Bava Basra 24a ~The Chatam Sofer, Rationalism, and Anatomy That Isn't There

In August 2013 a paper published in the otherwise sleepy Journal of Anatomy caused quite a sensation. Although doctors have been dissecting the human body for centuries, it seems that they missed a bit, and a team from Belgium announced that they had discovered a new knee ligament, which they called the anterolateral ligament. On today’s page of Talmud the rabbis describes the opposite phenomena. In it, the rabbis describe an anatomical part that is really hard to identify, and may not exist at all.  It is called the aliyah, which usually refers to an attic or the upper chamber of a house.

PROXIMITY or Majority?

The rabbis are trying to resolve the issue of who owns a dove found between two dove cots. How far could it hop, and what difference might that make with regards the decision?

בבא בתרא כג, ב

ניפול הנמצא בתוך חמשים אמה הרי הוא של בעל השובך חוץ מחמשים אמה הרי הוא של מוצאו נמצא בין שני שובכות קרוב לזה שלו קרוב לזה שלו מחצה על מחצה שניהם יחלוקו

With regard to a dove chick [nippul] that was found within fifty cubits of a dovecote, it belongs to the owner of the dovecote.If it was found beyond fifty cubits from a dovecote, it belongs to its finder.In a case where it was found between two dovecotes, if it was close to this one, it belongs to the owner of this dovecote; if it was close to that one, it belongs to the owner of that dovecote. If it was half and half, [i.e., equidistant from the two dovecotes,] the two owners divide the value of the chick.

Fair enough. But Abbaye, the great fourth century Babylonian sage had a different take. Perhaps we should not be concerned with proximity, but instead be concerned with who owns the majority of the doves in the area. And brings a proof that will surprise you.

אמר אביי אף אנן נמי תנינא דם שנמצא בפרוזדור ספיקו טמא שחזקתו מן המקור ואע"ג דאיכא עלייה דמקרבא

Abaye said: We learn in a Mishnah (Niddah 17b) as well that one follows the majority rather than proximity: With regard to blood that is found in the corridor [baperozdor],i.e., the cervical canal, and it is uncertain whether or not it is menstrual blood, it is ritually impure as menstrual blood, as there is a presumption that it came from the uterus, which is the source of menstrual blood. [And this is the halakha even though there is an upper chamber, which empties into the canal, which is closer.]

Here is that Mishnah in full:

נדה יז, ב

משל משלו חכמים באשה החדר והפרוזדור והעלייה דם החדר טמא דם העלייה טהור נמצא בפרוזדור ספקו טמא לפי שחזקתו מן המקור

The Sages had a parable with regard to the structure of the sexual organs of a woman [based on the structure of a house]: The inner room represents the uterus, and the corridor [perozdor] leading to the inner room represents the vaginal canal, and the upper story represents the bladder. 

Blood from the inner room is ritually impure. Blood from the upper story is ritually pure. If blood was found in the corridor, there is uncertainty whether it came from the uterus and is impure, or from the bladder and is pure. Despite its state of uncertainty ,it is deemed definitely impure, due to the fact that its presumptive status is of blood that came from the source ,i.e., the uterus, and not from the bladder. 

What anatomy is being discussed here? In particular, what is the aliyah, the “attic” of female genital anatomy? It turns out to be complicated.

the Aliyah surrounds the ovaries

From the Mishanh in Niddah, it is clear that the aliyah sometimes bleeds, and that this blood becomes visible when it passes into the vagina. Maimonides identifies the aliyah with the space that contains the ovaries and the fallopian tubes. In modern medicine the ovaries and the Fallopian tubes and tissues that support them are called the adenxa. They are further from the vagina that the uterus, and so this identification does not fit in with Abaye's anatomy in which the aliyah is closer to the vagina than is the uterus.

רמב׳ם הל׳ איסורי ביאה ה, ד

ולמעלה מן החדר ומן הפרוזדוד, בין חדר לפרוזדוד, והוא המקום שיש בו שתי ביצים של אישה, והשבילים שבהן מתבשלת שכבת זרע שלה--מקום זה הוא הנקרא עלייה.  וכמו נקב פתוח מן העלייה לגג הפרוזדוד, ונקב זה קוראין אותו לול; והאבר נכנס לפנים מן הלול, בשעת גמר ביאה

Above the uterus and the vagina, between the uterus and the vagina, is the place in which the two ovaries are found, and the tubes along which the sperm from intercourse matures, this place is called the aliyah. (Maimonides, Mishneh Torah Issurie Bi'ah 5:4)

As we said, the problem is that the space which contains the ovaries is inside the abdomen, and this space does not connect with the vagina. It connects via the Fallopian tubes with the uterus.  Although Maimonides does not identify the aliyah as the ovaries themselves, some have done so. But the problem with this is that the ovaries don't bleed unless they develop a large cyst which then ruptures. But even in this case they bleed into the abdomen, or into the uterus, again via the Fallopian tubes, and not directly into the vagina.

