Talmudology on the Parsha, Toledot: Esau and Orangutans

בראשית 25:27

וַֽיִּגְדְּלוּ֙ הַנְּעָרִ֔ים וַיְהִ֣י עֵשָׂ֗ו אִ֛ישׁ יֹדֵ֥עַ צַ֖יִד אִ֣ישׁ שָׂדֶ֑ה וְיַעֲקֹב֙ אִ֣ישׁ תָּ֔ם יֹשֵׁ֖ב אֹהָלִֽים׃

And the boys grew: and ῾Esav was a cunning hunter, a man of the field; and Ya῾aqov was a plain man, dwelling in tents.

In explaining the meaning of the phrase “a man of the field” Rashi has no problem adopting a straightforward and non-midrashic approach:

איש שדה. כְּמַשְׁמָעוֹ, אָדָם בָּטֵל וְצוֹדֶה בְקַשְׁתּוֹ חַיּוֹת וְעוֹפוֹת

איש שדה A MAN OF THE FIELD — Explain it literally (i.e., not in a Midrashic manner): a man without regular occupation, hunting beasts and birds with his bow.

The Seforno (Obadiah ben Jacob Sforno, Italy, 1475–1549) followed Rashi’s example:

איש שדה. יודע בעבודת האדמה

איש שדה A MAN OF THE FIELD - He was skilled as a farmer

Esau hunted mysterious animals

But the Gaon of Vilna, Rabbi Elijah ben Solomon (1720-1797) thought this verse deserved a more fanciful explanation. And boy, he does not disappoint:

דברי אליהו תילדות

פרשת תולדות ויגדלו נערים ויהי עשו איש יודע ציד איש שדה הפי' של איש שדה י ל עד"ז דהכתוב סיפר שעשו היה יודע איך יצוד את איש השדה והוא אדני השדה הנזכר בכלאים פ ח מ׳ה והוא ידעוני הכתוב בתורה וצורתו צורת אדם בפרצוף וידים ורגלים והוא מחובר בטבורו בחבל גדול היוצא מן הארץ.

ואין כל בריה רשאה לקרב אליו במלא מדת החבל כי חוא הורג וטורף כל הקרב אליו.

וכשרוצים לצודו מורים בחצים בחבל עד שנפסק החבל וצועק בקול מר ומיד הוא מת ועשו היה יודע איך לצודו חיים ושיעור הכתוב הוא כאילו נכתב ויהי עשו איש יודע ציד לאיש שדה

The phrase “a cunning hunter, a man of the field” means the following: Esau was an excellent hunter who was able to hunt the creature known as the Ish Sadeh (איש שדה). This is the creature that rules over the fields (אדני השדה) that is mentioned in the Mishnah in Kila’im (8:5). This is also the creature known as the yidoni (ידעוני) in the Torah (Lev 19:31). Its face has the features of a person, as are his arms and legs, and it is attached from its umbilicus with what appears to be thick cord which comes from the earth.

No creature may venture close to it because it kills and maims all who approach it.

When it is hunted, they aim their arrows at the cord until it breaks. The creature then cries out and immediately dies. However, Esau was able to capture it alive, and the verse should be understood as if it were written “and Esau knew how to hunt the Ish Hasadeh (איש שדה).”

Incidentally, this is explanation is not original to the Gaon. It can be found, word for word, in the commentary of Rabbi Ovadiah of Bertinoro (c. 1445-1515) to the Mishnah (Kila’im 8:5). But it goes back as far at the thirteenth century, as we will see below.

The Yidoni was ….an orangutan

As the Gaon mentions, the yidoni that he posits was hunted by Esau is mentioned in the Torah, though its identity is uncertain. The Koren Bible thinks it is a wizard:

ויקרא יט, לא

אַל־תִּפְנ֤וּ אֶל־הָאֹבֹת֙ וְאֶל־הַיִּדְּעֹנִ֔ים אַל־תְּבַקְשׁ֖וּ לְטמְאָ֣ה בָהֶ֑ם אֲנִ֖י יְהֹ’ אֱלֹקיכֶֽם׃

You shall not apply to mediums or wizards, nor seek to be defiled by them: I am the Lord your God.

But let’s take a look at the commentary on the Mishnah of Rabbi Israel Lipschitz (1782–1860), known as the Tiferes Yisrael. In one of his commentaries called Yachin, he offers a precise identification of the yidoni:

נ"ל דר"ל וואלדמענש הנקרא אוראנגאוטאנג והוא מין קוף גדול בקומת וצורת אדם ממש

This is the “wild-man” known as an orangutan; it is a large monkey whose size and shape is exactly like that of a human.

And he continues:

רק שזרעותיו ארוכים ומגיעין עד ברכיו ומלמדין אותו לחטוב עצים ולשאוב מים וגם ללבוש בגדים כבן אדם ממש. ולהסב על השולחן ולאכול בכף ובסכין ובמזלג, ובזמנינו אינו מצוי רק ביערות גדולות שבאפריקא, אולם כפי הנראה היה מצוי גם בסביבות ארץ ישראל בהרי הלבנון

It has long arms that reach down to its knees. It can be trained to carry wood and draw water, and even to wear people’s clothing. It can sit at the table and eat with a spoon, knife and fork. Today, however, it is only found in large jungles in Africa, but it appears that it one could be found around Israel, in the forests of Lebanon.

