,the ,surgery of ,ritual ,circumcision1 ,,by ,,jacob ,,snowman1 ,m4,d41 ,m4,r4,c4,s41 ,m4,r4,c4,p41 ,,lond4 ,medical ,officer of the ,initiation ,society1 c41 c4 ,,london3 ,,published ,,under ,,the ,,auspices ,,of ,,the ,,medical ,,board ,,of ,,the ,,initiation ,,society4 #aijd4 ,e4 ,w4 ,,rabbinowicz1 ,,printer1 #dh1 ,,commercial ,,street1 ,e4 ,,preface4 ,the object of the following few pages is to provide a basis of instruction in the surgical aspect of the ,jewish rite of circumcision4 ,the performance of this simple operation is not limited to medical men4 ,it is therefore essential that the lay ,mohel should possess a scientific knowledge of the important task he undertakes4 ,the ,initiation ,society which controls the instruction of ,mohelim has arranged a ,syllabus which guarantees such an acquaintance with the subject4 ,this little book is planned in accordance with that syllabus4 ,its main object is to bring the principles of ,,asepsis within the information of everyone acting as a ,mohel1 and to insist upon the urgent need of carrying these principles into practice4 ,j4 ,,snowman4 #aa1 ,,shoot-,,up-,,hill1 ,,brondesbury1 ,n4,w4 ,july #aijd4 ,,contents4 ,,page4 ,,chapter ,i4--,causes of ,infection of ,wounds4 #g ,,chapter ,,ii4--,results of ,infection of ,wounds4 #ac ,,chapter ,,iii4--,elements of the ,antiseptic method4 #ag ,,chapter ,,iv4--,surgical ,anatomy4 #bc ,,chapter ,v4--,technique of ,operation4 #bh ,the ,dressing4 ,abnormalities4 ,,chapter ,,vi4--,repair of the ,wound4 #ch ,,chapter ,,vii4--,hmorrhage4 #dd ,,chapter ,i4 ,infection of ,wounds4 ,the greatest advance in modern surgery has been to show how wounds become infected and cause general blood poisoning4 ,this applies both to wounds made by the knife of the ,surgeon as well as to accidental injuries4 ,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 infant4 ,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 proceedings4 ,heavy responsibility lies upon the ,mohel to carry out every case strictly in accord with the lessons of surgical cleanliness4 ,surgical ,cleanliness begins where ordinary cleanliness leaves off4 ,its object is to destroy certain minute particles of matter which are invisible to the naked eye1 but which are living organisms of a vegetable nature1 able to grow very luxuriantly in blood1 and wound discharges4 ,here they produce a poison which gets absorbed into the body1 causing serious symptoms of disease2 or they themselves enter the blood stream and circulate in it with even more disastrous results4 ,these organisms can be observed under the microscope1 but can only be seen by the naked eye when growing together in colonies after being planted in such substances as gelatine or broth1 or on the surface of a slice of potato4 ,they correspond exactly to the growth of mould or fungus on stale cheese or meat1 or to the growth of yeast in fermenting grape juice4 ,when seen separately under the microscope1 or when growing in the mass they possess very distinct characters so that the expert is able to distinguish the one from the other1 with the same confidence as a pear may be distinguished from a fig4 ,a large number of diseases is due to the growth in the body of certain of these organisms1 and in many diseases we can be sure of always finding the particular one responsible for the condition1 either in the blood or in the discharges from the body4 ,this is notably the case in ,consumption1 ,typhoid ,fever1 and ,malarial ,fever4 ,we often know how the organism has obtained entrance into the body2 it may be either by the lungs or the stomach1 or in other words through air or through food4 ,we are however only concerned just now with the organisms which enter the body by means of an open wound4 ,these nearly all belong to one class--micro-cocci4 ,they are minute round bodies about #a_/bejjj inch in diameter4 ,they possess the peculiarity of growing together in clusters like grapes1 or in chains4 ,they are responsible for the diseased conditions of wounds which delay healing1 for inflammation around wounds and for the general blood-poisoning which may result4 ,these organisms are very abundant in the dust of rooms1 on dirty clothes and unclean general surroundings1 and there can be no doubt that everybody is often infected by them4 ,but fortunately disease results only rarely1 because there are special powers resident in the vital tissues which enable them successfully to resist the poisonous effects of these organisms4 ,there are however certain circumstances in which they are liable to be more harmful than in others4 #a7 ,when they are absorbed in especially large numbers4 #b7 ,when absorbed in an especially active state4 #c7 ,when the body is in a condition of ill-health from whatever cause4 #d7 ,in the presence of cold4 ,each one of these circumstances is of special importance in relation to circumcision and may be commented on as follows4 #a7 ,the slightest departure from scrupulous cleanliness either on the genitals of the infant1 on the instruments or dressings used1 or on the hands of the ,mohel enormously increases the number of microbes which may possibly infect the wound4 ,hence the necessity for absolute ordinary cleanliness before resorting to antiseptic measures4 #b7 ,it is well known that these organisms exist in a very virulent form in unhealthy wounds1 in boils and in abscesses1 and the worst cases of blood poisoning have resulted from the direct infection of a healthy wound from an unhealthy one4 ,for this reason all the precautions in regard to the disinfection of the hands1 which will be referred to subsequently1 must be carried out with rigorous care1 when there has been any possibility of their having come in contact with such sources of infection4 #c7 ,the natural protective