Debate METZITZAH B’PEH

Metzitzah B’peh, Rabbinic Polemics and Applying the Lessons of History By N. Daniel Korobkin

ome time ago, a series of babies the practice, and argued that A. This tions and conclusions about this com- became infected with serious, life- was a religious rite and therefore not ponent of brit milah. Sthreatening sores in their groin within the purview of the medical com- areas shortly after they were circum- munity, B. That there was no conclusive The Situation Today cised. It was alleged both by physicians proof that the children had been infect- We are presently facing a signifi- and by some local rabbis that the sores ed by their mohel and C. Under no cir- cant divide within the Orthodox com- were the result of the mohel performing cumstances could a religious Jew deviate munity over this practice. In the sum- metzitzah b’peh—the ancient tradition from this age-old tradition of metzitzah mer of 2004, a clinical study from Israel of orally suctioning the wound after b’peh. appeared in Pediatrics, the journal of the incision. The mohel, it was alleged, may All these details may sound famil- American Academy of Pediatrics, appar- have had a communicable disease and iar, because they have appeared in one ently demonstrating that the practice of passed it on to the children, who, form or another recently in our media. metzitzah b’peh increases the risk of an because of their underdeveloped But the above is not a depiction of recent infant contracting the herpes simplex immune systems, were more susceptible events—all this occurred in the 1830s. virus (HSV).2 Early in 2005, news to the severe effects of this disease. As a As we hope to demonstrate, in broke that a prominent mohel in the result, some doctors condemned the this particular area of Jewish life, “There New York area had allegedly transmitted practice of metzitzah b’peh, and sought is nothing new under the sun.”1 As a HSV to a small number of infant government involvement to ban or at matter of fact, so much has been written patients through his practice of metz- least regulate the practice. Some rabbis about metzitzah b’peh in the last century itzah b’peh. The mohel in question was in the community reacted by defending and a half that it is difficult to condense ordered by the New York City all the material into one short article. Department of Health and Mental In addition to being a mohel, Rabbi Despite the voluminous material, we Hygiene to immediately desist from Korobkin is rabbi of Kehillat Yavneh of Los will still be left with the question of performing metzitzah b’peh. In Angeles, and director of community and syna- how much we can or cannot learn from December 2005, the commissioner of gogue services for the West Coast Orthodox the past. Although the facts of the pres- the same New York City department Union. The author wishes to thank Rabbi ent day seem identical to what went on Avrohom Teichman, Dr. Steven Weiss (both of issued an “open letter to the Jewish Los Angeles) and Rabbi Alan Wiener (of in the nineteenth century, sometimes community.” After documenting the Allentown, Pennsylvania) for their invaluable “the devil is in the details,” and certain statistically high number of HSV infec- input. details may drastically alter our percep- tions in infants who had had metzitzah Continued on page 26 24 JEWISH ACTION Winter 5767/2006 CONTROVERSY

The View from Israel By Mordechai Halperin Translated from the Hebrew by Yocheved Lavon

he second commandment writ- dwell in Eretz Yisrael and give their lives By attacking metzitzah, the Reformers ten in the Torah is that of brit for all the mitzvot. For what are you sought to gradually erode the Jewish Tmilah. A covenant between being beheaded? For circumcising my son. nation’s deeply rooted commitment to Israel and its Father in Heaven, brit For what are you being burned? For study- brit milah itself. milah is a mitzvah that is tied to the ing the Torah. For what are you being In recent years, private organiza- very identity of the Jewish nation. crucified? For eating matzah. For what tions dedicated to fighting the practice Throughout the generations, many of are you receiving a hundred lashes? For of brit milah have cropped up in Israel. our people have put their lives on the fulfilling the mitzvah of lulav. As in the past, these organizations begin line to fulfill it. Jews began sacrificing During the past two centuries war their attack by trying to get the govern- themselves for the sake of brit milah has been waged from time to time ment involved. In the early stages, they more than two millennia ago during the against the mitzvah of brit milah. appeal to health institutes and judicial tyrannical leadership of Antiochus and Ironically, the chief antagonists have authorities to ban metzitzah. Next, an the period of shemad under the been members of our own people. aggressive propaganda campaign is Romans. Testimony to this can be Activists from the Reform movement of launched with the aim of shifting public found in the Mechilta1 and in the the nineteenth century sought to abol- opinion. Recently, the Israeli television Midrash.2 ish brit milah through various strata- program Politika, broadcast by the gov- “To those who love and keep My gems, often calling upon the local ernment network, ran an interview with commandments.” This means those who authorities to help their cause. At times a couple that is waging a bitter fight they tried to erode the Jewish people’s against brit milah.3 Aside from making Rabbi Dr. Halperin was born in Jerusalem commitment to brit milah by whittling appeals to the health authorities and fil- and received his rabbinical ordination from away at the mitzvah itself. In other ing lawsuits, they have created two web Ponevezh Yeshiva in 1966. In 1987, he com- words, by eliminating certain aspects of sites to disseminate misinformation pleted his MD at The Hebrew University- the practice of brit milah, they hoped to about circumcision. On their web sites Hadassah Medical School. Formerly the direc- eventually call for its outright abolish- metzitzah b’peh is also a focal point. tor of the Jerusalem Medical Center for ment. One such aspect was metzitzah, The posekim have always con- Impotence & Infertility, Rabbi Dr. Halperin is currently the chief officer of medical ethics at which was more vulnerable to attack, cerned themselves with the halachic as Israel’s Ministry of Health, and the director of since the original knowledge upon well as the medical aspects of brit milah. the Dr. Falk Schlesinger Institute for Medical- which Chazal based the requirement However, when the very institution of had been lost, rendering it inexplicable. Halachic Research in Jerusalem. Continued on page 33

Winter 5767/2006 JEWISH ACTION 25 Continued from page 24 Will we become like our Russian the most extreme of whom will not per- b’peh the letter concluded: brethren in the past century who were mit metzitzah b’peh under any circum- During metzitzah b’peh the mouth forced under the Communists to conduct stances. of the mohel comes into direct contact with sacred bris[es] in underground bunkers the baby’s circumcision cut, risking trans- with sentries standing guard…. Are we Back to the Source mission of herpes simplex virus to the about to revisit those days in our own To better understand the issues, 4 infant. While severe illness associated with country? we first need to examine the reason why this practice may be rare, because there is If anything, the attack on metz- blood suctioning is a part of brit milah no proven way to reduce the risk of herpes itzah b’peh only strengthened the prac- in the first place. The mishnah in infection posed by circumcision which tice within the Chareidi community, as masechet Shabbat states: “We perform all includes metzitzah b’peh, the Health now this was viewed as a milchemet necessary acts for the milah on Shabbat: Department recommends that infants mitzvah—a religious war to defend a We circumcise, tear the mucosal mem- being circumcised not undergo metzitzah centuries-old tradition. brane [peri’ah], we suction, and we place b’peh. To help protect their baby, parents In the meantime, the Rabbinical upon the wound a bandage with cumin 6 should understand the risk of metzitzah Council of America had already issued powder.” b’peh—BEFORE the day of the bris, its own public policy statement, recom- In the ensuing gemara, Rav Papa while there is time to explore other mending, but not requiring, that mohe- states: “Any mohel that does not suction options…. lim desist from doing metzitzah b’peh, creates a health danger [sakanah], and The Department has reviewed all of and instead suction the blood through we therefore remove him from his 7 the evidence and there exists no reasonable post.” doubt that metzitzah b’peh can and has The simple understanding of the caused neonatal herpes infection. We have If anything, the attack on gemara is that metzitzah is not part of always maintained that it is our preference the actual mitzvah of circumcision; for the religious community to address metzitzah b’peh only instead, it is done to avoid any health these issues itself as long as the public’s strengthened the practice hazard to the child after the circumci- sion.8 health is protected. While some medical within the Chareidi professionals and others in the Jewish com- Rambam confirms this reading of munity have called on the Department to community, as now this the gemara by stating explicitly: “After completely ban metzitzah b’peh at this was viewed as a religious [circumcision and peri’ah], the mohel time, it is our opinion that educating the suctions the area sufficiently until blood community through public health infor- war to defend a centuries- flows from places far away from the mation and warnings is a more realistic wound; he does this in order that the old tradition. 9 approach.3 child not be endangered.” The negative response by the It is implicit from the Talmudic Chareidi community to this governmen- and post-Talmudic discussions that the tal position was swift and passionate. other, safer methods. The article, quot- method being advocated for suctioning Articles, signed open letters and kol ing Rabbi Hershel Schachter, a rosh the blood is via the mouth, that is, met- 10 koreh posters accused the Department of yeshivah of Rabbi Isaac Elchanan zitzah b’peh. No one entertained an Health of overstepping its authority; as Theological Seminary, stated the follow- alternate method for metzitzah until the a religious rite, brit milah was within the ing: nineteenth century. At the same time, purview of the rabbis, not the govern- Rav Yosef Dov Soloveitchik reports no special designation was given to the ment. Additionally, there were insuffi- that his father, Rav Moshe Soloveitchik, mouth by the halachic authorities other cient data to correlate metzitzah b’peh to would not permit a mohel to perform than that it was the most obvious and HSV. It was also argued that the moti- metzitza b’peh with direct oral contact, convenient method of suctioning. vations of the Department of Health and that his grandfather, Rav Chaim However, sources in kabbalistic lit- were less than pure; the city department Soloveitchik, instructed mohelim in Brisk erature do make reference to the benefit was comprised of secular, anti-religious not to do metzitza b’peh with direct oral of using specifically the mouth in the 5 Jews who had a much larger agenda: contact. mitzvah of brit milah. For example, the The recommendation to refrain from And so, for the time being, two seventeenth-century kabbalist Rabbi metzitzah b’peh was only one step camps remain within our people: those Avraham Azulai stated that man pos- removed from banning brit milah alto- who are pro-metzitzah b’peh, the most sesses a foreskin because of Adam’s sin gether, or at least banning non-physi- extreme of whom will not permit a brit in the Garden of Eden. cian mohelim. An editor in a Chareidi milah unless it includes metzitzah b’peh, The same parts of the body which newspaper wrote: and those who are anti-metzitzah b’peh, caused this distortion must restore the body

