חולין מז, ב
רבי נתן אומר פעם אחת הלכתי לכרכי הים באתה אשה אחת לפני שמלה בנה ראשון ומת שני ומת שלישי הביאתו לפני ראיתיו שהיה אדום אמרתי לה בתי המתיני לו עד שיבלע בו דמו המתינה לו ומלה אותו וחיה והיו קורין אותו נתן הבבלי על שמי
ושוב פעם אחת הלכתי למדינת קפוטקיא באתה אשה לפני שמלה בנה ראשון ומת שני ומת שלישי הביאתו לפני ראיתיו שהיה ירוק הצצתי בו ולא היה בו דם ברית אמרתי לה בתי המתיני לו עד שיפול בו דמו המתינה לו ומלה אותו וחיה והיו קורין אותו נתן הבבלי על שמי
Rabbi Natan says: Once I went to the cities overseas, where one woman came before me who circumcised her first son and he died, and she circumcised her second son and he died, and out of concern that circumcising her third son might cause him to die as well, she brought him before me. I saw that he was red, so I said to her: My daughter, wait for him until his blood is absorbed into him. She waited for him until his blood was absorbed into him and then circumcised him, and he survived. And they would call him Natan the Babylonian after my name.
Rabbi Natan further related: And on another occasion I went to the state of Cappadocia, and a woman came before me who circumcised her first son and he died, and she circumcised her second son and he died. Out of concern that circumcising her thirds on might cause him to die as well, she brought him before me. I saw that he was green. I looked at him and saw that he did not have the blood of circumcision in him, [i.e., he had a deficiency of blood such that no blood would emerge from the circumcision]. I said to her: My daughter, wait until his blood enters him. She waited for his blood to increase and then circumcised him, and he survived. And they would call his name Natan the Babylonian after my name.
Hemophilia A
We have had several occasions in the past to review cases similar of baby boys and the dangers of circumcision, most recently when we studied Chullin 4a and its relation to Hemophilia A. But this is the first time there is a discussion of skin color. Rabbi Natan describes a red looking baby boy and a green looking baby boy. Since in each case there were siblings who had died under similar conditions, it is reasonable to assume that these cases too were caused by hemophilia A. Rabbi Natan’s babies survived because they did not have two copies of the gene for hemophilia. Instead they carried only one copy of the gene which is the cause of this disease. It is a mutation in the F8 gene,which controls the manufacture of Factor VIII, a key component of the clotting cycle. You can see this in the diagram (showing a normal father and carrier mother.) Only half the boys will (on average) become hemophiliacs.
However, there are alternative suggestions, which do not ascribe these colors to hemophilia alone. Let’s start with…
The Red baby boy
In his classic work התלמוד וחכמת הרפואה -The Talmud and Medicine (Berlin 1928, p231-2), I.L Katzenelsohn claimed that the red baby disease is erythema neonatorum. His family also carried hemophilia (because his two brothers had bled to death after their circumcisions), but this third baby was also red. Erythema (toxicum) neonatorum is a common finding in newborns and is thought to be due to an immune reaction (though to what remains unknown). It is a benign condition, and needs no treatment. Rabbi Natan believes that a presumption of hemophilia can only be made once it has been seen three times. This had not yet happened (two previous brothers had died, not three) and so he ordered that the brit can go ahead once the redness cleared up. Luckily, the boy was only a carrier of hemophilia (he was heterozygous for the F8 gene), and so he survived the circumcision.
Others are not so sure what this redness indicated. “I have no idea to what the rabbis are referring to" wrote Dr. Abraham Abraham (that’s his real name, not a typo,) in his work on medical halacha נשמת אברהם, The Soul of Avraham (יורה דעה 263:3). He was a Professor of Medicine at Hebrew University and Hadassah Medical School, so if he is stumped I guess we all are. So now let’s turn to…
The Green Baby Boy
This one is really hard to figure out, because there isn’t agreement on precisely what is meant by the description that the baby is ירוק, green. Rashi describes it as “the color of grass” which is - at least in the summer - a nice green color. Tosafot, being Toasafot, disagrees, and suggests that it is a sky blue color. And even more colors appear in later halachic works.
Katzenelsohn believed the “green” color is more of a yellow one, which is common in neonatal jaundice. (“Where is the best place to detect neonatal jaundice?” I was asked as a medical student. “Um, the sclera?” I offered in reply. “Nope said the doctor, happily pimping me, “in the parking lot, - where the sun provides the best illumination.” But I digress). Neonatal jaundice is an almost universal finding in newborns, and results from a breakdown of the fetal hemoglobin that is no-longer needed now that the baby is ex-utero. Julius Preuss (Biblical-Talmudic Medicine, Jason Aronson 1978 p167) believes the green color does not mean green, but instead it means pale. In this reading the baby was anemic, meaning that it lacked hemoglobin.
And what would the green-is-really blue suggestion of Tosafot indicate? Well, blue skin is called cyanosis, and results from too-little oxygen reaching the tissues. The feet and toes of newborns are often blue for a couple of days, as they develop their own oxygen carrying capacity (having spent nine happy months relying on mom’s). Some of the things that cause peripheral cyanosis include the cold (that’s when your arteries no-longer want to shunt warm blood to your freezing fingers), heart failure (the heart is too tired to pump oxygenated blood to the peripheries) or chronic lung disease (the lungs just can’t get enough oxygen through them and into the bloodstream). Central cyanosis is usually much more serious. It can be caused by infections like pneumonia (and did I mention that it was a defining feature of impending death during the Great Influenza Pandemic of 1918?) In the context of a newborn, it may indicate congenital heart disease. Some forms of congenital heart disease are fatal, but today there are a number of operations (or sometimes several) that can save the neonate’s life.
The Overarching Principle of Brit Milah
Whatever the color of the little baby boy or the number of brothers who may have died as a result of circumcision, Jewish law has evolved from these descriptions in the Talmud to a position that is clear and absolute.
שולחן ערוך יורה דעה רס’ג, א
באלו הדברים שאין מלין ולד שיש בו חשש חולי דסכנת נפשות דוחה את הכל שאפשר לו למול לאחר זמן ואי אפשר להחזיר נפש אחת מישראל לעולם
In all of these conditions in which we do not circumcise the baby because of the risk of a fatal outcome, the circumcision is postponed to a later date [when the child is now healthy]. For it is possible to postpone the day of circumcision, but it is impossible ever to replace the soul of a Jewish baby.
