DANIEL POLIAK

Metzitzah Ba-Peh Under the Microscope: An Ancient Rite from a Modern Perspective
The Mishnah in Shabbat records that the penultimate act of the brit milah process is motzetzin, sucking of the blood from the wound.1 The accompanying Talmudic passage highlights the therapeutic importance of metzitzah, admonishing a mohel who refrains from sucking, since abstaining is perceived to be dangerous. Consequently, a mohel who fails to perform this stage of the process is forbidden to practice circumcision.2 While the Mishnah and Gemara refer to this act by the gerund motzetzim and do not specify a requisite oral component, linguists conclude that this suction procedure refers to one performed orally metzitzah ba-peh.3 The Talmud indicates that metzitzah ba-peh was manI thank R. Dr. Edward Reichman for his assistance in the research and organizing processes. 1 Shabbat 19:2. 2 Shabbat 133b. 3 Robin Judd, Circumcision and Modern Jewish Life: A German Case Study, 1843-1914, in Elizabeth Wyner Mark (ed.), The Covenant of Circumcision (Hanover, NH, 2003),148; Jacob Katz, Divine Law in Human Hands: Case Studies in Halakhic Flexibility (Jerusalem, 1998), 361, 376. Daniel Poliak is a second year medical student at the Albert Einstein College of Medicine 129

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dated along with bandaging and applying cumin salve for therapeutic purposes. Dr. Mordechai Halperin, a prominent Jerusalem mohel and physician and Chief of Medical Ethics of Israels Ministry of Health, astutely observes that from this gemara, it seems fairly clear that medical considerations are the only reasons for metzitzah.4 Since the Talmud omitted the theory for its medical determination, modern-day scholars and physicians have sought to determine the curative and prophylactic objectives of metzitzah ba-peh in light of both contemporaneous and modern-day medical knowledge. Currently, mohalim either perform the traditional rite with or without direct oral contact (by utilizing a glass tube), or abstain from the practice.5 Over the last two centuries, the renewed interest in proposing rationales for metzitzah has been a response to a rise in the number of reported complications attributed to the procedure. While suggesting taamei ha-mitzvot (the underlying rationale for religious rites) is a philosophically controversial pursuit often fraught with anachronistic arguments, proposing motivations for metzitzah differs, as the Talmud itself indicates that the practice has a rabbinically-instituted medicinal objective.6 From a historical perspective, this endeavor is particularly prone to pitfalls of hindsight bias in which, in the words of medical historian Sherwin Nuland, seemingly valid clarifications of the pasts effects on the present may be more suggestive than certain, and sometimes entirely wrong.7 Nonetheless, it
4 Mordechai Halperin, The View from Israel, Jewish Action (Winter 2006): 34. Others consider metzitzah to be an integral part of brit milah, maintaining that it should continue to be preformed regardless of the validity of its therapeutic aspect. For a list of those who adopt the latter approach, see Avraham Steinberg, Laws of Sucking the Blood (Metzitzah), Encyclopedia of Jewish Medical Ethics (Jerusalem, 1998), 202-3n. 165. 5 For an overview of opinions concerning the use of a tube instead of direct oral contact, see Shlomo Sprecher, Mezizah be-PehTherapeutic Touch, Hakirah (2006), 34, n. 49; 47-49. 6 Haleprin, supra n.4,34. 7 Sherwin Nuland, Bad Medicine, The New York Times (8 July 2008): Accessed online (http://www.nytimes.com/2007/07/08/books/review/Nuland. html?pagewanted=print) 16 September 2012 130

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behooves us to review the rationales for the institution of metzitzah as proposed by scientists this past century.8

The Salve of Saliva

Even after the advent of advanced anti-sepsis techniques and the proliferation of carbolic acid, a minority of late nineteenth-century and early twentieth-century physicians extolled the antiseptic value of saliva. Throughout the final decade of the nineteenth century, Dr. Naphtali Klein routinely published in the annual ha-Measef journal that his fellow French physicians erroneously dismissed the importance of metzitzah bapeh. He claimed that saliva poses no harm, and in fact serves as an anti-septic. Additionally, Klein (mistakenly) contended that by rinsing his mouth with a copious amount of alcohol or wine immediately before metzitzah, the mohel neutralizes the potency of any oral infections.9 Although modern science contradicts the tenets of this explanation, Klein, a respectable Parisian physician, publicized his dangerous beliefs through the robust Jewish press.

