The article below is a review of Dr. Tendler’s article that appeared in the August 2004 issue of "Pediatrics" magazine. His article has been denounced as junk science by several Doctors. This article starts by quoting all the terminology that is used in the article linking the process of MBP with herpes. A review of this language shows that there is not one documented link between MBP and herpes in any of the cases, nor does the article go beyond suggesting that it is possible. The wording is at times clever to lead the reader into thinking that the article speaks factually when that is clearly not the case. As a side note, the reason the article was published in “Pediatrics” and not in JAMA, NEJM, or Pediatric Infectious Disease Journal, is because the American Academy of Pediatrics (AAP), the publishers of “Pediatrics”, has an anti-circumcision policy since dating back to 1971. They are only too happy to publish an article that portrays circumcision in a bad light. There are outright lies in the article as well. I have not found the episode attributed to Semmelweis. The popular history relates that he found the connection between doctors not washing their hands following autopsies and higher a death rate in his hospital than in a local midwifery. I did not find any stories about Semmelweis and circumcision. Direct quotes are in quotation marks. Comments are in Parenthesis.
An objective critique, selected quotes from:
Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition - Pediatrics, August 2004
By Dr. Moshe Dovid Tendler and others.
Abstract
“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.”
"Formerly, the mohel took some wine in his mouth and applied his lips to the part involved in the operation and exerted suction, after which he expelled the mixture of wine and blood into a receptacle provided for this purpose; this procedure was repeated several times until bleeding stopped"
(Ed Note: This statement is false. Suction is applied once, bleeding is stopped by bandaging.)
“We present 8 infants who developed neonatal HSV-1 infection after oral metzitzah following ritual circumcision, most probably as a consequence of transmission by the mohel's saliva”
(This would usually be the conclusion of such an article, here, at the beginning of the article the authors present you with their conclusion then proceed to try to convince you that it is legitimate.)
METHODS
“the mouth cultures obtained from mohels all were negative for HSV.”
(Only three of the six Mohelim were tested for seropositivity)
DISCUSSION
it is likely that other infants were infected. We suspect, therefore, that this entity is underreported for cultural reasons and that the studies described here are only the "tip of the iceberg" of the true incidence of the disease
(Ed Note-This delibrate slur of the ultra-orthodox community is mentioned twice in the article without any substantiation or suggestion of how it might be accomplished. How does this under-reporting occur in the NYC communities of Williamsburg, Crown Heights, and BoroPark, where mandatory reporting of STDs is required of doctors and hospitals, and where MBP is performed almost exclusively on about 2000 babies a year? Are we to believe that a mother of a two week old sick baby takes her baby to Hackensack NJ because there's the "possiblity" that the illness maybe MBP related? Perhaps the the mother bribes the doctor not report it, while he's writing a prescrition for Acyclovir? Perhaps there's an underground network of doctors that need to clear the baby before he can go to a regular doctor or hospital? Or perhaps, and this is the most absurd, we are to believe the ultra orthodox mother of a sick baby does not bring her baby for treatment, because of "cultural" reasons? The authors and the publishers of this article owe the ultra-orthodox an apology for this unsubstantiated slur of their community.)
it was most likely that the infection was transmitted directly from this oral or salivary contact.
the act of metzitzah represents a potential source of orogenital transmission to the nonimmune infant whose skin integrity was disrupted by circumcision, especially if the infant is seronegative for HSV.
There is, however, the possibility that some previous cases were not reported for cultural reasons
In the 19th century, Ignaz Philipp Semmelweis (1818–1865) established the principles of hygiene and disease transmission, after neonatal tuberculosis was documented after circumcision by an infected mohel.
(Ed notes: I have serious doubts as to the truthfulness of the above captioned story. Every source I have located traced Semmelweis' discovery of disease transmission to his experience as head of the first maternity clinic in Vienna General Hospital in 1847. Sources A B C & others.
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
(Ed Note: The authors seem to imply that Semmelweis' March 1847 discovery was the source of a halachic ruling by Rabbi Schreiber, better known as the Chasam Sofer, prior to his death in 1839. This is obviously, highly unlikely. Furthermore, this alleged ruling is not mentioned in any of his responsa. Rather, it is in a letter, printed in Kochvay Yitzchok, that is a reply to R' Eliezer Horowitzs' suggestions about changing the accepted practice in regards to MBP because of governmental medical concerns. Rabbi Schreiber replies that he will agree with the change if a suitable doctor(s) will testify that cotton will achieve the same stated purpose as MBP. According to his responsa in Y"D, siman 175, the doctor(s) would have to be a practicing orthodox Jew(s). That condition was possibly never met. The Author of the S'dei Chemed, R' Chaim Midini, over 100 years ago questioned the whole story, being that this item was never printed in any of the responsa. It is also appropriate to mention here, that the Chasam Sofer was the biggest opponent to any change in traditional orthodox Judaism at the time, specificly against the Neologue [reform] movement, one of the foremost proponents of changing MBP. Also relevant is the fact that the "tube", originally a cup shaped glass, was not invented until 1887 by Professor Pettenkofer, a Hamburg doctor.)
