Arachin 4b ~ The Tumtum, the Androgyne, and the Fluidity of Gender

ערכין ד,ב

זכר - ולא טומטום ואנדרוגינוס

“A male” - and not a tumtum or androgyne.

In addition to male and female, the Talmud describes two other gender categories: tumtum and androgynous. The tumtum is a person whose genitalia are somehow hidden or covered, so that it is not known if they are male or female. In contrast, the genitalia of the androgyne (an ancient Greek word formed from ἀνδρός  andros - “man” and γυνή gune, - “woman”) are in plain sight. It just isn’t clear whether they are male or female organs. The two are mentioned on at least twenty-three pages of the Babylonian Talmud, and in no fewer than nine halachot in the Jerusalem Talmud, so let’s figure out what, from a medical perspective, they are.

The Tumtum

There is no ambiguity about the gender of a tumtum. We just need to get a glimpse of the genitals. (The eleventh century dictionary known as the Aruch connects the word tumtum with the word atum (אטום), meaning sealed.) The problem is that the genitals are covered by what is usually described as skin. Once this cover is surgically opened, the gender will be revealed. In fact according to Rav Ammi (Yevamot 64a), both Abraham and Sarah were each a tumtum. Yes, you read that correctly. Each had genitalia that were hidden. Rav Ammi suggests this as an explanation as to why the couple were infertile for so many years. Once the covering had been removed the couple could then procreate as normal, and along came Isaac.

אמר רבי אמי אברהם ושרה טומטמין היו שנאמר (ישעיהו נא, א) הביטו אל צור חוצבתם ואל מקבת בור נוקרתם וכתיב (ישעיהו נא, ב) הביטו אל אברהם אביכם ואל שרה תחוללכם

Rabbi Ami said: Abraham and Sarah were originally tumtumin, as it is stated: “Look to the rock from where you were hewn, and to the hole of the pit from where you were dug” (Isaiah 51:1), and it is written in the next verse: “Look to Abraham your father and to Sarah who bore you” (Isaiah 51:2),

רשי:

חוצבתם - נעשה לו זכרות: “Hewn”: He was made into a male

נוקרתם - נעשה לה נקבות : “From where you were dug” which made here a female

Urologists have yet to identify this syndrome.

Screen Shot 2019-06-17 at 2.31.21 PM.png

The Androgyne

In 1797 the physician James Parsons, published a book which he dedicated to the Royal Society of London, of which he was a Fellow: “ A Mechanical and Critical Inquiry into the Nature of Hermaphrodites.” Parsons noted that the Romans “had laws made against their Androgyni [which were] remarkably severe; for whensoever a child was reputed one of these, his sentence was to be shut up in a chest alive, and thrown into the sea…

Parsons was not only well-read in Roman law; he cited the fourth chapter of the Mishnah in Bikkurim, which contains a list of the ways in which the androgne sometimes resembles a man, and sometimes a woman:

ביכורים פרק ד

כֵּיצַד שָׁוֶה לַאֲנָשִׁים: מְטַמֵּא בְּלֹבֶן כַּאֲנָשִׁים, וְזוֹקֵק לְיִבּוּם כַּאֲנָשִׁים, וּמִתְעַטֵּף וּמִסְתַּפֵּר כַּאֲנָשִׁים, וְנוֹשֵׂא אֲבָל לֹא נִשָּׂא כַּאֲנָשִׁים, וְחַיָּב בְּכָל מִצְוֹת הָאֲמוּרוֹת בַּתּוֹרָה כַּאֲנָשִׁים:

In what ways is the andogyne like men?…He dresses like men; He can take a wife but not be taken as a wife, like men. [When he is born] his mother counts the blood of purification, like men; He may not be secluded with women, like men. He is not maintained with the daughters, like men…And he must perform all the commandments of the Torah, like men.

