Volume 46 Number 95
Produced: Sun Feb 13 10:36:35 EST 2005
Subjects Discussed In This Issue:
Circumcision Issues: Metzitza and Bronstein Clamp
[Nachum Klafter]
Metzitzah- how prevalent is it? (3)
[Ben Katz, Ira L. Jacobson, Avi Feldblum]
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From: Nachum Klafter <doctorklafter@...>
Date: Fri, 11 Feb 2005 10:12:05 -0800 (PST)
Subject: Circumcision Issues: Metzitza and Bronstein Clamp
I would like to share my thoughts and experiences about some
controversial aspects of Bris Milah. I am not a rabbi, and I am not
making recommendations for anyone else. Rather, I wish to enter for
your consideration some "real world" factors in the discussion of these
halakhic issues. I would also like to share my thinking as a halakhic
Jew who integrates modern medicine and science into my understanding of
HaShem's will.
I am a practicing physician and a trained mohel, with kabbalah from Rav
Yehuda Giyat of Yerushalayim, also signed by Rabbi Mordechai Eliyahu,
former Sephardi Chief Rabbi of Israel. (Rabbi Eliyahu did not test me,
but singed simply on the basis of Rav Giyat's endorsement, whom he knows
very well.)
When I was first trained, 11-12 years ago, I was originally very
reluctant to make use of any innovations with the circumcision
procedure. I endeavored to perform the metzitza (sucking of blood)
be-peh (with the mouth directly). I was also reluctant to use the
Bronstein Mogen Clamp. My own teacher, Rav Giyat, thought I was rather
chanyuk (too worried about deviating from the traditional way of doing
things), but he was tolerant of my frumkeit and said, "You can follow
those Ashkenazi rabbis if you really want to"? However, he insisted
that the Bronstein clamp yields a superior circumcision for mohalim with
limited experience, and he was adamant in asserting the opinion that
there are absolutely no halakhic problems or questions about
circumcisions done with this device. I realize, retrospectively, that
he wanted to expose me to other poskim who disagree with the prominent
Roshei Yeshiva of the Haredi world. Rav Giyat himself is higiya
le-hora'ah and is willing to posken certain shaylos (though I think he
has typically run them by Rav Eliyahu or another posek).
My attitudes about these issues have greatly changed as I have gained
experience in circumcision, life, and Torah. I do not perform
circumcisions frequently now as there is a very fine mohel in Cincinnati
who relies on brissin to augment his parnossah, and in any case it would
be very hard to integrate circumcisions into my hectic schedule as a
physician and assistant professor at the medical school. When I do
perform occasional circumcisions, I refuse to perform the metzitzah
be-peh, and I insist on using the Bronstein Clamp. I will explain why.
My experience as a mohel and physician lead me to the following
conclusions. The circumcisions I perform with a clamp are aesthetically
superior, heal much faster, yield less blood loss, will never require
sutures, require less manipulation with bandages, require no changing of
bandages, and go more quickly. There is 1-2 seconds (we have timed
this) of intense pain associated with the squeezing of the clamp before
the cut is made, but after the cut it appears to me that here is no
difference in the pain level. The fact that there is less manipulation
with the bandages, no requirement to change the bandages, and must
faster healing yields a great net reduction in the overall pain and
suffering of the infant which greatly outweighs the 1-2 seconds of
squeezing (at least, this is my informed judgment as a mohel and
physician). There are full time mohalim who are more skillful than I am
(though do I believe I am talented at it), and who can produce as good a
circumcision without the clamp as they can with it. However, I
certainly cannot.
I am intimately familiar with the halakhic questions which have been
raised about the clamp (lack of bleeding, pain from squeezing for child,
"killing" the foreskin with the clamp prior to cutting, introducing
innovations that make milah too easy for non-mohalim to do, introducing
any changes into the ritual,). However, I have spoken with numerous
rabbonim who have dealt with all of these issues compellingly, and
certain objections appear to be based on misunderstandings about the
actual procedure in the first place. In addition, the fact that I am so
confident that the circumcisions that I perform are far better with the
clamp than without is an additional basis for a heter with the Bronstein
clamp even according to poskim who are machmir with this device. For
the above reasons, I always use the clamp. If I were blessed with a
son, I would do the circumcision with the clamp.
