Shields, Clamps and the Mogen

 

 

 

For thousands of years, circumcisions were performed by hand, with a blade, without the use of any other instruments. Although experienced mohalim developed methods of successfully removing the foreskin and mucous membrane, the act of circumcision, by definition, has always entailed certain risks. Aside from the need to properly cut the or ha-mila and separate the or ha-peria from the glans, the mohel must cut in a manner which does not risk injuring the glans itself, and which minimizes pain to the child and excessive bleeding.

 

The Peri Megadim (18^th century), in his Eshel Avraham (OC 75:8) mentions the use of a silver pincer (tzevat kesef) during the circumcision ceremony. To this day, most mohalim use a shield, known as a Mogen. The mohel grasps the foreskin, either with a hemostat or his fingers, and pulls it through a thin slit in the round metal shield. The foreskin is held above the shield, while the glans is below. The mohel then cuts the foreskin with a special blade. Afterwards, depending on whether or not the mohel cuts the or ha-peria, the mohel will finish pulling the remaining skin below the corona and perform the metzitza (which we will discuss in a future shiur).

 

In recent years, clamps were invented in order to protect the glans and prevent excessive (or any) bleeding. By preventing bleeding, the procedure becomes not only more aesthetically pleasing, but there is no need for the wound to be checked days after the procedure.

 

This week, we will discuss these devices and why almost all halakhic authorities oppose the use of these clamps.

 

 

In the early 1930’s, physicians began searching for a method of circumcision with would minimize, if not eliminate, bleeding and medical complications. In 1935, the Goldstein Medical Company introduced the Gomco clamp, named after the manufacturer, which sought to improve infant circumcision. This clamp, made up of four separate parts, traps and then crushes the foreskin, while protecting the glans. Since the foreskin is essentially dead, the clamp ensures that the circumcision will be relatively rapid, without significant bleeding or sutures. To this day, a version of the original Gomco clamp is the most common instrument used in hospitals for circumcision.

 

Rabbinic organizations (Ha-Pardes 17 [1944] and 25 [1951]) and Poskim (R. Yosef Eliyahu Henkin, Eidut Le-Yisrael, p.144; R. Moshe Feinstein, Iggerot Moshe, YD 2:119; R. Tzvi Pesach Frank and R. Eliezer Waldenberg, Tzitz Eliezer 8:29) almost immediately opposed using the Gomco clamp. The Gomco clamp is almost universally rejected by the Poskim.

 

Another method of circumcision used in many hospitals is the “plastibell.” The plastibell is a single-use, disposable device which uses a tourniquet approach to infant circumcision. The device remains on the child for a number of days, during which the foreskin dries up and falls off of the infant. This method is possibly more problematic than the others, as the foreskin is not even cut.

 

As we shall see, numerous objections were raised against these methods of circumcision. Let us examine the arguments which appear in the writing of the Poskim, and let us briefly survey the rabbinic attitude towards a different clamp, known as the Mogen (Bronstein) clamp.

 

 

One of the first Poskim to articulate his objections to the Gomco clamp was R. Shalom Levine (1886-1984), Chief Rabbi of Minneapolis, Minnesota. In a responsum written shortly after the Agudas HaRabbonim of America and Canada rejected the Gomco clamp, R. Levine enumerates five reasons why he objects to the clamp.

 

First, he writes that if the clamp prevents all bleeding, drawing blood (hatafat dam) might be necessary afterwards, in order to fulfill the opinion of Rashi (Shabbat 134a s.v. Hakhi) who mentions a requirement of dam brit. Second, the foreskin, after being crushed by the clamp for a few minutes, is considered to be dead flesh (basar met). In addition, he objects to performing mila and peria together, as we discussed previously. He also raises the concern that if doctors and mohalim use the same device, the uneducated public may not realize that there is a difference between a brit mila and a medical circumcision. Finally, he notes that the clamp may cause additional pain and discomfort to the child.

 

Regarding the first objection, is there really an obligation to draw blood as part of the brit mila? Although the blessing recited over the circumcision of a convert or slave mentions the dam brit, it is not mentioned n the blessing recited before an ordinary brit mila.

 

There are a number of verses which allude to the blood of the circumcision ritual. For example, the Midrash (Shir Ha-shirim Rabba 5:3) maintains that the verse, “And I passed by you and saw you downtrodden with your blood, and I said to you, 'With your blood, live,' and I said to you, 'With your blood, live’” (Yechezkel 16:6) refers to the blood of circumcision.

 

This is the meaning of the verse, "I passed by you and saw you downtrodden with your blood, and I said to you, 'With your blood, live’” alludes to the Passover offering; “and I said to you, 'With your blood, live’” alludes to the blood of circumcision.

 

Similarly, the Mekhilta, cited by Rashi (Shemot 12:6) explains, regarding God’s command to take the paschal lamb four days before the Passover offering:

 

 

 

 

Although the Midrash relates these verses to the blood of circumcision, there are no Talmudic sources which imply that there is a halakhic requirement of dam brit.

 

There are, however, a couple of Rishonim who imply that there may be a requirement of dam brit. For example, Rashi (Shabbat 134a ,s.v. Hakhi garsinan) explains why a certain child described by the Gemara should not be circumcised: “if he is circumcised there will not be any dam brit, and there is a requirement of hatafat dam brit, as the verse says, ‘You too, with the blood of your covenant.’” Rabbeinu Nissim (Shabbat 53a) cites this as well.

 

There are other sources which imply that the blood of the mila symbolizes the blood of an offering. For example, Pirkei De-Rabbi Eliezer (Chapter 10) describes the response of the sailors on the ship with Yona after being saved.

