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:  http://www.ncbi.nlm.nih.gov/pubmed/8414860

The second article notes the previous one, but suggests that a 5% lidocaine-prilocaine cream is even better: http://www.ncbi.nlm.nih.gov/pubmed/10912985

See also this: https://www.uspharmacist.com/article/drug-therapy-considerations-in-circumcision
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 (some of which are outlined here - the views of Rabbi Eliezer Waldenberg, see also a discussion 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.