כֵּיצַד שָׁוֶה לַנָּשִׁים: מְטַמֵּא בְּאֹדֶם כַּנָּשִׁים, וְאֵינוֹ מִתְיַחֵד עִם הָאֲנָשִׁים כַּנָּשִׁים, וְאֵינוֹ עוֹבֵר עַל "בַּל תַּקִּיף" וְלֹא עַל "בַּל תַּשְׁחִית" וְלֹא עַל "בַּל תְּטַמֵּא לַמֵּתִים" כַּנָּשִׁים, וּפָסוּל מִן הָעֵדוּת כַּנָּשִׁים, וְאֵינוֹ נִבְעַל בַּעֲבֵירָה כַּנָּשִׁים, וְנִפְסַל מִן הַכְּהֻנָּה כַּנָּשִׁים:

And in what ways is he like women?… he must not be secluded with men, like women; And he doesn’t make his brother’s wife liable for yibbum (levirate marriage); And he does not share [in the inheritance] with the sons, like women; And he cannot eat most holy sacrifices, like women…. he is disqualified from being a witness, like women…

The Androgyne & Congenital Adrenal Hyperplasia

Ambiguous genitalia in neonates. From here.

Ambiguous genitalia in neonates. From here.

One of the most common causes of androgyny is congenital adrenal hyperplasia (CAH), caused by a mutation in the CYP21 gene. The adrenal glands, which sits atop the kidneys, are where the action takes place. They produce androgens, which are then converted into the potent sex hormone testosterone. In most (95%) cases of CAH, there is a deficiency of the enzyme 21-hydroxylase. As a result, the adrenal glands produce excessive amounts of the virilizing hormone androgen. (It also causes severe salt wasting, which can be very dangerous, but we are not getting into that now. And there are different severities of the syndrome, but you’ve got a limited attention span, so we will keep it simple.) This excessive androgen production does very little in (XY) males; their genitalia look normal. But in genetic (XX) baby girls the androgens affect the external genitalia and they may become ambiguous: the clitoris becomes enlarged, sometimes to the degree that it resembles a penis. In very severe cases the baby girl has what appears to be an empty scrotum, and may be raised as a boy, all the while being an XX girl with CAH.

Today all newborns are screened for 21-hydroxylase. The deficiency can be treated with hormone replacement, and the genital ambiguity may be corrected, although this latter intervention has, over the last decades, become very controversial.

Anecdotally, in the Western world most [intersex] babies were raised as female because the genitalia were easier to reconstruct... clinical experience suggests that cultural factors are very influential. This may be no bad thing as there is no ‘right’ medical answer and the child will have to grow up in the community into which it is born.
— Woodhouse, C.R.J. Intersex Surgery in the Adult. BJU International 2004. 93 (3): 57-65

The androgyne and the hermaphrodite

The Soncino Talmud identifies the androgyne as a hermaphrodite, that is, a person with both male and female genitalia. So does Goldschmidt’s German translation (“der zwitter”). Cases of true hermaphroditism are extremely rare, and there are only a few scattered case reports in the medical literature. (You can read one reported from Sheba Hospital in Tel Aviv here.) Rather than there being two sets, in these cases the genitalia are ambiguous, and although they have both ovarian and testicular tissue the scrotum does not always contain testes.

Alice Dreger, formerly a Professor of Medical Humanities and Bioethics at Northwestern University, (it’s complicated) wrote a terrific (and controversial) book that tackles some of the issues facing intersex people - those who were once called hermaphrodites. In the past, when faced these difficult cases of intersex or ambiguous genders, clinicians focused on what she calls a “gonadal division.” (Since biopsies and genetic sequencing were not available to the rabbis of the Talmud, they, like clinicians, focused on this gonadal division, for what else could they do?) But, she notes,

a system that emphasizes gonadal anatomy above all else suffers from two major deficits. First, it is scientifically questionable, because it relies on the anatomy of the gonads (functioning or not) more than any other considerations. Second, it provides little clinical help, often confusing and harming the patient, and sometimes also the physician.

Instead, she advocates for a description based on etiology and the patient’s needs. “Such an approach would have the salutary effects of improving patient and physician understanding and reducing the biases that are inherent in the use of the current language of 'hermaphroditism'.”

True hermaphrodites: defined as presenting at least one ovary and at least one testis, or at least one ovotestis...The scientific understanding of sexual development has progressed tremendously in the last 125 years, but the existing taxonomy does not reflect that progress. Scientists and clinicians now recognize that the structure of the gonads does not correlate simply with genotype, phenotype, physiology, diagnosis, or gender identity. The anatomy of testicular tissue in women with androgen insensitivity syndrome (AIS) is quite similar to the anatomy of testicular tissue in non- intersex males, yet their physiologies, phenotypes and gender identities differ markedly.
— Dreger, A, et al. Changing the Nomenclature/Taxonomy for Intersex. Journal of Pediatric Endocrinology & Metabolism 2005. 18, 729-733