Menachem ben Shalom (1249-1306) known as the Meiri, wrote an important commentary on the Talmud call Bet Habechirah - בית הבחירה and in it he too identifies the aliyah as the space between the uterus and the vagina in which the ovaries are found. He notes that in this space there are many blood vessels which may rupture and bleed directly into the vagina (עורקים שמתבקעים לפעמים), but as we have noted this is not biologically correct. Any bleeding from the adnexa is via the Fallopian tubes into the uterus itself, and certainly not directly into the vagina.

The Aliyah is the vagina

In his classic Biblisch-Talmudische Medezin published in 1911, Jacob Preuss identified the aliyah as the vagina. "It can be assumed with reasonable certainty" he wrote "that the cheder refers to the uterus, that the prosdor is the vulva, and that the aliyah is the vagina." However certain he may have been, Preuss is the only one to make this identification, which does not fit in with the text of the Mishanh. So let's try another suggestion.

The Aliyah is the Bladder

Sefer Ha'Arukh, Venice 1552.

Natan ben Yechiel of Rome, who died in 1106, wrote an influential lexicon of talmudic terms called the Sefer Ha'Arukh (ספר הערוך) which was first published around 1470. In that work the aliyah is identified as the urinary bladder. This identification also cannot be correct, because the bladder does not empty into the vagina, and because it does not lie between the uterus and the vagina but anterior to them. The commentary in the Schottenstein Talmud to Niddah 17b notes that a connection between the urethra and the vagina (known as a urethero-vaginal fistula) might account for bleeding from the bladder into the vagina. This is possible - though it is of course not normal anatomy.  

From here.

The AliyaH is a completely new structure

Meir ben Gedaliah of Lublin (d.1616) also considered the location of the aliyah in his modestly titled book Meir Einei Hakhamim - מאיר עיני חכמים - (Enlightening the Eyes of the Sages) first published in Venice in 1618.  He locates it between the uterus and the bladder, and provides two helpful schematics. The problem is that there is no such organ. You won't find it if you dissect a cadaver, and you won't find it in any textbook of anatomy (like this one). And as one astute radiologist and reader of Talmudology recently told me, you won't find it on an MRI either. Here is the text. 

Maharam Lublin. Meir Einei Hakhamim. Venice 1618. p255b.

This non-existent anatomy is also pictured in the Schottenstein Talmud (Niddah 17b), based on the difficult Mishanah.  

From Schottenstein Talmud Niddah 17b. Note that this does NOT correspond to the known female anatomy, but is a schematic based on Rashi's understanding.

The CHatam Sofer on the Aliyah

Moses Schreiber known as Chatam Sofer, (d. 1839) was a leader of Hungarian Jewry and he too weighed in on the issue in his talmudic commentary to Niddah (18a).

What is the "corridor" or the "room" or the "roof" or the "ground" or the "aliyah" ? After some investigation using books and authors experts and books about autopsies it is impossible to deny the facts that do not accord with the statements of Rashi or Tosafot or the diagrams of the Maharam of Lublin...but you will find the correct diagram in the book called Ma'asei Tuviah and in book Shvilei Emunah...therefore I have made no effort to explain the words of Rashi or Tosafot for they are incompatible with the facts...

Tuviah HaCohen, the Doctor from Padua

I couldn't find the diagram in any edition of the Shvilei Emunah to which the Chatam Sofer refers, so let's look at the diagram from Ma'asei Tuviah, which I happen to have in my own library.

Detail from Tuviah HaCohen, Ma'aseh Tuviah, Venice 1708. p132b.

A careful reading of the annotation (זז) reveals that Tuviah HaCohen (1652-1729) identifies the aliyah as that area containing the ovaries and the Fallopian tubes. In doing so he followed the opinion of Maimonides that we cited earlier, even though that does not in any way fit in with the understanding of Abaye and his ruling that blood found in the vagina that comes from the aliyah is not impure because it does not come from the uterus. Any gynecologist (or first year medical student completing their anatomy dissections) will tell you that blood from the adnexa (the ovaries and Fallopian tubes) can only get into the vagina via the uterus. But the most interesting part of this diagram is the very first line of text, at the top of the image. 