Although he does not mention this fun fact, it turns out that the etymology of the word orangutan is from the Malay words orang, meaning "person", and hutan, meaning "forest.” This is, I think you will agree, awfully close to the meaning of איש שדה, no?

If this seems to be a bit of a cholent, it is. The description of the Ish Sadeh as being attached to the earth by some kind of umbilical cord invokes another legend, known as the Vegetable Lamb of Tartary, or alternatively, the Barometz. This was a mythical creature that was half-plant and half animal, usually in the form of a sheep. Like this:

From Duret, Claude (d.1611), Histoire admirable des plantes et herbes esmerueillables et miraculeuses en nature: mesmes d'aucunes qui sont vrays zoophytes, ou plant-animales. Paris : N. Bvon, 1605 Plate, p.330: 'Portrait du boramets de Scythie ou Tartarie'

Except instead of a lamb, think orangutan.

Rabbi Herman Adler Chief Rabbi, weighs in…

In 1887 Henry Lee published an entire book on the legend, called, appropriately enough The Vegetable Lamb of Tarty (London: Sampson Low, Marston, Searle and Rivington, 1887). On pages 6–7, Lee describes his correspondence with Rabbi Hermann Adler, Chief Rabbi of the British Empire. Lee had heard that the legend is mentioned in the Jerusalem Talmud, but he could not find the citation and so he wrote to Rabbi Adler for some help. Here is the rabbi’s answer. Make of it what you will.

“It affords me much gratification to give you the information you desire on the Borametz. In the Mishna Kilaim, chap. viii. § 5 (a portion of the Talmud), the passage occurs:—‘Creatures called Adne Hasadeh (literally, “lords of the field”) are regarded as beasts.’ There is a variant reading,—Abne Hasadeh (stones of the field). A commentator, Rabbi Simeon, of Sens (died about 1235), writes as follows on this passage:—‘It is stated in the Jerusalem Talmud that this is a human being of the mountains: it lives by means of its navel: if its navel be cut it cannot live. I have heard in the name of Rabbi Meir, the son of Kallonymos of Speyer, that this is the animal called ‘Jeduah.’ This is the ‘Jedoui’ mentioned in Scripture (lit. wizard, Leviticus xix. 31); with its bones witchcraft is practised. A kind of large stem issues from a root in the earth on which this animal, called ‘Jadua,’ grows, just as gourds and melons. Only the ‘Jadua’ has, in all respects, a human shape, in face, body, hands, and feet. By its navel it is joined to the stem that issues from the root. No creature can approach within the tether of the stem, for it seizes and kills them. Within the tether of the stem it devours the herbage all around. When they want to capture it no man dares approach it, but they tear at the stem until it is ruptured, whereupon the animal dies.’ Another commentator, Rabbi Obadja of Berbinoro, gives the same explanation, only substituting—’They aim arrows at the stem until it is ruptured,’ &c. The author of an ancient Hebrew work, Maase Tobia (Venice, 1705), gives an interesting description of this animal. In Part IV. c. 10, page 786, he mentions the Borametz found in Great Tartary. He repeats the description of Rabbi Simeon, and adds what he has found in ‘A New Work on Geography,’ namely, that ‘the Africans (sic) in Great Tartary, in the province of Sambulala, are enriched by means of seeds like the seeds of gourds, only shorter in size, which grow and blossom like a stem to the navel of an animal which is called Borametz in their language, i.e. ‘lamb,’ on account of its resembling a lamb in all its limbs, from head to foot; its hoofs are cloven, its skin is soft, its wool is adapted for clothing, but it has no horns, only the hairs of its head, which grow, and are intertwined like horns. Its height is half a cubit and more. According to those who speak of this wondrous thing, its taste is like the flesh of fish, its blood as sweet as honey, and it lives as long as there is herbage within reach of the stem, from which it derives its life. If the herbage is destroyed or perishes, the animal also dies away. It has rest from all beasts and birds of prey, except the wolf, which seeks to destroy it.’ The author concludes by expressing his belief, that this account of the animal having the shape of a lamb is more likely to be true than that it is of human form.”

If you check the commentary of Rabbi Shimshon of Senz (c. 1150-1230) you will indeed find this explanation of the Mishnah in Kila’im:

ירושלמי (הל' ד') אמר רבי חמא ברבי עוקבא בשם רבי יוסי ברבי חנינא טעמא דרבי יוסי וכל אשר יגע על פני השדה (במדבר י״ט:ט״ז) בגדל מן השדה כלומר מין אדם הוא א"ר בר נש דטור הוא והוא חיי מטיבורא פסק טיבורא לא חיי ושמעתי בשם הר' מאיר ברבי קלונימוס מאשפירא שהיא חיה ששמה ידוע והיא ידעוני דקרא ומעצם שלה עושין כמין כשפים וכמין חבל גדול יוצא משורש שבארץ שבו גדל אותה החיה ששמה ידוע כעין אותם קישואין ודלועים אלא הידוע צורתו כצורת אדם בכל דבר בצורת פנים וגוף וידים ורגלים ומטיבורו מחובר לחבל היוצא מן השורש ואין כל בריה רשאי ליקרב כמלא החבל שטורפת והורגת כמלא החבל ורועה כל סביבותיה וכשבאין לצודה אין אדם רשאי לקרב אצלה אלא גוררין אותה אל החבל עד שהוא נפסק והיא מיד מתה:

Rabbi Shimshon credited the legend to “Meir, the son of Kallonymous of Speyer” whose identity I am still figuring out. But this appears to be the earliest Hebrew source for the myth of the Ish Sadeh as the Barometz, (or something like it).