The many Shades of Gender

We are used to think that when an egg carrying an X chromosome meets a sperm carrying an X or Y chromosome, one of two things will happen: a genetic female (46XX) or a genetic male (46XY) with genitalia to match. But in fact it is way more complicated than that. We know that there are at least 14 genes involved in the process of sexual differentiation, and many more will likely be discovered. A mutation or malfunction of any of these has a dramatic effect on the process of gender differentiation. For example if there is a defect in the enzymes involved in producing testosterone, there may be ambiguous external genitalia; deficiency of the enzyme 5α-reductase results in variable degrees of under-masculinized external genitalia and genital ambiguity; individuals with partial androgen insensitivity syndrome may also have ambiguous genitalia, and there is no consensus regarding an optimal sex of rearing them; and newborns with congenital adrenal hyperplasia, may have male appearing genitalia while all the time being 46XX.

We have previously noted the strange effects of yet gene discovered in the 1980s. This sex-determining gene on a tiny bit of the male Y chromosome is called the sry gene. That gene tells the body to develop into a male or female appearing body. Sometimes the sry gene sneaks off of the Y gene and makes its way into the DNA of an XX female. As a result, she will develop male anatomy while genetically remaining an XX female. (Please read that sentence again, just to be sure you have understood it.) And sometimes the sry gene on an XY genetic male can mutate and not work. In that case, the genetic male appears to have the organs of a female, which is what occurs in Swyer syndrome. (You can hear more about the amazing sex-changing effects of sry in this fascinating podcast.)

And then there is the small community in the Dominican Republic where there have been a number of cases in which little girls grow a penis and turn into little boys. These observations were first reported to the scientific community in 1974, and are caused by a deficiency of the steroid 5α-reductase. Here is how the BBC explained what is going on when they reported about it in 2015.

When you are conceived you normally have a pair of X chromosomes if you are to become a girl and a set of XY chromosomes if you are destined to be male. For the first weeks of life in womb you are neither…Then, around eight weeks after conception, the sex hormones kick in. If you're genetically male the Y chromosome instructs your gonads to become testicles and sends testosterone to a structure called the tubercle, where it is converted into a more potent hormone called dihydro-testosterone. This in turn transforms the tubercle into a penis. If you're female and you don't make dihydro-testosterone then your tubercle becomes a clitoris…the reason [some genetic males] don't have male genitalia when they are born is because they are deficient in an enzyme called 5-alpha-reductase, which normally converts testosterone into dihydro-testosterone.

So the boys, despite having an XY chromosome, appear female when they are born. At puberty, like other boys, they get a second surge of testosterone. This time the body does respond and they sprout muscles, testes and a penis.

So gender identity is very complicated. James Parsons, that physician who wrote the book on hermaphrodites in 1797 tackled some of the difficult questions that were addressed in Mishnah Bikkurim: can a hermaphrodite get married? (yes, but to which gender varies by case); can they be a witness? (only if the “predominating sex” is male); can they be ordained as a minister? (no); The rabbis were puzzled as to the “true” gender of the androgyne, and so classified them as sometimes male, and sometimes female. It was the best they could do at the time, and Parsons, writing 1,500 years later did the same. Thanks to modern medicine we have learned why these intersex cases occur, but as a society we have still a long way to go to help make their lives easier.

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Bechorot 55a ~ Where Does Your Blood Come From?

בכורות נה, א

אמר רב כהנא כרותא דדמא כבדא

Rav Kahana also states: The source of blood is the liver.

The liver has long been considered a very special organ (as indeed it is). The Babylonians used the organ for divination, as is mentioned in our own Book of Ezekiel (21:26):

כִּי־עָמַד מֶלֶךְ־בָּבֶל אֶל־אֵם הַדֶּרֶךְ בְּרֹאשׁ שְׁנֵי הַדְּרָכִים לִקְסָם־קָסֶם קִלְקַל בַּחִצִּים שָׁאַל בַּתְּרָפִים רָאָה בַּכָּבֵד׃

For the king of Babylon has stood at the fork of the road, where two roads branch off, to perform divination: He has shaken arrows, consulted teraphim, and inspected the liver.

