Polydactyly

Kiddushin 25a ~ Polydactyly

This is the first of two posts for Kiddushin 25 which will be studied on Thursday September 7th.

קידושין כה, א–ב

 א"ר חייא בר אשי אמר רב היתה לו יתרת וחתכה עבד יוצא בהן לחירות, אמר רב הונא והוא שנספרת על גב היד

Rav Hiyyah bar Ashi said in the name of Rav: if a slave had an extra finger and his master cut it off, the slave is freed on account of this act. Rav Huna said this only applies if the extra finger is in line with the others [lit. counted alongside the hand].  

Polydactyly (from the Greek daktylos, meaning finger), is a developmental abnormality in which there are more than the customary five fingers or toes at the end of the arms and legs. It has long been recorded in ancient civilizations - and is even mentioned in our own Hebrew Bible. Do you know who is described there as having a total of twenty four fingers and toes? (Click here to find out.)

Polydactyly is classified by the location of the extra digit: If it is found on the thumb or big toe, it is called preaxial polydactyly. If it is found on the the little (fifth) finger or toe it is called postaxial polydactyly.  Accessory digits in-between are classified according to their location and where they join the hand or finger. Syndactyly, on the other hand (!) occurs when there are fewer than five fingers or toes on each limb. (We will discuss syndactyly when we study tractate Bechorot, (daf 45a), on November 2nd 2026,  הבעל"ט.)

Rav Huna's Classification, and Swanson's classification

There are many different ways to classify polydactyly - although the most commonly used is the 1964 Swanson classification system, a modified version of which was adopted by the American Society for Surgery of the Hand and the International Federation of Societies for Surgery of the Hand in 1976. 

But Rav Huna, who died in Babylon around the year 296 CE, developed his own classification system long before Swanson, and it is based on simple observation: does the extra digit seem to begin in line with the other fingers, or does its origin seem to lie above them?  For Rav Huna, an extra digit that originated beyond the metacarpal-phalyngeal joint (the knuckle for our non-medical reader) in the hand, or beyond the metatarsal-phalageal joint in the foot did not have the legal status of a normal digit.  So an act of assault by the owner of a slave in which this kind of digit was amputated would not legally count as sufficient cause to allow the slave to gain his freedom.  With this information, look at the drawings below and decide in which case the loss of the extra digit would be sufficient cause for the slave to be freed.

Various forms of postaxial (ie. not on the big toe) Type A polydactyly of the foot, ranging from a partially duplicated fifth intermediate phalanx (top left) to a fully developed sixth digit, including the metatarsal (bottom right). From Case D…

Various forms of postaxial (ie. not on the big toe) Type A polydactyly of the foot, ranging from a partially duplicated fifth intermediate phalanx (top left) to a fully developed sixth digit, including the metatarsal (bottom right). From Case DT. Hill RJ. Merbs CF. Fong M. Polydactyly in the Prehistoric American Southwest.  Journal of Osteoarchaeology 2006: 6: 221–235.

If the slave had an extra fifth toe outlined in Figures 2-6, its loss would result in the slave going free. In all these cases, the extra digit arises in line with the base the the other toes (and in Figure 6, the extra toe is joined to an extra metatarsal). But in Figure 1, the extra fifth digit arises from the distal end of the fifth distal phalange (or, for our non-medical reader, the tip of the pinky); in this case its traumatic amputation by the slave's owner would not result in the slave gaining his freedom. 

This categorization appears to be another previously unrecognized medical first in the Talmud: Rav Huna's classification of polydactyly.   

היתה לו אצבע יתירה וחתכה, אם עומדת בסדר האצבעות יוצא לחירות
— שולחן ערוך יורה דעה הלכות עבדים סימן רסז סעיף כט
Polydactylous feet from Newspaper Rock in Indian Creek State Park, Utah. These carvings in rock are called petroglyphs, and were made by native Americans as long as 1,500  years ago.

Polydactylous feet from Newspaper Rock in Indian Creek State Park, Utah. These carvings in rock are called petroglyphs, and were made by native Americans as long as 1,500  years ago.

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Sotah 42~ Goliath, Polydactyly and Hereditary Gigantism

 

On today’s long page of Talmud, we read how the rabbinic imagination described the giant Goliath. It was Goliath who, you will recall, was smitten by a slingshot from David, the future King of Israel. The rabbis of the Talmud painted quite the picture of this not so gentle giant. While Goliath himself was “unblemished”, his mother cohabited with one-hundred men (plus one dog) or possibly even more, and when doing so she engaged in all manner of sexual positions.

