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                               The Surgery
                                   of
                                 Ritual
                              Circumcision,

                                   BY
                             JACOB SNOWMAN,

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

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

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

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




PREFACE.


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

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

                                                              J. SNOWMAN.

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




CONTENTS.


                                                          PAGE.

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

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

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

     CHAPTER IV.--_Surgical Anatomy._                       23

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

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

    CHAPTER VII.--_Hæmorrhage._                             44




CHAPTER I.

_Infection of Wounds._


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

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

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

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

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

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

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

    _2_) _When absorbed in an especially active state._

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

    _4_) _In the presence of cold._

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

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

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

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

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

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

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

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

[Illustration]




CHAPTER II.

_Results of the Infection of Wounds._


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

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

    1) Ulceration at the cut edge of the prepuce.

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

    3) Sloughing or mortification of the reflected mucous membrane.

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

Of the more serious results of infection the principal is _Erysipelas_
in its various forms. Here we find that as the signs of unhealthy
inflamm