Regarding metzitza: It is important to keep in mind that there is
absolutely no credible medical opinion that it is beneficial to
contaminate a foreskin wound with the saliva of the surgeon. I saw a
book called "Sanctity and Science"Bris Kerusa Bein Ha-Sefasayim" which
cites medical evidence of the healing properties of saliva for surgical
wounds. However, these papers were from 1912 and 1918 (if my memory is
correct). Apologists for metzitza be-peh should realize that it is very
disingenuous to start citing outdated medical literature to advocate a
position that is thoroughly rejected by medicine. There is, basically
no question about whether saliva according to our best medical
information is good for a wound. It is septic and promotes wound
infection.
The question, therefore, is not "Is saliva good"? We know it certainly
is not. The question is what we should do when the minhag for centuries
involves inclusion of a practice which is now thought to increase the
risk of serious injury and death, but which the Talmud and later
authorities felt was pro-healing. I was given the following pesak last
week by a Rosh Yeshiva (who wants to remain anonymous so he will not be
harassed by zeaots): If doing a bris among Orthodox Jews, use a sterile
syringe or a sterile glass tube for metzitza in order to avoid provoking
a quarrel with people who will be angry if metzitzh is omitted.
However, if among non-Observant, unknowledgeable Jews, omit metzitzah
entirely from the circumcision procedure. This pesak was personal and
limited to me, and it therefore cannot be relied upon by others.
I am open to anyone arguing with me, but please keep in mind that I have
received guidance in these issues from numerous rabbonim, poskim, and
mohalim over the last 12 years. My judgment about what is preferable
surgically and medically is informed both by my medical knowledge and my
experience doing circumcisions.
I certainly do not have any desire to persuade people to use the
Bronstein clamp, but I do think there are many relatively inexperienced
mohalim like me who could improve their outcomes if they used this
device. As far as metzitzah be-peh, the stakes on this issue have risen
with the recent reports of infants contracting serious illness and
death. HIV is still quite rare in North American Jewish Communities,
but it is not unheard of. It can't be dismissed from our consideration
of this question.
[Anticipating someone pointing out that the entire practice of
circumcision is called into question by some medical experts, I would
like to point out an important distinction. Circumcision is a Torah
obligation. We would do it even if there was a consensus of medical
opinion that it is not a healthful practice. The medical consensus
remains, by the way, that circumcision is fine or even beneficial.
Metzitza, however, is not even part of the mitzvah. It is an ancient
and medieval medical practice which was added to the circumcision ritual
in for the infant's heath benefit.]
-nachum klafter
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From: Ben Katz <bkatz@...>
Date: Fri, 11 Feb 2005 09:42:51 -0600
Subject: Re: Metzitzah- how prevalent is it?
>From: Ira L. Jacobson <laser@...>
> See the most comprehensive report to date in Pediatrics (URL:
> http://www.pediatrics.org/cgi/content/full/114/2/e259) where all
> tested mohalim (4/8; the others did not consent to be tested) were
> positive and 7/8 tested mothers were negative
>I am not taking a stand on the issue. My reaction is shock that a
>medical journal of any sort would report on "research" with such a tiny
>sample size and assign any degree of reliability to such a study.
Mr. Jacobson does not understand the nature of medical research
into uncommon diseases. Neonatal herpes has an incidence of about
1/5000 births. 8 cases due to circumcision is thus a very large number
of cases to discuss. If the mothers were tested and were seronegative
for HSV (not once, but 7 of 8 times) it is nearly impossible for any one
of them (let alone all 7) to have transmitted the infection to the
neonate, and there would have been almost no time for anyone else to do
so (except the mohel). Furthermore, the first "blip" on the CDC's radar
screen concerning AIDS was about 4 cases of a rare pneumonia seen in
homosexual men in San Francisco. Small case series can have a big
impact on medical knowledge.
