Editing Brit milah (section)

==== {{anchor|Oral suction}}''{{transliteration|he|Metzitzah B'Peh}}'' (oral suction) ====
The traditional method of performing ''metzitzah b'peh'' ({{langx|he|מְצִיצָה בְּפֶה}}, abbreviated as MBP<ref>{{Cite news |work=[[Forward.com]] |url=https://forward.com/life/192951/why-my-son-underwent-metzitzah-bpeh/ |first=Frimet |last=Goldberger |date=18 February 2014 |title=Why My Son Underwent Metzitzah B'Peh |quote=MBP is believed to be a commandment from God.. Chasam Sofer clearly stated his position on MBP.. I do not know all the answers, but banning MBP is not one of them.}}</ref>)—or oral suction<ref>{{Cite news
  | url         = http://www.thejewishweek.com/news/newscontent.php3?artid=11539
  | archive-url  = https://web.archive.org/web/20070522001308/http://www.thejewishweek.com/news/newscontent.php3?artid=11539
  | archive-date = 2007-05-22
  | title       = City Risking Babies' Lives With Brit Policy: Health Experts
  | last        = Nussbaum Cohen
  | first       = Debra
  | date        = October 14, 2005
  | newspaper   = [[The Jewish Week]]
}}</ref><ref>{{Cite news
  | archive-url  = https://web.archive.org/web/20061120073253/http://www.thejewishweek.com/news/newscontent.php3?artid=11833
  | archive-date = 2006-11-20
  | url         = http://www.thejewishweek.com/news/newscontent.php3?artid=11833&print=yes
  | title       = City Challenged On Ritual Practice
  | access-date  = 2007-04-19
  | last1        = Nussbaum Cohen
  | first1       = Debra
  | first2     = Larry
  | last2     = Cohler-Esses
  | date        = December 23, 2005
  | newspaper   = [[The Jewish Week]]
}}</ref>—has become controversial. The process has the ''[[mohel]]'' place his mouth directly on the infant's genital wound to draw blood away from the cut. Many circumcision ceremonies no longer use metzitzah b'peh,<ref>{{Cite news
 |url         = http://www.jta.org/2014/02/02/news-opinion/united-states/n-y-newborn-contracts-herpes-from-controversial-circumcision-rite
 |title       = N.Y. newborn contracts herpes from controversial circumcision rite
 |publisher   = [[Jewish Telegraphic Agency]]
 |date        = February 2, 2014
 |url-status     = live
 |archive-url  = https://web.archive.org/web/20140219113240/http://www.jta.org/2014/02/02/news-opinion/united-states/n-y-newborn-contracts-herpes-from-controversial-circumcision-rite
 |archive-date = February 19, 2014
}}</ref> but Haredi Jews continue to perform it, while traditional [[Karaite Judaism|Karaites]] and [[Beta Israel]] never practiced it.<ref name=haaretz>{{Cite news
 |url         = http://www.haaretz.com/opinion/.premium-1.549545
 |title       = Controversial circumcisions
 |author      = Eliyahu Fink and Eliyahu Federman
 |newspaper   = [[Haaretz]]
 |date        = Sep 29, 2013
 |url-status     = live
 |archive-url  = https://web.archive.org/web/20140210090831/http://www.haaretz.com/opinion/.premium-1.549545
 |archive-date = 2014-02-10
}}</ref><ref name="RCAMetzitzah">{{Cite web
 |url         = http://www.rabbis.org/news/article.cfm?id=100605
 |title       = Metzitza Be'Peh – Halachic Clarification
 |access-date  = 2007-04-06
 |date        = June 7, 2005
 |publisher   = [[Rabbinical Council of America]]
 |quote       = The poskim consulted by the RCA agree that the normative halacha permits using a glass tube, and that it is proper for mohalim to do so given the health issues involved.
