The Blessing We Don't Wish on Anyone

I got a call for a bris which included the question, "Our baby was sent to the NICU. Will this delay the bris?"

The proper answer to this question is "For what reason was he sent to the NICU?"

If the baby was brought there for observation and as a precaution because the doctors were concerned about something, then the next question follows, "Did they just observe and run tests? Or was any intervention required?" Because if he required antibiotics, then the bris date would likely be pushed off.

In this particular case, as the doctors did nothing but observe, they were just being cautious out of a concern, which was likely based on a need for the baby's system to mature ever so slightly, which is not a sign of illness, but just a simple sign of normal development.

So I told the mom, I think the bris will be taking place on time.

Her response: "So when will the bris be?"

If she called me Tuesday, and her baby had been born the previous day, I told her, "This coming Monday. In six days." To which she responded, "Oh boy..." indicating there is not enough time to prepare.

Of course, there is enough time, it's just overwhelming. But she is coming from a situation where her previous son (same mohel as this time!) had some issue which caused his bris to be delayed a week. Her most recent memory of bris preparation is having TWO WEEKS from birth until the bris.

Since the bris typically takes place on day-8 of life, from one perspective it is a blessing to have a little more time to prepare for the celebration.

On the other hand, that "blessing" usually means there is something wrong with the baby that is causing the bris to be delayed. And any kind of medical situation is not the kind of blessing we wish for a newborn.

Things happen. Hopefully the doctors are amazing at what they do. And all little boys should be able to have their brisses in a timely fashion.

Blogging Mohel Lives Life as well!

I've noted before that sometimes life gets in the way of blogging. Thank God, between the Jewish holidays, moving, Thanksgiving, and just plain business as a mohel and a husband and father (and rabbi of a synagogue!), things have been good, and quite busy!

One day we'll begin exploring new topics here. In the meantime, please check out the Welcome Message and the All You Need to Know Blog Post.

I look forward to hearing from you! Best of luck with your pregnancy, birth, and with your baby!

Holiday Season

This time of year always brings with it frantic calls from people whose timing has them needing to schedule a bris on a holiday.

I got a couple of calls for Rosh Hashana bris.
I'm doing a bris on Erev Yom Kippur (YK Eve).

And I am sure that come this Monday and Tuesday I will get calls seeking my availability for the holiday of Sukkot.

Alas, unless you come to me for the holiday (and you are always welcome!) I serve as a pulpit rabbi and cannot leave for the holiday. :(

Wishing everyone well, Shana Tova, and a year of healthy babies!!

The Bedside Manner Mohel

After my post-bris visit (which SHOULD BE a given with every mohel, but is not), I spent about 20 minutes talking to the baby's father, who gave me the whole history of how they found me. [a.k.a. "best kept secret in Florida" - flatterer]

There are a few mohels who have been in Florida for a very long time, such that "everyone" in certain circles uses them. In fact, before calling me, this couple called my friend Rabbi Howie Seif (the Knife), who was unable to serve because he was leaving town, but he gave them my name.

I do the same for him when I get calls when I am away.

But even Rabbi Seif wasn't the first mohel they lined up. All of their friends use a certain mohel, about whom they heard - from those very same friends - that his bedside manner is not what they need. Breaking the mold of just calling the guy everyone hires, they called around, got a few names, did their research and eventually got confirmation from a friend about me.

The phone calls: Baby's grandfather called. We spoke. Heavy focus on bedside manner being important.

Then the baby's father spoke. Again, assurances that the kind of bedside manner they'd be getting is what they are looking for.

And after the fact, after I spend 1/2 hour in their home the day before the bris, plenty of time at the bris (in minutes before and after) explaining what will happen, what did happen, and of course in caring for the baby, as well as another visit to their home to see the baby a few hours after the bris (to remove his bandage and make sure all was well), the father of the baby told me, "You were just what we needed."

I wish for all parents of a boy to have a similar experience as this one. Many mohels have a wonderful bedside manner, and give the time to the parents and explain everything, and address their concerns. 

Some, obviously, do not. Which is unfortunate. 

The bris is a holy act, a defining experience of the Jewish people for close to 4,000 years - in fact, the OLDEST TRADITION WE HAVE. Of course it should be joyous, of course it should be celebrated properly, and of course it is something we should be proud of and we should never need to defend it.

