Shabbat 156 ~ Talmudic Astrology

Astrology is mentioned in many pages of the Talmud, but today we study one of the most important of them. The Talmud does not question whether astrology works, for it assumes that it does. Rather, the discussion centers around the details of producing an astrological map for a person, and how the Jewish People can avoid their astrologically determined fate.

The first topic is how the the alignment of the planets define a person’s fate. According to Rabbi Yehoshua ben Levi the planets influence the day of the week. So if you are born on Sunday, you will be a person of extremes:

שבת קנו, א

אִי כּוּלֵּיהּ לְטֵיבוּ, אִי כּוּלֵּיהּ לְבִישׁוּ. מַאי טַעְמָא? דְּאִיבְּרוֹ בֵּיהּ אוֹר וָחוֹשֶׁךְ

Rather, one born on a Sunday is either completely for the best or completely for the worst. What is the reason for this? It is because both light and darkness were created on the first day of Creation.

If you are born on a Monday, you will be “a short tempered person” because on that day the upper waters were divided from the lower; there was division, which translates into a person who “divides” with his temper. And so on. Now given that 1/7 of the world’s population will be born on any given day of the week, this is rather a generalization, but let’s leave that aside. This opinion is challenged by Rabbi Chaninah, who explains that it is rather more complicated:

שבת קנו, א

אֲמַר לְהוּ רַבִּי חֲנִינָא, פּוּקוּ אֱמַרוּ לֵיהּ לְבַר לֵיוַאי: לֹא מַזַּל יוֹם גּוֹרֵם אֶלָּא מַזַּל שָׁעָה גּוֹרֵם. הַאי מַאן דִּבְחַמָּה — יְהֵי גְּבַר זִיוְתָן, יְהֵי אָכֵיל מִדִּילֵיהּ וְשָׁתֵי מִדִּילֵיהּ, וְרָזוֹהִי גַּלְיִין, אִם גָּנֵיב — לָא מַצְלַח. הַאי מַאן דִּבְכוֹכָב נוֹגַהּ — יְהֵי גְּבַר עַתִּיר וְזַנַּאי יְהֵי. מַאי טַעְמָא? מִשּׁוּם דְּאִיתְיְלִיד בֵּיהּ נוּרָא. הַאי מַאן דִּבְכוֹכָב — יְהֵי גְּבַר נָהִיר וְחַכִּים, מִשּׁוּם דְּסָפְרָא דְחַמָּה הוּא. הַאי מַאן דְּבִלְבָנָה — יְהֵי גְּבַר סָבֵיל מַרְעִין, בָּנֵי וְסָתַר, סָתַר וּבָנֵי, אָכֵיל דְּלָא דִּילֵיהּ וְשָׁתֵי דְּלָא דִּילֵיהּ וְרָזוֹהִי כַּסְיִין אִם גָּנֵב — מַצְלַח. הַאי מַאן דִּבְשַׁבְּתַאי — יְהֵי גְּבַר מַחְשְׁבָתֵיהּ בָּטְלִין. וְאִית דְּאָמְרִי: כל דִּמְחַשְּׁבִין עֲלֵיהּ בָּטְלִין. הַאי מַאן דִּבְצֶדֶק — יְהֵי גְּבַר צִדְקָן. אָמַר רַב נַחְמָן בַּר יִצְחָק: וְצַדְקָן בְּמִצְוֹת. הַאי מַאן דִּבְמַאְדִּים — יְהֵי גְּבַר אָשֵׁיד דְּמָא. אָמַר רַב אָשֵׁי: אִי אוּמָּנָא, אִי גַּנָּבָא, אִי טַבָּחָא, אִי מָהוֹלָא. אָמַר רַבָּה: אֲנָא בְּמַאְדִּים הֲוַאי. אָמַר אַבָּיֵי: מָר נָמֵי עָנֵישׁ וְקָטֵיל

