Circumcision as performed by the Jews upon the eighth day before the parts are developed would be a wise law for universal acceptance, but it is questionable if the surgeon is justified in chloroforming and performing a by no means trilling operation upon older children or adults when good results in many cases may be obtained by painless gradual dilatation.
Slitting of the prepuce is as a routine the best procedure in acquired phimosis. Though good results may be obtained by dilatation, this cannot be attempted in the presence of any acute inflammatory state of the foreskin or where there are warty growths or chancres. A sharp pointed bistoury being passed under the prepuce by the aid of a director, it is split up to the corona in the middle line of the penis on its dorsal aspect, and the mucous membrane and skin along the margins of the gaping wound are united by fine sutures; sometimes it may be necessary to snip away any redundant tissue with the scissors. This has the dis advantage of leaving an ungainly dewlap.
Circumcision is the more satisfactory operation in congenital cases, and especially where the prepuce is long. It should be performed, like the pre ceding operation, under a general anaesthetic owing to the great sensitive ness of the parts. The elongated prepuce is pulled forwards and clamped by the blades of a pair of forceps applied by the Davies-Colley method in an oblique direction forwards and downwards, after which the prepuce is cut off by the sweep of a sharp bistoury in front of the blades, as the glans lies safely behind the latter. The lining membrane of the remaining prepuce is next slit up on the dorsal aspect of the glans almost as far as the corona and neatly trimmed, after which the remaining narrow frill or collar of mucous membrane is stitched by a continuous or by interrupted sutures to the skin margin. When the original incision is skilfully made,
a pointed piece of skin remains, which can be sutured over the triangular area below the frenum. The surgeon frequently uses a subcuticular suture. Rapidity of healing depends on accuracy of suturing. With the sub cuticular suture the edges are brought together neatly, and as the suture is not tied and therefore " runs " there is no fear of oedema of the glans.
Some surgeons substitute a Clover's circumcision tourniquet for the blades of the dressing forceps, which are liable to slip, and scissors may advantageously be employed in the removal of the prepuce and in the slitting up of the mucous membrane which will be found to still cover the glans after the foreskin has been cut away in front of the tourniquet.
In very young subjects sutures are sometimes dispensed with, the edges of the skin and mucous membrane being brought into apposition and held by a narrow strip of lint or gauze wound round the penis. All bleeding vessels should be ligatured, and if the orifice of the urethra is found to be very narrow it should be enlarged by an incision directed for a short distance through its floor. Care should be taken that the frenum suffers no injury during the circumcision operation. Sterile Vaseline or Boric Acid Ointment makes a good dressing. The practice of sealing the wound up with collodion is a mistake, owing to the difficulty of removing the dressings. When these become caked with exudation or blood. the best plan is to place the patient in a warm bath till the lint or gauze becomes thoroughly soaked and softened.