פירוש המחבר כפי ידיעת הנתוח  

The author's explanation according to knowledge gained from an autopsy

Anatomical Theatre, Palazzo del Bo, at the University of Padua. It was built in 1594 by the anatomist who helped found modern embryology, Girolamo Fabricius. From here.

Here, perhaps for the first time, anatomical knowledge from an autopsy is being shared in Hebrew. At the medical school in Padua, two bodies (one of each sex) had to be dissected each year, and all the students attended- Tuviah included.  As a medical student, Tuviah would have stood in the famous anatomical theater and watched the dissection, perhaps following along in one of the textbooks based on those dissections. 

Facts Matter

As the Chatam Sofer noted, facts matter. The illustration in the work of the Maharam of Lublin was an example of trying to get the facts to fit the text of the Mishnah (or more precisely, the explanations of Rashi and Tosafot) but in doing so the Maharam created a fictitious anatomical part.

It is very unlikely that the rabbis of the Talmud witnessed human dissections. In the ancient world two Greeks, Herophilus of Chalcedon and  Erasistratus of Ceos (who lived in the first half of the third century BCE) were "the first and last ancient scientists to perform dissections of human cadavers." Facts about human anatomy became clear once human dissection began in the fourteenth century, but as is demonstrated by the Maharam of Lublin, these lessons did not always diffuse into the Jewish community.  The Chatam Sofer is often - and rightly  - cited as a force for tradition against the challenges from the outside world. But the Hatam Sofer, at least in so far as gynecology was concerned, had no time for a theory when the facts show otherwise. In an age of "alternative facts" the Chatam Sofer is a model of rationalism.

Bava Basra 20a ~ A Baby Born After Eight Months

Getty Images

A Baby at the Window

In tomorrow's page of Talmud we read a list of objects which, if placed in an opening between rooms, blocks the tumah (ritual impurity) from passing from one room into the next. Among that list is a baby born after only eight months of gestation:

בבא בתרא כ, א

 עשבין שתלשן והניחן בחלון או שעלו מאליהן בחלונות ומטלוניות שאין בהן שלש על שלש והאבר והבשר המדולדלין בבהמה ובחיה ועוף ששכן בחלון ועובד כוכבים שישב בחלון ובן שמנה המונח בחלון והמלח וכלי חרס וספר תורה כולם ממעטין בחלון 

Grass that was plucked and placed in an opening, or grass that grew by itself in an opening; scraps of fabric that are smaller than three by three fingerbreadths; a partially severed limb or a piece of flesh hanging from a domestic or a wild animal; a bird resting in an opening; an idol worshipper sitting in an opening; a baby born after only eight months of gestation lying in an opening; salt, earthenware vessels and a Torah scroll -all of these reduce the size of the opening and so prevent the tumah from passing through it.

The Talmud then questions this ruling about the premature child lying on a window between two rooms, one if which contains a source of tumah. Won't the mother of the baby carry the child away? How then can we suggest it will be a barrier to the tumah? The Talmud, as always, has a solution: the case is regarding a child born prematurely on Shabbat. Such a child is mukzteh, that is, it is in a category of objects that must not be moved on Shabbat: 

דתניא בן שמנה הרי הוא כאבן ואסור לטלטלו בשבת

For it was taught in a Braisa. A baby born at eight months of gestation is treated like a stone

[on Shabbat, because it is muktzeh.]

The premature baby is given the status of a stone because it was not considered to be viable, and as a non-viable human being it does not contract ritual impurity. So that's why the premature baby is listed along with grass, idol worshippers, and the severed limbs of cattle as preventing the transmission of tumah. Got it?

When we studied Yevamot we came across another case which pivoted on the viability of babies born at seven vs. eight months of gestation. The question there was about proving the paternity of a child, and the discussion hinges on the belief that while a child born after seven months of gestation would be viable, a child born at eight months gestation would not be so.  Rashi noted the following: בר תמניא לא חיי -  "an eight month fetus cannot survive." And so now we can ask, where on earth does this notion come from? 