The Greek physician Galen (129-c.207 CE) believed that the liver stored the four humors of the body, and, just like Rav Kahana, he claimed that it produced blood. But both were mistaken

Where your blood actually comes from

Diagram of liver.jpg

Blood is not made in the liver (unless you are a fetus) but in the bone marrow, which is the spongy middle bit of bones. And your bone marrow works really hard. Each day it makes 200,000,000,000 red blood cells, 150,000,000,000 platelet cells, and 20,000,000,000 lymphocytes. It all begins with an all powerful stem cell, which then can turn into (among other things) a red blood cell that carries oxygen and has life of only 120 days), a mast cell which is involved in inflammation and allergies, a neutrophil (also known as a “white blood cell”) which fights infections, or a macrophage, which is a microscopic vacuum cleaner and whose job get rid of all the cellular bits and pieces that don’t belong.

Hematopoiesis_simple.png


If one considers the annual cumulative cell production, one can calculate a total blood cell production rate of about...88 kg per year
— Fliedner T. M et al. Structure and Function of Bone Marrow Hemopoiesis: Mechanisms of Response to Ionizing Radiation Exposure. Cancer Biotherapy and Radiopharmaceuticals 2002; 17 (4) 405-426.

But in The Fetus, the Liver does make blood

In the growing embryo, blood is first made in the yolk sac, but at about 6 weeks gestation the fetal liver takes over. The liver happily churns out all the cells of the blood line, until, at about 5 months gestation, the bone marrow takes over. So neither Rav Kahana nor Galen were totally mistaken when he declared that the source of blood is the liver.

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Happy Yom Yerushalayim From Talmudology

The Nobel Prize, Jerusalem, and Being a Mensch

As we celebrate the liberation of Jerusalem with prayer and festive meals (and in Jerusalem itself, with parades and barbeques) let’s remind ourselves of a person who personifies the essence of a commitment to Jewish tradition, science and Zionism: Robert Aumann.

As we have mentioned before, in 2005 Aumann was awarded the Nobel Prize in Economics. It recognized his work on conflict, cooperation, and game theory (yes, the same kind of game theory made famous by John Nash, portrayed in A Beautiful Mind). Aumann worked on the dynamics of arms control negotiations, and developed a theory of repeated games in which one party has incomplete information.  The Royal Swedish Academy of Sciences noted that this theory is now "the common framework for analysis of long-run cooperation in the social science."

Jews have been yearning for the land of Israel, and for Jerusalem, for close to 2000 years – ever since the destruction of the Temple by the Romans in the year 70, and the ensuing exile of the Jewish people. In our central prayer, which we recite three times a day, we ask the Lord to “return to Jerusalem Your city in mercy, and rebuild it and dwell therein.” Jerusalem is mentioned many thousands of times in the scriptures, in our other prayers, in the Talmud, and indeed in all our sources. So when the state of Israel was established in 1948, my brother and I made a determination eventually to make our lives there.
— Robert Aumann. "Biographical." From Nobel.org

Aumann’s speech to the Swiss Academy was a moving testimony to the Zionist dream, in which he was proud to have played a part. And Aumann knows the price of this dream; his oldest child, Shlomo, was killed in action while serving in the Israel Defense Forces in the 1982 Lebanon War.

Here is what the good Professor said in Stockholm. It is surely the only Nobel Prize Banquet Speech ever to mention the return of the Jewish people to Jerusalem.

.ברוך אתה יי אלו-ינו מלך העולם הטוב והמיטיב

Blessed are you, God, our Lord, Monarch of the Universe, who is good and does good.

After partaking of a meal with fine wines, we recite this benediction when we are served with a superb wine.Your Royal Highnesses, we have, over the years, partaken of many fine wines. We have participated in the scientific enterprise: studied and taught, preserved, and pushed forward the boundaries of knowledge.

.למדנו ולימדנו, שמרנו ועשינו

We have participated in the human enterprise – raised beautiful families. And I have participated in the realization of a 2000-year-old dream – the return of my people to Jerusalem, to its homeland. And tonight, we have been served with a superb wine, in the recognition of the worth of our scientific enterprise. I feel very strongly that this recognition is not only for us, but for all of game theory, in Israel and in the whole world – teachers, students, colleagues, and co-workers. And especially for one individual, who is no longer with us – the mother of game theory, Oskar Morgenstern.

So, I offer my thanks to these, to the Nobel Foundation and the Nobel Committee, to our magnificent hosts, the country of Sweden, and to the Lord, who is good and does good.

