swells and becomes\nfirm and the tension of the fibrous material forming the main structure\nis called into play so that the process assumes the form of an erection.\nThe veins which should drain the penis of blood are compressed by the\naction of certain muscles and this adds to the engorgement of the organ.\n\nWhen the penis of an infant is in a state of erection the operation\nof circumcision can be more easily performed and the dressing more\nefficiently applied. The manipulation of the organ necessary to grasp the\nprepuce is generally sufficient to stimulate the increased blood supply\nrequisite for an erection. The skin of the penis does not share with\nthe rest of the organ, a greater amount of blood during this state. It\nstretches by its own elasticity.\n\nAll the arteries and veins of the penis run in the deep structures\npreviously alluded to, so that circumcision, in an infant at any\nrate, can never wound a blood vessel. The _Fr\u00e6num is freely supplied\nwith blood_, and if cut will produce troublesome h\u00e6morrhage, but a\ncircumcision in no way interferes with this part.\n\n[Illustration]\n\n\n\n\nCHAPTER V.\n\n_Technique of Operation._\n\n\nA good light is essential for the performance of circumcision.\n\nThe instruments required are as follows:--\n\n    1) _Knife_ of steel, to be made of one piece of metal without\n    joints, crevices or any ornamentation whatsoever. The handle\n    should be stout enough to permit a firm grasp upon it. The blade\n    should be about 5 inches in length and fully half inch in width.\n\n    2) _Shield._ This is a metal plate with a centre slit, the edges\n    of which are made to grasp the prepuce at the level of the\n    amputation. The Shield protects both the glans penis and the\n    scrotum from injury by the knife.\n\n    3) _Scissors._ These are required occasionally to cut through\n    the mucous membrane. They should be of the pattern known as the\n    \u201c_blunt pointed_.\u201d When it is evident that the mucous membrane\n    is very adherent to the glans, the separation of these two\n    structures may be effected by the use of a _Probe_. This is a\n    thin metal rod which is easily inserted under the mucous membrane\n    and swept round the glans so as to break through the adhesions.\n\nThe person who is to hold the infant, is seated on a chair with his feet\non the side rail of a second chair so as to keep the knees raised. The\nlatter must be kept close together. A firm pillow is placed on the knees\nand the infant is laid thereon facing the Mohel. When the necessary\nclothing has been loosened, the thighs and knees are bent up completely\n(flexed) and then the thighs are in addition rotated outwards, and kept\nin this position by the hands of the individual holding the infant.\n\nThe clothes should be displaced behind the buttocks of the infant so as\nto raise the part.\n\nThe antiseptic preparations described in Chapter iii. having been carried\nout, the operation is performed according to the following stages.\n\n    _Stage I._ The root of the penis is taken between the index and\n    middle fingers of the right hand palm downwards, and pressure\n    is made firmly backwards, the index finger being against the\n    scrotum, the middle finger against the lower portion of the\n    abdomen. This steadies the penis, keeps away the skin of the\n    scrotum, and helps towards producing an erection.\n\n    _Stage II._ Keeping these fingers in this position, the _glans is\n    grasped between the thumb and index finger of the left hand_. It\n    is important not merely to take hold of the foreskin, the glans\n    must be included between the fingers, and it must be examined\n    by them so as to discover where it ends. This is determined by\n    feeling the projecting rim of the Corona, and the neck beneath\n    it. The skin overlying this marks the precise position where the\n    shield is to be placed. When this position is accurately made\n    out the whole of the skin in front of it is withdrawn beyond the\n    glans by the fingers, and very firmly held upwards away from the\n    scrotum.\n\n    _Stage III._ The fingers are now to be removed from the root\n    of the penis, and the shield is taken into the right hand and\n    adjusted on the prepuce exactly at the level of the finger\n    tips which are grasping it. The _direction of the shield is\n    important_. It must _not_ be put on at right angles to the penis,\n    but obliquely upwards, i.e., the part of the shield held in the\n    hand must incline towards the abdomen of the infant, and the\n    other part away from it. In this way the circumcision will take\n    off the foreskin in a quill shape, and it will leave a sufficient\n    amount of skin on the under surface of the penis. If this\n    precaution is not observed there is a great risk of denuding the\n    under surface of the skin almost as far as the scrotum.