26 JEWISH ACTION Winter 5767/2006 to its natural perfection. Adam’s hands Talmudic era we have found more effec- of motive may raise questions about took the forbidden fruit and his mouth ate tive methods of achieving homeostasis those who disagreed with the Chatam it, so the hands of the mohel remove the and protecting the wound from infec- Sofer and maintained that metzitzah was foreskin and the blood is removed with the tion, and this is why halachic authorities specifically with the mouth. Was the mouth.11 do not require the use of cumin alone. often-fiery defense of metzitzah b’peh Similarly, contended the Chatam Sofer, based purely on halachic considerations, The Chatam Sofer and the Sponge based on the Mishnah, no one could or was it also out of a sense of duty to In 1837, Rabbi Eliezer Horowitz, argue that the mouth alone had to be preserve the mesorah (tradition) against the chief rabbi of Vienna, was presented used to suction the blood. the attacks of the Reform movement? with a dilemma. A number of children But here’s where the waters Was there a sentiment that a concession had become infected with sores after become murky. What was the true on the metzitzah issue would open a their circumcisions, and some had even motivation for wanting to abolish metz- slippery slope that would eventually do died. It was believed that their mohel itzah b’peh in the Viennese community? away with brit milah entirely? If so, we had transmitted a disease to them, and From a later letter from the same Dr. must look at the responsa of the era so a certain Dr. Wertheim of Vienna Wertheim who initiated the query to with a discriminating eye, and try to see asked Rabbi Horowitz if, instead of suc- Rabbi Horowitz, it seems the doctor where the halachic arguments end and tioning orally, it could be permitted to had another agenda. In communicating rabbinic rhetoric and polemics begin. squeeze out blood from the brit milah to the Jewish community Rabbi As we shall see, this may prove to be a Horowitz’s and the Chatam Sofer’s rul- area using a moistened sponge. Rabbi difficult task. ing, he is motivated to abandon metz- Horowitz’s inclination was to permit the While we cannot provide here an itzah b’peh by “the wish to remove from use of a sponge for metzitzah, but he exhaustive list of authorities who fiercely this important religious act any ugliness, did not want to dispense the heter with- debated this issue,14 we will cite one which affronts the eye of the expert as it out first consulting with his revered example of where anti-Reform rhetoric does the emotions of the layman.”13 rebbe, Rabbi Moshe Sofer, the Chatam and halachic arguments are intertwined. Sofer. In a letter to Rabbi Horowitz, the It is possible that Dr. Wertheim’s Rabbi Yaakov Ettlinger, in his famous Chatam Sofer wrote: motives were fueled by a desire, like so responsa work, Binyan Tzion, wrote two We only find metzitzah b’peh as a many Jewish Reformers of the time, to responsa on the issue of metzitzah, and requirement by the kabbalists, who assert abolish certain traditional practices that in both he strongly defended the prac- that one must mitigate the strict attribute appeared unsightly or primitive to the tice, calling metzitzah (not b’peh per se, of justice with the mouth and lips. non-Jewish world. During much of the just the act of suctioning) a “halachah However, we have no dealing with hidden nineteenth century, there was a concert- leMoshe miSinai,” a necessary tradition matters if there is at all even the slightest ed effort in many communities that dating back to Moses at Sinai.15 In his concern of a health hazard…. Therefore, were under the influence of the Reform as long as we can draw out the blood from movement to either abolish brit milah second responsum, he prefaces the issue the faraway places, it may be done in any entirely, or to have it done only by with the following: way possible. We should believe the experts physicians, or to at least eliminate metz- Ever since my ruling on metzitzah, regarding which act is as effective as oral itzah b’peh. During this time, an alarm- they have come to fight against me. They suctioning. I will go even further: Even if ing number of communities were doing furiously shoot arrows of falsehood and lies the Talmud had explicitly stated that one away with metzitzah or brit milah at me. Their words reveal three agendas: must suction with his mouth [I would still entirely. A. They speak arrogantly and disparaging- maintain that one may use a sponge], However, none of this changes the ly against the words of our Sages of blessed since the act of suctioning is not an inte- ruling of the Chatam Sofer. Apparently memory. B. They pour out humiliation gral part of the mitzvah of milah, but is oblivious to the motivations of the and ridicule against me, and have made rather merely done to avert danger to the questioner, the rabbi ruled, based on the me the brunt of their injurious speech, child. To wit, according to the halachah, if cold facts of the halachah, that metz- both covertly and overtly. C. They are con- one circumcises and does peri’ah but neg- itzah could be performed in any way tinuing with full intensity their deceitful lects to suction, he has completely fulfilled that would accomplish the health direc- campaign to abolish metzitzah. the mitzvah….12 tive. Note that the issue of metzitzah is The Chatam Sofer went on to the third on a list of three grievances demonstrate that applying cumin pow- Metzitzah B’peh: Another against the “enemy.” Clearly, the issue of der is also listed in the Mishnah as Battlefront Against the Reform the day was not only metzitzah, but also something done even on Shabbat, yet Movement the general war against Reform Judaism no one argues that only cumin must be Dr. Wertheim’s and others’ moti- and the Haskalah. Metzitzah was a used as a salve for the area. Since the vations are important because the issue major battlefront in this ongoing war.

Winter 5767/2006 JEWISH ACTION 27 Halachah LeMoshe MiSinai? when it became the target of attacks by with the mouth than the Chatam Sofer’s This is perhaps why we find that innovators, it aroused a defensive reaction previous dispensation of using a moist metzitzah is for the first time called by the Orthodox, irrespective of its sponge, and at the same time it protect- “halachah leMoshe miSinai” only in the halachic status. The Chatam Sofer advo- ed both the infant and the mohel. In nineteenth century.16 Until then, there cated the “elevation of the prohibition,” their public announcement to the was no need to strongly defend it from that is, giving a higher status to any prac- Jewish community, the two rabbis its detractors. By maintaining that the tice under attack than its original status in emphasized the need for using the tube practice was something dating back to the halachic hierarchy, as one of the means for medical reasons, and did not even Moshe Rabbeinu, it occupied an elevat- of defending rituals and customs.… In the intimate that it was any less desirable ed status of being a halachic imperative. time of the Chatam Sofer, metzitza was than metzitzah b’peh.20 The glass tube is Additionally, once something is a not yet a controversial subject, so he could used by many mohelim to this day. Mosaic tradition, it is much more diffi- deal with it on its own terms, and did not Curiously, Rabbi Hirsch, in a cult to suggest an alteration to that tra- need to employ the means of defense which scholarly responsum, permitted the met- dition. This was one further reason not he himself outlined. In the days of his zitzah tube in a much more subdued to tamper with the age-old tradition of descendants and students, metzitza was tone. As a combatant against Reform doing metzitzah orally. drawn into the whirlpool of confrontation Judaism, Rabbi Hirsch first attacked We also find a number of rabbis between innovators and conservatives, and those elements within the community of the era challenging the authenticity those who followed in the Chatam Sofer’s that sought to abolish metzitzah of the Chatam Sofer’s letter to Rabbi footsteps needed his method of defense.19 entirely.21 He then clearly stated that his Horowitz, which permitted metzitzah endorsement of the tube was not meant with a sponge. One anonymous source Public vs. Private for those who felt comfortable doing went so far as to charge that the letter Policy: Rabbi metzitzah b’peh, but only for those who was forged or adulterated.17 Others min- Hirsch’s Pesak have not to date been performing metz- imized the significance of the ruling in itzah at all, either because of a fear of that it applied only to a situation where contracting disease from the mohel, or the city’s mohel was known to have a because of governmental intimidation.22 communicable disease. Others suggested Why the change in tone between that had the Chatam Sofer known the The Metzitzah Tube. the public announcement and the motivation behind the query and that This diagram first scholarly ruling? We can only speculate the Jewish Reformers were seeking to appeared in 1888 and that on the one hand, Rabbi Hirsch felt abolish metzitzah entirely, he never was reprinted in the duty-bound to the German community, would have issued a lenient ruling; the journal HaMayan, which was already under tremendous Chatam Sofer was, after all, one of the no. 5 (1965). pressure to abolish metzitzah, to find most ardent opponents of the Reform some solution that would make every- movement. Yet others argued that the In 1888, reacting one feel comfortable again with brit fact that this pesak of the Chatam Sofer to a pervasive negative attitude toward milah practice. On the other hand, he did not appear in his book of responsa, metzitzah b’peh, Rabbi Samson Raphael may have felt a need to preserve the Shu”t Chatam Sofer, was proof that it Hirsch and Rabbi Azriel Hildesheimer, mesorah of metzitzah b’peh within a was not to be taken seriously or applied chief rabbis of Frankfurt and Berlin smaller enclave, as a means of combat- to other situations.18 respectively, came out with a joint rul- ing the Reform movement. In other Since the students of the Chatam ing that advocated doing metzitzah words, he may have taken a broader Sofer followed their rebbe’s tradition of using a newly invented device, the metz- communal stance that was different battling against the Reform movement, itzah tube. This was a glass tube, about from what he advocated for those in his it is ironic that they were faced with the 6.5 centimeters long, that was wide on inner circle. task of minimizing their rebbe’s pesak. one end and narrow on the other (see As Jacob Katz, author and editor of diagram). It could be placed over the The Present many books in medieval and modern area of the brit milah and the mohel Let us return to the present, where Jewish social history, maintains: could place his mouth over the narrow the division continues within our own Metzitzah by mouth, which to the end of the tube and suction the blood community. If we look at how the two observer appeared to be a part of the cir- with his mouth, without there being camps have reacted to HSV, we find cumcision rite, was challenged for reasons any physical contact between the mohel history repeating itself … almost. that were tainted with reformist ideas. and the infant or the infant’s blood. Granted, one side seeks to abolish—or Whatever the purpose of metzitza accord- This method was viewed as more in to at least diminish—the practice of ing to its original halachic categorization, keeping with the tradition of suctioning metzitzah b’peh, and the other side