Post-Operative Healing
Others have proposed that metzitzah was instituted to prevent hemorrhaging. In a lengthy ode to the benefits of circumcision, the nineteenth-century American physician Peter Charles Remondino warned against too rashly judging those old shepherds of the Armenian plains for adopting a practice
8 Speculation has not been reserved for scientists, as rabbis have also proposed rationales for metzitzah. See Kuntres Ha-Metzitzah in the 1962 New York reprint edition of Sedei Hemed, vol. 8, 23680 and 43350, as quoted in Sprecher supra , 17 n.5. 9 Naphtali Klein, Section 22, Hameasseph (1895); Section 181, Hameasseph (1897); Section 111, Hameasseph (1898). Quoted in Samuel Kohn, Die Geschichte der Beschneidung: bei den Juden (Cracow, 1903), 185, 187. Noting that it was a practice among some mohelim to first rinse with alcohol, Kohn warns of the dangers of exposing a fresh wound of an eight day old to alcohol. 131

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which to them was calculated to avert subsequent dangers.10 He then proceeded to argue that the Hebrews feared haemorrhage (sic), and suction would cause the depletion of the vessel for some distance. Thus, the ancients who perform[ed] the operation with rude implements and without haemostatic remedies or appliances, naturally followed the best means at their command. A similar theory was developed by Mordechai Halperin in the twenty-first century following the 2005 herpes outbreak. After adducing proof from a thirteenth-century circumcision compendium that explains that metzitzah ba-peh must be performed to prevent blood from clotting in the infants penis, and based on a novel reading of Rambams Mishnah Torah, Halperin speculates that the act prevents rare instances of hypoxia that could cause penile necrosis.11 He explains that the pressure gradient caused by vigorously sucking creates the appropriate pressure gradient to restore the required blood supply.12 Alternatively, some contemporary scientists have sought to incorporate germ theory, a notion that was foreign to even medieval physicians, to explain the intended benefit of metzitzah ba-peh. Since ancient medicine did not recognize the importance of sterilization, Dr. Cyril Fine, an adherent of the practice of traditional metzitzah who himself claimed to have performed over 25,000 circumcisions, notes that in antiquity, mohalim often exposed the open wound to numerous contagions present on their rudimentary surgical instruments. Indeed, due to the bodys inflammatory response, the third day following surgery was known to be the most painful day for the patient. Fine postulates that metzitzah rids the body of foreign bodies and infectious agents that spread through the blood10 Peter Charles Remondino, History of Circumcision from the Earliest Times to the Present (Philadelphia, 1891), 154. 11 Rambams formulation is as follows: After [circumcision and periah], the mohel suctions the area sufficiently until blood flows from places far away from the wound; he does this in order that the child not be endangered. (Mishneh Torah, Hilchot Milah 2:2) 12 Halperin, supra n.4, 34-5. 132

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stream following the procedure. Thus, patients who received metzitzah ba-peh did not experience increased pain or body temperature on the third day following surgery.13 A similar idea was developed in the late nineteenth century by Samuel Kohn, a physician and mohel in Vitebsk (present day Belarus), who wrote that since the ancient rabbis observed that surgery was followed by inflammation and fevers, metzitzah was instituted as a prophylaxis. Similar to Rambams prescription, Kohn asserted that metzitzah was used throughout the Middle Ages in venues other than circumcision, and he postulated that the rabbis instituted the practice to limit the amount of blood in circulation in order to stymie disease.14 In Kohns day, the concept of Humorism had recently lost favor among physicians; stating that a motivation for metzitzah was to limit blood was likely an attempt to use contemporary concepts to understand the institution of the ancient rite.

