This procedure has been practiced for ages from the time of Avraham Avinu (our father Abraham) and Moshe Rabainu (Moses our teacher). We make this conclusion because we have no record that this procedure was instituted through Rabbinical decree. And because we do not find any discussions in the Talmud or in the Rishonim commentaries about the halachik validity of using other methods to draw the blood, such as using a tube or pressing the organ near the wound, or by covering the wound with an absorbent material and then pressing on the wound to force the blood out, we therefore conclude that no other method was accepted.

The Talmud (Shabbos 133 b) quotes Rav Papa, that any mohel who does not do the third procedure loses his license to practice circumcision because he thereby does not minimize the danger of post operative complications. The mohel is also required to do this procedure on the Sabbath although he is performing a forbidden work of the Sabbath, because it is permitted to violate the Sabbath to save a life or to minimize the danger to a life. The explanation is, that a mohel must study the laws of circumcision to be licensed to perform circumcision; therefore it is his responsibility to minimize the potential post operative complications because he was the one who endangered the child through circumcising him. He may also tell someone else to do the procedure, but if there are no volunteers, he must do it. If there were no post operative dangers to the child, or if there were no therapeutic value with drawing of the blood, it would not be permitted on the Sabbath, and it would constitute only a mitzvah that the father is obligated to do if the mohel refuses.

During the period of the Chasam Sofer (Rav Moshe Sofer), several European governments interfered with the procedure, because of what they thought were hygienic sanitary reasons. They argued that drawing the blood orally would facilitate transmitting contagious diseases and especially during a plague. The Rabbinical authorities of these countries temporarily permitted a mohel to draw blood from the wound through other means, such as using a tube or pressing the organ near the wound, or by covering the wound with an absorbent material and then pressing on the wound to force the blood out. This leniency was given for the period that the plague was out of control, or for the period that the government threatened to abolish drawing of blood after circumcision, since it endangered lives. The leniency was also given for the period that the government threatened to do away with circumcision, because it is preferable not to do metzitzah bipeh than not to circumcise.

After becoming accustomed to this hygienic sanitary circumcision, and after the governments refrained from interfering with circumcision, these communities did not revert back to the age old procedure of orally drawing blood from the wound or metzitzah bipeh. The contemporary Rabbis of these communities justified this by rationalizing that there is, no mitzvah of metzitzah bipeh. There is only the requirement to diminish the post operative dangers through drawing blood from the wound, and this may be accomplished with a tube.

Dr. Daniel S. Berman, Chief of Infectious Diseases at the New York Westchester Square Hospital, wrote his opinion in a public letter to be found at the end of this article. He states that the process of orally drawing blood from the circumcision wound has a perfect safety record with regard to bacterial and viral infections.

When is a mohel permitted to perform a circumcision if he will not be allowed in any way to draw blood from the circumcision wound, thereby endangering the child through circumcision. In a case like this the infant would need a comprehensive medical checkup by several experts in the field and a written statement that if the circumcision is done by an expert mohel, and that although no blood will be drawn from the circumcision wound, the circumcision may be performed, and that the infant is not expected to develop any life threatening post-operative complications. The mohel then informs the father that he is doing only the first two steps of meelah and the last step, drawing blood from the wound, is the responsibility of the father. If possible, he may be able to press near the wound to draw blood.

This same logic may apply to a mohel circumcising where the father refuses to allow metzitzah bipeh. The mohel informs the father that he is doing only the first two steps of meelah and the last step, orally drawing blood from the wound, is the responsibility of the father. If he sees that the father will not do metzitzah bipeh, then he must draw the blood with a tube to minimize the danger. In a hospital situation, it is understood that the mohel is not assuming responsibility for metzitzah bipeh, and the mohel need not mention it to the father. However, if the circumcision can be done outside of the hospital, he should inform the father of the halachik advantage of doing it outside of the hospital because then he can do metzitzah bipeh. If in the hospital they can perform the circumcision on time mitzvah of meelah bizimano, because if done by the hospital's staff experts the procedure with this infant at eight days will not endanger him, but if done outside of the hospital with metzitzah bipeh they will have to postpone the circumcision until after the child is eight days old, then the circumcision is done on time at the hospital even though they are not allowed to do metzitzah bipeh. The reason is, if with the mitzvah of meelah bizimano one may violate a work of the Sabbath with a positive action, then one may also violate mitzvah of metzitzah bipeh through a negative action.

