Re: Scientific Methods of Wrestling by Paul Prehn

On Sat, 28 Jun 2008 16:37:50 -0400, Mark Goldberg
<msgoldberg@xxxxxxxxxxxxx> wrote:

WannabeSomeoneCares@xxxxxxxxx wrote:



I am glad that Kirk doesn't have your kind of perversion

Hey derfus... you were shown the facts; but lying is for you. It's your
only hope.

here's the facts you sick ***. From a medical journal no less...

you're from a sick and diseased culture and religion. No wonder the
Muslims despise you. No... wait, everybody despises you. Not just
the Muslims.





PEDIATRICS Vol. 114 No. 2 August 2004, pp. e259-e263

ELECTRONIC ARTICLE
Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish
Ritual Circumcision: Modern Medicine and Religious Tradition
Benjamin Gesundheit, MD*, Galia Grisaru-Soen, MD{ddagger}, David
Greenberg, MD§, Osnat Levtzion-Korach, MD||, David Malkin, MD¶, Martin
Petric, PhD#, Gideon Koren, MD**, Moshe D. Tendler,
PhD{ddagger}{ddagger}, Bruria Ben-Zeev, MD{ddagger}, Amir Vardi,
MD{ddagger}, Ron Dagan, MD§ and Dan Engelhard, MD||

* Pediatric Hematology/Oncology Unit, Soroka University Medical Center
and the Faculty of Health Sciences, Ben Gurion University, Beer Sheva,
Israel
{ddagger} Safra Children's Hospital, Sheba Medical Center, Tel Aviv
University, Tel Aviv, Israel
§ Pediatric Infectious Disease Unit, Soroka University Medical Center
and the Faculty of Health Sciences, Ben Gurion University, Beer Sheva,
Israel
|| Department of Pediatrics, Hadassah University Hospital, Ein Kerem, Jerusalem, Israel
¶ Division of Hematology and Oncology, Department of Pediatrics,
Hospital for Sick Children and the University of Toronto, Toronto,
Ontario, Canada
# Department of Pediatric Laboratory Medicine, Hospital for Sick
Children and the University of Toronto, Toronto, Ontario, Canada
** Department of Clinical Pharmacology and Toxicology, Hospital for
Sick Children and the University of Toronto, Toronto, Ontario, Canada
{ddagger}{ddagger} Department of Biology, Talmudic Law and Jewish
Medical Ethics, Yeshiva University, New York, New York


ABSTRACT

Objective. Genital neonatal herpes simplex virus type 1 (HSV-1)
infection was observed in a series of neonates after traditional
Jewish ritual circumcision. The objective of this study was to
describe neonate genital HSV-1 infection after ritual circumcision and
investigate the association between genital HSV-1 after circumcision
and the practice of the traditional circumcision.

Methods. Eight neonates with genital HSV-1 infection after ritual
circumcision were identified.

Results. The average interval from circumcision to clinical
manifestations was 7.25 ± 2.5 days. In all cases, the traditional
circumciser (the mohel) had performed the ancient custom of orally
suctioning the blood after cutting the foreskin (oral metzitzah),
which is currently practiced by only a minority of mohels. Six infants
received intravenous acyclovir therapy. Four infants had recurrent
episodes of genital HSV infection, and 1 developed HSV encephalitis
with neurologic sequelae. All four mohels tested for HSV antibodies
were seropositive.

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.

Key Words: ritual circumcision ? herpes simplex infection ? infection
of the newborn ? Jewish tradition

Abbreviations: HSV, herpes simplex virus

Biblical sources dictate routine ritual circumcision at 8 days of age
for Jewish boys. This procedure is widely accepted, and 60% to 90% of
newborn boys of the Jewish population in the United States undergo
this procedure,1,2 which also has an important cultural and historical
role. The medically beneficial versus harmful consequences have long
been debated.3 Circumcision has been reported to reduce the incidence
of urinary tract infections in infants,4 young boys under the age of 2
years,5 and preschool boys.6 Pathologic phimosis and paraphimosis is
precluded by the absence of a foreskin, and balanitis and posthitis
(inflammation of the prepuce) primarily affect uncircumcised male
individuals. Virtually all sexually transmitted diseases,7 including
human immunodeficiency virus infection,6,8 are reported to be more
common in uncircumcised men.

