Thursday, July 21, 2016

Twins - With A Twist

Yesterday I did a bris (double bris, really) for twins. Their parents have been married for 8 years (I think) and have gone public about their infertility and the herculean efforts they went through to get to this stage.

The story is explained in the video that is included here. Suffice it to say, they made the video to inspire others to see that miracles can happen in this day and age, and that having friends and family who love you can make all the difference.

And the brisses for the boys serve as a testament to the direction they're headed in the raising of THEIR SONS.

Here is how it went down on Facebook.

Wednesday, June 29, 2016

Topical Analgesics

I am not recommending this product. The picture is here to make this blog post more exciting
For those who want to numb the foreskin prior to the procedure, I recommend you speak with your pediatrician about what options there are, and getting a prescription for a topical analgesic.

Easily the most popular namebrand topical analgesic on the market today is EMLA cream.
Image result for EMLA cream
This is EMLA cream - probably the 5% stuff recommended in the 2nd article linked below

There are studies about other topicals used for circumcision. Of course, understand that all of these studies are done in hospitals where the circumcision procedure is typically considerably longer than a traditional bris. In these case-studies, the baby is "under the knife" or the circumcision instruments and implements for much longer.

The following options are for those who have a compounder nearby - or if your doctor has a prescription idea that sounds like something described below.

The first article I became aware of - saying a 30% lidocaine (with 70% acid-mantle base cream) if efficacious and does not have significant absorption of lidocaine in the body:

The second article notes the previous one, but suggests that a 5% lidocaine-prilocaine cream is even better:

See also this:
This one raises other options which include injections. Injections might be the most effective, but remember that no child likes shots, especially not in his penis, and that shots hurt when administered, and have the possibility of hurting later as well.

For those who want something to numb the area, I recommend topical creams as described above. The cream needs to be put on for at least 20 minutes before the procedure (though the longer it is on the more effective it is), and wrapped in place with a piece of plastic-wrap so it doesn't rub off in the diaper.

For those who opt not to do this, your baby, like millions before him through the generations, will be fine.

Tuesday, June 28, 2016

Tzitz Eliezer's Objections to Clamps

Rabbi Eliezer Waldenberg outlines very clearly his objections in one of his responsa. (Tzitz eliezer, 8:29)

A.  The mohel deceives the parents as they are hiring him to cut the foreskin with a knife as has been the custom. In fact, when the clamp is applied, the crushed skin becomes dead and limp such that, if left alone, it would fall off by itself (much like the stump of the umbilical cord of a newborn). He is therefore not cutting living tissue.
B.   There is no priah done when a clamp is applied.*
C.   There is no bleeding when a clamp kills the living tissue of a foreskin.
D.  When there is no bleeding, there is no possibility of doing metzitzah, another important component of the bris procedure.
E.  The blessings which are recited on this entire procedure are invalid because the procedure is invalid – therefore the blessings are considered brakhot levatala, blessings made in vain, a serious offense. (as per the 3rd of the Ten Commandments, Exodus 20:7)
F.   There is no excuse for the excessive pain inflicted upon the child through the crushing mechanism of the clamp. He quotes a renowned doctor’s comments about the trauma such a piercing pain can inflict upon a child, and the possibility of the child going into cardiac arrest.
G.  Regarding the approbation which was granted by the late Chief Rabbi Isaac Herzog over the use of the device, Rabbi Waldenberg records rabbi Herzog’s anger over being deceived by people who had described the clamp and its outcome. His glowing recommendation of its use was based on hearsay descriptions, and not personally witnessing the device in use. He subsequently retracted any former support of the device.
H.  Similarly, Rabbi Tzvi Pesach Frank had approved of the device until he actually saw it in action. After witnessing a bris performed with a clamp, he reportedly said, “This is not the circumcision which God commanded us to perform,” and proceeded to withdraw all his support for the clamp’s use.
I.    Rabbi Waldenberg concludes his comments with a charge to the community to see the clamp is eradicated from our midst and that a father should be strongly encouraged to avoid using a mohel who will use this device on his son.
(J.) Finally, in a later response, he claims that a mohel who uses this device on the Sabbath is in complete violation of desecrating the Sabbath (Chillul Shabbat). (Tzitz Eliezer 19:68)

* This argument is called to question by Rabbi Moshe Feinstein, Iggerot Moshe Y”D 1:155, who points out that any mohel might be skilled enough to do priah in the same moment as the milah. No one questions the validity of the bris if the mohel happens to remove the priah membrane along with the foreskin. He derives from a passage in the Talmud Yerushalmi Shabbat 17, Column 2, Chapter 19, Halakha 6 that there were mohels who were skilled in removing the priah membrane along with the foreskin, so much so that they were called to task if they had to go back and do priah after the milah because it was so accepted that the milah and priah would take place simultaneously, minimizing the invasiveness of the circumcision on the baby.  

Of Clamps and Circumcision Bleeding

I had a conversation today with a mother of the baby who was asking me about the need for blood at the circumcision.

