Zevachim 25b ~ Teaching By Humiliation

זבחים כה, ב

 אמר ליה תרדא...

R. Chiya bar Abba said to R. Zeira: "Scatterbrain"

 

As a medical student in London, humiliation came with the territory. There I was, on rounds on General Surgery Firm. At its head, the consultant surgeon.  Followed (in their correct pecking order) by two senior registrars, three or four registrars, several senior house officers and house officers, nurses, physiotherapists, and a couple of medical students.  We gathered around the bed of some poor patient who had recently undergone surgery. The consultant surgeon turned to me: "Mr. Brown" he said, looking at me atop of his professorial reading glasses, "how long is the anal canal?" Everyone else smiled, relieved to know they had not been asked this, rather challenging question. I had no idea, despite having once known this useful fact to pass my anatomy exams. "Thirty centimeters, sir" I replied, hopefully.  "Correct," said the surgeon, as he surveyed the menagerie of staff trailing him.  "If you are an elephant." And so ended my surgical career.

Teaching By Humiliation in the Talmud

The insult hurled by R. Chiya bar Abba said to R. Zeira in today's Daf Yomi תרדא –  is variously translated as "lunatic" (Schottenstein) "imbecile" (Koren) and "fool"(Soncino). The rabbis of the Talmud were not shy to call out those they felt were slow-witted or annoying. After Rabbi Yehudah HaNasi was asked a relatively innocent question by Levi, the great editor of the Mishnah replied כמדומה לי שאין לו מוח בקדקדו - "it appears to me that Levi has no brains in his head," an insult he repeated on at least one other occasion. Rabbi Tarfon had enough of  Rabbi Elazar when he told him "How long will you pile up meaningless  words and bring them against us." He even used the same insult against Rabbi Akivah. Rabbi Akivah! (See ילקוט שמעוני תורה פרשת בהעלותך רמז תשכה.) Rabbi Yishmael was called "a date palm" (and not in a good way) by Rabbi Eliezer (see ספרא תזריע פרשה ה).  One of my favorites though, came from Rabbi Dosa, who called his  younger brother "the first-born of Satan" which raised name calling among siblings to a whole new level.  I could go on, but you get the point. These guys could be really insulting.

Pimping in the Medical Literature

For the reader who is not medically trained, here's a new word: pimping. It's a real word that is OK to use in polite company (maybe).  According to the esteemed Journal of the American Medical Association, pimping is

a series of difficult and often intentionally unanswerable questions posed to a medical student or house staff in quick succession. The objective of pimping is to teach, motivate, and involve the learner in clinical rounds while maintaining a dominant hierarchy and cultivating humility by ridding the learner of egotism.

There is an art to pimping, according to Fredrick Brancati, the man generally thought to have invented the term in its medical content. Here is an excerpt from his classic 1989 paper, called, what else, The Art of Pimping:

Pimp questions should come in rapid succession and should be essentially unanswerable. They may be grouped into five categories:
1. Arcane points of history.These facts are not taught in medical school and are irrelevant to patient care—perfect for pimping. For example, who performed the first lumbar puncture? Or, how was syphilis named?
2. Teleology and metaphysics.These questions lie outside the realm of conventional scientific inquiry and have traditionally been addressed only by medieval philosophers and the  editors of the National Enquirer. For instance, why are some organs paired?
3. Exceedingly broad questions. For example, what role do prostaglandins play in homeostasis? Or, what is the differential diagnosis of a fever of unknown origin? Even if the intern begins making good points, after 4 or 5 minutes he can be cut off and criticized for missing points he was about to mention. These questions are ideally posed in the final minutes of rounds while the team is charging down a noisy stairwell.
4. Eponyms. These questions are favored by many old-timers who have assiduously avoided learning any new developments in medicine since the germ theory. For instance, where does one find the semilunar space of Traube? 
5. Technical points of laboratory research. Even when general medical practice has become a dim and distant memory, the attending physician-investigator still knows the details of his research inside and out. For instance, how active are leukocyte-activated killer cells with or without interleukin 2 against sarcoma in the mouse model? Or, what base sequence does the restriction endonuclease EcoRI recognize?
....pimping can create a hostile environment among the team members, suppress creativity or intellectual curiosity because of fear of embarrassment, and dehumanize students at the expense of maintaining medical hegemony.
— McCarthy, CP. McEvoy, JW. Pimping Medical Education. JAMA 2015; 314 (22). 2347-2348.