28 JEWISH ACTION Winter 5767/2006 argues that metzitzah b’peh is being maligned for all the wrong reasons. But is this really so? Can it be argued with the same vigor and conviction that medical profes- sionals in the twenty-first century are motivated by a desire to sanitize brit milah (and Judaism by extension), and are therefore misrepresenting the results of the clini- cal studies? 2006 is not 1836. The war against the Reform movement is long over (or at least it has changed from war to frosty détente). Accordingly, using the often- rhetorical arguments of the nineteenth-century rabbis may be a misapplication of historical precedent.23 In 1989, a kol koreh (public announcement) was issued by gedolim in both Israel and the United States regarding the practice of metzitzah b’peh in light of the new AIDS virus. The letter called upon all Jews to con- tinue the practice of metzitzah b’peh, unless the mohel or the infant was known to be a carrier of a communicable disease. It was signed by both admorim in the Chassidic community and respected roshei yeshivah in the Litvishe community. This kol koreh is being cited again as a defense for metzitzah b’peh despite the new health concerns, and that may be a perfectly appropriate defense. On the other hand, it may also be that a new assessment is called for in light of the new medical data, not having to do with AIDS, but with HSV, which, although not as lethal, is much more prevalent within the adult population.

When Torah and Science Clash One more matter deserves consideration. Around the same time of the Chatam Sofer’s responsum about metzitzah b’peh, the Tiferet Yisrael Mishnah commentary was first published. In it, Rabbi Yisrael Lipschutz initially argued that based on modern medicine, not only did the practice of metzitzah not reduce sakanah to the newborn, if anything, it endangered the child’s life further by increasing the risk of unstoppable bleeding. But does this mean that the rabbis of the Mishnah were wrong? How do we reconcile Talmudic science with modern science? Rabbi Lipschutz answers with the widely used principle of “nishtaneh hateva”—nature has changed since Talmudic times, and so what was dangerous then may not be dangerous today, and vice versa. Although the author concludes by defending metzitzah,24 his own con- flict over the discrepancy between the medical knowledge of the Sages and that of modern physicians becomes clear. While the medical arguments today against metz- itzah b’peh are different from those of the Tiferet Yisrael’s time, the tension between tradition and modernity is just as real. This, too, is part of the modern-day metzitzah b’peh controversy: How much credence should be invest- ed in modern science when it contradicts rabbinic wis- dom, and how are discrepancies between the two

Winter 5767/2006 JEWISH ACTION 29 The Truth About HSV Over one hundred years ago, tuberculosis and syphilis were associated with metzitzah b’peh. Today, it is mostly viruses like herpes and HIV that are HSV in the newborn population of concern to the Jewish public. As opposed to the youth and adult populations, newborn HSV infection cent of cases); infection may also occur What is herpes? can be a devastating disease. Newborns as the infant passes through the birth While herpes simplex virus, other- nearly always require hospitalization and canal and is exposed to infected secre- wise known as HSV, was scientifically intravenous antibiotics. tions (90 percent of cases). The overall investigated and described in the twenti- 1. In a third of cases, the disease risk of neonatal HSV infection is about eth century, the disease has been around localizes to the skin, eyes or mouth. .03 percent or 1 in 3,000 deliveries. for thousands of years. Indeed, the 2. In a third of cases, the disease In highly rare cases, a newborn Greeks were the first to use the term enters the central nervous system. may contract the infection after birth. herpes, meaning creeping or crawling, in (Thus, HSV can cause encephalitis.) HSV-1 can be acquired from exposure describing a variety of skin lesions, both 3. In a third of cases, HSV infects to infected family members, friends or infectious and non-infectious. multiple organs (brain, lung, liver, et hospital personnel. For instance, an Herodotus (484-425 BCE), the Greek cetera.) older sister who has a skin lesion on her historian, associated mouth ulcers and Babies with widespread infection hands and decides to change the diaper lip lesions with fever, calling them herpes have the worst prognosis; 60 percent die of her newly circumcised baby brother febrilis. before their first birthday, regardless of might unwittingly infect the infant. HSV is a part of the herpes virus treatment. Nearly 50 percent of babies family. There are over one hundred What are the symptoms? with herpes encephalitis will have viruses in this family, including chicken- impaired neurological function. Even in pox (varicella), Epstein-Barr (EBV) and As stated above, infected individu- als can spread the disease via oral or babies with localized infection where the Cytomegalovirus (CMV). HSV can genital secretions. To infect another mortality rate is zero, 9 percent of cause infections of the skin, the central individual, these secretions must come infants will end up with neurological nervous system and even organs. into contact with damaged or broken impairment. Once a baby is infected, Who is susceptible to contracting skin (or mucous membranes). The virus one cannot predict if he will develop the HSV? How it is transmitted? then multiplies at the site of the infec- worst clinical scenario. Clearly, neonatal Anyone can contract HSV, of tion before heading to the spine, where HSV infection is not a benign illness. which there are two types. During close it hibernates and enters a latent phase. At times, a stimulus may provoke it. How is it diagnosed? contact, HSV-1 is transmitted from per- HSV can be diagnosed by reliable son to person via infected saliva. HSV-2 The virus is then awakened from laten- cy and travels back to the skin where it blood tests. A viral culture can also be is transmitted though infected genital produces the characteristic skin lesion— taken—that is, a sample from a herpes secretions. However, oral-genital contact a small, fluid-filled skin blister that sore—and sent to the lab for testing. may cause infection with either type in breaks open, crusts over and then disap- However, a viral culture can be mislead- the oral or genital areas. About 80 per- pears. This virus is responsible for the ing: Even if the result is negative, one cent of all adults in the United States lesions seen around the mouth, eye and could still have herpes since the virus are infected with HSV-1, and about 50 genital areas. survives in the blister for only a short percent of children in the US are infect- Some people develop lesions time. ed with HSV-1 by age five. HSV-2 around their lips while others never affects approximately 20 percent of the develop signs of infection. Once infect- How is HSV prevented US population. ed, an individual has HSV for life and in the newborn? HSV can infect newborn children can continue to shed the virus intermit- A pregnant mother can protect (neonatal herpes) in a few ways. A fetus tently (although this probably declines her newborn child with her maternal can be infected in utero if a mother who with old age). Thus, one can be infected HSV antibody for about six months doesn’t have antibodies to HSV gets and not realize it and can transmit the (providing that the mother’s initial infected during pregnancy (5 to 8 per- infection and not know it. infection didn’t occur during that preg- nancy). Hand washing with soap and A graduate of Yeshiva University, Dr. Yitzchak How is it treated? Ariel is board certified in internal medicine HSV cold sores in children and water before touching a newborn is piv- and infectious diseases. He practices in adults usually don’t need to be treated; otal. The New York State Department Manhattan and Brooklyn. He has lectured on however, there are creams or tablets with of Health recommends not kissing a this topic for the Association of Orthodox anti-viral medication that can be taken baby if one has cold sores on the mouth Jewish Scientists. to alleviate the symptoms. or lips.

