An "Inspired" Teaching

At a recent bris, the baby's grandfather told me a joke:

What blessing does a girl say at a bris? Shelo Asani BOY!

[Translation - "For not having made me a boy." The joke is because there are three blessings that are said in the morning, that begin with the phrase "shelo asani" - for not having made me "x" - and one of them is "Shelo Asani GOY"]

Anyway, while not specifically related to the actual bris and process the baby goes through, I was inspired to find a new explanation for these three blessings, with Bris Milah being an ingredient to my novel interpretation.

It is spelled out in much detail in this post in my other blog.

Enjoy!

Some Thoughts on Metzitzah

[Note from 4/30/11 - see here for more on this subject]
Metzitzah is the ancient practice of drawing blood from the wound after the excision of the foreskin. There is much debate amongst rabbinic authorities as to how this is to be done. Sadly, much of it has become a politicized debate to the point that the different sides of the aisle often cannot see or recognize the validity of a differing opinion.

In the Talmud, the main reason for removing a mohel from his position, ie not allowing him to continue to practice as a mohel, was if he did not perform metzitzah. (Babylonian Talmud Shabbat 133b, Maimonides Laws of Milah 2:2, Shulchan Arukh Y”D 264:3) Bear in mind, the lack of metzitzah does not a non-kosher bris make. (Avnei Nezer Y”D 338, especially letter “י”, mishneh Halakhot 13:21 (Menashe klein))

Only the mohel who does not do metzitzah has questioned legitimacy. The baby and his bris are deemed kosher, with no further procedure necessary to rectify the flaws of the practices of the mohel.

The Talmud is not clear how metzitzah is to be done. As long as a mohel does metzitzah (many call it "Metzitzah B'Peh" or "Metzitzah B'feh" - drawing blood with the mouth, or the power of the mouth), be it orally or with a tube, he is Talmudically fit to be a mohel (assuming of course, his character is otherwise exemplary).

***************************************************************

Much ink has been spilled over metzitzah. The only Jews who require metzitzah are the Orthodox and some Conservative communities.

How metzitzah is done is the subject of debate, though just about everyone who does it has the mouth involved, in some way performing suction of blood from the wound.

• Some have the mouth directly touching the open wound.
• Others have a sterile tube directly touching the open wound, while the mouth provides the suction to draw the blood.

Both methods have rabbinic authorities backing them, and either one is acceptable to most Jews. While I did not poll either community, I imagine that if someone from either camp discovered a bris had been done using the method of metzitzah to which they do not subscribe, they would be unlikely to declare the bris invalid or the mohel who did it invalid.
They certainly would not require the baby to have a wound reopened so metzitzah could be done the other way. Also, metzitzah is never done on an adult circumcision or for hatafat dam brit.

While I do advocate metzitzah be done, with a tube, it is worth noting that if for some reason the metzitzah is not done at all, whether by choice or by oversight, no one questions the validity of the bris itself.

The reason I recommend the tube is because I value the cause of sterility and good hygienic practice in the bris procedure. While Jews circumcise their sons because of the inherent spiritual value, I feel there is no excuse for subjecting the baby to the possibility of any infection - which can so obviously come to a baby through the direct contact of a stranger's saliva with the baby's open wound and the baby's blood which is truly "his life" (see Deuteronomy 12:23)

Final, and perhaps most important note: What sometimes is lost in translation is that the advocates for using a tube are not arguing or declaring a ban on metzitzah or even metzitzah b’peh! They are actually suggesting metzitzah b’peh be accomplished using a tube which can achieve the same result as the mouth, using the strength of the mouth.

I added to this topic in a different posting (as linked at the top of this page)

Pinch Hitting

It wasn't the first time, but it was special.

I received a phone call late last night, "Might you be available to do a bris tomorrow morning?" As things work out, thank God I was available.

"This is a late call. What could have happened?" I wondered.

"The mohel we called apparently had business in Guatemala and is stuck there."

Good thing he called to tell them before this morning.

"Sure. No problem. I'll be there."