 Last year an Australian team published a paper titled "Teaching by humiliation” and mistreatment of medical students in clinical rotations. They found that 74% had experienced and 83% had witnessed teaching by humiliation during their adult clinical rotations; smaller proportions had experienced (29%) or witnessed (45%) it during their pediatric rotations, which just proves what everyone already knows.  Pediatricians are all nice. 

 

All this pimping comes with a down side. "Students’ responses to these practices" wrote the Australian researchers, "ranged from disgust and regret about entering the medical profession to endorsement of teachers’ public exposure of a student’s poor knowledge. Reported victims and perpetrators included junior medical staff, who were subjected to the practices as much as students and were equally likely to be the perpetrators, alongside senior medical and nursing staff."

As a deeply ingrained cultural, institutionalised practice, mistreatment requires focused action to replace the existing culture with one of compassion, tolerance and respect.
— Scott, KM. et al. “Teaching by humiliation” and mistreatment of medical students in clinical rotations: a pilot study. Medical Journal of Australia 2015; 203(4): 1-6

Talmudic Insults and Respect for the talmid

In today's page of Talmud, R. Chiya bar Abba called R. Zeira a "scatterbrain." Rabba called R. Amram the same thing back in Bava Kamma (105b.) In fact he called him a scatterbrain again in Bava Metziah, so he must really have meant it.  This epithet seems to have been the "moron" of its day. Even the great Abayye must have felt a little miffed when he was called a scatterbrain by Rava bar Hannan.  

It seems demeaning to use language like this, and out of place given the words of the Mishnah (Avot 2:10) יהי כבוד חבירך חביב עליך כשלך - "let your friend's honor be as important to you as your own." Rabbi Yair Chaim Bachrach (Germany, 1638-1732) addressed talmudic insults in his book of responsa called Chavvot Yair, first published in 1699. Apparently things were getting out of hand in Germany, where the talmudic art of humiliating had evolved. Yeshivah students now also yelled and gesticulated rather enthusiastically as they sparred with their learning partners:

 מש"כ קפיצה וסיפוק וריקוד תוך הפלפול איש נגד רעהו שזה גורם בלי ספק שחבירו ימהר לעשות כמעשהו וירקוד ג"כ כנגדו וירים קולו בצעקה גדולה ומרה יותר ולא ישמע איש שפת חבירו ואין זה רק מנהג יהוא וכל המרבה בה ה"ז משוגע 

Students jump and dance around each other in the middle of expounding a subject, and this will cause, without doubt, that other students will do the same and will leap and raise their voices in a louder and more bitter cry. No one will be able to listen to the voice of his partner. This is nothing other than a ridiculous custom, and anyone who does this often is a mesgugah...  

Rabbi Bachrach then rose to the defense of those who used talmudic insults, claiming that they did so with only good intentions. They did it, he said, in order to bring out the very best they could in those they insulted. (כלם י"ל שהיו חבריהם וגודלים מהם ולא קפדי כלל). Hmmm. I'm not convinced.

Insults don't work, not for medial students and not for any students.  Ad hominem attacks are now, alas, the currency of many public or political (especially political) debates, though they usually say more about the person uttering them than the person against whom they are directed. It seems that the rabbis of the Talmud were just as susceptible as the rest of us to this all-too-common failing. We can all do better. 

תנו רבנן: שלשה שונאין זה את זה, אלו הן: הכלבים, והתרנגולין, והחברין. ויש אומרים: אף הזונות. ויש אומרים: אף תלמידי חכמים שבבבל
The rabbis taught: three groups hate each other: Dogs, roosters, and sorcerers. Some say: so do prostitutes. And others say: so do the sages in Babylon...
— פסחים דף קיג עמוד ב

[Mostly a repost from here.]

