3rd. Some infants are born apparently circumcised. On examination it will be found that a considerable amount of prepuce still remains on the upper surface of the penis, while the under surface may be quite free. In these cases the whole of the remaining prepuce is grasped between the fingers and the operation is performed in the usual manner. Here also the underlying mucous membrane should be entirely cut away after it has been torn through.
CHAPTER VI.
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.