It is a wonderful feeling to be called for a bris. It is an honor to be able to fill in on such short notice. In most cases, people appreciate the mohel and the role he plays just because the service is unique and is recognized as being so helpful in performing a special mitzvah. In cases like this, circumstances being what they are, the feeling is different, in a wonderful way, because I know the family's need was more urgent, more pressing, due to time constraints.

And thank God, the bris went well, the baby is doing wonderfully, and everyone seems happy.

Welcome, Miami Beach. I look forward to returning to you soon!

Timing the Bris

The Bris takes place in daylight hours of the eighth day of the baby’s life. The day of birth is considered the first day of life, unless the baby is born after sunset, in which case the following day is considered the first day.

While a bris is never performed earlier than the eighth day of a baby's life, a bris may be delayed under very specific circumstances:

a. If the baby was born by ceasarian section and the eighth day is the Sabbath or a Festival

b. A baby who contracts an illness must be completely healed before he has his bris.

c. A premature or otherwise very small baby will wait until he achieves a suitable weight for him to withstand the stress of the bris.

While there is no exact definition of a healthy size, many mohels arbitrarily follow a five pound range (give or take a couple of ounces) as a minimal weight upon which to circumcize. Doctors will often clear the baby at lower weights, but when a mohel is uncomfortable due to size reasons it is better to be safe than sorry. Once the baby reaches five pounds, however, if the mohel continues to push it off, it is worth seeking another mohel so as not to continue delaying this important, timely mitzvah.

ps. When a baby is being circumcised for the sake of conversion (most typically on account of adoption - though some mohels will do such when the baby's mother is not Jewish), it need not take place on the eighth day of his life because there is no "mitzvah" to circumcise him. In this case, the circumcision should take place sooner than later, but the timing will be determined based on when the baby arrives at his adoptive family, and when they are ready to have his circumcision.

Why We Name the Baby at the Bris

[Subsequent to writing this, I wrote an article on this subject which appears in my other blog]

There is no Biblical injunction to name a baby boy at his bris. It is clear that when the forefathers were born they were named immediately - Yitzchak was given his name first (Genesis 21:3), THEN he was circumcised in the following verse (21:4).

When Yitzchak's sons were born, they were named immediately (25:25-26). Each of Yaakov's sons was named as soon as he was born (Chapters 29-30).

[Full disclosure: God changed Abraham's name from "Avram" to "Avraham" after he circumcised himself.]

So why do we name the baby at the bris?

This leads into a larger question of why we do all the things we do at the bris? Why does the ceremony look the way it does now? How much of it is rooted in Kabbalistic practices? Medieval practices? European practices? Middle Eastern practices?

After all, the Torah only commands that the baby be circumcised on the eighth day, and perhaps a celebration should accompany the circumcision. But there is no mention of a sandak, Elijah (who of course had not been born yet), or the formalized ceremony we see today, including the naming taking place after the circumcision.

What if the bris is postponed for health reasons, or not performed at all because of a history of hemophilia in the family? Is the baby not named? Of course the baby is given a name! Which would indicate that naming at the bris is not all that significant.

So why do we name the baby at the bris?

Here are a few ideas I have found in researching this question

A. When Elijah the Prophet is present

In Genesis 2:19, the Torah says וכל אשר יקרא לו האדם נפש חיה הוא שמו. That after meeting all the animals, Adam gave each one a name.

I read somewhere that the acronym of the first five words of this phrase are the letters of the name אליהו - Eliyahu/Elijah. The first letters of the next three words, נ, and ח, and ה have a numerical value of 63, which is the same as the word נביא - prophet.

The last word is שמו, which means "his name," and we have found our significance. When Elijah the Prophet is present, that is when "his name" is proclaimed.

B. Completing a Jewish Identity

Some will argue that the bris is the final step in making a baby a Jew, and so his name comes at this highly significant moment. I have already debunked this myth.