For me, life has been – and still is – one tremendous joyride, one magnificent tapestry. There have been bad – very bad – times, like when my son Shlomo was killed and when my wife Esther died. But even these somehow integrate into the magnificent tapestry. In one of his beautiful letters, Shlomo wrote that there can be no good without bad. Both Shlomo and Esther led beautiful, meaningful lives, affected many people, each in his own way.
— Robert Aumann.

Robert Aumann and his cousin, Oliver Sacks

In 2015 the late great neurologist and author Oliver Sacks wrote a moving piece called The Sabbath. In it he recalled growing up in the orthodox Jewish community of north-west London. “Though I could not understand the Hebrew in the prayer book” he wrote “I loved its sound and especially hearing the old medieval prayers sung, led by our wonderfully musical hazan.”

But Sacks had a secret: he was attracted to men. His father made him admit to this, but Sacks asked that he not tell his mother. Sacks continues:

He did tell her, and the next morning she came down with a look of horror on her face, and shrieked at me: “You are an abomination. I wish you had never been born.” (She was no doubt thinking of the verse in Leviticus that read, “If a man also lie with mankind, as he lieth with a woman, both of them have committed an abomination: They shall surely be put to death; their blood shall be upon them.”)

The matter was never mentioned again, but her harsh words made me hate religion’s capacity for bigotry and cruelty.

Sacks wrote about his homosexuality for the first time in his 2015 autobiography On the Move: A Life. And he found love later in his life, with his partner Bill Hayes, with whom he lived until Sacks died in 2015.

The cruel treatment Sacks received from his mother must have been a life-long burden, but Sacks found some solace in the behavior of his cousin - Robert Aumann. Let’s let Sacks tell the story:

During the 1990s, I came to know a cousin and contemporary of mine, Robert John Aumann, a man of remarkable appearance with his robust, athletic build and long white beard that made him, even at 60, look like an ancient sage. He is a man of great intellectual power but also of great human warmth and tenderness, and deep religious commitment — “commitment,” indeed, is one of his favorite words. Although, in his work, he stands for rationality in economics and human affairs, there is no conflict for him between reason and faith.

He insisted I have a mezuza on my door, and brought me one from Israel. “I know you don’t believe,” he said, “but you should have one anyhow.” I didn’t argue.

Towards the end of his life Sacks paid one last visit to Aumann.

I had felt a little fearful visiting my Orthodox family with my lover, Billy — my mother’s words still echoed in my mind — but Billy, too, was warmly received. How profoundly attitudes had changed, even among the Orthodox, was made clear by Robert John when he invited Billy and me to join him and his family at their opening Sabbath meal.

The peace of the Sabbath, of a stopped world, a time outside time, was palpable, infused everything, and I found myself drenched with a wistfulness, something akin to nostalgia, wondering what if: What if A and B and C had been different? What sort of person might I have been? What sort of a life might I have lived?

Robert Aumann, is not just a Zionist or a Nobel Laureate. He something far, far more important. He is a mensch.

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Bechorot 45b ~ Syndactyly, and Talmudology Keeps a Promise

Remember Polydactyly?

In April 2016, which is to say over three years ago, Talmudology wrote about polydactyly, when the Daf Yomi cycle studied Kiddushin 25. There we wrote: “We will discuss syndactyly when we study tractate Bechorot, (daf 45a), on June 1st, 2019,  הבעל"ט” And here we are. Tomorrow, June 1st 2019 (which is Shabbat) we will learn Bechorot 45, and we are therefore delighted to keep our promise and explain syndactyly, which is the condition in which one or more adjacent digits are fused together. But first, have a quick re-read of that earlier post; it will help put this medical condition into perspective…….Done? OK then, here we go.

The Cohen with fused digits

Tomorrow we continue the discussion of physical abnormalities which would prohibit a Cohen from serving in the Temple. The Mishnah reads as follow:

בכורות לה,ב

אצבעותיו מורכבות זו על זו או קלוטות למעלה עד הפרק כשר למטה מן הפרק וחתכה כשר

A priest whose fingers or toes are configured one upon the other, or one whose fingers or toes are attached, is likewise disqualified. But if they were attached from above the palm of the hand or the bottom of the foot only until the middle joint, he is fit. If they were attached below the joint, higher up on the finger or toe, and he cut to separate them, he is fit. 

The case here is a Cohen with, say two fingers or two toes that are fused together, so that it appears that there is a digit missing. The hand may look like this:

Palm view of classic simple syndactyly of left long and ring fingers. Over 50% of all webbed fingers occur like this.From here.