power of the body against infection is diminished when the general health is below the normal standard4 ,this occurs in infants mainly1 when they are premature1 or suffering from jaundice1 sickness or diarrha1 congenital disease of the heart or other organs4 ,in these circumstances the circumcision must be delayed4 ,when the parts are unduly bruised1 the local resistance is considerably lowered2 hence the paramount necessity of the operation being performed neatly and dexterously4 ,if these micro-cocci have already found access to the body in other parts1 as evidenced by purulent ophthalmia 7i4e4 matter discharging from the eye lids7 or suppuration about the navel1 it is important that these conditions be cured before the circumcision is undertaken1 because experience shows that in their presence the risks of a general blood infection are increased4 #d7 ,there is a special liability for the skin of an infant1 particularly in the region of the scrotum1 to become irritated by its excretions and to present the eruption known as eczema4 ,the folds of the groin occasionally suffer in the same way1 the skin becoming reddened and peeling4 ,these cases demand medical attention before operation1 owing to special risks of infection4 ,no infant presenting a rash of any kind should be circumcised without previous examination by a doctor1 because it may indicate constitutional disease4 #e7 ,cold always indicates that the bodily processes are deficient in activity4 ,infants are especially liable to cold1 and hence the necessity to supply them with abundant artificial warmth4 ,this is especially required during the exposure which a circumcision involves1 and therefore due attention must be paid to the temperature of the room where the operation takes place1 draughts must be avoided1 and adequate protection of the infant when carried from and to the bedroom1 must be ensured4 ,illustration ,,chapter ,,ii4 ,results of the ,infection of ,wounds4 ,the name usually given to the conditions which result from wound infection is ,septic ,disease4 ,this includes both the mild and the grave troubles which may ensue4 ,the mild forms of infection usually appear as interference with the rapid healing of the circumcision wound4 ,the principal of these are3-- #a7 ,ulceration at the cut edge of the prepuce4 #b7 ,ulceration in the raw tissue left on the under surface of the penis between the reflected mucous membrane and the cut skin4 #c7 ,sloughing or mortification of the reflected mucous membrane4 ,these conditions are usually attended with some amount of swelling2 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 system4 ,of the more serious results of infection the principal is ,erysipelas in its various forms4 ,here we find that as the signs of unhealthy inflammation around the wound occur1 symptoms of constitutional illness begin4 ,the infant becomes feverish1 there is loss of appetite1 rapid breathing and wasting supervene1 with a profound alteration in the general appearance4 ,the signs evident1 locally1 are redness of the skin increasing to a vivid blush which spreads on to the thighs1 scrotum or abdomen4 ,the surface is tender1 and the edge of the red patch is sharply defined from the surrounding healthy skin4 ,the disease is most active at this sharp margin for it is there that the micro-cocci may be found in abundance4 ,the glands in the groin become swollen and tender1 and the circumcision wound1 failing to heal will probably inflame and suppurate4 ,while this is going on1 a poison is being manufactured by the microbes in their growth1 and this poison being absorbed into the circulation1 generally proves fatal to the infant4 ,the process is usually limited to the skin1 and its uppermost layer is often raised into blebs containing clear or discoloured blood serum4 ,but the morbid change may take place first in the tissues under the skin1 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 inflamed4 ,in these cases the organisms readily enter the blood stream and being carried away to distant organs set up infection in these4 ,these are necessarily the most hopeless cases of blood-poisoning4 ,so far we have briefly considered infection by the group of organisms known as micro-cocci4 ,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 wound4 ,the one is the ,tetanus 7lockjaw7 ,bacillus1 the other is the ,tubercle ,bacillus4 ,in ,tetanus the first symptom noticed is that the infant is unable to suck1 and on examination it will be found that this is due to cramp of the muscles of the jaw1 which become fixed and hard4 ,the face assumes a peculiar aspect which is quite characteristic of this disease1 spasms of the limbs and then convulsions of the whole body take place1 the joints become stiff and the case is almost invariably fatal4 ,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 circumcision1 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 ,tuberculosis4 ,a number of these cases have been reported from time to time1 and in some of them it apparently led to general ,tuberculosis 7consumption74 ,the foregoing brief statements exhaust most of the possibilities of wound infection by means of micro-organisms4 ,there is however another source of infection1 not yet definitely proved to be of microbic origin1 which has important relations to circumcision4 ,this is the poison of ,syphilis4 ,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 ,metzizah4 ,on the other hand1 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 poison1 and is capable of infecting a healthy individual when it is brought into contact with any wound1 abrasion or other breach of surface4 ,illustration ,,chapter ,,iii4 ,elements of the ,antiseptic ,method4 ,the purpose of ,antiseptic ,surgery is to avoid the occurrence of the