Kiddushin 82a ~ The Best Doctors Go to Hell

קידושין פב, א

רבי יהודה אומר משמו החמרין רובן רשעים והגמלין רובן כשרין הספנין רובן חסידים טוב שברופאים לגיהנם והכשר שבטבחים שותפו של עמלק

Rabbi Yehuda said in the name of Abba Gurya: Most donkey drivers are evil; most camel drivers are righteous; most sailors are pious; the best of doctors is destined for hell; and even the best butcher is a partner with Amalek.

"The best of doctors is destined for hell". Thats quite a statement for Rabbi Yehudah to make.  Writing in The Atlantic several years ago, the late Sherwin Nuland told this (probably apocryphal) story:

Imprisoned in a tower in Madrid, disabled by syphilis and further weakened by an abscess in his scalp, the French king Francis I asked of his captor, the Holy Roman Emperor Charles V, that he send his finest Jewish physician to attempt a cure. At some point after the doctor arrived, Francis, in an attempt at light conversation, asked him if he was not yet tired of waiting for the messiah to come. To his chagrin, he was told that his healer was not actually Jewish, but a converso who had long been a baptized Christian. Francis dismissed him, and arranged to be treated by a genuine Jew, brought all the way from Constantinople.

Whether true or not, the story illustrates the esteem in which Jewish doctors were - and often still are held.  So what did Rabbi Yehudah mean by condemning the best physicians to hell? Let's take a quick survey of some of the answers suggested through the ages.

1. Rashi (France, 104-1105)

Rashi gives this explanation:

טוב שברופאים לגיהנם. אינו ירא מן החולי ומאכלו מאכל בריאים ואינו משבר לבו למקום ופעמים שהורג נפשות ויש בידו לרפאות העני ואינו מרפא

The best doctors go to hell. The do not fear sickness. They eat the food of the healthy, and they do not act humbly before God. Sometimes they kill, and sometimes they are able to heal a poor person but do not do so.

Rashi gives five reasons why even good doctors are, well, not so good. First, believe that they themselves cannot become sick (אינו ירא מן החולי). Second, they eat a  diet of those who are healthy (ומאכלו מאכל בריאים) and so apparently avoid illness themselves.  As a result of both of these factors, they are rather proud of themselves (ואינו משבר לבו למקום. Sidebar: what's the difference between God and a cardiothoracic surgeon? God doesn't think he's a cardiothoracic surgeon...) Fourth, they make mistakes that kill the patient (פעמים שהורג נפשות), and finally, according to Rashi, they are so focused on the business end of medicine that they only heal those who can pay.

While Rabbi Yehudah made a general statement about the destiny of good physicians, Rashi, writing in eleventh century France, was not short of examples of bad ones. No doubt Rashi's comments reflected the contemporary practice of medicine. But if, as Rashi suggests, doctors would eat a healthy diet and so avoid becoming sick themselves, why did they not share this information - even at a price? Moreover, there is no evidence that any diet could play any role in delaying (or curing) many causes of death in the pre-antibiotic era: cholera, smallpox, plague and regular plain old pneumonia. Rashi's explanation raises far more questions than it answers. So let's keep going...

2. The Ramban - Moses ben Nachman (Spain, 1195-1270)

ואין לך ברפואות אלא ספק סכנה, מה שמרפא לזה ממית לזה וזו שאמרו 'טוב שברופאים  לגיהינום' לגנות דרכן של רופאים בפשיעות וזדונות שלהם. – תורת האדם שער המיחוש - ענין הסכנה ד"ה אבל 

Medical interventions are nothing but a danger. What heals one person kills another. And this is what is meant when they said "the best doctors go to hell" - to disparage the practice of physicians and their malpractice...

Ramban is sweeping in his assessment of the practice of medicine: medical interventions are nothing but dangerous (ואין לך ברפואות אלא ספק סכנה).

3. The Meiri - Menachem ben Meir (France 1249-1316)

מפני שכמה פעמים שופך דמים מפני הייאוש ואינו משתדל כראוי במלאכת רפואתו או שאינו יודע לפעמים סבת החולי ודרך רפואתו, ועושה עצמו בקי. בית הבחירה קידושין פ

For often they shed blood, because they give up and do not try to apply their trade as physicians appropriately.  At other times they do not know the etiology of the disease and how it should be treated, and yet pretend as it they do.

Here is a rather different explanation. It is not that medicine is intrinsically worthless (as the Ramban opined), but that physicians are not diligent about how they practice, and do not admit when they are not knowledgeable. Presumably if the physicians were more scrupulous and more honest about the limits of their own knowledge, Meiri would not have them condemned to hell.