30 JEWISH ACTION Winter 5767/2006 resolved? Is reliance upon today’s physi- former is for the direct benefit to my tact with unclean fingers or an unclean cians a betrayal of our tradition, or is it own son’s soul; the latter is for the blade; metzitzah also prevents swelling and in keeping with the Talmudic teaching nation of Israel. Clarity on the issues, in closes the blood vessels, therefore reducing that health issues supersede all other this situation as in so many others, is bleeding. considerations? This thorny issue may one’s greatest ally. JA 9. Mishneh Torah, Hilchot Milah 2:2. also have contributed to today’s forma- See, however, Shu”t Meshiv Nefesh (ibid.), tion of two separate camps within the Notes who—remarkably—provided a novel argu- Orthodox community on the metzitzah 1. Kohelet 1:9. ment that even Rambam maintained that b’peh issue. 2. Benjamin Gesundheit et al., metzitzah is an integral part of the mitzvah “Neonatal Genital Herpes Simplex Virus and is not done merely because of sakanah. Final Thoughts Type 1 Infection After Jewish Ritual 10. See Shulchan Aruch, Yoreh Deah It is important for mohelim and Circumcision: Modern Medicine and 265:10, Rema’s commentary: “We spit the parents to always remember the Religious Tradition,” Pediatrics (August metzitzah blood into dirt.” This clearly indi- Shulchan Aruch’s instruction that the 2004): 114; 259-263, DOI: cates that the mohel had sucked the blood baby’s health is the prime directive for 10.1542/peds.114.2.e259. The article has into his mouth. the mohel: come under considerable criticism by some 11. From Chesed LeAvraham, quoted One must be very cautious in these physicians and rabbis. Daniel S. Berman, in Rabbi Y. Goldberger, Sanctity and Science (Jerusalem, 1991). areas, and not circumcise any child when MD, FACP, an infectious-disease specialist, 12. This letter was first printed in there is even a suspicion of illness. Danger wrote a well-reasoned article arguing that 1845 by Menachem Mendel Stern in the to life is the overriding concern, for it is the Pediatrics study was fraught with inaccu- periodical Kochvei Yitzchak. It is quoted in a possible to delay a brit [milah], but it is racies and unsubstantiated conclusions. number of secondary sources, including impossible to restore a Jewish life.25 3. The open letter is available online Rabbi Rami Cohen, Bris Avraham HaKohen Accordingly, the burden of proof at http://www.nyc.gov/html/doh/down- (New York, 1993), 192. is on those who would practice metz- loads/pdf/std/std-bris-commishletter.pdf. A 13. Quoted in Jacob Katz, Divine itzah b’peh to effectively demonstrate fact sheet entitled, “Before the Bris: How to Protect Your Infant Against Herpes Virus Law in Human Hands (Jerusalem, 1998), that the clinical studies are flawed, that Infection Caused by Metzitzah B’peh,” is a 362. It is also possible that Dr. Wertheim their conclusions of a health hazard are follow-up to the open letter, and is also mentioned this reason not because of any not supported by the evidence and that available online at http://www.nyc.gov/ Reform leanings, but rather because he the alarms being raised are unfounded.26 html/doh/html/std/std-bris.shtml. wished to divert attention from the mohel While there is definitely basis for 4. From Yated Ne’eman, 18 February who was alleged to have infected children. an insistence on metzitzah b’peh, prima- 2005; also quoted in an article by Eric J. Perhaps he simply wished to save the mohel rily from kabbalistic sources, one should Greenberg in the 4 March 2005 issue of the from embarrassment and loss of livelihood. carefully consider the risks involved Forward. For more quotes, articles and pho- 14. We refer the serious student to a when contemplating the practice for tos of posters, go to http://hydepark.hevre. number of compilation sources. One of the one’s own newborn son. Certainly, it is co.il/hydepark/topic.asp?topic_id=1287989. more important sources in Hebrew is Sdei worthwhile to consult one’s rabbinic 5. The full policy statement can be Chemed 8, Kuntres Hametzitzah (pp. 236- authority. Additionally, one should pay found on the RCA web site at http://www. 450), which reviews the various opinions to careful attention to the reason why met- rabbis.org/news/article.cfm?id=100605. date and forcefully defends metzitzah b’peh. zitzah b’peh is being advocated so 6. Mishnah Shabbat 19:2. Also extremely helpful is Katz (pp. 357- strongly within certain circles. If the rea- 7. Shabbat 133b. 402). See also Rabbi Yosef Weisberg, Otzar son is predicated on halachic and kab- 8. See Shu”t Avnei Nezer, Yoreh Deah, HaBrit 4, “Milchemet Hametzitzah.” balistic imperatives, that is one thing. If, sec. 338, where the author acknowledges 15. Shu”t Binyan Tzion, sec. 23 and 24. however, the reason to stand firmly on that this is the simple understanding of the 16. See also Shu”t Maharam Shick, this practice is to preserve the greater gemara, but then offers an alternate interpre- Orach Chaim, sec. 152 and Shu”t Mahari good of a pristine mesorah for Klal tation, which would define metzitzah as an Asad, sec. 258. Katz (p. 401), quoting from Yisrael’s future, unadulterated and pro- integral part of the mitzvah. See also Shu”t a letter written by the Chatam Sofer to tected from a potential slippery slope, Meshiv Nefesh 2, sec. 6. Regardless, the vast Rabbi Tzvi Hirsh Chajes, writes that under then a new parent may wish to consid- majority of authorities agree that if metz- certain circumstances, the Chatam Sofer er: Do I wish to expose my newborn itzah is not performed, the circumcision is advocated the “elevation of the prohibition,” son to the minor infection risks, not still kosher. How does suctioning the blood that is, overstating the prohibited nature of because of a halachic imperative, not remove the health hazard? The following a certain practice when it had come under because it is really “halachah leMoshe opinions are offered by Sdei Chemed 8 in attack as one of the means of defending the miSinai,” but rather for the sake of pro- Kuntres Hametzitzah: Metzitzah prevents practice against the Reform movement. It tecting tradition in Klal Yisrael? The infection by cleaning the wound after con- should not be surprising that this term can

Winter 5767/2006 JEWISH ACTION 31 be used hyperbolically, for we find that by the time of the Chatam Sofer’s death of this writing, negotiations are still ongoing Chazal themselves attributed certain prac- metzitzah b’peh had become a battlefield with the New York City Department of tices as “halachah leMoshe miSinai” when issue, it is more likely that the family omit- Health, but it appears that the city’s more these practices were in reality only of later, ted it to avoid the controversy. public opposition to metzitzah b’peh has rabbinic origin. See commentary of Rabbi 19. Katz, pp. 401-402. made it difficult to broker such a compro- Chajes to Chagigah 3b; see also Tiferet 20. This point is emphasized by mise. Yisrael commentary to Mishnah Yoma 2:2 Mordechai Breuer in Modernity Within 24. Tiferet Yisrael to Mishnah Shabbat (end of note 12). Accordingly, the nine- Tradition: The Social History of Orthodox 19:2. Although he advocates the preserva- teenth-century rabbis were merely following Jewry in Imperial Germany (New York, tion of metzitzah, the author also concludes Chazal ’s example. 1992), 259. with a novel halachic position regarding 17. Katz (pp. 376-377) quotes from 21. Anyone who has the audacity to metzitzah on Shabbat, which indicates some an anonymously penned article, “Metzitzah suggest that the Sages’ ruling that “any mohel level of equivocation. See Shu”t Binyan from the Medical and Religious who does not perform metzitzah [endangers Tzion (sec. 23 and 24) for a response to Perspective,” published in Der Treue Zions- the child and] is removed from his post” Tiferet Yisrael. While Tiferet Yisrael is pre- Wächter, no. 46, 24 November 1846. The (Shabbat 133b) no longer applies to us … pared to argue nishtaneh hateva, he does not author warns against relying on the names places himself on the side of the Reform. If one go so far as to argue that Chazal were sim- of authorities like the Chatam Sofer, whose subscribes to this, then instead of bringing his ply relying on imperfect medical knowledge. ruling was “forged or distorted.” This argu- son into the covenant of Avraham Avinu, he is This is in contradistinction to Rabbi ment apparently caught on, as it was also bringing him into the covenant of the Reform. Avraham ben HaRambam’s position on cited in the 1870s by Rabbi Chaim Hirsch Once again, we are faced with a such matters. For more on this subject, see Mannheimer (a student of the Chatam halachic responsum that is intertwined with Yehudah Levi, The Science in Torah Sofer), in his Ein HaBedolach, 13. polemical rhetoric against the Reform (Jerusalem, 2004). 18. See Katz, who calls this final argu- movement. 25. Yoreh Deah 263:1. ment “specious” because it was the Chatam 22. Shu”t Shemesh Marpei, sec. 55. 26. All authorities agree that when Sofer’s family and students who compiled 23. The counter-argument to this is the sakanah factor is clear and present, such the rav’s responsa posthumously and chose that, indeed, the war is not over. It may be as when either the baby or the mohel is what to include and what to exclude. Since more than coincidence that the New York known to have a communicable disease, City Department of Health, which is com- metzitzah should not be done orally. Even prised mostly of secular Jews, is the most Rabbi Yosef Shalom Elyashiv, who has been vocal in its anti-metzitzah b’peh stance, while widely quoted as a defender of metzitzah the New York State Department of Health, b’peh, has ruled accordingly. The point of which is mostly non-Jewish, has not taken a dispute is merely whether or not there is a position on the matter. This point was con- sakanah when no known contagion is pres- veyed to me by a prominent Chassidic ent. It has been communicated to me both mohel who performs metzitzah b’peh. by my beloved teacher, the late Rabbi Yosef Perhaps because of its less oppositional Weisberg, former chief mohel of Jerusalem, stance, the state’s health department has and by several mohelim who meticulously been more successful in brokering a com- perform metzitzah b’peh within the promise, taking into account the health Orthodox community, that as a matter of concerns of the medical community and the course they do not perform metzitzah b’peh religious concerns of the Chareidi commu- when the parents are not observant, even nity. In June 2006, the Central Rabbinical when there is no knowledge that either parent Congress of the USA and Canada, a possesses a communicable disease. Apparently, Chassidic group in Williamsburg, agreed to in these cases the risk factor is too great even the state’s health commissioner’s order to for the most ardent metzitzah b’peh advo- self-regulate community mohelim with new cates. Another issue to consider is that many standards. The standards entail that all authorities permit metzitzah to be done by mohelim sanitize their hands similarly to sur- someone other than the mohel (see Ketzot geons, clean their mouths with a sterile alco- HaChoshen 382:2). Accordingly, a father hol wipe and rinse for at least thirty seconds who wishes to minimize risk and at the with mouthwash, cover the circumcised area same time preserve the practice can perform with antibiotic ointment and sterile gauze metzitzah b’peh himself on his son (of and agree to be tested for HSV if a baby course, after consultation with the mohel on shows evidence of HSV following a brit how the procedure is done). It has been my milah where metzitzah b’peh was used, along personal practice as a mohel to offer this with his parents and health care workers. As alternative to any interested parent.

