_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.
_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_.
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