משנה כריתות טז ,א–ב
וְעוֹד שְׁאָלָן רַבִּי עֲקִיבָא. אֵבָר הַמְדֻלְדָּל בִּבְהֵמָה, מַהוּ. אָמְרוּ לוֹ, לֹא שָׁמַעְנוּ. אֲבָל שָׁמַעְנוּ בְּאֵבָר הַמְדֻלְדָּל בְּאָדָם, שֶׁהוּא טָהוֹר. שֶׁכָּךְ הָיוּ מֻכֵּי שְׁחִין שֶׁבִּירוּשָׁלַיִם עוֹשִׂין, הוֹלֵךְ לוֹ עֶרֶב פֶּסַח אֵצֶל הָרוֹפֵא וְחוֹתְכוֹ עַד שֶׁהוּא מַנִּיחַ בּוֹ כִשְׂעֹרָה, וְתוֹחֲבוֹ בְסִירָה, וְהוּא נִמְשָׁךְ מִמֶּנּוּ, וְהַלָּה עוֹשֶׂה פִסְחוֹ, וְהָרוֹפֵא עוֹשֶׂה פִסְחוֹ. וְרוֹאִין אָנוּ שֶׁהַדְּבָרִים קַל וָחֹמֶר
Rabbi Akiva further asked: What is the status of a dangling limb of an animal [Does it impart ritual impurity like a severed limb]? They said to Rabbi Akiva: We have not heard a ruling from our teachers in that specific case, but we have heard with regard to a dangling limb of a person that it is ritually pure.
And this is what the people in Jerusalem would do, who were afflicted with boils and whose limbs were dangling due to their affliction: on the eve of Passover, each of them would go to the doctor, who would cut the affected limb almost completely off, but he would leave it connected by a hairbreadth of flesh, so that neither the doctor nor the afflicted would be rendered ritually impure by a severed limb. Then, the doctor would impale the limb on a thorn attached to the floor or the wall, and the afflicted would pull away from the thorn, thereby completely severing the limb.
That’s quite a graphic description; I do hope it didn’t spoil your breakfast. On today’s page of Talmud we digress to resolve the important question of the ability of a partially severed animal limb to transmit ritual impurity. A completely severed limb certainly transmits impurity, but what if the limb remains partially attached? Rabbi Akiva was hoping for an answer but his colleagues could only provide a ruling regarding a partially severed human limb. Good news, they replied: it doesn’t.
And what are we to make of the historical tidbit that the Mishnah provides? Here is Rashi’s explanation as to why those afflicted with “boils” would amputate their partially severed limbs before Passover:
וחותכו : לא משום טהרה שקודם לכן נמי טהור אלא שלא יהא מאוס ברגל באבר המדולדל
They would cut it off: Not because they needed to do so to become ritually pure, because before then, when the limb was still partially attached, they were also ritually pure. Rather, they amputated the limb so that they would not appear repulsive on the Festival.
A partially attached limb looks unsightly, so the unfortunate person would remove it in order not to put the pilgrims off of their food, (in this case a Passover sacrificial lamb). But because a completely severed human limb imparts ritual impurity, they were faced with a quandary. Once the limb is amputated, it renders both the amputee and the surgeon ritually impure, since both were in contact with it. But those who are impure may not eat the Passover sacrifice. So what to do? There was a workaround. The surgeon would amputate most, but no all of the limb, and the patient would impale the limb on a hook and pull himself away. The limb would be quickly removed and since the patient was not in contact with the severed arm or leg or whatever, (and neither was the surgeon), they could go on their merry way eating the Passover lamb in a state of ritual purity.
Gangrene and Falling Limbs
One possible cause of the “boils” described in the Mishnah is leprosy. This bacterial disease was rife (and still is found in parts of) the Middle East. It causes resorption of the bone and loss of toes, fingers and the nose. However, leprosy is usually identified with tzara’at - and the leper would have already been declared ritually impure and was thus ineligible to join and eat the Passover sacrifice. So the disease described in the Mishnah - שְׁחִין (shekhin) - is likely different from leprosy.
Perhaps it was gangrene. Gangrene is the death of tissue, caused by a loss of the blood flow, and we discussed it when we studied Avodah Zarah. Here’s a brief recap:
Gangrene is a very serious condition. (You can see all kinds of pictures of gangrene here.) It is mostly seen on the feet, but I've seen gangrene of the hands and fingers as well. When mountain climbers (and the homeless) loose fingers and toes, it's from gangrene. There are two kinds of gangrene. In wet gangrene, bacteria invade tissue which have little or no blood supply. They feed on the tissue and produce a great deal of pus; hence the description "wet". Left untreated, the patient will likely become septic and die. Amputation is often the only treatment option.
Dry gangrene has a slower onset, and the tissue looks mummified or cracked; hence the term "dry". It does not usually cause infection or death. After several days, it becomes obvious where the black dead tissue ends and the pink health tissue begins. At that time, the tissue can be amputated; commonly, it just falls off (like here, but don't look if you are eating). The case of the Mishnah could be one of dry gangrene, but the services of a surgeon are not always needed. The healthy flesh is clearly demarcated from the dead tissue, which just…falls off.
In an enticing paper published last year titled Hallmarks of Amputation Surgery, the authors point out that the earliest human remains with evidence of an amputation are dated approximately 4900 BCE. “The remains were a skeleton of a male who was lacking bones in the left forearm, wrist, and hand. Analysis of the possible site of amputation indicated a clear oblique section through the medial and lateral epicondyle consistent with the flint tools available at the time. The amputation was successful and he not only survived the amputation but lived for months or years afterward.” In ancient Egypt, amputations were performed as a retribution for a judicial punishment, and there are crimes and law offenses punished with amputation as early as the Babylonian era in the law code of Hammurabi. In addition the Egyptians performed medical amputations, but “they were feared more than death and thought to affect the amputee in the afterlife.”
Moving along several hundred centuries, Hippocrates (460-370 BCE) recommended amputation to stop gangrene but only as a last resort; he suggested the amputation be performed distal to the necrotic demarcation at the time, where the flesh was dead and had completely lost sensation. “In the first century Aulus Cornelius Celsus (25 BCE–50 CE) in his work De medica proposed an amputation for a gangrenous limb; he advised cutting between the living and diseased part, but not through a joint. He also proposed the ligation of vessels to control blood loss, the proximal division of bone in order to allow a “flap” of skin to cover the stump, and the packing of the wound with lint soaked in vinegar to prevent further infections.”
The French surgeon Ambroise Pare (1520-1590) is considered the father of modern surgery, and he advised amputations not only for infected or injured limbs, but for the removal of cancerous growths too. Here is how to get the job done, from an english translation (The Workes of that Famous Chirurgion Ambrose Parey) published in London in 1649:
The Religious Impulse on seeing tragedy
Today’s discussion reminds us of the desperate circumstances in which people found themselves before the advent of modern medicine. Without access to antibiotics, minor skin infections might develop into necrosis of the tissues and there would be a need to amputate an arm or a leg. But the rabbis never missed an opportunity to praise God, however awful or hopeless a situation. And so they instituted a blessing to be made “on seeing an amputee or one afflicted with boils:” “Blessed be He, the True Judge.” It’s a blessing we hope never to have to make.