The (Second) Great American Eclipse

Once again, it is coming. Tomorrow, on Monday April 8th there will be a solar eclipse visible to millions of people across north America.  It will be the first total eclipse to cross the continental United States since 2017, which I was lucky enough to witness with my family from Charleston, South Carolina. This time, some 31 million people in the US will be in the path of the witness the spectacle of the totality, when the day turns to night.

From GreatAmericanEclipse.com

I will be traveling to Indianapolis to witness the totality. Some time ago I considered a Talmudology Eclipse weekend, but happily, I could not pull that off since I must be in Chicago for a family event. It will the second total eclipse for me, and I am ready with my viewing glasses.

What does the Talmud have to say about the cause of a solar eclipse? (You would be very surprised.) You can find my essay on the topic here, which was published in the journal Hakirah. Since there are no new Jewish aspects to this eclipse as opposed to the one I witnessed in 2017, the essay remains current, other than for the descriptions and timing on that event.

Do go and see the total solar eclipse. It will (once again) be incredible.

Happy viewing.

The Forward, Sunday Jan 25, 1929

Bava Metzia 36b ~ Marshes, Miasmas and Bad Air

בבא מציעא לו, ב

אתמר פשע בה ויצאת לאגם ומתה כדרכה אביי משמיה דרבה אמר חייב... הכא חייב מ"ט דאמרינן הבלא דאגמא קטלה

It was stated: If a custodian was negligent in watching an animal, and it escaped to a marsh and died there of natural causes...Abaye said in the name of Rabbah: he is liable to pay for the animal...because we say that the foul air of the marsh killed it...

Two buffaloes gather by the waters of the Chebayesh marsh in Nassiriya, southeast of Baghdad, February, 2015. Image from here.

As Rashi explains, the custodian is liable because his negligence was the cause of the animal's death. 

הכא איכא למימר בפשיעה מתה. שאם היתה בבית לא מתה, ויציאתה לאגם היא פשיעת מיתתה, דשמא הבל המצוי באגם קטלה

Here you can say that it died due to negligence. For if the animal was kept at home it would not have died, but its going out to the marsh is the negligent act that resulted in its death,  for perhaps the foul air of the marsh killed it.

Today's page of  Talmud suggests that just walking in a marsh can kill you because of the poisonous air that exists there.  We’ve encountered the notion of poisonous air before in Bava Kamma (55a) where Rav Nachman suggested that a fall into a pit of less than ten tefachim was not lethal because foul air was only found at a depth of ten tefachim. According to Rav Nachman, the one who digs a pit is only liable for damages caused by foul air, rather than the trauma of the fall itself. Rav Nachman goes on to clarify that foul air may not always kill, but instead may just cause physical injury, or in his words "אין הבל למיתה ויש הבל לנזקין."

As we shall see, this notion "of bad air" was an ancient belief that lasted all the way through modern times, and the Talmud reflected a widely held theory of noxious air that came to be called the Theory of Miasmas. A miasma was a poisonous vapor or mist that caused illness or disease. Infection was thought to affect people who inhaled these bad vapors. In this way the miasma theory was used to explain the spread of contagious diseases, or the death of wandering animals.

Origins of the Miasma theory of Disease

Dana Tulodziecki, from the Department of Philosophy at Purdue University, has a nice working definition of the miasmatic theory. Here it is. 

...diseases were brought about and passed on through decomposing organic material that would disperse into the air as noxious and disease-causing odours, the miasmas. This noxious air in turn would affect potential victims, causing a variety of diseases of differing strengths. The type of disease, as well as its severity were thought to depend on the complex interplay between a number of factors, some related to the miasmas themselves (such as climate and weather, which were thought to affect miasmatic natures), some related to the potential sufferers of diseases (such as factors relating to the sturdiness of their constitutions or their values, which were thought to affect their susceptibility to various diseases), and some related to the local circumstances in which miasmas existed (such as overcrowding or bad ventilation, which were thought to compound whatever problems were already present).

The word miasma comes from the Greek μίασμα meaning pollution.  The theory dates back to Hippocrates (~460-377 BCE) who wrote about it in his classic work, On Air, Water and Places:

Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they are not at all alike, but differ much from themselves in regard to their changes. Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality.

And here's a word describing a disease you've heard of that means bad air. Malaria, from the Italian mal aria.