dangers of infection referred to in the preceding chapter4 ,there are many methods of carrying out the system1 but the present description being limited to the requirements of circumcision does not aim at being exhaustive4 ,the two objects aimed at are3 #a7 ,the prevention of any micro-organisms gaining entrance to the wound4 ,this end is attained by the disinfection of the hands and especially the thumbnails of the operator1 of the instruments and dressings used2 and by perfect cleanliness of the genitals of the infant4 ,it may be said that the brief exposure of the parts during the performance of the circumcision carries with it no risk of infection1 because the organisms we have been considering are not usually airborne4 #b7 ,the application of such dressings as will keep the wound in an aseptic condition4 ,even the small amount of discharge from a circumcision wound forms a splendid soil for the growth of micro-organisms4 ,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 material4 ,the most convenient antiseptic for general use is ,carbolic ,acid4 ,this is a clear1 colourless liquid of rather oily consistence1 which rapidly becomes converted into solid crystals in cold weather4 ,when required for purposes of disinfection it should be mixed with #ci times its quantity of water1 or roughly one pint of water requires one tablespoonful of pure ,carbolic ,acid to make a solution of #a in #dj4 ,this solution is required for soaking the hands after they have been washed with soap and warm water1 and the nails scrubbed with a nail brush4 ,this latter proceeding is one of ordinary cleanliness1 the soaking in the ,carbolic ,acid solution1 which should be warm1 is in order to obtain ,surgical ,cleanliness4 ,it will be readily understood1 that if the hands come in contact with any possible source of infection after this soaking1 then it must be repeated before beginning the operation4 ,the disinfection of the hands must be the last stage in all the preparations for the circumcision4 ,a similar solution of #a in #dj ,carbolic ,acid may be used for placing the instruments in before the operation4 ,they are to be taken directly out of the solution as required4 ,a shallow dish of a material easily cleaned1 as metal1 glass or porcelain should be filled with #b ounces 7#e tablespoons7 of water which has been boiled1 and to this one half a teaspoonful of ,carbolic ,acid is added1 taking care that the acid is thoroughly well mixed up with the water and not allowed to float about in droplets4 ,if the instruments are scrupulously clean1 i4e41 if they have been washed thoroughly with soap and hot water1 they require to remain for one hour in the ,carbolic ,acid solution to render them sufficiently disinfected for operating purposes4 ,it is therefore quicker1 as it is also more scientific1 to sterilize the instruments before using them4 ,by sterilizing them we kill any micro-organisms that may be present on them1 and we are then confident that no living germs are carried to the wound by means of the instruments4 ,in other words they are aseptic4 ,instruments are sterilized by boiling for about ten minutes in clean water4 ,it is useful to add washing soda in the proportion of #e grains to every two tablespoons of water4 ,it is obvious that the instruments must be of metal1 as no other material will stand boiling4 ,they must be made in such a way as to prevent the accumulation of dust or dirt in joints or crevices4 ,compact apparatus for sterilization is supplied by every surgical instrument maker4 ,the instruments are usually placed on a wire gauze tray with handles and then into the sterilizing dish1 so that when the boiling is completed1 they are lifted out on this tray by means of hooks supplied for the purpose4 ,they are at once transferred to the shallow dish containing the #a in #dj ,carbolic ,acid solution detailed above4 ,by these means the instruments are cooled ready for use1 for obviously they cannot be taken directly out of the boiling water with the fingers2 and the fact that they are in an antiseptic solution1 prevents the access of any germs during the short interval before they are actually handled4 ,the dressings used in ,circumcision should consist only of lint and gauze4 ,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 circumcision4 ,these dressings are supplied by manufacturers1 already sterilized by exposure to super-heated steam1 and rendered antiseptic by various chemical agents4 ,carbolic ,acid used for the hands and the instruments1 is often employed for the dressings1 the antiseptic being fixed in the lint and the gauze by a special process4 ,most surgeons1 however1 prefer 8double cyanide0 dressings1 in which the antiseptic used is a salt known as cyanide of zinc and mercury4 ,from the first dressing until the circumcision is absolutely healed nothing but gauze need be used4 ,in a normal case no other application of any kind whatsoever is required4 ,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 gauze4 ,when this is done a piece of tape is twisted round the lint to retain it in position4 ,the tape and the lint must both be sterilized like the gauze4 ,the best course to adopt in regard to the dressings is to obtain them from a reliable firm of manufacturers1 who will supply them ready cut to the pattern required1 packed in small sealed aseptic tin cases ready for use4 ,having adopted all these precautions the ,mohel may be confident that in regard to his own hands1 the instruments1 and the dressings he has exercised every care which surgical science demands4 ,the only other important detail which demands attention is the part concerned in circumcision4 ,it is obvious that all the safeguards hitherto considered are valueless unless the infant himself is in a perfectly