The Surgery of Ritual Circumcision

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.