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Zevachim 22b ~ On the Physical and Mental Dangers of Circumcision

Milah knife..jpg

An uncircumcised Cohen may not, we are told in a Mishnah, offer sacrifices at the Temple in Jerusalem.  Just how did the Mishnah know this? In tomorrow's daf, we learn the answer:

זבחים כב,ב

 אמר רב חסדא דבר זה מתורת משה רבינו לא למדנו מדברי יחזקאל בן בוזי למדנו: כל בן נכר ערל לב וערל בשר לא יבא אל מקדשי לשרתני

Rav Chisdah says: We did not learn this matter from the Torah of Moses, our teacher; rather, we learned it from the words of the prophet Ezekiel, son of Buzi: “No stranger, uncircumcised in heart or uncircumcised in flesh, shall enter into My Sanctuary to serve Me” 

From the words "uncircumcised in flesh" the Talmud learns that a Cohen for whom circumcision would be life-threatening is forbidden to take part in sacrificial rites.  Earlier, (on page 15b) Rashi explains how circumcision might be dangerous:

 ערל. כהן שמתו אחיו מחמת מילה

Not circumcised: This means a Cohen whose brothers have died due to circumcision.

To understand the today's daf, we need to remind ourselves of the genetics of hemophilia. So let's go.

X-LINKED HEMOPHILIA A

The classic teaching about bleeding deaths and circumcision is found in Yevamot 64a.

יבמות סד, א 

תניא מלה הראשון ומת שני ומת שלישי לא תמול דברי רבי רבן שמעון בן גמליאל אומר שלישי תמול רביעי לא תמול... א"ר יוחנן מעשה בארבע אחיות בצפורי שמלה ראשונה ומת שניה ומת שלישית ומת רביעית באת לפני רבן שמעון בן גמליאל אמר לה אל תמולי

It was taught: If she circumcised her first son and he died, and her second son and he too died, she should not circumcise her third son, so taught Rebbi.  Rabbi Shimon ben Gamliel stated that she should indeed circumcise her third child, but [if he died] she must not circumcise her forth...Rabbi Yochanan said that there was once a case in Zippori in which four sisters had sons:  The first sister circumcised her son and he died, the second sister circumcised her son and he died, the third sister circumcised her son and he died, and the forth sister came to Rabbi Shimon ben Gamliel and he told her "you must not circumcise your son" (Yevamot 64:)

The Talmud here is describing a disease that is affected through the maternal line (hence the four sisters - all of whom seem to pass this disease on to their male children). The disease is X-linked Hemophilia A; the term X-linked indicates that the faulty gene is carried on the X chromosome, which is men is always inherited from the mother. Hemophilia A is an X-linked recessive genetic disease, first described by the American physician John Conrad Otto, who in 1803 described a bleeding disorder that ran in families and mostly affected the men. John Hay from Massachusetts published an account of a "remarkable hemorrhagic disposition" in the New England Journal of Medicine in 1813.

NEJM report of hemophilia 1813.png

If the mother is a carrier  - as were each of the four sisters in Zippori - then she has a one in four chance of passing on the disease to a child, and that affected child will always be a son:

In Yevamot, the rabbis argued over a technical point - that is, how many cases of bleeding are needed to establish a pattern. According to Rebbi (that is  Rebbi Yehuda Ha-Nasi, c. 135-217 CE.) two cases were sufficient, while Rabbi Shimon ben Gamliel insisted on three cases before ruling that there was a life threatening pattern.  Indeed the disease in boys must have been very perplexing, because (as you can see in the diagram above) not every boy would be affected. In fact, if the mother is a carrier and the father is not, there is only a 50% chance of a boy having hemophilia.  It is this fact that perhaps explains the dispute between Rebbi and Rabbi Shimon ben Gamliel regarding how many children need to exhibit the disease before we can assume that any future male child will also have it.  If every boy born in the family would have been a hemophiliac, Rabbi Shimon's ruling would have seemed unnecessarily cruel.  But since by chance, half of the boys born might not have hemophilia, the need to demonstrate the prevalence of the disease (in a society in which its genetic foundations were not known) seems eminently sensible.

In  Hemophilia A there are various genetic mutations that result in low levels of clotting factors. These levels may be only mildly decreased, or so low that severe life threatening hemophilia results. It is treated with transfusions of clotting factors which restore the levels to normal. Although these transfusions must be given several times a week in those with severe disease, there is hope that recombinant clotting factors can lengthen the time between the needed transfusions.

