Circumcision - Part Two
Infectious Disease & Immunity
According to Biblical law, a male infant should be circumcised at the age of 8 days as a sign of the eternal covenant between God and the Jewish people (Genesis 17:10–14; Leviticus 12:3). According to classical rabbinical interpretation, performance of this religious ritual offers medical advantages, a view upheld by many modern medical authorities, as noted earlier.
The Babylonian Talmud (Sabbath 133b), the main rabbinical literature completed in the fifth century of the common era, states that for the sake of the infant, the mohel is obliged to perform the metzitzah" so as not to bring on risk." The nature of the risk was not specified. It specifically states that "this procedure is performed for the sake of the infant's safety and if a mohel does not perform the suction [of the wound], this is deemed dangerous and he is to be dismissed." To prevent medical complications, the Talmud permits only an experienced and responsible mohel to perform the ritual circumcision.
The Talmud (Tossefta Shabbath 15:8) was aware of potential medical problems that could arise from ritual circumcision13 and in fact provided the first description of hemophilia in the history of medicine, manifested as a familial bleeding disorder that required circumcision to be postponed.14
In the 19th century, Ignaz Philipp Semmelweis (1818–1865) established the principles of hygiene and disease transmission,15 after neonatal tuberculosis was documented after circumcision by an infected mohel.16 Since then, most rabbinical authorities modified their approach in response to these findings.
Because the Talmudic injunction to perform metzitzah did not explicitly stipulate oral suction, >160 years ago, Rabbi Moses Schreiber (Pressburg, 1762–1839), a leading rabbinical authority, ruled that metzitzah could be conducted by instrumental suction,16 a ruling quickly adopted by most rabbinical authorities.17 Consequently, the great majority of ritual circumcisions are performed today with a sterile device and not by oral suction by the mohel. However, some orthodox rabbis have felt threatened by criticism of the old religious customs and strongly resist any change in the traditional custom of oral metzitzah
The cultural process of replacing ancient customs by modern wound care has to be encouraged by a heightened awareness of this potentially life-threatening medical complication.16
On the basis of our observations, the medicolegal impact of neonatal infection by the mohel has to be redefined. Our findings provide evidence that ritual Jewish circumcision with oral metzitzah may cause oral–genital transmission of HSV infection, resulting in clinical disease including involvement of the skin, mucous membranes, and HSV encephalitis. Furthermore, oral suction may not only endanger the child but also may expose the mohel to human immunodeficiency virus or hepatitis B from infected infants. The same consideration that led the Talmudic sages once to establish the custom of the metzitzah for the sake of the infant could now be applied to persuade the mohel to use instrumental suction.
Indeed, after our first cases, the Chief Rabbinate of Israel pronounced in 2002 the legitimacy of using instrumental suction in cases in which there is a risk of contagious disease
. We support ritual circumcision but without oral metzitzah, which might endanger the newborns and is not part of the religious procedure.
ACKNOWLEDGMENTS
Dina Averbuch, MD, diagnosed and treated patient 4.
FOOTNOTES
Received for publication Nov 20, 2003; accepted Feb 18, 2004.
Reprint requests to (R.D.) Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, 84101, Israel. E-mail: rdagan@bgumail.bgu.ac.il
Poland RL. The question of routine neonatal circumcision. N Engl J Med.1990; 322 :1312 –1315[ISI][Medline]
Wiswell TE. Circumcision circumspection. N Engl J Med.1997; 336 :1244 –1245[Free Full Text]
Wallerstein E. Circumcision. The uniquely American medical enigma. Urol Clin North Am.1985; 12 :123 –132[ISI][Medline]
Linshaw MA. Controversies in childhood urinary tract infections. World J Urol.1999; 17 :383 –395[CrossRef][ISI][Medline]
Roberts KB, Akintemi OB. The epidemiology and clinical presentation of urinary tract infections in children younger than 2 years of age. Pediatr Ann.1999; 28 :644 –649[ISI][Medline]
Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJ, Ronald AR. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis.1994; 21 :201 –210[ISI][Medline]
Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health.1994; 84 :197 –201[Abstract]
Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet.1999; 354 :1813 –1815[CrossRef][ISI][Medline]
Hammerberg O, Watts J, Chernesky M, Luchsinger I, Rawls W. An outbreak of herpes simplex virus type 1 in an intensive care nursery. Pediatr Infect Dis J.1983; 2 :290 –294[ISI]
Rubin LG, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatr Infect Dis J.2000; 19 :266 –268[CrossRef][ISI][Medline]
Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Isr Med Assoc J.2003; 5 :893 –894[ISI][Medline]
Libman MD, Dascal A, Kramer MS, Mendelson J. Strategies for the prevention of neonatal infection with herpes simplex virus: a decision analysis. Rev Infect Dis.1991; 13 :1093 –1104[ISI][Medline]
Preuss J. Julius Preuss’ Biblical and Talmudic Medicine. Rosner F, trans-ed. New York, NY: Ktav Publishers; 1971:375
Rosner F. Hemophilia in the Talmud and rabbinic writings. Ann Intern Med.1969; 70 :833 –837[ISI][Medline]
Semmelweis I, Carter K. The etiology, concept, and prophylaxis of childbed fever. In: Wisconsin Publications in the History of Science and Medicine No. 2. Madison, WI: University of Wisconsin Press; 1983: 263
Katz J. Controversy over the Mezizah, the unrestricted execution of the rite of circumcision. In: Law in Human Hands—Case Studies in Halakhic Flexibility. Jerusalem, Israel: Magnes Press, Hebrew University; 1998:357–402
Shields Y. The making of Metzitzah. Tradition.1972; 13 :36 –48
--------------------------------------------------------------------------------
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
According to Biblical law, a male infant should be circumcised at the age of 8 days as a sign of the eternal covenant between God and the Jewish people (Genesis 17:10–14; Leviticus 12:3). According to classical rabbinical interpretation, performance of this religious ritual offers medical advantages, a view upheld by many modern medical authorities, as noted earlier.