Rabbi Chanina said to his students who heard all this: Go and tell the son of Leiva’i, Rabbi Yehoshua ben Levi: It is not the constellation of the day of the week that determines a person’s nature; rather, it is the constellation of the hour that determines his nature. 
One who was born under the influence of the Sun will be a radiant person; he will eat from his own resources and drink from his own resources, and his secrets will be exposed. If he steals he will not succeed, because he will be like the sun that shines and is revealed to all. 
One who was born under the influence of Venus will be a rich and promiscuous person. What is the reason for this? Because fire was born during the hour of Venus, he will be subject the fire of the evil inclination, which burns perpetually. 
One who was born under the influence of Mercury will be an enlightened and expert man, because Mercury is the sun’s scribe, as it is closest to the sun. 
One who was born under the influence of the Moon will be a man who suffers pains, who builds and destroys, and destroys and builds. He will be a man who eats not from his own resources and drinks not from his own resources, and whose secrets are hidden. If he steals he will succeed, as he is like the moon that constantly changes form, whose light is not its own, and who is at times exposed and at times hidden. 
One who was born under the influence of Saturn will be a man whose thoughts are for naught. And some say that everything that others think about him and plan to do to him is for naught. 
One who was born under the influence of Jupiter [tzedek] will be a just person [tzadkan]. … 
One who was born under the influence of Mars will be one who spills blood. Rav Ashi said: He will be either a blood letter, or a thief, or a slaughterer of animals, or a circumciser. Rabba said: I was born under the influence of Mars and I do not perform any of those activities. Abaye said: My Master also punishes and kills as a judge.

The dispute is whether the planets influence everyone born on a specific day of the week, regardless of the time of their birth, or whether the influence of all the planets is felt daily, with each celestial body influencing successive hours. Or as Rabbi Chaninah puts it on today’s page of Talmud: לֹא מַזַּל יוֹם גּוֹרֵם אֶלָּא מַזַּל שָׁעָה גּוֹרֵם - it is not the celestial sign of the day that influences the nature of a person, but the celestial sign of the hour of birth that influences their nature.

“There is no constellation that rules over Israel”

So in the Talmud, everyone agreed that astrology was a real phenomenon. They just differed in some of its details. Later we read of another dispute, this one between Rabbi Chananiah and Rabbi Yochanan. The former believed מַזָּל מַחְכִּים, מַזָּל מַעֲשִׁיר, וְיֵשׁ מַזָּל לְיִשְׂרָאֵל- “A constellation makes one wise and a constellation makes one wealthy, and there is a constellation for the Jewish people that influences them.” But Rabbi Yochanan believed אֵין מַזָּל לְיִשְׂרָאֵל- “there is no constellation that rules over the Jewish People.” Now at face value Rabbi Yochanan meant precisely what he stated - that the Jewish People is somehow immune to the usual influences of the stars and planets. Except his words were never understood in that way. For example the great medieval commentator Rashi explained that through prayer and charity, Israel could change its destiny, a destiny that would otherwise have been predicted by astrology.

This is also how another great medieval exegete, Ibn Ezra (d. 1164) explained how Israel was not subject to astrological determinism.

אבן עזרא שמות פרק לג פסוק כא 

ואתן לך משל חשוב, שהיתה מערכת הכוכבים שיגדל נהר על עיר אחת וישטוף אנשים או ימותו. ובא נביא והזהירם, שישובו אל השם בטרם בא יום רעתם. ושבו אליו בכל לבם. ובעבור שדבקו בו, נתן בלבם, שיצאו אנשי העיר לחוץ להתפלל אל השם. והנה עשו כן. וביום ההוא גדל הנהר פתאום כמנהגו, כאשר ראינו בעינינו פעמים רבות ושטף כל העיר. והנה לא סרה גזירת השם והוא הצילם, 

I will explain this with an important analogy. Perhaps the alignment of the stars caused a river to overflow and flood a town, sweeping away its inhabitants or drowning them. Now if a prophet came and warned them of the impending danger, and told them to repent before God lest this terrible event would occur, and they truly repented, this would not happen…for on that predicted day of the flood, God would cause all of the inhabitants to flee the city to pray to him. And when the river suddenly burst its banks, God would have saved them…

That’s the meaning of “there is no constellation the rules over Israel.” Your destiny is always written in the stars, but you can, if you try hard enough, manage to change it. So really even the Jewish People are subject to the rules of astrological prediction, but they have, as it were, an escape clause.

