Shabbat 129a-b ~ Blood Letting

Today’s page of Talmud starts a deep dive into to all things bloodletting. Here is a sample:

Shabbat 129a-b

Rab Judah said in Rab's name: One should always sell [even] the beams of his house and buy shoes for his feet. If one has let blood and has nothing to eat, let him sell the shoes from off his feet and provide the requirements of a meal therewith. What are the requirements of a meal? — Rab said: Meat; while Samuel said: Wine. Rab said meat: life for life. While Samuel said, Wine: red [wine] to replace red [blood]. ..For Samuel on the day he was bled a dish of pieces of meat was prepared; R. Johanan drank until the smell [of the wine] issued from his ears; R. Nahman drank until his milt swam [in wine]; R. Joseph drank until it [the smell] issued from the puncture of bleeding. Raba sought Wine of a [vine] that had had three [changes of] foliage.

…Rab and Samuel both say: If one makes light of the meal after bleeding his food will be made light of by Heaven, for they say; He has no compassion for his own life, shall I have compassion upon him! 

Rab and Samuel both say: He who is bled, let him not sit where a wind can enfold [him], lest the cupper drained him [of blood] and reduced it to [just] a revi’it, and the wind come and drain him [still further], and thus he is in danger. 

Samuel was accustomed to be bled in a house [whose wall consisted] of seven whole bricks,  and a half brick [in thickness]. One day he bled and felt himself [weak]; he examined [the wall] and found a half-brick missing.

Rab and Samuel both say: He who is bled must [first] partake of something and then go out; for if he does not eat anything, if he meets a corpse his face will turn green; if he meets a homicide he will die; and if he meets swine, it [the meeting] is harmful in respect of something else.

Rab and Samuel both say: One who is bled should tarry awhile and then rise, for a Master said: In five cases one is nearer to death than to life. And these are they: When one eats and [immediately] rises, drinks and rises, sleeps and rises, lets blood and rises, and cohabits and rises.

Samuel said: The correct interval for blood-letting is every thirty days. Samuel also said: The correct time for bloodletting is on a Sunday Wednesday and Friday, but not on Monday or Thursday…

“Rabbi Yochanan said: the sages made blood letting in Israel like a healing that has no limit.”

— Talmud Ketuvot 52b

Blood letting is mentioned in many places in the Talmud. For example, in Ketuvot (52b) there is a discussion that hinges on the frequency of the procedure. The issue discussed there is whether you should undergo therapeutic venesection - blood-letting - regularly (like using the gym) or save it for special occasions (like a birthday or anniversary)? The question of who should pay for a widow's blood-letting session depends on the resolution of this conundrum. If blood-letting is considered a rare or one-off intervention, then the costs of the procedure should be borne from the fixed proceeds from the widow's Ketuvah. But if the procedure needs to performed often and regularly, it is considered to be more like the ongoing expense of food; in that case the costs must be borne by the heirs of the deceased husband and not by the woman herself using up the proceeds of her Kutuvah.  It's at this point in the discussion that Rabbi Yochanan speaks up, who tells us that “the sages made blood letting in Israel like a healing that has no limit.” In Israel blood-letting was performed on a regular basis, and so - at least in this particular case - the heirs were required to pay for it.  

The Origins of blood letting

At its core, blood-letting depends on the principle of the four humors in the body, which seems to have come from the Greeks around the 5th century BCE. According to this theory, there are four humors or systems that regulate the human body. If they are in balance, all is good. But if that balance is upset, disease follows.

The four humors are blood, phlegm, black bile and yellow bile. The only one of these that is readily accessible to the outside is blood, of course. So the idea grew that if a person was ill, it was because there was too much blood. Or as Galen put it, blood was the most dominant of the humors. And the treatment? To get rid of some of that unnecessary blood. And so bloodletting was born. The four humors were also thought to correspond to the four elements from which all matter is built, like this:

How to be a blood-letter

Brass scarificator circa 1840. The thirteen blades were drawn across the arm or leg, and the blood flowed out. Made by Tiemann & Co.; Manufacturers of Surgical Instruments & Every Description of Cutlery; No. 63 Chatham St.; New York.

There were various ways to remove the blood. You could use leeches, or you could cut the arms or legs and induce bleeding. And then there was a surgical procedure which was simple enough and rather brutal. You went to the blood letter and he sliced into your vein. After a while, when the blood-letter had determined that you'd lost just the right amount of blood, the wound was bandaged, and off you went, looking forward to being cured of whatever had led you to the blood-letter in the the first place. The procedure was thought to be the way to cure any number of illnesses, including fever and asphyxia (Yoma 84a). As we mentioned, it dates back at least to the 5th century BCE, and is mentioned in the writings of Erasistratus (300-260 BCE) who opposed the procedure, and Galen (c. 130-200 CE) who used it and taught that it was an important tool that could heal the sick.

Blood letting over the centuries

The procedure, which had been in use almost 2,000 years, only stopped being part of standard medical practice in the late 19th and early 20th century.  Bloodletting certainly contributed to the death of an American President. Here is how I described the story in my book on influenza:

Not three years after he resigned as the first president of the United States, George Washington was on his deathbed. As a last-ditch effort to save him, doctors opened his veins to thwart the infection ravaging his throat. Washington endured four rounds of bloodletting, the last one only a few hours before he succumbed.