Marshes as Dangerous Places in ROman Times

In the first century BCE, the Roman writer Marcus Vitruvius Pollio (born ~80–70 BCE) had this to say about the dangers of the swamps and marshes:

The neighborhood of a marshy place must be avoided; for in such a site the morning air, uniting with the fogs that rise in the neighborhood, will reach the city with the rising sun; and these fogs and mists, charged with the exhalation of the fenny animals, will diffuse an unwholesome effluvia over the bodies of the inhabitants, and render the place pestilent.

Vitruvius (for some reason he is known by his middle name) lived about two hundred years before Rabbah (d.~330CE) and Rabbah's nephew Abaye (d.~339 CE), and here he implicated marshes with the causes of disease - because of the dangerous vapors they contain. Fast forward about 1,500 years and the great Florence Nightingale made the air a central part of her call for better conditions for the working class.

The very first cannon of nursing, the first and the last thing upon which a nurses's attention must be fixed, the first essential to the patient, without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM...Again, a thing I have often seen both in private houses and institutions. A room remains uninhabited...the air is stagnant, musty, and corrupt as it can by possibility be made. It is quite ripe to breed small-pox, scarlet fever, diphtheria, or anything else you please.

“From inhaling the odour of beef the butcher’s wife
obtains her obesity”

— Professor H Booth The Builder, July 1844

Do Miasmas cause cholera?

The miasmatic theory became a big deal in the discussion of the causes of the terrible cholera epidemics that ravaged London in the 1850s and beyond. William Farr was a statistician of repute; he held the important sounding position of Statistical Superintendent of the General Register Office. Farr believed that the theory completely explained both the transmission of cholera and where it struck, and his model is a reminder of how scientists can get it terribly wrong. Farr the statistician thought, along with others, that rotting organic matter would give rise to miasmas. In addition, he thought that the conditions “which are so constantly found in alluvial [muddy] soils, lying on a level with or below the tidal waters” were particularly good sources for producing miasmas.  He obtained the death rates from cholera, which he believed demonstrated that “cholera was three times more fatal on the coast than in the interior of the country”.  As Tulodziecki notes, Farr found just what the miasma theory predicted: that wherever high concentrations of miasma were predicted, the mortality rate from cholera was high, and wherever the miasma theory predicted that the concentrations of miasma were lower, so was the mortality rate.  But Farr took this to the next level. Being a good scientist he developed a law that made predictions about the death rates from cholera, that related these to the elevation of the soil. Here is what he found:

[T]he mortality from cholera in London bore a certain constant relation to the elevation of the soil, as is evident when the districts are arranged by groups in the order of their altitude. We place the districts together which are not on an average 20 feet above the Thames, and find that on this bottom of the London basin the mortality was the at the average rate of 102 in 10,000: in the second group, at 20 and under 40 feet of elevation, or on the second terrace, the mortality from cholera was the rate of 65 in 10,000; in the third group, or on the third terrace 40-60 feet high, the mortality from cholera was at the rate of 34 in 10,000; in the fourth group, 60-80 feet high, the mortality from cholera was at the rate of 27 in 10,000; in the fifth group, 80-100 feet high, the mortality was at the rate of 22 in 10,000; in a district 100 feet high, the mortality was 17 in 10,000; in Hampstead, about 350 high, the mortality was 8, or deducting a stranger infected at Wandsworth, but who died there, 7 in 10,000... [b]y ascending from the bottom to the third terrace, the mortality is reduced from 102 to 34; by ascending to the sixth terrace it is reduced to 17 … It will be observed, that the number representing the mortality on the third terrace is one-third of the number 102, representing the mortality on the first, and that the mortality on the sixth terrace is one-sixth part of the mortality on the first….

Here are Farr’s original tables:

Farr, W. Report on the mortality of cholera in England, 1848-49. London, W. Clowes 1852. lxii

From which he developed Farr’s Law of Elevations and produced this lovely diagram to show the relationship between the death rates from cholera and the elevation.

Farr, W. Report on the mortality of cholera in England, 1848-49.  London, W. Clowes 1852. lxv.

