Thursday, September 29, 2005

Daf Yomi Shabbat 147b: Resetting Dislocated Vertebrae

(Please note: The following discussion is not lemaaseh. As always, consult your local Orthodox Rabbi.)

Over at the Rif's blog, the Rif cited lehalacha a discussion in the gemara about resetting joints or vertebrae of an infant if they become dislocated.
Rabba bar bar Chana said {in our gemara, he cites Rabbi Yochanan}: To swaddle an infant on Shabbat is permitted. But we learnt {in the Mishna} ONE MAY NOT STRAIGHTEN AN INFANT['S LIMBS]? There it refers to the spinal vertebrae, which appears as building.
{If one is dislocated it may not be reset.}

Rav Chana of Bagdad cited Shmuel:

{Shabbat 148a}
The halacha is that one may reset a fracture.
{He held that this is the correct reading of the Mishnah.}

And so is the halacha.
Angel One left an interesting and insightful comment on the blogpost.
2 things bothered me about not being able to set an infant's vertebrae should one become dislocated. (Admittedly this is Rashi's interpretation of the passage).

1) When is a dislocated vertebrae in an infant NOT a life or death situation? Especially since you can't tell an infant: "don't move, the doctor will come in an hour".

2) Why only infants? Does this rule apply to adults too?

And I decided to prepare a response - one somewhat lengthy such that this is a more appropriate venue. Note this is a question regarding the gemara, not the Rif.

A) The Cop-Out
My immediate reaction to the question was a cop-out. That is, if you look carefully, Rabbi Yochanan did not make the joints/vertebrae distinction. The one troubled by the fact that there is a contradiction, and the attempt at harmonization, is presented by the anonymous narrative voice of the gemara, the stama degemara, which might be late, and which frequently attempts harmonization.

This harmonization reads into the Mishna words that are not technically there - the Mishna just says "straighten," and this would seem to be able to refer to resetting any dislocation, not just the vertebrae. Rabbi Yochanan's statement, about "swaddling," whose purpose seems to be resetting dislocations {"straightening"} of all types. Why assume the Mishna is speaking of a specific type of dislocation?

Indeed, one might easily say that Rabbi Yochanan intended to argue against the law as laid down in the Mishna. He is after all a first generation Palestinian Amora, and is privy to other traditions - just as bar Kappara and Rav Hoshaya Rabba record braytot with alternative positions, or versions of statements. This is actually not uncommon for Rabbi Yochanan. (One might also say "Tanna hu u-falig.") Then, the Mishna claims one may not reset any dislocations on children, just as the Mishna says one may not reset any fractures (in general). Rabbi Yochanan argues and states that one may.

In fact, we see a similar dispute in the following portion of the gemara (cited above in anticipation). That is, the Mishna stated that one may not reset a broken bone, and Shmuel claims that the halacha is that one may in fact set a broken bone. The fact that Shmuel uses the word halacha implies that he knows it is a matter of dispute. Shmuel, the first generation Babylonian Amora, here had a different tradition - what might be termed a different version of the Mishna, or else a different tradition of the halacha but encoded outside the Mishna, perhaps in a brayta. In this instance, no harmonization is attempted to distinguish between different types of fractures.

One would add, then, that the problem in the Mishna is not one of boneh {from the words "looks like boneh," it would seem to be of Rabbinic decree} but rather one of refua on Shabbat, which is in many instances forbidden (and which seems to be the trend of the cases listed in the Mishna). (Cases involving danger to life are an exception.)

If so, the issue with dislocated vertebrae being an extremely dangerous condition finds no purchase. Or does it? For Rabbi Yochanan and for the original meaning in the Mishna (and perhaps one should also say lehalacha...), there is no problem. However, the stama degemara did offer an explanation - perhaps the correct one, and perhaps not. We should understand his position.

B) Why Dislocated Vertebrae Do Not Pose A Danger - Explaining the stama's position

In order to explain the thought process of the stama degemara, one needs very specific medical knowlege. This medical knowledge is not the one common today, but rather the one prevalent in Talmudic (or perhaps slightly post-Talmudic) times. This is difficult, because there is actually an ancient dispute about the nature and treatment of dislocated vertebrae, so how do you know you are looking at the correct ancient source which was adopted by the gemara?

What we know for certain is that the stama degemara must have thought that some spinal dislocation did not pose a danger to life. For if there were danger to life, there would be no issue of refua on Shabbat. Indeed, there would be no issue of boneh {building}, even Biblical in origin, for danger to life supercedes this. (And if it "appears" to be building, then any prohibition would perhaps be Rabbinic, in which case it would surely be superceded by danger to life.)

Let us turn to Latin encyclopedist, Celsus, Aulus Cornelius, from about 14 CE. His only extant work, De Medicina (On Medicine), is an 8 book treatise on medicine. In his eighth book, he writes:
13 As I stated in the first part, the head is held by two processes, inserted into two cups in the highest vertebra. These processes sometimes slip out backwards; with the result that the sinews under the occiput are stretched, and the chin fixed to the chest; the man cannot drink or speak, and sometimes has involuntary emission of semen; upon these symptoms death very quickly supervenes. Now I thought this condition should be described, not that there is any treatment for it, but that it may be recognized by these indications, and that those who have lost someone in this way may not deem the medical man to have been at fault.

14 The same fate awaits those whose spinal vertebrae have been dislocated; for this cannot happen without rupture of the marrow in the middle of them, and of the two little membranes which pass oust between the two processes at the side, and of the sinews which hold them together. But the vertebrae may slip pout both backwards and forwards, above the diaphragm or below it.

