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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.


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

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. :)