Chapter 15

MEZIZAH, THE FOURTH OR OBJECTIONABLE ACT OF SUCTION.

Biblical and rabbinical traditions throw no light on the origin of the details of the operation as now performed. That it was anciently performed with a knife of stone is certain; an event common in its general observance, and which seems to have pervaded all nations or races, howsoever remote or scattered, that it has induced Tylor[60] to ascribe the origin of the rite to the stone age. We are told that when Moses was returning to the land of Egypt he had neglected circumcising his son, and that because of that neglect he nearly lost his son's life; his wife, Zipporah, the daughter of the Midian king and priest, Jethro, seeing the danger and knowing its cause, took her little son Gershom and circumcised him with a stone knife, and offered the foreskin to God as a peace-offering. Just where the wine was first used we are not told. Wine, however, was an emblem of thanksgiving, and, being one of the fruits of the earth, was considered an acceptable offering to God. It has since, in some form or other, either as wine or as the representative of either divine or human blood, been used in both the Catholic and Protestant Churches in their ceremonials or vicarious sacrifices, or imitations of old customs. Circumcision was by many connected with a blood sacrifice; it was so suggested by the words of Zipporah at the circumcision of Gershom: "And Zipporah, his Midianitish wife, took up a sharp stone and cut off the foreskin of her son, and cast it at his feet and said, 'Surely a _Khathan_ of blood art thou to me.'" Much speculation has followed the use of this word _Khathan_, which, in the ordinary Arabian, may mean either husband or son-in-law; it also means a newly-admitted member of a family; a similar word means "to provide a wedding feast," and one other word from the same root and branch means "to give or receive a daughter in marriage." In our own day, the _mohel_, or ministerial circumciser, makes it a practice to draw a little blood from the skin of such as are presented for the rite, but whom nature has not furnished with sufficient foreskin for the operation. The application, thrice repeated, of the blood and wine to the lips of the child, is probably used as a sign of the sealing of the compact. Wine is mentioned in connection with the High-Priest Melchisedeck as the wine of thanksgiving at his meeting with Abraham; wine was presented to Aaron by the angel, who, giving him a crystal glassful of good wine, said to him: "Aaron, drink of this wine which the Lord sends you as a pledge of good news." Originally, circumcision must have consisted of the simple removal of the foreskin, and the elaboration of the ceremonial details must have been a subsequent occurrence; persons wounding their fingers will instinctively carry them to their mouth, and it may be that the suction practiced by the Hebrews had its origin in this natural hæmostatic suggestion. Wine as a hæmostatic and as an emblem of thanksgiving and an acceptable offering naturally came in as an accessory.

This practice--which, in the old, patriarchal days of the simple shepherds, when men only lived on the flesh of their own flocks, their diet, however, consisting mostly of cakes of flour, milk, honey, a few herbs, or the flesh of the goat or sheep--could not have been as objectionable as it is at the present day, with blood and secretions in a continued ferment through diet and habits. Man, living in the open air of Armenia, Palestine, or Arabia, sleeping in the open tents of our Biblical forefathers, living on the simple diet of a shepherd's camp, with the abstemiousness that those climates naturally induce in man, could not help but be healthy. In those early days, when neither passion, anxiety, nor worry disturbed either digestion or sleep, man had no vitiated secretions, wine was then a rarity, and water was the drink. One of the early patriarchs on such diet would have furnished a dainty and savory dish to the most fastidious cannibal, who is now tormented by the _komerborg kawan_, this being a term used by the Australian cannibals to designate the peculiar nausea that is induced in them when they recklessly eat of white man,[61]--something which they do not experience from feasting on the savages who live on the simple diet of a pastoral tribe. This primitive gastronomic science in regard to cannibalism even reached such a pitch of refinement that, as has been previously mentioned, some tribes even resorted to emasculation to improve the flavor of the animal juices, which by this procedure became less acrid. The Arabian and Oriental traditions bring us down tales of how, on the same principles, human beings intended to grace the festive platter were fed exclusively on rice. The salivary and buccal secretions, under such a simple diet as that indulged in by our Biblical forefathers, become bland and harmless; not only harmless, but even antiseptic and positively beneficial, acting on the same principle as local applications of pepsin. So that the practice, at the time of the patriarchs and in their own family, of this part of the rite could not have offered the same objection that it does at the present day. The modern house-dweller, living on a mixed diet and in a climate that induces him to eat grossly, both as to quality and quantity, partaking more or less of vinous, spirituous, or fermented liquors, as well as indulging in tobacco, is quite another being from the Arabian or Armenian shepherd of former days. Business anxieties and worry also have a very pronounced effect; so that, with the change in the conditions of man and the inception and multiplication of diseased conditions, as well as the creation of constitutional and transmissible diseases, this practice of suction should have been stopped.