Seven vs Eight Months of gestation in antiquity

Homer's Iliad, written around the 8th century BCE,  records that a seven month fetus could survive. But it is not until Hippocrates (c. 460-370 BCE, or some 500 years before Shmuel), that we find a record of the belief that a fetus of eight months' gestation cannot survive, while a seventh month fetus (and certainly one of nine months gestation) can.  His Peri Eptamenou (On the Seventh Month Embryo) and Peri Oktamenou (On the Eight-Month Embryo) date from the end of the fifth century BCE, but this belief is viewed with skepticism by Aristotle.

In Egypt, and in some other places where the women are fruitful and are wont to bear and bring forth many children without difficulty, and where the children when born are capable of living even if they be born subject to deformity, in these places the eight-months' children live and are brought up, but in Greece it is only a few of them that survive while most perish. And this being the general experience, when such a child does happen to survive the mother is apt to think that it was not an eight months' child after all, but that she had conceived at an earlier period without being aware of it.

The belief that an eight month fetus cannot survive has a halakhic ramification: Maimonides ruled that if a boy was born prematurely in the eighth month of his gestation and the day of his circumcision (eight days after his birth) fell out on shabbat, the circumcision - which otherwise would indeed occur on Shabbat, is postponed until Sunday, the ninth day after his birth. 

רמב׳ם הל' מילה יד, א

מי שנולד בחדש השמיני לעבורו קודם שתגמר ברייתו שהוא כנפל מפני שאינו חי... אין דוחין השבת אלא נימולין באחד בשבת שהוא יום תשיעי שלהן

A child born after eight months of gestation before being fully formed is treated as a stillbirth because it will not live...and we do not set aside the laws of Shabbat [to circumcise him] but he is circumcised on Sunday, which is the ninth day of his life.

This belief persisted well into the early modern era. Here is a state–of–the–art medical text published in 1636 by John Sadler.  Read what he has to say on the reasons that an eight month fetus cannot survive (and note the name of the publisher at the bottom of the title page-surely somewhat of a rarity then): 

Saturn predominates in the eighth month of pregnancy, and since that planet is "cold and dry"," it destroys the nature of the childe". That, or some odd yearning of the child to be born in the seventh but not the eight month (according to Hippocrates) is the reason that a child born at seven and nine months' gestation may survive, but not one born at after only eight months. 

Evidence from Modern Medicine

Today we know that gestational length is of course critical, and that, all things being equal, the closer the gestational length is to full term, the greater the likelihood of survival. We can state with great certainty, that an infant born at 32 weeks or later (that's about eight months) is in fact more likely to survive than one born at 28 weeks (a seven month gestation.) In fact, a seven month fetus has a survival rate of 38-90% (depending on its birthweight), while an eight month fetus has a survival rate of 50-98%. Here is the data, taken from a British study.

Draper, ES, Manktelow B, Field DJ, James D. Prediction of survival for preterm births by weight and gestational age: retrospective population based study British Medical Journal 1999; 319:1093.

More recently, a study from the Technion in Haifa showed that even the last six weeks of pregnancy play a critical role in the development of the fetus. This study found a threefold increase in the infant death rate in those born between  34 and 37 weeks when compared full term babies.  

You can read more on the history of the eight month fetus in a 1988 paper by Rosemary Reiss and Avner Ash.  From what we have reviewed, the talmudic belief that a seven month fetus can survive but an eight month fetus cannot is one that was widely shared in the ancient world, and even in the early modern era.  But all the evidence we have today firmly demonstrates that it is simply not true.

[Repost in part from Yevamot 42.]

Bava Basra 16b ~ Here Comes the Sun

בבא בתרא טז, ב 

רבי שמעון בן יוחי אומר אבן טובה היתה תלויה בצוארו של אברהם אבינו שכל חולה הרואה אותו מיד מתרפא ובשעה שנפטר אברהם אבינו מן העולם תלאה הקדוש ברוך הוא בגלגל חמה אמר אביי היינו דאמרי אינשי אידלי יומא אידלי קצירא

Rabbi Shimon ben Yochai said: there was a precious stone that hung from the neck of Abraham our forefather. Any sick person who looked at it was instantly cured.  When Abraham our forefather died, the Holy One, Blessed be He, hung this stone in the orb of the sun. Abaye said, this is what is meant by the popular saying "when the sun is lifted, sickness is lifted"

Abaye, the great Babylonian sage of the fourth century, commented on a statement made Rabbi Shimon ben Yochai about two centuries earlier, and suggested that sunlight helps heal.  This was not the only time Abaye opined about the health benefits of sunlight. We came across another example when we studied Nedarim: 

נדרים  ח, ב

שמש צדקה ומרפא אמר אביי ש"מ חרגא דיומא מסי ופליגא דר"ש בן לקיש דאמר אין גיהנם לעולם הבא אלא הקב"ה מוציא חמה מנרתיקה צדיקים מתרפאין בה ורשעים נידונין בה

“The sun of righteousness, with healing in its rays” (Malachi 3:20)...Abaye said: “We learn from here that the dust of the sun heals”…Rabbi Shimon ben Gamliel said, “there is no hell in the world to come. Rather God takes the sun out of its canopy; the righteous are healed by it and the wicked are punished by it” (Nedarim 8b.)