סוטה מב, ב

״וַיֵּצֵא אִישׁ הַבֵּינַיִם מִמַּחֲנוֹת פְּלִשְׁתִּים וְגוֹ׳״. מַאי ״בֵּינַיִם״? אָמַר רַב: שֶׁמְּבוּנֶּה מִכל מוּם. וּשְׁמוּאֵל אָמַר: בֵּינוֹנִי שֶׁבְּאֶחָיו. דְּבֵי רַבִּי שֵׁילָא אָמַר: שֶׁהוּא עָשׂוּי כְּבִנְיַן. רַבִּי יוֹחָנָן אָמַר: בַּר מְאָה פָּפֵי וַחֲדָא נָאנָאי.

The verse introduces Goliath: “And a champion [ish habeinayim] went out from the camp of the Philistines, named Goliath” (I Samuel 17:4). The Gemara asks: What is indicated by the term beinayim? Rav said: The word is related to the root beit, nun, heh, meaning build, and means that he is built [muvneh] perfectly and free of any blemish. And Shmuel said: The word is related to the word bein, meaning between, and means that he was the middle [beinoni] among his brothers. A Sage from the school of Rabbi Sheila said: The word is related to the root beit, nun, heh, meaning build, and means that he was made strong as a building [binyan]. Rabbi Yochanan said: The word is related to the word bein, meaning between, and means that he was born from among many, as follows: He was the son of one hundred fathers [pappi] and one dog [nanai], as his mother engaged in sexual intercourse with one hundred men and a dog, and he was fathered from among them.

״וְגלְיָת שְׁמוֹ מִגַּת״. תָּנֵי רַב יוֹסֵף: שֶׁהַכֹּל דָּשִׁין אֶת אִמּוֹ כְּגַת. כְּתִיב ״מַעֲרוֹת״, וְקָרֵינַן ״מַעַרְכוֹת״. תָּנֵי רַב יוֹסֵף: שֶׁהַכֹּל הֶעֱרוּ בְּאִמּוֹ

The verse recounts that he was “named Goliath, of Gath” (I Samuel 17:4). Rav Yosef taught: This is because everyone would thresh his mother by cohabiting with her like people do in a winepress [gat], where everyone tramples. It is written that Goliath came from “the caves [me’arot] of the Philistines” (I Samuel 17:23), but we read, according to the Masoretic text: He came from among “the ranks [ma’arkhot] of the Philistines.” What is meant by the written term me’arot? Rav Yosef taught: The word is related to the word he’era, meaning penetrated, and implies that everyone penetrated [he’eru], i.e., engaged in sexual intercourse with, his mother.

כְּתִיב ״הָרָפָה״, וּכְתִיב ״ערְפָּה״, רַב וּשְׁמוּאֵל חַד אָמַר: ״הָרָפָה״ שְׁמָהּ, וְלָמָּה נִקְרָא שְׁמָהּ ״ערְפָּה״ — שֶׁהַכֹּל עוֹרְפִין אוֹתָהּ מֵאַחֲרֶיהָ, וְחַד אָמַר: ״ערְפָּה״ שְׁמָהּ, וְלָמָּה נִקְרָא שְׁמָהּ ״הָרָפָה״ — שֶׁהַכֹּל דָּשִׁין אוֹתָהּ כְּהָרִיפוֹת, וְכֵן הוּא אוֹמֵר: ״וַתִּקַּח הָאִשָּׁה וְתִפְרֹשׁ הַמָּסָךְ עַל פְּנֵי הַבְּאֵר וַתִּשְׁטַח עָלָיו הָרִפוֹת״. וְאִי בָּעֵית אֵימָא מֵהָכָא: ״אִם תִּכְתּוֹשׁ אֶת הָאֱוִיל בַּמַּכְתֵּשׁ בְּתוֹךְ הָרִיפוֹת בַּעֱלִי״.

