It can be understood that the results of suction would be in some measure analogous to those left by the application of an Esmarch bandage on a limb. The ancients, performing the operation with rude implements and having no hæmostatic remedies or appliances, naturally followed the best means at their command; they evidently feared hæmorrhage, and their rule in regard to exemption shows us that they recognized the existence of hæmorrhagic diathesis or other transmissible peculiarities of constitution. This same fear of hæmorrhage probably suggested the second step of the operation being performed, as it is by laceration instead of by cutting instruments, showing in this an evident desire to limit the cutting part of the operation to as small a limit as possible. Against an infant who has decided hæmorrhagic tendency, we are about as helpless as were the ancient Hebrews, and, while the Turkish or some of the Arabian methods of performing the operation may be said in ordinary cases—by the application of cord and the consequent constriction—to limit the danger from subsequent hæmorrhage, still, in the hæmorrhagic diathesis this would not be of any avail; so, as already observed, we must not too rashly judge those old shepherds of the Armenian plains for adopting a practice which to them was calculated to avert subsequent dangers, or their descendants following in their footsteps, until having learned better, even if that practice is to us disgusting, primitive, and useless.

Cases occur,—happily not frequently,—of alarming and uncontrollable hæmorrhage. The following case is suggestive of the alarming extent and persistence that may attend one of those hæmorrhagic cases, even when recovery eventually takes place. It is reported by Dr. Sannanel in the Gazetta Toscana delle science medicale e fisiche of 1844. The case was that of a Jewish infant circumcised on the eighth day. Some hours after the operation the child was observed to be bleeding; the hæmmorrhage would only cease for a few moments, and then come on with increased force, and which proved rebellious to ordinary remedies. Dr. Sannanel was called during the night of the third day after the operation. A number of physicians had been in attendance, and neither ice, astringents, pressure, nor any usual hæmostatic means had had the least effect; cautery with nitrate of silver, sulphuric acid, and the actual cautery by means of heated iron were tried in succession, without any good results. Ten days passed in this manner, the hæmmorrhage only ceasing for a few moments at a time, and the child was nearly exsanguinated from the continued serous seepage and the paroxysmal hæmorrhages, when a lucky application of caustic potassa almost immediately stopped the hæmorrhage. This case was seen by nearly all the leading medical men of Leghorn, who lent their aid and counsel to save the little life. The case is interesting from the length of time it persisted, and that even after all the loss of blood and suffering that the little fellow endured he survived.[63]

Dr. Epstein, of Cincinnati, in a letter of March 29, 1872, to the Israelite of that city, mentions a nearly fatal case from hæmorrage after the rite of “Milah,” and gives the result of his experience in such cases. He argues that Hitouch or Hitooch alone, or the first step or cutting off of the prepuce, performed with ordinary care, could hardly be followed up with any more serious results than can be controlled with the application of a little acidulated water. The second act, or Periah, the act of laceration, he looks upon as one that calls for coolness, judgment, and skill, as the membrane should only be torn so far and no farther, the thin, inner fold of the prepuce being vascular only in the sulcus back of the corona and at its lower attachment, where it forms the frenum, or bridle; any carelessness or over-anxiety on the part of the operator in tearing this membrane too far back results in danger of hæmorrhage; especially is this part of the operation liable to be badly done if the inner preputial fold is thick and resisting, as in that case undue force may carry the laceration back into the vascular tissue. The means suggested by Dr. Epstein to arrest hæmorrhage are those ordinarily used in hæmorrhagic cases, such as will be given presently. The doctor regrets that the operators are not as they should be, physicians, and that, when mohels are employed, persons are not sufficiently exacting as to their qualifications.[64]

In France the government has managed to secure more safety in the operation. By a royal decree of date of May 25, 1845, in compliance with a desire expressed by the Hebrew Consistory, it was ordered that no one should exercise the functions of a mohel or of schohet, without being duly authorized to perform said functions by the Consistory of the Circonscription; and that all mohels and schohets shall be governed in the exercise of their functions by the Departmental Consistory and the General Consistory. By virtue of this decree a regulation was passed by the Consistories on the 12th of July, 1854, ordering that thereafter circumcision should only be performed in a rational manner, and by a properly qualified person. Suction was likewise abolished, and the wound directed to be sponged with wine and water. This decree and the resulting regulations have been of the greatest benefit to the French Israelites, and some attention to the matter would not be amiss in the United States.

This reformation has met with the approval of the leading French Jews, whose General Consistory decided that suction was not necessarily a part of the religious rite, and that, as it was undoubtedly introduced into the rite on the days of primitive surgery, it was perfectly rational to suppress this operative accessory, now that that same science, in its enlightenment, pronounced it unsafe. The whole body of the Congregation did not tamely submit to what they considered an innovation, and from some of the mohels all possible resistance was opposed to prevent the abolishment of this part of the operation from becoming a law. So determined was this opposition in some instances that the Consistory of Paris found it necessary to impose on all the mohels an obligation, bound by an oath, that they would respect the law. Those who refused to take the obligation gave up their vocation.

The Grand Rabbi of Paris, at the time of this reformation, M. Ennery, was one of the most zealous supporters of the new departure. The influence of the French pervaded northward, and the mezizah was abolished in Brunswick, Dr. Solomon, a learned Hebrew of that State, being instrumental in having it done legally. The discussion of this subject, in 1845, had one very happy effect,—the supporters of the reformed idea of the rite issued a circular letter to all the leading continental surgeons and medical men asking for their opinion on several points in relation thereto, especially, however, on this part of the rite. The opinions of many of these will be referred to in the medical part of this work.

The after-treatment of the circumcised infant is governed more or less by local habits and the individual intelligence of the mohel and his experience. After turning back the inner fold of the prepuce, the parts are covered with a small, square bandage, with an aperture to admit the passage of the glans. This, and the subsequent small bandage of old linen, which is calculated to hold it in place, are slightly coated with a powder composed of lycopodium, with the slight addition, at times, of Monsel’s salts, alum-powder, or some vegetable astringent. Over these another compress is placed, to prevent the friction of the clothes of the infant or of the bedding. The infant then receives a final benediction, and the godmother then receives the child in her arms and carries it to its cot or crib. The operator generally visits the infant in the afternoon of the operation, and carefully inspects the dressings, to see that no hæmorrhage has supervened.

It is customary to place the child in a bath, either the same evening or on the following morning, the object of this being to remove and to facilitate the removal of the dressings, which are more or less saturated and clotted with blood. After the removal of these, the wound is redressed, as previously, except that some cerate—ointment of roses or some other mild ointment—is used. Some prefer the simple water dressing from beginning to end. Since the introduction of creasote, acid phénique, and carbolic acid, many mohels are in the practice of washing the parts with water impregnated with one of these before performing the operation, and using subsequently the same form of lotion at every dressing. In case of hæmorrhage there is an hæmostatic water or lotion, which has been long used by the German and Polish mohels with considerable success, and which, in ordinary cases, has been found to be all that was required. This water, called by the French “Mixture d’arguesbusade,” “Eau vulneraire spiriteuse de Theden,” and by the Germans as “Spritzwasser” and “Schusswasser,” is composed as follows:—

Acetic acid,10grammes.
Rectified spirits of wine,5”
Diluted sulphuric acid,2½”
Clarified honey,8”

This mixture is well mixed and filtered, and is then kept in a tightly-stoppered vial.