The Surgery of Ritual Circumcision

by Jacob Snowman

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 inflammation around the wound occur, symptoms of constitutional illness begin. The infant becomes feverish, there is loss of appetite, rapid breathing and wasting supervene, with a profound alteration in the general appearance. The signs evident, locally, are redness of the skin increasing to a vivid blush which spreads on to the thighs, scrotum or abdomen. The surface is tender, and the edge of the red patch is sharply defined from the surrounding healthy skin. The disease is most active at this sharp margin for it is there that the micro-cocci may be found in abundance. The glands in the groin become swollen and tender, and the circumcision wound, failing to heal will probably inflame and suppurate. While this is going on, a poison is being manufactured by the microbes in their growth, and this poison being absorbed into the circulation, generally proves fatal to the infant.

The process is usually limited to the skin, and its uppermost layer is often raised into blebs containing clear or discoloured blood serum. But the morbid change may take place first in the tissues under the skin, 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 inflamed. In these cases the organisms readily enter the blood stream and being carried away to distant organs set up infection in these. These are necessarily the most hopeless cases of blood-poisoning.

So far we have briefly considered infection by the group of organisms known as micro-cocci. 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 wound. The one is the Tetanus (lockjaw) Bacillus, the other is the Tubercle Bacillus.

In Tetanus the first symptom noticed is that the infant is unable to suck, and on examination it will be found that this is due to cramp of the muscles of the jaw, which become fixed and hard. The face assumes a peculiar aspect which is quite characteristic of this disease, spasms of the limbs and then convulsions of the whole body take place, the joints become stiff and the case is almost invariably fatal.

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 circumcision, 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 Tuberculosis. A number of these cases have been reported from time to time, and in some of them it apparently led to general Tuberculosis (consumption).