clean condition4 ,the disinfection of the skin of an adult before an operation is always a serious and difficult matter1 because the skin harbours so many micro-organisms1 including the very micro-cocci referred to previously4 ,elaborate measures are therefore employed for the skin disinfection4 ,but in the case of an infant the skin cannot be supposed to be such a probable source of wound infection4 ,it is sufficient that the genitals be washed about half an hour before circumcision1 with soap and warm water1 and subsequently a fomentation of ,boracic lint applied4 ,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 skin4 ,if it is thought desirable to employ such a dusting powder1 it should be a mixture of equal parts of ,boracic ,acid and ,starch4 ,the infant having been prepared as here stated1 the circumcision may proceed as soon as he is put in position4 ,should any soiling have taken place1 the infant must again be cleansed1 and in this case the genitals must be washed with the ,carbolic ,acid solution 7#a in #dj7 by means of a swab of cotton wool4 ,illustration ,,chapter ,,iv4 ,surgical ,anatomy4 ,it is essential for the ,mohel to possess a knowledge of the structure of the organ on which he operates4 ,the skin of the penis is continuous on the upper surface with the skin of the abdomen1 and on the under surface with that of the scrotum4 ,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 taken4 ,if the traction on the foreskin is too forcible and the skin of the scrotum is therefore pulled up tightly1 there is a danger of the scrotal skin being slit up to some extent4 ,the intimate connection of the skin of the penis and scrotum must always be kept well in mind4 ,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 urethra4 ,here it leaves the glans and joins the outer skin4 ,the name given to this structure is mucous membrane1 and the method of dealing with it constitutes the principal portion of the art of circumcision4 ,this mucous membrane is the whitish glistening structure which appears after the removal of the skin4 ,it is important to note the disposition of this mucous membrane1 as revealed after the amputation of the prepuce4 #a7 ,it usually covers over the glans right up to the orifice of the urethra4 #b7 ,it may be reflected off the glans before reaching this point1 and become continuous with or adherent to the skin lining4 ,in this case the glans will not be completely covered by the mucous membrane1 because a small portion will have been cut off in the first stage of the operation4 ,in those cases the membrane missing from the upper part of the glans will be found on the inside of the amputated foreskin4 #c7 ,in other cases this inner mucous membrane is very deficient covering only three quarters or less of the surface of the glans1 the remaining portion being adherent to the inner surface of the foreskin4 ,the consistence of this membrane is such that it can be easily torn through but1 #a7 ,it may be elastic so that it stretches without tearing4 #b7 ,it may be so thin that it is liable to be pushed down by the nails instead of being torn4 #c7 ,it may be so thick as to necessitate the use of the scissors to cut it4 ,it may be loosely applied to the glans so that the thumb nails are easily inserted beneath it1 or it may be so adherent that great difficulty is experienced in tearing it through and peeling it off the glans4 ,an important fold of this membrane1 triangular in shape is attached to the under surface of the glans below its base reaching almost up to the opening of the urethra4 ,this is called the ,frnum1 and it is fully exposed during the second stage of the operation4 ,the body of the penis itself is composed of three parts4 ,on the upper surface behind the glans are the two ,corpora ,cavernosa1 united firmly together1 but leaving a hollow on their under surface for the ,corpus ,spongiosum which is prolonged beyond them in an enlarged extremity known as the glans4 ,the constriction beneath the glans is called the ,cervix or ,neck1 while the projecting rim of the glans above this is called the ,corona4 ,occasionally there are found here small masses of soft creamy material1 which is the natural secretion of the part4 ,the canal of the urethra runs in the corpus spongiosum4 ,each of these three corpora is firmly united to the pubic bone behind4 ,they are constructed of an outer sheath from the inner surface of which numerous fine membranous partitions stretch1 dividing the whole up into numerous small compartments4 ,these compartments are lined with a fine network of veins1 which are able to expand with blood and to distend and fill up these spaces4 ,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 erection4 ,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 organ4 ,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 applied4 ,the manipulation of the organ necessary to grasp the prepuce is generally sufficient to stimulate the increased blood supply requisite for an erection4 ,the skin of the penis does not share with the rest of the organ1 a greater amount of blood during this state4 ,it stretches by its own elasticity4 ,all the arteries and veins of the penis run in the deep structures previously alluded to1 so that circumcision1 in an infant at any rate1 can never wound a blood vessel4 ,the ,frnum is freely supplied with blood1 and if cut will produce troublesome hmorrhage1 but a circumcision in no way interferes with this part4 ,illustration ,,chapter ,v4 ,technique of ,operation4 ,a good light is essential for the performance of circumcision4 ,the instruments required are as follows3-- #a7 ,knife of steel1 to be made of one piece of metal without joints1 crevices or any ornamentation whatsoever4 ,the handle should be stout enough to permit