More palatable, the name is a completion of the individual's identity. If the bris completes his physical body (as Abraham is told in Genesis 17 to "walk before Me and become complete" through the act of circumcision), it is only after the bris that his name can be given to him. (Rabbi Menachem Azariah deFano (1548-1620), "Mamaarei Rama MiPano")

C. Tumah/Tahara

Until the bris he was uncircumcised – which is not the ideal state of a male Jew. Any name he may have had until his bris was unbecoming to his identity as a Jew – so he receives a Hebrew name at his bris, in celebration of his new physical status.

***********

There are differences of opinion as to when girls are named in relation to their birth, but everyone agrees that a girl is given her name on a day when the Torah is read, when her father is called for an aliyah or some other Torah reading participatory role.

For more on this subject - regarding boys and girls, see this article

Don't Use the Mogen Clamp!

An article in the Atlanta Journal-Constitution has reported on a lawsuit against the makers of the Mogen clamp. (text of article produced below)

I have never been a fan of this clamp (see method 1 here), and even the FDA has issued warnings against clamps because of their potential of irreversible damage

Simply put, no step in the circumcision procedure should be irreversible until the actual removal of the foreskin. Once the shield is in place, it is important to double check that the proper area of skin is ready to be excised. In the event the shield was initially applied incorrectly, it can simply be removed and repositioned - no harm done.

Once a clamp is put in place, anything in its clamping mechanism is essentially dead skin, and the excision/amputation which follows is irreversible.

PLEASE TELL ALL YOUR FRIENDS AND FAMILY - DO NOT ALLOW A MOHEL TO USE THIS DEVICE ON YOUR BABY, UNLESS HIS TRACK RECORD IS PERFECT WITH IT!

*****************************************************************************
Atlanta lawyer wins $11 million lawsuit for family in botched circumcision
By Ty Tagami


The Atlanta Journal-Constitution
Monday, July 19, 2010

The maker of an instrument used in circumcisions claimed that injury was impossible with its use, but after an infant lost a portion of his penis during an operation with the Mogen clamp, a judge awarded $10.8 million in damages against the company.

The judgment handed down Friday in New York involves an Atlanta lawyer who has been crusading against circumcision as a dangerous and unnecessary practice.

Attorney David Llewellyn won a similar case in Atlanta last year and the injury behind that prior lawsuit in Fulton County Superior Court put the New York clamp manufacturer on notice about the danger of the device, his current lawsuit said.

The baby in the current case, identified in court documents only as L.G., lost the entire glans, or head, of his penis after it was pulled into the jaws of the clamp, according to a federal magistrate's order. On Friday, U.S. District Judge Jack B. Weinstein ordered Mogen Circumcision Instruments of New York to pay $10.8 million in compensatory and punitive damages to the Florida boy, now 3, and his parents.

The parents "are extraordinarily distraught and angered that this company tells people it can't happen," Llewellyn said.

It's unclear whether they will ever collect the money. Mogen is already in default on a $7.5 million judgment in 2007 from a Massachusetts lawsuit, Llewellyn said.

The company is going out of business, according to a woman who answered the phone at its Brooklyn headquarters Monday. The woman, who said she was a secretary and would identify herself only as D. Rotter, the person whom Llewellyn said was served papers in the lawsuit. She said increased competition has undermined their business.

"It's just kind of dwindling down to nothing," she said, adding that the phones at the Mogen office were scheduled to be disconnected Tuesday. Mogen didn't defend itself in court, and Rotter said it was because the company couldn't afford it.

She said the Mogen clamp is "painless and safe" when used properly. The case involving the Florida boy was "unfortunate," she said, adding that "any medical mishap is unfortunate."

In this case, a New York mohel, or Jewish ritual circumcisor, performed the operation in the baby's home, Llewellyn said. The mohel negotiated a separate settlement, the terms of which Llewellyn would not disclose.

Llewellyn won another circumcision case in 2009 over an operation at South Fulton Medical Center. In that case, which involved a baby identified only as D.P. Jr., the mother contended that the doctor who circumcised him removed too much tissue and that his pediatrician failed to respond when a nurse complained of excessive bleeding.