“I am just going,” Washington said to his secretary, Tobias Lear, at that point.

“He died by the loss of blood and the want of air,” said a family friend and doctor, William Thornton—who suggested that Washington could be reanimated by a transfusion of lamb’s blood.

Thankfully, the doctors decided not to proceed with the re-animation attempt. Writing in 1875, one Englishman could not bring himself to believe that the era of blood-letting was really  over. "Is the relinquishment of bleeding final?" he wrote, 

or shall we see by and by, or will our successors see, a resumption of the practice? This, I take it, is a very difficult question to answer; and he would be a very bold man who, after looking carefully through the history of the past, would venture to assert that bleeding will not be profitably employed any more.

But blood letting was far from over. It was even suggested as a therapy by doctors during a severe influenza outbreak at a British Army camp in northern France in the winter of 1916-17.  Here is what they wrote, using the medical term “venesection” rather than the more brutal term “bloodletting.”

The doctors noted that venesection did not help, but the reason was probably that it had not been performed soon enough. Remember this was at the time of your grandparents and great-grandparents. And the name of journal in which this was published? The Lancet, named for the very implement used to perform the procedure.

“The importance of bloodletting, as a medicinal agent, in comparison with other means of cure, is shown in various aspects. It is a remedy the most frequently called for in general practice’ and often of itself, and without the aid of other means, accomplishes all we wish. ”

— Henry Clutterbuck. On the Proper Administration of Blood-letting. London, 1840.

Modern Medicine and the Practice of Blood-Letting

There is absolutely no place for this intervention today, other than for a couple of rare disorders. One is polycythemia vera.  In this illness, the body makes too many red blood cells (hence its name, poly=many, kytos=cells, hamia=blood), and one way to keep the illness in check is to remove those excess blood cells at a regular intervals.  Another rare disorder that is sometimes treated with therapeutic blood-letting is hemochromatosis, in which there is a build up of iron in the body.  But other than for these rare diseases, blood-letting, (called today phlebotomy or venepuncture, which do sound a whole lot more palatable but describe the same procedure) is harmful. Do not try this at home.  

Having made this very clear, let's introduce some nuance. Palliative blood-letting may be useless, but from this it does not follow that it is a good idea to restore the hematocrit (the concentration of red blood cells in the blood) to normal in every disease state. For example, virtually all patients on  dialysis (due to chronic kidney disease) become anemic, but in these patients, trying to restore the hemoglobin concentration to a higher level (~13g/dL for those interested) seems to be associated with increased risk, when compared with those in whom the hemoglobin level was lower. And when tiny premature babies get anemic, there does not seem to be an advantage to keeping the hemoglobin in a higher range (though to be fair, more research needs to be done). But these two examples do not in any way lend support to the notion that blood-letting is anything other than a really bad idea.  

A prayer by the Patient

We no longer practice this useless intervention, but the prayer associated with it is worth recalling. Maimonides ruled (Berakhot 10:21) that before undergoing blood-letting, the patient pray the procedure be effective,and this ruling is found as part of normative Jewish practice, recorded in the (שולחן ערוך (אורח חיים רל ס׳ק ד:

הנכנס להקיז דם אומר "יהי רצון מלפניך ה' אלהי שיהא עסק זה לי לרפואה כי רופא חנם אתה". ולאחר שהקיז אומר "ברוך רופא חולים

Before undergoing blood letting say: May it be your will Lord my God, that this procedure will heal me, for you are an unconditional healer. And when it is finished he says: Blessed are you God, healer of the sick.

The medical procedures have changed, but the prayers have stayed the same.

Photo of bloodletting in 1860. Yes, that's right, 1860. From the Burns Archive

[Re-posted (with a few changes) from Yevamot 72a]

Shabbat 121b ~ Rabbis and Rabies

שבת קכא, ב

חֲמִשָּׁה נֶהֱרָגִין בְּשַׁבָּת, וְאֵלּוּ הֵן: זְבוּב שֶׁבְּאֶרֶץ מִצְרַיִם, וְצִירְעָה שֶׁבְּנִינְוֵה, וְעַקְרָב שֶׁבְּחַדְיָיב, וְנָחָשׁ שֶׁבְּאֶרֶץ יִשְׂרָאֵל,  

Five creatures may be killed even on Shabbat, and they are: The poisonous fly that is in the land of Egypt, and the hornet that is in Ninveh, and the scorpion that is in Chadyab, and the snake that is in Israel, and a mad dog in any place.

The Talmud allows a person to kill a mad dog on Shabbat, even though this is an act that is normally forbidden. The reason is that they are likely to bite people and transmit a deadly disease that we call rabies.

Rabid dogs in the Talmud

Elsewhere in the Talmud, the rabbis describe the many features of a rabid dog.

יומא פג, ב

ת"ר חמשה דברים נאמרו בכלב שוטה פיו פתוח ורירו נוטף ואזניו סרוחות וזנבו מונח על ירכותיו ומהלך בצידי דרכים וי"א אף נובח ואין קולו נשמע

The Sages taught in a baraita: Five signs were said about a mad dog: Its mouth is always open; and its saliva drips; and its ears are floppy and do not stand up; and its tail rests on its legs; and it walks on the edges of roads. And some say it also barks and its voice is not heard. 

Many of these features are certainly found in rabid dogs. They are not able to swallow and therefore drool; cranial nerve abnormalities may be the cause drooping ears. It will appear skittish, and because of the way its larynx is affected because it cannot swallow, it cannot bark properly. Thus “its voice is not heard.”