It is written that Goliath’s mother was: “Harafa” (II Samuel 21:16), and in another place it is written: “Orpah” (Ruth 1:4), and the Gemara will soon explain that this was the same woman. Rav and Shmuel engaged in a dispute concerning this matter. One of them said: Her name was Harafa, and why is she called by the name Orpah? It is because everyone came at her from behind [orfin] her, i.e., sodomized her. And one of them said: Her name was Orpah, and why is she called by the name Harafa? It is because everyone threshed her like groats [harifot], i.e., engaged in sexual intercourse with her, and so it says that this word means groats: “And the woman took and spread the covering over the well’s mouth, and strewed groats [harifot] thereon” (II Samuel 17:19). And if you wish, you can say from here: “Though you should crush a fool in a mortar with a pestle among groats [harifot], yet will not his foolishness depart from him” (Proverbs 27:22).

״וְאֶת אַרְבַּעַת אֵלֶּה יֻלְּדוּ לְהָרָפָה בְּגַת וַיִּפְּלוּ בְיַד דָּוִד וּבְיַד עֲבָדָיו״. מַאי נִינְהוּ? אָמַר רַב חִסְדָּא: סַף וּמָדוֹן גלְיָת וְיִשְׁבִּי בְּנוֹב.

The Gemara continues its discussion of the battle of David and Goliath. “These four were born to Harafa in Gath; and they fell by the hand of David, and by the hand of his servants” (II Samuel 21:22). The Gemara asks: What are the names of the four siblings mentioned here? Rav Chisdah said: They are Saph, and Madon, Goliath, and Ishbi in Nob (see II Samuel 21:16–20).

״וַיִּפְּלוּ בְיַד דָּוִד וּבְיַד עֲבָדָיו״, דִּכְתִיב: ״וַתִּשַּׁק ערְפָּה לַחֲמוֹתָהּ וְרוּת דָּבְקָה בָּהּ״. אָמַר רַבִּי יִצְחָק, אָמַר הַקָּדוֹשׁ בָּרוּךְ הוּא: יָבוֹאוּ בְּנֵי הַנְּשׁוּקָה, וְיִפְּלוּ בְּיַד בְּנֵי הַדְּבוּקָה. דָּרֵשׁ רָבָא: בִּשְׂכַר אַרְבַּע דְּמָעוֹת שֶׁהוֹרִידָה ערְפָּה עַל חֲמוֹתָהּ — זָכְתָה וְיָצְאוּ מִמֶּנָּה אַרְבָּעָה גִּבּוֹרִים, שֶׁנֶּאֱמַר: ״וַתִּשֶּׂנָה קוֹלָן וַתִּבְכֶּינָה עוֹד״,

It says: “And they fell into the hands of David and his servants.” Why? It is because of the acts of their forebears, as it is written: “And Orpah kissed her mother-in-law, and Ruth cleaved to her” (Ruth 1:14). Rabbi Yitzchak says: The Holy One, Blessed be He, said: The children of the one who kissed, referring to the four giants descended from Orpah, will come and fall into the hand of the children of the one who cleaved, referring to David, who was descended from Ruth. Rava taught: As a reward for the four tears that Orpah shed in sadness over her mother-in-law, she merited four mighty warriors descended from her, as it is stated: “And they lifted up their voice and wept again” (Ruth 1:14).

כְּתִיב: ״חֵץ חֲנִיתוֹ״, וְקָרֵינַן ״עֵץ חֲנִיתוֹ״. אָמַר רַבִּי אֶלְעָזָר: עֲדַיִין לֹא הִגִּיעָנוּ לַחֲצִי שִׁבְחוֹ שֶׁל אוֹתוֹ רָשָׁע. מִכָּאן שֶׁאָסוּר לְסַפֵּר בְּשִׁבְחָן שֶׁל רְשָׁעִים. וְלָא לִפְתַּח בֵּיהּ כְּלָל! לְאוֹדוֹעֵי שְׁבָחֵיהּ דְּדָוִד.

It is written about Goliath: “And the half [chetz] of his spear was like a weaver’s beam” (I Samuel 17:7), and we read, according to the Masoretic tradition: “And the shaft [etz] of his spear.” Rabbi Elazar says: The written version of the text demonstrates that we have not yet reached half [chrtzi] of the praise of that wicked man. Only half of his spear was as long as a weaver’s beam, but the Masoretic reading offers a less impressive description. It is learned from here that it is prohibited to relate the praise of wicked people. The Gemara asks: If so, then the verse should not begin by praising him at all. The Gemara answers: It was necessary in this case in order to relate the praise of David, who defeated Goliath.