The tip of the penis was placed in a biohazard bag and might have been reattached if he'd gotten attention in time, Llewellyn said in 2009. His lawsuit in New York says D.P. Jr. lost a third of his glans.

The jury found that both the pediatrician and the physician who performed the circumcision were negligent, and awarded $2.3 million to the plaintiffs. South Fulton Medical Center was absolved of liability.

In Friday's decision, the court determined that Mogen had to pay for medical expenses and for the years of psychotherapy that will be needed. The boy suffers pain when he urinates, the court order says. He will eventually be able to have sex, but he is likely to be embarrassed and will likely have trouble forming "meaningful" relationships with girls, it adds. "At 3 years old, L.G. is aware that he looks different from other boys based on both his own observations and comments from other children which make him feel inferior ."

The Sandak

The sandak is the person who holds the baby during the surgery component of the bris ceremony. It is considered the highest honor that can be given, as the sandak shares the unique distinction, along with the baby's father and the mohel, of the bris day being like a holiday for him.

This means that just like the father and mohel, if the sandak attends prayer services prior to the bris, he will cause the entire congregation to automatically join in the celebration of his holiday, to the point they will not recite the "Tachanun" (supplication) prayer, which beseeches God to help us in our hour of suffering. Who can possibly be suffering on a holiday?

It is sometimes asked if the baby's father can serve as the sandak. He may!

Contary to the Ashkenazic custom mentioned below about not repeating sandak in a family, a father is the only person who CAN serve in this role multiple times for his own sons. I remember attending a bris in Israel where the baby was the 10th boy in the family (talk about having it down to a system!), and the father was being sandak for the third or fourth time.  The reason? They had honored everyone else already once (who might play ths role otherwise) and as it's the father's mitzvah to be as involved as possible in the bris, the father chose to play the role of Sandak to fulfill his responsibility in the best way he could.

Where does the word SANDAK come from?

Some people think it comes from Greek:

Although circumcision is probably the most ancient of all the Jewish rites that are practiced today, neither of these two words is anywhere near as venerable. The older of the two, sandak, is a Hebrew loan word from Greek, as easily can be seen from its earliest appearance in Jewish sources in the 13th-century midrashic anthology Yalkut Shimoni, where it occurs as sandakos - סנדיקוס, with the Greek first-declension, nominative-case singular ending. This is curious, since nearly all Greek borrowings in old Hebrew date to the pre-Islamic period, when Greek was the spoken language of the eastern Mediterranean world.
Presumably, then, sandakos was in use among Jews for hundreds of years before this but simply left no record. Its etymology is from syndikos, i.e., an advocate in a trial, and also, a backer or supporter. Syndikos was a word commonly used in Greek to translate the Latin patronus, which also could mean either a legal counsel or a
social patron — and just as the Roman patronus had a moral if not legal obligation to assist whomever the person to whom his patronage is extended, so the Jewish sandak was originally thought of, it would seem, as responsible for the circumcised child throughout his life. For this reason, the sandak was traditionally chosen from among the close friends or relatives of the parents of the child, with whom he was expected to maintain a lifelong bond.

But why should we assume this Jewish role was borrowed from the Greeks? Especially when they (or at least Antiochus Epiphanes - starting 4th paragraph) banned circumcision? (This tradition has been around a lot longer than this new theory)

WHAT IS THE JEWISH SOURCE FOR THE SANDAK?


One approach is that סנדק is actually an acronym for סנגור נעשה דינו קטיגור - which means that the "defender becomes the prosecutor." This idea stems from the Kabbalistic work - The Zohar (p. 255) - which explains "When the little boy is undergoing his surgery, the sitra achra is broken down and has no power - because the bris becomes a litigator against him on behalf of Israel."