The Cause of Rabies

ממאי הוי רב אמר נשים כשפניות משחקות בו ושמואל אמר רוח רעה שורה עליו

From where did the dog become mad? Rav said: Witches play with it and practice their magic on it, causing it to become mad. And Shmuel said: An evil spirit rests upon it.

Like all infectious diseases, the cause of rabies remained unknown until the germ theory of disease and much later the discovery of viruses. Hence the reasonable suggestion that it was caused by witchcraft or an evil spirit.

But rabies is not caused by witchcraft. It is caused by a virus from the family Rhabdoviridae called Lyssavirus. It is found on all continents except Antartica. (Australia has only a certain variant of rabies which you can read about here.) Because the virus is very fragile, it cannot survive outside of its host, so you cannot get it from the environment. An animal has to bite you.

In his famous work History of Animals, Aristotle thought that rabies could not be transmitted from a rabid dog to a human.

Dogs suffer from three diseases; these are named rabies, dog-strangles, foot-ill. Of these, rabies produces madness, and when rabies develops in all animals that the dog has bitten, except man, it kills them; and this disease kills the dogs too. The strangles too destroys the dogs; and only few survive after the foot-ill. Rabies also attacks camels. But elephants are said to be immune to all ailments, but to be troubled by internal winds.

But Aristotle was wrong. Dogs can certainly transmit rabies to people. In fact, rabid dogs are the most common cause of transmission of rabies worldwide. But other mammals can also transmit this dreadful disease, as you can see below.

Global distribution of mammalian rabies reservoirs and vectors. From Charles E Rupprecht, Cathleen A Hanlon, and Thiravat Hemachudha. Rabies Re-examined. Lancet Infect Dis 2002; 2: 327–43

A Case of Rabies in the US

An estimated 59,000 people die worldwide each year from rabies. That’s about one person every nine minutes. In the US the disease is virtually unknown; only between one and three people per year get the disease. Here is a case report of a what happened in 2018 when a man caught rabies in Utah, courtesy of Morbidity and Mortality Reports, published by the CDC.

On October 17 and 18, 2018, a man aged 55 years who lived in Utah sought chiropractic treatment in Idaho for neck and arm pain thought to be caused by a recent work-related injury. On October 19, he was evaluated in the emergency department of hospital A for continued neck pain, nuchal muscle spasms, burning sensation in his right arm, and numbness in the palm of his right hand. He had no fever, chills, or other symptoms of infection. Dehydration was a concern because the patient reported he was unable to drink liquids because of severe pain and muscle spasms. The patient received a prescription for a steroid for muscle spasms and decreased sensation in the right arm and was discharged home.

Two days later, on October 20, the patient developed shortness of breath, tachypnea,{rapid breathing] and lightheadedness and reported he had not been able to sleep for 4 days; he was transported by ambulance to hospital B. The patient continued to have right upper extremity pain and severe esophageal spasms, causing him to refuse oral fluids. Because of his worsening symptoms and acute delirium, he was transferred to hospital C.

On October 21, the patient was intubated for airway protection {ie sedated and connected to a breathing machine]. His symptoms worsened, with fever to 104.7°F (40.4°C), and he became comatose on October 25. Additional exposure history collected from family members included ownership of two healthy dogs and a healthy horse, and a recent grouse-hunting trip where the patient had dressed and cleaned the birds while wearing gloves. High-dose corticosteroid treatment was initiated for presumed autoimmune encephalitis. Because of refractory seizures beginning on October 26, he was transferred to hospital D on October 28, where steroids were continued. On November 3, an infectious disease physician was consulted at hospital D who noted that the patient’s symptom of spasms when swallowing suggested a possible diagnosis of rabies. When specifically questioned about the patient’s exposure to wild animals, family members reported extensive contact with bats that had occupied the patient’s home in the weeks before illness onset… The patient continued to decline, supportive care was withdrawn, and he died on November 4, 19 days after symptom onset.

It took four hospitals over two weeks to diagnose the cause as rabies, because the disease is so very rare in the US that doctors naturally don’t consider it. By then there was nothing that could be done to save the patient. At post-mortem specimens were collected, which indicated that the virus identified was that of a rabies virus variant associated with Mexican free-tailed bats (Tadarida brasiliensis).

The treatment of rabies

Here is the Talmudic remedy for rabies.

יומא פד, א

דנכית ליה מיית מאי תקנתיה אמר אביי ניתי משכא דאפא דדיכרא וניכתוב עליה אנא פלניא בר פלניתא אמשכא דאפא דיכרא כתיבנא עלך כנתי כנתי קלירוס ואמרי לה קנדי קנדי קלורוס יה יה ה' צבאות אמן אמן סלה ונשלחינהו למאניה ולקברינהו בי קברי עד תריסר ירחי שתא ונפקינהו ונקלינהו בתנורא ונבדרינהו לקטמיה אפרשת דרכים והנך תריסר ירחי שתא כי שתי מיא לא לישתי אלא בגובתא דנחשא דילמא חזי בבואה דשידא וליסתכן כי הא דאבא בר מרתא הוא אבא בר מניומי עבדא ליה אימיה גובתא דדהבא 

 One bitten by a mad dog will die. The Gemara asks: What is the remedy? Abaye said: Let him bring the skin of a male hyena and write on it: I, so-and-so, son of so-and-so, am writing this spell about you upon the skin of a male hyena: Kanti kanti kelirus. And some say he should write: Kandi kandi keloros. He then writes names of God, Yah, Yah, Lord of Hosts, amen amen Selah. And let him take off his clothes and bury them in a cemetery for twelve months of the year, after which he should take them out, and burn them in an oven, and scatter the ashes at a crossroads. And during those twelve months of the year, when his clothes are buried, when he drinks water, let him drink only from a copper tube and not from a spring, lest he see the image of the demon in the water and be endangered, like the case of Abba bar Marta, who is also called Abba bar Manyumi, whose mother made him a gold tube for this purpose.