32 JEWISH ACTION Winter 5767/2006 Continued from page 25 of halachah for the procedure, rules that religious significance as well as medical brit milah is under attack and metzitzah were designed to decrease the minimal benefits. is being used as ammunition in the risk even further. These rules include Metzitzah as a religious obligation assault, the posekim need to take a dif- detailed guidelines for the entire proce- is mentioned in the mystical portions of ferent approach. Therefore, any compre- dure, from the preparatory stage the Torah.12 In the last two centuries, as hensive discussion of metzitzah should through the performance of the surgery well, a number of famous posekim have deal not only with the medical/halachic itself and the post-operative stage, until declared that an attack on the tradition issues but also with some aspects of the the follow-up care.10 They also include of metzitzah is tantamount to an attack ideological battle against metzitzah, the necessary preconditions for brit on the mitzvah of brit milah itself.13 which is linked to the effort to uproot milah as regards the baby’s health condi- Nevertheless, many posekim, including the practice of brit milah. tion. Rambam’s medical/halachic guide- the Chatam Sofer, the Ketzot line is a typical example: Hachoshen, the Netziv of Volozhin,14 A Medical Overview Only an infant free of any illness is the Avnei Nezer15 and, more recently, Circumcision is the most com- circumcised, for danger to life precludes Rabbi Shlomo Zalman Auerbach and mon surgical procedure performed on other considerations; brit milah can be the Tzitz Eliezer, have ruled that the males in the United States4 and in Israel. performed after the specified time, but the purpose of metzitzah is solely medical. It is performed as a religious obligation life of an individual can never be Some have pointed out that even on nearly 100 percent of Jewish males restored.11 the posekim who maintain that metz- and on more than 90 percent of itzah is a religious obligation (that is, Muslim males. In former times, circum- Stages of the Milah Procedure that metzitzah is part of the mitzvah of cision was performed exclusively for reli- Halachic brit milah involves four brit milah) may not have based their gious reasons, but since the Second main stages: 1. Preparation before the statements purely on halachic reasoning, World War,5 millions of newborns brit milah—these preparations may be but to a large extent were responding to (between 60 and 90 percent of newborn characterized essentially as preventive attacks against brit milah. Those who males in the United States)6 have been medicine; 2. Performance of the sur- make this claim are supported by the circumcised for medical or cosmetic rea- gery—incision and splitting of the halachic literature on metzitzah, which sons. The most striking medical advan- membrane; 3. Metzitzah and 4. indicates rather clearly that metzitzah is tage of removal of the foreskin is its Supportive care after the circumcision. a medical requirement instituted by association with a drastic reduction in Chazal because of the risk involved in the risk of penile cancer.7 In the second neglecting to perform it. In addition, half of the twentieth century, about By attacking metzitzah, the one cannot ignore the difficulty of 11,000 uncircumcised American men Reformers sought to gradual- defending a medical guideline imposed died of penile cancer,8 and nearly all of ly erode the Jewish nation’s by Chazal in the absence of sufficient these deaths could have been prevented medical knowledge to explain it. by a simple procedure of excising the deeply rooted commitment Furthermore, proclaiming that metz- foreskin at an early age. to brit milah itself. itzah is an inseparable part of the com- During the past year, another mandment of brit milah is an effectual medical advantage of circumcision was means today, as in the past, of fending discovered. In a controlled prospective What is Metzitzah? off attacks against the Divine covenant study, circumcision was shown to pro- The original technique for the of circumcision.16 tect against contagion with AIDS by a performance of metzitzah employs the The Gemara states that the factor of about 60 percent.9 human mouth. The mohel brings the requirement of metzitzah stems from Admittedly, circumcision is not baby’s organ into his mouth immediate- medical considerations; it is meant to totally risk-free; however, the risks are ly after the excision of the foreskin and minimize risk to the infant’s life and extremely low. In the second half of the sucks blood from it vigorously. This health17: twentieth century, only four deaths action lowers the internal pressure in the Rav Pappa said, “A mohel who does caused by complications resulting from tissues of the organ, in the blood vessels not perform metzitzah endangers the baby the procedure occurred in the United of the head of the organ and in the and is dismissed.” States, compared to the 10,000 deaths exposed ends of the arterioles that have Is this not obvious? Since we dese- that it prevented during the same peri- just been cut. Thus, the difference crate the Shabbat for it, it obviously must od. Since Chazal were, characteristically, between the pressure in the blood ves- be a danger to omit it [and thus it is prop- aware of the possible risks associated sels in the base of the organ and the er to dismiss someone who fails to do it. with the performance of brit milah, they pressure in the blood vessels at its tip is What does Rav Pappa’s statement add?] laid down medical rules with the force increased. This requirement has deep You might say [had Rav Pappa not

Winter 5767/2006 JEWISH ACTION 33 made this statement] that this blood is further reaches” of the organ is the goal endangers the infant and is dismissed’ stored up [so sucking it out is not a dese- of metzitzah and the reason for it; i.e., because blood will clot within the organ cration]. Now we have learned [from Rav the very fact that blood stays in the fur- and this is dangerous.” Pappa] that the blood is the result of a ther reaches poses a danger to the infant (These words clearly cannot be wound [thereby sucking it out is desecrat- (perhaps because of concern that infec- referring to coagulated blood at the ure- ing the Shabbat]. tious agents harbored there should be thral opening, for any experienced From this gemara it seems fairly drained away and drawn out). mohel will realize that such blood can clear that medical considerations are the 2. “Extraction of blood from the be wiped away easily, and there is cer- only reason for metzitzah, for the further reaches” is merely an indication tainly no need for forceful sucking to gemara states that the very fact that met- that metzitzah was performed with the remove it. Furthermore, sucking blood zitzah is permitted on Shabbat indicates required level of force, and a flow of for the purpose of removing the coagu- that failing to perform it poses a risk to blood from this area tells us that the lated blood is not a melachchah, while life. From this we can derive that metz- metzitzah has achieved its purpose. (A the Gemara states that the sucking of itzah cannot be defined as part of the physiological explanation for this inter- blood [for the purpose of metzitzah] is a ritual of brit milah, which overrides pretation will follow.) melachah, and is only permitted because Shabbat in and of itself, independent of Whichever way we understand it prevents a potential sakanah.) the laws of pikuach nefesh.18 Rambam, the physiological process by This gemara seems to be the which metzitzah prevents endangering Explaining Metzitzah source of the interpretation (i.e., that the infant is not elucidated in Rambam, Rabbi Hagozer’s explanation metzitzah is performed because of med- might be translated into modern med- ical reasons) adopted by many posekim, ical terms as follows26: Immediately after both Rishonim and Acharonim, includ- Since Chazal did not specify incising or injuring an artery, the arteri- ing Rambam, the Shulchan Aruch,19 the al walls contract and obstruct, or at least 20 the nature of the risk pre- Chochmat Adam and, as mentioned reduce, the flow of blood.27 Since the above, the Chatam Sofer, the Ketzot vented by metzitzah, the arterioles of the orlah, or the foreskin, Hachoshen, the Netziv of Volozhin,21 medical information upon branch off from the dorsal arteries (the 22 the Avnei Nezer, Rabbi Auerbach and which they based their ruling arteries of the upper side of the organ), the Tzitz Eliezer. cutting away the foreskin can result in a was lost over time. temporary obstruction in these dorsal Rambam’s Approach—“Until Blood arteries. This temporary obstruction, in the Further Reaches Is Extracted” just as it is not elucidated in the caused by arterial muscle contraction, From a simple reading of Gemara. A decisive interpretation of continues to develop into a more endur- Rambam,23 one can conclude that the Rambam may be derived from studying ing blockage as the stationary blood reason for metzitzah is medical: “How is the words of other Rishonim, such as begins to clot. The tragic result can be circumcision performed? One cuts those of Rabbi Yaakov Hagozer. severe hypoxia (deprivation of the sup- through the entire foreskin covering the ply of blood and oxygen) of the glans crown, and then splits the soft mem- Rabbi Yaakov Hagozer—“Blood penis.28 If the arterial obstruction brane under the skin with one’s finger- Will Clot Within the Organ, and becomes more permanent, gangrene fol- nail, pulling it this way and that way This Is Dangerous” lows; the baby may lose his glans, and it until the flesh of the crown is revealed. In the sefer of Rabbi Hagozer,25 may even become a life-threatening situ- And then one sucks the circumcision until who lived in Germany during the peri- ation. Such cases have been known to blood in the further reaches is extracted, so od of the Ba’alei HaTosefot, explicit occur. that [the infant] will not be endangered, guidelines are given for the performance Only by immediately clearing the and any mohel who does not perform of metzitzah, and this time with a clear blockage can one prevent such clotting metzitzah should be dismissed. After medical explanation of the practice: from happening. Performing metzitzah metzitzah, he should apply a dressing or “How is metzitzah performed? immediately after circumcision lowers bandage or something of that nature.”24 After splitting the membrane, one takes the internal pressure within the tissues Rambam’s statement “And then the organ into his mouth and sucks and blood vessels of the glans, thus rais- one sucks the circumcision until blood blood out with all one’s strength, because ing the pressure gradient between the in the further reaches is extracted, so blood coagulates within the top of the blood vessels at the base of the organ that [the infant] will not be endan- organ, and a danger is posed if one does and the blood vessels at its distal end— gered” has been interpreted in two dif- not perform the sucking. As it says in the glans as well as the excised arterioles ferent ways. Perek Rabbi Eliezer, Rav Pappa said, ‘A of the foreskin, which branch off of the 1. “Extraction of blood from the mohel who does not perform metzitzah dorsal arteries. This increase in pressure