“...together with its rational appearance, astrology has the immense advantage to proposes a global, holistic approach for apprehending the world, via a link between humans and the cosmos.”

— Phillipe Zirka. Astronomy and Astrology. The Role of Astronomy in Society and Culture Proceedings IAU Symposium No. 260, 2009. International Astronomical Union 2011 D. Valls-Gabaud & A. Boksenberg, eds.

How Talmudic Astrology worked

For many centuries there were thought to be only seven celestial bodies that determined a person’s future. They are the Sun, the Moon, Mercury, Venus, Mars, Jupiter and Saturn (though not in that order). The order of these bodies was based on how quickly they appear to move across the sky, with Saturn moving the slowest, and the Moon the quickest. So the order would be

Saturn-> Jupiter ->Mars-> Sun->Venus->Mercury-> Moon->Saturn…etc

This sequence is also the furthest from the Earth (Saturn) to the nearest (Moon) in the Ptolemaic system, in which the earth is at the unmoving center of the universe. This pattern was common to most of those who practiced astrology, and is by no means a uniquely Jewish creation.

Each of these celestial bodies rules over one day, or according to Rabbi Chaninah, one hour of each day starting with sunrise. So at sunrise on Day One (which we happen to call SUNday) the Sun is dominant. In hour two it is Venus, hour three, Mercury, and so on until all the hours of the week are filled. Here is how Rabbi Chaninah’s system works, shown for the first three of the seven days of the week:

The Controlling Mazzalot and The Hours of the Week*
Night of Sunday		Day of Sunday
Hour	Mazzal	Hour	Mazzal
1 (Sunset)	Mercury	1 (Sunrise)	Sun
2	Moon	2	Venus
3	Saturn	3	Mercury
4	Jupiter	4	Moon
5	Mars	5	Saturn
6	Sun	6	Jupiter
7	Venus	7	Mars
8	Mercury	8	Sun
9	Moon	9	Venus
10	Saturn	10	Mercury
11	Jupiter	11	Moon
12	Mars	12	Saturn
Night of Monday		Day of Monday
Hour	Mazzal	Hour	Mazzal
1 (Sunset)	Jupiter	1 (Sunrise)	Moon
2	Mars	2	Saturn
3	Sun	3	Jupiter
4	Venus	4	Mars
5	Mercury	5	Sun
6	Moon	6	Venus
7	Saturn	7	Mercury
8	Jupiter	8	Moon
9	Mars	9	Saturn
10	Sun	10	Jupiter
11	Venus	11	Mars
12	Mercury	12	Sun
Night of Tuesday		Day of Tuesday
Hour	Mazzal	Hour	Mazzal
1 (Sunset)	Venus	1 (Sunrise)	Mars
2	Mercury	2	Sun
3	Moon	3	Venus
4	Saturn	4	Mercury
5	Jupiter	5	Moon
6	Mars	6	Saturn
7	Sun	7	Jupiter
8	Venus	8	Mars
9	Mercury	9	Sun
10	Moon	10	Venus
11	Saturn	11	Mercury
12	Jupiter	12	Moon
Etc
*Based on Judah Landa, Torah & Science, Ktav 1991

Why is bloodletting prohibited on a Tuesday?