Well, the first sentence is certainly correct: “One bitten by a mad dog will die.” In fact the Jerusalem Talmud (Berachot 8:5) states that you will never hear of a case in which a person was bitten by a mad dog and actually survived, presumably despite the use of male hyena skin.

However, today there is a remedy for a person who was bitten, so long as you get to them quickly. You can give the person rabies immunoglobulin which contains the antibodies to fight the virus. But you have to give it right away, and the patient needs a total of five shots over a month. Once the patient develops symptoms, as the man from Utah did, this intervention does not work, and the disease is uniformly fatal. In all of medical literature there is but a single case report from 2005 of a person who survived after developing the symptoms of rabies. The patient was a 15 year old girl who had been bitten by a bat that she was trying to remove from her room. The doctors thought that her chances of survival were negligible, and offered hospice care as one option and aggressive therapy with antivirals as another. They told the girl’s parents about “the probable failure of antiviral therapy and the unknown effect of the proposed therapy, as well as the possibility of severe disability if the patient were to survive.” Faced with this awful choice the parents requested aggressive care. The girl was in a coma for almost a month, but survived, although she was left with residual neurological problems.

“Survival of this single patient does not change the overwhelming statistics on rabies, which has the highest case fatality ratio of any infectious disease. Any regimen may be ineffective in cases associated with extremes of age, massive traumatic inoculation, or delayed diagnosis and must be coupled with strategies to reduce the risk of complications from long-term treatment in the intensive care unit.”

— Willoughby R.E et al. Survival after Treatment of Rabies with Induction of Coma. N Engl J Med 2005; 352:2508-2514.

The Mishnah in Yoma (8:6) suggests a controversial remedy for a person bitten by a rabid dog.

 מִי שֶׁנְּשָׁכוֹ כֶלֶב שׁוֹטֶה, אֵין מַאֲכִילִין אוֹתוֹ מֵחֲצַר כָּבֵד שֶׁלוֹ, וְרַבִּי מַתְיָא בֶן חָרָשׁ מַתִּיר

If one was bit by a mad dog, they do not feed him the lobe of its liver. But Rabbi Matia ben Harash permits it.

Before you email me with the idea that perhaps this would give the patient some antibodies, you should know that it would not. First, you are likely to get a mouthful of the rabies virus which may increase your exposure dose if you had any open sores or cuts allowing it to enter the bloodstream. Second, a rabid dog won’t have made some or perhaps any antibodies. That’s why it is rabid. And third, You need to get antibodies into the bloodstream. They will be broken down in the harsh environment of the stomach, rendering them useless.

In fact the Talmud Yerushalmi (Yoma 8:5) records that the German servant of Rabbi Yudin was bitten by a mad dog and was given the its liver to eat. But he died, leaving the Talmud to conclude for a second time that you will never hear of a case in which a person survived a dog bite from a rabid dog.

ירושלמי יומא 8:5

גרמני עבדיה דר' יודן נשייא נשכו כלב שוטה והאכילו מחצר כבד שלו ולא נתרפא מימיו אל יאמר לך אדם שנשכו כלב שוטה וחיה

In his commentary on the Mishnah, Maimonides, who was of course a physician himself, ruled that we do not accept the position of Rabbi Matia:

רמב׳ם פירוש המשניות יומא 8:6

ואין הלכה כרבי מתיא בן חרש בזה שהוא מתיר להאכיל לאדם הכבד של כלב שוטה כשנשך כי זה אינו מועיל אלא בדרך סגולה. וחכמים סוברים כי אין עוברין על המצות אלא ברפואה בלבד ר"ל בדברים המרפאין בטבע והוא דבר אמתי הוציאו הדעת והנסיון הקרוב לאמת. אבל להתרפאות בדברים שהם מרפאים בסגולתן אסור כי כוחם חלוש אינו מצד הדעת ונסיונו רחוק והיא טענה חלושה מן הטועה

We do not follow the opinion of Rabbi Matia ben Harash, who permitted feeding the liver of a rabid dog to a person who was bitten, because it does not help, and is only a protective charm (segula). The rabbis only permitted the commandments to be ignored when using real medicines, that is to say, things that have been tested and work, and shown to work with certainty through testing. But it is forbidden to use any kind of charm because they don’t have any power [lit. their power is weak] and experience is limited and this is a mistaken approach…

Although the rabbis of the Talmud suggested remedies for a bite from a mad (rabid) dog, none would work. And today, if you are bitten and show symptoms of rabies, we are basically in the same position, with no medical interventions that work. How humbling.