As you might have expected, those who represented religion chimed about the causes of the terrible cholera epidemic. One of those was Henry Whitehead, who served as an assistant priest at the Church of St Luke's in Soho, located in the heart of the 1854 London cholera outbreak. It was all God's will, only this time God was acting through the medium of miasmas:

Henry Whitehead. The Cholera in Berwick Street. London, Hope & Co. 1854. p.13

The Real Cause of Cholera

Scanning electron microscope image of V. Cholerae

As we have noted before, the true cause of cholera is an infectious agent, called Vibrio Cholerae. If it finds its way into your intestine, its toxin will cause the cells of your gut to excrete water at a remarkable rate. The result is overwhelming dehydration, and death may follow in a matter of hours. (By the way, water-borne cholera epidemics are still common. After the 2012 Haitian earthquake over 9,000 people died from cholera. That's 9,000 people who survived the earthquake itself, only to die from drinking water that was infected with cholera. Later, the UN announced it would pay compensation to the victims and their families, since it was United Nations peacekeepers who introduced the cholera epidemic to Haiti in 2010. Now back to the London epidemic of 1854.)  Farr had great data and a compelling theory, on par with the talmudic belief that at the bottom of a shallow pit, bad air would kill you. But Farr’s Law of Elevations is wrong. The transmission of cholera has nothing to do with the elevation of those it infects.  It is a water-borne disease, and if the water is cleaned of cholera, the disease vanishes. End of story.  

It's Hard to Be Right....

It was John Snow who investigated the cholera epidemic of 1854 and discovered its source was a contaminated water pump.  Snow, whose day job was anesthesiologist to Queen Victoria, had to convince a skeptical group of physicians, including those who believed in the miasmatic theory and the compelling data of miasmatist-in-chief William Farr. Although we know Snow was absolutely correct, here is the kind of opposition he encountered, from an editorial on the pages of Britain's leading medical journal The Lancet:

Why is it, then, that Dr. Snow is so singular in his opinion? Has he any facts to show in proof? No!... But Dr. Snow claims to have discovered that the law of propagation of cholera is the drinking of sewage-water. His theory, of course, displaces all other theories. Other theories attribute great efficacy in the spread of cholera to bad drainage and atmospheric impurities. Therefore,says Dr. Snow, gases from animal and vegetable decomposition are innocuous ! If this logic does not satisfy reason, it satisfies a theory; and we all know that theory is often more despotic than reason. The fact is, that the well whence Dr. Snow draws all sanitary truth is the main sewer. His specus, or den, is a drain. In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again.

Wow. And you thought politics was a tough profession.  Anyway time went on and more evidence was found to support Snow and the water-borne model of cholera against Farr and the air-borne explanation.  In 1866 the snarky Lancet had a volte-face (that's a U-turn in Britain, or a flip-flop here in the US) and admitted Snow had been right all along, though it came a little late for poor Dr Snow. He had died eight years earlier.

We understand that the sisters of the late Dr. Snow are now in a position of considerable pecuniary difficulty; they are, in fact, almost if not entirely without means. The researches of Dr. Snow are among the most fruitful in modern medicine. He traced the history of cholera. We owe to him chiefly the severe induction by which the influence of the poisoning of water-supplies was proved. No greater service could have been rendered to humanity than this; it has enabled us to meet and combat the disease, where alone it is to be vanquished, in its sources or channels of propagation...Dr. Snow was a great public benefactor, and the benefits which he conferred must be fresh in the minds of all.

Why We Believed in the Miasma Theory of Disease

What explains the persistence of the theory of miasmas from at least 400 BCE, through the times of our own Talmud Bavli and on to London in the middle of the nineteenth century?  In his excellent book The Ghost Map, (subtitled The story of London's most terrifying epidemic and how it changed science, cities, and the modern world) Steven Johnson has an explanation that is as compelling as any I have read. 

The perseverance of miasma theory into the nineteenth century was as much a matter of instinct as it was intellectual tradition. Again and again in the literature of miasma, the argument is inextricably linked to the author’s  visceral disgust at the smells of the city. The sense of smell is often described as the most primitive the senses, provoking powerful feelings of lust or repulsion…Modern brain-imaging technology has revealed the intimate physiological connection between the olfactory system and the brain's emotional centers. In fact, the seat of many of those emotional centers -the limbic system- was once called the rhinencephalon, literally "nose-brain" or "smell-brain." A 2003 study found that strong smells triggered activity in both the amygdala and the ventral insula…Both regions can be thought of as alarm centers of the brain; in humans, they possess the capacity to override the neocortical systems where language-based reasoning occurs…

The human brain appears to have evolved an alert system whereby a certain class of extreme smells triggers an involuntary disgust response that effectively short-circuits one’s ability to think clearly, and produces a powerful desire to avoid objects associated with that smell. It is easy to imagine the evolutionary pressures that would bring this trait into being. Once again microbes are at the center of the story. Eating meat or vegetation that has already begun the decomposition process poses a significant health risk, as does eating foods that have been contaminated with fecal matter-precisely because of the microbial life-forms that are doing the decomposing...