4. Jacob ben Asher (Germany 1270-1343)

שנתנה לו רשות לרפאות ומצווה היא ... והזריז הרי זה משובח ואם מונע עצמו הרי זה שופך דמים .... ואם לא נתעסק בה כלל הרי זה שופך דמים ובן גיהינום הוא בוודאי.  טור, יורה דעה של"ו 

Permission has been given to heal, and to do so is a mitzvah...and one who is eager to heal is to be praised, but if he [is able to heal but] does not do so, he is considered to have shed blood...and if he does not engage in medicine he is considered to have shed blood and is certainly destined to hell...

Jacob's explanation is novel and turns from critic to job coach. Medicine is so important - (presumably because he felt that it actually worked) that one who could be a physician but does not choose this path (he's talking to you, lawyers) is "certainly destined to hell" (ובן גיהינום הוא בוודאי). 

5. Shlomo ibn Virga (Spain, ~1460-1554)

שיראה לעולם גיהינום פתוח לפניו אם ייהרג האיש שהרפואה על ידו ובזה יעיינו ויעשו החריצות הראוי, וה'טוב' הוא כאשר יחשבו שהם עתידים לירש גיהינום אם לא יכוונו כראוי   , במחשבה ועיון. שבט יהודה ירושלים תשט״ו, קי’ג

The physician should act as if hell itself is open before him if his treatments kill the patient.  In this way, will he will act with caution and diligence. The "best" of physicians is one who acts as if he might one day inherit hell, unless he is appropriately careful and attentive...

Ibn Virga (the author of שבט יהודה) turns the Rabbi Yehudah's phrase from descriptive to cautionary: be a good doctor or else you could go to hell. Could the fact that he was himself a physician have influenced his novel explanation?

6. The Maharal - Judah ben Bezalel Leviah (Prague, 1512-1609)

מי שהוא רופא ואינו בעל תורת אלוקים עם זה הרי כל עניינו שהוא מעיין כחומרי בלבד, לכך הוא בעל גיהינום.  ספר נצח ישראל, ל'

A physician who is not also an expert in God's Torah will view his subjects as nothing but material beings.  Therefore he is destined for hell...

The Maharal, who viewed the world as ruled by both material and spiritual forces, explained Rabbi Yehuda as giving a warning. But unlike the warning Ibn Virga saw - to be the best doctor you could be - the Maharal saw the Rabbi Yehuda warning the physician to be part rabbi too - and to view his healing powers as derived from God.  

7. Joseph Almanzi (Italy, 1801-1860)

Almanzi, poet and book collector, took this whole doctors-go-to-hell thing to a whole new new level. He wrote a poem titled The Worst Doctors Go to Hell, which I suppose is a lot better than sending the best of them there. The poem is part of collection published in Padua in 1858. Here it is in the original:

Like all poetry, it's a lot better, and a lot more caustic in the original, but here is a flavor:

Wicked Doctor !
You have lied against God's commands
You have despised his Torah
And the laws of humanity
"Do not kill, do not commit adultery" - you erased these like a passing cloud
And you have made "Do not steal" into contrition the graveside...
 
You have shed innocent blood; therefore against you,
To avenge the myriads of those who died on your account
Spirits and demons will come like good times

The Super Sad True Story of Medicine from Hippocrates to the Nineteenth Century

In Thomas Dekker’s The Honest Whore, we are told that it is far safer to fight a duel than to consult a doctor. In Ben Johnson’s Volpone doctors are said to be more dangerous than the diseases they treat, for ‘they flay a man / before they kill him’
— David Wootton. Bad Medicine. Doctors Doing Harm Since Hippocrates. Oxford University Press 2006. 139.

The history of doctors doing more bad than good is a long and sad tale. From the time of Hippocrates until about 1865 (when Lister pioneered antiseptic surgery), if you were sick, injured or ailing, you were better off not going to a doctor. Let me repeat that, to be sure there is no misunderstanding: until about 1865, all doctors did more harm than good

Hippocrates of Cos is believed to have lived from about 460-375 BCE. It was he and his successors who seem to have first suggested that daily life should be managed to insure the right amount of food, drink, sleep, exercise.  In addition, the Hippocratic school believed that excess fluids could- and should be eliminated from the body in one of three ways: by using emetics to induce vomiting, by using purgatives to induce diarrhea, and by letting blood.  Later, a fourth “therapy” was introduced: cautery, in which hot irons were applied to the body.  None of these therapies helped any internal conditions, and the only benefits from Hippocratic practitioners was in setting bones and lancing boils. In addition to introducing purgatives, laxatives and blood letting, there was another "contribution" made by the ancient medics: the four humors.

