Friday, March 31, 2006

Circumscribing Circumcision

"Re "Doctors Advocate Pain Relief for Circumcision"(Science Times, Dec 30):Circumcisions performed by mohel, Jews authorized to perform theprocedure called bris, take about one minute, thus minimizing pain. The standard surgical procudure last more than 10 minutes.

It is a biblical prohibition to cause anyone unnecessary pain. Although the study in question recommends a series of injections into the shaft of the penis, the pain from these injections may be equivalent to the pain of circumcision. A much safer and effective topical analgesic, applied one hour before the procedure, exists. Thirty percent lidocaine in an acid mantle base is effective and should be used even during ritual circumcision.

Signed Rabbi Moshe Tendler Dec 31, 1997.

Rabbi Tendler is refering to an article published in the New England Journal of Medicine a few months ago which compared an analgesic cream to placebo in terms of pain relief. The babies who received the analgesic cream cried less on average. So while the cream may not be 100 effective in all babies, it can provide relief for many .

One person inthe New York Times article is quoted as stating that the foreskin is generally anesthetic (pain free) and therefore there is no need for an anesthetic. I would respectfully disagree with this statement.

Ozzie Orbach"

See here.

I went to a bris yesterday morning and based on the baby's reactions it was pretty obvious that no anesthetic was used. And I know this is hardly a unique way of going about the bris. I also recognize that the cream is not the optimum solution for this kind of pain and especially for post-operative pain, but it is, at least, a step in the right direction.

How widely are such anesthetic procedures used in the Orthodox world, and why aren't they used more often? Is there any Halachic reasoning that would lead people to not want to use anesthetics?

16 comments:

Nice Jewish Guy said...

I completely agree. I can think of no halachic reaon why anaesthetic should not be used. Just because anaesthesia was not around for circumcision 50 years ago doesn't mean we shouldn't use it today. And any uncircumcised adult should be able to confirm whether the foreskin is really insensitive to pian!

FrumGirl said...

I don't know much about this but I would have assumed that it was up to date... I guess I was wrong... ouch!!!!! Poor babies!

Orthoprax said...

Frumgirl,

My uncle is a mohel in Israel. He's told me that he doesn't use anesthetics before the procedure, but he makes sure to give the baby a drop of wine afterwards - which definitely does help.

When I saw him last it didn't occur to me to ask me why he wouldn't use them. Though I suspect there is some foolish religious motive behind it.

onionsoupmix said...

From what I hear, the concern is that it makes the area more slippery and you don't want the knife slip sliding away. Mazel tov ! You have a girl !

Orthoprax said...

Onion,

Seriously? Have these people never heard of paper towels?

If that's an actual answer I think that's just silly. The actual equipment is made in such a way that slipping is nearly impossible.

kasamba said...

Sometimes, traditon must be rethought as technology moves further along.
Even the oral sucking of the blood could be done by suction cup.
How many babies need to suffer before they reconsider?

Nice Jewish Guy said...

He's told me that he doesn't use anesthetics before the procedure, but he makes sure to give the baby a drop of wine afterwards - which definitely does help.

If you can use wine to soothe the child/decrease pain, you should be able to use aneasthetic. You could even argue kal v'chomer that since wine is enterally administrated, a topical like lidocaine should be OK.

Orthoprax said...

NJG,

Yes, but the wine is given after the procedure, not before. That isn't a reason why not to use anesthetic, but it undermines a kal v'chomer.

Jeff said...

Plenty of mohelim give the baby the wine before the bris.

Orthoprax said...

Jeff,

I've been to a few brit milahs in my day and I've never seen the mohel give the baby wine before the procedure. Maybe I have had a poor sampling.

lakewoodyid said...

Listen to this, Ortho. I asked a mohel today about anesthetics. A real charedi mohel. He told me that halachakly, it might be OK, but the reason many don't do it, is because during (I think) pe'riah, the mohel feels with his fingers the softer flesh vs the harder flesh, and accordingly, he knows what to pull off.

When you use anesthetics, the softer area can get firmer, and the mohel can have a difficult time getting it right. He mentioned to me a mohel, with over 25 years experience who got sued for a million bucks over such a circumstance, and ever since, the mohel doesn't use anesthetics. Luckily, that mohel had insurance.

Orthoprax said...

LY,

If that's true then I guess that is understandable - to an extent. I mean, there has got to be some way of reducing pain while keeping complication rates at the same levels, but there isn't even any organized effort towards that goal. They are far too comfortable doing things the way they've been doing it.

I also thought that the equipment they use directs them exactly where to cut and they don't have to do any feeling. But I've gotten that second hand so I'm not sure.

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Anonymous said...

In Australia and New Zealand, secular circumcision isn't common any more, but when it's done, it's done 5 minutes after an injection of lidocaine.

Circumcision without the same degree of pain management that is the standard in dentistry should be illegal.

Videos (see YouTube) showing the circumcisions of gentile infants are gross as hell.

No argument I've read against local anesthesia before circumcision has come anywhere near convincing me. However, let me venture a conjecture (I'm neither mohel nor urologist, and have never been to a bris!) Recall that at birth, the foreskin is almost always fused to the glans. Hence it is awkward to forcibly separate foreskin from the glans, and to cut the former off, unless the underlying penis is fairly well defined. Otherwise doing a circumcision is a bit like peeling an eel. The way forward here is to make the baby at least partly erect by fingering his penis. This cannot work if the penis has been numbed with lidocaine.

Medical circumcision after 1 year of age is performed under general anesthesia. This is generally not a problem, because by then the foreskin has usually separated from the glans.

My bottom line? Bris is something that a Jewish male should decide for himself, between his 18th birthday and 3 months before his (first) marriage. It should be done with lidocaine.

Orthoprax said...

Anon,

I've seen many circumcisions - both in the hospital on day one or two of birth by a doctor and many on day 8 by a mohel. It's not at all awkward or difficult to separate the foreskin from the glands, it just takes the right tools.

While the operation does appear painful and the baby does get agitated, they also quiet down rapidly, especially with the oral application of glucose in the hospital or a drop of wine at a bris.

I imagine that subjecting a baby to an injection of lidocaine could easily be just as painful as the circumcision itself - and likely rife with more complications. The penis is tiny! Injecting into your field could very easily make the procedure that much more difficult.

I think the expectation for any Jewish male is that he would want to be circumcised and it would be a real burden on them to go through with it as an adult where it's a more severe operation (general anesthesia!)compared to an infant when it takes a few minutes and they don't even remember it.