Let’s leave these imaginative rabbinic interpretations and read what the Bible itself has to say. In the Book of Samuel, the height of Goliath is described “six cubits and a span.” He was covered with armor, and his appearance was so awesome that none of the Israelites dared to fight against him. Until David showed up:

וַיֹּאמֶר֮ דָּוִד֒ יְהֹוָ֗ה אֲשֶׁ֨ר הִצִּלַ֜נִי מִיַּ֤ד הָֽאֲרִי֙ וּמִיַּ֣ד הַדֹּ֔ב ה֣וּא יַצִּילֵ֔נִי מִיַּ֥ד הַפְּלִשְׁתִּ֖י הַזֶּ֑ה {ס} וַיֹּ֨אמֶר שָׁא֤וּל אֶל־דָּוִד֙ לֵ֔ךְ וַיהֹוָ֖ה יִהְיֶ֥ה עִמָּֽךְ׃

The Lord,” David went on, “who saved me from lion and bear will also save me from that Philistine.” “Then go,” Saul said to David, “and may the Lord be with you!”

And you probably already know the end of the story:

וַיֶּחֱזַ֨ק דָּוִ֤ד מִן־הַפְּלִשְׁתִּי֙ בַּקֶּ֣לַע וּבָאֶ֔בֶן וַיַּ֥ךְ אֶת־הַפְּלִשְׁתִּ֖י וַיְמִתֵ֑הוּ וְחֶ֖רֶב אֵ֥ין בְּיַד־דָּוִֽד׃

Thus David bested the Philistine with sling and stone; he struck him down and killed him. David had no sword;

וַיָּ֣רץ דָּ֠וִ֠ד וַיַּעֲמֹ֨ד אֶל־הַפְּלִשְׁתִּ֜י וַיִּקַּ֣ח אֶת־חַ֠רְבּ֠וֹ וַֽיִּשְׁלְפָ֤הּ מִתַּעְרָהּ֙ וַיְמֹ֣תְתֵ֔הוּ וַיִּכְרת־בָּ֖הּ אֶת־רֹאשׁ֑וֹ וַיִּרְא֧וּ הַפְּלִשְׁתִּ֛ים כִּי־מֵ֥ת גִּבּוֹרָ֖ם וַיָּנֻֽסוּ׃

So David ran up and stood over the Philistine, grasped his sword and pulled it from its sheath; and with it he dispatched him and cut off his head. When the Philistines saw that their warrior was dead, they ran.

Pierre Puget (1620-1694). David Gazing at Goliath's Head. From the collection of  the Museum of Civilization, Quebec City, Canada. 

Goliath certainly stuck fear into all he met. But why was he so tall, and did this have anything to do with David’s ability to knock him out with his slingshot? Today, Talmudology answers these pressing questions.

Other Giants in the Bible

Before we proceed, we should note that Goliath’s gigantism was not the only example of its kind in the Bible. Giants first appear in Bereshit, as a sort of super-hero:

בראשית 6:4

הַנְּפִלִ֞ים הָי֣וּ בָאָ֘רֶץ֮ בַּיָּמִ֣ים הָהֵם֒ וְגַ֣ם אַֽחֲרֵי־כֵ֗ן אֲשֶׁ֨ר יָבֹ֜אוּ בְּנֵ֤י הָֽאֱלֹהִים֙ אֶל־בְּנ֣וֹת הָֽאָדָ֔ם וְיָלְד֖וּ לָהֶ֑ם הֵ֧מָּה הַגִּבֹּרִ֛ים אֲשֶׁ֥ר מֵעוֹלָ֖ם אַנְשֵׁ֥י הַשֵּֽׁם׃ {פ}

It was then, and later too, that the Nephilim appeared on earth—when divine beings cohabited with the human women, who bore them offspring. Such were the heroes of old, the men of renown.

The exact relationship between the various races of biblical giants is a little hard to follow. The Nephilim (Numbers 13:32-33), are found before and after the flood. The Emites, the Ammonites (or Anakites) and the Rephaim (Deuteronomy 2:10-11), existed only after the Flood, and they appear to be separate entities. Here is a quick recap:

The Anakim seem to be derived from the Nephilim. The Rephaim although similar to the Nephilim, appear to be distinct from them with respect to family lineage. Deuteronomy 2.21 states the Rephaim were largely subdued by the Ammonites which ‘dwelt in their stead’ One of the most prominent Rephaim was Og, King of Bashan, who slept in ‘a bedstead of iron; nine cubits was the length, and four cubits the breadth of it’ (Deuteronomy 3:11). A cubit was the distance from the elbow to the fingertips. He appears to be one of the last survivors of the Rephaim.

