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.
CHAPTER VII.
Hæmorrhage.
Trouble from bleeding is an exceedingly rare occurrence at the circumcision of an infant, because no arteries or veins are cut through. But the possibility of its occurrence, however, remains, and therefore some points regarding it should come within the information of every Mohel. It will be his duty to apply first aid, and consequently a knowledge of the principles of the treatment of hæmorrhage should be familiar to him.
There are three varieties of bleeding.
1st. Capillary. This consists of the oozing of blood from various points on a cut surface. The vessels are minute hair-like structures, and bleeding from them is invariably stopped by firm pressure. This loss of blood occurs in more or less degree at every circumcision, and in the vast majority of cases is arrested by the natural process previously explained.
2nd. Arterial. The distinctive sign of this kind of bleeding is that it issues forth from the wound in spurts, and not in a continuous stream. Each spurt corresponds to a heart beat. This variety of hæmorrhage can only occur if an artery is cut through, i.e., a vessel which carries blood away from the heart to supply the tissues of the body.
3rd. Venous. This bleeding is due to the wound of a vessel which returns blood to the heart after it has circulated through the tissues. These vessels are called veins. The blood is dark in colour and issues from one definite spot in a continuous stream.
Treatment. For practical purposes only the first variety of hæmorrhage need be considered here. Circumcision in an infant should never interfere with an artery or vein; but in the event of this accident occurring a pledget of cotton-wool or lint must be firmly compressed with bandage around the bleeding point until the proper method can be adopted to deal with it. This consists of seizing the bleeding point with an instrument constructed for the purpose (artery forceps) and then twisting up the tissue caught in the forceps, or applying a ligature. This is a purely surgical proceeding, and as every case of hæmorrhage should without delay receive qualified medical attention nothing further need be said on this matter here.
In most cases the application of the dressing with very firm pressure suffices to arrest the inevitable bleeding of every circumcision. The bandaging cannot be considered satisfactory until the blood ceases to ooze through the dressing. In adjusting the diapers it must be seen that the thighs are tied together so that they are immovable, perfect rest being indispensable for the control of hæmorrhage. This treatment is merely a mechanical aid to the natural processes which arrest bleeding, and in the vast majority of cases is perfectly successful.
There are however certain drugs which may be applied to a bleeding surface to hasten the coagulation of the blood. These are called astringents. These are not to be used indiscriminately as many of them injure the tissues and interfere with the healing of the wound. If pressure alone is insufficient to stop the hæmorrhage and the local application of an astringent is to be tried, the part must first be carefully washed with an antiseptic solution, so as to see precisely where the bleeding is actually coming from. Strips of lint soaked in the astringent solution are then carefully applied and retained in position by the firm pressure of a bandage.
The following are the principal drugs which may be used in this way.
1.) Compound Tincture of Benzoin.
2.) Tincture of Hazeline.
3.) Strong solution of Alum in hot water.
4.) Solution of Tannic Acid (4 grains to the ounce.)
5.) Solution of Adrenalin Chloride.
The last of these has the reputation of being the most powerful astringent known.
A solution of Perchloride of Iron is often used, but this is open to the objection of injuring the delicate living tissues.