So to recap:

Here is what we have discovered:

There was a legend about a half-plant-half animal that appears to begin around the 11th century with a Rabbi Meir, who perhaps lived before 1196, perhaps in Speyer. Rabbi Shimshon of Sens passed the legend down, and it travelled from Ashkenaz to Italy where it appears in the writings of the Seforno. It then appears in some form in Ma’aseh Tuvia published in 1707, and then finds its way to the Gaon of Vilna, who sort of mixed it together with the Ish Sadeh, from where, perhaps, the Tiferet Yisrael got his explanation of an orangutan (but not a Boramtez). I am sure there are others along the way, but it is time to stop. There are tehilim that must be said for our brothers and sisters in Israel.

אַחֵינוּ כָּל בֵּית יִשְׂרָאֵל

הַנְּתוּנִים בַּצָּרָה וּבַשִּׁבְיָה

הָעוֹמְדִים בֵּין בַּיָּם וּבֵין בַּיַּבָּשָׁה

הַמָּקוֹם יְרַחֵם עֲלֵיהֶם

וְיוֹצִיאֵם מִצָּרָה לִרְוָחָה

וּמֵאֲפֵלָה לְאוֹרָה

וּמִשִּׁעְבּוּד לִגְאֻלָּה

הָשָׁתָא בַּעֲגָלָא וּבִזְמַן קָרִיב

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Talmudology on the Parsha, Chayei Sarah: Camels

בראשית 24: 10–19

וַיִּקַּ֣ח הָ֠עֶ֠בֶד עֲשָׂרָ֨ה גְמַלִּ֜ים מִגְּמַלֵּ֤י אֲדֹנָיו֙ וַיֵּ֔לֶךְ וְכל־ט֥וּב אֲדֹנָ֖יו בְּיָד֑וֹ וַיָּ֗קם וַיֵּ֛לֶךְ אֶל־אֲרַ֥ם נַֽהֲרַ֖יִם אֶל־עִ֥יר נָחֽוֹר׃

וַיַּבְרֵ֧ךְ הַגְּמַלִּ֛ים מִח֥וּץ לָעִ֖יר אֶל־בְּאֵ֣ר הַמָּ֑יִם לְעֵ֣ת עֶ֔רֶב לְעֵ֖ת צֵ֥את הַשֹּׁאֲבֹֽת׃

וַיֹּאמַ֓ר יְהֹוָ֗ה אֱלֹהֵי֙ אֲדֹנִ֣י אַבְרָהָ֔ם הַקְרֵה־נָ֥א לְפָנַ֖י הַיּ֑וֹם וַעֲשֵׂה־חֶ֕סֶד עִ֖ם אֲדֹנִ֥י אַבְרָהָֽם׃

הִנֵּ֛ה אָנֹכִ֥י נִצָּ֖ב עַל־עֵ֣ין הַמָּ֑יִם וּבְנוֹת֙ אַנְשֵׁ֣י הָעִ֔יר יֹצְאֹ֖ת לִשְׁאֹ֥ב מָֽיִם׃

וְהָיָ֣ה הַֽנַּעֲרָ֗ אֲשֶׁ֨ר אֹמַ֤ר אֵלֶ֙יהָ֙ הַטִּי־נָ֤א כַדֵּךְ֙ וְאֶשְׁתֶּ֔ה וְאָמְרָ֣ה שְׁתֵ֔ה וְגַם־גְּמַלֶּ֖יךָ אַשְׁקֶ֑ה אֹתָ֤הּ הֹכַ֙חְתָּ֙ לְעַבְדְּךָ֣ לְיִצְחָ֔ק וּבָ֣הּ אֵדַ֔ע כִּי־עָשִׂ֥יתָ חֶ֖סֶד עִם־אֲדֹנִֽי׃

וַֽיְהִי־ה֗וּא טֶ֘רֶם֮ כִּלָּ֣ה לְדַבֵּר֒ וְהִנֵּ֧ה רִבְקָ֣ה יֹצֵ֗את אֲשֶׁ֤ר יֻלְּדָה֙ לִבְתוּאֵ֣ל בֶּן־מִלְכָּ֔ה אֵ֥שֶׁת נָח֖וֹר אֲחִ֣י אַבְרָהָ֑ם וְכַדָּ֖הּ עַל־שִׁכְמָֽהּ׃

וְהַֽנַּעֲרָ֗ טֹבַ֤ת מַרְאֶה֙ מְאֹ֔ד בְּתוּלָ֕ה וְאִ֖ישׁ לֹ֣א יְדָעָ֑הּ וַתֵּ֣רֶד הָעַ֔יְנָה וַתְּמַלֵּ֥א כַדָּ֖הּ וַתָּֽעַל׃

