Chapter V: Technique of Operation

A good light is essential for the performance of circumcision.

The instruments required are as follows:--

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_Circumcision in Abnormal Cases._

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

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

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

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