1) Knife of steel, to be made of one piece of metal without joints, crevices or any ornamentation whatsoever. The handle should be stout enough to permit a firm grasp upon it. The blade should be about 5 inches in length and fully half inch in width.

2) Shield. This is a metal plate with a centre slit, the edges of which are made to grasp the prepuce at the level of the amputation. The Shield protects both the glans penis and the scrotum from injury by the knife.

3) Scissors. These are required occasionally to cut through the mucous membrane. They should be of the pattern known as the “blunt pointed.” When it is evident that the mucous membrane is very adherent to the glans, the separation of these two structures may be effected by the use of a Probe. This is a thin metal rod which is easily inserted under the mucous membrane and swept round the glans so as to break through the adhesions.

Stage I. The root of the penis is taken between the index and middle fingers of the right hand palm downwards, and pressure is made firmly backwards, the index finger being against the scrotum, the middle finger against the lower portion of the abdomen. This steadies the penis, keeps away the skin of the scrotum, and helps towards producing an erection.

Stage II. Keeping these fingers in this position, the glans is grasped between the thumb and index finger of the left hand. It is important not merely to take hold of the foreskin, the glans must be included between the fingers, and it must be examined by them so as to discover where it ends. This is determined by feeling the projecting rim of the Corona, and the neck beneath it. The skin overlying this marks the precise position where the shield is to be placed. When this position is accurately made out the whole of the skin in front of it is withdrawn beyond the glans by the fingers, and very firmly held upwards away from the scrotum.

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 manoeuvre 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.

Stage VII. The dressing consists of a strip of sterilized and antiseptic lint or gauze long enough to encircle the penis below the glans two or three times, and wide enough to cover the whole space between the corona and the root of the penis, i.e. 4¼ in. × ¾ in. The first layer of dressing is applied entirely below the glans and covers over the whole of the reflected mucous membrane. Care must be taken to apply this strip of lint at the very root of the penis and to begin on the under surface; otherwise there is a tendency for the dressing in this latter position only to just to reach the edge of the incision and to push it back towards the scrotum and thus increase the size of the raw area.

The glans must be quite free of the dressing encircling the penis and must project completely beyond the strip of lint applied below it. This piece of lint or gauze adheres quite well by itself, but to ensure its remaining in position, it is better to secure it by surrounding it once or twice with a piece of sterilized tape and twisting up the ends. If this is done too tightly it may obstruct the free flow of urine, or congest the glans.

The dressing is completed by covering over the naked and projecting glans with a square piece of antiseptic gauze. A diaper folded in the ordinary triangular shape is then put on, and this is secured firmly by means of broad tape. Two or three turns must be given round the thighs so as to keep them fixed, and the ends are to be tied over the hip.

During the after treatment the re-dressing may be regulated as follows. After about 10 or 12 hours, but at any rate within the first 24 hours, the piece of gauze covering the glans must be removed and the tape surrounding the dressing untwisted and also removed. If the circumcision has been properly and carefully performed, so that the whole of the mucous membrane and skin are kept back by the dressing, and the whole of the glans remains exposed, nothing further need be done but to replace some fresh gauze over the glans. On the following day the whole of the dressing should be removed, and gauze be re-applied around the penis leaving the end of the glans free. This dressing will fall off when the infant is in the bath, and may be renovated as often as necessary. As an alternative procedure the whole dressing may be removed after the first 24 hours, and the part re-dressed with gauze.

1st. In some cases the penis is sunken into the pubic skin, so that on grasping the prepuce the whole integument of the penis is pulled up leaving the organ itself buried in the skin behind. It will be found that in many of these cases the testicles have not descended into the scrotum. The first stage of the operation, in these instances, is all important. The root of the penis is embraced between the second and third fingers of the right hand as previously explained and firm pressure backwards is made until a definite erection is made. The amount of skin to be amputated must be very accurately estimated, the shield carefully adjusted in an oblique direction, as in these cases the inclusion of some of the skin of the scrotum is very easy. The mucous membrane often proves to be very thick, but whatever its consistence may be it should be cut away with scissors after reflection as this proceeding helps to prevent the glans sinking back into the skin. A careful examination of the infant must be made in these cases because they frequently denote immature development, and call for postponement of the performance of the circumcision.

2nd. The prepuce is sometimes deficient. The upper portion of the glans may be exposed and project beyond the short prepuce. The amount of the latter which should be removed is so small, that on pulling it forward there is not sufficient in the small circle of skin for the fingers to obtain a firm grasp. In this case forceps should be employed to hold the foreskin.

3rd. Some infants are born apparently circumcised. On examination it will be found that a considerable amount of prepuce still remains on the upper surface of the penis, while the under surface may be quite free. In these cases the whole of the remaining prepuce is grasped between the fingers and the operation is performed in the usual manner. Here also the underlying mucous membrane should be entirely cut away after it has been torn through.