Now if there is a race of giants, then we are dealing with some hereditary element. Some believe that the cause of this gigantism was “hyperthyroidism, possibly due to underlying pituitary gland, or other endocrine, dysfunction.”

In 2014, two medical geneticists suggested that Goliath and his close kin likely had a hereditary autosomal dominant pituitary gene. First, they reconstructed Goliath’s family tree, based on the descriptions given in both the Book of Samuel and Divrie Hayomim, the Book of Chronicles:

 

From Donnelly and Morrison. Hereditary Gigantism – the biblical giant Goliath and his brothers. Ulster Med J 2014;83(2):86-8.

 
 

From Donnelly and Morrison. Hereditary Gigantism – the biblical giant Goliath and his brothers. Ulster Med J 2014;83(2):86-88.

 

Not all of the sons of Goliath are identified. His third son is not named, and so in the family tree above, the geneticists called him Exadactylus because “he had on every hand six fingers, and on every foot six toes. (Samuel II, 21:20-21). This family tree suggests an inherited cause, or in medicalese, “a hereditary autosomal dominant pituitary gene, such as AIP,” where AIP is the gene for aryl hydrocarbon receptor-interacting protein. Other studies have shown that a mutation in this gene causes familial isolated pituitary adenoma (FIPA). Normally, the pituitary gland makes and then stops making growth hormone (GH). FIPA is a non-cancerous growth in the pituitary gland that causes it to make way too much GH. As a result, the bones and organs keep receiving the signal to grow and grow more. Hence gigantism, or in medicalese, acromegaly.

Sultan Kösen in 2010.

And here is a fun fact about acromegally. A Kurdish farmer named Sultan Kösen who was born in 1982 is the current Guinness World Record holder for tallest living male. He is 251 cm tall (and for you non-metric folks, that’s 8 feet 2.82 in). He had a pituitary tumor, and in 2010 doctors at the University of Virginia zapped the tumor in Kosen's pituitary gland to stop its excess production of growth hormone.

Now back to our medical geneticists, with their helpful explanation:

Pituitary adenomas can be present in a number of genetic conditions, such as multiple endocrine neoplasia type 1, Carney complex, and Familial Isolated Pituitary Adenoma (FIPA). FIPA is an autosomal dominant condition with incomplete penetrance, caused by germline mutations of the aryl hydrocarbon receptor interacting protein (AIP) gene4. Patients with AIP mutations have an earlier mean age at diagnosis than AIP mutation-negative patients. The age of Goliath is not clear, but early onset of pituitary tumours is typical of hereditary gigantism and limitation of lateral vision is common. Goliath himself had a shield bearer precede him, possibly to indicate to Goliath the direction of the approaching foe.

And this condition also explains why Goliath didn’t see that sling shot coming:

Goliath was killed by David who threw a stone at his forehead (Samuel 17:49). This gives further evidence that he suffered from pituitary gland dysfunction; a pituitary tumour pressing on his optic chiasm, and consequent visual disturbance due to pressure on his optic nerve, would have made it difficult for him to see the stone in his lateral vision. Pituitary giants look impressive in terms of stature, but may not have speed and agility to match their perceived strength.

In conclusion, Goliath may have had an AIP mutation causing early onset autosomal dominant pituitary gigantism and one of his sons may have had a syndrome involving both AIP and BBS1, which could some way account for the physical characteristics of his family and their good success rate on the battle field until they met David.
— From Donnelly and Morrison, op cit.

And what about the six fingers and six toes of Goliath’s unnamed son? We have discussed polydactyly before, when we noted Rav Hiyyah bar Ashi’s helpful ruling that “if a slave had an extra finger and his master cut it off, the slave is freed on account of this act. Rav Huna said this only applies if the extra finger is in line with the others [lit. counted alongside the hand],” but in Goliath’s family the polydactyly is a bit of a mystery:

Polydactyly has not been described in association with FIPA. The AIP gene lies on chromosome 11q13.3. The Bardet-Biedl gene, BBS1, is located close by on chromosome 11q13.2. Bardet-Biedl syndrome type I is characterized by rod-cone dystrophy, truncal obesity, cognitive impairment and postaxial polydactyly. The protein encoded by BBS1 is thought to play a role in limb development. It is unlikely that Goliath’s family had FIPA caused by a microdeletion which also involved BBS1, as the genetic distance between the BBS1 and AIP genes is separated by a 1 Mb gene- packed region. Such a gap makes an inherited contiguous gene syndrome unlikely as there would have been too many other features. Very rarely BBS1 patients have symmetric exadactyly; most commonly it is present in one or two extremities, upper and lower - not in all four.