 |url-status     = dead
 |archive-url  = https://web.archive.org/web/20070415221929/http://www.rabbis.org/news/article.cfm?id=100605
 |archive-date = April 15, 2007
}}</ref><ref name="Hartog">{{Cite news
 |first       = Kelly
 |last        = Hartog
 |url         = http://www.jewishjournal.com/home/preview.php?id=13676
 |title       = Death Spotlights Old Circumcision Rite
 |newspaper   = [[The Jewish Journal of Greater Los Angeles]]
 |date        = February 18, 2005
 |access-date  = 2006-11-22
 |quote       = Metzizah b’peh — loosely translated as oral suction — is the part of the circumcision ceremony where the mohel removes the blood from the baby's member; these days the removal of the blood is usually done using a sterilized glass tube, instead of with the mouth, as the Talmud suggests.
 |url-status     = live
 |archive-url  = https://web.archive.org/web/20061213112130/http://www.jewishjournal.com/home/preview.php?id=13676
 |archive-date = December 13, 2006
}}</ref> The practice poses a serious risk of spreading [[herpes]] to the infant.<ref name="Gesundheit">{{Cite journal
 |last            = Gesundheit
 |first           = B.
 |date            = August 2004
 |title           = Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition
 |journal         = Pediatrics
 |volume          = 114
 |issue           = 2
 |pages           = e259–63
 |url             = http://pediatrics.aappublications.org/cgi/reprint/114/2/e259.pdf
 |doi             = 10.1542/peds.114.2.e259
 |access-date      = 2006-06-28
 |pmid            = 15286266
 |issn            = 1098-4275
 |display-authors = etal
 |url-status         = live
 |archive-url      = https://web.archive.org/web/20060723081226/http://pediatrics.aappublications.org/cgi/reprint/114/2/e259.pdf
 |archive-date     = 2006-07-23
|doi-access= free
 }}</ref><ref>{{Cite news|url=http://www.nydailynews.com/new-york/jewish-baby-contracted-herpes-bris-article-1.2055911|title=Another Jewish baby has contracted herpes through bris|work=[[New York Daily News]] |date=24 December 2014 |url-status=live|archive-url=https://web.archive.org/web/20151208042913/http://www.nydailynews.com/new-york/jewish-baby-contracted-herpes-bris-article-1.2055911|archive-date=2015-12-08}}</ref><ref>Staff (8 June 2012) [https://news.yahoo.com/extreme-orthodox-jewish-circumcision-illegal-093500919.html Should extreme Orthodox Jewish circumcision be illegal?] {{webarchive|url=https://web.archive.org/web/20160305082226/http://news.yahoo.com/extreme-orthodox-jewish-circumcision-illegal-093500919.html |date=2016-03-05 }} ''The Week'', Retrieved 30 June 2012</ref><ref>{{Cite news|url=https://www.usatoday.com/story/news/2015/02/21/nyc-orthodox-jews-in-talks-over-ritual-after-herpes-cases/23798751/|title=NYC, Orthodox Jews in talks over ritual after herpes cases|work=[[USA Today]] |url-status=live|archive-url=https://web.archive.org/web/20160710134721/http://www.usatoday.com/story/news/2015/02/21/nyc-orthodox-jews-in-talks-over-ritual-after-herpes-cases/23798751/|archive-date=2016-07-10}}</ref> Proponents maintain that there is no conclusive evidence that links herpes to ''Metzitza'',<ref name="matziv.com">{{Cite web |url=http://www.matziv.com/pictures/drbermanarticlemetzitzah |title=Archived copy |access-date=2012-07-09 |url-status=dead |archive-url=https://web.archive.org/web/20120617162008/http://www.matziv.com/pictures/drbermanarticlemetzitzah |archive-date=2012-06-17 }}</ref> and that attempts to limit this practice infringe on religious freedom.<ref>{{Cite web
 |url         = http://collive.com/show_news.rtx?id=22284&hl=metzitza
 |title       = Lawsuit Unites Jewish Groups