The trouble is that survival strategies optimized for a hunter-gatherer lifestyle play out differently in a modern city of two million people. Civilization had produced many transformations in the experience of human life: farms, wheels, books, railroads. But civilized life had another distinguishing feature: it was a lot smellier. Densely packed populations of people without modern waste-management systems produced powerfully repellent odors...

The miasmatists had plenty of science and statistics and anecdotal evidence to demonstrate that the smells of London weren't killing people.But their gut instincts - or, more like it, their amygdalas- kept telling them otherwise. All of John Snow's detailed, rigorous analysis of the water companies and the transmission routes...couldn't compete with a single whiff of the air...The miasmatist wsere unable to override the alarm system that had evolved so many aeons before.They mistook the smoke for the fire.

Abaye and Rava on Miasmas

We opened this post pointing out that it was Abaye who explained why the watchman of an animal that escaped to a marsh and died there was responsible for damages:  the miasmas of the marshes killed it and the watchman should have been, well, more watchful. However Rava, who often sparred with Abaye over points of law, disagreed, and exempted the watchman from liability. When your time is up, it's up, and the animal would have died anyway, or as Rava put it: "With respect to the Angel of Death, what does it matter to me if the animal is here or there." Jewish law, the halakha, ruled like Rava, but it is worth noting that Rava too believed in the marsh miasmas, at least according to the medieval talmudist Avraham ben David (Ra'avad, d. 1198), as quoted in the sixteenth century work Shitta Mekubetzet:

שיטה מקובצת בבא מציעא דף לו, ב 

ראב"ד

סבירא ליה לרבא שאין האויר מזיק אלא לענין חליי הגוף אבל לענין מיתה לא מעלה ולא מוריד

Rava believed that the atmosphere causes only morbidity but not mortality...

Today we know that the air we breathe does indeed have a great impact on your health. One study from MIT estimated that there are 200,000 premature deaths in the US each year from combustion emissions. But do rotten smells, marshes and ground floor apartments cause disease? Nope. But it's taken over two thousand years to realize that.  

Talmudology on the Parsha, Shmini: ~ How Many Letters are in a Sefer Torah?

ויקרא 10:16

אֵ֣ת ׀ שְׂעִ֣יר הַֽחַטָּ֗את דָּרֹ֥שׁ דָּרַ֛שׁ מֹשֶׁ֖ה וְהִנֵּ֣ה שֹׂרָ֑ף וַ֠יִּקְצֹ֠ף עַל־אֶלְעָזָ֤ר וְעַל־אִֽיתָמָר֙ בְּנֵ֣י אַהֲרֹ֔ן הַנּוֹתָרִ֖ם לֵאמֹֽר׃

Then Moses carefully inquired about the goat of sin offering, and it had already been burned! He was angry with Eleazar and Ithamar, Aaron’s remaining sons, and said,

In this week’s parsha, Moses gets angry with Eleazar and Ithamar, two of the sons of Aaron. What is of interest to us this week is not why Moses was angry. Instead we will focus on two short words in the verse above “דרש דרש” meaning “he carefully inquired.” Most of the classic commentaries interpret this to mean that Moses asked two questions, rather than just one. But the Talmud occupies itself not with the meaning of these words, but their location in a Sefer Torah. They are, according to talmudic tradition, the halfway point in the number of words in the Torah.

קידושין ל, א

לפיכך נקראו ראשונים סופרים, שהיו סופרים כל האותיות שבתורה, שהיו אומרים: וא"ו דגחון חציין של אותיות של ספר תורה, דרש דרש  חציין  של תיבות, והתגלח של פסוקים

Therefore the early sages were called "counters" - soferim - because they counted all the letters of the Torah. They used to say: the letter vav of the word Gachon (Lev.11:42) is the half-way point of the letter of a Torah. The words "darosh darash" (Lev. 10:16) represent the half way point of the number of words in the Torah. The verse that begins with the word "Vehitgalach" (Lev.13:33) is the half way point of the number of verses in the Torah...