In other words, in a kabbalistic sense, the sitra achra is always trying to find flaws in the activities of the Children of Israel, constantly making them the defendants before God. But the bris is so powerful, and the helpful role the Sandak plays in protecting the baby and allowing the mohel to do his job properly, changes the keepers of the faith from being defendants against this evil spirit to being prosecutors against him. "How dare you suggest we are not keeping the law and following God's commandments when you see we begin at the very beginning of life with the covenant of our faith, the covenant of circumcision?"

Not as exciting

Yashresh Yaakov suggests that the numerical value of the word Sandak = 218, if you add the values, סנדק =
60 + 50 + 4 + 100 + the 4 letters of the word = 218, which refers to a "ריח ניחוח" - a sweet fragrance from a spice offering (ריח = 218). This most likely relates to the idea that the Sandak is compared to one who brings such an offering when he is holding the baby on his lap during the bris.

No Matter the Source...

... The Sandak is a great honor. It is often given to the baby's grandfather or great-grandfather, if the baby is blessed to have one.

The role can not be shared during a bris.

Amongst Jews of Ashkenazic descent there is a custom for parents not to reuse a sandak for another son of theirs. Essentially, the idea is to "spread the wealth around" (to coin a phrase) and give others a chance to play this highly significant and symbolic role.

Amongst Jews of Sephardic descent (Spain, North Africa and Middle East), the same person might be sandak every time, if the individual is a highly respected dignitary, such as a "Hakham" or great rabbi, or even the patriarch of a family.

The Importance of Trust

Time and time again I get calls from people who have used the services of a different mohel, who ask me questions they don't want to ask their mohel, after the fact.

I am happy to help however I can.

But the obvious question becomes, "Why did you not ask these questions before?"

And the follow-up, "Why aren't you comfortable asking these questions to your mohel?"

The excuses are what they are, but they usually boil down to a few points:
"He isn't open enough."
"He says a lot but does not really leave us open to asking questions."
"He seems to not be aware of what we're going through."

These are very unfortunate cases. Would you ever go to a doctor who you felt you couldn't talk to after he operated on you? I hope not!

It is important to trust your mohel, and to be able to have a frank and open conversation about the process. What happens, what happened, and what needs to be done to give the baby the "thumbs-up" and "clear" and "good to go" symbols...

When you call me, this is the service you get. We talk a few days before the bris (when it is possible, I will come and meet you and your son a few days before the bris as well), we talk the day of the bris, before the bris, after the bris (while the baby is being cared for), and later on when I come visit him to remove the bandage and to make sure all is good.

I call a few days later to see how all is going. I am always available by phone, and am happy to come take a look to assure you all is good (post-bris) if I can help reassure you in any way.


[Though if I am a distance away, I have found that sending me a photo through the phone works just as well!]



You are always in the loop, always in the know, you are always aware of what is going on or has gone on with your baby.

Give a call - be in touch - I look forward to meeting you.

A Comprehensive List of the Honors at a bris

The explanations for these roles and who gets them can primarily be found here, and in the latter half of this post.

Some of them have further explanations elsewhere in the blog: kvatter, Elijah's chair , etc.

THE LIST
* items marked with an asterisk are most commonly done,
- items marked with a dash and in parentheses are possibilities, but not necessary
* Kvatter - male and female who bring baby in to the room (transfer baby from Mom to Dad)

* Kisei Eliyahu/Elijah's Chair - places the baby on a specially designated chair

(- Min Hakisei (from the chair) - gives baby to his father)

* Sandak - holds the baby during the bris

(- Min Hasandak (very uncommon to have this) - takes baby off lap of sandak to give to...)

* Amidah L'brachos (Sometimes called the standing sandak) - holds the baby after the circumcision, for blessings (and naming - next honor)

(- Amidah for Krias Hashem - an additional honoree who takes the baby after two blessings and holds him while he is given his name)

* Brachos - the person who recites the blessings (in a mildly-traditional crowd, the rabbi or mohel will usually do this), and either does or does not name the baby (next honor)

(- krias hashem - the one who first announces the baby's up-until-now secret Hebrew name. Sometimes the person who says the blessings will also name the baby)

(- birkat hamazon - the one who leads the grace after the meals, particularly and ideally in the presence of a minyan of men.)

