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Metzitza Ba-peh

One of the most controversial aspects of brit mila is the metzitza ba-peh. As we shall see, the Talmud (Shabbat 133a) mentions metzitza ba-peh, oral suction, as one of the three stages of the ritual circumcision. Following the mila and peria, the mohel places his mouth directly on the wound to draw blood out from the cut.
In recent years, this practice has been criticized due to the fear that oral suction may infect the infant or the mohel with herpes or other infectious diseases. While some continue the ancient practice, others perform the oral suction through a glass tube, eliminating all direct contact with the infant.
This week, we will attempt to summarize the different understandings of metzitza ba-peh and relate to the controversy surrounding this practice for almost three centuries.
The Mishna (Shabbat 133a) states:
When the eighth day of a baby’s life occurs on Shabbat, he must be circumcised on that day. Therefore, one performs all the necessities of the circumcision, even on Shabbat: One circumcises the foreskin, and uncovers the skin by removing the thin membrane beneath the foreskin, and sucks the blood from the wound, and places on it both a bandage (ispelanit) and cumin as a salve.
This mishna presents the stages of ritual circumcision — mila, peria and metzitza — and teaches that all three stages are permitted on Shabbat.
The Talmud appears to understand metzitza as a medical procedure, intended to protect the infant from infection. Indeed, the Gemara explains that metzitza, which would ordinarily be prohibited, is permitted on Shabbat because failure to do so constitutes a “danger.” In fact, the Gemara even equates metzitza with the last part of the mishna, applying a bandage:
Just as in the case of a bandage and cumin, failure to do what is necessary with these items poses a danger to the child, here too, if he does not perform the sucking after circumcision, it poses a danger to the child.
The Talmud is actually so concerned for the welfare of the child, Rav Papa states: “A craftsman (i.e., professional mohel) who does not draw the blood after every circumcision is a danger [to the child undergoing circumcision], and we remove him [from his position as a mohel].”
            The Rambam (Hilkhot Mila 2:2) describes metzitza ba-peh:
Afterwards, one should suck the place of the circumcision until all the blood in the further reaches is extracted, lest a dangerous situation arise. [This step is referred to as metzitza.] Any [mohel] who does not perform metzitza should be removed from his position. After one has performed metzitza, one should apply a bandage, a compress or the like.
It is noteworthy, as we shall see, that he writes that the mohel should “suck ... until all the blood in the further reaches is extracted.”
Some suggest that metzitza is not only for the health of the infant; rather, it is to be viewed as an integral part of the mila process. They bring a proof from the principle of tzitzin ha-me’akkevin. The Talmud (Shabbat 133b) teaches that on Shabbat, the mohel must be careful only to cut skin which is an integral part of the ritual circumcision.
One who circumcises on Shabbat, as long as he is engaged in the circumcision, he may return [and remove shreds of skin that were not cut properly]. This is the ruling both for shreds of skin and flesh that invalidate the circumcision if they are not cut [i.e., the child is not considered circumcised if they remain], and for shreds that do not invalidate the circumcision if they are not cut.
But if the mohel has withdrawn [from engaging in the mitzva of circumcision], he may return for shreds that invalidate the circumcision [if they were not cut, as the mitzva has not yet been properly performed], but he may not return for shreds that do not invalidate the circumcision if they are not cut.
The Talmud rules that as long as one is still engaged in the act of circumcision, he may continue to cut even those shreds of flesh which are not an integral part of the circumcision.
The Rishonim disagree as to whether one who has already removed the membrane (peria), but not yet performed metzitza, may still continue to cut the skin which is not integral to the brit mila (tzitzin she-einan me’akkevin). The Rambam (ibid. 6; see Ran, Shabbat 133b, who appears to disagree) maintains that as long as the mohel has not yet performed the metzitza, he may continue cutting, which may imply that the metzitza is viewed as an integral part of the mitzva. (See Kuntras Zikhron Mordekhai by R. Yitzchak Feigenbaum.)
Similarly, some explain the custom to pour the blood of the metzitza onto sand or dirt, as one does with the foreskin, as indicating that metzitza is more than just a medical procedure, but an actual ritual. This behavior, attributed to the Maharil, is cited by the Rema (YD 265:10) as normative practice.
The practice of metzitza ba-peh is codified by the Rishonim, as well as by the Shulchan Arukh (YD 264:3).