But for the parents of the baby, there is a natural tension and unease. Because the baby is, after all, undergoing surgery, and we want that to go well, and for the baby to be in a good place as far as his healing is going, as quickly as possible after the bris. And the parents sometimes need to be coddled through the experience, because as much as we want to do it, it doesn't make the experience an easy one.

Enter the Bedside Manner Mohel. And all will be OK!!

Twins again - and French origin

Judging by most of the population's proclivity for having children in single doses, multiple births are not very common. Of course, with IVF and other fertility advancements, multiples have probably become more common these days - nonetheless, most people have one baby at a time.

In the last few years I've presided over brisses of twins around 10 times (with a few additional situations where one of the twins was a girl - so it was only one bris).

In two cases (two separate sets of twins) the parents were living in the US but had relatively recently moved here from France - can't get into all the reasons why, though I'm sure that one reason is obvious to everyone. 

What's up with French Jews having twins? :)

It is most fun for me for two reasons as well. My last name is a European word which means "ticket" - and it is so French of a word that these lovely families feel an additional connection with me owing to my French origins, beyond our being Jewish. (FTR, I know of no Billets from France, and I speak as much French as Huckleberry Finn)

The second reason is harder to explain, but it is 100% true. While I speak a decent Hebrew and with an undistinctly American accent (living in Israel for a year as a kid helped me fashion my own version of an Israeli accent - though my vocabulary limitations are a dead giveaway), every time I'm in Israel and find myself in Jerusalem, whether in conversation with a vendor or when either asking for or giving directions to someone, I'm inevitably asked "Ata Tzorfati?" (Are you French?) Maybe it's a complexion thing, or maybe it's a style of Hebrew-speak, but it has happened so many times I don't even wonder what it's all about anymore.

Anyway - point is, there is a connection beyond words that exists between me and French Jewry. And I am always honored to be the mohel for the twins - and even enjoy the occasional single bris that life brings my way. 

How I explain what happens in a bris

Letting the cat out of the bag here will take away a little of the entertainment factor from those who will hear this shpiel in the future, but I imagine that this, like all blog posts, will eventually get lost in the blogosphere.

For the record, I've described how things look after the bris here and here and here, and I've even offered a link to a medical website that shows textbook images (computer generated, not photos) of a pre-circumcised and post-circumcised penis.

In the moments before or especially AFTER the bris, I like to explain to parents what has happened to their son.

Then I pull out my model, the one I "carry with me always" - and here it is:

Imagine my fist being hidden by the cuff of my sleeve (if you look carefully, you can detect it below the cuff). Now: CUFF = FORESKIN.  FIST = GLANS (head of the penis)

In the act of circumcision, the foreskin (imagine the entire cuff) is grabbed and excised, leaving the glans to emerge from the incision-spot, to be completely exposed and not covered by the shaft-skin, (or the shirt below the cuff.)

Watch as it emerges.

The tip emerges

It takes a second or two.

Almost completely out

And then we are free and clear!

You didn't really think I was going to cut the cuff of my shirt just for a demonstration, did you?

It is important to note that the fist (GLANS) is free and clear of any skin so that nothing will heal attached to it. Anything attached to the glans makes the bris "unkosher" and needing a repair.

It is important to also know that below the foreskin is a membrane that we aim to remove during the circumcision as well. Sometimes it comes off during the circumcision, sometimes it needs to be torn and folded back, and sometimes it needs to be excised afterwards - using hemostat and scissors.

One of the things I do is use a marker to help guide the incision so that the skin that should remain on the shaft remains, and we avoid having a significant amount of extra skin removed.

In other words - this should be avoided:

We want the glans to be revealed, but we don't need to reveal the lower layer of the shaft..

Now that I've given away my secret, what will I do for fun in explaining this stuff? Maybe not everyone will read this blog post. There is hope!

Twins - With A Twist

Yesterday I did a bris (double bris, really) for twins. Their parents have been married for 8 years (I think) and have gone public about their infertility and the herculean efforts they went through to get to this stage.

The story is explained in the video that is included here. Suffice it to say, they made the video to inspire others to see that miracles can happen in this day and age, and that having friends and family who love you can make all the difference.