The Babylonian Talmud (Sabbath 133b), the main rabbinical literature completed in the fifth century of the common era, states that for the sake of the infant, the mohel is obliged to perform the metzitzah" so as not to bring on risk." The nature of the risk was not specified. It specifically states that "this procedure is performed for the sake of the infant's safety and if a mohel does not perform the suction [of the wound], this is deemed dangerous and he is to be dismissed." To prevent medical complications, the Talmud permits only an experienced and responsible mohel to perform the ritual circumcision.
The Talmud (Tossefta Shabbath 15:8) was aware of potential medical problems that could arise from ritual circumcision13 and in fact provided the first description of hemophilia in the history of medicine, manifested as a familial bleeding disorder that required circumcision to be postponed.14
In the 19th century, Ignaz Philipp Semmelweis (1818–1865) established the principles of hygiene and disease transmission,15 after neonatal tuberculosis was documented after circumcision by an infected mohel.16 Since then, most rabbinical authorities modified their approach in response to these findings.
Because the Talmudic injunction to perform metzitzah did not explicitly stipulate oral suction, >160 years ago, Rabbi Moses Schreiber (Pressburg, 1762–1839), a leading rabbinical authority, ruled that metzitzah could be conducted by instrumental suction,16 a ruling quickly adopted by most rabbinical authorities.17 Consequently, the great majority of ritual circumcisions are performed today with a sterile device and not by oral suction by the mohel. However, some orthodox rabbis have felt threatened by criticism of the old religious customs and strongly resist any change in the traditional custom of oral metzitzah
The cultural process of replacing ancient customs by modern wound care has to be encouraged by a heightened awareness of this potentially life-threatening medical complication.16
On the basis of our observations, the medicolegal impact of neonatal infection by the mohel has to be redefined. Our findings provide evidence that ritual Jewish circumcision with oral metzitzah may cause oral–genital transmission of HSV infection, resulting in clinical disease including involvement of the skin, mucous membranes, and HSV encephalitis. Furthermore, oral suction may not only endanger the child but also may expose the mohel to human immunodeficiency virus or hepatitis B from infected infants. The same consideration that led the Talmudic sages once to establish the custom of the metzitzah for the sake of the infant could now be applied to persuade the mohel to use instrumental suction.
Indeed, after our first cases, the Chief Rabbinate of Israel pronounced in 2002 the legitimacy of using instrumental suction in cases in which there is a risk of contagious disease
. We support ritual circumcision but without oral metzitzah, which might endanger the newborns and is not part of the religious procedure.
ACKNOWLEDGMENTS
Dina Averbuch, MD, diagnosed and treated patient 4.
FOOTNOTES
Received for publication Nov 20, 2003; accepted Feb 18, 2004.