Many a mohel follows a compromise policy incorporating the hygienic issue. They claim that, although no one has proved that viral transmission occurs through mitzitzah bipeh there is still no comprehensive international study to prove this. Consequently, where there is reason to suspect that the patient may have a contagious disease, such as with a non-observant family, or a family that have recently become observant, or an adult who was not observant in his youth, and considering modern life styles, they may be suspected of carrying contagious diseases, then the mohel will draw blood from the wound with a tube, and wear surgical gloves when circumcising, when he feels it necessary. If the mohel has a contagious disease, he will appoint someone else to orally draw the blood from the wound. However, if the family have been observant of the halacha since their youth and they say that they have no contagious diseases, and the infant has been checked and found negative, then there is no reason not to do mitzitzah bipeh.

If the mohel's family custom from Europe is to do mitzitzah bipeh, but the mohel performs all circumcisions by afterwards drawing blood from the wound with a tube, or he does circumcision with gloves, then this action is motivated because he does not want to dirty himself with the blood of the circumcision and he is acting disrespectfully towards the mitzvah. If the father's family custom from Europe is to do mitzitzah bipeh, and he tells the mohel that he wants him to draw the blood of the wound with a tube and not orally, the father is considered acting disrespectfully towards the mitzvah.

During the year 5,748 (1998), the fear of an AIDS epidemic spread across the globe. Jews who practiced mitzitzah bipeh began questioning this practice. In response, the well known international Rabbinical organizations, The Agudas Harabanim, Union of Orthodox Rabbis, and The Hisachdus Harabanim, Central Rabbinical Congress, publicly announced that there is no halachik basis to institute any changes of this age old practice of mitzitzah bipeh, and that anyone who feels that he has a specific problem with this must consult a competent Rabbinical tribunal for a ruling.

(For the record, the author describes himself as a modern orthodox Jew, who davens in a young Israel. He shares a mutual acquaintance with Rabbi Fisher, who asked him to review the information available. He was not "pressured" by the charedei community, as some have suggested, to pen this article, or the letter to Rav Eliyashiv, Shlita. Also keep in mind that one out of 3800 babies born in the USA is born with Herpes, yet not one case was found in the US at the time Dr. Tendler published his article. There is clearly no methodology shown that separates the eight cases cited in the article, from the causes of the hundreds of other neonatal cases of Herpes that must have occurred in the eight hospitals in two countries cited, during the same time period. In the another of the YU shiurim Dr.Tendler claims that "JAMA [Journal of the American Medical Association] turned us down because 'it was too hot to handle' ". We are currently trying to determine if the article was refused because it was junk science or if it was even submitted.-Ed)

I am writing in response to a recent article that appeared in the journal Pediatrics that purports to establish the possibility of a causal relationship between the practice of oral suctioning of blood (metzitzah bepeh) as part of a religious circumcision and neonatal Herpes infection. I am a Board Certified Infectious-Disease specialist practicing in New York City and Westchester County. I have been in practice since 1987. I am currently the Chief of Infectious-Disease at New York Westchester Square Hospital and the former Chief of Infectious- Disease at White Plains Hospital Medical Center.

First, it should be known that Herpes simplex infection involving the lips, cold sores, was first described by the Roman physician, Herodotus, in the year 100 A.D. He named it Herpes Febrilis. The virus was grown in a laboratory in 1925. Metzitzah bepeh, as part of the circumcision procedure, was first described in the Talmud, which was compiled in Babylonia in the sixth century. Most of the laws described in the Talmud had been practiced for hundreds of years prior to that time. It is likely that Herpes simplex infection and metzitzah bepeh have coexisted for the past 2000 years! Until this article appeared in Pediatrics in August of 2004, there had never been an observation of any relationship between neonatal Herpes infection and metzitzah bepeh. In fact, there has never been an observation of transmission of any virus in this procedure, including HIV, hepatitis A, hepatitis B, hepatitis C, Epstein-Barr virus, and Cytomegalovirus.