Shabbat 109b ~ Curing Snakebites

The Palestinian Viper צפע ארצישראלי. Vipera palaestinae

Snake Bites Everywhere

Snake bites were a widespread fear in ancient Israel. The Talmud warns that snakes can be found in houses and records a snake attack that occurred in the toilet, so going to the bathroom was a risk to one’s life. (Snakes still appear to make relieving oneself in the Holy Land a dangerous enterprise, if this report is to be believed.)  There was also a great fear of drinking water into which a snake may have expelled some venom, and loyal Talmudology readers may recall that we previously examined this concern (and included a clip of a man safely drinking freshly expelled snake venom. Actually, if you remember, there is no danger, even in places where snakes are found. Snakes only discharge their venom when they intend to bite, not when stopping for a drink. And even if there was venom in the liquid, snake venom is not absorbed by the human gastrointestinal tract, so it would have absolutely no effect. But I digress.)

In tomorrow’s page of Talmud, the fear of snakes is taken to a whole new level, at least for women. What should a woman do if she thinks she is being being pursued by a particularly amorous snake? How can she get that snake to give up the chase? And finally, what can she do if the snake has already entered her is an act of carnal intimacy?

All this shows how dangerous snakes were, and so when they did not bite, it was considered to be miraculous. Hence the Mishnah (Avot 5:5) records that one of the ten miracles that occurred during the time of the Second Temple was that no person was ever injured by a snake.

In today’s page of Talmud, we focus on a cure for a snakebite:

שבת קט,ב

 האי מאן דטרקיה חיויא ליתי עוברא דחמרא חיורתא וליקרעיה ולותביה עילויה והני מילי דלא אישתכח טרפה ההוא

One who was bitten by a snake should have the fetus of a white donkey brought to him, and it should be torn open and placed on the snakebite.

At first the suggestion sounds ridiculous. Why on earth should a donkey’s fetus cure a snakebite, and what difference does the color of the mother donkey make? But we can begin to make sense of the suggestion by noting the Aramaic words for snake (chivyah) and white (chivrah). Say them out loud. There was a belief that “like cures like” and while we are still at a loss to describe why a donkey’s fetus might be used, we can at least make sense of the white aspect of the whole thing.

snake bites in Israel and around the world

The Talmudic concern for snakebites clearly reflected a reality: they are prevalent in the middle east, and were often deadly. Indeed snakebites remain a threat in Israel and beyond (though in my six years of working in Jerusalem as an emergency physician I recall treating only one victim; he was a handler at a private snake collection- who should have known better.)

In the US, venomous snakes are found in every state except Maine, Alaska and Hawaii, and each year in the US there are about 2,000 recorded venomous snakebites that result in about 6 deaths. The World Health Organization estimates that snakes kill between 20,000 and 94,000 people per year.

Kastururante A. et al. The Global Burden of Snakebite. PLOS Medicine 2008. 5:1591-1604

Snakes are such a problem for Israel and its neighbors that in 1998 the Israel Defense Forces (IDF) and the Jordanian Armed Forces held a joint conference on the topic. Since snakes are cold blooded, they are virtually inactive in the winter months, and summer time can be too hot for them; hence they are most active in the spring and fall. Just as the Talmud described in Yevamot 116b, the IDF found that the peak incidence for snakebites is May (that is, harvest time). 

Snakebites in the IDF. Average incidence per month, 1993-1997. From Haviv, J, et al. Field treatment of snakebites in the Israel Defense Forces. Public Health Rev 1988; 26:24-256.

There are at least eight species of poisonous snake found in Israel, of which the most common is the Palestine Viper, (shown in the photo at the top of the page) which is found in all regions north of Be’er Sheva. It is this snake that is responsible for all the fatal snake bites in Israel, though the IDF reported not one fatality during its five year study period. 

sidebar: palestinian or israel viper?

Let's re-read that last paragraph:

“There are at least eight other species of poisonous snake found in Israel, of which the most common is the Palestine Viper”

Is that its real name? Well, it depends who you ask, or perhaps, in what language you ask. The snake's Latin name is Vipera palaestinae, and its Hebrew name is...צפע ארצישראלי! The snake could have been given a Hebrew name that was transliterated from the Latin, i.e. צפע פלסטיני – but that's not what whoever chose the name decided to do.  Outside the case of the viper in the Jerusalem Zoo, this multiple naming is evident:

(It's not only snakes that have may have a crisis of identity. The chamomile flower, common in Israel, is called by its scientific name Anthemis palaestina, and in Hebrew it is קחוון ארצישראלי. Similarly the Terebinth; it is known to the scientific community as Pistacia palaestina, and in Hebrew as אלה ארץ-ישראלית. I could go on, but the point is made.)

One snake living happily, called two names by two peoples. There's a lesson there somewhere. But I digress.

the treatment of snake bites in the Talmud - and today

As we noted, today’s page of Talmud offers a remedy for the unfortunate person bitten by a snake (of either the Palestinian or Israeli variety. Not the person. The snake.)

If one is bitten by a snake, he should take an embryo of a white donkey, tear it open, and place it on the bite

How does this advice compare with the IDF field manual? Not very well, as you can see from this list of the field treatment do's and dont's from the Medical Corps of the IDF.  Embryos of white donkeys do not make it. (Donkey embryos as a therapy also fail to make a fascinating 1953 report of 65 cases of viper bite in Israel.)

Haviv, J, et al. Field treatment of snakebites in the Israel Defense Forces. Public Health Rev 1988; 26:24-256.