This chart had very practical ramifications. Earlier in this tractate Shabbat, in a long passage about how and when to perform the medical intervention called bloodletting, we read the following:

שבת קכט,ב

אָמַר שְׁמוּאֵל: פּוּרְסָא דִדְמָא — חַד בְּשַׁבְּתָא, אַרְבָּעָה, וּמַעֲלֵי שַׁבְּתָא, אֲבָל שֵׁנִי וַחֲמִישִׁי — לָא

בִּתְלָתָא בְּשַׁבְּתָא מַאי טַעְמָא לָא? מִשּׁוּם דְּקָיְימָא לֵיהּ מַאְדִּים בְּזָוֵוי

Shmuel said: Bloodletting should be performed on a Sunday, Wednesday and Friday, but not on a Monday or Thursday. And why may bloodletting not be performed on a Tuesday? Because we know that Mars is dominant during the even hours.

A quick glance at the table above will reveal that on Tuesday (the third day of the Jewish week) sunrise (or hour one) is under the influence of Mars, and so is the eighth hour of the day. As Rashi explains, this is particularly dangerous,

שמזל מאדים משמש בו בשעות זוגות ומזל מאדים ממונה על החרב ועל הדבר ועל הפורעניות והזוגות קשין שהן רשות לשדים  

For Mars is dominant during an even hour, and Mars has control over the sword, over pestilence, and over punishment, and during an even hour there is an increased danger, because this is when demons are given permission to destroy…

It seems that Tuesday is a very bad day to let blood, since Mars, the “destroyer” has influence in the eighth hour, and 2x2x2=8, so there are a lot of dangerous even hours (or something like that). As a result, best not to undergo the procedure.

But does Astrology work?

No. There a a myriad of reasons why not. Here is just one: why should randomly picked patterns of stars, light years from one another should influence anything here on Earth? The constellations are, after all, a human construct. It is as if an actor on stage picked out a man in the second row, a woman in the mezzanine, and another woman at the front of the balcony, and saw in their pattern a triangle. That is what happens when when we “see” constellations. Here is a second problem: How can object so far from Earth could influence our lives, for their gravitational effects are far weaker than those of the table lamp sitting next to you on your desk. Are we now going to suggest other kinds of yet to be discovered material waves that “influence” us? A third: why do astrologers not take into account the constellations in the southern hemisphere? Surely they too must have an important effect, but they are not part of the Talmudic system, nor of many modern astrology charts. Just because the people who developed the whole notion of astrology were not aware of them, surely does not negate the influence they must exert on out futures?

More importantly than a lack of a mechanism is the simple fact that in study after study, astrologers have not been able to predict anything that would not have ben expected by chance. My favorite example of this is the 1985 study by Shawn Carlson, published in the prestigious journal Nature. It is important because it was designed with input from both scientists and astrologers.The thesis was that

the positions of all the planets (all planets, the Sun and the Moon plus other objects defined by astrologers) at the moment of birth can be used to determine the subject’s general personality traits and tendencies in temperament and behavior, and to indicate the major issues which the subject is likely encounter

and it sounds very much like the astrological beliefs found in today’s page of Talmud.

So a group of volunteers told astrologers the details of their birth, and from these a “natal chart” (or horoscope) was drawn up. There could be no identifying clues in the chart. Each volunteer was then given three natal charts; her own and two others, and asked to pick out the one that best described themselves. There were 83 volunteers, whose natal charts were drawn up over a ten week period. If the astrologers could accurately predict a person’s future, that chart should stand out and be correctly chosen by the person to whom it belonged. If it could not, then the correct chart would only be chosen 1/3 of the time. And guess what, it was indeed chosen….only 1/3 of the time. (There are many more details about the study including other tests that were performed, and how the statistical analysis was performed.)

Of course there are critics of this experiment, and those in one camp will generally not be swayed by the other. One may object to astrology because it is not “scientific”, but there are lots of things that are true and are not scientific; like love, or longing. And as anyone who has recently perused a bookshop in Israel can testify, the whole astrology thing has had a renaissance there.