a firm grasp upon it4 ,the blade should be about #e inches in length and fully half inch in width4 #b7 ,shield4 ,this is a metal plate with a centre slit1 the edges of which are made to grasp the prepuce at the level of the amputation4 ,the ,shield protects both the glans penis and the scrotum from injury by the knife4 #c7 ,scissors4 ,these are required occasionally to cut through the mucous membrane4 ,they should be of the pattern known as the 8blunt pointed40 ,when it is evident that the mucous membrane is very adherent to the glans1 the separation of these two structures may be effected by the use of a ,probe4 ,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 adhesions4 ,the person who is to hold the infant1 is seated on a chair with his feet on the side rail of a second chair so as to keep the knees raised4 ,the latter must be kept close together4 ,a firm pillow is placed on the knees and the infant is laid thereon facing the ,mohel4 ,when the necessary clothing has been loosened1 the thighs and knees are bent up completely 7flexed7 and then the thighs are in addition rotated outwards1 and kept in this position by the hands of the individual holding the infant4 ,the clothes should be displaced behind the buttocks of the infant so as to raise the part4 ,the antiseptic preparations described in ,chapter iii4 having been carried out1 the operation is performed according to the following stages4 ,stage ,i4 ,the root of the penis is taken between the index and middle fingers of the right hand palm downwards1 and pressure is made firmly backwards1 the index finger being against the scrotum1 the middle finger against the lower portion of the abdomen4 ,this steadies the penis1 keeps away the skin of the scrotum1 and helps towards producing an erection4 ,stage ,,ii4 ,keeping these fingers in this position1 the glans is grasped between the thumb and index finger of the left hand4 ,it is important not merely to take hold of the foreskin1 the glans must be included between the fingers1 and it must be examined by them so as to discover where it ends4 ,this is determined by feeling the projecting rim of the ,corona1 and the neck beneath it4 ,the skin overlying this marks the precise position where the shield is to be placed4 ,when this position is accurately made out the whole of the skin in front of it is withdrawn beyond the glans by the fingers1 and very firmly held upwards away from the scrotum4 ,stage ,,iii4 ,the fingers are now to be removed from the root of the penis1 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 it4 ,the direction of the shield is important4 ,it must not be put on at right angles to the penis1 but obliquely upwards1 i4e41 the part of the shield held in the hand must incline towards the abdomen of the infant1 and the other part away from it4 ,in this way the circumcision will take off the foreskin in a quill shape1 and it will leave a sufficient amount of skin on the under surface of the penis4 ,if this precaution is not observed there is a great risk of denuding the under surface of the skin almost as far as the scrotum4 ,stage ,,iv4 ,the knife is then taken in the right hand and with one sweep along the shield the foreskin is amputated4 ,the knife must be handled firmly1 and the cut made from the heel4 ,the cut circular edge of the skin immediately retracts behind the corona1 though on the under surface the amount of skin remaining may fall short of this level4 ,stage ,v4 ,the amputated foreskin and the knife are now put aside1 the shield having already fallen off4 ,the ,mohel will now1 at a glance1 observe the disposition of the mucous membrane covering the glans4 ,he insinuates the nail of one thumb under its edge1 and seizes it between the nail and the index finger4 ,when this is grasped the manuvre is repeated with the thumbnail and index finger of the other hand1 keeping the two hands close together4 ,before proceeding further1 the ,mohel must be sure that he has a firm hold of the membrane4 ,the next step is to tear the membrane down in the centre1 until the prominent edge of the corona is exposed4 ,this tearing may be completed with one movement of the hands1 but if the membrane is long more than one movement may be required to tear it through completely4 ,when the neck below the corona is seen1 the flaps are reflected laterally backwards1 so that the torn edges of the mucous membrane may join the cut edge of the skin4 ,care must be taken that the membrane is peeled off as far as possible 7i4e4 till its junction with the frnum7 from the under surface of the glans and reflected directly backwards so as to unite with the cut edge of the skin4 ,the essence of the operation consists in the proper performance of this stage4 ,if not performed efficiently the resulting circumcision is very imperfect4 ,the mistakes usually made by beginners are as follows3 #a7 ,the mucous membrane is stretched without being torn through2 the glans then projects completely giving the impression that it has been exposed by the proper method4 #b7 ,the membrane is rolled back over the glans instead of being torn back4 #c7 ,the membrane is cleared off from the upper surface of the glans1 but is not sufficiently peeled off from the under surface4 ,stage ,,vi4 ,the operation is really completed with the preceding stage4#a ,the practice of ,metzizah may now be carried out by means of a swab of sterilized1 cotton wool with which the penis is to be firmly compressed4 ,this will effectually absorb the small amount of blood free in the tissues and at the same time helps to clean up the part4 ,stage ,,vii4 ,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 times1 and wide enough to cover the whole space between the corona and the root of the penis1 i4e4 #d in4 in4 ,the first layer of