During a discussion about the permissibility of healing on Shabbat, we read the following:
שבת קלד,א
אָמַר אַבָּיֵי, אֲמַרָה לִי אֵם: הַאי יָנוֹקָא דְּלָא יְדִיעַ מַפַּקְתֵּיהּ, לְשַׁיְיפֵיהּ מִישְׁחָא וְלוֹקְמֵיהּ לַהֲדֵי יוֹמָא, וְהֵיכָא דְּזִיג — לִיקְרְעֵיהּ בִּשְׂעָרְתָּא שְׁתִי וָעֵרֶב. אֲבָל בִּכְלִי מַתָּכוֹת — לָא, מִשּׁוּם דְּזָרֵיף
Abaye said: my nurse told me: In the case of a baby whose anus cannot be seen, [as it is obscured by skin,] let one rub it with oil and stand it before the light of the day. And where it appears transparent, let one tear it with a barley grain widthwise and lengthwise. However, one may not tear it with a metal implement because it causes infection and swelling.
This is a fascinating piece of Talmud for a number of reasons. First, the medical knowledge Abaye shared comes from the nurse who raised him (for he was an orphan). Since women were the ones who helped in childbirth, it was they who were most experienced in identifying neonatal disorder.
Second, the problem that is described is a congenital defect, one that is the result of a malformation during the development of the growing fetus. We have encountered these before; it would seem that the Cohanim had a high rate of polydactyly, or extra digits on their hands.
Third, the intervention is one of the earliest descriptions of neonatal surgery of any sort (perhaps with the exception of circumcision). Fourth, it describes in detail the surgical steps to be taken to fix the problem. Fifth, it demonstrates that the operation had evolved over time, and that earlier techniques using metal probes were associated with poor outcomes. The women had used their observation and experience to perfect the procedure.
Finally, the fact that there was a procedure for this congenital problem at all, and that it had been perfected through trial and error, means that what is today called an imperforate anus must have been fairly prevalent, and not something seen only once in a lifetime.
The spectrum of anorectal malformations
From here.
The abnormality described in this page of Talmud is one of several anorectal malformations which occur in about one in 4,000 births. Some, like the mild case described by Abaye, are mild. A small skin flap covers the opening of the anus and can be fixed with a simple incision, in this instance with a barley seed. Others are far more serious and are associated with other malformations in the urogenital system and lower spine. Because of their different genital anatomy, boys and girls have different associated complications. For example, boys may have a connection to the prostate gland, while girls may have malformation in which rectum, vagina, and urethra are fused together into a single common channel that opens into a single orifice. These may be corrected with surgery, some of it simple, much of it complicated. Other congenital defects associated with this condition are gastrointestinal, and about 30% of these neonates have additional cardiac defects. In short, there is a wide spectrum of problems that may be associated with a neonate born with an imperforate anus.
The technique described by Abaye’s nurse would only be of benefit in the very mildest cases, in which a simple skin plug covers the opening. For the majority of babies born in Talmudic times with an anorectal disorder, the procedure sadly, would not have helped. They would have required complex surgery that has only been around in the last fifty years or so. Even today, about a third of the children who undergo surgical repair have associated fecal incontinence.
The skills of Abaye’s nurse
Abaye’s nurse was not only knowledgeable about the imperforate anus. In the same page of Talmud she offers other medical advice, all of it to do with the period immediately following childbirth. She gave advice as to the bandage to be used after circumcision, how to encourage a neonate to suckle, how to resuscitate a baby that has stopped breathing, and under what medical conditions a circumcision must be postponed. Childbirth and care of the neonate has long been the provenance of women, starting with the Hebrew midwives Shifrah and Pu’ah who lied to Pharaoh in order to save the male Jewish babies from certain death. The knowledge that midwives passed down to each other saved countless babies from the complications of childbirth or the rigors immediately following it. While some of their advice was certainly in error from our modern perspective (Abaye’s nurse recommended placing a baby in a sieve and shaking her in order to get her to urinate,) their knowledge and skills often worked. Otherwise we would not be here to tell about it.