Maimonides’ opposition to Astrology

But don’t just take my criticisms of astrology. None other than Maimonides himself was absolutely opposed to its practice in any way, as he outlined in his Mishnah Torah. In addition, in his famous Letter to the Jews of Marseilles of 1194 he went further, and denounced astrology as “an irrational illusion of fools and a baseless deception that was subversive to the faith and teachings of Judaism.” Here are a few choice excerpts:

no man should believe anything unless attested by one of three principles. First, rational proof as in mathematical sciences; secondly, the perception by one of the five senses… and third, tradition derived from the prophets and the righteous…

Some misguided people wrote thousands of books on the subject and many ignorant people wasted their precious years pouring over them, mistaking vanity for knowledge and ascribing consummate wisdom to their authors. There seems to be a fatal disease and abysmal mischief among most people, with the exception of a select divinely inpired remnant, to the effect that whatever is found in books is instantly acceptable as truth, especially if the books are ancient…Know my masters that I investigated these matters extensively… There was not a single book translated into Arabic on the subject that I have not studied and investigated in depth…

…all the assumptions of the astrologers with regard to the forecasting of impeding events, or the determination of one's destiny by the constellation at the time of one’s birth are irrational superstitions devoid of any scientific basis…. 

For if man's life is predestined by an external force that coercively casts him into a frozen mould or impels him to act in a certain way without his own choice, then of what value are the precepts and the teachings of the Torah? It would appear thus that their views are not only invalidated by scientific thought… but in their folly the astrologers tend to reject the Mosaic Law.

Maimonides ends his letter with a powerful call to rationalism and a rejection of all superstitions, including astrology.

I am aware that it is possible to find some individual opinions of our sages in the Talmud, the Mishnah and Midrashim supporting astrological assumptions about the potency of the stars… This should not be disturbing to you inasmuch as we must never abandon practical Halakhah for the sake of upholding dialectical arguments. Moreover, it is not feasible to surrender demonstrative rational knowledge and embrace the opinion of one individual sage who might have missed a crucial point at that time or he may have proffered an allegorical remark not to be taken literally or that his statement was meant as a temporary measure referring to a specific incident. For is it not apparent that many statements of the Torah cannot be taken literally but, as is clear from scientific evidence, require interpretation that will make them acceptable to rational thought.

The attraction and repulsion of astrology

In fact, there has always been a tension between a belief in a pre-determined destiny written in the heavens, and the utter disdain for such a practice. Here, for example is how Samuel (d. 254 CE), who was famous as both an astronomer and physician, thought about it:

דברים רבא 8:6

 מַהוּ לֹא בַשָּׁמַיִם הִוא. שְׁמוּאֵל אָמַר אֵין הַתּוֹרָה מְצוּיָה בְּאִיסְטְרוֹלוֹגִין שֶׁאֻמְנוּתָן בַּשָּׁמָיִם

What is the meaning of the words “it is not in the heavens” (Deut 30:12)? Samuel explained, the Torah is above the work of astrologers who study the heavens…

Although he taught that the Torah (and presumably those who observe it) were beyond the influence of the stars, Samuel never believed that astrology was a foolish undertaking. The passage continues:

אָמְרוּ לִשְׁמוּאֵל הֲרֵי אַתָּה אִיסְטְרוֹלוֹגִין וְגָדוֹל בַּתּוֹרָה, אָמַר לָהֶן לֹא הָיִיתִי מַבִּיט בְּאִיסְטְרוֹלוֹגִים אֶלָּא בְּשָׁעָה שֶׁהָיִיתִי פָּנוּי מִן הַתּוֹרָה, אֵימָתַי כְּשֶׁהָיִיתִי נִכְנָס לְבֵית הַמָּיִם

They said to Shmuel, but aren't you an astrologer and also great in Torah? He said to them, I only look at the astrological signs when I am free from the Torah. When is that? When I enter the bathhouse

Samuel never dismissed astrology, but he only turned to it when he was free from the study of Torah. Today, about a third of Americans believe in astrology. Once, one-hundred percent of all people did. So perhaps we are slowly heading in the right direction.

