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.