Bava Basra 24a ~ Anatomy That Isn't There

In August 2013 a paper published in the otherwise sleepy Journal of Anatomy caused quite a sensation. Although doctors have been dissecting the human body for centuries, it seems that they missed a bit, and a team from Belgium announced that they had discovered a new knee ligament, which they called the anterolateral ligament. Today's page of Talmud describes the opposite phenomena. In it, the rabbis describe an anatomical part that is really hard to identify, and may not exist at all.  It is called the aliyah, which usually refers to an attic or the upper chamber of a house.

Majority or Proximity?

It all begins with a discussion of how to resolve uncertainty about the status of a found object. Do we assume the object comes from a class of similar objects that is in the majority, or do we assume that it is in the class of similar objects that is found in proximity?  According to Rabbi Hanina we are to follow the class of objects in the majority

 אמר רבי חנינא רוב וקרוב הולכין אחר הרוב ואע"ג דרובא דאורייתא וקורבא דאורייתא אפילו הכי רובא עדיף

This ruling of Rabbi Hanina is then supported by Abaye:

אמר אביי אף אנן נמי תנינא דם שנמצא בפרוזדור ספיקו טמא שחזקתו מן המקור ואע"ג דאיכא עלייה דמקרבא

Abaye said: We have learned this in a Mishnah (Nidda 17b) [that one follows the majority rather than proximity]: With regard to blood that is found in the vagina [prozdor], it is ritually impure as menstrual blood, as there is a presumption that it came from the uterus, [which is the most common source of menstrual blood]. And this is the halakha even though there is an upper chamber [עלייה], which empties into the canal, which is closer.

The Mishnah cited by Abaye is found in Niddah (17b), and it is there that the Talmud's gynecological anatomy is described. Here is that Mishanh: 

משנה נדה ב, ה

 משל משלו חכמים באשה החדר והפרוזדור והעלייה דם החדר טמא דם העלייה טהור נמצא בפרוזדור ספקו טמא לפי שחזקתו מן המקור 

The Sages analogized the anatomy of women through a parable: a chamber [חדר], a corridor [פרוזדור], and an upper chamber [עלייה]. The blood of the chamber is impure. Blood from the aliyah is pure. If [blood is] found in the corridor, [and we are unsure of its origin] out of doubt it is impure, because it is presumed to have come from the source [i.e. from the chamber, which is the most common source of bleeding].

The חדר, the chamber, is uniformly identified with the uterus, the medical term for the womb.  Of this there is no controversy. The פרוזדור, the corridor, is identified as the vagina, though according to Maimonides it includes the cervix, which is the neck of the uterus. So what, and where, is this aliyah ? This is the question we will focus on for the rest of this post. 

the Aliyah surrounds the ovaries

From the Mishanh in Niddah, it is clear that the aliyah sometimes bleeds, and that this blood becomes visible when it passes into the vagina. Maimonides identifies the aliyah with the space that contains the ovaries and the fallopian tubes. In modern medicine the ovaries and the Fallopian tubes and tissues that support them are called the adenxa. They are further from the vagina that the uterus, and so this identification does not fit in with Abaye's anatomy in which the aliyah is closer to the vagina than is the uterus.

רמב׳ם הל׳ איסורי ביאה ה, ד

ולמעלה מן החדר ומן הפרוזדוד, בין חדר לפרוזדוד, והוא המקום שיש בו שתי ביצים של אישה, והשבילים שבהן מתבשלת שכבת זרע שלה--מקום זה הוא הנקרא עלייה.  וכמו נקב פתוח מן העלייה לגג הפרוזדוד, ונקב זה קוראין אותו לול; והאבר נכנס לפנים מן הלול, בשעת גמר ביאה

Above the uterus and the vagina, between the uterus and the vagina, is the place in which the two ovaries are found, and the tubes along which the sperm from intercourse matures, this place is called the aliyah. (Maimonides, Mishneh Torah Issurie Bi'ah 5:4)

As we said, the problem is that the space which contains the ovaries is inside the abdomen, and this space does not connect with the vagina. It connects via the Fallopian tubes with the uterus.  Although Maimonides does not identify the aliyah as the ovaries themselves, some have done so. But the problem with this is that the ovaries don't bleed unless they develop a large cyst which then ruptures. But even in this case they bleed into the abdomen, or into the uterus, again via the Fallopian tubes, and not directly into the vagina.

Menachem ben Shalom (1249-1306) known as the Meiri, wrote an important commentary on the Talmud call Bet Habechirah - בית הבחירה and in it he too identifies the aliyah as the space between the uterus and the vagina in which the ovaries are found. He notes that in this space there are many blood vessels which may rupture and bleed directly into the vagina (עורקים שמתבקעים לפעמים), but as we have noted this is not biologically correct. Any bleeding from the adnexa is via the Fallopian tubes into the uterus itself, and certainly not directly into the vagina.

The Aliyah is the vagina

In his classic Biblisch-Talmudische Medezin published in 1911Jacob Preuss identified the aliyah as the vagina. "It can be assumed with reasonable certainty" he wrote "that the cheder refers to the uterus, that the prosdor is the vulva, and that the aliyah is the vagina." However certain he may have been, Preuss is the only one to make this identification, which does not fit in with the text of the Mishanh. So let's try another suggestion.

The Aliyah is the Bladder

Sefer Ha'Arukh, Venice 1552.