Shabbat 136 ~ The Tumtum, the Androgyne, and the Fluidity of Gender

The Mishnah that we learned two days ago (134b) teaches that certain acts, normally prohibited on Shabbat, are permitted if the Shabbat is the day of a newborn’s circumcision, or brit milah. For example, a newborn boy may be bathed in warm water on Shabbat in preparation for his circumcision. Although such bathing is usually prohibited it was permitted in this instance, because bathing was thought to have important healing properties, But there are exceptions to this exception, also noted in the Mishnah.

שבת קלד,ב

סָפֵק וְאַנְדְּרוֹגִינוֹס — אֵין מְחַלְּלִין עָלָיו אֶת הַשַּׁבָּת. וְרַבִּי יְהוּדָה מַתִּיר בְּאַנְדְּרוֹגִינוֹס

If there was a question about whether or not to circumcise the baby, or if the baby was an androgyne, we do not desecrate the Shabbat [in order to perform the circumcision]. But Rabbi Yehuda permits a Shabbat circumcision in the case of the adrogyne.

Let’s put to one side the case in which there was “a question about whether or not to circumcise” (it has to do with whether the baby was born prematurely, in the eighth month of pregnancy and you can read more about it here), and focus on the androgyne. In today’s page of Talmud we read a statement from the Sifra that excludes two groups of people from the category of being a male (at least in so far as the laws of human valuation is applied).

שבת קלו, ב

 דְּתַנְיָא: ״הַזָּכָר״ — וְלֹא טוּמְטוּם וְאַנְדְּרוֹגִינוֹס. יָכוֹל לֹא יְהֵא בְּעֵרֶךְ אִישׁ אֲבָל יְהֵא בְּעֵרֶךְ אִשָּׁה — תַּלְמוּד לוֹמַר: ״הַזָּכָר״, ״וְאִם נְקֵבָה הִיא״. זָכָר וַדַּאי, נְקֵבָה וַדָּאִית — וְלֹא טוּמְטוּם וְאַנְדְּרוֹגִינוֹס

As it was taught in the Sifra, the halakhic midrash on Leviticus, with regard to the verse: “Then your valuation shall be for the male from the age of twenty years until the age of sixty years, your valuation shall be fifty shekel of silver, after the shekel of the Sanctuary” (Leviticus 27:3). The Sages inferred: “The male” means the definite male but not a tumtum or an androgynus.

Although in the Mishnah in Shabbat only mentioned the case of the androgyne, it is frequently mentioned together with the androgynus. In Jewish law, these two groups are neither completely male or completely female, but are at some times treated as male, and at others female.

The tumtum is a person whose genitalia are somehow hidden or covered, so that it is not known if they are male or female. In contrast, the genitalia of the androgyne (an ancient Greek word formed from ἀνδρός  andros - “man” and γυνή gune, - “woman”) are in plain sight. It just isn’t clear whether they are male or female organs. The two are mentioned on at least twenty-three pages of the Babylonian Talmud, and in no fewer than nine halachot in the Jerusalem Talmud  (and we have written on some of them before). So let’s figure out what, from a medical perspective, they are.

The Tumtum

There is no ambiguity about the gender of a tumtum. We just need to get a glimpse of the genitals. (The eleventh century dictionary known as the Aruch connects the word tumtum with the word atum (אטום), meaning sealed.) The problem is that the genitals are covered by what is usually described as skin. Once this cover is surgically opened, the gender will be revealed. In fact according to Rav Ammi (Yevamot 64a), both Abraham and Sarah were each a tumtum. Yes, you read that correctly. Each had genitalia that were hidden. Rav Ammi suggests this as an explanation as to why the couple were infertile for so many years. Once the covering had been removed the couple could then procreate as normal, and along came Isaac.