Palm view of classic simple syndactyly of left long and ring fingers. Over 50% of all webbed fingers occur like this.From here.

maydeletesmaller.jpg

Or in extreme cases like this:

The hand of the patient with syndactyly of several digits. From Biesecker L.G.The Greig cephalopolysyndactyly syndrome. Orphanet Journal of Rare Diseases 2008, 3:10

The hand of the patient with syndactyly of several digits. From Biesecker L.G.The Greig cephalopolysyndactyly syndrome. Orphanet Journal of Rare Diseases 2008, 3:10

These photos are all obviously from young children, which is good news. Surgeons are able to separate the fused fingers or toes, generally when the infant is 1-2 years old, and so there are now few adults around in whom the condition went uncorrected.

The Classification of Syndactyly

Syndactyly (from the Greek syn = together; dactylos=digit) occurs in about 2-3 per 10,000 live births In 10-40% there is a family history of the condition and is twice as common among males (remember these facts for later). In about half of all cases there are bilateral and symmetrical fusions, and while it may be an isolated finding, in many cases it is part of a genetic disorder like Apert’s or Poland’s syndrome.

There are several different types and subtypes, depending on whether the condition is classified based on an anatomical approach, a genetic or molecular approach, a descriptive approach or an embryological classification. One classification, from a 2012 review of the topic published in The European Journal of Human Genetics, is shown below.

Schematic diagrams of syndactyly types (I-a–III). Shaded digits depict cutaneous fusion only, while bony synostosis is represented by black digital elements within the shaded area. The grey digital elements show hypoplastic phalanges or clinodactyly…

Schematic diagrams of syndactyly types (I-a–III). Shaded digits depict cutaneous fusion only, while bony synostosis is represented by black digital elements within the shaded area. The grey digital elements show hypoplastic phalanges or clinodactyly/brachydactyly. The digital elements with amorphous borders symbolize dysplastic bones. From Malik S. Syndactyly: phenotypes, genetics and current classification. European Journal of Human Genetics (2012) 20, 817–824;

What Causes Syndactyly? It’s often the genes

Syndactyly sometimes runs in families, so in these cases a genetic cause was long suspected. For example, fusion of the fourth and fifth metacarpals (an uncommon type of syndactyly) was first described 1928 and was initially thought to have an X-linked recessive trait. It was later classified as an autosomal dominant inheritance, found in some families with male-male transmission as well as females affected. But we are now able to exactly pinpoint some of the genetic causes. Type I, Apert syndrome, is associated with the FGFR2 gene (to be exact the the loci 10q26). Type II, (Carpenter syndrome) is linked to RAB23 gene, and Type V, also known as Pfeiffer syndrome is been linked to the FGFR 1 and 2 genes.

A family with three generations of ring and small finger involvement, none of which was ever surgically corrected. From Flatt A. Webbed Fingers. In The Care of Congenital Hand Anomalies, 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1994:228–…

A family with three generations of ring and small finger involvement, none of which was ever surgically corrected. From Flatt A. Webbed Fingers. In The Care of Congenital Hand Anomalies, 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1994:228–275.

Why did the Mishnah Discuss Syndactyly in Cohanim?

At first, the discussion of syndactyly as a disqualification for a Cohen seems rather odd. I mean really, how many cases could there have been? But the reason that the Mishnah spent time on this is now obvious. In many cases it is a genetic disorder, mostly affecting men. To be a Cohen you must be the child of a father who is a Cohen. As we have already learned, there are several “Cohen related genes,” and now we can add to the list the possibility that one of the many genetic causes of syndactyly was linked to those who were Cohanim, and who might pass the gene to their male children.

As we saw in an earlier post, the rabbis of the Mishnah and Talmud described different medical observations without realising that they originated from a single cause (like alcoholic liver disease) or had a genetic component. How lucky we are to have this knowledge at our fingertips (sorry). The rabbis would have wanted no less.

[Extra credit: The Wiki page on Syndactyly notes that “The earliest appreciation of syndactyly as a birth anomaly…can be traced back to the Andalusian Muslim surgeon Al-Zahrawi (d. 1013 CE).” This should obviously be corrected, since it was mentioned as a birth defect in the Mishnah, edited c. 200 CE, some eight hundred years earlier. Can someone please edit the page so that it is accurate? Thanks.]

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