34 JEWISH ACTION Winter 5767/2006 gradient (by a factor of four to six!) can this illness…. In the doctors’ judgment, the question (Shu”t Orach Chaim 152), resolve an acute temporary blockage and this evil came upon them as a result of the that because it was difficult to dismiss restore blood flow to the glans, thus sig- metzitzah performed by the mohel’s the Viennese mohel due to his highly nificantly reducing both the danger of mouth, and yet the mohel was examined respected status, this was truly a case of immediate, acute hypoxia and the dan- and found to be clean and uncontaminat- sha’at hadchak. In any case, the Chatam ger of developing a permanent obstruc- ed by any trace of the illness. Nonetheless, Sofer’s understanding of the reason tion by means of coagulation. How do there is cause for concern…. Chazal instituted metzitzah as a require- we know when a temporary blockage The Chatam Sofer responded: ment is clear. has successfully been averted? When the …[My correspondent] has written “blood in the further reaches [i.e., the well, for we do not find a stipulation that The War Against Metzitzah proximal dorsal artery] is extracted,” as metzitzah be performed with the mouth As stated earlier, since Chazal did Rambam has stated. exclusively, except among kabbalists who not specify the nature of the risk pre- According to the explanation of say that the din is sweetened through the vented by metzitzah, the medical infor- Rabbi Hagozer, which is supported by mouth and the lips, and we do not con- mation upon which they based their current medical knowledge, it is easy to cern ourselves with these hidden matters in ruling was lost over time. (Rabbi understand why Chazal viewed the fail- a situation in which there is even the Hagozer’s sefer was first printed only in ure to perform metzitzah with such slightest suspicion of danger … and fur- 5652 [1892], and physiology books severity, and ruled that one may violate thermore, I say that even if it were explic- explaining the process of constriction of Shabbat in order to carry it out. itly stated in the Talmud that one must do cut arteries were written only in the last Additionally, we can understand why it metzitzah with one’s mouth, in any case half-century).29 The mitzvah of metz- is that a mohel who omits it should be this is not an intrinsic part of the mitzvah itzah, therefore, became the soft under- dismissed and deprived of the right to of brit milah, but is done because of dan- belly, subject to attack in the struggle perform britot. ger to life, and one who circumcises and over traditional brit milah. Likewise, the words of Rambam splits the membrane and does not perform It is no wonder, then, that when may now be interpreted unequivocally. metzitzah has nevertheless completed the the Reformers started waging their war “Until blood in the further reaches is mitzvah, and the child is eligible for on brit milah in the nineteenth century, extracted” constitutes only an indication trumah [i.e., if he is a Kohen], and his voices began to be heard in the medical that metzitzah has been performed with father may bring the Pesach offering; the community calling for a ban on metz- the requisite exertion of force. child, however, is at risk until an action is itzah. There were three main arguments Extraction of blood from the further performed to extract blood from the fur- against metzitzah30: A. Lack of a com- reaches tells us that the metzitzah has ther reaches. And in Perek Rabbi Eliezer, prehensible medical reason; B. Concern achieved its purpose, and any existing Rav Pappa learns, “Like a bandage or a over transmission of infectious diseases blockage of the dorsal arteries has been medicinal powder to stop bleeding, which from the person performing the metz- cleared. is necessary because the circumcised infant itzah to the infant and C. Concern that is in a situation of danger, metzitzah, too, metzitzah might increase bleeding in the The Chatam Sofer—“Metzitzah Is is necessary for a similar reason (since it is area of the incision. Not an Intrinsic Part of the done for therapeutic reasons, we need not The claim that there was no med- Mitzvah; It Is Practiced Only be particular if the doctors devise a differ- ical reason for metzitzah was vigorously Because of Sakanah” ent therapy as a substitute), and this is the rebutted. Since those who made the In 1836, Rabbi Eliezer Horowitz, law pertaining to metzitzah. Even if the claim had no way of knowing what author of Yad Eliezer and a student of Mishnah had mentioned metzitzah by medical reason Chazal had in mind the Chatam Sofer, posed the following mouth, one may still use an alternative when they instituted metzitzah, they question to his teacher: Is it permissible means to accomplish the aim. But the doc- could not point to any “change in to circumcise without doing metzitzah, tors must be warned that they must be nature” in the modern world that would and to use a sponge for the purpose able to testify that the sponge is truly per- render metzitzah unnecessary. But it is instead of the mouth? Rabbi Horowitz forming the same action as metzitzah per- not merely emunat chachamim that is explained his question as follows: formed by mouth. Beyond this, there is no the basis for rejecting the claim of those There have been cases here in our concern, in my humble opinion. who see no purpose for metzitzah. A city [Vienna] of children who were cir- It is clear from the question that rational assessment of the experience of cumcised by an expert mohel, and a the situation in Vienna, in which the generations also justifies rejecting this malignant tzara’at broke out on their skin, newborn boys were facing a tangible same claim.31 History demonstrates that covering the whole area of the circumci- danger, was a case of sha’at hadchak Chazal scrutinized medical findings sion, and then spread over their entire (extenuating circumstances). The with a critical eye and did not see them- bodies, and many children have died of Maharam Shick adds, in his response to selves as bound by Aristotelian dogma.32

Winter 5767/2006 JEWISH ACTION 35 For example, they stated that heredity is to metzitzah through a tube. If the that britot performed by mohelim are as not only maternal, but paternal as well, dimensions of the tube are suited to the safe as those performed by doctors. contradicting the Greek sages.33 Chazal size of the baby’s organ and allow for recognized pathological anatomy 1,500 the required rise in the pressure gradi- The Problem of AIDS years earlier,34 and were aware of patho- ent, then the difference between metz- With the spread of AIDS during logical symptoms pertaining to brit itzah b’peh and metzitzah through a tube the past generation, the topic of metz- milah hundreds of years before modern is negligible. Metzitzah b’peh is nonethe- itzah has come into question again, but medicine documented them. less preferable, as it does not depend on from the opposite perspective. There is As for the concern about the mechanical adjustment of the tube to fit concern among mohelim about perform- transmission of infectious diseases, three the organ. ing metzitzah on as-yet-uncircumcised main ways of preventing this have Third preference should be given to adults who have immigrated to Israel developed over the years: metzitzah performed by a pumping from countries where AIDS is wide- 1. Insistence on a healthy mohel35 machine connected to a metzitzah tube. spread, or on newborns whose mothers’ (not forgetting the advantage gained by In addition to the proportional disad- health conditions are unclear, in view of the presence of AGA antibodies in the vantages caused by the use of a tube, the the fact that the AIDS virus can easily saliva of a healthy person, which can use of a machine makes it difficult to pass through the placenta from the even contribute to the healing of the control the force of the suction. mother’s bloodstream to that of the wound, a well-known phenomenon in Last preference is given to the use fetus. Undoubtedly, metzitzah b’peh per- the animal world.); 2. Disinfecting the of a sponge. A sponge scarcely raises the formed on an infected individual poses mouth with antiseptic substances such pressure gradient, and certainly does not a danger to the mohel. as alcohol or wine36 and 3. Performing raise it enough to open an obstructed Posekim faced with this question metzitzah through a sterile glass tube,37 artery. Suction applied by hand through could make any of three possible rul- 38 or with a pump or a sponge. a sponge is almost tantamount to will- ings: 1. To continue performing metz- From a medical standpoint, the fully omitting metzitzah. (Although, it itzah b’peh despite the risk; 2. To delay claim that metzitzah is liable to increase should be noted that such an omission the brit milah until a blood test con- bleeding at the site of the incision is might possibly be required in certain firms that the candidate for brit milah unsupported. The isplanit (bandage) cases where metzitzah itself poses a high (or his mother, in the case of a new- and the kamon (a medicinal powder) risk to the infant.) born) is not infected with a deadly virus mentioned in the Mishnah, and the or 3. To perform metzitzah through a “powder of medications that stop bleed- The Situation in Israel tube, so as to avoid direct contact ing” mentioned in the Shulchan Aruch With the precedents of Vienna between the subject’s blood and the were intended to prevent prolonged and other places, with the increase in mohel’s mouth. bleeding. Since these measures are taken public awareness of hygiene and with When this question came up near- immediately after metzitzah under the the loss of our knowledge of the medical ly twenty years ago, both Rabbi mohel’s control, from a medical view- benefits of metzitzah, we have come to a Auerbach39 and Rabbi Yosef Shalom point, this claim lacks any validity. situation where approximately 90 per- Elyashiv40 chose the third alternative— cent of britot in Israel are carried out that the mohel should perform metz- Prioritization of Metzitzah with a substitute for metzitzah b’peh— itzah through a tub—for cases of infant In light of the medical purpose of i.e., suction by means of a tube. circumcision. Rabbi Shmuel Wosner41 metzitzah, metzitzah and its alternatives Nevertheless, among the Chareidi popu- wrote a similar pesak concerning brit can be placed in order of preference. lation there is continued insistence milah on adult immigrants. Rabbi From a physiological point of view, met- upon doing traditional metzitzah b’peh Elyashiv clearly explained the reasoning zitzah performed with the mouth while taking appropriate hygienic meas- behind his pesak: “The gedolim of the should be given first preference. The ures. previous generation already struggled pressure gradient created by forceful In Israel, metzitzah b’peh is per- with this problem. HaRav HaGaon Rav sucking with the mouth is greater by a formed at less than 10,000 britot annu- Yitzchak Elchanan of Kovno, HaGaon factor of six or more than the pressure ally (in the Chareidi sector) out of some Rav Yitzchak Yaakov [Reb Itchele] of gradient between the base of the organ 50,000 britot that take place in the total Ponevezh, HaGaon Rav Yechiel Michel and its top when there is local blockage population. It should be noted that in [Epstein] of Navardok, HaGaon Rav between the two areas. Metzitzah b’peh Israel, no harm had been observed dur- Chaim Ozer of Vilna and others, all of also enables better control over the force ing the past century among babies upon blessed memory, came to the conclusion exerted, so as to ensure the desired which traditional metzitzah was per- that ‘in a situation in which the slightest result. formed—until this past decade. Similar concern of danger to life exists, one Second preference should be given studies carried out in Israel have shown should not insist on meticulous fulfill-