And the brisses for the boys serve as a testament to the direction they're headed in the raising of THEIR SONS.

Here is how it went down on Facebook.

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.

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.

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.

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.

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.

This is Actually Really Important

When I first saw this, and the notation that atheists will now be protected under a religious freedom act, I thought, "That's a funny joke."

But in reality, it suggests that no one can be persecuted for their beliefs, or their choice to not believe.

More importantly, it means that anti-circumcision people who persecute mohels can be prosecuted.

I'm all for it.

http://www.thejewishweek.com/news/national/house-passes-bill-protecting-circumcision-ritual-slaughter-religious-freedoms

Washington — A bill unanimously approved by the U.S. House of Representatives would extend religious protections to advocates of circumcision and ritual slaughter as well as atheists, addressing what its sponsors describe as an increase in religious persecution in recent years.

The bill, passed Monday, would broaden the definition of “violations of religious freedom” in the International Religious Freedom Act of 1998 to include the persecution of advocates of male circumcision or ritual animal slaughter. Atheists would become a new protected class.

The measure, which moves to the Senate for consideration, was named for retired Rep. Frank Wolf, R-Va., a longtime champion of human rights who authored the 1998 law.

“The world is experiencing an unprecedented crisis of international religious freedom, a crisis that continues to create millions of victims; a crisis that undermines liberty, prosperity and peace; a crisis that poses a direct challenge to the U.S. interests in the Middle East, Russia, China and sub-Saharan Africa and elsewhere,” Rep. Chris Smith, R-N.J., who authored the bill, said in a statement.

There have been increasing calls in recent years in northern European countries for an end to circumcision and ritual slaughter, spurred in part by anti-Muslim hostility, U.S. government and European Jewish officials have said.

The bill’s tier system for how well or poorly countries protect religious freedom would be similar to the one used in the annual State Department report on human trafficking. That report is influential, and countries seeking the good graces of the United States strive to improve their ranking by cracking down on the practice.

Smith is the chairman of the House subcommittee on human rights, and as a co-chairman of the Helsinki Committee, the congressional panel that monitors human rights overseas, has made the resurgence of anti-Semitism in Europe a focus.

Smith’s office, announcing the passage of the bill, headlined the statement “Combating Persecution of Christians and Anti-Semitism,” although many of its protections would extend in the current climate to moderate Sunni Muslims and non-Sunni Muslim sects in the Middle East, Afghanistan, Pakistan and Myanmar.

Rep. Anna Eshoo, D-Calif., the bill’s lead Democratic sponsor, said in the same statement that the bill would “better address the religious freedom and violent extremism problems being experienced in the 21st century.”

The bill integrates the 1998 law’s protections into U.S. national security priorities, mandating that the ambassador at large for religious freedom – currently Rabbi David Saperstein, a veteran Reform movement leader — report directly to the secretary of state. It also adds new requirements for presidential reporting to Congress on religious freedom violations and training for diplomats in identifying violations of religious freedoms.

Read more at http://www.thejewishweek.com/news/national/house-passes-bill-protecting-circumcision-ritual-slaughter-religious-freedoms#GxKU6Wx8pbXOw5lZ.99

Tools of the Trade VI - Forceps

Of course there are different kinds of forceps!  (Why are you thinking of these ?)

This is not a bris instrument

These forceps (the ones I use) look more like large tweezers to most people - and that's what they are.

Some people might use it to grab skin they need to contend or deal with in the scheme of bandaging.

I use them as the sterile go-between from my hands, to pick up or move sterile instruments or
bandages when I'm setting things up before I've put gloves on.

Because a bris takes places in stages - prep, circumcision, checking baby afterwards - there is a lot of shifting between gloves and sterility to non-sterility. As a result, there are times when it is helpful to have an extension of the hand whose tip touches nothing but sterile items, while its handle comes in contact with a clean-but-not-sterile hand.

Tools of the Trade V - Hemostats and Scissors

Straight Hemostat

I know, I know. They all look like scissors. And while one of them certainly IS a pair of scissors (see below), I assure you that the others ones are not cutting implements. Or instruments, for that matter.

So what are they for?

The straight hemostat is the key ingredient that allows for this form of bris to take place. Its job is to grab the foreskin and the membrane beneath it at the same time so the circumcision can take place in one-step.