Ben Z. Katz, M.D.
Children's Memorial Hospital, Division of Infectious Diseases
2300 Children's Plaza, Box # 20, Chicago, IL 60614
e-mail: <bkatz@...>
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From: Ira L. Jacobson <laser@...>
Date: Fri, 11 Feb 2005 14:16:53 +0200
Subject: Re: Metzitzah- how prevalent is it?
Eitan Fiorino stated the following, first quoting my comment:
My reaction is shock that a medical journal of
any sort would report on "research" with such a
tiny sample size and assign any degree of
reliability to such a study.
As someone immersed in the medical literature as a profession, I
profess no "shock" whatsoever at the contents of this paper, which
I have just finished reading. It does not claim to be a
randomized, controlled clinical trial - rather, it is essentially
a case series. Case reports and case series are very commonly
reported in the medical literature.
Case reports at times discuss rare phenomena, and as such are just that.
The article under discussion, however, makes far-reaching conclusions,
to wit, "Conclusion. Ritual Jewish circumcision that includes metzitzah
with direct oral/genital contact carries a serious risk for transmission
of HSV from mohels to neonates, which can be complicated by protracted
or severe infection. Oral metzitzah after ritual circumcision may be
hazardous to the neonate."
Now if the case studies, for example, represent four cases out of tens
of millions, then the conclusion seems unwarranted. Not to mention a
likely hillul hashem. First they say "carries a serious risk," and then
they backtrack and say "may be hazardous."
Mike Gerver writes:
The sample may be small, but if it was properly selected, it is
large enough to eliminate, with a high degree of confidence, the
hypothesis that herpes infections are hardly ever caused by the
mohel.
A sample of four mohalim! After reconsidering my statement, I can only
say, "You must be joking!"
As one more aside, I wouldn't be so quick to dismiss the
statistical significance of even this tiny sample. In this report
there were 8 babies with herpes, it appears 8 mothers (all of whom
did not have clincial herpes, though 1 had very low titers), 6
mohels, only 3 of which consented to serologic testing, and 3 of
the 3 were positive. If one compares 0/8 negative mothers to 3/3
positive mohels, that is p=0.006 by Fisher's exact test (2-tailed
comparison) - statistically significant by anyone's definition.
That may not be the best way to compare these groups (I'm no
biostatistician), but I think that makes the point.
I think if the population consists of tens of millions of britot mila, a
sample of four or eight is laughable. The conclusion to be drawn from
this study is that *those four* mohalim should take up another
profession. That is a totally justifiable conclusion. Perhaps regular
testing of all mohalim would be a justifiable recommendation.
IRA L. JACOBSON
mailto:<laser@...>
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From: Avi Feldblum <feldblum@...>
Date: Sun, 13 Feb 2005 10:35:05 -0500 (EST)
Subject: Metzitzah- how prevalent is it?
I find Ira's response on this topic very hard to understand. I don't think
it is just Ira's, but here on mail-jewish, he is clearly taking the front
line for this response / position to this topic.
I cannot understand why we would want to wait to gather additional
statistics on a situation like this. I think that there is no-one who
disagrees that the probability for a serious negative outcome related to
metzitzah b'peh is very low. But so what! I think it is very clear that
there have been a number of cases, and the medical evidence is that it is
very likely related to metzitzah b'peh. The fundimental purpose of
metzitzah b'peh was to give medical protection to the infant. With our
current medical knowledge, it is clear that it provides no positive
protection to the infant and has the potential for serious negative
outcomes. It is also clear, that there are halachic alternatives that
totally negate the risk.
I do not understand any position that advocates continuing this practice
without the most stringent safeguards taken. I also do not understand why
the Rabbinic leadership do not take a much more active stance to
discourage or forbid metzitzah b'peh in favor of alternate halachically
permissable options.
Avi Feldblum
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End of Volume 46 Issue 95