There are a few aspects to how we answer this question:
1. Blood at the bris is significant. There are a number of passages in the Bible and discussions in the Talmud which indicate the importance of blood at a bris. The Covenant with Abraham, and moreso the Covenant with the Israelite nation were all forged over blood. (I've addressed this topic here)

2. A Bloodless Circumcision is not a bris - it would require Hatafat Dam Bris to turn the circumcision into a bris.

3. A bloodless circumcision is usually accomplished through the use of a clamp. Aside from the Halakhic objections to using a clamp (which I haven't outlined elsewhere, but I've talked about clamps here), there are potential dangers inherent in using clamps. True, most cases turn out OK. But I'd much rather not run the risk of a potential bad story through exercising the kind of precaution that prevents the kinds of problems clamps could bring about.

Google "lawsuit" and "Mogen Clamp" or "Gomco clamp" or "circumcision clamp" and you'll see what I mean.

We (good mohels) are careful to cause a minimal loss of blood, working quickly and efficiently to bandage and control the wound.

There are ways to cut down on the amount of bleeding, using certain bandages and hemostasis-bringing powders. And, of course, the right kind of pressure. All in all, and in the scheme of things, not a big deal.

Thank God, we (the Jewish people) have been doing this for a very long time, and we have a good track record to show for it.

May it continue to be so, Amen.

Friday, June 10, 2016

Tools of the Trade VIII - GLOVES

Just like the discussion about a MARKER/ Surgical Pen, this one, which would seem obvious, is another example of what places one mohel in the "more responsible than another mohel" category.

To put it simply, in our times, would you EVER be comfortable with a medical practitioner not wearing medical gloves when doing any kind of procedure which involves your bleeding?

I didn't think so.

So why is it that for a bris, people are not careful to ascertain that the mohel is wearing gloves?
YES. There are many mohels who do not use gloves. And just about every excuse they employ for why they don't is really unacceptable.

Sterile gloves come in a box like this.

Inside the box you have individually packaged pairs of gloves that look like this when opened:

I have written about Gloves HERE and HERE. There really is no excuse not to use them. And parents have the responsibility to make sure their mohel does.

Noting the delivery of my last case of gloves - always exciting to get mail

Thursday, June 9, 2016

Tools of the Trade VII - The MARKER

We've been through all the standard items that just about every mohel uses or should use. Now we get into the realm of what makes one mohel demonstrate his being more responsible than another mohel.

The only place which I'll leave open for debate is the Magen shield v. the MOGEN clamp. While I don't recommend the clamp (I don't own one and have never used one) for both safety reasons and halakhic reasons, if the operator using it knows what he is doing, I believe the bris is kosher at least b'dieved (not in the ideal sense, but nonetheless kosher).

HOWEVER, using a surgical pen to mark the edge of the foreskin is what truly makes a mohel a cut above (no pun intended) everyone else.

The foreskin, as everyone likely knows, is very malleable. It is designed to accommodate a significant amount of stretching. As such, when the mohel pulls on it to set it up for circumcision, he can no longer tell where the proper edge of the foreskin is, UNLESS IT HAS BEEN MARKED. Surgeons mark any incision they are going to make. Does a baby deserve any less care in the effort to give him an aesthetically-pleasing circumcision?

So this tool should be in every mohel's arsenal. And every mohel should take the extra minute or two to mark the foreskin, and he should be blessed to follow the mark when circumcising, so the baby can have not just a circumcision, but a nice-looking circumcision. As even as possible all around, with the proper amount of foreskin - not more, not less - being removed, per our sacred Mitzvah.

Saturday, May 21, 2016

This is Actually Really Important

When I first saw this, and the notation that atheists will now be protected under a religious freedom act, I thought, "That's a funny joke."

But in reality, it suggests that no one can be persecuted for their beliefs, or their choice to not believe.

More importantly, it means that anti-circumcision people who persecute mohels can be prosecuted.

I'm all for it.

Washington — A bill unanimously approved by the U.S. House of Representatives would extend religious protections to advocates of circumcision and ritual slaughter as well as atheists, addressing what its sponsors describe as an increase in religious persecution in recent years.
The bill, passed Monday, would broaden the definition of “violations of religious freedom” in the International Religious Freedom Act of 1998 to include the persecution of advocates of male circumcision or ritual animal slaughter. Atheists would become a new protected class.
The measure, which moves to the Senate for consideration, was named for retired Rep. Frank Wolf, R-Va., a longtime champion of human rights who authored the 1998 law.
“The world is experiencing an unprecedented crisis of international religious freedom, a crisis that continues to create millions of victims; a crisis that undermines liberty, prosperity and peace; a crisis that poses a direct challenge to the U.S. interests in the Middle East, Russia, China and sub-Saharan Africa and elsewhere,” Rep. Chris Smith, R-N.J., who authored the bill, said in a statement.
There have been increasing calls in recent years in northern European countries for an end to circumcision and ritual slaughter, spurred in part by anti-Muslim hostility, U.S. government and European Jewish officials have said.
The bill’s tier system for how well or poorly countries protect religious freedom would be similar to the one used in the annual State Department report on human trafficking. That report is influential, and countries seeking the good graces of the United States strive to improve their ranking by cracking down on the practice.
Smith is the chairman of the House subcommittee on human rights, and as a co-chairman of the Helsinki Committee, the congressional panel that monitors human rights overseas, has made the resurgence of anti-Semitism in Europe a focus.
Smith’s office, announcing the passage of the bill, headlined the statement “Combating Persecution of Christians and Anti-Semitism,” although many of its protections would extend in the current climate to moderate Sunni Muslims and non-Sunni Muslim sects in the Middle East, Afghanistan, Pakistan and Myanmar.
Rep. Anna Eshoo, D-Calif., the bill’s lead Democratic sponsor, said in the same statement that the bill would “better address the religious freedom and violent extremism problems being experienced in the 21st century.”
The bill integrates the 1998 law’s protections into U.S. national security priorities, mandating that the ambassador at large for religious freedom – currently Rabbi David Saperstein, a veteran Reform movement leader — report directly to the secretary of state. It also adds new requirements for presidential reporting to Congress on religious freedom violations and training for diplomats in identifying violations of religious freedoms.