Blunt edged scissors

Bent Hemostat

The bent hemostat and the blunt scissors are sometimes used, to remove the "tzitzin ha'm'akvin" - the extra membrane, or the inexact skin that may have resulted from the bris. This is not specifically the mohel's fault or the result of a job poorly-done, as much as it is just the circumstances and the reality. (Sometimes it might be the mohel's fault, but he is taking the opportunity to fix it in a manner that he can). Why blunt? So it doesn't poke or stab the baby - our goal is foreskin and membrane removal, nothing more.

Remember that the mohel's job is to produce an as-beautiful-as-possible circumcision. And he does not have the benefit of the privacy of the operating room to do that. This is why some cases produce the need for the two-step process, which is probably better presented as "making things pretty."

Simply put, these are primarily the back-up instruments the mohel carries in his bag-of-tricks, which come in handy sometimes or often.

Of course, there are mohels who will claim to never use them. They are either VERY expert mohels, or they are not sharing everything about themselves. :)

Tools of the trade IV - Probe

The Probe is used to separate the mucosal membrane from the glans before circumcision.

A quick anatomy lesson is in order - I will explain using a simple model.

Imagine you are wearing a cuffed shirt and a jacket. Pull both sleeves - of shirt AND jacket - over your fist. The fist = the glans of the penis, your shirt cuff = the mucosal membrane below the foreskin, your jacket over the shirt cuff = the foreskin. Now imagine your sleeve is attached to your fist through natural adhesions.

In a "kosher bris" circumcision, the goal is to get both the foreskin and membrane removed completely from the glans. This is why the term Or HaPriah (עור הפריעה) is used for the membrane - it is the "skin" (mucosal membrane really) that must be removed (after the foreskin is removed) in order to completely uncover (פרע) the glans.

Were we to only circumcise your jacket, the cuff of your sleeve would remain. Your fist would appear uncircumcised, and, in fact, your jacket might grow back.

This is why both the foreskin AND the membrane must be removed. The first step in achieving the goal of removing the membrane is breaking apart the adhesions that attach the membrane to the glans. This is accomplished with a probe.

The probe is inserted through the front of the foreskin and is moved around the outer edge of the glans (with care taken not to enter the meatus (the hole of the glans)) so the adhesions can be separated. this allows for the mohel to grab the foreskin and most (or all) of the membrane in one fell swoop.

Some old school mohels do not use a probe and they try to accomplish the same thing with their fingernails. They claim it is less painful to the baby to work mostly with fingers and less with "instruments."

I say, We all want to minimize discomfort to the baby. But we should also want to give the baby the best circumcision possible, while following the dictates of our law in using recognizably useful instruments. So whether a mohel uses a single-tipped or a double-tipped probe, it is an instrument which is helpful, important, and advisable to use to help that membrane be accessed easily.

Tools of the Trade III - Double Edged Knife

Traditional Izmel - double-edged knife

Modern Innovation - the Double-Edged Scalpel

Tehillim (Psalms 149)

6Lofty praises of God in their throats and a double-edged sword in their hands,

ורוֹמְמוֹת אֵל בִּגְרוֹנָם וְחֶרֶב פִּיפִיּוֹת בְּיָדָם

What are we supposed to use to excise the foreskin?

שולחן ערוך יורה דעה הלכות מילה סימן רסד: סעיף ב

בכל מלין, ואפילו בצור ובזכוכית ובכל דבר הכורת, חוץ מבקרומית של קנה, לפי שקסמים נתזים ממנו ויבא לידי כרות שפכה. יז] ומצוה מן המובחר למול בברזל, בין בסכין בין במספרים, ונהגו למול בסכין. 

The Shulchan Arukh YD 264:2 says: We circumcise with anything: even a stone, glass, or anything that cuts. Except for a reed, because it has splinters with may cause damage [to an important tube]. It is an enhanced form of the mitzvah to do the circumcision with steel - whether with a knife or with scissors. But the custom is to use a knife. 

The Midrash attaches the above verse from Tehillim to the concept of Bris Milah, suggesting that the knife that should be used should be like a double edged sword. 

The problem with the more "traditional" knife is that it needs to be sharpened, and then sterilized. But the sterilization then makes the knife less sharp. So one is faced with the Catch-22 of wanting the knife to be as sharp as possible, and also wanting it to be sterile and still sharp.