We are not given much other detail about Exadactylus so a new BBS1 mutation due to some complex rearrangement is unlikely – a new mutation in an autosomal dominant polydactyly gene might explain his symmetrical phenotype. If he had pituitary disease and six digits – he may have looked an intimidating foe - but he may not have been a great warrior in action.

Roman Acromegally

Hereditary acromegaly. It’s not just for the Philistines. It can be found in the family of the Roman Emperor Maximinus Thrax (173-238). [Really. That is his name. He’s not a character from Asterix and Obelisk.] In a 2019 paper an international medical team suggested that the emperor (who was assassinated by his own troops during the siege of Aquileia in May 238) had “an endocrine disorder caused by a tumour in the anterior pituitary gland secreting an excess of growth hormone (GH) causing elevated insulin-like growth factor (IGF-1) levels before puberty (prepubertal gigantism).” And it wasn’t only the emperor. The authors believe that his son Gaius Iulius Verus Maximus (217/220-238), was affected by the same disorder. This suggestion is supported by a passage in the Historia Augusta [XXVII.2] which describes Gaius in this way:

He gave such promise of height, moreover, that he might have reached his father’s stature [proceritatis videbatur posse illius esse, ut ad paternam staturam perveniret] had he not perished in his twenty-first year, in the very flower of his youth, or, as some say, in his eighteenth.”

The medical team continued:

“Even though concise, the source reveals two decisive elements: firstly, the emperor’s son was much taller than average and, secondly, he was still growing despite having already reached the postpubertal age. If he had not perished prematurely, he would have most likely reached his father’s stature. Besides the phenotypical descriptions provided by this classical source, Gaius Iulius Verus Maximus’ facial morphology, as can be appreciated on minted coins does reinforce the hypothesis that he also suffered from acromegalic gigantism, potentially of a hereditary nature. This is characterized by early-onset excessive acceleration of linear growth and body size caused by a pituitary somatotroph or lactosomatotroph adenoma. Patients who present with acromegalic gigantism show such phenotypical characteristics as coarse facial features, frontal bossing, prognathism, increased interdental space, diastema, as well as marked enlargement of hands and feet, soft tissue swelling and increased appetite. Insufficiency of other pituitary hormones, because of the presence of a pituitary macroadenoma compressing normal anterior pituitary structures, may result in central hypogonadism, hypothyroidism and hypocortisolism. The epiphysial growth plates will not close due to untreated hypogonadism leading to continuous growth, even after the age at which normal persons reach puberty. Mutations of the aryl hydrocarbon receptor interacting protein (AIP) are at present the most frequent mutations causing pituitary gigantism.

Gaius Iulius Verus Maximus denarius, son of Maximinus.

So there it is. From a couple of biblical verses and a brief excerpt from a Roman history book we can learn so much about the natural causes of Goliath’s height.

Had enough acromegaly for now? OK. Next time, in our last post of this most fascinating masechet , we will discuss talmudic embryology.

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Bechorot 45b ~ Syndactyly, and Talmudology Keeps a Promise

Remember Polydactyly?

In April 2016, which is to say over three years ago, Talmudology wrote about polydactyly, when the Daf Yomi cycle studied Kiddushin 25. There we wrote: “We will discuss syndactyly when we study tractate Bechorot, (daf 45a), on June 1st, 2019,  הבעל"ט” And here we are. Tomorrow, June 1st 2019 (which is Shabbat) we will learn Bechorot 45, and we are therefore delighted to keep our promise and explain syndactyly, which is the condition in which one or more adjacent digits are fused together. But first, have a quick re-read of that earlier post; it will help put this medical condition into perspective…….Done? OK then, here we go.

The Cohen with fused digits

Tomorrow we continue the discussion of physical abnormalities which would prohibit a Cohen from serving in the Temple. The Mishnah reads as follow:

בכורות לה,ב

אצבעותיו מורכבות זו על זו או קלוטות למעלה עד הפרק כשר למטה מן הפרק וחתכה כשר

A priest whose fingers or toes are configured one upon the other, or one whose fingers or toes are attached, is likewise disqualified. But if they were attached from above the palm of the hand or the bottom of the foot only until the middle joint, he is fit. If they were attached below the joint, higher up on the finger or toe, and he cut to separate them, he is fit. 