\n\n    _Stage IV._ The knife is then taken in the right hand and with\n    one sweep along the shield the foreskin is amputated. The knife\n    must be handled firmly, and the cut made from the heel. The cut\n    circular edge of the skin immediately retracts behind the corona,\n    though on the under surface the amount of skin remaining may fall\n    short of this level.\n\n    _Stage V._ The amputated foreskin and the knife are now put\n    aside, the shield having already fallen off. The Mohel will now,\n    at a glance, observe the disposition of the mucous membrane\n    covering the glans. He insinuates the nail of one thumb under\n    its edge, and seizes it between the nail and the index finger.\n    When this is grasped the man\u0153uvre is repeated with the thumbnail\n    and index finger of the other hand, keeping the two hands close\n    together. Before proceeding further, the Mohel must be sure that\n    he has a firm hold of the membrane.\n\n    The next step is to tear the membrane down in the centre, until\n    the prominent edge of the corona is exposed. This tearing may be\n    completed with one movement of the hands, but if the membrane is\n    long more than one movement may be required to tear it through\n    completely.\n\n    When the neck below the corona is seen, the flaps are reflected\n    laterally backwards, so that the torn edges of the mucous\n    membrane may join the cut edge of the skin. Care must be taken\n    that the membrane is peeled off as far as possible (i.e. till its\n    junction with the fr\u00e6num) from the under surface of the glans and\n    reflected directly backwards so as to unite with the cut edge of\n    the skin.\n\n    The essence of the operation consists in the proper performance\n    of this stage. If not performed efficiently the resulting\n    circumcision is very imperfect. The mistakes usually made by\n    beginners are as follows:\n\n    1) The mucous membrane is stretched without being torn through;\n    the glans then projects completely giving the impression that it\n    has been exposed by the proper method. 2) The membrane is rolled\n    back over the glans instead of being torn back. 3) The membrane\n    is cleared off from the upper surface of the glans, but is not\n    sufficiently peeled off from the under surface.\n\n    _Stage VI._ The operation is really completed with the preceding\n    stage.[1]\n\n    The practice of Metzizah may now be carried out by means of a\n    swab of sterilized, cotton wool with which the penis is to be\n    firmly compressed. This will effectually absorb the small amount\n    of blood free in the tissues and at the same time helps to clean\n    up the part.\n\n    _Stage VII._ The _dressing_ consists of a strip of sterilized and\n    antiseptic lint or gauze long enough to encircle the penis below\n    the glans two or three times, and wide enough to cover the whole\n    space between the corona and the root of the penis, i.e. 4\u00bc in. \u00d7\n    \u00be in. The first layer of dressing is applied entirely below the\n    glans and covers over the whole of the reflected mucous membrane.\n    Care must be taken to apply this strip of lint at the very root\n    of the penis and to begin on the under surface; otherwise there\n    is a tendency for the dressing in this latter position only\n    to just to reach the edge of the incision and to push it back\n    towards the scrotum and thus increase the size of the raw area.\n\n    The glans must be quite free of the dressing encircling the penis\n    and must project completely beyond the strip of lint applied\n    below it. This piece of lint or gauze adheres quite well by\n    itself, but to ensure its remaining in position, it is better\n    to secure it by surrounding it once or twice with a piece of\n    sterilized tape and twisting up the ends. _If this is done too\n    tightly it may obstruct the free flow of urine, or congest the\n    glans._\n\n    The dressing is completed by covering over the naked and\n    projecting glans with a square piece of antiseptic gauze. A\n    diaper folded in the ordinary triangular shape is then put on,\n    and this is secured firmly by means of broad tape. Two or three\n    turns must be given round the thighs so as to keep them fixed,\n    and the ends are to be tied over the hip.