As a result, the double edged scalpel was created in recent years, to maintain the Midrashic custom of a double edged sword, while at the same time allowing for a scalpel that is for one time use, that is sharpened in the best way (with a laser?) and sterilized. 

Many mohels (including I) use a single-edged and single-use scalpel blade because it removes the need to sharpen or sterilize (scalpel blades come that way) and it allows for the swiftest (and hopefully least painful) circumcision. I have seen mohels use a back-and-forth motion (shudder!) while really all that is needed is a smoothe incision.

Could I look into getting the double-edged scalpel? I suppose. But it's not necessary. At most it is a (likely kabbalistic) stringency. The main mitzvah is to have the foreskin removed.

[I've joked in the past that the need to have a double-edged scalpel is good for the mohel who can't otherwise see, and is not sure which side is the sharp one. Of course if the mohel can't see....]

Tools of the Trade II - The Metzitzah Tube

Metzitzah - previously unknown outside of the insular world of bris milah, now a household word. What is it? Why is it done? Isn't it barbaric? Is it safe? 

I've addressed all these questions - and several essays on the subject appear on the Metzitzah Page. There is also a youtube video linked there in which the two methods of metzitzah are demonstrated.

In this posting, we are going to understand what the tubes featured so beautifully in this picture I borrowed from these guys is for, and how it is used. 

The goal of metzitzah is to draw "distant bloods" from the spot of the circumcision. While some accomplish this through squeezing the fresh circ with sterile gauze, the more traditional way to do metzitzah is with the power of the mouth. Metzitzah B'feh is often translated to mean "Suction with the mouth" and it is accomplished in one of two ways.

1. Putting the mouth directly on the wound (yes - you read correctly)

2. Putting a sterilized tube over the penis, creating a vacuum, and using the tube like a straw (goal is to draw blood out, not to get blood in mouth)

The bottom part of the photo is where the mohel puts his mouth. The top part of the photo is the part that fits easily over the baby's organ immediately post-foreskin-excision.

In my case, I put gauze in the tube to avoid any transfer of fluids between parties. It does not deter the vacuum power created when the tube is applied properly.

For traditional Jews who continue to practice metzitzah (much longer discussion for why - see Metzitzah page), this should be the preferred method over placing a mouth on a fresh wound, as putting a sterile tube on an open wound is no different than putting a sterile gauze pad on the fresh wound.

It removes any possibility for a "problem," and it brings honor to a practice that is a vestige from an ancient time, that, unlike circumcision which has a Biblical source and continues to be a hallmark of the Jewish people's identity, metzitzah has no Biblical basis, and need not take place at all for the circumcion to be kosher. 

Tools of the Trade I - the Shield

What IS that thing?

I remember the first time I actually looked at the instruments the mohel lays out on the table, I saw that device and thought "O my God. It's an amputator!"

Of course, as I was probably around 9, I don't think I knew the word amputate yet, so this might be a little revisionist.

BUT - the truth is - that is NOT an amputator. It is actually the most important device a mohel could own. It is called a shield - in Hebrew, a "Magen" (מגן), and it's goal is to shield all the parts we don't want to cut from being nicked or otherwise by the scalpel/blade we use to excise the foreskin.

The parts we don't want to cut include the glans, the scrotum, the baby's belly, not to mention the sandak's hands.

When a traditional bris milah is performed, the foreskin is grabbed and drawn foreward, and this shield is applied in such a manner that the only thing on the outside is the foreskin, while below it is everything else. The mohel simply cuts along the shield, and the circumcision is complete.

The best way to know exactly where to apply that shield, because once foreskin is being drawn forward all the skin looks the same and can result in an uneven cut, or a taking off too much or too little cut, is to draw a line on the foreskin following the circumference of the highest point of the glans all around.

Once the line is drawn and the foreskin is drawn forward correctly, a simple (and correct) application of the shield along the surgical line will result in a beautiful circumcision, and a baby who is otherwise protected from anything beyond our stated goal of removing the foreskin.

Please note the Magen above is not to be confused with this device - called the MOGEN Clamp. I do not own a Mogen Clamp (more about clamps here) and I do not recommend its use. There are mohels who use it - hopefully with good care and with positive results. But Google "Mogen Clamp" before you allow any mohel to use it on your son.