וַיָּ֥רץ הָעֶ֖בֶד לִקְרָאתָ֑הּ וַיֹּ֕אמֶר הַגְמִיאִ֥ינִי נָ֛א מְעַט־מַ֖יִם מִכַּדֵּֽךְ׃

וַתֹּ֖אמֶר שְׁתֵ֣ה אֲדֹנִ֑י וַתְּמַהֵ֗ר וַתֹּ֧רֶד כַּדָּ֛הּ עַל־יָדָ֖הּ וַתַּשְׁקֵֽהוּ׃

וַתְּכַ֖ל לְהַשְׁקֹת֑וֹ וַתֹּ֗אמֶר גַּ֤ם לִגְמַלֶּ֙יךָ֙ אֶשְׁאָ֔ב עַ֥ד אִם־כִּלּ֖וּ לִשְׁתֹּֽת׃

וַתְּמַהֵ֗ר וַתְּעַ֤ר כַּדָּהּ֙ אֶל־הַשֹּׁ֔קֶת וַתָּ֥רץ ע֛וֹד אֶֽל־הַבְּאֵ֖ר לִשְׁאֹ֑ב וַתִּשְׁאַ֖ב לְכל־גְּמַלָּֽיו׃

And the servant took ten camels of the camels of his master, and departed; for all the goods of his master were in his hand: and he arose, and went to Aram-naharayim, to the city of Nahor. And he made his camels kneel down outside the city by a well of water at the time of evening, at the time that the women go out to draw water. And he said, O Lord God of my master Avraham, I pray Thee, send me good speed this day, and show kindness to my master Avraham. Behold, I stand here by the well of water; and the daughters of the men of the city come out to draw water: and let it come to pass, that the girl to whom I shall say, Let down thy pitcher, I pray thee, that I may drink; and she shall say, Drink, and I will give thy camels drink also: let her be she that Thou hast appointed for Thy servant Yitzhaq; and thereby shall I know that Thou hast shown kindness to my master.

And it came to pass, before he had done speaking, that, behold, Rivkah came out, who was born to Betu᾽el, son of Milka, the wife of Nahor, Avraham’s brother, with her pitcher upon her shoulder.And the girl was very fair to look upon, a virgin, neither had any man known her: and she went down to the well, and filled her pitcher, and came up. And the servant ran to meet her, and said, Let me, I pray thee, drink a little water of thy pitcher. And she said, Drink, my lord: and she hastened, and let down her pitcher upon her hand, and gave him drink. And when she had done giving him drink, she said, I will draw water for thy camels also, until they have done drinking.

There are a lot of camels mentioned in this week’s parsha. And they needed a lot of water. And about ten years ago, there were a lot of reactions to a paper published by a couple of archeologists from Tel Aviv University. It had this catchy title: The Introduction of Domestic Camels to the Southern Levant: Evidence from the Aravah Valley.

When were the first Levantine Camels?

Lidar Sapir-Hen and Erez Ben-Yosef had set out to answer a simple question: What is the earliest evidence of camels in the Levant, that is to say, the area around Israel, Syria, Lebanon and Jordan. They hypothesised that the camel “substantially facilitated trade across the vast deserts of Arabia, promoting both economic and social change.” So when, they wondered, did that all happen?

The evidence

Camels had been depicted in the 10-9th centuries B.C.E. at the earliest, and appeared in text as early as the 9th century B.C.E. But none of this could answer the question as to whether or not domesticated camels were used before the Iron Age, about 1200-600 B.C.E. In and around Israel, the earliest evidence of domestic camels from analysis of fragments of their bones was dated to the 11th–9th centuries B.C.E. Here is what the archeologists concluded:

Current data from copper smelting sites of the Aravah Valley enable us to pinpoint the introduction of domestic camels to the southern Levant more precisely based on stratigraphic contexts associated with an extensive suite of radiocarbon dates. The data indicate that this event occurred not earlier than the last third of the 10th century BCE and most probably during this time. The coincidence of this event with a major reorganization of the copper industry of the region—attributed to the results of the campaign of Pharaoh Shoshenq I—raises the possibility that the two were connected, and that camels were introduced as part of the efforts to improve efficiency by facilitating trade.

Camel remains from Late Bronze and Iron Age sites in the Aravah Valley. From Sapir-Hen, Lidar, and Erez Ben-Yosef. "The introduction of domestic camels to the southern Levant: evidence from the Aravah Valley." Tel Aviv 40.2 (2013): 277-285.

More recent evidence has come from the genetic analysis of wild and domesticated camels and reveals that “at least two, but more likely a minimum of six wild maternal lineages were captured during the process of domestication.” Still, this doesn’t shed light on the question of when exactly camels were domesticated.

Be careful what you read

Interestingly, the camel paper mentioned nothing about the Bible. But this did not stop sites like National Geographic from reporting that it had suggested that camels came to the area of Abraham and Eliezer “centuries later than the Bible says.” And in an article about the paper, The New York Times declared that “camels had no business in Genesis.”