\n\n    During the after treatment the re-dressing may be regulated as\n    follows. After about 10 or 12 hours, but at any rate within the\n    first 24 hours, the piece of gauze covering the glans must be\n    removed and the tape surrounding the dressing untwisted and also\n    removed. If the circumcision has been properly and carefully\n    performed, so that the whole of the mucous membrane and skin are\n    kept back by the dressing, and the whole of the glans remains\n    exposed, nothing further need be done but to replace some fresh\n    gauze over the glans. On the following day the whole of the\n    dressing should be removed, and gauze be re-applied around the\n    penis leaving the end of the glans free. This dressing will fall\n    off when the infant is in the bath, and may be renovated as often\n    as necessary. As an alternative procedure the whole dressing may\n    be removed after the first 24 hours, and the part re-dressed\n    with gauze.\n\n        [1] The performance of Metzizah according to statutory\n        Jewish Law consists of suction by the mouth. The original\n        sources of this practice indicate that it was considered\n        an essential part of the operation in the same way as the\n        dressing of the wound was. Failure to carry out this measure\n        was regarded as constituting a serious risk to the infant.\n        The possible dangers of this practice have become obvious\n        during recent years and direct suction of the wound is, from\n        every point of view, inadmissible. In order to carry out the\n        ancient practice a device is used by some Mohelim by which\n        the suction is performed through a small glass tube with a\n        perforation at its end and containing a piece of absorbent\n        wool in its interior.\n\n\n_Circumcision in Abnormal Cases._\n\nThe penis is subject to many departures from its usual anatomy, but here\nit will only be necessary to notice some of the more usual abnormalities.\n\n    _1st._ In some cases the penis is sunken into the pubic skin, so\n    that on grasping the prepuce the whole integument of the penis\n    is pulled up leaving the organ itself buried in the skin behind.\n    It will be found that in many of these cases the testicles have\n    not descended into the scrotum. The first stage of the operation,\n    in these instances, is all important. The root of the penis is\n    embraced between the second and third fingers of the right hand\n    as previously explained and firm pressure backwards is made until\n    a definite erection is made. The amount of skin to be amputated\n    must be very accurately estimated, the shield carefully adjusted\n    in an oblique direction, as in these cases the inclusion of some\n    of the skin of the scrotum is very easy. The mucous membrane\n    often proves to be very thick, but whatever its consistence may\n    be it should be cut away with scissors after reflection as this\n    proceeding helps to prevent the glans sinking back into the skin.\n    A careful examination of the infant must be made in these cases\n    because they frequently denote immature development, and call for\n    postponement of the performance of the circumcision.\n\n    _2nd._ The prepuce is sometimes deficient. The upper portion of\n    the glans may be exposed and project beyond the short prepuce.\n    The amount of the latter which should be removed is so small,\n    that on pulling it forward there is not sufficient in the small\n    circle of skin for the fingers to obtain a firm grasp. In this\n    case forceps should be employed to hold the foreskin.\n\n    _3rd._ Some infants are born apparently circumcised. On\n    examination it will be found that a considerable amount of\n    prepuce still remains on the upper surface of the penis, while\n    the under surface may be quite free. In these cases the whole\n    of the remaining prepuce is grasped between the fingers and\n    the operation is performed in the usual manner. Here also the\n    underlying mucous membrane should be entirely cut away after it\n    has been torn through.\n\n[Illustration]\n\n\n\n\nCHAPTER VI.\n\n_Repair of the Wound._\n\n\nAs the whole difference between a scientific operator and a merely\nmechanical Mohel lies in an appreciation of the process of repair in the\nwound inflicted, it becomes necessary to consider this in detail.