אמר רבי אמי אברהם ושרה טומטמין היו שנאמר (ישעיהו נא, א) הביטו אל צור חוצבתם ואל מקבת בור נוקרתם וכתיב (ישעיהו נא, ב) הביטו אל אברהם אביכם ואל שרה תחוללכם

Rabbi Ami said: Abraham and Sarah were originally tumtumin, as it is stated: “Look to the rock from where you were hewn, and to the hole of the pit from where you were dug” (Isaiah 51:1), and it is written in the next verse: “Look to Abraham your father and to Sarah who bore you” (Isaiah 51:2),

רשי:

חוצבתם - נעשה לו זכרות: “Hewn”: He was made into a male

נוקרתם - נעשה לה נקבות : “From where you were dug” which made here a female

Urologists have yet to identify the syndrome responsible for Rav Ami’s teaching.

The Androgyne

In 1797 the physician James Parsons, published a book which he dedicated to the Royal Society of London, of which he was a Fellow: “ A Mechanical and Critical Inquiry into the Nature of Hermaphrodites.” Parsons noted that the Romans “had laws made against their Androgyni [which were] remarkably severe; for whensoever a child was reputed one of these, his sentence was to be shut up in a chest alive, and thrown into the sea…

Parsons was not only well-read in Roman law; he cited the fourth chapter of the Mishnah in Bikkurim, which contains a list of the ways in which the androgne sometimes resembles a man, and sometimes a woman:

ביכורים פרק ד

כֵּיצַד שָׁוֶה לַאֲנָשִׁים: מְטַמֵּא בְּלֹבֶן כַּאֲנָשִׁים, וְזוֹקֵק לְיִבּוּם כַּאֲנָשִׁים, וּמִתְעַטֵּף וּמִסְתַּפֵּר כַּאֲנָשִׁים, וְנוֹשֵׂא אֲבָל לֹא נִשָּׂא כַּאֲנָשִׁים, וְחַיָּב בְּכָל מִצְוֹת הָאֲמוּרוֹת בַּתּוֹרָה כַּאֲנָשִׁים:

In what ways is the andogyne like men?…He dresses like men; He can take a wife but not be taken as a wife, like men. [When he is born] his mother counts the blood of purification, like men; He may not be secluded with women, like men. He is not maintained with the daughters, like men…And he must perform all the commandments of the Torah, like men.

כֵּיצַד שָׁוֶה לַנָּשִׁים: מְטַמֵּא בְּאֹדֶם כַּנָּשִׁים, וְאֵינוֹ מִתְיַחֵד עִם הָאֲנָשִׁים כַּנָּשִׁים, וְאֵינוֹ עוֹבֵר עַל "בַּל תַּקִּיף" וְלֹא עַל "בַּל תַּשְׁחִית" וְלֹא עַל "בַּל תְּטַמֵּא לַמֵּתִים" כַּנָּשִׁים, וּפָסוּל מִן הָעֵדוּת כַּנָּשִׁים, וְאֵינוֹ נִבְעַל בַּעֲבֵירָה כַּנָּשִׁים, וְנִפְסַל מִן הַכְּהֻנָּה כַּנָּשִׁים:

And in what ways is he like women?… he must not be secluded with men, like women; And he doesn’t make his brother’s wife liable for yibbum (levirate marriage); And he does not share [in the inheritance] with the sons, like women; And he cannot eat most holy sacrifices, like women…. he is disqualified from being a witness, like women…

The Androgyne & Congenital Adrenal Hyperplasia

Ambiguous genitalia in neonates. From here.

One of the most common causes of androgyny is congenital adrenal hyperplasia (CAH), caused by a mutation in the CYP21 gene. The adrenal glands, which sits atop the kidneys, are where the action takes place. They produce androgens, which are then converted into the potent sex hormone testosterone. In most (95%) cases of CAH, there is a deficiency of the enzyme 21-hydroxylase. As a result, the adrenal glands produce excessive amounts of the virilizing hormone androgen. (It also causes severe salt wasting, which can be very dangerous, but we are not getting into that now. And there are different severities of the syndrome, but you’ve got a limited attention span, so we will keep it simple.) This excessive androgen production does very little in (XY) males; their genitalia look normal. But in genetic (XX) baby girls the androgens affect the external genitalia and they may become ambiguous: the clitoris becomes enlarged, sometimes to the degree that it resembles a penis. In very severe cases the baby girl has what appears to be an empty scrotum, and may be raised as a boy, all the while being an XX girl with CAH.

