In today’s page of Talmud comes this ruling:
יומא ל, א
דְּאָמַר רַבִּי אַמֵּי: אָסוּר לְאָדָם שֶׁיֵּצֵא בְּנִיצוֹצוֹת שֶׁעַל גַּבֵּי רַגְלָיו, מִפְּנֵי שֶׁנִּרְאֶה כִּכְרוּת שפְכָה, וּמוֹצִיא לַעַז עַל בָּנָיו שֶׁהֵן מַמְזֵרִים
Rabbi Ami said: It is prohibited for a man to go out with the drops of urine that are on his legs, because he appears as one whose penis has been crushed. [A man with that condition is incapable of fathering children. People who see urine on his legs might suspect that he is suffering from that condition] and spread rumors about his children that they are mamzerim [which is a person born of a forbidden relationship. Therefore, one must be certain to brush the drops of urine from his legs].
Rabbi Ami’s teaching goes like this. If a man has drops of urine on his legs, people might think that this happened because he has a penile malformation. And if that’s the case, he couldn’t have fathered any children, because of his malformation. And if he does happen to have children, rumors will spread that they could not have been sired by the man in question. And then they might be declared mamzerim.
There is in fact a Torah prohibition forbidding a man with a penile malformation to marry (Deut 23:2):
לֹֽא־יָבֹ֧א פְצֽוּעַ־דַּכָּ֛א וּכְר֥וּת שָׁפְכָ֖ה בִּקְהַ֥ל יְהוָֽה׃
No one whose testes are crushed or whose member is cut off shall be admitted into the congregation of the Lord.
The precise meaning of these categories are not certain. But the Tosefta (a group of teachings that sort of supplement the those found in the Mishnah) adds some details:
תוספתא יבמות 10:4
איזהו כרות שפכה כל שנכרת הגיד מן העטרה ולפנים אם נשתייר מן עטרה לפנים אפי' כחוט השערה סמוך לראש ומקיף את כולה כשר ניקב מלמטה פסול מפני שהוא שופך נסתם כשר מפני שהוא מוליד וזהו פסול שחוזר להכשירו מעוך וכתות נתוק וכרות כולם בביצים דברי ר' יהודה ר"א בן יעקב אומר כולם בגיד ר' יוסי אומר מעוך וכתות בביצים נתוק וכרות בגיד
Who is considered a man “whose member is crushed (כרות שפכה)”? …a man whose hole [i.e. his urethra] is at the base of the penis is forbidden [to marry] for he is a man who spills his seed [- that is, he is incapable of fertilization].
Hypospadiasis in Greek Literature
The disorder that is described in today’s page of Talmud is a called hypospadiasis. This is a congenital (meaning birth) defect, and occurs when the penis does not form properly in utero. As a result the urethera, which is the thin tube that carries urine out of the bladder and into the toilet bowl, does not end at the tip of the penis, but rather at some other place, usually in the midline of the shaft.
It was first described by Aristotle in the 4th century BCE. He noted that boys with this disorder would sit when they urinated, rather than stand.
There have been instances of boys in whom the termination of the penis has not coincided with the passage through which the residue from the bladder passes out, so that the passage came too low; and on this account they sit in order to pass water, and when the testes are drawn up they seem from a distance to have both male and female generative organs.
Of course this would avoid the very problem that is dealt with in today’s page of Talmud, namely, how to keep spots of urine off of one’s legs. (It would seem that the sages of the Talmud didn’t think this one through…)
The term hypospadiasis comes from the Greek physician Galen, who lived some 500 years after Aristotle. Hypo means under and spadon means a fissure. Other ancient physicians also mention the malformation, like Heliodorus (1st century CE), Antyllos (2nd century CE) and the Byzantine physician Oribasius (c.320-400 CE.)
Talmudic and Modern Medical classifications of Hypospadiasis
The Talmud in Yevamot details some of the different types of hypospodiasis:
יבמות עו, א
אמר רב יהודה אמר שמואל ניקב ונסתם כל שאילו נקרי ונקרע פסול ואי לאו כשר הוי בה
רבא היכא אילימא למטה מעטרה אפי' נכרת נמי אלא בעטרה עצמה איתמר נמי אמר רב מרי בר מר אמר מר עוקבא אמר שמואל ניקב בעטרה עצמה ונסתם כל שאילו נקרי ונקרע פסול ואי לאו כשר
Rav Yehuda said that Shmuel said: If a man’s member had been punctured and it later healed and the hole closed up with flesh, in any case where, if he would emit semen, it would tear open again, he is unfit to enter into the congregation; but if not, he is fit.
Rava discussed this ruling and raised a question: Where is this perforation? If we say it is below the corona, at the end of the man’s member, why should this perforation render him unfit? Even if the member was entirely severed, he would also be fit. Rather, the hole is in the corona itself, that is, at the point where the corona meets the rest of the member. It was also stated explicitly that this is the case, as Rav Mari bar Mar said that Mar Ukva said that Shmuel said: If a man’s member had been punctured in the corona itself, and it later healed and the hole closed up with flesh, in any case where if he would emit semen it would tear open again, he is unfit; but if not, he is fit.