\n\nThe area of the circumcision wound extends between the corona of the\nglans and the circular cut edge of the skin. The skin of the penis\nalways retracts, so that if the shield has been placed in the position\npreviously indicated, the skin will not after the circumcision reach\nquite up to the corona; the neck of the glans will be well exposed. This\nis the condition to be attained in ritual circumcision.\n\nThe mucous membrane, after being torn through and reflected covers\nover the area of the resulting wound. _The planning of the operation\nshould be so carried out that the torn edges of the mucous membrane may\nunite with the cut edge of the skin._ This approximation is not usually\ncomplete all round the wound. The tearing through of the mucous membrane\nproduces a narrow V shaped rent; this is widened out when the membrane\nis reflected, and if carefully apposed to the cut skin, will unite with\nit. But the edge of that portion of the membrane peeled off from the\nunder surface of the glans will often fail to unite with the exit edge\nof the skin on the under surface of the penis. It frequently does not\nreach as far back as the cut skin, especially when the foreskin has been\nfreely removed or when the mucous membrane has a tendency to curl up.\nThe result in the majority of circumcisions is that the upper portion of\nthe wound heals rapidly, where the lacerated edge of the mucous membrane\nhas united to the cut edge of the skin, while on the under surface, the\nmucous membrane will adhere to the raw surface of the penis left by the\nretracting skin, but there will probably be a gap where the membrane has\nfailed to reach the cut edge of the skin. This gap will necessarily be\nvery small when the reflection of the mucous membrane has been complete.\nWhere approximation of the two edges occurs union is rapid and healing by\n\u201cfirst intention\u201d results. Where some loss of substance occurs the gap\nbecomes gradually filled by what is called _granulation tissue_, and the\nterm \u201csecond intention\u201d is given to the healing process.\n\n\n_Healing by first intention._\n\nIn amputating the foreskin a number of minute hair-like blood vessels\nwhich permeate the skin are cut through. There is little or no bleeding,\nbecause the blood immediately clots, and almost at once a rim of coagulum\nis formed at the margin of the circumcision. Besides this the injury\ndestroys a minute amount of living tissue known as _connective tissue\ncells_. The wound causes a special degree of activity in the adjacent\nblood vessels, so that certain important constituents of the blood\nflow out of the vessels and invade the cut margin where the blood has\ncoagulated.\n\nThis invasion consists of the fluid portion of the blood--or lymph, and\nthe solid elements called white corpuscles--or leucocytes. These latter\nremove the cells which have been killed by the injury, and get rid of the\nblood clot, probably by a process of digestion. When this is effected,\nthe way is paved for the healing, i.e. the formation of the scar.\n\nThe naked-eye evidence of all this is to be found in the moisture or\nexudation on the surface of a wound. As this forms on both surfaces of\na wound, the exudation is the first bond of union. The fluid portion\nof this exudation becomes absorbed, and what remains of it forms the\nscaffolding on which the scar is built up. The scar consists of new\nconnective tissue cells which have grown into this framework, and\nmultiplied rapidly, causing firm cohesion of the two separate surfaces.\n\nIn order that these new cells should be properly nourished they require\na sufficient blood supply, and it is found that while their formation is\nproceeding minute new blood vessels shoot forth from the existing ones,\nand they grow into the soft newly developing scar tissue. Owing to this\nfact, free oozing of blood takes place when a healing wound is disturbed.\n\nIn the operation of circumcision it is well seen how the circulation of\nthe blood re-acts to injury. When the mucous membrane covering the glans\nis exposed it looks pale and translucent, because of its scanty blood\nsupply and its thinness. Very soon after it has been torn through, its\nwhole character changes. It becomes engorged with blood, it becomes red\nand congested it loses its translucency, and at its lacerated edge the\nprocess of healing takes place as detailed above.