The business of counting the letters in the Torah was apparently taken very seriously - so much so that one of the names by which the rabbis of the Talmud were known  - soferim - means "those who count."  To this day, the person who handwrites a Sefer Torah is called a counter (סופר), and not a writer (כותב). The Talmud emphasizes that this counting exercise was taken so seriously that the letters, words and verses were counted, and counted again. 

קידושין ל, א

בעי רב יוסף וא"ו דגחון מהאי גיסא או מהאי גיסא א"ל ניתי ס"ת ואימנינהו מי לא אמר רבה בר בר חנה לא זזו משם עד שהביאו ספר תורה ומנאום

Rav Yosef asked a question: This letter vav of the word Gachon, is it part of the first half or part of the second half of the letters of the Torah? They said to him, "let us bring a Torah scroll and count! For didn't Rabbah bar bar Channah say in a similar context: "They did not move from there until they brought a Torah scroll and counted all its letters"...

 The View of Tradition, And OF the Journal Tradition

Writing in Tradition in 1964, the late scholar Louis Rabinowitz (d. 1984) asked how Orthodox Jews should regard the text of the Torah , "...upon which depends the whole enduring magnificent structure of the Oral Law and the Halakhah, in comparison with those texts which show variants from it?"  Here is his reply:

“The answer is surely simple and logical. “The early scholars were called Soferim,” declares the Talmud (Kid. 30a) “because they were wont to count (soferim) all the letters of the Torah.” The meticulous manner in which they carried out this task is sufficiently indicated in the same passage by the information which it elicited to the effect, for instance, that the vav of gachon (Lev. 9:42 - [sic]) marks the half-way mark of the letters of the Torah, the words darosh darash of Lev. 10:16 the dividing line between the words...


With what loving care and sacred devotion, then, did they jealously guard every letter of the text! What exhaustive and detailed regulations they laid down in order to ensure that the copying of the scrolls should be completely free from human error! There has been nothing like it in the history of literature or religion, and in this respect the Massoretic text stands indisputably in a class by itself.”

— Louis Rabinowitz. Torah Min Ha-Shamayim.Tradition: A Journal of Orthodox Jewish Thought, 1964-5: 7;1: 34-45

Leaving aside the ironic typographic error that mis-references the location of the vav of Gachon, was the late rabbi Rabinowitz correct in remarking on the "loving care and sacred devotion," with which "they jealously guard every letter of the text"?

So how many letters are there in a Torah?

There are varied counts given for the number of letters in the Torah, but a couple of results seem to be most popular.

• 304, 805 From here, and here and here, and from Even-Shoshan (see below).

• 304,801 From here.

One website shares the source code used to count the words and letters in Torah; its results are shown below, and are off by four when compared to others who claim to have counted.

Letters and Words in the Torah
	Words	Letters
בראשית	20,614	78,063
שמות	16,714	63,527
ויקרא	11,950	44,790
במדבר	16,408	63,529
דברים	14,295	54,892
TOTAL	79,981	304,801

And How Many Verses Are There?

The same website gives a count of 5,844 verses in the Torah.  Rabbi Yair Chaim ben Moses Bachrach (d. 1702), author of the Chavot Ya'ir, notes that there are 5,845 verses in the chumashim he used. But today's daf of Talmud records that there are 5,888 verses. And here is the count from Even-Shoshan's קונקורדנציה חדשה (New Concordance of the Bible):

From Even-Shoshan (ed.) A New Concordance of the Bible. Kiryat Sefer, Jerusalem 1987.

Side-Bar: From Where did Even-SHoshan Get his word count?

Even-Shoshan lists his reference as Rabbi Chaim Mordechai Brecher, who published a Yiddish translation of the entire Hebrew Bible. (Brecher was born in what is now the Ukraine in 1880 and died in New York in 1965.  His Yiddish translation was published in New York in 1941, and was republished six times, the last in 1957.)  At the end of the second volume of his translation (p. נא), R. Brecher addressed the thorny question of the letter and word counts in our Torahs, and had this to say:

The truth is, this [question of how many words there are in a Sefer Torah] is astonishing, and I couldn't rest because of it. So I decided to count them, and I, myself, counted all the words in the entire Torah. In order to make it clear to the reader that I didn't make a mistake in my count, I am here providing a list of all the verses in all the chapters as they are currently divided...My count is correct. As the ancient wise men say: Love Plato, love Aristotle, and love the truth most of all.