A Different explanation FROM Rabbenu Tam

In tomorrow's daf in Zevachim, we learn that there were indeed examples where what we call hemophilia A had been diagnosed, and as a result there were Cohanim who remained uncircumcised as adults. At least according to Rashi. But his grandson, Rabbenu Tam, has a different explanation. The Cohen did not have a clotting disorder. Rather, he was afraid of the pain of the procedure:

ערל. מפרש רבינו שלמה  בכל מקום שמתו אחיו מחמת מילה ור"ת מפרש דמומר לערלות וקרי ליה לבו לשמים לפי שאינו עושה אלא מדאגת צער המילה

According to Rabbenu Tam, this Cohen does not refuse circumcision as an act of religious rebellion. Rather, he refuses because of the pain involved in the procedure. Rabbenu Tam does not explain why the parents of the Cohen in question had not has him circumcised as a newborn - when he was in no position to object. But he makes a larger point: that a Jewish man who, out of fear, refuses to be circumcised - or to circumcise his newborn son - is not considered to be a religious rebel. Instead, he is called "one whose intentions are for the sake of heaven" - קרי ליה לבו לשמים.

Perhaps this expansive thinking of Rabbenu Tam might include today those who choose not to give their Jewish children a Brit Milah, because of concerns about informed consent.  Iceland recently introduced legislation to ban circumcision until a child reached the age of consent and could make an informed decision about his own genital future.  Rabbenu Tam would of course have wanted all Jewish newborn boys to have a Brit Milah and be welcomed into the Covenant of Abraham, but might he also understand those who felt differently?

[Partial repost from Repost from Yevamot 64a.]

Tagged: Hemophilia ACircumcision

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Horayot 10a ~ Halley's Comet, or Rabbi Yehoshua's Comet?

הוריות י,א

כי הא דר' גמליאל ורבי יהושע הוו אזלי בספינתא בהדי דר' גמליאל הוה פיתא בהדי רבי יהושע הוה פיתא וסולתא שלים פיתיה דר' גמליאל סמך אסולתיה דרבי יהושע אמר ליה מי הוה ידעת דהוה לן עכובא כולי האי דאיתית סולתא אמר ליה כוכב אחד לשבעים שנה עולה ומתעה את (הספינות) [הספנים] ואמרתי שמא יעלה ויתעה אותנו]

Rabban Gamliel and Rabbi Yehoshua were traveling together on a ship. Rabban Gamliel had sufficient bread for the journey, while Rabbi Yehoshua had bread and also some flour. [The journey lasted longer than expected, and] when Rabban Gamliel’s bread was finished he relied on Rabbi Yehoshua’s flour for nourishment. Rabban Gamliel said to Rabbi Yehoshua: How did you know from the outset that we would have such a substantial delay that you would need more flour? Rabbi Yehoshua said to Rabban Gamliel: There is one star that rises once in seventy years and misleads sailors at sea, causing their journeys to be extended. And I said: Perhaps that star will rise during our journey and mislead us.

Rabbi Yehoshua knew that a comet would likely be visible during his sea voyage, and that its light would confuse the sailors who navigated by the stars.  That comet returned about once every 70 years.  Does that remind you of anything?

Halley's Comet

Halley's comet last made an appearance in 1986. I remember looking up at the night sky with my father, and being thoroughly disappointed. Alas, the comet and the earth were on opposite sides of the sun, which made the quality of the appearance "the worst in two thousand years." 

Comet over 5th ave and Broadway.jpg

Other visits from Halley's comet were far more spectacular. In 1066 the comet was so bright that it was threaded onto the the 230 foot-long Bayeux Tapestry recording the Norman conquest of England. In 1531 it was seen for three weeks, and was visible even when the moon was full. And in 1910 the comet shone so brightly that it made its way onto postcards commemorating the spectacle.

 The orbit of Halley's Comet.  From  here .

The orbit of Halley's Comet.  From here.

Renaming the comet for Rabbi Yehoshua

There are several claims for the oldest written description of Halley's Comet. The Chinese described its appearance as early as 240 BCE, but the current record is a Greek record of the comet from 467BCE.  In contrast there is apparently no dispute about the earliest description of the length of the comet's orbit.  That accolade has been awarded to Edmund Halley who, using data from comet sightings in 1531, 1607 and 1682 suggested that the eponymous comet had a periodicity of about 76 years. But today's page of Talmud is clear: a comet with an orbit of about 70 years was identified by Rabbi Yehoshua. We know that "Halley's" Comet appeared in 66CE, when both Rabbi Yehoshua and Rabban Gamliel (II) were young men, and it must be to this comet that Rabbi Yehoshua referred.  Therefore it is Rabbi Yehoshua who should be honored with first describing the periodicity of the comet, and not Halley.  This is both self-evident and beyond question. It is also another of several examples which we have mentioned elsewhere in which scientific principles or facts were not properly attributed to the talmudic rabbis who first identified them. And so Talmudology is delighted to rename the comet Yehoshua's Comet.