A HISTORY OF HELIOTHERAPY

In 1903, the Nobel prize for Medicine was awarded to a Dane named Niels Finsen. Finsen had invented a focusable carbon-arc torch to treat – and cure – patients with lupus vulgaris, a painful skin infection caused by tuberculosis.  While this was the start of the modern medical use of phototherapy, using the sun as a source of healing is much, much older. Older even than the Talmud, which mentions it in today’s daf. 

“The Nobel Prize in Physiology or Medicine 1903 was awarded to Niels Ryberg Finsen “in recognition of his contribution to the treatment of diseases...with concentrated light radiation, whereby he has opened a new avenue for medical science”

Perhaps the earliest reference to heliotherapy – that is, using sunlight to heal - is found in Egyptian papyrus records from over 3,500 years ago, which record using the sun, together with ingesting a local weed, to treat skin conditions. The active ingredients of that weed, Ammi majus, were isolated in 1947. These ingredients, together with heliotherapy, were used in the first clinical trials to treat vitiligo, which were conducted, rather fittingly, in Egypt.  Further work determined that it was only a narrow part of the sun’s spectrum that was needed to treat vitiligo, psoriasis, and other skin conditions, and so lamps were developed that produced only narrow band ultraviolet light (UVB). These UVB lamps are now a mainstay of treatment for psoriasis.

“For most white people, a half-hour in the summer sun in a bathing suit can initiate the release of 50,000 IU (1.25 mg) vitamin D into the circulation within 24 hours of exposure”

— — Environmental Health Perspectives 2008:116;4. A162

SUNLIGHT FOR HEALTHY BONES

But ultraviolet light – UVB – can also be extremely dangerous. Too much exposure to sunlight will cause skin cancer, as the light produces molecules that directly damage DNA. Here is the great paradox of sunlight – too much of it will burn and can kill – but get the dose right and it is not only curative, but essential for healthy living. Sunlight is needed to produce vitamin D in the skin, and vitamin D is needed to produce healthy bones. Without it, you will develop rickets, a skeletal deformity that is characterized by bowed legs. 

Typical presentation of 2 children with rickets. The child in the middle is normal; the children on both sides have severe muscle weakness and bone deformities, including bowed legs (right) and knock knees (left). From Holick M. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004;80(suppl):1678S–88S.

SUNLIGHT FOR A HEALTHY IMMUNE SYSTEM

The sun’s light has been shown to have effect the immune system, although many of these effects are only poorly understood. 

When some nerve fibres are exposed to sunlight, they release a chemical called neuropeptide substance P. This chemical seems to produce local immune suppression.  Exposure to the ultraviolet wavelengths in sunlight can change the regulation of T cells in the body which can also modulate autoimmune diseases.

SUNLIGHT TO TREAT MELANOMA?

While sunlight can cause skin cancer, it has been shown to release a hormone called alpha melanocyte-stimulating hormone. This hormone appears to limit the damage to DNA damage from sunlight and so may actually reduce the risk of melanoma (but don't try this as a treatment yet. It's certainly not ready for prime time.)

SUNLIGHT FOR YOUR MOOD

Then there’s sunlight for your mood. Seasonal affective disorder – SAD – is caused by a lack of exposure to sunlight, which most affects those living in the northern latitudes in the winter.  SAD was first described in 1984 by Norman Rosenthal working at the National Institute of Mental Health but why it happens is still something of a mystery.  Rosenthal went on to write several best selling books on SAD and how to beat it. The answer appears to be something to do with sitting in front of a lamp that mimics sunlight (but the evidence that this works is still controversial).