Wednesday, May 4, 2016

Tools of the Trade VI - Forceps

Of course there are different kinds of forceps!  (Why are you thinking of these ?)
This is not a bris instrument

These forceps (the ones I use) look more like large tweezers to most people - and that's what they are.

Some people might use it to grab skin they need to contend or deal with in the scheme of bandaging.

I use them as the sterile go-between from my hands, to pick up or move sterile instruments or
bandages when I'm setting things up before I've put gloves on.

Because a bris takes places in stages - prep, circumcision, checking baby afterwards - there is a lot of shifting between gloves and sterility to non-sterility. As a result, there are times when it is helpful to have an extension of the hand whose tip touches nothing but sterile items, while its handle comes in contact with a clean-but-not-sterile hand.

Tuesday, May 3, 2016

Tools of the Trade V - Hemostats and Scissors

Straight Hemostat
I know, I know. They all look like scissors. And while one of them certainly IS a pair of scissors (see below), I assure you that the others ones are not cutting implements. Or instruments, for that matter.

So what are they for?

The straight hemostat is the key ingredient that allows for this form of bris to take place. Its job is to grab the foreskin and the membrane beneath it at the same time so the circumcision can take place in one-step.
Blunt edged scissors
Bent Hemostat

The bent hemostat and the blunt scissors are sometimes used, to remove the "tzitzin ha'm'akvin" - the extra membrane, or the inexact skin that may have resulted from the bris. This is not specifically the mohel's fault or the result of a job poorly-done, as much as it is just the circumstances and the reality. (Sometimes it might be the mohel's fault, but he is taking the opportunity to fix it in a manner that he can). Why blunt? So it doesn't poke or stab the baby - our goal is foreskin and membrane removal, nothing more.

Remember that the mohel's job is to produce an as-beautiful-as-possible circumcision. And he does not have the benefit of the privacy of the operating room to do that. This is why some cases produce the need for the two-step process, which is probably better presented as "making things pretty."

Simply put, these are primarily the back-up instruments the mohel carries in his bag-of-tricks, which come in handy sometimes or often.

Of course, there are mohels who will claim to never use them. They are either VERY expert mohels, or they are not sharing everything about themselves. :)

Tuesday, April 26, 2016

Tools of the trade IV - Probe

The Probe is used to separate the mucosal membrane from the glans before circumcision.

A quick anatomy lesson is in order - I will explain using a simple model.

Imagine you are wearing a cuffed shirt and a jacket. Pull both sleeves - of shirt AND jacket - over your fist. The fist = the glans of the penis, your shirt cuff = the mucosal membrane below the foreskin, your jacket over the shirt cuff = the foreskin. Now imagine your sleeve is attached to your fist through natural adhesions.

In a "kosher bris" circumcision, the goal is to get both the foreskin and membrane removed completely from the glans. This is why the term Or HaPriah (עור הפריעה) is used for the membrane - it is the "skin" (mucosal membrane really) that must be removed (after the foreskin is removed) in order to completely uncover (פרע) the glans.

Were we to only circumcise your jacket, the cuff of your sleeve would remain. Your fist would appear uncircumcised, and, in fact, your jacket might grow back.

This is why both the foreskin AND the membrane must be removed. The first step in achieving the goal of removing the membrane is breaking apart the adhesions that attach the membrane to the glans. This is accomplished with a probe.

The probe is inserted through the front of the foreskin and is moved around the outer edge of the glans (with care taken not to enter the meatus (the hole of the glans)) so the adhesions can be separated. this allows for the mohel to grab the foreskin and most (or all) of the membrane in one fell swoop.

Some old school mohels do not use a probe and they try to accomplish the same thing with their fingernails. They claim it is less painful to the baby to work mostly with fingers and less with "instruments."

I say, We all want to minimize discomfort to the baby. But we should also want to give the baby the best circumcision possible, while following the dictates of our law in using recognizably useful instruments. So whether a mohel uses a single-tipped or a double-tipped probe, it is an instrument which is helpful, important, and advisable to use to help that membrane be accessed easily.