Intelligent rabbis, devoted to their religion, are necessarily prone to defend any of the details in its ceremonials that age and practice have sanctioned, and even some of the later writings of Israelism seem to make the mezizah, or suction, a necessary and ceremonial detail. In the "Guimara," composed in the fifth century, Rabbi Rav Popè uses these words: "All operators who fail to use suction, and thereby cause the infant to run any risk, should be destituted of the right to perform the ceremony." In the "Mishna" it says, "It is permitted on the Sabbath to do all that is necessary to perform circumcision, excision, denudation, and suction." The "Mishna" was composed during the second century. The celebrated Maimonides lent it his sanction, as in his work on circumcision he advises suction, to avoid any subsequent danger. Our modern Israelites are supposed, as a rule, to have taken their authority, aside from previous usage and custom, from the "Beth Yosef," which was written by Joseph Karo, and subsequently annotated by the Rabbi Israel Isserth. In all of these sanctions, however, there is no reason expressed why it should be performed.[62] Maimonides undoubtedly looked upon this act as having a decided tendency or action in depleting the immediate vessels in the vicinity of the cut surface, and that the consequent constriction in their calibre would prevent any future hæmorrhage. That this is the natural result of suction is a fact readily understood by any modern physician. The depletion of the vessel for some distance in its length, with the contraction in the coat that follows, is certainly a better preventive to consequent hæmorrhage than the simple application of any styptic preparation that can only be placed at the mouth of the vessel, but which leaves its calibre intact. Hot water, or an extreme degree of cold, will answer to produce this contraction and depletion, but there is here a local physical reaction that is more liable to occur than when the contraction has taken place naturally, as when induced by depletion, instead of by the stimulus of either heat or cold. So that if, in the light of modern civilization and changed conditions of mankind, and the existence of diseases which formerly did not exist, we are now convinced that suction is dangerous, we should not judge the ancients too hastily or rashly for having adopted the custom, as it is certainly not without some scientific merit; although, authorities are not wanting who hold that suction or depletion increases the danger of hæmorrhage.

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, 10 grammes. 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.

Dr. Bergson uses a mixture composed of diluted sulphuric acid, 1 part; alcohol, 3 parts; honey, 2 parts; and 6 parts of wine vinegar.

Hæmostatic powders are also used by the Hebrews, being more conveniently kept or carried than the hæmostatic waters. In Russia and in Poland they are composed of decomposed or decayed hawthorn-wood powder and lycopodium. That of Berlin is composed of Armenian bole, red clay, dragons' blood, powdered rose-leaves, powdered galls, and powdered subcarbonate of lead. In France a hæmostatic fluid, composed of dragons' blood digested in turpentine, is in vogue. The Eau de Pagliari is also used; it is composed of a mixture of tincture of benzoin, 8 ounces; powdered alum, 1 pound; and 10 pounds of water, boiled together for six hours, and is considered a powerful styptic. In addition to these, burnt linen, spiders' webs, starch-powder, powdered alum, and plaster-of-Paris powder are used by different mohels. Touching the bleeding points with a pointed pencil of nitrate of silver is also a practice understood by the Jewish circumcisers.