dressing is applied entirely below the glans and covers over the whole of the reflected mucous membrane4 ,care must be taken to apply this strip of lint at the very root of the penis and to begin on the under surface2 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 area4 ,the glans must be quite free of the dressing encircling the penis and must project completely beyond the strip of lint applied below it4 ,this piece of lint or gauze adheres quite well by itself1 but to ensure its remaining in position1 it is better to secure it by surrounding it once or twice with a piece of sterilized tape and twisting up the ends4 ,if this is done too tightly it may obstruct the free flow of urine1 or congest the glans4 ,the dressing is completed by covering over the naked and projecting glans with a square piece of antiseptic gauze4 ,a diaper folded in the ordinary triangular shape is then put on1 and this is secured firmly by means of broad tape4 ,two or three turns must be given round the thighs so as to keep them fixed1 and the ends are to be tied over the hip4 ,during the after treatment the re-dressing may be regulated as follows4 ,after about #aj or #ab hours1 but at any rate within the first #bd hours1 the piece of gauze covering the glans must be removed and the tape surrounding the dressing untwisted and also removed4 ,if the circumcision has been properly and carefully performed1 so that the whole of the mucous membrane and skin are kept back by the dressing1 and the whole of the glans remains exposed1 nothing further need be done but to replace some fresh gauze over the glans4 ,on the following day the whole of the dressing should be removed1 and gauze be re-applied around the penis leaving the end of the glans free4 ,this dressing will fall off when the infant is in the bath1 and may be renovated as often as necessary4 ,as an alternative procedure the whole dressing may be removed after the first #bd hours1 and the part re-dressed with gauze4 #a ,the performance of ,metzizah according to statutory ,jewish ,law consists of suction by the mouth4 ,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 was4 ,failure to carry out this measure was regarded as constituting a serious risk to the infant4 ,the possible dangers of this practice have become obvious during recent years and direct suction of the wound is1 from every point of view1 inadmissible4 ,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 interior4 ,circumcision in ,abnormal ,cases4 ,the penis is subject to many departures from its usual anatomy1 but here it will only be necessary to notice some of the more usual abnormalities4 #ast4 ,in some cases the penis is sunken into the pubic skin1 so that on grasping the prepuce the whole integument of the penis is pulled up leaving the organ itself buried in the skin behind4 ,it will be found that in many of these cases the testicles have not descended into the scrotum4 ,the first stage of the operation1 in these instances1 is all important4 ,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 made4 ,the amount of skin to be amputated must be very accurately estimated1 the shield carefully adjusted in an oblique direction1 as in these cases the inclusion of some of the skin of the scrotum is very easy4 ,the mucous membrane often proves to be very thick1 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 skin4 ,a careful examination of the infant must be made in these cases because they frequently denote immature development1 and call for postponement of the performance of the circumcision4 #bnd4 ,the prepuce is sometimes deficient4 ,the upper portion of the glans may be exposed and project beyond the short prepuce4 ,the amount of the latter which should be removed is so small1 that on pulling it forward there is not sufficient in the small circle of skin for the fingers to obtain a firm grasp4 ,in this case forceps should be employed to hold the foreskin4 #crd4 ,some infants are born apparently circumcised4 ,on examination it will be found that a considerable amount of prepuce still remains on the upper surface of the penis1 while the under surface may be quite free4 ,in these cases the whole of the remaining prepuce is grasped between the fingers and the operation is performed in the usual manner4 ,here also the underlying mucous membrane should be entirely cut away after it has been torn through4 ,illustration ,,chapter ,,vi4 ,repair of the ,wound4 ,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 inflicted1 it becomes necessary to consider this in detail4 ,the area of the circumcision wound extends between the corona of the glans and the circular cut edge of the skin4 ,the skin of the penis always retracts1 so that if the shield has been placed in the position previously indicated1 the skin will not after the circumcision reach quite up to the corona2 the neck of the glans will be well exposed4 ,this is the condition to be attained in ritual circumcision4 ,the mucous membrane1 after being torn through and reflected covers over the area of the resulting wound4 ,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 skin4 ,this approximation is not usually complete all round the wound4 ,the tearing through of the mucous membrane produces a narrow ,v shaped rent2 this is widened out when the membrane is reflected1 and if carefully apposed to the cut skin1 will unite with it4 ,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 penis4 ,it frequently does not reach as far back as the cut skin1 especially when the foreskin has been freely removed or when the mucous membrane has a tendency to curl up4 ,the result in the majority of circumcisions is that the upper portion of the wound heals rapidly1 where the lacerated edge of the mucous membrane has united to the cut edge of