The direction of the displacement is indicated either by a swelling or by a hollow at the back. If it happens above the diaphragm, there is paralysis of the arms, and vomiting or spasm follow, breathing is difficult, pain is severe, and hearing blunted. If below the diaphragm, the lower limbs are paralysed, the urine is suppressed, or sometimes is passed involuntarily. From such accidents the man dies more slowly than when the head is displaced, yet within three days.

As for what Hippocrates said, that when a vertebra has been displaced backwards, the man is to be laid out on his face, and stretched out, while an assistant presses his heel upon the displaced bone and pushes it inwards, that procedure is only to be adopted when the bone has slipped out a little, not if there is a total displacement. For occasionally weakness of the sinews causes a vertebra, although not displaced, to project a little, either backwards or forwards. This is not a fatal accident, but we cannot press upon a vertebra from within; it cannot even be touched; and if it is pressed upon from outside, it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.
So Celsus surely felt that most instances of dislocated vertebrae were extremely dangerous. Perhaps one might say that since he dies more slowly, there is more time to fix it, and so one can wait a few hours until after Shabbat.

Or better, perhaps the case the gemara speaks of is the latter case. To cite Celsus again:
For occasionally weakness of the sinews causes a vertebra, although not displaced, to project a little, either backwards or forwards. This is not a fatal accident, but we cannot press upon a vertebra from within; it cannot even be touched; and if it is pressed upon from outside, it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.
Here is an instance of non-fatal dislocation of vertebrae. It is not only non-fatal, but (if I understand him correctly) Celsus seems to recommend against treating it at all, for it is pointless - or at least that one will need to repeatedly put it back in place.

Since this type of spinal dislocation was known, it would seem that this is the case offered by the gemara to harmonize Rabbi Yochanan and the Mishna.

C) Why specifically an infant?
This solved the difficulty of how the gemara could recommend delaying resetting dislocated vertebrae on Shabbat. But why specifically a child or an infant? Does the same apply to an adult?

In terms of dangerous spinal dislocations, certainly both a child and adult can be treated, the appearance of boneh be darned! In terms of setting fractures of bones (the next segment in the gemara), neither the Mishna nor Shmuel mentioned children specifically, and anyway, we rule like Shmuel that it is permitted.

What is left? The issue of whether one may reset dislocated bones in general, or this non-fatal spinal dislocation. Both of these are stated in terms of children or infants. Why?

Back to Celsus. From the same book, chapter 11:
Since all joints, including the jawbone and vertebrae, are held in place by strong sinews, they are displaced either by force or after some accident which has ruptured or weakened the sinews, and this occurs more readily in boys and youths, than in the more robust. And these joints slip out forwards, backwards, inwards, outwards, some in all directions, some in certain only. And there are some signs which are common to all, some special to each; there is always a swelling in the part into which the bone has ruptured, and a hollow whence the bone has receded.
These signs are found in all, but others only in some cases; these I will describe when speaking of each separately. But while it is possible for all joints to slip out, yet not all can be replaced. For the head is never forced back into position, nor is a spinal vertebra, nor a jawbone which has been dislocated forwards on both sides, and has become inflamed before it has been replaced. Again, any joints which have slipped owing to a lesion of their sinews, even when forced back into position slip out again. Also when joints have been dislocated in childhood, and have not been replaced, there is less growth than elsewhere.
The flesh of all which are out of place wastes, and in the near more than in the distant part of the limb; for instance, if the upper arm-bone is not in its place, the wasting is more here than in the forearm, more in the forearm than in the hand.
Again, according to the site and character of the accidents, more or less use of the limb is retained; and the more use is retained, the less does it waste. Now every dislocation ought to be replaced before there is inflammation; but if this has set in already, the limb is not to be disturbed until after it subsides; only when it has ended should replacement be attempted in the limbs which allow of it. But for this much depends upon the general constitution of the patient and his sinews. For if his body is slender, and humid, if sinews are weak, the bone is readily replaced; but just as the bones slips out more easily in the first instance, so the replacement is less secure. With an opposite type of constitution the replacement is more lasting but there is more difficulty in restoring that which has been put out of position. The inflammation should be relieved by applying greasy wool saturated with vinegar: there should be abstinence from food, in the case of the stronger joints, for three days, some he said for five; warm water is drunk, enough to relieve thirst; this regimen must be followed more strictly after dislocation of bones which are held in place by strong and large muscles; far more strictly indeed if fever supervenes;
then after the fifth day there should be hot-water fomentation; when the wool is removed, a cerate must be applied made with cyprus oil with the addition of soda, until all inflammation has ended. Then the limb is to be rubbed, good food given and wine in moderation; and now also the natural use of the limb is to be encouraged; because though movement when it gives pain is harmful, it is otherwise most beneficial to the body. After these generalities, I will now speak of particular cases.
The Mishna, and Rabbi Yochanan, might be speaking of infants and children because it is the more common case (dibra torah behoveh), since bones and spinal vertebrae are more easily dislocated, because of weakness of the sinews.

Further, Celsus said that if pressure is exerted from without, "it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed." As a child ages, and his constitution improves, the strength of the sinews increases, and the dislocation is less likely to recur.

Another reason it is important to reset dislocations in children is, as Celsus said, "Also when joints have been dislocated in childhood, and have not been replaced, there is less growth than elsewhere." Thus, perhaps one might argue that here is a reason to reset the dislocation as soon as possible, even on Shabbat - a reason not applicable to a non-fatal dislocation in an adult. So perhaps it would not apply to adults.

I have not conducted a search in Rishonim/Acharonim on whether resetting non-spinal dislocations only applies to infants (that is more a Hirhurim thing to do). Again, consult your local Orthodox Rabbi as regards any practical application of the gemara.

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