 |access-date  = 2013-01-01
 |date        = Oct 24, 2012
 |publisher   = collive.com
 |url-status  = dead
 |archive-url  = https://web.archive.org/web/20151208074650/http://collive.com/show_news.rtx?id=22284&hl=metzitza
 |archive-date = 2015-12-08
}}</ref><ref>{{Cite news
 |url         = https://www.nytimes.com/2012/06/13/nyregion/new-york-proposes-consent-waiver-for-circumcision-ritual-associated-with-herpes.html?_r=0
 |title       = City Urges Requiring Consent for Jewish Rite
 |access-date  = 2013-02-01
 |date        = June 12, 2012
 |newspaper   = [[The New York Times]]
 |url-status     = live
 |archive-url  = https://web.archive.org/web/20170625012551/http://www.nytimes.com/2012/06/13/nyregion/new-york-proposes-consent-waiver-for-circumcision-ritual-associated-with-herpes.html?_r=0
 |archive-date = June 25, 2017
}}</ref><ref>{{Cite news
 |title       = Assault on Bris Milah Unites Jewish Communities
 |url         = http://crownheights.info/jewish-news/47779/assault-on-bris-milah-unites-jewish-communities/
 |publisher   = CrownHeights.info
 |date        = October 25, 2012
 |url-status  = dead
 |archive-url  = https://web.archive.org/web/20141001153737/http://crownheights.info/jewish-news/47779/assault-on-bris-milah-unites-jewish-communities/
 |archive-date = October 1, 2014
 |access-date = September 29, 2014
}}</ref>

The practice has become a controversy in both secular and [[Jewish medical ethics]]. The ritual of ''metzitzah'' is found in [[Mishnah]] Shabbat 19:2, which lists it as one of the four steps involved in the circumcision rite. Rabbi [[Moses Sofer]], also known as the Chatam Sofer (1762–1839), observed that the Talmud states that the rationale for this part of the ritual was hygienic—i.e., to protect the health of the child. As such, the Chatam Sofer issued a ruling to perform ''metzitzah'' with a sponge instead of oral suction in order to safeguard the child from potential risks. He also cited a passage in Nedarim 32a as a warrant for the position that metzitzah b’peh was not an obligatory part of the circumcision ceremony.<ref>{{Cite news
  | url         = http://www.thejewishweek.com/top/editletcontent.php3?artid=4591
  | title       = Editorial & Opinion
  | newspaper   = [[The Jewish Week]]
  | access-date  = 2012-04-25
  | url-status     = dead
  | archive-url  = https://web.archive.org/web/20061120073118/http://www.thejewishweek.com/top/editletcontent.php3?artid=4591| archive-date=November 20, 2006}}</ref><ref>{{Cite web |last=Macdowell |first=Mississippi Fred |date=2010-04-26 |title=On the Main Line: Rabbi Moshe Sofer's responsum on metzitzah. |url=http://onthemainline.blogspot.com/2010/04/rabbi-moshe-sofers-responsum-on.html |access-date=2022-05-23 |website=On the Main Line}}</ref> It relates the story that a mohel (who was suspected of transmitting herpes via metzizah to infants) was checked several times and never found to have signs of the disease and that a ban was requested because of the "possibility of future infections".<ref>{{Cite book
  | url   = https://books.google.com/books?id=-vbWAAAAMAAJ&q=divine+law+in+human+hands
  | title = Divine Law in Human Hands
| isbn = 978-9652239808
| last1 = Katz
| first1 = Jacob
| year = 1998
| publisher = Magnes Press