MOGEN Clamp

Here is a picture of a silver Magen/shield (I had other pictures, but Google sometimes takes them away)

Available, With Flexibility

A sizable percentage of my recent brisses have come to me by way of the Internet, often from people who found themselves, late in the game, without a mohel.

Usually I'll get a call the day the baby is born, or the day after, but I've been seeing a trend of people calling 1, 2, or 3 days before the bris.

Weird, I know.

Sometimes they "forgot" to arrange something.

Sometimes they just realized what a bris is.

Sometimes the mohel they hired cancelled on them.

Sometimes they were waiting to call because the baby had a medical condition that delayed the bris.

No matter the reason, from a Jewish perspective, the more on-time a baby can get his bris taken care of, the better it is. If we can make it work schedule-wise and parents have the flexibility to work within my availability at such later notice (and me with them too!) the role to bring these babies into the mark of the Covenant is a role I continue to cherish.

Even at late notice. :)

Well, That Was Flattering

I got a call on Tuesday, "Hi. Are you available for a bris on Thursday?"

It isn't common to be called so late in the game, unless something happened - a mohel cancelled, or the situation is complicated.

Before I got to ask questions such as, "Is the baby ok? Is his mother Jewish?" etc., my mind starting racing... Thursday? Wait... that's.... PURIM

OK. I've had brisses on Purim before - not the most convenient day, but still, a bris on the 8th day is a bris on the 8th day.

"Where are you located?"

"North Orlando."

O.

Translate to my squeezing 6 hours worth of driving into an already full Purim-day schedule - I said I don't think I can do it. And I called a colleague, asking if he's available - I'll give them his name if he has the time.

I called back the parents, I'm not available, but my friend is.

"We'll call you back."

I get a callback from the father - to whom I had explained my Purim conflicts, and he said, well, "What if we do it at the Chabad of Melbourne, FL - a.k.a "Chabad of the Space and Treasure Coasts."

You'd be willing to drive over an hour from your home to have the bris in Melbourne, just so I can take off 2.5 hours of  my own drive, so I can make it?

"Yes. We've done our research. Really liked what we read in your blog. And we really want you to be our son's mohel."

How could I say no? I planned for the Purim bris.

Later that night, or on Wednedsay (it's all a blur by now), the father called me to tell me the baby's jaundice (bilirubin count) was rising, and that they were going to have the bris on Sunday, would I be available?

I told them what I always tell people who are concerned about a mid-level bilirubin count. "I think your baby's numbers are fine. He should have his bris on Purim. I can make it that day if you do the bris in Melbourne. It's your call."

They decided - based on the input of their rabbis, to delay the bris to Sunday. Which was today!

I left my house at 5:30am to arrive 8:15 for davening, and for the 9am bris.

I am grateful that it worked out this way, that everyone is happy (with the bris being delayed slightly, etc).  I've had phone calls before when people were "disappointed" if I wasn't available. But they usually take the next mohel's number and move on. I can't recall the last time people were willing to so accommodate their own schedule and inconvenience themselves just so I could be their son's mohel. It was quite atypical and very flattering. Thank you!

My Gratitude and Your Responsibility As a Parent

Last week I was privileged to serve as the mohel for an Israeli family living in the Aventura area. I doubt this information will be enough to identify them. :)

The baby's mother called me for the first time around 3 months ago, after scouring my website. She had a lot of questions. We talked about a lot of things, mostly sterility, track record, healing time, what happens with the baby afterwards.

To make a long story just a little shorter than it could be, they hired me. The bris went beautifully. And all is good. I am always grateful for the trust parents put in my mohel-skills, and I thank God that this is the run-of-the-mill experience we share together.

When I called around a week after the bris to see how baby is, she told me that a friend of hers just used a certain mohel - who caters to a large segment of the Israeli population in Hollywood, Aventura, etc - and the child had bleeding problems and needed to go the hospital, where he was placed on antibiotics for an infection, and kept there for 3 days.

The woman I serviced was shocked and dismayed, and I am horrified as well. Because, except in the rare case of previously undetected hemophilia, THIS SHOULD NEVER HAPPEN.