Metzitza With a Sponge
The role of metzitza ba-peh remained central throughout the Middle Ages. Indeed, the piyut traditionally recited after Birkat Ha-mazon at the festive meal held in honor of the brit mila states:
May the Compassionate One bless the one who cut the flesh of the foreskin (mila), split the membrane (peria) and drew off the blood of the circumcision (metzitza). The efforts of a timid or faint-hearted man would be invalid; he could not have performed these three acts.
These three acts are perceived as equal components of the ritual circumcision.
R. Yisrael Lifschitz (1782–1860), in his Mishnaic commentary, Tiferet Yisrael (Shabbat 19:2), questions whether metzitza ba-peh is truly necessary, but concludes that “since even the doctors concede that it is of some value, we must abide by the words of the Rabbis.” That said, he cautions that on Shabbat the mohel should not use a great deal of suction, in order to avoid violating the Sabbath.
With the rise of the Reform movement and those challenging traditional Jewish practices, some questioned whether metzitza was at all effective. Furthermore, they noted that it was a highly unaesthetic act, which should be abolished for that reason alone.
In 1837, R. Eliezer Horowitz, a student of R. Moshe Sofer and author of Yad Eliezer, turned to his teacher after a number of infants who were circumcised by the same mohel became sick. The local doctors determined that the mohel was responsible for their sickness, due to metzitza ba-peh. R. Horowitz writes that a local doctor insisted that applying a sefog (sponge or swab) to the wound would achieve the same result.
R. Sofer accepts his student’s suggestion and writes:
You have written correctly that there is no mention that metzitza must be done actually by mouth, except by the Kabbalists who say that it must be done by the mouth and lips. We have no right to rely on mysticism when there is the possibility of the slightest danger…
Therefore, it is only necessary for us to remove blood from distant places, no matter how it is done. We must trust experts to let us know which method is as effective as sucking with the lips…
In the Chapter Rabbi Eliezer De-mila, Rav Papa compares metzitza to the bandage or cumin, i.e., that they are necessary to prevent danger; and nowadays, we do not use the same type of bandage or cumin as was described in Talmudic times. This proves that since this is done for medical reasons, one need not be particular if doctors have found other suitable medications. The same applies also to metzitza; even had the Mishna stated "direct oral suction," nevertheless we could use any similar technique. However, the expert doctors should be warned to testify truthfully as to whether the sefog is as effective as suction by mouth, and besides this we have no need to be concerned, according to my opinion.
R. Sofer clearly believes that there is no inherent reason to perform the suction orally. This letter appears in R. Horowitz’s Yad Eliezer (55), not in the Shut Chatam Sofer. This position was accepted and implemented by numerous Poskim in many cities, including by R. Yitzchak Elchanan Spector in Kovno.
R. Moshe Schick (Maharam Schick, YD 244) insists that this ruling was intended only as a hora’at sha’a, a ruling for a specific community in specific circumstances. He testifies that he has been a mohel “for over forty years and there has never been a case or a weakness due to [metzitza ba-peh], and all of the mohalim of the generation can testify to this.” Incidentally, R. Tzvi Chajes (Maharatz Chajes, No. 60) disagrees, and writes: ". . . and therefore anything that helps to remove danger like metzitza is acceptable."
R. Yaakov Ettlinger (1798-1871) disagrees with R. Sofer’s lenient opinion (see Binyan Tziyon 1:23-4). Although R. Sofer had already passed away in 1839, R. Ettlinger cautiously writes: ‘‘Although one does not answer the lion after his death, if he were still alive, I would argue with him while sitting at his feet.’’ He called upon the rabbinic establishment to ‘‘examine how far things will go if you decide in favor of the scientists’ view over what we have received from the Sages of the Talmud... God forbid that everything will be overturned, and most of the Torah, as it is practiced in all the diaspora of Israel, will be abolished.’’ In a responsum written in 1846, he rules that metzitza may only be performed orally.
It is interesting to note that, in 1906, R. Chayim Ozer Grodzinski (cited by R. Sinai Schiffer, “Mitzvat Ha-metzitza,” p. 106) reports that almost all of the mohalim in Vilna perform metzitza with a sponge. He attributes this to the fact that mohalim were suffering from oral diseases and to the fact that the glass tubes had not yet reached Vilna.