the skin1 while on the under surface1 the mucous membrane will adhere to the raw surface of the penis left by the retracting skin1 but there will probably be a gap where the membrane has failed to reach the cut edge of the skin4 ,this gap will necessarily be very small when the reflection of the mucous membrane has been complete4 ,where approximation of the two edges occurs union is rapid and healing by 8first intention0 results4 ,where some loss of substance occurs the gap becomes gradually filled by what is called granulation tissue1 and the term 8second intention0 is given to the healing process4 ,healing by first intention4 ,in amputating the foreskin a number of minute hair-like blood vessels which permeate the skin are cut through4 ,there is little or no bleeding1 because the blood immediately clots1 and almost at once a rim of coagulum is formed at the margin of the circumcision4 ,besides this the injury destroys a minute amount of living tissue known as connective tissue cells4 ,the wound causes a special degree of activity in the adjacent blood vessels1 so that certain important constituents of the blood flow out of the vessels and invade the cut margin where the blood has coagulated4 ,this invasion consists of the fluid portion of the blood--or lymph1 and the solid elements called white corpuscles--or leucocytes4 ,these latter remove the cells which have been killed by the injury1 and get rid of the blood clot1 probably by a process of digestion4 ,when this is effected1 the way is paved for the healing1 i4e4 the formation of the scar4 ,the naked-eye evidence of all this is to be found in the moisture or exudation on the surface of a wound4 ,as this forms on both surfaces of a wound1 the exudation is the first bond of union4 ,the fluid portion of this exudation becomes absorbed1 and what remains of it forms the scaffolding on which the scar is built up4 ,the scar consists of new connective tissue cells which have grown into this framework1 and multiplied rapidly1 causing firm cohesion of the two separate surfaces4 ,in order that these new cells should be properly nourished they require a sufficient blood supply1 and it is found that while their formation is proceeding minute new blood vessels shoot forth from the existing ones1 and they grow into the soft newly developing scar tissue4 ,owing to this fact1 free oozing of blood takes place when a healing wound is disturbed4 ,in the operation of circumcision it is well seen how the circulation of the blood re-acts to injury4 ,when the mucous membrane covering the glans is exposed it looks pale and translucent1 because of its scanty blood supply and its thinness4 ,very soon after it has been torn through1 its whole character changes4 ,it becomes engorged with blood1 it becomes red and congested it loses its translucency1 and at its lacerated edge the process of healing takes place as detailed above4 ,all scars are at first pink in colour1 because more new blood vessels are formed than are required for the permanent nourishment of the part when completely healed4 ,in the course of time these blood vessels shrink and waste away and the scar becomes whiter even than the adjacent skin4 ,this occurs also in the mucous membrane which remains pink for a considerable time4 ,the membrane in fact undergoes the first stage of inflammation as a reaction to the injury it has sustained4 ,the blood vessels become enormously dilated1 and its blood supply increased4 ,it presents the best conditions for healing along the edges where it has been torn1 but the whole of its outer surface also1 which1 after reflection becomes opposed to the raw surface between the corona and the cut foreskin inferiorly1 becomes united by a similar process to this raw area4 ,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 foreskin1 in which healing takes place by granulation or second intention4 ,the details of this method of healing are similar to the first2 the discharge or exudation from the wound takes place in the same manner1 but as there are not two surfaces to unite to each other1 this exudation simply covers over the wound in the form of a whitish or pale yellow layer of lymph4 ,the fluid discharge should be tolerably clear2 if it tends to be thick or milk like in colour it indicates that there has been some accidental contamination of the wound1 or that the vital powers necessary for normal healthy repair are below the average4 ,it shows that the inflammatory re-action of the tissues which is the essential requisite for healing has been excessive4 ,in this case not only has the wound been invaded by the white blood cells1 which as previously explained1 form the groundwork of the new tissue cells2 but a further step has taken place4 ,these white cells have been thrown off the surface of the wound and together with the exuded fluid go to form 8pus0 or matter4 ,all this causes delay in the healing4 ,but eventually the wound becomes filled up by the growth of new connective tissue cells2 these continue to multiply until the surface is reached1 when the uppermost or epithelial layer of the cut edge of the adjoining skin grows over it1 constituting a continuous skin covering4 ,the defects in the healing process may therefore be briefly summed as being due to some interference with the natural course of physiological repair4 ,they may be comprised under the following heads4 #a7 ,deficient vitality of the infant4 #b7 ,infection of wound4 #c7 ,imperfect performance of the operation especially when the tearing through and reflection of the mucous membrane has been incomplete4 ,these defects are to be prevented by a careful examination of the health of the infant previously to the circumcision1 by the employment of ,antiseptic measures1 and by carefully carrying out the