If you are not sure how to include everyone you need to include, let me know. We can always squeeze another one in. avbillet@gmail.com

When Baby is Cranky - Is Tylenol a Solution?

The impetus for this posting comes from two incidents which took place in the last few weeks.


1. Tylenol, and other OTC baby pain medications had some kind of recall (the details did not concern me personally as my children don't use any of the items in question, and I never recommend any of them as a mohel)


2. Someone I know, who lives in New York, had his son circumcised by a local NY mohel, and called me that evening, after his baby had an unusually difficult day, to confirm that what his mohel had told him was "normal" in the post-op care of the baby. Details to follow.


I will not address the Tylenol recall directly, as it is not my area of expertise. But the issue which is raised often enough is whether there is room to give the baby tylenol if he seems cranky after the bris?


My answer is twofold. Firstly, let your pediatrician recommend tylenol or something to ease your baby's discomfort. Most mohels I know are not physicians, and while they can offer advice, they are not in charge of your baby's long-term care. Even if the mohel IS a physician, if he (or she - there are female Dr. physicians who are mohelets) is not your baby's physician, the questions about medications should be directed to the primary long-term caregiver.


Secondly, and this leads into the second impetus as mentioned above, your baby should not feel discomfort after the bris.


You may ask, how could a baby not feel discomfort after going through this surgery? I don't know the answer to this question, but I can report on what I've observed.


Post-bris, most babies who have a bandage placed on comfortably, who have their needs met (clean diaper and full belly), sleep nicely, eat nicely, wet their diapers consistently, etc. They cry under the same conditions they cried for before the bris: dirty diaper, hungry, tired... The main difference will be that baby might wince when he urinates - which would be directly impacted by the bris.


So what causes a baby to be cranky after the bris?

The number one item that causes a baby discomfort is an uncomfortable bandage. It could be the material does not agree with him. The bandage may also be on too tight, constricting what should otherwise be an easy urine-flow.


In my personal experience, when I fiddle (as necessary, after the bris) to get a new bandage on, the baby will usually cry as I am reapplying a gauze pad. Once I am finished and leave the baby alone, he is usually calm and comfortable, the crying stops, and he either eats or goes right to sleep.


Solutions


And so I asked the father of the baby three questions:

1. Is it bleeding? (usually indicative of either a case that requires attention or a bandage that fell off prematurely)

2. Has the baby urinated? (if not, there is too much constriction on account of the bandage, and it needs to either be loosened, removed, or replaced with a looser and softer bandage)

3. Will your mohel come and check it?


If the bandage is on too tightly - guess what - Tylenol or Motrin ain't gonna do a thing.

*************************



I mentioned in a different posting that it is normal to see swelling after the bris, particularly on the ventral side of the penis. In this case, that was not as much of a concern from my perspective (though the father did see swelling and was concerned about it).


In the end, the mohel did come and check, he removed the bandage (or loosened it) and baby was able to urinate more readily, easily and comfortably.


The point of this story is not to knock another mohel. It is to encourage you to avoid jumping to conclusions, to avoid worrying, and to realize there may be a very simple solution.


I have taken steps to avoid this problem. The bandage I leave on the baby is a softer one, which usually comes off on its own a few hours after the bris. I remind parents from the get-go that they need to report to me if the baby has not urinated a few hours after the bris. I consciously put the bandage on tight enough to constrict the bleeding, but not so tight to be uncomfortable for baby.

With the exception of babies who are extremely hungry after the bris, most babies I care for are calm when I finally leave them alone, and may even sleep comfortably for a few multi-hour stretches, waking up for feedings and diaper changes.


And I tell the baby's mother, "You see how he is now? That is how he should be throughout the rest of the day, except when he is telling you he is hungry or needs to be changed (which is when he normally cries anyway)."


Instead of Tylenol being the solution, let us return to appropriate TLC which will undoubtedly help ease the pain and make the ordeal so much easier for parents and baby.