In an interview with the Times, a Dr. Mizrahi, (not sure which one, could be this one or this one,) professor of Hebrew culture studies at Tel Aviv University who was not directly involved in the research, had this to say:

“One should be careful not to rush to the conclusion that the new archaeological findings automatically deny any historical value from the biblical stories…Rather, they established that these traditions were indeed reformulated in relatively late periods after camels had been integrated into the Near Eastern economic system. But this does not mean that these very traditions cannot capture other details that have an older historical background.”

Given the appalling reporting by The New York Times on the Gaza war, it’s best to heed this advice and not rush to a conclusion. Not in war, and not in peace.

Anyway, maybe there were camels…

Writing in 2020 in The Times of Israel, Joshua Berman from Bar-Ilan University (and author of Ani Maamin: Biblical Criticism, Historical Truth and the Thirteen Principles of Faith) was also critical of The New York Times:

Camels in Genesis are right where they belong. It is true that camels were not domesticated in Israel until the time of Solomon. But read Genesis carefully and you see that all its camels come from outside of Israel, from Syria, Mesopotamia, and Egypt, where there is ample evidence of domestication of the camel during the period of the patriarchs.

Marc Chavalis, Professor of History at the University of Wisconsin, also addressed the question in an article he wrote in 2018 for Biblical Archaeology Review. Chavalis presented several pieces of evidence to suggest that camels were indeed domesticated in Mesopotamia long before the time of Abraham and Eliezer:

1. On a plaque from Eshnunna in modern Iraq there appears to be a camel being ridden by a person. This plaque dates from the mid-third millennium B.C.E, well before the time of Abraham et al.

2. A text from Puzrish-Dagan in modern Iraq (perhaps) records camel deliveries. It dates from the 21st-century B.C.E

3. An 18th-century B.C.E. text (quoting from an earlier third millennium text) from Nippur in modern Iraq says, “the milk of the camel is sweet.” Chavalas explained why he thinks this refers to a domesticated camel:

Having walked in many surveys through camel herds in Syria along the Middle Euphrates River, I believe that this text is describing a domesticated camel; who would want to milk a “wild camel”? At the very least, the Bactrian camel was being used for dairy needs at this time.

4. A 17th-century text from Alalakh in Turkey includes camels in a list of domesticated animals that required food.

5. Lastly, a cylindrical seal, probably from what is now the Turkish-Syrian border from the 18th-century B.C.E. shows a two-humped camel carrying two riders. It is now in the Walters Art Museum in Baltimore. Take a moment, and you can clearly see it:

All of these examples, Chavalis wrote,

…provide evidence that at the very least, the Bactrian camel was already known and domesticated in Mesopotamia by the time of Abraham. The relatively poor representation of camels in these texts does not imply their relative rarity; they may have been prestigious. So the Biblical writers may have been highlighting Abraham’s great wealth by mentioning camels. I think this evidence is more than enough to discount the idea that the Genesis source superimposed camels in the patriarchal narratives. The writer of Genesis wrote about camels anecdotally; they add little to the narrative, except for implying Abraham’s wealth.

And so we once again have an example in which absence of evidence (no camel remains found that date to before 1,000 B.C.E) does not mean evidence of absence (there were no camels earlier than 1,000 B.C.E.). Archaeologists beware.

...by the second millennium, there were at least some domesticated camels. Thus, camel domestication had taken place in Mesopotamia by the time of Abraham. Accordingly, Chavalas argues that the camels in the stories of Abraham in Genesis are not anachronistic.
— Megan Sauter, Did Camels Exist in Biblical Times? Bible History Daily, Jan 7, 2023



אַחֵינוּ כָּל בֵּית יִשְׂרָאֵל

הַנְּתוּנִים בַּצָּרָה וּבַשִּׁבְיָה

הָעוֹמְדִים בֵּין בַּיָּם וּבֵין בַּיַּבָּשָׁה

הַמָּקוֹם יְרַחֵם עֲלֵיהֶם

וְיוֹצִיאֵם מִצָּרָה לִרְוָחָה

וּמֵאֲפֵלָה לְאוֹרָה

וּמִשִּׁעְבּוּד לִגְאֻלָּה

הָשָׁתָא בַּעֲגָלָא וּבִזְמַן קָרִיב

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Kiddushin 82a ~ The Best Doctors Go to Hell. Or to Israel.

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, 1004-1105)

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, they 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. Just ot make the point, here, also from today’s daf, a talmudic assessment of these blood-letters come surgeons:

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.

Finally, An Explanation of "The best Doctors 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 and 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.

For one will nor find in the annals of history any city whose salvation was achieved through the wisdom of Torah scholars. Thus, my advice is that everywhere, except for Poland (where clergy are treated well), one should choose a profession outside the world of Torah, and the field of medicine superior to all others. Other professions are simply a waste of time and money, and ultimately yield no benefit.
— Joseph Delmedigo, Meshiv Nefesh, 42

ּAnd Yet, Medicine is a great profession

Despite the damning evaluation of Talmud about the best of physicians, the practice of medicine was always seen as a wonderful profession for Jews. Here are a few examples, but caveat emptor, they all come from um, physicians.