A Hellenistic Model
Others seek to understand the rational for metzitzah by placing it in its historical-medical context. Shlomo Sprecher objects to Halperins alleged forced reading and unscientific theory, and instead develops a working theory based on Hellenistic medical knowledge.15 Pathology, according to the Greeks, was predicated on the precarious balance of the four vital humors; bloods propensity to spill out and stagnate made
13 Cyril Fine, Hom Ha-Yom (Hebrew), Ha-Shabbat Tzohar (October 23, 2010): 2, 8. In this article, explaining Avrahams encounter with the three angels in Genesis 18:1-3, Fine notes that the phrase hom ha-yom does not relate to the heat of the day, but rather Avrahams febrile state, as this encounter occurred three days following his circumcision. A project report of Operation Abraham, a joint initiative by Israeli and Senegalese physicians to promote adult male circumcision in Africa, reports that Fine is considered the grandfather of adult male circumcision in Israel. See Inon Schenker and Adama Nadir, Training Healthcare Teams in Scaling-Up Male Circumcision for HIV Prevention in Africa (Project Report, Jerusalem, 2009). 14 Kohn, supra n.8, 174. 15 Sprecher, supra n.7, 19-22. 133

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it prone to cause disease.16 Therefore, the Hippocratic Corpus taught that: [A]ll wounds draw their inflammation and swelling from the surrounding parts, because of the blood flowing into them. In every recent woundit is expedient to cause blood to flow from it abundantly, for thus will the wound and the adjacent parts be less attacked with inflammation When the blood flows, they become drier and less in size, as being thus dried up.17 Sprecher states that this became a predominant view in ancient medicine, and Hippocratess theory on the risks of coagulation were adopted and promulgated by Galen. The Talmud often concurred with Galens teachings, and thus it also adopted an imbalance of humors perspective of pathology. Interestingly, Sprecher notes that R. Nahum Rabinovitch reports that Rambam also prescribed metzitzah for snake-bite victims because metzitzah was purported to prevent inflammation.18 Sprecher thus elegantly illustrates how the rationale for metzitzah was consistent with, and a product of, Hellenistic medical knowledge and practice.

Conclusion
Throughout the ages, brit milah has been the bte noire of those seeking to undermine Jewish ritual. Indeed, from a homiletic perspective, it appears that the mitzvah was destined to garner increased scrutiny. When God introduces the commandment to Avraham, He implores him to Walk before Me and be

16 Guido Majno, The Healing Hand: Man and Wound in the Ancient World (Boston, 1991), cited in Sprecher, 19. 17 Ibid. 18 Nachum E. Rabinovitch, Mishnah Torah im Perush Yad Peshutah, Sefer Ahavah (Jerusalem, 1984), vol. 2, 1274, quoted in Sprecher, ibid., 21. 134

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whole (tamim).19 Ibn Ezra interprets tamimas unflinchingly accept brit milah without asking for its rationale, apparently perceiving that the physical representation of our Divine covenant might be called into question. Our discussion has demonstrated that although the precise mechanism attributed to protection conferred by metzitizah ba-peh may not have been apparent or accurate in Mishnaic times, empirical evidence may have propelled mohalim to institute seemingly efficacious practices. Medical students are introduced to the tenets of cultural competency, and often assume that seemingly obscure, traditionally-inspired remedies are confined to immigrants from remote and exotic locales. The evolution of metzitzah ba-peh reminds us of our own heritages therapeutic traditions. As science develops and the medical history of antiquity comes to light, we are given new perspectives to understand and evaluate the motivations of our ancestors and place their actions in its historical context.

19 Genesis 17:1. 135