Despite the perfect record of 2000 years, if one were concerned and wished to investigate the possibility of transmission of Herpes simplex through metzitzah bepeh, one could do so in several ways. The best approach would be to follow a cohort of babies born. One would examine them daily from birth to be sure that there was no rash prior to the circumcision and then conduct an epidemiologic study of all those infants who developed neonatal Herpes (Herpes infection in children less than six weeks old). One would study all of the contacts of these babies, including parents, caretakers, siblings, other relatives, and friends. One would investigate what type of contact these individuals had with the infant. One would look into whether these babies had circumcision, whether metzitzah bepeh was part of the procedure, and then study the individual who did the circumcision, whether it be a physician or mohel. All contacts would be studied in a uniform manner, using antibody testing and PCR testing of saliva. Ultimately, the way to link anybody to the infant with neonatal Herpes would be through DNA analysis of the virus.

A weaker method to investigate this possibility would be to study retrospectively all cases of neonatal Herpes in a certain area or institution. One would then conduct the same detailed epidemiologic analysis of all the contacts of this infant. The deficiency in this method is that one would not be sure as to exactly when the infection began. If the diagnosis was made after a circumcision, one could not of be sure that the illness did not develop beforehand. Again, DNA matching would be the way to link any contact to the infant.

The least effective method would be to study retrospectively the case histories of all infants in a certain time period who were discharged from the hospital with a diagnosis of neonatal Herpes. This kind of information can be obtained from the Information Services department of hospitals. In this kind of study, the epidemiologic information would be far more difficult to obtain, as the infants would have to be tracked down long after their discharge from the hospital.

This study does not use any of these methods. In fact, it is not clear at all how this study was conducted. It is stated in the "Methods" section, "the 8 cases were collected from personal communication and the experience of the authors from 1997 to 2003. Clinical data from all patients were collected, and follow-up was conducted during hospitalization and after the discharge of the infants from the hospital."

How were these eight cases collected? Were there any other cases of neonatal Herpes during this time? How does "personal communication" differ from "the experience of the authors." Were the data collected retrospectively or prospectively? None of this is clear from the study.

In all other studies analyzing transmission of viruses from one human to another, the method has been to prove by DNA analysis that the virus is shared by the two individuals. Examples of this can be found in other viruses. For example, in the 1980s, there was an outbreak of HIV associated with one dentist in Florida. The Center for Disease Control (CDC) in the United States determined through DNA analysis that the virus was shared by the dentist and a group of patients who were infected. There was a case of possible transmission of HIV from an orthopedic surgeon to a patient in France published in the Annals of Internal Medicine in 1999. Again, the relationship was established with DNA sequence analysis. There was a case of hepatitis B transmission from a thoracic-surgery resident to multiple patients in 1992 reported in the New England Journal of Medicine in 1996. Likewise, the CDC found that the DNA was identical in the hepatitis virus of the surgeon and in that of the patients who acquired it from him. This is the method of establishing transmission of viruses.

In the literature of transmission of Herpes virus infection, this also has been the method of establishing transmission. There was a case reported in the Journal of Pediatrics in 1983 of a neonate who acquired HSV-1 from his father. In this case, the father developed a large lesion on his lip soon after his son developed HSV-1 infection. Through DNA analysis, it was determined that the virus acquired by the son was identical to that of his father.

In all of the studies, another essential piece was to exclude the possibility that the virus could have been contracted in some other way. This was done through detailed epidemiologic analysis.

In this study, there is absolutely no evidence linking the DNA of Herpes virus in any mohel to any infant. In fact, there is no live virus obtained from any mohel. The authors admit that the mouth cultures obtained from mohels were all negative for HSV. Despite the author's own observation in the introduction that, "postnatal transmission usually results from non-genital infection of a care-giver, including parent or nursery personnel with oral lesions," there is also no discussion at all as to what other individuals came into contact with these infants and how it was determined that they could not have transmitted the virus to these infants.