}}</ref> [[Moshe Schick]] (1807–1879), a student of Moses Sofer, states in his book of Responsa, ''She’eilos u’teshuvos Maharam Schick'' (Orach Chaim 152,) that Moses Sofer gave the ruling in that specific instance only because the mohel refused to step down and had secular government connections that prevented his removal in favor of another mohel, and the Heter may not be applied elsewhere. He also states (''Yoreh Deah'' 244) that the practice is possibly a Sinaitic tradition, i.e., [[Halacha l'Moshe m'Sinai]]. Other sources contradict this claim, with copies of Moses Sofer's responsa making no mention of the legal case or of his ruling applying in only one situation. Rather, that responsa makes quite clear that "metzizah" was a health measure and should never be employed where there is a health risk to the infant.<ref>{{Cite web |url=http://onthemainline.blogspot.com/2012/04/chasam-sofers-ruling-on-metzitzah-be.html |website=onthemainline.blogspot.com |title=The Chasam Sofer's ruling on Metzitzah Be-peh |date=April 16, 2012 |url-status=dead |archive-url=https://web.archive.org/web/20150402175402/http://onthemainline.blogspot.com/2012/04/chasam-sofers-ruling-on-metzitzah-be.html |archive-date=April 2, 2015 |access-date=March 23, 2015 }}</ref>

[[Chaim Hezekiah Medini]], after corresponding with the greatest Jewish sages of the generation, concluded the practice to be [[Halacha l'Moshe m'Sinai]] and elaborates on what prompted Moses Sofer to give the above ruling.<ref>Sdei Chemed vol. 8 p. 238</ref> He tells the story that a student of Moses Sofer, [[Lazar Horowitz]], [[Chief Rabbi of Vienna]] at the time and author of the responsa ''Yad Elazer'', needed the ruling because of a governmental attempt to ban circumcision completely if it included ''metztitzah b'peh.'' He therefore asked Sofer to give him permission to do ''brit milah'' without ''metzitzah b'peh.'' When he presented the defense in secular court, his testimony was erroneously recorded to mean that Sofer stated it as a general ruling.<ref>{{Cite web
 |url        = http://dhengah.org/metzitzah4dummies/metzitzah4dummies.htm
 |archive-url = https://web.archive.org/web/20070927001229/http://dhengah.org/metzitzah4dummies/metzitzah4dummies.htm
 |url-status   = dead
 |archive-date = 2007-09-27
 |title      = Kuntres Hamiliuim
 |publisher  = Dhengah.org
 |access-date = 2012-04-25
}}</ref> The [[Rabbinical Council of America]] (RCA), which claims to be the largest American organization of Orthodox rabbis, published an article by mohel Yehudi Pesach Shields in its summer 1972 issue of ''Tradition'' magazine, calling for the abandonment of Metzitzah b'peh.<ref>{{Cite web
 |url         = http://traditionarchive.org/news/article.cfm?id=103933
 |title       = The Making of Metzitzah
 |publisher   = Tradition
 |access-date  = 2014-05-02
 |url-status  = dead
 |archive-url  = https://web.archive.org/web/20140502221419/http://traditionarchive.org/news/article.cfm?id=103933
 |archive-date = 2014-05-02
}}</ref> Since then the RCA has issued an opinion that advocates methods that do not involve contact between the mohel's mouth and the infant's genitals, such as the use of a sterile syringe, thereby eliminating the risk of infection.<ref name=haaretz /> According to the [[Chief Rabbinate of Israel]]<ref>{{Cite web |url=http://cbci16.b1.cdn.co.il/imagebank/orig/orig_041F747012AB47F9A57A42BD87D1E8C4.JPG |title=Archived copy |access-date=2013-04-26 |url-status=dead |archive-url=https://web.archive.org/web/20140222013130/http://cbci16.b1.cdn.co.il/imagebank/orig/orig_041F747012AB47F9A57A42BD87D1E8C4.JPG |archive-date=2014-02-22 }}</ref> and the [[Edah HaChareidis]]<ref>{{Cite web |url=http://cbci16.b2.cdn.co.il/imagebank/orig/orig_C65A7314BA5E41F0B7EF10BFC75E4195.JPG |title=Archived copy |access-date=2013-04-26 |url-status=dead |archive-url=https://web.archive.org/web/20140222013129/http://cbci16.b2.cdn.co.il/imagebank/orig/orig_C65A7314BA5E41F0B7EF10BFC75E4195.JPG |archive-date=2014-02-22 }}</ref> ''metzitzah b'peh'' should still be performed.