Shem Tov ibn Falaquera (1224-1290)

ibn Falaquera was Spanish physician. Here is what he wrote in Sefer ha-Mevakesh,

I too have heard that the sages enjoin one to learn a wholesome occupation which can serve as protection against the vagaries of fate... Wise men have stated that the practice of medicine is superior to all other occupations, for it is both a profession and science and is closest to the science of nature.

Joseph Delmedigo 1591-1655

Joseph Delmedigo, was born Island of Crete in 1591. He had a very broad Jewish and secular education, and at the age of fifteen he left for Italy, where he enrolled in the University of Padua. There he studied astronomy, mathematics, natural science, and medicine. And there he was taught by a certain Galileo Galilei. Delmedigo was both a physician and an astronomer, and did not have nice things to say about Torah scholars:

For one will nor find in the annals of history any city whose salvation was achieved through the wisdom of Torah scholars. One would be better served with craftsmen and builders, this is even truer for the Jewish people, as we do not possess fields, or vineyards, of property. Thus, my advice is that everywhere, except for Poland (where clergy are treated well), one should choose a profession outside the world of Torah, and the field of medicine superior to all others. Other professions are simply a waste of time and money, and ultimately yield no benefit. In medicine, one can draw on the books of medicine in the Jewish tradition...

Benjamin Wolff Gintzburger

Benjamin Wolff Gintzburger, “the scion of a distinguished rabbinical family from Lithuania, and the first Jew to graduate with a medical degree from the University of Göttingen” which he obtained in 1743. He thought there was something rather divine about the practice of medicine.

No one, indeed, will deny ancient Hebrew medicine its fame, not only on account of divine testimony dating back to the most remote times, but also due to its special support, The same miraculous hand that has guided the chosen people also keeps the laws of healing nature in their utmost stability... Thus, it is evident that the divine hand, to be venerated everywhere, confirms, sustains and assists the power of medicine... When I thus praise the masters of Hebrew medicine, to mention these here is necessarily only a beginning, They have enriched the art born of human endeavor and furthered it by their ability and industry."

Aaron Solomon Gumpertz (1723-1769)

The German physician and (and friend of Moses Mendelssohn) Aaron Solomon Gumpertz graduated from the University of Frankfurt in 1751. In his commentary on the ibn Ezra called Megaleh Sod, he explains why he became a physician.

And I searched here and there, exploring the different professions, both the easy and the challenging, which is the just and clear path for one who wishes to glorify Him, which is enrobed in kindness and righteousness, and I did not find but the profession of medicine, that we have learned through tradition was practiced by great Torah scholars like Ramban, Rambam, Ralbag, Ri mi-Candia Yosef Shlomo Delmedigo], and many, many others in addition, throughout the generations. They were glorified and honored through its put-suit, for its practice is valuable and honored, service akin to the service of God.... unlike the professions of carpentry and building. With one unified voice they say, blessed is he who chooses it (medicine] and inclines his heart to the heavens... and his reward will be great.

(Want more on what Jewish physicians thought of the practice of medicine? See this wonderful article by Dr Eddie Reichman in the latest edition of Hakira, from where these examples are taken. Yes, it is behind a paywall. So pay up, it’s a great journal.)

Doctors aren’t so bad, really

Last week, together with about 1,000 others, I was on a Zoom update from Israel’s Ministry of Health for physicians, nurses and paramedics who want to volunteer and come to Israel. I don’t know if I heard this correctly, but I thought one of the representatives said that some 7,000 physicians had signed up to date. Wow. And really, times have changed. The best of us don’t deserve to go to hell. The best of us want to go to Israel.

Blessed is he who chooses medicine and inclines his heart to the heavens
— Megaleh Sod, Aaron Solomon Gumpertz (1723-1769)

  תם ונשלם מסכת קידושין וסדר מועד

וברוך מתיר אסורים ושומר עמו ישראל לעולם ועד


אַחֵינוּ כָּל בֵּית יִשְׂרָאֵל

הַנְּתוּנִים בַּצָּרָה וּבַשִּׁבְיָה

הָעוֹמְדִים בֵּין בַּיָּם וּבֵין בַּיַּבָּשָׁה

הַמָּקוֹם יְרַחֵם עֲלֵיהֶם

וְיוֹצִיאֵם מִצָּרָה לִרְוָחָה

וּמֵאֲפֵלָה לְאוֹרָה

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הָשָׁתָא בַּעֲגָלָא וּבִזְמַן קָרִיב

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Talmudology on the Parsha, Vayera: Visiting the Sick

בראשית 18:1

וַיֵּרָ֤א אֵלָיו֙ ה׳ בְּאֵלֹנֵ֖י מַמְרֵ֑א וְה֛וּא יֹשֵׁ֥ב פֶּֽתַח־הָאֹ֖הֶל כְּחֹ֥ם הַיּֽוֹם׃

And the Lord appeared to him [Amraham] by the terebinths of Mamre,

as he sat in the tent door in the heat of the day.