Here's another fun fact about Rabbi Yehoshua's Comet of 66CE. It was described by the Jewish historian Josephus, who wrote that "a star resembling a sword stood over the city; a comet persisted for a long time." Josephus also recorded that the comet was seen during Pesach in 66CE. He wrote that it was taken as a good omen by those who started the Jewish rebellion against the Romans which lasted until the destruction of the Temple in 70CE.  And who was it who led another rebellion some sixty years later? Why, it was Bar Kochvah - the Son of the Star.

1835 - The First Hebrew Book about Halley's Comet

 Hayyim Zelig Slonimski aged seventy-five. From   The Jewish Encyclopedia ,  New York, Funk and Wagnalls, 1912.

Hayyim Zelig Slonimski aged seventy-five. From The Jewish Encyclopedia, New York, Funk and Wagnalls, 1912.

To coincide with the appearance of Halley's Comet in 1835, a Hebrew book called Kokhava Deshavit (The Comet) was published in Vilna. It described where and when the comet would be visible with precise coordinates for the inhabitants of Bialystok, as well as an explanation of the nature of comets and their orbits. The author was the remarkable Hayyim Zelig Slonimski, (1810-1904), the founding editor of Hazefirah (The Dawn), a weekly Hebrew-language newspaper first published in Warsaw in 1862. He also wrote Mosdei Hokhmah (The Foundation of Wisdom), a work on algebra, and struck up a friendship with the famed German naturalist and explorer Alexander von Humboldt (1769–1859). Not content with all this, Slonimski invented a method to send two telegraphs simultaneously over one wire (which was a very big deal at the time,) and developed a calculating machine that he later presented to the Imperial Academy of Sciences in St. Petersburg. It was so successful that in 1845 the Russian minister of education made Slonimski an honorary citizen, a remarkable honor given the general oppression faced by the Jews at the time.

 Orbit of Halley’s Comet from  Kokhava Deshavit,  Vilna, 1835. Note that the outermost planet is Uranus. The second edition of the book (1857) described the discovery of Neptune in 1846. From the  Talmudology Library .

Orbit of Halley’s Comet from Kokhava Deshavit, Vilna, 1835. Note that the outermost planet is Uranus. The second edition of the book (1857) described the discovery of Neptune in 1846. From the Talmudology Library.

In Kokhava Deshavit Slonimski  explained Kepler's three laws of planetary motion, outlined Newton’s law of universal gravitation, and described the discovery of stellar aberration by the British astronomer James Bradley, which was an early, indirect proof of the validity of the heliocentric model of the solar system. After a description of each of the planets, Slonimski returned to the nature of comets in general and Halley’s Comet in particular. He described some of the astronomers whose findings helped explain what comets were, and ended with a depiction of the expected path of the comet.

In 1909 Mark Twain famously wrote that

I came in with Halley's Comet in 1835. It is coming again next year [1910], and I expect to go out with it. It will be the greatest disappointment of my life if I don't go out with Halley's Comet. The Almighty has said, no doubt: "Now here are these two unaccountable freaks; they came in together, they must go out together."

And he was right. He died on April 21, 1910, one day after the comet's closest approach to Earth. Twain thought the story of Halley's Comet was personal.  But Hayyim Slonimski knew that the story of the comet was national. He hoped that its reappearance would be celebrated by his descendants who had returned to their Jewish homeland. He ended his book describing how the comet would pass by the Earth, then circle behind the Sun, and then reappear sometime in March 1836. After that,

...it will continue along its path gradually becoming dimmer to the inhabitants of the Earth as it follows its orbit, until it will reappear [in 1910]. May it be then as a sign and wonder for our children after us in the Holy Land. Amen.

And so it was.

 

[For more about Hayyim Zelig Slonimski and his life as orthodox Jewish scientist, Talmudology is glad to offer this excerpt, taken from here.]

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