 

The sailors saw all the signs, the miracles, and the great wonders which the Holy One, blessed be He, did unto Yona, and they stood and they cast away every one his god, as it is said, "They that regard lying vanities forsake their own shame" (Yona 2:9). They returned to Jaffa and went up to Jerusalem and circumcised the flesh of their foreskins, as it is said, "And the men feared the Lord exceedingly; and they offered an offering unto the Lord" (ibid 1:16) … This [offering] refers to the blood of the covenant of circumcision, which is like the blood of an offering.

 

Similarly, the Midrash (Vayikra Rabba 27) teaches that just as an offering can only be offered of an animal which is at least eight days old, so too an infant is circumcised on the eighth day. This idea finds expression in halakhic literature. For example, the Shulchan Arukh (YD 265:8) states that the father of the infant should stand next to the mohel and appoint him as his agent. The Gra (Bei’ur Ha-Gra 40) explains that this is not just so that he can appoint the mohel as his agent, but because just as a person stands next to his offering (Taanit 27a), so too the father should stand next to the infant.

 

R. Ben-Zion Meir Hai Uziel, first Sephardic Chief Rabbi of the State of Israel, (Mishpetei Uziel, YD 2:48), insists that there is a mitzva of hatafat dam brit, and rules that a brit mila performed without blood is akin to a mila performed without peria. Furthermore, one who performs such a brit mila on Shabbat has violated the Shabbat. Although most Acharonim who write about clamps raise this issue, R. Uziel’s position is possibly the most extreme. We will dedicate next week’s shiur to a broader treatment of hatafat dam brit.

 

 

In addition to the other concerns raised by his contemporaries, R. Yitzchak Ya’akov Weiss (Minchat Yitzchak 5:24) questions whether a brit performed with a clamp is even valid, as the mohel is cutting dead skin. He writes:

 

 

Indeed, the Shulchan Arukh (YD 264:2) rules that the brit mila must be performed with a blade.

 

As mentioned above, in addition to these two concerns, i.e., the absence of dam brit and whether cutting dead flesh is considered to be an act of mila, the Poskim raise other concerns. For example, circumcision performed with a clamp excises both the or ha-mila and or ha-peria; as we discussed previously, some authorities insist that the peria must be performed after the mila. Also, a circumcision performed with a clamp does not require metzitza, as there is very little, if no bleeding. Some simply object to any chance in the traditional manner of mila, i.e., cutting the foreskin with a knife. Some Acharonim even suggest that once the clamp has been attached to the infant, the blessing can no longer be said, as the foreskin is effectively removed when the clamp is attached.

 

As mentioned above, the Poskim almost unanimously reject the use of the Gomco Clamp. Furthermore, although versions of it are still used in hospitals, it is known to be a long and painful process, and numerous infants have been seriously wounded by the clamp, as if it is not used properly, the clamp, when closed, may crush or cut the top of the glans.

 

 

In 1955, a prominent New York mohel, Rabbi Harry Bronstein, introduced what become known as the Mogen clamp, or the Bronstein Mogen. He introduced this clamp in order to meet the expectations of both the medical and rabbinic community. Rabbi Bronstein received the approval of R. Eliezer Silver (see Ha-Pardes 30:1).

 

The Mogen Clamp is much easier to use than the Gomco clamp, and is actually more similar to the traditional shield (Mogen). The foreskin is pulled through a narrow gap in which the glans is protected. However, the shield is then closed on the foreskin, crushing the or ha-mila as described above. Some mohalim  attach this clamp before the brit, and then, when the infant is brought to the ceremony, the mohel can cut the foreskin immediately. There is still bleeding when the Bronstein clamp is used, although the wound is cleaner and the mohel usually does not need to see the child the next day.

 

Not only does R. Eliezer Silver (Ha-Pardes 30:1) support this method, R. Soloveitchik (Halakhic Positions of Rav Soloveitchik, Vol.4, p. 134) also permits using the Mogen, as long as there is a bit of bleeding. When used properly, the Bronstein Mogen does not prevent blood supply to the foreskin, and therefore the foreskin is not necessarily considered to be dead, and blood is drawn during the ceremony.

 

R. Moshe Feinstein relates to this clamp in a number of responsa (YD 2:119, 3:98, and 3:99). R. Feinstein writes that using the clamp is against the “spirit of the rabbis,” and therefore he would not attend a brit at which a clamp was used. However, since there is always a bit of blood, he writes that the brit mila is valid. R. Shlomo Zalman Auerbach (Nishmat Avraham 5, pp. 86-87) permits a mohel to use the Mogen clamp, as long as there is dam brit, if the parents insist. This ruling seems to have been for extenuating circumstances.

 

R. Eliezer Waldenberg (Tzitz Eliezer 20:52; see also 8:29 and 10:38) disagrees and rules that a mohel should refuse to perform a brit mila with the Mogen clamp. He writes that he is not only concerned with the appearance of using a clamp; he has fundamental reservations about whether the mila can be performed properly with a clamp.

 

In practice, while the Gomco clamp and other modern mechanisms are not used by traditional mohalim, some mohalim in America use the Bronstein Mogen, especially when it is preferable to perform a circumcision with minimal bleeding, which doesn’t need to be checked the next day (i.e., a mila performed far away). However, aside from the halakhic objections raised above, some express concern that even the Bronstein Mogen may injure the infant, and therefore its use is often discouraged.

 

Next week, we will discuss hatafat dam brit.