For their dislike, they advance what appear to be very adequate reasons; and, in such a matter they must have enjoyed a far wider special experience than any practitioner without the Hebrew pale.
The following extract from Erichsen's Science and Art of Surgery (Ninth Edition, 1888) may be regarded as a typical account of the ordinary surgical operation in vogue at the present day. The italics are the present writer's:
Circumcision in boys or adults may be most conveniently performed in the following way. The surgeon restrains hæmorrhage during the operation by tying a tape tightly around the root of the penis, or by compressing the organ in Clover's circumcision tourniquet, a most useful instrument, which can be slackened or tightened at any time. He next draws the elongated prepuce slightly forwards, until the portion of it which corresponds to the back of the glans is brought just in front of that structure. He then seizes the projecting prepuce immediately in front of the glans with a pair of narrow-bladed polypus-forceps, which he gives to an assistant, who must hold them tightly; or he grasps it and protects the glans by means of a plate which I have had constructed for this purpose. With one sweep of the bistoury he cuts off all that portion of the integument which projects beyond the forceps, which are then taken away. It will now be found that he has removed only a circle of skin, but that the mucous membrane lining it still tightly embraces the glans; this he slits up, by introducing the point of a pair of scissors at the preputial orifice; and then, trimming off the angles of the flaps, he turns back the mucous membrane and attaches it to the edge of the cutaneous incision by a sufficient number of fine catgut sutures. Before introducing these, he will generally find it necessary to ligature a small artery on each side of the penis, and one or two in the frænum. The best dressing in children will be some simple ointment, such as boracic acid ointment, or the glans may be simply smeared with a little vaseline. After every act of micturition the parts should be well sponged with boracic acid lotion or Condy's fluid and water. In the adult, union by first intention may often be obtained by a dry dressing of iodoform-wool thickly covered with collodion, so as to protect it from the urine. This may be left unchanged for four or five days. There is usually a good deal of swelling of the mucous membrane about the frænum, and some solid œdema usually remains for some weeks after the operation. This gradually subsides, and a linear cicatrix remains, which causes the patient no inconvenience....
The chief points to be attended to in the performance of this operation, and on which its after-success is most dependent, are—1. That too much skin be not removed; 2. That the mucous membrane be slit up to the base of the glans; 3. That too much of it be not removed; 4. That all bleeding vessels be tied with catgut ligatures, which must be cut short; 5. That the mucous membrane be well turned back, so as to cover the gap left by the retracted skin; 6. That all sutures be of catgut, which will be absorbed, and thus save the pain of taking them out.
The modus operandi of different surgeons varies in particular details, usually of a slight and unimportant character. The pithy description contained in Maunders Operative Surgery may be appropriately quoted:
The extremity of the foreskin being seized with forceps is drawn well forwards; the whole prepuce is embraced with the blades of dressing-forceps, immediately anterior to the glans penis, and cut off in front of the latter instrument. As soon as the forceps are removed, the skin will become retracted, leaving the mucous membrane still about the glans; this is slit up longitudinally as far as the corona, when it may be turned back, and its edge will come into apposition with the circular wound in the skin. The operation is now complete; but in the adult it will be well to introduce a few interrupted sutures.
The prepuce has sometimes been slit up longitudinally on a director. Although well suited to cases of adventitious phimosis in the adult, the method is in no way adapted to the congenital form, and has never found general favour with the medical profession. It has no advantages over circumcision; although retaining the prepuce, it still leaves the glans largely uncovered; and the sharp corners of the divided skin, unless trimmed and rounded off, produce a very unsightly after-appearance.
In performing circumcision many surgeons hold the clamp or dressing forceps which protect the glans inclined obliquely downwards and forwards, so as to leave a portion of the prepuce in the neighbourhood of the frænum unremoved. As one of the main advantages claimed for the operation is the prevention of future infection by retention of morbid material in the preputial folds, such a practice would seem to indicate a lurking disbelief in the validity of this pretension. If it be reasonable and right to excise the structure on these grounds, and if that proceeding be attended by such salutary effects; it is only logical not to do things by halves, but to make the excision as complete as possible. Thus Liston made his section near the frænum, 'so as to retain the skin on the glans, which is of advantage.' The use of the elastic ligature, and of the écraseurs, both ordinary and galvanic, for the performance of circumcision, are cruel and fantastic modes of effecting that object, which hardly need any expression of condemnation; and which it is difficult to believe can ever have been seriously advocated. Keyes (Diseases of the Urinary Organs, 1888), after breaking up adhesions with an oiled probe, marks an aniline line around the foreskin, and amputates the skin, &c., in front of this mark; thus previously estimating the amount of tissue to be removed.[13]
For operations involving the amputation of the whole, or nearly the whole prepuce, the following advantages are claimed:—
(a) Greatly enhanced local cleanliness throughout after-life.