Metzitza with a Tube
In 1850, the governments of Austria, Germany and France prohibited the practice of metzitza ba-peh.  This led R. Michael Cahn, rabbi of the German city Fulda, in 1887, to design a small tube which would enable a mohel to orally extract blood from the wound without direct contact. This method very quickly gained the approval of many rabbis, including R. Azriel Hildesheimer (see Ha-darom 36, p. 66) and R. Shimshon Raphael Hirsch (Shemesh Marpeh 54-56). Numerous rabbis reluctantly sanctioned its use, due to government pressure (Shut R. Yitzchak Elchanan 69) or a substantial fear of injury to the infant or mohel (see, for example, Teshuvot Rabaz 3:226, published by R. Chanokh Henikh Shafran).
In 1900, R. Alexander Tertis, a mohel from London, published a short book on this topic, entitled Dom Bris, in which he cites many well-known rabbis who either support or do not object to this method. For example, R. Shalom Ha-Kohen of Vilna writes that there is no description of metzitza in the Talmud, as it is a medical procedure which is to be performed according to the most efficient medical standards.
R. Yechiel Michel Epstein also supported the use of a glass tube for metzitza ba-peh, but interestingly, he appears to have changed his mind. In his Arukh Ha-shulchan (YD 264:19), he acknowledges that metzitza is not part of the mitzva, but he still prohibits the use of a sefog and insists that metzitza be done by oral suction, as this has been the traditional custom. He does, however, write that the mohel must have a clean and healthy mouth. In a letter to R. Tertis, however, he praises those who invented the suction tube.
These Poskim view metzitza as no different than bandaging the wound, not as an integral part of the mitzva (see, for example, Iggerot Moshe, YD 1:223). In addition, some Poskim insist that the tube also fulfill the Rambam’s description, above, of metzitza ba-peh. R. Chayim Soloveitchik instructed the local mohalim not to perform metzitza ba-peh, at all, and that was the view of his son, R. Moshe Soloveitchik, as well as R. Yosef Dov Soloveitchik (see Nefesh HaRav, pg. 243).
In the past century, R. Avraham Yitzchak Ha-Kohen Kook (Da’at Kohen 142) permitted performing metzitza through a glass tube. Similarly, his successor R. Yitzchak Ha-Levi Herzog (Pesakim U-khtavim 4:84), first Ashkenazic Chief Rabbi of the State of Israel, in a letter to Dr. B. Homa (1955), wrote:
 In my humble opinion it is as clear as the midday sun, that metzitza forms no part whatsoever of the actual precept of mila
It has already been generally agreed that metzitza performed by means of an apparatus such as mentioned, is as effective as metzitza ba-peh. And since, in the opinion of experts, there is potential danger to the child from direct use of the mouth and it is necessary to exercise care, it follows therefore that anyone who insists that metzitza must be done by mouth only, is in my opinion, mistaken and is leading others astray in a matter where there is a possibility of danger.
This is the opinion of R. Tzvi Pesach Frank (Har Tzvi 214) as well.
Despite the alternate methods of extracting blood from the wound, either with a sponge or a tube, some Acharonim still insist that metzitza must be performed by direct oral suction (see those cited by Sedei Chemed, Vol. 8, Kuntras Metzitza). In addition to the views of R. Moshe Schick and R. Yaakov Ettlinger, cited above, R. Yaakov Breisch (Chelkat Yaakov, YD 143) objects to this practice, invoking the ongoing battle with the Reform movement as an additional reason to be strict.
Recent Years
In recent years, the “metzitza ba-peh” controversy has erupted again.
First, there has been a rise in neonatal herpes cases attributed to metzitza ba-peh. For example, health officials in New York City, where there has been mandatory reporting since 2006, reported 24 cases of babies who contracted herpes following metzitza ba-peh. Two of those infants died, two suffered brain injury, and others developed long-term health problems. In 2012, The New York City Board of Health required that parents sign a consent form before their child is circumcised with metzitza ba-peh; that policy was repealed in 2015. New York City was so concerned about the risk to newborns that it distributed 20,000 posters, in English and Yiddish (!), describing the dangers.