technique of the operation4 ,illustration ,,chapter ,,vii4 ,hmorrhage4 ,trouble from bleeding is an exceedingly rare occurrence at the circumcision of an infant1 because no arteries or veins are cut through4 ,but the possibility of its occurrence1 however1 remains1 and therefore some points regarding it should come within the information of every ,mohel4 ,it will be his duty to apply first aid1 and consequently a knowledge of the principles of the treatment of hmorrhage should be familiar to him4 ,there are three varieties of bleeding4 #ast4 ,capillary4 ,this consists of the oozing of blood from various points on a cut surface4 ,the vessels are minute hair-like structures1 and bleeding from them is invariably stopped by firm pressure4 ,this loss of blood occurs in more or less degree at every circumcision1 and in the vast majority of cases is arrested by the natural process previously explained4 #bnd4 ,arterial4 ,the distinctive sign of this kind of bleeding is that it issues forth from the wound in spurts1 and not in a continuous stream4 ,each spurt corresponds to a heart beat4 ,this variety of hmorrhage can only occur if an artery is cut through1 i4e41 a vessel which carries blood away from the heart to supply the tissues of the body4 #crd4 ,venous4 ,this bleeding is due to the wound of a vessel which returns blood to the heart after it has circulated through the tissues4 ,these vessels are called veins4 ,the blood is dark in colour and issues from one definite spot in a continuous stream4 ,treatment4 ,for practical purposes only the first variety of hmorrhage need be considered here4 ,circumcision in an infant should never interfere with an artery or vein2 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 it4 ,this consists of seizing the bleeding point with an instrument constructed for the purpose 7artery forceps7 and then twisting up the tissue caught in the forceps1 or applying a ligature4 ,this is a purely surgical proceeding1 and as every case of hmorrhage should without delay receive qualified medical attention nothing further need be said on this matter here4 ,in most cases the application of the dressing with very firm pressure suffices to arrest the inevitable bleeding of every circumcision4 ,the bandaging cannot be considered satisfactory until the blood ceases to ooze through the dressing4 ,in adjusting the diapers it must be seen that the thighs are tied together so that they are immovable1 perfect rest being indispensable for the control of hmorrhage4 ,this treatment is merely a mechanical aid to the natural processes which arrest bleeding1 and in the vast majority of cases is perfectly successful4 ,there are however certain drugs which may be applied to a bleeding surface to hasten the coagulation of the blood4 ,these are called astringents4 ,these are not to be used indiscriminately as many of them injure the tissues and interfere with the healing of the wound4 ,if pressure alone is insufficient to stop the hmorrhage and the local application of an astringent is to be tried1 the part must first be carefully washed with an antiseptic solution1 so as to see precisely where the bleeding is actually coming from4 ,strips of lint soaked in the astringent solution are then carefully applied and retained in position by the firm pressure of a bandage4 ,the following are the principal drugs which may be used in this way4 #a47 ,compound ,tincture of ,benzoin4 #b47 ,tincture of ,hazeline4 #c47 ,strong solution of ,alum in hot water4 #d47 ,solution of ,tannic ,acid 7#d grains to the ounce47 #e47 ,solution of ,adrenalin ,chloride4 ,the last of these has the reputation of being the most powerful astringent known4 ,a solution of ,perchloride of ,iron is often used1 but this is open to the objection of injuring the delicate living tissues4 ,secondary ,hmorrhage4 ,besides the bleeding which may occur immediately on the infliction of a wound1 there is another variety which may take place subsequently1 known as ,secondary ,hmorrhage4 ,this occurs when there is some failure in the process previously described1 by which the wound heals4 ,the coagulum is disturbed and the vessels are practically re-opened1 or the coagulum becomes softened through the action of an infective agent4 ,as a rule secondary hmorrhage indicates some form of infection4 ,often in changing the dressing there is a minute amount of hmorrhage4 ,this is due to injuring the developing blood vessels in the newly growing scar tissue4 ,hmorrhage due to constitutional conditions4 ,some infants are born with a tendency to bleed1 without any evident cause1 either from the nose1 bowels1 or in the skin4 ,the separation of the navel may be followed by bleeding4 ,many of these cases are due to hereditary disease of one character or another4 ,of these1 there is one which requires special mention1 because when fatal hmorrhage has occurred after circumcision it has been due to it4 ,this is ,hmophilia4 ,subjects of this disease are called ,bleeders1 and it usually only affects males4 ,it runs in families1 one or two members may be affected while the rest are free4 ,the females in a family of 8bleeders01 though they may not suffer themselves1 transmit the disease to their children4 ,in this condition the slightest injury will start profuse hmorrhage4 ,the use of a toothbrush may be sufficient to cause severe bleeding from the gums4 ,if the family history of any child reveals the presence of this disease circumcision must not be performed4 ,should the operation have taken place in ignorance of the condition the difficulty in controlling the hmorrhage1 and its recurrence if at all relieved will at once confirm the presence of ,hmophilia4 ,the nature of the bleeding in this condition is that referred to before as ,capillary4 ,illustration