R. Brecher's total word count is 79,976 (although this count actually comes from here) - and so his half way point in the Torah is word #39,988. 

The Misplaced Middle of the Torah

According to the Talmud, the middle letter of the Torah is the Vav of the word Gachon, (גחון) found in פרשת שמיני. However this claim is way off. Since there are about 304,805 letters in the Torah scrolls in use today, (I say about because of what we have just noted regarding the precise count,) the middle letter would be letter # 152,403, the first word of this verse (Lev 8.29):

ויקרא פרק ח פסוק כט 

ויקח משה את החזה ויניפהו תנופה לפני יקוק מאיל המלאים למשה היה למנה כאשר צוה יהו–ה את משה 

However the Vav of the word Gichon, is letter #157,236 - off by 4,833 letters. Oy.

It's no better regarding the words. If we go with the actual word count as being 79,980, then the middle words are # 39,990 and #39,991. These are the words יצק אל in verse below (Lev. 8:18):

ויקרא פרק ח פסוק טו 

וישחט ויקח משה את הדם ויתן על קרנות המזבח סביב באצבעו ויחטא את המזבח ואת הדם יצק אל יסוד המזבח ויקדשהו לכפר עליו

But the middle words of the Torah, according to Today's daf, are דרש דרש found over 900 words later (Lev.10:16):

ויקרא פרק י פסוק טז 

ואת שעיר החטאת דרש דרש משה והנה שרף ויקצף על אלעזר ועל איתמר בני אהרן הנותרם לאמר

That's a lot of letters to miscount, especially if your name is "the counter." Several suggestions have been made to address these discrepancies:

1.  The text of the Torah that the rabbis of the Talmud were using was significantly different to the one we use today.  This is possible, but then why does the Talmud never cite of any of these extra words and verses? The discrepant count is about 3% - that's a lot of missing text.

2.  The rabbis in the Talmud were not good at math. Again, possible, but the Talmud claims that they took the counting so seriously that they were called COUNTERS. It also claims that they undertook the counting exercise on several different occasions.  Were they really that bad at math?

3. The rabbis in the Talmud didn't mean this count to be taken literally. While many apologists like this answer, it is at total odds with the text. The Talmud states: they counted.

4.  The rabbis guesstimated the count. Perhaps the rabbis never really counted, but guessed at where the middle of the Torah lay: somewhere in the middle of the middle of the Five Books. After that, the letter vav of the word Gachon became the official midpoint, even though it was not accurate.  The problem with this suggestion is again, that the Talmud states that the soferim actually counted, and counted again. Not that they guessed, and guessed again.  

Science, Math and Judaism

Of all the scientific disciplines, it is mathematics that is first introduced to us. We teach toddlers to count, sometimes before they can even walk, and we all pursue some kind of mathematical training through high school.  Unlike medicine or physics or biology or astronomy, mathematics is something we all do, to some degree.  And we all understand what counting means.  This passage in the Talmud is the most readily understandable example of a conflict between science and Judaism. It is a conflict in which the basic text of rabbinic Judaism declares a fact that is, well, just not a fact.  Some find this conflict to be so intellectually troubling that their only path is to reject Jewish practice. Others, equally aware of the conflict, are comfortable with their intellectual position in which the scientific inaccuracies of the Talmud require no wholesale rejection of Jewish practice. Where do you fit on this spectrum, and, perhaps more importantly, what can you do to engage in a respectful dialogue with those whose opinions on these matters are not your own?

Bava Metzia 30b ~ Visiting the Sick

 בבא מציעא ל ,ב 

דתני רב יוסף והודעת להם זה בית חייהם את הדרך זו גמילות חסדים (אשר) ילכו זה ביקור חולים בה זו קבורה ואת המעשה זה הדין אשר יעשון זו לפנים משורת הדין

Rav Yosef taught: The verse states (Ex. 18:20):

"You shall make known to them" -this refers to their livelihood

"The way" - this refers to good deeds

"That they may walk"  - this refers to visiting the sick...

According to Rav Yosef, Moses was instructed to let the people know that they must pursue a livelihood, perform kind acts and visit the sick.  Let's remind ourselves of the importance of that last one, with a repost from Nedarim 39. There, we read the following:

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)

Some time ago 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

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. 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 so in the daf that we will learn tomorrow, Rav Shisha suggested the following rule: "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... ”

— Nedarim 40b