 SUNLIGHT FOR BABIES WITH JAUNDICE

Sunlight is also a great treatment for babies with neonatal jaundice. This condition is very common and is caused when the baby breaks down the fetal hemoglobin with which it was born. A product of that breakdown is bilirubin, and if this is allowed to build up in the tissues it can cause lethargy, difficultly feeding, and in rare and extreme cases, brain damage. However, sunlight (or more precisely, the blue band of the spectrum at 459nm)  breaks down this dangerous bilirubin molecule into a harmless one called biliverdin.  So the best treatment for a newborn baby with mild jaundice is to put them out in the sun.  (Failing that, or if the degree of jaundice is not mild, you can consider phototherapy in the hospital.) 

The absorbance spectrum of bilirubin bound to human serum albumin (white line) is shown superimposed on the spectrum of visible light. Clearly, blue light is most effective for phototherapy, but because the transmittance of skin increases with increasing wavelength, the best wavelengths to use are probably in the range of 460 to 490 nm. Term and near-term infants should be treated in a bassinet, not an incubator, to allow the light source to be brought to within 10 to 15 cm of the infant (except when halogen or tungsten lights are used), increasing irradiance and efficacy. For intensive phototherapy, an auxiliary light source (fiber-optic pad, light-emitting diode [LED] mattress, or special blue fluorescent tubes) can be placed below the infant or bassinet. If the infant is in an incubator, the light rays should be perpendicular to the surface of the incubator in order to minimize loss of efficacy due to reflectance. From Maisels and McDonagh. Phototherapy for Neonatal Jaundice. New England Journal of Medicine 2008.358;920-928.

SUNLIGHT FOR INFECTIOUS DISEASES

 We don't treat infectious diseases with sunlight any more. But it wasn't always that way. Less than eighty years ago sunlight was recommended as a therapy for some patients with tuberculosis. The authors, writing in the journal Diseases of the Chest were cautious:

Even in those cases where the sun can be of great value, it is in no sense a specific cure for any manifestation of tuberculosis. Rest, good food, and fresh air, are still the fundamentals in treating all forms of the disease; and the sun, where it should be used, is only a valuable adjutant...Heliotherapy is not indicated in all cases of tuberculosis. The majority of patients with this disease should never use it...It is not a sure cure for any type of tuberculosis, but is often, especially in some of the extrapulmonary cases, a very valuable—or even necessary—aid.

In today's daf, Abaye once again noted that the sun can heal. His insight were more correct than he could ever have guessed.  

“Bright light therapy and the broader realm of chronotherapy remain underappreciated and underutilized, despite their empirical support. Efficacy extends beyond seasonal affective disorder and includes nonseasonal depression and sleep disorders, with emerging evidence for a role in treating attention-deficit/hyperactivity disorder, delirium, and dementia.”

— — Schwartz and Olds. The Psychiatry of Light. Harvard Review of Psychiatry 2015. 23 (3); 188.S

[Repost from Nedarim 8.]

Bava Basra 12b ~ Prophecy and Mental Illness

בבא בתרא יב, ב 

א"ר יוחנן מיום שחרב בית המקדש ניטלה נבואה מן הנביאים וניתנה לשוטים ולתינוקות

Rabbi Yochanan said: "After the destruction of the Holy Temple the power of prophecy was taken from the prophets and given to the mentally ill and to children. 

A long time ago I saw a patient in the emergency department who was brought in by ambulance after a worried relative called about his odd behavior. The patient had long been hearing voices. In his apartment the medics had found a little clay model of Jerusalem which the voices had told him to besiege. He told the medics that the voices had told him to lay on his right side for exactly three hundred and ninety days, which he had done.  He survived by eating through a store of barley, beans and lentils which those same voices had told him to prepare. The voices also told him to bake bread over a fire that burned human excrement, but the patient had protested, and the voices agreed to let him burn animal dung instead.  

In The Madhouse — Plate 8. From A Rake's Progress, William Hogarth, 1734.

Actually I made that up. Although I've treated hundreds of acutely schizophrenic, delusional or manic patients as an ER doctor, I have never treated a person like the one I just described.  But there was a person who did follow the voice in his head that told him to do all these things -the clay models, the laying on one side for over a year, the animal dung to bake bread.  All of it. His name was Ezekiel, and he was a prophet in our Bible.