The case here is a Cohen with, say two fingers or two toes that are fused together, so that it appears that there is a digit missing. The hand may look like this:

Palm view of classic simple syndactyly of left long and ring fingers. Over 50% of all webbed fingers occur like this.From here.

Palm view of classic simple syndactyly of left long and ring fingers. Over 50% of all webbed fingers occur like this.From here.

maydeletesmaller.jpg

Or in extreme cases like this:

The hand of the patient with syndactyly of several digits. From Biesecker L.G.The Greig cephalopolysyndactyly syndrome. Orphanet Journal of Rare Diseases 2008, 3:10

The hand of the patient with syndactyly of several digits. From Biesecker L.G.The Greig cephalopolysyndactyly syndrome. Orphanet Journal of Rare Diseases 2008, 3:10

These photos are all obviously from young children, which is good news. Surgeons are able to separate the fused fingers or toes, generally when the infant is 1-2 years old, and so there are now few adults around in whom the condition went uncorrected.

The Classification of Syndactyly

Syndactyly (from the Greek syn = together; dactylos=digit) occurs in about 2-3 per 10,000 live births In 10-40% there is a family history of the condition and is twice as common among males (remember these facts for later). In about half of all cases there are bilateral and symmetrical fusions, and while it may be an isolated finding, in many cases it is part of a genetic disorder like Apert’s or Poland’s syndrome.

There are several different types and subtypes, depending on whether the condition is classified based on an anatomical approach, a genetic or molecular approach, a descriptive approach or an embryological classification. One classification, from a 2012 review of the topic published in The European Journal of Human Genetics, is shown below.

Schematic diagrams of syndactyly types (I-a–III). Shaded digits depict cutaneous fusion only, while bony synostosis is represented by black digital elements within the shaded area. The grey digital elements show hypoplastic phalanges or clinodactyly…

Schematic diagrams of syndactyly types (I-a–III). Shaded digits depict cutaneous fusion only, while bony synostosis is represented by black digital elements within the shaded area. The grey digital elements show hypoplastic phalanges or clinodactyly/brachydactyly. The digital elements with amorphous borders symbolize dysplastic bones. From Malik S. Syndactyly: phenotypes, genetics and current classification. European Journal of Human Genetics (2012) 20, 817–824;

What Causes Syndactyly? It’s often the genes

Syndactyly sometimes runs in families, so in these cases a genetic cause was long suspected. For example, fusion of the fourth and fifth metacarpals (an uncommon type of syndactyly) was first described 1928 and was initially thought to have an X-linked recessive trait. It was later classified as an autosomal dominant inheritance, found in some families with male-male transmission as well as females affected. But we are now able to exactly pinpoint some of the genetic causes. Type I, Apert syndrome, is associated with the FGFR2 gene (to be exact the the loci 10q26). Type II, (Carpenter syndrome) is linked to RAB23 gene, and Type V, also known as Pfeiffer syndrome is been linked to the FGFR 1 and 2 genes.

A family with three generations of ring and small finger involvement, none of which was ever surgically corrected. From Flatt A. Webbed Fingers. In The Care of Congenital Hand Anomalies, 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1994:228–…

A family with three generations of ring and small finger involvement, none of which was ever surgically corrected. From Flatt A. Webbed Fingers. In The Care of Congenital Hand Anomalies, 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1994:228–275.

Why did the Mishnah Discuss Syndactyly in Cohanim?

At first, the discussion of syndactyly as a disqualification for a Cohen seems rather odd. I mean really, how many cases could there have been? But the reason that the Mishnah spent time on this is now obvious. In many cases it is a genetic disorder, mostly affecting men. To be a Cohen you must be the child of a father who is a Cohen. As we have already learned, there are several “Cohen related genes,” and now we can add to the list the possibility that one of the many genetic causes of syndactyly was linked to those who were Cohanim, and who might pass the gene to their male children.

As we saw in an earlier post, the rabbis of the Mishnah and Talmud described different medical observations without realising that they originated from a single cause (like alcoholic liver disease) or had a genetic component. How lucky we are to have this knowledge at our fingertips (sorry). The rabbis would have wanted no less.