This discussion seems to be focussed on injuries to the penis, rather than congenital malformations like hypospodiasis, but it demonstrates that the rabbis took the classification of penile injuries and malformations very seriously. Rav Huna, for example, states that המטיל מים משתי מקומות פסול -”a man who urinates from two openings” cannot marry a Jew. This is a good description of a urethral fistula, in which there is an additional tract in the urethra that ends somewhere other than at the tip of the penis.
So much for the Talmud’s classification. Today, the disorder is classified by where the tip of the urethra (called the urethral meatus) is located, and as you can see in the diagram below, the meatus can be close to the tip of the penis, where it should be, or quite far from it. This classification is not the end of the story however, because there may be other things that make life difficult, like curvature of the penis.
The meatal locations in varying degrees of hypospadias. The potential meatal locations of hypospadias in varying presentations, ranging from glanular hypospadias to perineal hypospadias. From Chen Y et al. The current state of tissue engineering in the management of hypospadias. Nature Reviews Urology. February 2020
hypospadias in ancient Greek art
There is one (and so far only one) example of a representation of hypospadias in ancient Greek art. As Konstantinos Laios of the History of Medicine Department at the Medical School of the University of Athens in Greece pointed out in his article on the subject, it is known as the “phallus-vulva” vase, and dates back to around 610 BCE. It was discovered at Naucratis in Egypt in an unspecified sanctuary, but one probably belonging to Aphrodite. As you can just about see in the rather poor quality image from the paper, there is a hole at the base of the penis that “led archeologists to conclude that …[it] was the representation of a vulva, which was reinforced by the small-dot decoration around it. Therefore, it was believed that this decoration depicted male and female genitals seeking fertility. Moreover, in a cult or sexual context, it was associated with the god Dionysus and goddess Aphrodite.”
The so-called “phallus-vulva” vase. Part of the archaic Greek pottery of Chios. From Konstantinos Laios, Marianna Karamanou, George Androutsos. A unique representation of hypospadias in ancient Greek art. Can Urol Assoc J 2012;6(1):e1-2.
But Dr. Laios thinks there is more to this vase:
From our point of view, this phallus has the typical characteristics of a third degree penoscrotal hypospadias. The absence of the chordee is not problematic and the place of the meatus denotes an erected form to unveil the hole. This is a unique case, as other examples of hypospadias representation in ancient Greek art are not known.
Repair of Hypospodiasis - Then and Now
The Talmud in Yevamot actually records a kind of plastic surgery operation that was described by the famous Babylonia sage Abaye:
יבמות עו, א
שלח ליה רב אידי בר אבין לאביי היכי עבדינן מייתינן שערתא ומסרטינן ליה ומייתינן תרבא ושייפינן ומייתינן שומשנא גמלא ומנכתינן ליה ופסקינן ליה לרישיה ודוקא שערתא אבל פרזלא מזרף זריף וה"מ קטן אבל גדול מיקפולי מיקפל
Rav Idi bar Avin sent the following question to Abaye: What should we do to expedite the healing of such a perforation? Abaye answered: We bring a sharp-edged grain of barley and lacerate the area around the hole with it. We then bring fat and rub it on the spot, and afterward we bring a large ant [shumshena] and let it bite inside the hole. [This leads to bleeding and the formation of a scab, which eventually heals as new flesh grows there.] We also cut off the ant’s head so that it should remain in place until the wound is fully healed. And this procedure must be done specifically with a grain of barley, but an iron tool would cause inflammation [zareif ]. And this applies only to a small perforation, but a large one will eventually peel off and reopen.
(And that ant thing? It’s real, though given the location of the wound, I would think twice.) Compare the surgery recommended in the talmudic era with this description of what is around the corner:
Urethral tissue engineering has been studied for many years with increasingly promising results. However, for repair of hypospadias specifically, creation of a long, tubular construct with the ability to facilitate robust angiogenesis and fast regeneration is required. New technologies could improve generation of this type of construct. Amongst the various advances are the use of nanotechnology and 3D bioprinting. Nanotechnology enables researchers to directly influence the cellular microenvironment and influence processes such as vascularization and wound healing. In particular, nanofibres composed of synthetic or natural polymers are effective in altering the microenvironment as modules of drug delivery or sensors for cellular migration. Extracellular matrix mimicking nanofibres have been used to evaluate the spatial and temporal processes of cell emergence onto damaged or organized matrices, which can potentially be used to characterize the process of wound healing in hypospadias repair and identify risk factors for fistula formation. They are also effective in local drug delivery…
3D bioprinting also has applications in tissue engineering. The use of the now commercially available 3D bioprinter might enable urethral constructs to be printed with specifications tailored to each patient’s needs. Furthermore, the precision and accuracy of the printer might help make cell seeding more uniform than conventional methods.
It is a technology that is still in its infancy, but is already being used to save lives and help restore human dignity. It would take a while to explain it all to Abaye, but once he grasped the idea, he would, no doubt, be very willing to swap his barley and biting ants for a nice new shiny 3-D printer.
Future applications of 3D bioprinting and nanotechnology in hypospadias repair. The use of 3D bioprinting and nanoparticles along with cellularization to create urethral constructs for hypospadias repair. Autologous stem cells can be collected, cultured and incorporated into 3D bioprinted urethral constructs tailored to the patient’s needs and supplemented with nanoparticles for use in repair. From Chen Y et al. The current state of tissue engineering in the management of hypospadias. Nature Reviews Urology. February 2020.