36 JEWISH ACTION Winter 5767/2006 ment of the custom of our ancestors, in a new situation, in contrast to the cussion: the significance of new epi- the words of Rav Chaim Berlin.” (Note prevalent situation in the past. 3. An demiological data indicating possible that this response is similar to that of absence of antibodies in the mothers’ risk of HSV-1 infection among new- the Chatam Sofer to the rav of Vienna.) blood means that their newborn sons borns in the Chareidi population as a receive no such antibodies through the result of undergoing metzitzah b’peh. New Conditions Among the Israeli placenta, and therefore are vulnerable In light of the Jewish people’s sen- Chareidi Population to infection by HSV-1. sitivity to external limitations placed on About four years ago, the follow- the procedure of brit milah, it was ing data were brought before Israel’s The Memo to Mohelim decided that the new epidemiological Interdepartmental Committee on Although the epidemiological data information should immediately be sub- Supervision of Mohelim, an advisory do not provide a sufficient foundation mitted for halachic judgment, with the committee composed of rabbanim, doc- for an unambiguous medical conclu- aim of considering a temporary halachic tors and mohelim: during the three sion, it was agreed that they indicate a ruling (hora’at sha’ah) on the proper years leading up to that time, seven possible risk to newborn boys in the method of performing metzitzah given newborns from the Chareidi sector were Chareidi sector. This situation obliges us the new situation. infected with herpes simplex virus to take steps to eliminate, or at least (HSV), all of whom had undergone reduce, the risk while recognizing the Meeting with Rabbi Wosner traditional metzitzah b’peh. Five of the Jewish people’s sensitivity to external On Monday, April 7, 2003, a mothers were examined to determine if limitations placed on the procedure of lengthy meeting took place in the home they were carriers of the virus; four of brit milah. In other words, careless of Rabbi Wosner42 and was attended by them were not carriers, whereas one action is liable to adversely affect Jewish representatives of the Interdepartmental mother was found to be a carrier with a communities around the world and to Committee, including Dr. Moshe low level of antibodies. limit their freedom to carry out the Westreich of the Ministry of Health, In one of the cases, no antibodies mitzvah of brit milah as prescribed by Dr. Eli Yosef Schussheim, this writer at all against HSV-1 were found in the tradition. Therefore, on May 22, 2002, and Rabbi Babayof. After the details of mohel, indicating that he had never Rabbi Avraham Babayof, director of the the problem were presented to Rabbi been exposed to the virus. In the rest of Department of Britot at Israel’s Chief Wosner by the participating doctors, he the cases, in which antibodies were dis- Rabbinate and head of the clearly repeated the main points of the covered in the mohel, in no case was Interdepartmental Committee on facts he had just heard, and then the subspecies of the virus found in the Supervision of Mohelim, issued a memo summed up his halachic opinion in the mohel’s body positively identified by to mohelim on the subject of metzitzah. following principles. DNA examination with the subspecies The document pointed out that 1. “It is not within our ability or found in the infected newborn. Thus in halachah permits metzitzah through a power to annul the mitzvah of each of the cases there was no proof tube in cases where there is concern of metzitzah, which has been handed down that the mohel was, or was not, the contagion, and that the mohel has a from our ancestors as metzitzah b’peh, source of the infection. The question is, duty “to inform the parents of the nor would we ever contemplate it. How much caution must we take? infant, at the time he is engaged to per- 2. “The risks of HSV infection are The recent occurrence of HSV- form the brit [milah], of the two not to be ignored. And therefore, metz- infected newborns in the Chareidi sec- options for carrying out metzitzah, and itzah b’peh is to be carried out only by tor is due to three epidemiological facts: to come to a decision with their partici- mohelim or other persons who do not 1. More than 80 percent of the adult pation.” harbor the virus in their bodies. population in Israel, including mohelim, As more cases of HSV in new- 3. “A mohel who is a talmid are latent carriers of HSV-1. 2. Forty borns in the Chareidi population chacham and sees that risk is present in percent of young mothers in the emerged, it was decided to conduct fur- the situation he is in must act according Chareidi sector are not carriers of the ther discussions on the matter. The to the halachah and not cause endanger- virus, apparently as a result of better deliberations took place in the office of ment; but if he makes a change in the hygiene and living conditions that pre- the general director of the Chief technique of metzitzah, this is to be only vail among the younger generation. Rabbinate on Thursday, March 13, as a hora’at sha’ah [applicable to the situ- Thus, fewer women of childbearing age 2003. The participants included Rabbi ation at hand].” in the Chareidi sector are exposed to Babayof and the members of the These statements were written HSV, and the percentage of mothers Interdepartmental Committee, which down by this writer as they were said, with antibodies to the HSV-1 virus has included rabbanim, mohelim, doctors, and were read back on the spot to dropped from about 80 percent to the legal advisor of the Chief Rabbinate Rabbi Wosner, who confirmed their about 60 percent. This seems to reflect and this writer. The subject under dis- accuracy. But because of the sensitivity

Winter 5767/2006 JEWISH ACTION 37 of the issue, a copy of the statements been forced to stand in the breach to actually infected an infant he circum- was immediately handed over to Rabbi prevent any alteration of the laws of brit cised with a virus. On the other hand, Wosner’s office, and we were asked to milah, which were commanded to us at the epidemiological data point to the delay its publication until we received Sinai, including any change in the possibility that there have been cases of authorization. received technique of metzitzah. contagion of newborns, although it has When no authorization was 2. “If it is known that the mohel has not been proven who caused the infec- received in the course of a month, I a particular illness which, by means of tion. Likewise, even if we attribute all conducted about ten discussions on the metzitzah b’peh, could infect the infant, the isolated reported cases of infection issue by telephone with Rabbi Shlomo if the harm is prevalent (shachiach hezei- to the mohelim, it still remains a very Gelber, Rabbi Wosner’s representative. ka), one should exercise leniency in this rare phenomenon, roughly one case in In the course of these discussions, manner only: by performing metzitzah several thousand britot, a substantially it became evident that at the time in with an implement.” In other words, lower risk than that posed by other sur- Israel an ideological war was being deviating from the traditional method gical procedures. waged against the performance of tradi- of performing metzitzah should be done In light of these facts, it is impera- tional brit milah. During an ideological only in situations defined in halachah as tive to find a balance between the war of this nature, great dedication and “shachiach hezeika” (a situation in which responsibility to prevent even “the self-sacrifice as well as absolute insis- the risk is real from an epidemiological slightest concern of danger to life,” and tence on observing tradition are point of view). the responsibility to avoid leaving any demanded of us. Throughout 2003, 3. The definition of “shachiach opening for attack upon the mitzvah of news reports and pseudo-news reports hezeika” as it pertains to this issue is a traditional brit milah. The task of in Israel left a clear impression that a halachic decision of great significance, achieving this balance is in the hands of relentless struggle was being conducted and therefore it is put into the hands of the posekim. The following lines, there- by parties interested in shifting the the chachmei hador. fore, should be viewed as a halachic/ national consensus on brit milah and, as Therefore, the major practical medical deliberation before the a first step, reducing the performance of conclusions are as follows: chachamim. britot by traditional mohelim. 4. A mohel who is known to be On the practical level one must In the wake of our continued infected with a virus in a situation differentiate, in my opinion, between deliberations, and as a result of Rabbi defined as shachiach hezeika should not five situations. Wosner’s justified assessment that the perform brit milah using an implement Situation 1: If the mohel has never attack on traditional metzitzah consti- for metzitzah if there is another mohel been suspected of transmitting HSV to tutes part of a more general war on brit who is able to do the metzitzah in an infant he has circumcised, there is no milah itself, handling of the issue was accordance with tradition, without devi- medical or halachic impediment to entrusted to Rabbi Moshe Shaul Klein, ations. allowing him to continue performing a moreh tzedek in Rabbi Wosner’s beit 5. If there is no other mohel, and metzitzah b’peh in accordance with the din. the mohel infected with the virus in a tradition received from our ancestors. situation defined as shachiach hezeika is Situation 2: If a medical examina- Rabbi Klein’s Letter performing the brit milah, then he is tion identifying the subspecies of the On August 19, 2003, Rabbi Klein required to carry out metzitzah with a virus has shown that the mohel is the wrote a long letter to me in which he sterile implement and he is forbidden to source of the child’s infection, then, restated Rabbi Wosner’s position. After carry out metzitzah b’peh. according to all opinions, this mohel is a short introduction about the impor- 6. A policy that mohelim should forbidden from this point on to per- tance of brit milah in general, and about check themselves for infectious diseases form metzitzah in the traditional man- the mitzvah of traditional metzitzah in (when there are no symptoms arousing sus- ner. particular, and after citing the Jewish picion) should not be instituted, for this is The third, fourth and fifth situa- people’s self-sacrifice throughout the the beginning of the breach in the battle to tions are intermediate. generations for the sake of observing abolish metzitzah b’peh, and the holy Situation 3: HSV has appeared in this mitzvah as prescribed by halachah, Torah is eternal in every generation, to a newborn shortly after his brit milah, Rabbi Klein went on to state a few carry out the mitzvah unchanged, as but the subspecies of viruses found in major principles in the name of Rabbi received by Moshe on Sinai. the baby do not match that of the virus Wosner, namely43: in the mohel’s system. It is difficult in 1. The mitzvah of milah, com- Preventive Measures in the Age this case to prohibit the mohel from manded to us by Hakadosh Baruch Hu, of Herpes performing traditional metzitzah in the has withstood attack throughout the The medical data include no sci- future (unless his rabbanim have generations, and gedolei Yisrael have entific proof that any particular mohel instructed him otherwise), since the