Rashi, the famous eleventh century commentator, cites a statement by Rabbi Hama that explains what exactly it was that God was doing when he appeared to Abraham:

רש׳י שם

וירא אליו. לְבַקֵּר אֶת הַחוֹלֶה. אָמַר רַבִּי חָמָא בַּר חֲנִינָא, יוֹם שְׁלִישִׁי לְמִילָתוֹ הָיָה, וּבָא הַקָּבָּ"ה וְשָׁאַל בִּשְׁלוֹמוֹ (בבא מציעא פ"ו)

וירא אליו AND THE LORD APPEARED UNTO HIM to visit the sick man. R. Hama the son of Hanina said: it was the third day after his circumcision and the Holy One, blessed be He, came and enquired after the state of his health (Bava Metzia 86b)

More from Rabbi Hama

Rabbi Hama bar Hanina, who lived in Israel in the third century CE turned his exegetical comment into a social action program. Here it is:

סוטה יד, א

ואמר רבי חמא ברבי חנינא מאי דכתיב אחרי ה' אלהיכם תלכו וכי אפשר לו לאדם להלך אחר שכינה והלא כבר נאמר כי ה' אלהיך אש אוכלה הוא אלא להלך אחר מדותיו של הקב"ה מה הוא מלביש ערומים דכתיב ויעש ה' אלהים לאדם ולאשתו כתנות עור וילבישם אף אתה הלבש ערומים הקב"ה ביקר חולים דכתיב וירא אליו ה' באלוני ממרא אף אתה בקר חולים

Rabbi Chama the son of Rabbi Chanina said: What is the meaning of the verse (Deut 13:5) "You should follow the Lord your God"? Is it possible for a human to follow the Divine?...The verse mean that you should emulate God's attributes. Just as he clothed the naked...you should clothe the naked. Just as Holy One, Blessed be He visited the sick...you too should visit the sick...

The Talmud on visiting the sick

For Rabbi Hama, visiting the sick should be performed because it's the right thing to do: after all, God himself visited Abraham as he was recovering from circumcision. Elsewhere, the rabbis of the Talmud taught that visiting the sick wasn’t just a kind action; it actually aided in their recovery:

נדרים לט, ב - מ, א

תניא ביקור חולים אין לה שיעור ... אמר אביי: אפי' גדול אצל קטן רבא אמר אפי' מאה פעמים ביום אמר רבי אחא בר חנינא כל המבקר חולה נוטל אחד מששים בצערו

יצא ר' עקיבא ודרש: כל מי שאין מבקר חולים כאילו שופך דמים. כי אתא רב דימי אמר: כל המבקר את החולה גורם לו שיחיה וכל שאינו מבקר את החולה גורם לו שימות

Visiting the sick is a mitzvah that has no limit... Abaye said that even an important person must visit a lesser person who is ill...Rava said: [you must visit a sick person] even one hundred times a day...Rabbi Acha bar China said: "Whoever visits a sick person takes away one-sixtieth of his suffering...

Rabbi Akiva expounded and said: "Whoever does not visit the sick, it is as if he sheds blood." When Rav Dimi came [from Israel to Babylon] he said: "Whoever visits the sick causes the person to live, and whoever does not visit the sick, causes the person to die." (Nedarim 39b-40a)

Visiting the Sick in the Modern Intensive Care Unit

Many years ago, as part of my day job, I visited the famous Grady Memorial Hospital in Atlanta, and was privileged to be given a tour of their new Neurocritical Care Unit, part of the Marcus Stroke and Neuroscience Center (and thank you, Bernie "Home Depot" Marcus). While the unit has all the fancy equipment you'd expect, what impressed me the most was a feature I had not seen in any other intensive care unit (ICU): every patient room has an adjoining suite where a family member can eat, sleep, shower and wait (and there is a lot of waiting in ICUs). There are no visiting hours; the family member literally lives in the ICU with their loved one.  My tour guide explained that the unit sees the presence of  visitors as a way of offering the best care to the patient. It is a wonderful approach to the care of the sick - but it wasn't always like that.

A HISTORY OF VISITING THE SICK - IN HOSPITALS

Visiting times in hospitals still vary greatly, and many have an open door policy. But not too long ago, you might only be able to visit a patient in a hospital for a couple of hours each week. In the 1870s, Doncaster Royal Infirmary in Britain limited visiting to three afternoons a week - which was a more generous policy than that of the Royal Berkshire Hospital, which allowed only one 15 minute visits twice a week. In a survey of over 400 British hospitals conducted in 1988, over a quarter of those which replied allowed visiting for no more than two hours a day. Perhaps these restrictive policies were in response to some visitors who abused the generosity of Britain's glorious National Health Service. 

[A more open visiting policy] proved to be a disaster, primarily because of abuse of the system by visitors. Many would arrive promptly at 8 am and stay all day. They would bring sandwiches and flasks . . . and camp out by their relative’s bed . . . Others would eat patients’ food, [and] ask for extra cups of tea...there was even a threat of violence from a visitor asked to leave temporarily...
— Alderman B. Hospital visiting hours. BMJ 1988;296:1798-9.

