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.

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.

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.

Secondary HÆmorrhage.

Besides the bleeding which may occur immediately on the infliction of a wound, there is another variety which may take place subsequently, known as Secondary HÆmorrhage. This occurs when there is some failure in the process previously described, by which the wound heals. The coagulum is disturbed and the vessels are practically re-opened, or the coagulum becomes softened through the action of an infective agent. As a rule secondary hÆmorrhage indicates some form of infection.

Often in changing the dressing there is a minute amount of hÆmorrhage. This is due to injuring the developing blood vessels in the newly growing scar tissue.

HÆmorrhage due to constitutional conditions.

Some infants are born with a tendency to bleed, without any evident cause, either from the nose, bowels, or in the skin. The separation of the navel may be followed by bleeding. Many of these cases are due to hereditary disease of one character or another. Of these, there is one which requires special mention, because when fatal hÆmorrhage has occurred after circumcision it has been due to it. This is HÆmophilia. Subjects of this disease are called Bleeders, and it usually only affects males. It runs in families, one or two members may be affected while the rest are free. The females in a family of “bleeders”, though they may not suffer themselves, transmit the disease to their children. In this condition the slightest injury will start profuse hÆmorrhage. The use of a toothbrush may be sufficient to cause severe bleeding from the gums. If the family history of any child reveals the presence of this disease circumcision must not be performed. Should the operation have taken place in ignorance of the condition the difficulty in controlling the hÆmorrhage, and its recurrence if at all relieved will at once confirm the presence of HÆmophilia. The nature of the bleeding in this condition is that referred to before as Capillary.