\n\nAll scars are at first pink in colour, because more new blood vessels are\nformed than are required for the permanent nourishment of the part when\ncompletely healed. In the course of time these blood vessels shrink and\nwaste away and the scar becomes whiter even than the adjacent skin. This\noccurs also in the mucous membrane which remains pink for a considerable\ntime. The membrane in fact undergoes the first stage of inflammation\nas a reaction to the injury it has sustained. The blood vessels become\nenormously dilated, and its blood supply increased. It presents the best\nconditions for healing along the edges where it has been torn, but the\nwhole of its outer surface also, which, after reflection becomes opposed\nto the raw surface between the corona and the cut foreskin inferiorly,\nbecomes united by a similar process to this raw area.\n\nIn those cases where the reflection of the mucous membrane has not been\nperfect a gap will be left between its margin and the cut foreskin, in\nwhich healing takes place by _granulation or second intention_.\n\nThe details of this method of healing are similar to the first; the\ndischarge or exudation from the wound takes place in the same manner,\nbut as there are not two surfaces to unite to each other, this exudation\nsimply covers over the wound in the form of a whitish or pale yellow\nlayer of _lymph_. The fluid discharge should be tolerably clear; if it\ntends to be thick or milk like in colour it indicates that there has been\nsome accidental contamination of the wound, or that the vital powers\nnecessary for normal healthy repair are below the average. It shows\nthat the inflammatory re-action of the tissues which is the essential\nrequisite for healing has been excessive. In this case not only has\nthe wound been invaded by the white blood cells, which as previously\nexplained, form the groundwork of the new tissue cells; but a further\nstep has taken place. These white cells have been thrown off the surface\nof the wound and together with the exuded fluid go to form \u201c_pus_\u201d or\n_matter_. All this causes delay in the healing. But eventually the wound\nbecomes filled up by the growth of new connective tissue cells; these\ncontinue to multiply until the surface is reached, when the uppermost or\nepithelial layer of the cut edge of the adjoining skin grows over it,\nconstituting a continuous skin covering.\n\nThe _defects in the healing process_ may therefore be briefly summed as\nbeing due to some interference with the natural course of physiological\nrepair. They may be comprised under the following heads.\n\n    1) Deficient vitality of the infant.\n\n    2) Infection of wound.\n\n    3) Imperfect performance of the operation especially when the\n    tearing through and reflection of the mucous membrane has been\n    incomplete.\n\nThese defects are to be prevented by a careful examination of the health\nof the infant previously to the circumcision, by the employment of\nAntiseptic measures, and by carefully carrying out the technique of the\noperation.\n\n[Illustration]\n\n\n\n\nCHAPTER VII.\n\n_H\u00e6morrhage._\n\n\nTrouble from bleeding is an exceedingly rare occurrence at the\ncircumcision of an infant, because no arteries or veins are cut through.\nBut the possibility of its occurrence, however, remains, and therefore\nsome points regarding it should come within the information of every\nMohel. It will be his duty to apply first aid, and consequently a\nknowledge of the principles of the treatment of h\u00e6morrhage should be\nfamiliar to him.\n\nThere are _three varieties of bleeding_.\n\n    1st. _Capillary._ This consists of the oozing of blood from\n    various points on a cut surface. The vessels are minute hair-like\n    structures, and bleeding from them is invariably stopped by firm\n    pressure. This loss of blood occurs in more or less degree at\n    every circumcision, and in the vast majority of cases is arrested\n    by the natural process previously explained.\n\n    2nd. _Arterial._ The distinctive sign of this kind of bleeding\n    is that it issues forth from the wound in spurts, and not in a\n    continuous stream. Each spurt corresponds to a heart beat. This\n    variety of h\u00e6morrhage can only occur if an artery is cut through,\n    i.e., a vessel which carries blood away from the heart to supply\n    the tissues of the body.\n\n    3rd. _Venous._ This bleeding is due to the wound of a vessel\n    which returns blood to the heart after it has circulated through\n    the tissues. These vessels are called veins. The blood is dark in\n    colour and issues from one definite spot in a continuous stream.