A simple way to link the infants to the mohels was available in the case of the two infants who were circumcised by the same mohel five weeks apart. As it appears from the Methods section that clinical data were collected from the patients during hospitalization, there should have been a comparison of the DNA of the Herpes virus of the two infants. If the viruses matched, and it was determined that the mohel was the only person who came into contact with both infants, even in the absence of Herpes virus being cultured from the mohel, one would have to suspect seriously that the mohel was the source. It would not be conclusive evidence; as in every other study I described, DNA was obtained from the person suspected of transmitting the virus. However, it would be worrisome. Why was this not done? If it was done, why was it not mentioned?

With regard to sero-positivity, the Results section of the study states, "most infants and their mothers were sero-negative for HSV; only patient 7 and his mother were sero-positive with a titer of 1:16." It does not state how many of the mothers and infants were actually tested. It states that, " four mohels could be tested, and they were found to be sero-positive for HSV." It does not state whether they were sero-positive for HSV-1 or HSV-2. If they were seropositive for HSV-2, it would obviously have no significance. In any case, the authors fail to mention that 90% of adults are sero-positive for HSV.

Several other points of the study need to be addressed. In describing the procedure of metzitzah bepeh, the authors state in the Introduction, "this procedure was repeated several times until bleeding stopped." I have interviewed several mohels. The actual process is to do one instant of suctioning accomplished so quickly that eyewitnesses looking to observe are often unable to even see that it was done.

Also in the Introduction, the authors state, "the ancient procedure of metzitzah, also carries a risk of infection, and currently most mohels use an appropriate suction device, such as a mucous extractor." This is stated as a fact without any citation. There is no information anywhere that this procedure carries a risk of infection.

In the Discussion, the authors state, "because shedding of HSV-1 in the saliva of both the symptomatic and asymptomatic individuals has been documented repeatedly, the act of metzitzah represents a potential source of oral genital transmission...". In fact, little is known about shedding of HSV-1 in the saliva of asymptomatic individuals. In a recent review of HSV shedding, (online publication called antiviral research www.sciencedirect.com volume 6351) the authors state, "there are few [case] data on the transmission of HSV-1 from patients who were sero-positive for HSV-1 but have a negative history of herpes labialis."

The authors also stated in their Discussion, "there is, however, the possibility that some previous cases were not reported for cultural reasons." This comment is pure speculation and is of no value.

The authors conclude that "our findings provide evidence that ritual Jewish circumcision with oral metzitzah may cause oral-genital transmission of HSV infection." No evidence at all has been provided. The authors also state, "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." There is absolutely no data to establish such transmission.

We have a history of 2000 years of metzitzah bepeh and Herpes infections running parallel courses but never crossing paths. Thousands and thousands of babies over the years have had metzitzah bepeh without a single case of documented transmission of herpes virus or any other virus. In thinking of infections, one would worry that there might be a higher incidence of post- circumcision wound infections caused by bacteria from the mouth of the mohel doing metzitzah bepeh. No such observation has ever been made.

Why is it that viral transmission doesn't occur? Why don't bacterial infections happen? First, as I stated before, we do not know what the incidence of shedding is in an adult who never has had a reactivation of Herpes infection. It may be nonexistent. It also may be that even if such an individual were to shed, the virus that he has may be weaker in quality and less in quantity and thus unable to transmit virus. It may be the explanation as to why such a person never developed reactivation in the form of cold sores. Furthermore, it is known that saliva is not an efficient way of transmitting virus. Saliva is known to have components that weaken viruses. In fact, HIV, a highly contagious virus, has never been shown to be transmitted through saliva. An individual has never been shown to transmit HIV to another individual with intimate kissing. It also may be possible that by putting wine in the mouth, the virus, if it were to be present, would be further diluted. Finally, the time of contact between the mohel and the baby is so brief that the possibility of transmission is further reduced. Some of these factors would also explain why no bacterial infections have been associated with this procedure.

In summary, metzitzah bepeh has a perfect safety record for 2000 years with regard to bacterial infections and viral infections. This study is a feeble attempt to taint this record.

I hope this information is of value to you.

Respectfully yours, Daniel S. Berman, M.D.,F.A.C.P.