38 JEWISH ACTION Winter 5767/2006 possibility that he is the source of the always concerned themselves not only Infection Risk: The ANRS 1265 Trial,” infection has been to a large extent con- with the halachic aspects of brit milah PLoS Med 2, no. 11 (1995): e298. troverted. but also with its medical aspects. 10. See Shabbat, chap. 19, mishnayot Situation 4: If another possible Therefore the gedolim of the previous 3-4, and the ensuing sugyot in the Gemara, source for the infection has been discov- generation already stated that “in a situ- and posekim. ered (a parent, for example), in this ation in which the slightest concern of 11. Hilchot Milah, chap. 1, halachah case, too, the mohel should not be pro- danger to life exists, one should not 18. hibited from performing traditional insist on meticulous fulfillment of the 12. Citations are found in Sefer metzitzah, since many infants had been custom of our ancestors.” However, Habrit, siman 265, p. 215-16, and similarly circumcised by him without ill effects, when the very institution of brit milah in the Chatam Sofer quoted in a subsequent and furthermore, there is another plau- is under attack and metzitzah is being note. sible source of the infection. used as ammunition in the assault, the 13. Among them are the Maharam Situation 5: HSV has appeared in posekim had to take a different Shick, the Binyan Tzion, the Mahari Assad, newborns shortly after their brit milah, approach. The right balance between the Divrei Yatziv and the Minchat Yitzchak. yet, while no other likely source for the these approaches is always the preroga- 14. Shu”t Meshiv Davar, chalak 2, infection has been found and the possi- tive of the gedolim, bayamim hahem and siman 55, beginning from “Michtav.…” bility that it was transmitted by the bazman hazeh. JA 15. Shu”t Avnei Nezer 10, siman 338. mohel has not been negated, there is no 16. See Avodah Zarah, chap. 2, mish- proof from a subspecies examination Notes nah 5; Talmud Bavli, ad loc., 35a and Perush that that mohel is actually the source. 1. Mechilta Bachodesh, chap. 6, cited Rabbeinu Chananel, ad loc., citing the In the last situation, on the scien- in Perush HaRamban al HaTorah, Aseret Talmud Yerushalmi. tific level we have no proof that the HaDibbrot. 17. Shabbat 133b. mohel is the cause, nor do we have 2. Yalkut Shimoni, parashat Yitro, 18. Although some (the Mahari Assad proof that he is not. Therefore we must remez 292; also in Vayikra Rabbah (Vilna), and others) have contrived to reject this bring into our calculations the rule parashah 32, starting from “Vayeitzei ben.” conclusion, it is difficult to take the sugya derived from the sugya of “one whose 3. The interview appeared on out of its simple context. brothers have died as a result of [brit] Tuesday, 20 June 2006. 19. Ibid. milah” (Yevamot 64b), which deter- 4. S.D. Niku, et al., “Neonatal 20. Chochmat Adam 149, 14. mines that sometimes, in cases of evi- Circumcision,” Urol Clin North Am 22, no 21. Shu”t Meshiv Davar, chalak 2, dent risk, there is no need for absolute 1 (February 1995): 57-65. siman 55, beginning from “Michtav…” proof in order to attribute the illness to 5. Sharon Bass, “Circumcision Persists 22. Shu”t Avnei Nezer 14, siman 338. 44 a plausible cause. (In other words, the Despite Doctors’ Disapproval,” Maine Times 23. Hilchot Milah, chap. 2. rules of chazakah now enter into the 29, no. 9 (January 1997). 24. I.e., “or a medicinal powder that calculations.) The question here is not 6. Thomas E. Wiswell, “Circumcision stops [the] bleeding,” Shulchan Aruch, 14, so simple. Is it proper to prohibit metz- Circumspection,” New England Journal of 264, 3. itzah b’peh in this situation on the Medicine 336, no. 17 (24 April 1997): 25. Zichron Brit LaRishonim (Berlin, grounds that “danger is regarded with 1244-1245. 5652), 20. more stringency than a Torah prohibi- 7. An editorial in the New England 26. Mordechai Halperin, MD, David tion” and we have a responsibility to Journal of Medicine, the world’s most widely Fink, PhD, and David Rosen, MD, “A New prevent even “the slightest concern of distributed medical journal, stated: Insight to Mysterious Talmudic Rulings: danger to life,” or is there still room to Furthermore, circumcision reduces the Metzitzah and Bathing in Warm Water in permit it, with certain limitations? risk of penile cancer. In uncircumcised men, the Performance of Jewish Ritual The New York State Department the lifetime risk of this cancer is about 1 in Circumcision—A Modern Explanation for of Health recently formulated the fol- 500, as compared with a risk of 1 in 50,000 Their Institution and its Clinical, Halachic, lowing solution to the metzitzah b’peh to 1 in 12 million in circumcised men controversy. The agreed-upon solution (Thomas E. Wiswell, ibid.). and Legal Significance,” JME 5, no 2 (June is to permit a subsequent metzitzah after In other words, the risk of penile can- 2006): 26-44. situation 5 takes place only if the mohel cer in uncircumcised men is from 100 to 27. The constriction is caused in part takes preventive anti-herpes medication 24,000 times higher than in circumcised by a nervous reflex, but principally by a on the day of the brit milah and for at men. local reaction of the smooth muscle layer of least three days before it. 8. Ibid. the artery. This apparently leads to induc- Brit milah is a mitzvah that is tied 9. B. Auvert, et al., “Randomized, tion of an action potential (resulting in con- to the very identity of our Jewish Controlled Intervention Trial of Male traction) that can travel along several cen- nation. Nevertheless, the posekim have Circumcision for Reduction of HIV timeters of the arterial wall. (See A.C.

Winter 5767/2006 JEWISH ACTION 39 Guyton, Textbook of Medical Physiology, 5th ed. [Philadelphia, 1976], 99.) 28. It should be mentioned that in most cases, this blockage would have no effect on the alternative blood supply of the glans, which comes from the well-protected and padded urethral arteries. However, in those instances where a congenital anomaly affects the urethral arteries (and there have been not a few such instances), a transient blockage of the dorsal arteries can cause severe hypoxia of the glans. 29. In the absence of a clear tradition on the nature of the danger averted by metzitzah, there has been much speculation. See the Sdei Chemed, addenda to Rabbi Moshe Bunim Pirotinsky, Kuntres HaMetzitzah; Sefer HaBrit (New York, 5733), siman 264; Rabbi Avraham Kahn, Brit Avraham HaKohen al Rabbeinu Ya’avetz, Hilchot Milah (Brooklyn, 5754), 190-91 and Avraham Steinberg, Encyclopedia Hilchatit-Refuit 3 (Jerusalem, 5752), under milah. 30. See Rabbi Avraham Yitzchak HaKohen Kook, Da’at Kohen, 140-42; Brit Avraham HaKohen 191-92 andTiferet Yisrael, Shabbat 19, mishnah 2. 31. See Rabbi Samson Raphael Hirsch, Shu”t Shemesh Marpeh, simanim 54-55, cited in Brit Avraham HaKohen, 194-195. 32. Rabbi Yitzchak Bar-Sheshet (Ribash), Shu”t HaRibash, 447. 33. Ribash, ibid. 34. Avraham Steinberg, Mavo Lefrakim Befatologiah BaTalmud Uvenosei Keilav, Sefer Asya 6, pp. 193-198. 35. Shu”t Shemesh Marpeh, siman 54; Rabbi Asher Anshil Greenwald, Zocher HaBrit (Ozharad-Ungver, 5691), 12, 31. 36. Zocher HaBrit 11, 18-19. 37. Shu”t Shemesh Marpeh, siman 58, cited in Brit Avraham HaKohen, 195 and Da’at Kohen, 141-142. 38. See Avraham Steinberg, Refuah Vehalachah—Halachah Lema’aseh, ed. M. Halperin (Jerusalem, 2006), under milah, 253- 316. 39. Cited in Nishmat Avraham 4, 1st ed., part 14, siman 264a. 40. Kovetz Teshuvot 1, siman 102. 41. Shu”t Shevet HaLevi 8, siman 267. 42. Rabbi Wosner, as a posek, is known to be a follower of the Maharam Shick. 43. The words in italics are verbatim quotations; the rest is my synopsis. 44. See also Avnei Nezer, 10, 325, ot gimmel, which states that even if the child’s brothers were endangered, the third son is not to be circumcised; Shu”t Shem Aryeh, siman 31, which pro- hibits circumcising even a child whose first two brothers died, but the next two lived; the line of reasoning attributed to Rabbi Chaim of Brisk on the definition of a chazakah based on an event that occurred three times and the Encyclopedia Talmudit 13, under chazakah, pp. 739-760, comments 1, 5 and 7. I have dealt with this issue elsewhere at length, and space prohibits delving deeply into it here.

40 JEWISH ACTION Winter 5767/2006