The practice of ''metzitzah b'peh'' posed a serious risk in the transfer of [[Herpes simplex virus|herpes]] from [[mohel]]im to eight Israeli infants, one of whom suffered brain damage.<ref name="Gesundheit" /><ref>{{Cite web
  | url         = http://my.webmd.com/content/article/91/101352.htm?lastselectedguid=%7B5FE84E90-BC77-4056-A91C-9531713CA348%7D
  | title       = Rare Circumcision Ritual Carries Herpes Risk
  | publisher   = [[WebMD]]
  | access-date  = 2012-04-25
  | url-status     = dead
  | archive-url  = https://web.archive.org/web/20050920215004/http://my.webmd.com/content/article/91/101352.htm?lastselectedguid=%7B5FE84E90-BC77-4056-A91C-9531713CA348%7D| archive-date=September 20, 2005}}</ref> When three New York City infants contracted herpes after ''metzizah b'peh'' by one ''mohel'' and one of them died, New York authorities took out a restraining order against the ''mohel'' requiring use of a sterile glass tube, or pipette.<ref name="Hartog" /><ref name="NewmanNYT">{{Cite news
 |first       = Andy
 |last        = Newman
 |title       = City Questions Circumcision Ritual After Baby Dies
 |url         = https://www.nytimes.com/2005/08/26/nyregion/26circumcise.html?ex=1164344400&en=31f8462c34a55f16&ei=5070
 |newspaper   = [[The New York Times]]
 |date        = August 26, 2005
 |access-date  = 2006-11-23
 |url-status     = live
 |archive-url  = https://web.archive.org/web/20130515144532/http://www.nytimes.com/2005/08/26/nyregion/26circumcise.html?ex=1164344400&en=31f8462c34a55f16&ei=5070
 |archive-date = May 15, 2013
}}</ref> The mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease.<ref name="NewmanNYT" /><ref name="Lohud">{{Cite web
  | url       = http://www.lohud.com/apps/pbcs.dll/article?AID=/20060621/NEWS03/606210352/1197/
  | title       = State offers new guidelines on oral-suction circumcision
  | access-date       = 2006-06-28
  | last       = Clarke
  | first       = Suzan
  | date       = June 21, 2006
  | publisher       = [[The Journal News]]
  | archive-url       = https://web.archive.org/web/20060706171003/http://www.lohud.com/apps/pbcs.dll/article?AID=%2F20060621%2FNEWS03%2F606210352%2F1197%2FRSS01
  | archive-date       = 2006-07-06
  | url-status       = dead
  }}</ref> In September 2005, the city withdrew the restraining order and turned the matter over to a rabbinical court.<ref>{{Cite news
 |url=http://www.thejewishweek.com/news/newscontent.php3?artid=11412
 |title=City: Brit Case To Bet Din
 |access-date=2006-11-23
 |last=Nussbaum Cohen
 |first=Debra
 |date=September 23, 2005
 |newspaper=[[The Jewish Week]]
 |url-status=dead
 |archive-url=https://web.archive.org/web/20061120073353/http://www.thejewishweek.com/news/newscontent.php3?artid=11412
 |archive-date=2006-11-20
}}</ref> Thomas Frieden, the Health Commissioner of New York City, wrote, "There exists no reasonable doubt that 'metzitzah b'peh' can and has caused neonatal herpes infection....The Health Department recommends that infants being circumcised not undergo metzitzah b'peh."<ref>{{Cite news
 |first       = Debra
 |last        = Nussbaum Cohen
 |title       = Controversy rages in New York over circumcision practice
 |url         = http://www.jewishledger.com/articles/2006/02/23/news/news02.txt
 |newspaper   = [[The Jewish Ledger]]
 |date        = February 23, 2006
 |access-date  = 2006-11-23
 |url-status     = dead
 |archive-url  = https://web.archive.org/web/20060429154742/http://www.jewishledger.com/articles/2006/02/23/news/news02.txt
 |archive-date = April 29, 2006
}}</ref> In May 2006, the Department of Health for New York State issued a protocol for the performance of metzitzah b'peh.<ref>{{Cite web |date=November 2006 |title=Circumcision Protocol Regarding the Prevention of Neonatal Herpes Transmission |url=http://www.health.state.ny.us/diseases/communicable/herpes/newborns/circumcision_protocol.htm |url-status=dead |archive-url=https://web.archive.org/web/20070205033348/http://www.health.state.ny.us/diseases/communicable/herpes/newborns/circumcision_protocol.htm |archive-date=February 5, 2007 |access-date=2006-11-23 |publisher=Department of Health, New York State |quote="The person performing metzizah b'peh must do the following: wipe around the outside of the mouth thoroughly, including the labial folds at the corners, with a sterile alcohol wipe, and then discard in a safe place. Wash hands with soap and hot water for 2–6 minutes. Within 5 minutes before metzizah b'peh, rinse mouth thoroughly with a mouthwash containing greater than 25% alcohol (for example, Listerine) and hold the rinse in mouth for 30 seconds or more before discarding it."