Snake venom produces its deadly effects by causing a coagulopathy, which is the general name for a breakdown in the normal way the blood clots.  When things get really bad, snake venom causes a consumption coagulopathy, in which (as its name implies),  all the vital bits that are needed for blood to clot are consumed, leaving the poor victim susceptible to life-threatening uncontrollable bleeding. Here's a chart of the clotting pathways that medical students have to learn (a process only slightly less painful than a snake bite itself,) with the bits that venom attacks shown in green.

Diagram of the clotting pathway showing the major clotting factors (blue) and their role in the activation of the pathway and clot formation. The four major groups of snake toxins that activated the clotting pathway are in green and the intermediate or incomplete products they form are indicated in dark red. There are four major types of prothrombin activators, which either convert thrombin to form the catalytically active meizothrombin (Group A and B) or to thrombin (Group C and D). From Maduwage K, Isbister GK. Current Treatment for Venom-Induced Consumption Coagulopathy Resulting from Snakebite. PLoS Negl Trop Dis 2014. 8(10): 1-13.

The standard treatment for snake envenomation is antivenom. (This is a technical term for something that is anti the venom.) In the 1950s  antivenom was already part of the standard  treatment of viper bites in Israel, though apparently it was then called by the far fancier name of "serum antivenimeux."  (If chemistry or immunology is your thing, you can read more about how viper antivenom was made in Israel here.) These antivenoms work in a number of ways, one of which is by blocking the toxin and preventing it from binding to its target (i.e. those green diamonds in the diagram above).

snakes that heal

Snakes aren't only associated with coma, convulsions and death.  They are - paradoxically -  often associated with those who heal.  Here is the cover of Fred Rosner's book; notice what looks like two snakes wrapped around a winged pole.  Compare that image with the insignia of the US Army Medical Corps below.

The lower image is the caduceus, the rod carried by the Greek god Hermes (known as Mercury when in Rome). But in fact this double-snake flying-rod has nothing to do with healing, and is erroneously -though very widely- used as a medical emblem.  But as an article in the Journal of the American Medical Association points out, the adoption of the double-snaked caduceus of Hermes - at least in the US - is likely due to its having been used as a watermark by the prolific medical publisher John Churchill.   

The correct mythological association is with the Staff  of Asklepios, the ancient Greco-Roman god of medicine. In one legend, a snake placed some herbs into the mouth of another serpent that Asklepios had killed, and the dead snake was restored to life.  As a mark of respect, Asklepios adopted as his emblem  a snake coiled around his staff.  While the US Army Medical Corps uses the caducues as its badge, on its regimental flag the US Army Medical Command uses the more appropriate single snaked staff. Oh, and a rooster.  

U.S. Army Medical Command Regimental Flag. Don't ask about the rooster...

Fortunately, the Israel Defense Forces clearly know a caduceus from an Asklepios. They adopted the correct Greco-Roman mythological symbol for the medical unit of the first Jewish army in 2,000 years.

The Greeks may have had their tradition, but we have ours. And in ours, it is never the snake that heals.

“עשה לך שרף ושים אותו על נס, והיה כל הנשוך וראה אותו וחי. וכי נחש ממית או נחש מחיה? אלא בזמן שישראל מסתכלין כלפי מעלה ומשעבדין את לבם לאביהן שבשמים היו מתרפאים, ואם לאו היו נימוקים...

”Make a fiery snake and place it on a pole, and it will be that anyone who is bitten will look at it and live” [Numbers 21:8] But is a snake the source of life and death? Rather, the verse means that when Israel looked up and submitted their heart to their Father in Heaven, they were healed, but if they did not do so, they perished.”

— Mishnah Rosh Hashanah 3:8

Shabbat 108-110 ~ Might Talmudic Medicines Really Work?

For the next couple of days, those who study the Talmud following the one-page-a-day Daf Yomi cycle will spend some time reading about cutting edge medical practices.  In Babylon. About 1,500 years ago. Here's a smattering of some of those practices:

For  a hand or foot wound

• Immerse the wound in wine (especially if you are from Mehoza). For injuries to the back of the hand, use vinegar instead (Shabbat 108b).

For liver worms

• Swallow some white cress. If that does not help, you should fast, and then take fatty meat and place it on coals and suck the bone and swallow vinegar. If that does not help, take the sawdust that was scraped from the shell of a thorn bush from top to bottom, (though not from bottom to top, since perhaps then the worms will come out through the mouth). Then boil the scrapings in beer at twilight and the next day close your nostrils and drink it. Then defecate on the trunk of a palm tree (Shabbat 109b).

For a snake bite

• Tear up the fetus of a white donkey. Apply to the wound (Shabbat 109b).

For a genital discharge

• Boil three pans of Persian onions in wine. Drink the mixture (Shabbat 110b). If the discharge persists, take a fistful of cumin, saffron, and fenugreek, cook them in wine, and give drink, while saying to the patient: “Stop emitting your discharge” (Shabbat 110b).

For jaundice

• Drink grasshopper brine. If your chemist lacks grasshopper brine, substitute with brine of small birds, enter a bathhouse, and smear yourself (Shabbat110b).

For toothache

• Swish with wine vinegar (Shabbat 111a).