Both immediate and long-term complications of ritual circumcision are
rare, probably because of the specific and meticulous precautions
required by Jewish law. Only an experienced and qualified circumciser,
the mohel, is allowed to perform circumcision. Historically, Jewish
ritual circumcision consists of 3 parts: 1) the excision of the outer
part of the prepuce (milah), 2) slitting of the foreskin's inner
lining to facilitate the total uncovering of the glans (peri'ah), and
3) the sucking of the blood from the wound. 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
(metzitzah). The first 2 parts are the act of circumcision, whereas
the removal of the blood was done for medical reasons of wound care.
However, the ancient procedure of metzitzah also carries a risk of
infection, and currently most mohels use an appropriate suction
device, such as a mucus extractor.

The incidence of neonatal herpes simplex virus (HSV) infections ranges
from 1 to 6 per 20 000 live births. Most neonatal HSV infections
result from exposure to infectious maternal genital secretions at
delivery. Postnatal transmission usually results from nongenital
infection of a caregiver, including parent or nursery personnel with
oral lesions.9 Nosocomial transmission in nurseries has been
documented.9 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.


METHODS


Neonates who developed genital HSV-1 infection after circumcision from
the following medical centers were evaluated: Soroka University
Medical Center (Beer Sheva, Israel); Safra Children's Hospital, Sheba
Medical Center (Tel Aviv, Israel); Hadassah Hospitals at Mt. Scopus
and Ein Kerem (Jerusalem, Israel); and the Hospital for Sick Children
(Toronto, Ontario, Canada). There is no official registry in the
United States or in Israel to document the incidence of medical
complications after ritual circumcision. The percentage of metzitzah
performed by oral versus instrumental suction could not be evaluated
statistically. The 8 cases were collected from personal communication
and the experience of the authors from 1997 to 2003. Clinical data
from all patients were collected, and follow-up was conducted during
hospitalization and after the discharge of the infants from the
hospital.

Identification of herpesvirus from lesions was performed by
microscopic examination of Tzanck preparations and electron microscopy
of specimens directly from the lesions. The virus was determined to be
HSV-1 by immunofluorescence microscopy, isolation in cell culture, or
polymerase chain reaction. HSV serostatus and seroconversion were
determined by complement fixation or enzyme immunoassays. In all
cases, the details of the circumcision procedures were reviewed. When
possible, the mohel was tested for virus shedding in saliva and for
HSV serostatus. Tests were performed separately in the diagnostic
virology laboratory routinely used by each hospital.


RESULTS


Eight neonates with documented genital HSV-1 infections were
identified (Table 1). In all cases, the mohel had performed the
ancient custom of oral metzitzah. On 2 occasions, the same mohel
performed the circumcision in 2 different infants: patients 1 and 4
(an interval of 5 years) and patients 7 and 8 (an interval of 5
weeks).


View this table:
[in this window]
[in a new window]
TABLE 1. Clinical and Laboratory Findings of 8 Neonates With
Genital HSV-1 Infection After Ritual Circumcision Followed by Oral
Metzitzah


The mean birth weight was 3220 g (standard deviation: ±696). The
circumcision of patient 1 was delayed because he was born prematurely,
and the circumcision of patient 3 was delayed because of suspected
sepsis. All other infants were circumcised on day 8 of life. The mean
interval from circumcision to HSV clinical infection was 7.25 ± 2.5
days. On admission, all infants were reported to have poor appetite.
Mean temperature was 37.8 ± 0.8°C. Vesicular rash over the scrotum and
penis was noted in all patients (Fig 1). In 5 patients, Tzanck
preparation was performed and showed cellular changes consistent with
herpesvirus; in 1 case, herpes group virus was detected by negative
contrast electron microscopy. HSV was isolated from all patients. None
of the mothers had clinical evidence of oral or vaginal herpes. Most
infants and their mothers were seronegative for HSV; only patient 7
and his mother were seropositive with a titer of 1:16. In patient 7, a
cerebrospinal fluid sample was positive for HSV-1 by polymerase chain
reaction, consistent with the clinical course and radiologic diagnosis
of HSV encephalitis.


Figure 1
View larger version (66K):
[in this window]
[in a new window]
Fig 1. Genital HSV-1 infection after ritual circumcision (from
patient 6).


