The Surgery of Ritual Circumcision

by Jacob Snowman

This solution is required for soaking the hands after they have been washed with soap and warm water, and the nails scrubbed with a nail brush. This latter proceeding is one of ordinary cleanliness, the soaking in the Carbolic Acid solution, which should be warm, is in order to obtain Surgical Cleanliness. It will be readily understood, that if the hands come in contact with any possible source of infection after this soaking, then it must be repeated before beginning the operation. The disinfection of the hands must be the last stage in all the preparations for the circumcision. A similar solution of 1 in 40 Carbolic Acid may be used for placing the instruments in before the operation. They are to be taken directly out of the solution as required. A shallow dish of a material easily cleaned, as metal, glass or porcelain should be filled with 2½ ounces (5 tablespoons) of water which has been boiled, and to this one half a teaspoonful of Carbolic Acid is added, taking care that the acid is thoroughly well mixed up with the water and not allowed to float about in droplets.

If the instruments are scrupulously clean, i.e., if they have been washed thoroughly with soap and hot water, they require to remain for one hour in the Carbolic Acid solution to render them sufficiently disinfected for operating purposes. It is therefore quicker, as it is also more scientific, to sterilize the instruments before using them. By sterilizing them we kill any micro-organisms that may be present on them, and we are then confident that no living germs are carried to the wound by means of the instruments. In other words they are aseptic. Instruments are sterilized by boiling for about ten minutes in clean water. It is useful to add washing soda in the proportion of 5 grains to every two tablespoons of water. It is obvious that the instruments must be of metal, as no other material will stand boiling. They must be made in such a way as to prevent the accumulation of dust or dirt in joints or crevices.

Compact apparatus for sterilization is supplied by every surgical instrument maker. The instruments are usually placed on a wire gauze tray with handles and then into the sterilizing dish, so that when the boiling is completed, they are lifted out on this tray by means of hooks supplied for the purpose. They are at once transferred to the shallow dish containing the 1 in 40 Carbolic Acid solution detailed above. By these means the instruments are cooled ready for use, for obviously they cannot be taken directly out of the boiling water with the fingers; and the fact that they are in an antiseptic solution, prevents the access of any germs during the short interval before they are actually handled.

The dressings used in Circumcision should consist only of lint and gauze. 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 circumcision. These dressings are supplied by manufacturers, already sterilized by exposure to super-heated steam, and rendered antiseptic by various chemical agents. Carbolic Acid used for the hands and the instruments, is often employed for the dressings, the antiseptic being fixed in the lint and the gauze by a special process. Most surgeons, however, prefer “double cyanide” dressings, in which the antiseptic used is a salt known as cyanide of zinc and mercury.

From the first dressing until the circumcision is absolutely healed nothing but gauze need be used. In a normal case no other application of any kind whatsoever is required. 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 gauze. When this is done a piece of tape is twisted round the lint to retain it in position. The tape and the lint must both be sterilized like the gauze.

The best course to adopt in regard to the dressings is to obtain them from a reliable firm of manufacturers, who will supply them ready cut to the pattern required, packed in small sealed aseptic tin cases ready for use.

Having adopted all these precautions the Mohel may be confident that in regard to his own hands, the instruments, and the dressings he has exercised every care which surgical science demands. The only other important detail which demands attention is the part concerned in circumcision. It is obvious that all the safeguards hitherto considered are valueless unless the infant himself is in a perfectly clean condition. The disinfection of the skin of an adult before an operation is always a serious and difficult matter, because the skin harbours so many micro-organisms, including the very micro-cocci referred to previously. Elaborate measures are therefore employed for the skin disinfection. But in the case of an infant the skin cannot be supposed to be such a probable source of wound infection. It is sufficient that the genitals be washed about half an hour before circumcision, with soap and warm water, and subsequently a fomentation of Boracic lint applied. 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 skin. If it is thought desirable to employ such a dusting powder, it should be a mixture of equal parts of Boracic Acid and Starch.

The infant having been prepared as here stated, the circumcision may proceed as soon as he is put in position. Should any soiling have taken place, the infant must again be cleansed, and in this case the genitals must be washed with the Carbolic Acid solution (1 in 40) by means of a swab of cotton wool.