We could go on but no doubt you've got the idea.  While I doubt there are many of us eager to look for a pregnant white donkey should we be bitten by a snake, some ancient remedies appear to have remarkable healing properties. Here, for example is a review of the healing properties of acetic acid, better known as vinegar, which today’s page of Talmud recommends for a number of different conditions. It was published in a paper earlier this year.

Vinegar is generally acknowledged to act as a mild disinfectant, and pure acetic acid has been shown to exhibit various bactericidal effects at concentrations similar to or lower than those typically found in vinegar. This includes the ability to kill cells of key opportunistic pathogens living as monospecies biofilms (clinical isolates of the Gram-negative species Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter cloacae, and Proteus mirabilis, plus the Gram-positive species Staphylococcus aureus. As a weak acid, it can readily cross cell membranes and collapse the cross-membrane proton gradient necessary for ATP synthesis; once inside the cell, acetic acid alters the cytoplasmic pH, and this can cause DNA damage and protein unfolding. A clinical trial into the effectiveness of acetic acid for treating burn wound infections is under way in the United Kingdom.

“ A rich source of new antimicrobials potentially resides in medieval and early modern medical texts”

— Harrison F, Roberts AEL, Gabrilska R, Rumbaugh KP, Lee C, Diggle SP. 2015. A 1,000-year-old antimicrobial remedy with antistaphylococcal activity. mBio 6(4):e01129- 15.

A 1,000-Year-Old Antimicrobial Remedy

Bald’s eyesalve. A facsimile of the recipe, taken from the manuscript known as Bald’s Leechbook (London, British Library, Royal 12, D xvii).

I am not aware of any published descriptions of attempts to test these talmudic remedies. But a recent paper described something close. It was an attempt to reproduce a remedy described in Bald's Leechbook, an English medical text written in the tenth century. This text, which exists as a single copy in the British Library in London, contains a number of remedies, including those for what appear to be microbial infections.  Here's one of them:  

Make an eyesalve against a wen [a lump in the eye]: take equal amounts of cropleac [an Allium species] and garlic, pound well together, take equal amounts of wine and oxgall, mix with the alliums, put this in a brass vessel, let [the mixture] stand for nine nights in the brass vessel, wring through a cloth and clarify well, put in a horn and at night apply to the eye with a feather; the best medicine.

The most likely clinical condition that correlates with a wen is a hordeolum, or, in non-medical language, a sty. It's a bacterial infection of an eyelash follicle, caused by a common bacterium called Staph. Aureus. They are easily treated with antibiotic cream and warm compresses. A group of medical researchers (with the help of a historian from the School of English and Centre for the Study of the Viking Age at the University of Nottingham) tested the effect of Bald’s eyesalve on Staph. aureus. They wanted to to determine if it worked at all.  If it did, they wanted to see if its efficacy could be attributed to a single ingredient, or whether it only worked when all the ingredients were combined according to the instructions laid down by Bald.  

Of course the first thing the scientists needed to do was to figure out what some of ingredients were. For example, copleac might be an onion, or a leek. (Actually, they couldn't figure out which of the two it was, so they made two variants of the recipe.) Next, they took both the recipe, and controls, which were the individual ingredients alone, and after leaving them to stand for "nine nights" as the Leechbook requires (læt standan ni􏰍on niht) they applied them to colonies of Staph Aureus. Then they counted the number of colonies of the bacteria that remained.

Two hundred microliters of ES-Onion or ES-Leek (batch A, filled circles, and batch B, open circles) or of each individual ingredient preparation was added to five 1-day-old cultures of S. aureus growing at 37°C in a synthetic wound. After 24 h of further incubation, the collagen was dissolved to recover cells for agar plate counts. The control treatment was sterile distilled water left to stand for 9 days in the presence of brass, which was also present in all other preparations, to simulate the presence of a copper alloy vessel Asterisks denote treatments whose results were significantly different from those of the control. From Harrison F, Roberts AEL, Gabrilska R, Rumbaugh KP, Lee C, Diggle SP. 2015. A 1,000-year-old antimicrobial remedy with antistaphylococcal activity. mBio 6(4):e01129-15.

To their great delight they found the recipe was only effective when all the ingredients were present. They even tested whether it was necessary to wait for nine days and reported that "the number of viable cells left after treatment with either version...was [significantly] lower when the eyesalve had been left to stand for 9 days prior to use." In other words, the potion concocted only worked when the recipe was followed in its entirety; skipping any part decreased the efficacy.    

“What is the remedy for a boil? — Abaye said: [A mixture of] ginger and silver dross and sulphur and vinegar of wine and olive oil and white naphtha laid on with a goose’s quill.”

— Gittin 86a

But the next experiments were no less remarkable. The researchers tested the potion on methicillin-resistant Staph. Aureus (MRSA) which is an entirely modern "superbug". Through the indiscriminate and widespread use of antiobiotics, this strain of Staph. Aureus has grown resistant to the usual antibiotics, and is very real health problem.  The researchers tested the onion (ES-O) and leek (ES-L) versions against a standard antibiotic used to treat MRSA, called vancomycin, using mice that had been infected with the superbug. Vancomycin, the standard modern therapy, did not cause significant reductions in viable bacteria, but "ES-O and ES-L caused statistically significant drops in the numbers of viable cells recovered from wounds." In fact when compared to our modern vancomycis, the Leechbook potions caused a ten-fold reduction in the number of viable MRSA cells recovered. Of course there's a long way between a single small study done on cell cultures and mice, and a drug that is safe and effective in humans. But this story reveals how come very old medical texts may contain treatments that work, and another analysis of an old Welsh medical text published in the Journal of Ethnopharmacology also found several ingredients with antimicrobial activity.