“You also, son of man, take a brick and lay it before you and inscribe a city on it, even Jerusalem. Then lay siege against it, and build a fort against it, and build a mound against it; set camps and place battering rams against it all around. Moreover take for yourself an iron plate and set it up for a wall of iron between you and the city. And set your face against it so that it is besieged, and lay siege against it. This shall be a sign to the house of Israel. As for you, lie down on your left side and lay the iniquity of the house of Israel upon it. According to the number of the days that you lie on it, you shall bear their iniquity. For I have laid upon you the years of their iniquity according to the number of the days, three hundred and ninety days. So you shall bear the iniquity of the house of Israel. When you have accomplished them, lie again on your right side, and you shall bear the iniquity of the house of Judah forty days. I have appointed you each day for a year. Therefore you shall set your face toward the siege of Jerusalem, and your arm shall be uncovered, and you shall prophesy against it. I will lay bands upon you, and you shall not turn yourself from one side to another until you have ended the days of your siege. Also take for yourself wheat, and barley, and beans, and lentils, and millet, and spelt, and put them in one vessel and make bread. According to the number of the days that you lie on your side, three hundred and ninety days, you shall eat it. ...You shall eat it as barley cake, having baked it in their sight with dung that comes out of man.... Then I said, “Ah, Lord God! My soul has not been defiled. For from my youth up even until now I have not eaten of that which dies of itself, or is torn in pieces, nor has abominable meat come into my mouth. Then He said to me, “I have given you cow dung instead of man’s dung over which you shall prepare your bread.””

— Ezekiel 4:1-15

In today's page of Talmud, Rabbi Yochanan declares not that prophecy is dead, but that the kind of things once said by the prophets of the Bible will henceforth be said by those with mental illness (שוטים) and children.  Rabbi Yochanan may have been the first to see the overlap of mental illness and the kinds of things once said by prophets of the Bible, but today psychiatrists and others involved in the care of the mentally ill have noted this overlap too.

Abraham and Moses on the Psychiatrist's Couch

In 2012, three psychiatrists from the Harvard  Medical School asked a simple question: How does a psychiatrist today help a patient to understand that their psychotic symptoms are not caused by supernatural visitations, "when our civilization recognizes similar phenomena in revered religious figures?" So the psychiatrists set off to examine the way in which revelation of the divine was described in the Bible, "with the intent of promoting scholarly dialogue about the rational limits of human experience." All this was to "educate persons living with mental illness, healthcare providers, and the general public that persons with psychotic symptoms may have had a considerable influence on the development of Western civilization."

They analyzed four religious figures, including two from our tradition, from a behavioral, neurologic, and neuropsychiatric perspective. They found that, based on the text of the Bible, Abraham had no affective, neurological or medical conditions, and since he showed no evidence of disorganization, they doubted that Abraham had classic schizophrenia too.  But they raised the possibility of his having paranoid schizophrenia. This is a subtype of schizophrenia "that tends to manifest little or no disorganization, has preserved functional affect, and is associated with better occupational and social functioning." The psychiatrists based this diagnosis on the voices Abraham kept hearing, and "a very Abraham-centered worldview of dispensing universal blessings and curses based on one’s interactions with Abraham." Moses had "auditory and visual hallucinations of a grandiose nature with delusional thought content." He also exhibited "hyperreligiosity, grandiosity, delusions, paranoia, referential thinking, and phobia (about people viewing his face)." They were not certain though, if Moses displayed symptoms of paranoid schizophrenia, or if instead, he may have had a bipolar disorder.  Jesus also displayed auditory and visual hallucinations, "delusions, referential thinking, paranoid-type thought content, and hyperreligiosity"(!) The Harvard psychiatrists also note that the lifetime risk of suicide in schizophrenia is 5-10%, and that Jesus "appears to have deliberately placed himself in circumstances wherein he anticipated his execution." Finally Paul is analyzed. He seems to have had a large number of  auditory and visual perceptual experiences "that resemble grandiose hallucinations with delusional thought content." They reject the suggestion that he suffered from temporal lobe epilepsy, and they note that Paul wrote a great deal. This kind of productive writing, they claim, "tends to be more strongly associated with mood disorders than psychosis or epilepsy. This is persuasive toward Paul having a mood disorder, rather than schizophrenia or epilepsy."

Murray, E. Cunningham M. Price B . The Role of Psychotic Disorders in Religious History Considered. Journal of Neuropsychiatry and Clinical Neurosciences 2012; 24:410–426

The point of all this analysis was not to test the the faith of those who believe in the prophetic abilities of Abraham, Moses, Jesus or Paul. Rather, it was to emphasize how those with what we today would describe as the florid symptoms of mental illness are revered as religious teachers. And one more thing.  They claimed not to have any disrespect for those with religious beliefs towards any of these four figures.