Sefer Ha'Arukh, Venice 1552.

Natan ben Yechiel of Rome, who died in 1106, wrote an influential lexicon of talmudic terms called the Sefer Ha'Arukh (ספר הערוך) which was first published around 1470. In that work the aliyah is identified as the urinary bladder. This identification also cannot be correct, because the bladder does not empty into the vagina, and because it does not lie between the uterus and the vagina but anterior to them. The commentary in the Schottenstein Talmud to Niddah 17b notes that a connection between the urethra and the vagina (known as a urethero-vaginal fistula) might account for bleeding from the bladder into the vagina. This is possible - though it is of course not normal anatomy.  

From here.

From here.

The AliyaH is a completely new structure

Meir ben Gedaliah of Lublin (d.1616) also considered the location of the aliyah in his modestly titled book Meir Einei Hakhamim - מאיר עיני חכמים - (Enlightening the Eyes of the Sages) first published in Venice in 1618.  He locates it between the uterus and the bladder, and provides two helpful schematics. The problem is that there is no such organ. You won't find it if you dissect a cadaver, and you won't find it in any textbook of anatomy (like this one). And as one astute radiologist and reader of Talmudology recently told me, you won't find it on an MRI either. Here is the text. 

Maharam Lublin. Meir Einei Hakhamim. Venice 1618. p255b. 

Maharam Lublin. Meir Einei Hakhamim. Venice 1618. p255b. 

This non-existent anatomy is also pictured in the Schottenstein Talmud (Niddah 17b), based on the difficult Mishanah.  

From Schottenstein Talmud Niddah 17b.  Note that this does NOT correspond to the known female anatomy, but is a schematic based on Rashi's understanding.  

From Schottenstein Talmud Niddah 17b.  Note that this does NOT correspond to the known female anatomy, but is a schematic based on Rashi's understanding.  

The Hatam Sofer on the Aliyah

Moses Schreiber known as Hatam Sofer, (d. 1839) was a leader of Hungarian Jewry and he too weighed in on the issue in his talmudic commentary to Niddah (18a).

What is the "corridor" or the "room"  or the "roof" or the "ground" or the "aliyah" ? After some investigation using books and authors experts and books about autopsies it is impossible to deny the facts that do not accord with the statements of Rashi or Tosafot or the diagrams of the Maharam of Lublin...but you will find the correct diagram in the book called Ma'asei Tuviah and in book Shvilei Emunah...therefore I have made no effort to explain the words of Rashi or Tosafot for they are incompatible with the facts...

Tuviah HaCohen, the Doctor from Padua

I couldn't find the diagram in any edition of the Shvilei Emunah to which the Hatam Sofer refers, so let's look at the diagram from Ma'asei Tuviah, which I happen to have in my own library.

Detail from Tuviah HaCohen,  Ma'aseh Tuviah, Venice 1708. p132b.

Detail from Tuviah HaCohen,  Ma'aseh Tuviah, Venice 1708. p132b.

A careful reading of the annotation (זז) reveals that Tuviah HaCohen (1652-1729) identifies the aliyah as that area containing the ovaries and the Fallopian tubes. In doing so he followed the opinion of Maimonides that we cited earlier, even though that does not in any way fit in with the understanding of Abaye and his ruling that blood found in the vagina that comes from the aliyah is not impure because it does not come from the uterus. Any gynecologist (or first year medical student completing their anatomy dissections) will tell you that blood from the adnexa (the ovaries and Fallopian tubes) can only get into the vagina via the uterus. But the most interesting part of this diagram is the very first line of text, at the top of the image. 

פירוש המחבר כפי ידיעת הנתוח  

The author's explanation according to knowledge gained from an autopsy

Anatomical Theatre, Palazzo del Bo, at the University of Padua. It was built in 1594 by the anatomist who helped found modern embryology, Girolamo Fabricius. From here.

Anatomical Theatre, Palazzo del Bo, at the University of Padua. It was built in 1594 by the anatomist who helped found modern embryology, Girolamo Fabricius. From here.

Here, perhaps for the first time, anatomical knowledge from an autopsy is being shared in Hebrew. At the medical school in Padua, two bodies (one of each sex) had to be dissected each year, and all the students attended- Tuviah included.  As a medical student, Tuviah would have stood in the famous anatomical theater and watched the dissection, perhaps following along in one of the textbooks based on those dissections. 

Facts Matter

As the Hatam Sofer noted, facts matter. The illustration in the work of the Maharam of Lublin was an example of trying to get the facts to fit the text of the Mishnah (or more precisely, the explanations of Rashi and Tosafot) but in doing so the Maharam created a fictitious anatomical part.

It is very unlikely that the rabbis of the Talmud witnessed human dissections. In the ancient world two Greeks, Herophilus of Chalcedon and  Erasistratus of Ceos (who lived in the first half of the third century BCE) were "the first and last ancient scientists to perform dissections of human cadavers." Facts about human anatomy became clear once human dissection began in the fourteenth century, but as is demonstrated by the Maharam of Lublin, these lessons did not always diffuse into the Jewish community.  The Hatam Sofer is often - and rightly  - cited as a force for tradition against the challenges from the outside world. But the Hatam Sofer, at least in so far as gynecology was concerned, had no time for a theory when the facts show otherwise. In an age of "alternative facts" the Hatam Sofer is a model of rationalism.

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