[For more on the the story of the discovery of Bald'eye remedy, listen to this wonderful podcast:]

Data Mining a Medieval Medical Text

Earlier this year a group of scientists took the Bald’s Leechbook idea to the next level. Perhaps medieval medical texts could be turned into electronic databases which could then be explored by a computer algorithm. This time the text was the 15th-century Lylye of Medicynes, which focuses on remedies to treat symptoms of microbial infection. (The book is a Middle English translation of Bernard of Gordon’s Lilium Medicinae, originally completed in the early 14th century. The text is extant in one manuscript, University of Oxford, Bodleian Library, MS. Ashmole 1505.)

The book has an amazing 3,548 ingredients (747 unique names) used to treat 124 unique disease names, of which 41 could be classified as potential skin, mouth, or eye infections. Then the team looked to see which ingredients were commonly used together, and built patterns of ingredients, like this:

Example of an ingredient network. The nodes in yellow are ingredients of a recipe for the treatment of fistula in lacrimali; those in blue are ingredients of a recipe for the treatment of pascionibus oris. Ingredients found in both recipes are colored both yellow and blue. Thicker links join pairs of ingredients that appear in both recipes.

In this way the group could identify which ingredients were core components. These were then tested for activity against two Gram-positive opportunistic soft tissue pathogens (Staphylococcus aureus and Enterococcus faecalis) and two Gram-negative opportunistic soft tissue pathogens (Escherichia coli and Pseudomonas aeruginosa).

As you can see in the table above, there are some interesting results. The combination of Aloe vera and breast milk could interfere with the killing effects of honey (for P. aeruginosa and E. coli) or those of frankincense plus sumac (for P. aeruginosa, E. coli and S. aureus); however, in the case of E. faecalis, combining bile with honey or combining frankincense-sumac with honey led to the synergistic emergence of bactericidal activity.

Perhaps, noted the authors, “the combinations of honey, acetic acid, bile, and frankincense and/or sumac may be worth investigation for their ability to potentiate each other’s antibacterial effects…”

“If medieval physicians really did use observation and experience to design effective antimicrobial
medicines, then this predates the generally accepted date for the adoption of a rational scientific method (the formation of the Royal Society in the mid-17th century) and the modern age of antibacterial medicine (Lister’s use of carbolic acid in the late 19th century) by several hundred years.”

— Harrison F, Roberts AEL, Gabrilska R, Rumbaugh KP, Lee C, Diggle SP. 2015. A 1,000-year-old antimicrobial remedy with antistaphylococcal activity. mBio 6(4):e01129-15

The 2015 Nobel Prize for an Ancient Remedy

“ ...take one bunch of Qinghao, soak in two sheng of water, wring it out to obtain the juice and ingest it in its entirety”

— Extract from The Handbook of Prescriptions for Emergency Treatments by Ge Hong (283–343 CE).

Another example of the medical wisdom of some ancient texts was acknowledged by the Nobel Prize Committee, no less. In 2015, the Nobel Prize in Medicine was shared by the Chinese physician Youyou Tu "for her discoveries concerning a novel therapy against Malaria." Professor Tu led a team that screened more than 2,000 traditional Chinese medical herbs for antimalarial activity. Extracts from a herb known locally as Qinghao, (Artemisia annua) inhibited the malarial parasite and was successfully tested on mice in 1971. Clinical studies in the 1980s established the efficacy of artemicinin (as it came to be called). This drug is now part of the standard treatment for malaria worldwide.  Yet it was first identified in a Chinese medical text from the third century CE. - the era of the Mishnah and early Talmud.

But do be careful…

Ancient texts certainly may contain efficacious treatment, though the odds are stacked against them. Today only a very tiny number of compounds that are screened for possible medical benefit ever make it to early trials, and of those most fail. It would take a lot of convincing to get Pfizer to test a "woodcock with its throat cut with a coin" for headache.  Until then, it is best to follow the words of another very old source of wisdom, Rav Sherira Gaon, who died around the year 1000 CE. (and so lived around the time of the composition of Bald's Leechbook). 

אוצר הגאונים, חלק התשובות, גיטין דף ס"ח ע"ב, סימן שע

צריכין אנן למימר לכון, דרבנן לאו אסותא אינון, ומילין בעלמא דחזונין בזמניהון...אמרונין, ולאו דברי מצוה אינון. הלכך לא תסמכון על אלין אסותא, וליכא דעביד מינהון מידעם, אלא בתר דמיבדיק וידע בודאי מחמת רופאים בקיאים, דההיא מילתא לא מעיקא לה וליכא דליתיה נפשיה לידי סכנה. והכין אגמרו יתנא ואמרו לנא אבות וסבי דילנא, דלא למעבד מן אילין אסותא אלא מאי דאיתיה

We must tell you that the rabbis were not physicians. Whatever they saw in their day, they addressed, but these matters are not mitzvot. Therefore, do not rely on these remedies. They must not be applied until they have been tested by expert physicians, who can be sure that the remedy will not cause harm or danger. This is what our ancestors have taught us. We should not apply these remedies unless they have been tested...

[A largely updated post originally published here.]