_Repair of the Wound._
As the whole difference between a scientific operator and a merely
mechanical Mohel lies in an appreciation of the process of repair in the
wound inflicted, it becomes necessary to consider this in detail.
The area of the circumcision wound extends between the corona of the
glans and the circular cut edge of the skin. The skin of the penis
always retracts, so that if the shield has been placed in the position
previously indicated, the skin will not after the circumcision reach
quite up to the corona; the neck of the glans will be well exposed. This
is the condition to be attained in ritual circumcision.
The mucous membrane, after being torn through and reflected covers
over the area of the resulting wound. _The planning of the operation
should be so carried out that the torn edges of the mucous membrane may
unite with the cut edge of the skin._ This approximation is not usually
complete all round the wound. The tearing through of the mucous membrane
produces a narrow V shaped rent; this is widened out when the membrane
is reflected, and if carefully apposed to the cut skin, will unite with
it. But the edge of that portion of the membrane peeled off from the
under surface of the glans will often fail to unite with the exit edge
of the skin on the under surface of the penis. It frequently does not
reach as far back as the cut skin, especially when the foreskin has been
freely removed or when the mucous membrane has a tendency to curl up.
The result in the majority of circumcisions is that the upper portion of
the wound heals rapidly, where the lacerated edge of the mucous membrane
has united to the cut edge of the skin, while on the under surface, the
mucous membrane will adhere to the raw surface of the penis left by the
retracting skin, but there will probably be a gap where the membrane has
failed to reach the cut edge of the skin. This gap will necessarily be
very small when the reflection of the mucous membrane has been complete.
Where approximation of the two edges occurs union is rapid and healing by
“first intention” results. Where some loss of substance occurs the gap
becomes gradually filled by what is called _granulation tissue_, and the
term “second intention” is given to the healing process.
_Healing by first intention._
In amputating the foreskin a number of minute hair-like blood vessels
which permeate the skin are cut through. There is little or no bleeding,
because the blood immediately clots, and almost at once a rim of coagulum
is formed at the margin of the circumcision. Besides this the injury
destroys a minute amount of living tissue known as _connective tissue
cells_. The wound causes a special degree of activity in the adjacent
blood vessels, so that certain important constituents of the blood
flow out of the vessels and invade the cut margin where the blood has
coagulated.
This invasion consists of the fluid portion of the blood--or lymph, and
the solid elements called white corpuscles--or leucocytes. These latter
remove the cells which have been killed by the injury, and get rid of the
blood clot, probably by a process of digestion. When this is effected,
the way is paved for the healing, i.e. the formation of the scar.
The naked-eye evidence of all this is to be found in the moisture or
exudation on the surface of a wound. As this forms on both surfaces of
a wound, the exudation is the first bond of union. The fluid portion
of this exudation becomes absorbed, and what remains of it forms the
scaffolding on which the scar is built up. The scar consists of new
connective tissue cells which have grown into this framework, and
multiplied rapidly, causing firm cohesion of the two separate surfaces.
In order that these new cells should be properly nourished they require
a sufficient blood supply, and it is found that while their formation is
proceeding minute new blood vessels shoot forth from the existing ones,
and they grow into the soft newly developing scar tissue. Owing to this
fact, free oozing of blood takes place when a healing wound is disturbed.
In the operation of circumcision it is well seen how the circulation of
the blood re-acts to injury. When the mucous membrane covering the glans
is exposed it looks pale and translucent, because of its scanty blood
supply and its thinness. Very soon after it has been torn through, its
whole character changes. It becomes engorged with blood, it becomes red
and congested it loses its translucency, and at its lacerated edge the
process of healing takes place as detailed above.
All scars are at first pink in colour, because more new blood vessels are
formed than are required for the permanent nourishment of the part when
completely healed. In the course of time these blood vessels shrink and
waste away and the scar becomes whiter even than the adjacent skin. This
occurs also in the mucous membrane which remains pink for a considerable
time. The membrane in fact undergoes the first stage of inflammation
as a reaction to the injury it has sustained. The blood vessels become
enormously dilated, and its blood supply increased. It presents the best
conditions for healing along the edges where it has been torn, but the
whole of its outer surface also, which, after reflection becomes opposed
to the raw surface between the corona and the cut foreskin inferiorly,
becomes united by a similar process to this raw area.
In those cases where the reflection of the mucous membrane has not been
perfect a gap will be left between its margin and the cut foreskin, in
which healing takes place by _granulation or second intention_.
The details of this method of healing are similar to the first; the
discharge or exudation from the wound takes place in the same manner,
but as there are not two surfaces to unite to each other, this exudation
simply covers over the wound in the form of a whitish or pale yellow
layer of _lymph_. The fluid discharge should be tolerably clear; if it
tends to be thick or milk like in colour it indicates that there has been
some accidental contamination of the wound, or that the vital powers
necessary for normal healthy repair are below the average. It shows
that the inflammatory re-action of the tissues which is the essential
requisite for healing has been excessive. In this case not only has
the wound been invaded by the white blood cells, which as previously
explained, form the groundwork of the new tissue cells; but a further
step has taken place. These white cells have been thrown off the surface
of the wound and together with the exuded fluid go to form “_pus_” or
_matter_. All this causes delay in the healing. But eventually the wound
becomes filled up by the growth of new connective tissue cells; these
continue to multiply until the surface is reached, when the uppermost or
epithelial layer of the cut edge of the adjoining skin grows over it,
constituting a continuous skin covering.
The _defects in the healing process_ may therefore be briefly summed as
being due to some interference with the natural course of physiological
repair. They may be comprised under the following heads.
1) Deficient vitality of the infant.
2) Infection of wound.
3) Imperfect performance of the operation especially when the
tearing through and reflection of the mucous membrane has been
incomplete.
These defects are to be prevented by a careful examination of the health
of the infant previously to the circumcision, by the employment of
Antiseptic measures, and by carefully carrying out the technique of the
operation.
[Illustration]