HELP PATIENTS GET WELL SOONER - BY VISITING THEM

According to Rabbi Acha bar China, visiting the sick actually aids in their recovery (“Whoever visits a sick person takes away one-sixtieth of his suffering...). Perhaps this is less far-fetched than it sounds. In 2006 an Italian group reported the results of a study on the effects of hospital visitors on patient outcomes in its small intensive care unit.  The ICU changed its visiting policy from a restricted one (one visitor twice a day for thirty minutes) to an unrestricted one every two months.  After two years of this alternating policy, the authors compared the outcomes of their 226 patients. Despite significantly higher environmental microbial contamination during the unrestricted visiting periods, septic complications were similar. But the risk of cardiocirculatory complications was twice as high in the restricted visiting periods, which were also associated with a (non-significantly) higher mortality rate. The unrestricted group was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. The authors concluded that "liberalizing the visiting hours seems to be more protective because it is associated with a reduction in severe cardiovascular complications."

Incidence, with Odds Ratio and 95% Confidence Intervals, of septic and major cardiovascular complications in patients enrolled during the restricted (RVP) and unrestricted visiting periods (UVP) adjusted for age, gender, and time of enrollment.…

Incidence, with Odds Ratio and 95% Confidence Intervals, of septic and major cardiovascular complications in patients enrolled during the restricted (RVP) and unrestricted visiting periods (UVP) adjusted for age, gender, and time of enrollment. RR indicates relative risk; UT, urinary tract; pul., pulmonary; and CV compl., cardiovascular complication. From Fumagalli et al. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial. Circulation. 2006;113:946-952.

Writing in The Journal of the American Medical Association in 2004, Donald Berwick and Meeta Kotogal called for a change in the policy of restricted visiting hours in intensive care units.  They noted three areas which are often of concern to ICU staff when considering the question of visiting hours.  They also noted that although these concerns seem reasonable, the scientific literature tells "quite a different story."

Physiologic Stress for the Patient: "The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress." 

Barriers to the Provision of Care: "The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians." 

Exhaustion of Family and Friends: "The third concern is that constant visiting with the patient may prove exhausting for family and friends who fail to recognize the need to pace themselves. While that does sometimes happen, it is also true that open visiting hours help alleviate the anxiety of family and friends, allowing them to spend time with the patient when they want and to feel more secure and relaxed during the time they are not with the patient. One study found that open visitation had a beneficial effect on 88% of families and decreased anxiety in 65% of families."

A review of visitation policies in ICUs produced by the American College of Critical Care Medicine Task Force went one step further and found "no evidence that pets that are clean and properly immunized should be restricted from the ICU environment." So don't forget to bring the dog next time you visit a family member or friend in the ICU (or anywhere else for that matter). 

“...the preponderance of the literature supports greater flexibility in ICU visitation policies. Descriptive studies of the physiologic effects of visiting on mental status, intracranial pressure, heart rate, and ectopy demonstrated no physiologic rationale for restricting visiting. In fact, in seven of 24 patients with neurologic injuries, family visits produced a significant positive effect, measured by decrease in intracranial pressure.
— Davidson et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Critical Care Medicine 2007; 35 (2): 612.

HOW TO VISIT A FRIEND WHO'S SICK - THEN, AND NOW

Most of the evidence about the benefits of visiting the sick that we've been discussing have centered on the ICU- because that's where most of the research has been done. But for most of the time, an ill friend will not be in the ICU, or even in the hospital. Instead they will be at home, and so that is where the visit will occur.  Sadly, the ability to be a friend to a friend who is sick does not come easy to all of us.  Here's what Letty Pogrebin noted, in her recent book How to be a Friend to a Friend Who's Sick:

It's not uncommon for people to freeze or panic in the company of misery, botch gestures that were meant to ease, attempt to problem-solve when we have no idea what we're talking about, say the wrong thing, talk too much, fidget in the sick room, sit too close to the patient or stand too far away. Some of us don't visit our sick friends at all...

The Talmud sensed that visitors need some guidelines as to how to behave, and Rav Shisha suggested the following rule (Nedarim 40): "One should not visit a sick person in the first three hours of the day or in the last three hours of the day." In addition, the Talmud notes that "one who goes to visit the sick should not sit on the bed nor on a bench or a chair, but instead should wrap himself up in his cloak and sit on the ground, because the divine presence rests above the bed of a sick person." While we may no-longer follow this advice, the suggestion that we take our visits to the sick seriously is one that we should heed. Let's close with some more advice, updated for the modern era, from Pogrebin's 2013 handbook (p86-86):

  1. Ask the patient to be honest with you and all their friends.

  2. Be honest with yourself about your attitude toward the visit.

  3. Think through your role in the visit.

  4. Don't visit if you can't abide silence.

  5. Be prepared to respond without flinching to whatever scene or circumstances greet you during your visit.

  6. Be sensitive to your friend's losses.

  7. Talk honestly with your children about the demands illness makes on friendship and how important it is to visit people who want company.

“What is the reward given for visiting the sick in this world? “God will guard him and restore him to life and he will be fortunate on earth, and You will not give him over to the desire of his foes.” [Ps 41:3.]:
”God will guard him” - from the evil inclination.
”And restore him to life” - from his suffering.
”And he will be fortunate on earth”- in that everyone will take pride in him.
”And You will not give him over to the desire of his foes”- for he will have good friends...
— TB Nedarim 40a.
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