Reprint requests to (R.D.) Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, 84101, Israel. E-mail: rdagan@bgumail.bgu.ac.il
Poland RL. The question of routine neonatal circumcision. N Engl J Med.1990; 322 :1312 –1315[ISI][Medline]
Wiswell TE. Circumcision circumspection. N Engl J Med.1997; 336 :1244 –1245[Free Full Text]
Wallerstein E. Circumcision. The uniquely American medical enigma. Urol Clin North Am.1985; 12 :123 –132[ISI][Medline]
Linshaw MA. Controversies in childhood urinary tract infections. World J Urol.1999; 17 :383 –395[CrossRef][ISI][Medline]
Roberts KB, Akintemi OB. The epidemiology and clinical presentation of urinary tract infections in children younger than 2 years of age. Pediatr Ann.1999; 28 :644 –649[ISI][Medline]
Moses S, Plummer FA, Bradley JE, Ndinya-Achola JO, Nagelkerke NJ, Ronald AR. The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis.1994; 21 :201 –210[ISI][Medline]
Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health.1994; 84 :197 –201[Abstract]
Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet.1999; 354 :1813 –1815[CrossRef][ISI][Medline]
Hammerberg O, Watts J, Chernesky M, Luchsinger I, Rawls W. An outbreak of herpes simplex virus type 1 in an intensive care nursery. Pediatr Infect Dis J.1983; 2 :290 –294[ISI]
Rubin LG, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatr Infect Dis J.2000; 19 :266 –268[CrossRef][ISI][Medline]
Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Isr Med Assoc J.2003; 5 :893 –894[ISI][Medline]
Libman MD, Dascal A, Kramer MS, Mendelson J. Strategies for the prevention of neonatal infection with herpes simplex virus: a decision analysis. Rev Infect Dis.1991; 13 :1093 –1104[ISI][Medline]
Preuss J. Julius Preuss’ Biblical and Talmudic Medicine. Rosner F, trans-ed. New York, NY: Ktav Publishers; 1971:375
Rosner F. Hemophilia in the Talmud and rabbinic writings. Ann Intern Med.1969; 70 :833 –837[ISI][Medline]
Semmelweis I, Carter K. The etiology, concept, and prophylaxis of childbed fever. In: Wisconsin Publications in the History of Science and Medicine No. 2. Madison, WI: University of Wisconsin Press; 1983: 263
Katz J. Controversy over the Mezizah, the unrestricted execution of the rite of circumcision. In: Law in Human Hands—Case Studies in Halakhic Flexibility. Jerusalem, Israel: Magnes Press, Hebrew University; 1998:357–402
Shields Y. The making of Metzitzah. Tradition.1972; 13 :36 –48
--------------------------------------------------------------------------------
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
posted by Paul Mendlowitz | 7:48 PM
14 Comments:
UOJ,
good enough evidence for me.you're not as bad as they want to make you.i also checked two other points you made with other people and they agreed that you were right.
jewboy-what other issues was he right?
hasidic rebbes in europe were paid to keep their people from leaving europe.also almost all hasidic organizations steal money from thew goverment.
also that the kutler and margolis families are a bunch of crooks and the yeshivas real estate is owned by them personally.
The purpose is to elucidate the sheer destruction and the trivialization of authentic halacha.
How do you standby and permit these degenerates to represent themselves as our leaders and spokesmen?
It's insanity!
Shame on Yisroel Belsky for attending that meeting with the ignoramuses.
Nobody gives a damn about those hasidim, not even the hasidim themselves.
They are the worst haters of ALL Jews, including their own groups.
many hassids get degrees by clep and correspodence courses
tendler is an old drunk I know him
he's stupid can't see past his own noze, very arrogant, has his own agenda
for years YU wanted to get rid of him
Yitzy,
What are you talking about? The Chassidim do not pursue college degrees - even with CLEP. Maybe some of the girls do - the ones not very Chasiddish - but the guys who are fed up w/ the BS just rebel (drugs, gambling, women)they can't even write a sentence, forget about college!)
stop with the "dear" it's annoying!
This comment has been removed by the author.
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The information quoted here is word for word from Tendlers article. Look up Semmelweis's history for starters and you'll see Dr. Tendler is a pathological liar. Semmelweis had nothing to do with either circumcision or tuberculosis. The two books that are quoted by Semmelweis and Katz make no mention of such an incident. There is no responsa in Chasam Sofer (Rabbi Moses Schreiber) permitting use of "Instumental suction". The Chasam Sofer died in 1939, Semmelweis made his discovery in may 1847. The "Tube" was invented in approximately 1887 by Prof. Max van Pettenkoifer. During the 10 years of Tendler's study (1994-2003) 20,000 babies in NYC had metzitzah b'peh and he couldn't locate one single case in the entire USA! The article is BS from beginning to end. Read it "we suspect", "has the potential", "may", "might", most likely", etc. Nowhere do the make, or attempt to make, a concrete connection to a mohel.
Tendlers article:
http://pediatrics.aappublications.org/cgi/content/full/114/2/e259 ;
Some of Tendler's Lies:
http://dhengah.org/mbp/tendlervstendler.htm ;
A refutation of the article:
http://dhengah.org/mbp/Tendlercritique.htm
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