[Extra credit: The Wiki page on Syndactyly notes that “The earliest appreciation of syndactyly as a birth anomaly…can be traced back to the Andalusian Muslim surgeon Al-Zahrawi (d. 1013 CE).” This should obviously be corrected, since it was mentioned as a birth defect in the Mishnah, edited c. 200 CE, some eight hundred years earlier. Can someone please edit the page so that it is accurate? Thanks.]

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Kiddushin 25a ~ Polydactyly

קידושין כה, א–ב

 א"ר חייא בר אשי אמר רב היתה לו יתרת וחתכה עבד יוצא בהן לחירות, אמר רב הונא והוא שנספרת על גב היד

Rav Hiyyah bar Ashi said in the name of Rav: if a slave had an extra finger and his master cut it off, the slave is freed on account of this act. Rav Huna said this only applies if the extra finger is in line with the others [lit. counted alongside the hand].  

Polydactyly (from the Greek daktylos, meaning finger), is a developmental abnormality in which there are more than the customary five fingers or toes at the end of the arms and legs. It has long been recorded in ancient civilizations - and is even mentioned in our own Hebrew Bible. Do you know who is described there as having a total of twenty four fingers and toes? (Click here to find out.)

Polydactyly is classified by the location of the extra digit: If it is found on the thumb or big toe, it is called preaxial polydactyly. If it is found on the the little (fifth) finger or toe it is called postaxial polydactyly.  Accessory digits in-between are classified according to their location and where they join the hand or finger. Syndactyly, on the other hand (!) occurs when there are fewer than five fingers or toes on each limb. (We will discuss syndactyly when we study tractate Bechorot, (daf 45a), on June 1st, 2019,  הבעל"ט.)

Rav Huna's Classification, and Swanson's classification

There are many different ways to classify polydactyly - although the most commonly used is the 1964 Swanson classification system, a modified version of which was adopted by the American Society for Surgery of the Hand and the International Federation of Societies for Surgery of the Hand in 1976. 

But Rav Huna, who died in Babylon around the year 296 CE, developed his own classification system long before Swanson, and it is based on simple observation: does the extra digit seem to begin in line with the other fingers, or does its origin seem to lie above them?  For Rav Huna, an extra digit that originated beyond the metacarpal-phalyngeal joint (the knuckle for our non-medical reader) in the hand, or beyond the metatarsal-phalageal joint in the foot did not have the legal status of a normal digit.  So an act of assault by the owner of a slave in which this kind of digit was amputated would not legally count as sufficient cause to allow the slave to gain his freedom.  With this information, look at the drawings below and decide in which case the loss of the extra digit would be sufficient cause for the slave to be freed.

Various forms of postaxial (ie. not on the big toe) Type A polydactyly of the foot, ranging from a partially duplicated fifth intermediate phalanx (top left) to a fully developed sixth digit, including the metatarsal (bottom right). From Case D…

Various forms of postaxial (ie. not on the big toe) Type A polydactyly of the foot, ranging from a partially duplicated fifth intermediate phalanx (top left) to a fully developed sixth digit, including the metatarsal (bottom right). From Case DT. Hill RJ. Merbs CF. Fong M. Polydactyly in the Prehistoric American Southwest.  Journal of Osteoarchaeology 2006: 6: 221–235.

If the slave had an extra fifth toe outlined in Figures 2-6, its loss would result in the slave going free. In all these cases, the extra digit arises in line with the base the the other toes (and in Figure 6, the extra toe is joined to an extra metatarsal). But in Figure 1, the extra fifth digit arises from the distal end of the fifth distal phalange (or, for our non-medical reader, the tip of the pinky); in this case its traumatic amputation by the slave's owner would not result in the slave gaining his freedom. 

This categorization appears to be another previously unrecognized medical first in the Talmud: Rav Huna's classification of polydactyly.   

היתה לו אצבע יתירה וחתכה, אם עומדת בסדר האצבעות יוצא לחירות
— שולחן ערוך יורה דעה הלכות עבדים סימן רסז סעיף כט
Polydactylous feet from Newspaper Rock in Indian Creek State Park, Utah. These carvings in rock are called petroglyphs, and were made by native Americans as long as 1,500  years ago.

Polydactylous feet from Newspaper Rock in Indian Creek State Park, Utah. These carvings in rock are called petroglyphs, and were made by native Americans as long as 1,500  years ago.

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