"a ruling quickly adopted by most rabbinical authorities"
(Ed Note: This statement is totally False. His students rejected any change, specifically his student, Rabbi Moshe Shick, vehemently opposed any change. There was also a proclamation signed by 36 leading Russian Rabbis, 230 Hungarian and German Rabbis declaring that no change was sanctioned. The document is brought in S'dei Chemed. A seperate letter by Rabbi Jakob Danison relates the custom was changed in Vilna due to government pressure for medical reasons, against the will of Chief Rabbi Shlomo Hacohain and the Beth Din of Vilna, this was confirmed by a second letter from R' Chaim Ozer Grodzinski)
“Consequently, the great majority of ritual circumcisions are performed today with a sterile device and not by oral suction by the mohel”
(Ed Note: The above comment comes on the tail of the following statement from the methods section:
"The percentage of metzitzah performed by oral versus instrumental suction could not be evaluated statistically"
How can you state the "great majority" if you don't have statistics?)
“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”
“Our findings provide evidence that ritual Jewish circumcision with oral metzitzahmay cause oral-genital transmission of HSV infection”
Furthermore, oral suction may not only endanger the child but also may expose the mohelto human immunodeficiency virus or hepatitis B from infected infants.
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.
(Ed Note: That is very broad reading of this document that says you must use MBP unless the mohel has an open lesion in his mouth)
"We support ritual circumcision but without oral metzitzah, which might endanger the newborns and is not part of the religious procedure".
(Ed Note: Who are doctors to decide that it's not part of the religious procedure?)
(Ed Note- The article is conjecture from beginning to end. There is no conclusive link in any case cited. In short the article reads as follows:)
"may" be hazardous to the neonate / "most probably" as a consequence of / "it is likely" that other infants were infected/
"We suspect", therefore / "it was most likely" that the infection was transmitted /
represents a "potential source" of orogenital transmission / however, "the possibility" that some previous cases were not reported /
this "potentially" life-threatening medical complication / oral metzitzah "may" cause oral-genital transmission/
oral suction "may" not only endanger the child / which "might" endanger the newborns/
SOME questions concerning the article:
1)The article states "The incidence of neonatal herpes simplex virus (HSV) infections ranges from 1 to 6 per 20 000 live births. (1 out of 3200 in the U.S.) Most neonatal HSV infections result from exposure to infectious maternal genital secretions at delivery" What steps were taken to exclude these cases from the usual causes that statistically infect a certain number of neonates? Why was this process not stated?
2) The article states "Methods. Eight neonates with genital HSV-1 infection after ritual circumcision were identified." To exactly which methods does this refer? See question 1.
3)What was the total number of neonatal herpes cases diagnosed in the hospitals involved? Was it above the statistical average, consistent, or below? Why was this not reported? What is the division between HSV-1 infections and HSV-2 infections? Why are all HSV infections lumped together?
4)The article states that most mothers tested seronegatove for HSV. They would show negative if they were having an active first episode of HSV during the birth of the child. Was a follow up done 4 months later to see if they were still negative? Until this is done, they cannot be excluded as possible sources of infection.
5) The article states diagnosis of onset of HSV was a mean 7.25 ± 2.5 days after circumcision and MBP. What is the mean diagnosis time in the general non-MBP cohort population? The same? or 8 days earlier? If it's the same it would seem to discredit the article. Why was this not reported? A side note: The chart accompanying the article shows the two weakest babies, those who had the bris delayed to 16 days and 31 days respectively, exhibited symptoms 4 days after MBP. For the record, the incubation period for HSV is about 14 days.
6) The article states 2 Mohalim both had two cases among their brissim. Was the virus of each of the two patients DNA checked for a match? If they matched each other, this would cast a heavy suspicion on the Mohel involved. If it did not match, the Mohel would immediately be exonerated in at least one case. Why was this not done or not reported? Equally significant is the fact that the two cases 5 weeks apart that were attributed to one Mohel were in the same hospital. How was the hospital excluded as a source of infection? Why was this not stated.
7) The article states "Semmelweis (1818–1865) established the principles of hygiene and disease transmission, after neonatal tuberculosis was documented after circumcision by an infected mohel." The first observed case that I found, was reported in 1887. Twenty two years after Semmelweis died. It was included with other cases in a 1913 article in published in JAMA. Why was the Semmelweis case not included if it was reported 22 years earlier and the granddaddy of all infection cases? It should have been well known in medical circles.
8) Why was it not stated in the article but rather buried in the chart, that two of the babies (25% of study group) recovered spontaneously without any treatment. Furthermore, what is the credibility of the attending physician, that is so inept that he: A) Identifies a potentially fatal disease but does not prescibe treatment; B) Only recognized the disease after the patient recovered spontaniously?
9) The article is also written in a very shoddy and sloppy manner. It states the cases were diagnosed between 1997 and 2003, when in fact the chart shows them to be between 1994 and 2002. The patients are listed in non-chronological order and no apparent sequence. The chart lists several re-occurences in certain babies over a several month period. This would have been a great opportunity to recheck the serology of the mother when she brought the baby for treatment. This was not done. It would have been a great opportunity to DNA the viruses of the children to crosscheck against each other in the cases of the two mohelim, each accused of infecting two choldren. This was not done. The article states that babies were presented 7.25 ± 2.5 days after MBP. Which would be between 4.75 and 9.75 days. In fact they were presented between 4 - 11 days. Which is 7.25 ± 3.75 days. This is all very significant when the incubation period for HSV is 14 days. Birth weight was reported as
3220 g (standard deviation: ±696) when in fact it was -1340 +880. The premature birth should have been excluded from the averages.10) There are more questions. The questions listed here "are only the 'tip of the iceberg'"......
Conclusion: There is not one single case to date, of Metzitzah B'peh being conclusively linked to a Herpes infection by a Mohel.
