In 1954, Rabbi Harry Bronstein, a Brooklyn mohel who'd previously invented the Nutech clamp - that's the one that looks like a hacksaw - invented the Mogen clamp. Mogen means shield (and in fact what we call in English the Star of David is Mogen David in Hebrew, the Shield of David.) It resembles a barzel, but one whose two blades are hinged together, and brought together with a cam.
This is a step backward to straight-line cutting, but mohels like it because it's quick and resembles the traditional method. Unlike the barzel, it closes to crush the foreskin before it is cut. Described as "the least painful method" though there is no reason this should be so, and "able to be used without previous experience." With the glans below and completely out of sight, it can be trapped in the locked slit. And as Grossman points out, the meatal lips often project from the glans and into the clamp. It opens no wider than 3mm in order not to admit the glans - but it is not possible to see whether this has in fact happened: Varney's Midwifery - in a chapter written by a mohalet - says 'Using the Mogen clamp has the distinct disadvantage of making the circumcision a "blind" procedure. The glans of the penis cannot be seen (so anomalies may not be discovered until after the circumcision) and is thus at risk of being cut.'
This occurred in Florida in 2004, and the parents sued both the mohel and the Mogen company. They won $10.7 million, and the Mogen company went out of business.
Plastibell™
Come the 1950s, plastics and the age of disposables, and the Plastibell - developed out of the Ross Ring in 1950 - became the method of choice. Like the Gomco, it requires a dorsal slit and tearing of the foreskin from the glans before it can be fitted.
Then the foreskin is pulled up over the bell, and the ligature tied to crush it into the groove. Everything distal to the ligature dies, and to stop this upsetting parents too much, it may be cut off first.
A grooved plastic dome (with a handle, designed to be broken off) placed under the foreskin (which must be slit and forcibly separated from the glans to allow entry). A ligature (thread) is tied tightly around the foreskin, crushing it into the groove, causing it to become necrotic (to die) and drop off. Varney's Midwifery, citing Gee and Ansell, says "the Plastibell has a higher incidence of infection."
SPOILER (clicca per visualizzare)
Plastibell circumcision: A minor surgical procedure of major importance.
Samad A, Khanzada TW, Kumar B. Department of Surgery, Isra University, Hyderabad, Pakistan.
J Pediatr Urol. 2009 Jun 12.
OBJECTIVE: To determine ... the Plastibell impaction rate in various age groups.
...
RESULTS: ... The overall complication rate was 7.4%. Plastibell impaction [the Plastibell™ ring trapped by the swollen penis] was the commonest complication, encountered after 6.1% of procedures, and was managed by cutting the Plastibell. The impaction rate was only 2.3% for babies under 3 months, but gradually increased to 26.9% for children over 5 years.
Samad A, Khanzada TW, Kumar B. Department of Surgery, Isra University, Hyderabad, Pakistan.
J Pediatr Urol. 2009 Jun 12.
OBJECTIVE: To determine ... the Plastibell impaction rate in various age groups.
...
RESULTS: ... The overall complication rate was 7.4%. Plastibell impaction [the Plastibell™ ring trapped by the swollen penis] was the commonest complication, encountered after 6.1% of procedures, and was managed by cutting the Plastibell. The impaction rate was only 2.3% for babies under 3 months, but gradually increased to 26.9% for children over 5 years.
One study of 2000 PlastibellTM circumcisions found a complication rate of 2.8%, "the most frequent being minor infection and hemorrhage. Other complications included a tight Plastibell ring that can cause constriction of the glans penis, irregular skin margin, inadequate skin excision and migration proximally [up the penis] of the Plastibell ring as the glans swells with venous engorgement. There have been isolated cases of necrotizing fasciitis, ruptured bladder, retention of urine secondary to glandular prolapse, and retention of the Plastibell device.
Preputome
A cross between the Circumcision Forceps and the Gomco was the Preputome, invented in 1945 by a Brooklyn doctor called Al Akl.
(It was not actually a preputome, because it didn't cut. A better name would have been "prepustat".) It thoughtfully provided a hole through which the baby could urinate on the doctor. Since the bell pressed the glans downward, it could wedge some of the corona against the ring as the clamp was closed, allowing it to be cut along with the foreskin. The Preputome never became popular (especially not with babies).
Sheldon clamp II
The first of its two pairs of flat jaws grasps the acroposthion, the second set, the foreskin proper, ahead of the glans - if the boy is lucky. A straight cut is made between the two sets, resulting in a low circumcision similar to the tribal cut. Making the operator slice into a small aperture in the instrument almost guarantees an awkward cut. The Sheldon Clamp has reportedly been withdrawn because of lawsuits, but was still in use as late as 1994.
Sheldon Clamp (showing how glans can be damaged)
The design seems simply unfortunate; it's hard to understand how it ever left the drawing- board.
Tibone Clamp
Even simpler was the Tibone clamp of 1944 This lost the leverage provided by the Gomco, and was more awkward to fit. Also, says Grossman, the side arm of the C was too close to the bell, and got in the way of the scalpel. (You'd have thought that was easy to fix). The device never gained any popularity.
Improved Bloodless (Maryan) Clamp
Another variant on the Gomco was the Improved Bloodless Circumcision Clamp invented by a Dr H O Maryan in 1954:
This had three interchangable bells, and supported the screw on a tiny lintel, like an early printing press, that pulled instead of pushing.
Glansguard
A doctor called Melges invented the Glansguard as late as 1972. It resembles a kitchen bag-sealer. It has a built in knife. It doesn't guard the glans, especially when it's put on upside down, hence the clear message, "This Side Up".
Turner clamp
So did the Turner Clamp of 1952, but it is operates in the reverse direction, the bell crushing the prepuce down on the aperture.
Both had the problem of the Tibone times two, the supports of the bell getting in the way of the scalpel on both sides. Neither eclipsed the Gomco.
Leff clamp
Flat clamping continued with the Leff Clamp, invented in 1950, which looked like, and worked like, a large paper clip, used in conjuction with a barzel.
Kantor clamp
In 1953, a Texas physician called Kantor merged a haemostat with a barzel.
Its linear cuts, as with all linear devices, resulte in crushed "dog ears" at the front and back of the penis.
Ross Rings
The first of the tourniquet devices was the metal Ross ring.
In five sizes (reusable, as the handsome art deco walnut case implies), it included one groove for the ligature and one to catch the scalpel as it cut off the foreskin.
Its tiny handle was on an angle, perhaps to align with the axis of the penis and follow the line of the sulcus. But in that case the small notch on the outside is on the wrong side to accommodate the frenulum, as one commentary suggests. (Its purpose may actually be to facilitate the knot.) An enclosed leaflet reportedly "Says the device is to be left in place for 24 to 72 hours."
Reference:(For instruments from 1920-1980) Grossman E. The Evolution of Circumcision Technique. In Circumcision: A Pictorial Atlas of its History, Instrument Development and Operating Techniques. Great Neck: Todd & Honeywell 1982]