Second, in 2004, a clinical study appeared in Pediatrics, the official journal of the American Academy of Pediatrics (Vol. 114, No. 2), authored jointly by medical academicians and Talmudic scholars, including Benjamin Gesundheit, M.D.; Moshe D. Tendler, Ph.D.; Bruria Ben-Zeev, M.D.; and others. In this article, “Neonatal Genital Herpes Simplex Virus Type 1 Infection after Jewish Ritual Circumcision: Modern Medicine and Religious Tradition,” the authors came to the following conclusion:
Our findings provide evidence that ritual Jewish circumcision with oral metzitzah may cause oral–genital transmission of HSV infection, resulting in clinical disease including involvement of the skin, mucous membranes, and HSV encephalitis. Furthermore, oral suction may not only endanger the child but also may expose the mohel to human immunodeficiency virus or hepatitis B from infected infants. The same consideration that led the Talmudic sages once to establish the custom of the metzitzah for the sake of the infant could now be applied to persuade the mohel to use instrumental suction.
The findings of this article are challenged by Daniel S. Berman, M.D., F.A.C.P., an infectious-disease specialist, who argues that the Pediatrics study was fraught with inaccuracies and unsubstantiated conclusions. Similarly, Prof. Avraham Steinberg, a pediatric neurologist, rabbi, and an associate clinical professor of medical ethics at the Hebrew University, insists that the article mentioned above does not conclusively establish a relationship between metzitza ba-peh and the cases of neonatal herpes.
In addition, Rabbi Dr. Mordechai Halperin, the chief officer of medical ethics at Israel’s Ministry of Health and the director of the Dr. Falk Schlesinger Institute for Medical Halachic Research in Jerusalem, attempts to explain the medical benefit of metzitza ba-peh. He writes:
Immediately after incising or injuring an artery, the arterial walls contract and obstruct, or at least reduce, the flow of blood. Since the arterioles of the orlah, or the foreskin, branch off from the dorsal arteries (the arteries of the upper side of the organ), cutting away the foreskin can result in a temporary obstruction in these dorsal arteries. This temporary obstruction, caused by arterial muscle contraction, continues to develop into a more enduring blockage as the stationary blood begins to clot. The tragic result can be severe hypoxia (deprivation of the supply of blood and oxygen) of the glans penis. If the arterial obstruction becomes more permanent, gangrene follows; the baby may lose his glans, and it may even become a life-threatening situation. Such cases have been known to occur.
Only by immediately clearing the blockage can one prevent such clotting from happening. Performing metzitza immediately after circumcision lowers the internal pressure within the tissues and blood vessels of the glans, thus raising the pressure gradient between the blood vessels at the base of the organ and the blood vessels at its distal end — the glans as well as the excised arterioles of the foreskin, which branch off of the dorsal arteries. This increase in pressure gradient (by a factor of four to six!) can resolve an acute temporary blockage and restore blood flow to the glans, thus significantly reducing both the danger of immediate, acute hypoxia and the danger of developing a permanent obstruction by means of coagulation. How do we know when a temporary blockage has successfully been averted? When the “blood in the further reaches [i.e., the proximal dorsal artery] is extracted,” as Rambam has stated.
In addition, Rabbi Dr. Halperin raises the concern that those who challenge metzitza ba-peh really intend to challenge the very mitzva of brit mila.
In 2005, the Rabbinical Council of America (RCA) issued a statement clarifying their position. The statement outlined four positions: those who maintain that metzitza ba-peh is strictly a medical matter, those who suggest performing metzitza with other device which draws blood from the wound, those who require that metzitza be fulfilled through suction generated by the mouth through a tube, and those who insist that metzitza must be performed orally. The RCA issued the following conclusion:
The poskim consulted by the RCA (Rabbi Gedalia Dov Schwartz, Av Beit Din of the Beth Din of America and of the Chicago Rabbinical Council; Rabbi Hershel Schachter of RIETS/YU and the Union of Orthodox Congregations of America; and Rabbi Mordechai Willig of RIETS/YU and Segan Av Beit Din of the Beth Din of America) agree that the normative halacha undoubtedly permits the third view, and that it is proper for mohalim to conduct themselves in this way given the health issues involved in the fourth view… Those who wish to follow their customs in accordance with the above-noted authorities are certainly entitled to do so, but the RCA is firmly of the opinion that in light of current realities and medical knowledge it is proper, and preferable, to use a tube.
In practice, it appears that while use of a glass tube has become standard in the Modern Orthodox world and within Religious Zionist communities, mohalim in the Chassidic communities, in Israel and abroad, as well as in the Charedi community, still perform metzitza ba-peh.

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