My "client" told me her friends ridiculed her for hiring me (they don't know me), and for not going with the go-to guy. The difference, she told me, is that she researched this, made many phone calls, interviewed mohels, and determined, through what she found, who was best for her family and situation. And was so pleased with our encounters that she said, "When we have our next son, I'm calling you first!"

This particular mohel in question has a track record of sending kids to the hospital. I have spoken to several doctors who have treated his patients. He might be a nice man when dealing with people. But he badmouths every mohel in South Florida, tells parents he is the only one who gives a "kosher brit," while he doesn't wear gloves or use safety techniques to protect the baby from harm. All of which, of course, is disgraceful behavior.

so here it comes; YOUR RESPONSIBILITY AS A PARENT

Do your Research
Know What Questions to Ask
Know What Answers You are Looking For
And remember, we are dealing with YOUR BABY and NOT the MOHEL'S EGO

If your mohel has an excellent track record, and babies never go to the hospital because of his work, Baruch Hashem, great.You still owe it to him to do your research.

I thank God EVERY DAY that no baby that I have circumcised has ever needed medical intervention as a direct result of the bris I have done. I bless every mohel and parent to have a similar track record.

The Photo That Went Viral

Yesterday's bris was for a baby who was born on the smaller side - around 4 lbs 10 oz - so his bris was delayed until he got a little bigger and stronger.

Immediately after the bris, his mother pulled out a shirt her friend had given her. It was super cute - and quite culturally in tune.

As of this writing it has been shared dozens of times, and seen by over 15,000 people, according to Facebook's stats. 

What do you think?

OK. This is the best shirt ever.
Posted by Rabbi Avi Billet, Mohel on Tuesday, March 15, 2016

Photos of A Healing Bris

Don't worry.

It's not what you think.

At least not here.

I don't put pictures of brisses - before or after - for a variety of reasons, most of which you can probably imagine. But as it is helpful to know what you will be seeing, I am happy to share with you a link of a pdf, put together by Dr. David Bolnick, Mohel, which contains one picture of a pre-bris penis, and 4 pictures of the healing process over a few weeks' time.

Here is the link. The photos are on page 16.

http://brismilah.com/bris.pdf

The swelling, as you can see, can get pretty ugly. It is not always that extreme, and, in some cases, if much of the membrane is removed in the process, most of that swelling will not be present.

Every baby is different, and every bris has a different outcome. Hopefully it all works out the same in the end for everyone!

[So use a marker!!!!!]

Is Metzitzah Right For You?

Before the year 2000, metzitzah was a practice only people in the observant community knew about. When stories came out about babies contracting herpes after a bris, including some babies who died from the virus, metzitzah became a household word, and knowledge of the practice (even among those who couldn't recall the word) became a matter of concern.

What is metzitzah?

Metzitzah is understood to be the act of drawing blood "from distant places" out of the circumcision wound immediately after the removal of the foreskin. The word itself has many possible translations. Of course, technically any drawing of blood can be done with a gauze pad or sponge, or through a tube (such as is done when blood is taken for a blood test or for a blood bank), or, as is the "traditional" way through vacuum-suction as created by the power of the mouth. In this latter formula, there are two ways this has been done: a. through the medium of a straw, sterilized pipette, or inverted syringe, or b. through direct oral contact of the mouth. See both methods in this video (link is to youtube)

Is Metzitzah Necessary

There is no question that while the Talmud lists metzitzah as one of three steps of a traditional circumcision, that the practice of drawing out blood reflects the medical knowledge of the time, and that any vestige of metzitzah is a nod to an ancient tradition. 

However, as we don't take medical advice from the Talmud some of the great rabbis of today and yesteryear suggested that metzitzah in any form is unnecessary מעיקר הדין, as an absolute obligation (Rabbi Joseph B. Soloveitchik, Rabbi Herschel Schachter). Certainly there is no justification for putting a mouth on an open wound, knowing what we know of today in terms of hygiene and bacteria. 

If Unnecessary, Why Do It?

Since the Talmud says to do it, many traditional mohels will still do metzitzah via the alternative method which does not put the baby (or the mohel!) in danger. It fulfills tradition without any harm as the only things touching the baby are sterilized in the same machine as the surgical instruments.