\n\n_Treatment._ For practical purposes only the first variety of h\u00e6morrhage\nneed be considered here. Circumcision in an infant should never interfere\nwith an artery or vein; but in the event of this accident occurring a\npledget of cotton-wool or lint must be firmly compressed with bandage\naround the bleeding point until the proper method can be adopted to deal\nwith it. This consists of seizing the bleeding point with an instrument\nconstructed for the purpose (artery forceps) and then twisting up the\ntissue caught in the forceps, or applying a ligature. This is a purely\nsurgical proceeding, and as every case of h\u00e6morrhage should without delay\nreceive qualified medical attention nothing further need be said on this\nmatter here.\n\nIn most cases the application of the dressing with very firm pressure\nsuffices to arrest the inevitable bleeding of every circumcision. _The\nbandaging cannot be considered satisfactory until the blood ceases to\nooze through the dressing._ In adjusting the diapers it must be seen that\nthe thighs are tied together so that they are immovable, perfect rest\nbeing indispensable for the control of h\u00e6morrhage. This treatment is\nmerely a mechanical aid to the natural processes which arrest bleeding,\nand in the vast majority of cases is perfectly successful.\n\nThere are however certain drugs which may be applied to a bleeding\nsurface to hasten the coagulation of the blood. These are called\n_astringents_. These are not to be used indiscriminately as many of\nthem injure the tissues and interfere with the healing of the wound.\nIf pressure alone is insufficient to stop the h\u00e6morrhage and the local\napplication of an astringent is to be tried, the part must first be\ncarefully washed with an antiseptic solution, so as to see precisely\nwhere the bleeding is actually coming from. Strips of lint soaked in the\nastringent solution are then carefully applied and retained in position\nby the firm pressure of a bandage.\n\nThe following are the principal drugs which may be used in this way.\n\n    1.) Compound Tincture of Benzoin.\n\n    2.) Tincture of Hazeline.\n\n    3.) Strong solution of Alum in hot water.\n\n    4.) Solution of Tannic Acid (4 grains to the ounce.)\n\n    5.) Solution of Adrenalin Chloride.\n\nThe last of these has the reputation of being the most powerful\nastringent known.\n\nA solution of Perchloride of Iron is often used, but this is open to the\nobjection of injuring the delicate living tissues.\n\n\n_Secondary H\u00e6morrhage._\n\nBesides the bleeding which may occur immediately on the infliction of a\nwound, there is another variety which may take place subsequently, known\nas Secondary H\u00e6morrhage. This occurs when there is some failure in the\nprocess previously described, by which the wound heals. The coagulum is\ndisturbed and the vessels are practically re-opened, or the coagulum\n_becomes softened through the action of an infective agent_. As a rule\nsecondary h\u00e6morrhage indicates some form of infection.\n\nOften in changing the dressing there is a minute amount of h\u00e6morrhage.\nThis is due to injuring the developing blood vessels in the newly growing\nscar tissue.\n\n\n_H\u00e6morrhage due to constitutional conditions._\n\nSome infants are born with a tendency to bleed, without any evident\ncause, either from the nose, bowels, or in the skin. The separation of\nthe navel may be followed by bleeding. Many of these cases are due\nto hereditary disease of one character or another. Of these, there is\none which requires special mention, because when fatal h\u00e6morrhage has\noccurred after circumcision it has been due to it. This is _H\u00e6mophilia_.\nSubjects of this disease are called _Bleeders_, and it usually only\naffects males. It runs in families, one or two members may be affected\nwhile the rest are free. The females in a family of \u201cbleeders\u201d, though\nthey may not suffer themselves, transmit the disease to their children.\nIn this condition the slightest injury will start profuse h\u00e6morrhage. The\nuse of a toothbrush may be sufficient to cause severe bleeding from the\ngums. If the family history of any child reveals the presence of this\ndisease circumcision must not be performed. Should the operation have\ntaken place in ignorance of the condition the difficulty in controlling\nthe h\u00e6morrhage, and its recurrence if at all relieved will at once\nconfirm the presence of H\u00e6mophilia. The nature of the bleeding in this\ncondition is that referred to before as _Capillary_.\n\n[Illustration]","title":"The Surgery of Ritual Circumcision","tradition":"scripture-revelation","translated_text":null,"word_count":8434}