Friday, June 10, 2016

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.

Noting the delivery of my last case of gloves - always exciting to get mail

Thursday, June 9, 2016

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.

Saturday, May 21, 2016

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.

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.


Wednesday, May 4, 2016

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.

Tuesday, May 3, 2016

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. :)

Tuesday, April 26, 2016

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.

Monday, April 25, 2016

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....]

Thursday, April 21, 2016

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. 

Tuesday, April 12, 2016

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.


For fun - more pictures of magen shields. Note the differences in style, width of slit and whether there is a groove in the slit. And, of course, any ornamental components, such as gold, silver, or with engraving. :

Wednesday, April 6, 2016

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. :)