}}</ref> [[Antonia Novello]], Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to "allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health".<ref>{{Cite web|url=http://www.health.state.ny.us/diseases/communicable/herpes/newborns/2006-05-08_letter_to_rabbis.htm |title=Dear Rabbi Letter |access-date=2006-11-23 |last=Novello |first=Antonia C. |date=May 8, 2006 |publisher=Department of Health, New York State |quote=The meetings have been extremely helpful to me in understanding the importance of metzizah b'peh to the continuity of Jewish ritual practice, how the procedure is performed, and how we might allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health. I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation. |url-status=dead |archive-url=https://web.archive.org/web/20070218224659/http://www.health.state.ny.us/diseases/communicable/herpes/newborns/2006-05-08_letter_to_rabbis.htm |archive-date=February 18, 2007}}</ref> Later in New York City in 2012 a 2-week-old baby died of herpes because of metzitzah b'peh.<ref>{{Cite web |url=https://abcnews.go.com/Health/baby-dies-herpes-virus-ritual-circumcision-nyc-orthodox/story?id=15888618 |title=Baby Dies of Herpes in Ritual Circumcision By Orthodox Jews |author=Susan Donaldson James |date=March 12, 2012 |website=abcnews.go.com |url-status=live |archive-url=https://web.archive.org/web/20170419065328/https://abcnews.go.com/Health/baby-dies-herpes-virus-ritual-circumcision-nyc-orthodox/story?id=15888618 |archive-date=April 19, 2017 }}</ref>

In three medical papers done in Israel, Canada, and the US, oral suction following circumcision was suggested as a cause in 11 cases of neonatal herpes.<ref name="Gesundheit" /><ref>Rubin LG, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatric Infectious Diseases Journal. 2000. 19(3) 266–67.</ref><ref>Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Israel Medical Association Journal. [http://www.ima.org.il/imaj/ar03dec-14.pdf 2003 Dec;5(12):893-4] {{webarchive |url=https://web.archive.org/web/20121021093342/http://www.ima.org.il/imaj/ar03dec-14.pdf |date=October 21, 2012 }}</ref> Researchers noted that prior to 1997, neonatal herpes reports in Israel were rare, and that the late instances were correlated with the mothers carrying the virus themselves.<ref name="Gesundheit" /> Rabbi Doctor [[Mordechai Halperin]] implicates the "better hygiene and living conditions that prevail among the younger generation", which lowered to 60% the rate of young Israeli Haredi mothers who carry the virus. He explains that an "absence of antibodies in the mothers' blood means that their newborn sons received no such antibodies through the placenta, and therefore are vulnerable to infection by HSV-1".<ref name="Halperin">{{Cite journal |last=Halperin |first=Mordechai |author-link=Mordechai Halperin |date=Winter 2006 |title=Metzitzah B'peh Controversy: The View from Israel |url=http://www.ou.org/jewish_action/article/8987 |journal=[[Jewish Action]] |volume=67 |issue=2 |pages=25, 33–39 |archive-url=https://web.archive.org/web/20120306221308/http://www.ou.org/jewish_action/article/8987 |archive-date=March 6, 2012 |access-date=February 15, 2007 |quote=The mohel brings the baby's organ into his mouth immediately after the excision of the foreskin and sucks blood from it vigorously. This action lowers the internal pressure in the tissues of the organ, in the blood vessels of the head of the organ and in the exposed ends of the arterioles that have just been cut. Thus, the difference between the pressure in the blood vessels in the base of the organ and the pressure in the blood vessels at its tip is increased. This requirement has deep religious significance as well as medical benefits....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.28 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 metzitzah 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. |translator-first=Yocheved |translator-last=Lavon}}</ref>