Six infants were admitted to the hospital and received intravenous
acyclovir therapy. Four infants had recurrent episodes of genital
herpes, and 1 infant presented with severe encephalitis followed by
long-term neurologic sequelae, including seizures. Only four mohels
could be tested, and they were found to be seropositive for HSV; the
mouth cultures obtained from mohels all were negative for HSV.


DISCUSSION


In the 8 infants presented here, the association between genital HSV-1
infection and the performance of the ancient procedure of oral
metzitzah during the circumcision is strongly suggested on the basis
of the following criteria: exclusive genital distribution of the
lesions, timing of their appearance (4?11 days after circumcision),
isolation of HSV-1, absence of HSV exposure in mothers (based on both
clinical observation and negative serology in most of the mothers),
and absence of clinical signs and symptoms consistent with HSV
infections among family members. Furthermore, although the oral
metzitzah is performed by only a minority of mohels, all infants
described here underwent this procedure.

On 2 occasions, patients 1 and 4 and patients 7 and 8, the
circumcision was performed in different infants by the same mohel. On
1 occasion, the interval between the 2 cases was 5 weeks; in the
other, 5 years. In previous reports, HSV-1 genital infection occurred
in 2 infants who were circumcised by the same mohel 10 years
apart.10,11 Because HSV-1 can be secreted intermittently in saliva for
several days to weeks, 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.

Because in every case the mohel had removed the blood by mouth after
cutting the foreskin, it was most likely that the infection was
transmitted directly from this oral or salivary contact. All of the
mohels who consented to be tested were seropositive. The likelihood of
other sources for an HSV-1 infection in the area of the glans penis in
the region of the wound of the circumcision is minimal.12 Because
shedding of HSV-1 in the saliva of both symptomatic and asymptomatic
individuals has been documented repeatedly, 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.

The genital infection in 7 patients remained localized, but patient 7
developed HSV encephalitis followed by long-term brain damage
manifested by seizures and infantile spasms. Four infants experienced
recurrent episodes of genital herpes simplex and received long-term
prophylaxis with oral acyclovir.

In the past, reports of HSV genital infections after circumcision have
been relatively rare, not withstanding the high frequency of active
herpes labialis among the population, which would include the
mohels.10 This may be accounted for in part by the observation that
all but 1 of these cases were seronegative for antibody to HSV, which
suggests that seropositive infants might be protected to some degree.
Likewise, the practice of oral metzitzah is limited to only a small
subset of ritual circumcisions. There is, however, the possibility
that some previous cases were not reported for cultural reasons. To
clarify this statement, the cultural background requires elaboration.

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@xxxxxxxxxxxxxxxxx


REFERENCES


1. Poland RL. The question of routine neonatal circumcision. N Engl
J Med.1990; 322 :1312 ?1315[ISI][Medline]
2. Wiswell TE. Circumcision circumspection. N Engl J Med.1997; 336
:1244 ?1245[Free Full Text]
3. Wallerstein E. Circumcision. The uniquely American medical
enigma. Urol Clin North Am.1985; 12 :123 ?132[ISI][Medline]
4. Linshaw MA. Controversies in childhood urinary tract infections.
World J Urol.1999; 17 :383 ?395[CrossRef][ISI][Medline]
5. 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[Medline]
6. 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]
7. Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually
transmitted diseases. Am J Public Health.1994; 84 :197
?201[Abstract/Free Full Text]
8. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10
years and counting. Lancet.1999; 354 :1813
?1815[CrossRef][ISI][Medline]
9. 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
10. Rubin LG, Lanzkowsky P. Cutaneous neonatal herpes simplex
infection associated with ritual circumcision. Pediatr Infect Dis
J.2000; 19 :266 ?268[Medline]
11. 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[Medline]
12. 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]
13. Preuss J. Julius Preuss? Biblical and Talmudic Medicine. Rosner
F, trans-ed. New York, NY: Ktav Publishers; 1971:375
14. Rosner F. Hemophilia in the Talmud and rabbinic writings. Ann
Intern Med.1969; 70 :833 ?837
15. 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
16. 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
17. Shields Y. The making of Metzitzah. Tradition.1972; 13 :36 ?48

PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of
Pediatrics




.

Loading