Although the four-humor system seems to have first been suggested by Polybus, who was the son-in-law of Hippocrates, it was made popular by Galen (~130-201 AD): blood, phlegm, black bile and yellow bile.  Galen (who claimed to have discovered a new kind of bile- black- which was noted as sediment if blood was allowed to stand and separate) attributed disease to an over abundance of one or the other of the humors, and so bloodletting became a cure for almost all conditions. This remained true until the late nineteenth century.  

According to the masterful historian David Wooten, if you look at therapies and not theories, then ancient medicine survived into the nineteenth century – and beyond. Although ideas about the body changed as a result of the scientific revolution, medical therapies changed very little, if at all. Bloodletting was the main medical therapy in talmudic times, and in 1500, 1800, and even 1850. Of course it was not only of no benefit, but was certainly of great harm. It continued to be used because it looked like it was working: the patient's pulse would slow, his temperature would drop, and he would fall into a sound sleep.

Trust not the physician;
His antidotes are poison and he slays
— William Shakespeare. Timon of Athens, iv, iii, 434-436.

The Discovery of the Placebo Effect

James Gillray (1757-1815). Metallic Tractors. Wellcome Library for the History and Understanding of Medicine, London

James Gillray (1757-1815). Metallic Tractors. Wellcome Library for the History and Understanding of Medicine, London

None of the supposed remedies used by physicians were ever tested against each other - or against nothing, (and they all did more harm than doing nothing). But eventually someone suggested testing medical interventions for their efficacy.  That someone was John Haygarth (1740-1827), a British physician, who was skeptical of a new popular treatment "just arrived from America", which involved metallic tractors placed on the body to relieve pain through the agency of animal magnetism. These tractors had been invented by a Philadelphia physician Elisha Perkins, and were apparently all the rage in America; one historian noted that "George Washington, no less, purchased a set for the use of his own family, as did the Chief Justice, the Honorable John Marshall, who gave his judgement that 'the effects wrought are not easily ascribed to imagination, great and elusive as is its power'." Back in England, John Haygarth put the tractors to the test in 1799: he manufactured sham tractors made of wood, and tested them on five patients at the Bath Infirmary. Equal effects were found with both the Perkins and the fake tractors - and the placebo effect had (at long last) been discovered.

Haygarth's discovery was about far more than these silly metal rods, because it suggested that much of what standard medicine was offering was a placebo effect at best (or a dangerous intervention at worst).  Haygarth's work raised this question: shouldn't other orthodox medical treatments be tested too?

Bloodletting is finally Unmasked - Kinda

Bloodletting - the best that medicine could offer from Hippocrates, through the times of the Talmud until the nineteenth century was finally tested in the late 1820s, by the very French sounding French physician Pierre-Charles-Alexandre Louis (1787–1872).  Louis set to test the theory of another French doctor, Francois Joseph Victor Broussais, who claimed that all fevers were due to an inflammation of the organs. "Accordingly", wrote the epidemiologist Alfredo Morabia, 

leeches were applied on the surface of the body corresponding to the inflamed organ and the resultant bloodletting was deemed to be an efficient treatment. For example, the chest of a patient suspected of having pneumonitis was covered with a multitude of leeches. Broussais’s theories were highly regarded by contemporary French physicians. His influence can be assessed using an economic measure: in 1833 alone, France imported 42 million leeches for medical use.

Louis tested this extreme form of bloodletting in 77 patients, and found results that were all over the place.  More patients died who were bled early, but their duration of disease was also shorter, when compared with those who were bled later. Sadly, Louis did not conclude that bloodletting was dangerous, but that "its influence was limited". Louis is now recognized as setting the groundwork for the modern practice of epidemiology, in which outcomes are measured and counted. Interestingly, using a modern analysis of Louis' bloodletting results, "the group bled during the first four days of disease does worse (P-value=0.07), and this would appear to make a protective effect of bleeding highly unlikely." The efficacy of bloodletting was finally being tested, and though it would remain a staple therapy for several more decades, fortunately, its days were numbered.  