Discussion about a potential role for the supernatural is outside the scope of our article and is reserved for the communities of faithful, religious scholars, and theologians, with one exception. It is our opinion that a neuropsychiatric accounting of behavior need not be viewed as excluding a role for the supernatural. Herein, neuropsychiatric mechanisms have been proposed through which behaviors and actions might be understood. For those who believe in omnipotent and omniscient supernatural forces, this should pose no obstacle, but might rather serve as a mechanistic explanation of how events may have happened. No disrespect is intended toward anyone’s beliefs or these venerable figures.

Nocturnal Hallucinations in Israeli Ultra-Orthodox Jews

Since Rabbi Yochanan described prophecy as being given to those with mental illness, it might be worth looking at the content of some hallucinations in the Jewish mentally ill.  Is there anything in their hallucinations that we could perhaps interpret as prophecy? Let's turn to a helpful paper published in 2001, which described the nocturnal hallucinations in 122 ultra-orthodox Jewish Israeli men. The authors were two psychiatrists who noted that this symptom of nocturnal hallucinations only seemed to affect male members of the ultra-orthodox population.  The group who experienced these nocturnal hallucinations were younger than other patients with symptoms of mental illness, "and their visit was more often associated with a request for a psychiatric evaluation before receiving an exemption from compulsory army service." But let's put that rather disquieting fact aside, and move on. The majority of the hallucinations were frightening, and included figures of the sort that "may appear among the fears of ultra-orthodox men," including (and I'm not making this up) "policemen, soldiers [and] Sephardi men." 

From Greenberg D. Brome, D.  Nocturnal Hallucinations in Ultra-orthodox Jewish Israeli Men. Psychiatry 2001. 64 (1); 81-90.

Now you might be thinking that this group included a fair number of malingerers who were keen to avoid military service. The psychiatrists considered that possibility too, but noted that about 45% of the men came for more than one visit, and about 11% did not not request a recommendation letter for the army.  So they concluded that "the night hallucinations are a real clinical and culturally determined phenomenon, which in a minority of cases may have been misused and presented for purposes of gaining exemption from army service."  In any event, most ended up with a diagnosis of "subnormality and/or psychosis," with a generally good prognosis. But there is nothing that appears to be particularly prophetic in the thoughts of this group of mentally ill Jewish men.

“We suggest that some of civilization’s most significant religious figures may have had psychotic symptoms that contributed inspiration for their revelations. It is hoped that this analysis will engender scholarly dialogue about the rational limits of human experience and serve to educate the general public, persons living with mental illness, and healthcare providers about the possibility that persons with primary and mood disorder-associated psychotic-spectrum disorders have had a monumental influence on civilization.”

— Murray, E. Cunningham M. Price B . The Role of Psychotic Disorders in Religious History Considered.Journal of Neuropsychiatry and Clinical Neurosciences 2012; 24:410–426

On the origin of prophecy today

In his seventeenth century commentary on the Talmud, R. Samuel Eliezer ben R. Judah HaLevi Edels, better known as the Maharsha, suggests that there are different kinds of prophecy.

"Not all prophecy is the same. For the prophecy of the prophets was endowed by God, Blessed be He, or one of His angels, whereas the prophecy of the mentally ill and children is endowed by a demon..."

Which may only serve to scare the mentally ill even more. R. Yochanan's statement reminds us that the line between mental disease and religiously inspired hallucinations (or delusions) is very blurred, and that, whatever the source of their visions and hallucinations, the mentally ill deserve more than our pity or support. They deserve our respect.

מהרש"א חידושי אגדות מסכת בבא בתרא דף יב עמוד ב 

וענין שנטלה מן הנביאים ונתנה לשוטים אין הנבואות שוות דנבואת נביאים ע"י הש"י או ע"י מלאכיו אבל נבואת השוטים ותינוקות אינו אלא ע"י שד דהכי מחלק בפרק הרואה בין החלומות שיש מהן ע"י המלאך ויש מהן ע"י שד

“If you hear a car backfire and you believe that it may be a pistol shot, that is an illusion. If you hear a pistol shot when there has been no sound (either of a pistol or a car backfiring), that is a hallucination. If you hear a pistol shot and believe that it is God firing a pistol at you because you [as a physician] have ordered inappropriate lab tests, that is a delusion. If [a physician] decides he is ordering too many laboratory tests in the absence of an external sensory stimulus, that is called enlightenment.”

— Joseph Sapira. The Art and Science of Bedside Diagnosis. Williams & Wilkins 1990. p518.