I always do metzizah with a sterile pipette. Of late, when families specifically request "no metzitzah" I have been ready to accomodate them in light of the teaching of Rabbis Soloveitchik and Schachter.

For more on Metzitzah, see the Metzitzah Page

"So, why should I choose to hire you as my son's mohel?"

Time to repost what makes the MohelBillet experience unique!

Here are links to two of the times I've answered this question (in different ways)

http://www.mohelinsouthflorida.com/2011/07/what-makes-you-different.html


http://www.mohelinsouthflorida.com/2014/10/the-sensitivity-factor.html

Safety Precautions - What you need to know...

...and what you need to insist your mohel does!

Circumcision is a relatively easy procedure, with minimal risk to a baby when done under the following conditions:
1. Baby is 100% healthy.
2. Operator is skilled at his work
3. Sterile conditions are maintained
4. The proper amount of foreskin is removed.
5. Bandaging is done well - minimizing loss of blood

Any mohel who is not careful about #1 is not fit to be a mohel.

Any mohel with a good reputation plus experience is surely good for #2.

Unfortunately, the last three are never a guarantee, unless the mohel takes certain precautions and has a good track record.

With regard to sterility
Mohel should wear gloves when operating. Period. End of story. I wear gloves, of course. But you will be surprised how often this is not a given, and something you cannot take for granted.

Maintaining Sterility brings honor to this mitzvah. Living in the Middle Ages does not.

The highest standards of sterilizing instruments is in a sterilizing oven or autoclave machine, and not through cold sterilization. And trying to mimic an operating room as best as possible.

Surgical Instruments should be laid out on a sterile drape - not on a laundered diaper cloth (amongst other suggestions)

Metzitzah - will be the subject of the next blog post. Though here is a link to the Metzitzah page

Proper amount of foreskin removed
There is no room for mohel-arrogance when it comes to your baby's penis

Mohel should use a surgical pen to mark where the edge of the foreskin is (and he should follow his estimation) [Here's a horrible story that was completely avoidable which a nurse told me about a bris she attended]

Taking off too much skin is harmful for the baby in the long-term

Leaving baby bleeding
There is never any excuse for this. I would rather take as much time as necessary to make sure baby is fine than have a parent call me saying "the diaper was all bloody!" I find myself sometimes saying to parents, after my immediate post-bris check-up, "Your baby is fine - everything is great! I apologize only for the amount of time it took for him to clot."

Knowing What Circumcision Is

Hopefully, anyone who is hiring a mohel understands that the act of Bris Milah includes a circumcision, and a circumcision is a surgical procedure in which the foreskin is removed. 

I don't post pictures on my blog of the before and after. But you can get a decent idea of the difference between how things look from this illustration. (*Graphic* but in a medical textbook sort of way)

While that illustration is nice and perfect, there is a healing process that every baby goes through after the circumcision. Here is my description of how things look before and afterwards.

These are the Methods of Circumcision that are generally utilized by mohels

Understanding the difference between a Clamp v Shield (shield method is more traditional)

And among the reasons why I don't recommend a clamp

Streamlining the Blog

There are two purposes for this blog:
1. It serves as my website as a mohel.
2. To provide information for the community of Jews who are researching Bris Milah on the Internet.

According to Blogger's count of these things, here is the current pageview stats from around the world - beyond the United States (which dwarfs the others) - over the last six years.

Ukraine	19439
Israel	10711
China	4004
Russia	3928
Germany	3233
France	2797
United Kingdom	2163
Canada	1295
Netherlands	607

So, as #2 is purpose has a mind of its own (thank you Internet), I'm going to try to bring things together in a more orderly fashion over the next few blog posts - essentially making the equivalent of pages dedicated to specific areas. Instead of rewriting the blog (always an interesting option!), I'll be putting together posts that are Tables of Contents for the areas of interest that have been raised thus far. Some of the "pages" which are linked at the top already do this. But it will provide more of a sense of order than the way the blog is currently structured.

Should be fun! 

We'll start with the most popular blog posts of all time:

How do you spell Mohel?

What Methods of circumcision are typically used by mohels?

What is jaundice? What happens when baby is 'yellow'?

A debate with an individual who disagrees about metzitzah

Is the mohel an expert? Certified? What are the different statuses of mohels?