Rabbi Dr. Lampronti on Doctors Gone Bad

Returning to our troubling phrase "the best of doctors go to hell," perhaps the most intriguing - and prescient  - explanation is that of Isaac Lampronti(1679– 1756). Lampronti was an Italian Jew who studied medicine at Padua. He completed his studies at the age of twenty-two and returned to his home town of Ferrara in northern Italy.  There he became a rabbi and eventually rose to become the head of the yeshivah in the city, all while continuing to practice medicine. Lampronti introduced a curriculum of dual learning in his yeshivah, which, according to the historian David Ruderman, became “the quintessential Jewish institution of learning in Italy, where Judaism and the biological sciences, along with the propaedeutic language training necessary to pursue both, were meaningfully infused.” Lampronti is best known for his lengthy alphabetical encyclopedia of Jewish law, Pahad Yizhak (The Fear of Isaac), in which each entry contained material from the Mishnah, Talmud, later commentaries, and the responsa literature, in addition to updates from contemporary science.  Here is his entry on the phrase from today's daf:

טוב שברופאים לגיהנם... ורבו עליה הפירושים... ואני אומר, דעל הקירורגים נאמרה, יען וביען הם משנים מצות החכם ובפרט בהקזת דם מרבים או ממעטים כפי שיכלם הקצר וממיתים החולים, וכמה פעמים ראיתי אני הצעיר המחבר כאלה לרוע

The best doctors go to hell: There are many explanations of this...and I believe that this is referring to surgeons, for this reason: they change the commandment of the wise, in particular with regard to bloodletting. They take more or less blood based on their limited understanding, and by doing so they condemn the patient to death. And there are a number of occasions in which I,  your young author, have seen this and its bad outcome...    

Let's be clear here. Lampronti was not suggesting that bloodletting was nonsense.  As a physician who had trained in Padua he was certain to believe it was effective. Rather, he blamed physicians - or rather surgeons - for using the intervention imprecisely, in so doing, "condemned the patient to death." When Rabbi Yehudah condemned the best doctors to hell, it was these surgeons and their bloodletting to whom he referred.

Finally, An Explanation of "Good Doctos Go to Hell"

Celsus…in the first century AD, recommended blood letting for severe fever, paralysis, spasm, difficulty in breathing or talking, pain, rupture of internal organs all acute (as opposed to chronic) diseases, trauma, vomiting of blood. It was still being used as a nearly universal remedy in the middle of the nineteenth century.
— David Wooten. Bad Medicine. Oxford University Press 2006. p37.

In terms of medical texts, little changed from the time of Hippocrates until the mid-seventeenth century, when discoveries of the circulation were made.  Wooten sums up the unchanging world of medicine by noting that  

...from the fifth century BC until the end of the nineteenth century…doctors found patients who were prepared of pay for treatment that was at best ineffectual, and usually deleterious.  Throughout this period, surgery…was commonly fatal, which the common therapies were bloodletting, purging and emetics, all of which weakened patients. Advances in knowledge, as such as the discovery of the circulation of the blood, had no pay-off in terms of advances in therapy, so that we might say that all progress was in human biology none of it in medicine.

Before 1865, doctors could set some broken bones, reduce dislocations lance boils.  Later, they could prescribe opium for pain, quinine for malaria, digitalis for some causes of dropsy, mercury for syphilis, and orange and lemon juice for scurvy. But that was it, and for two-thousand years medicine remained essentially unchanged. "A doctor in ancient Rome "wrote Wooten, "would have done you just about as much good as a doctor in early nineteenth-century London, Paris, or New York." Which is to say, no good at all. 

We have noted before that The Principle of Charity asks a reader to interpret the text they are reading in a way that would make it optimally successful.  We are now in a position to do just that for Rabbi Yehudah's puzzling  declaration "the best doctors go to hell". For before the introduction of antiseptic surgery in 1865, the best of doctors could not be separated from the worst. Their interventions did no good, and often harmed or killed their patients. They were at best useless, and at their worst, agents of death.  Perhaps this is why Rabbi Yehudah condemned them to hell.

Let's conclude with the Talmud's evaluation of the contributions bloodletters, found on the very last page of Kiddushin, the last masechet in Nashim.

קידושין פב, א

תנו רבנן עשרה דברים נאמרו בגרע מהלך על צידו ורוחו גסה ונתלה ויושב ועינו צרה ועינו רעה אוכל הרבה ומוציא קימעא וחשוד על העריות ועל הגזל ועל שפיכות דמים 

Our Rabbis taught: Ten things were said of a blood-letter. He is haughty and has a conceited spirit, he leans back when sitting, has a grudging eye and an evil eye; he eats much and excretes little; and he is suspected of adultery, robbery and bloodshed.

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