Today all newborns are screened for 21-hydroxylase. The deficiency can be treated with hormone replacement, and the genital ambiguity may be corrected, although this latter intervention has, over the last decades, become very controversial.

“Anecdotally, in the Western world most [intersex] babies were raised as female because the genitalia were easier to reconstruct... clinical experience suggests that cultural factors are very influential. This may be no bad thing as there is no ‘right’ medical answer and the child will have to grow up in the community into which it is born.”

— Woodhouse, C.R.J. Intersex Surgery in the Adult. BJU International 2004. 93 (3): 57-65

The androgyne and the hermaphrodite

James Parsons, A Mechanical and Critical Inquiry into the Nature of Hermaphrodites. London 1797. p85.

The Soncino Talmud and the Koren Talmud identifies the androgyne as a hermaphrodite, that is, a person with both male and female genitalia. So does Goldschmidt’s German translation (“der zwitter”). Cases of true hermaphroditism are extremely rare, and there are only a few scattered case reports in the medical literature. (You can read one reported from Sheba Hospital in Tel Aviv here.) Rather than there being two sets, in these cases the genitalia are ambiguous, and although they have both ovarian and testicular tissue the scrotum does not always contain testes.

Alice Dreger, formerly a Professor of Medical Humanities and Bioethics at Northwestern University, (it’s complicated) wrote a terrific (and controversial) book that tackles some of the issues facing intersex people - those who were once called hermaphrodites. In the past, when faced these difficult cases of intersex or ambiguous genders, clinicians focused on what she calls a “gonadal division.” (Since biopsies and genetic sequencing were not available to the rabbis of the Talmud, they, like clinicians, focused on this gonadal division, for what else could they do?) But, she notes,

a system that emphasizes gonadal anatomy above all else suffers from two major deficits. First, it is scientifically questionable, because it relies on the anatomy of the gonads (functioning or not) more than any other considerations. Second, it provides little clinical help, often confusing and harming the patient, and sometimes also the physician.

Instead, she advocates for a description based on etiology and the patient’s needs. “Such an approach would have the salutary effects of improving patient and physician understanding and reducing the biases that are inherent in the use of the current language of 'hermaphroditism'.”

“True hermaphrodites: defined as presenting at least one ovary and at least one testis, or at least one ovotestis...The scientific understanding of sexual development has progressed tremendously in the last 125 years, but the existing taxonomy does not reflect that progress. Scientists and clinicians now recognize that the structure of the gonads does not correlate simply with genotype, phenotype, physiology, diagnosis, or gender identity. The anatomy of testicular tissue in women with androgen insensitivity syndrome (AIS) is quite similar to the anatomy of testicular tissue in non- intersex males, yet their physiologies, phenotypes and gender identities differ markedly.”

— Dreger, A, et al. Changing the Nomenclature/Taxonomy for Intersex. Journal of Pediatric Endocrinology & Metabolism 2005. 18, 729-733

The many Shades of Gender

We are used to think that when an egg carrying an X chromosome meets a sperm carrying an X or Y chromosome, one of two things will happen: a genetic female (46XX) or a genetic male (46XY) with genitalia to match. But in fact it is way more complicated than that. We know that there are at least 14 genes involved in the process of sexual differentiation, and many more will likely be discovered. A mutation or malfunction of any of these has a dramatic effect on the process of gender differentiation. For example if there is a defect in the enzymes involved in producing testosterone, there may be ambiguous external genitalia; deficiency of the enzyme 5α-reductase results in variable degrees of under-masculinized external genitalia and genital ambiguity; individuals with partial androgen insensitivity syndrome may also have ambiguous genitalia, and there is no consensus regarding an optimal sex of rearing them; and newborns with congenital adrenal hyperplasia, may have male appearing genitalia while all the time being 46XX.

We have previously noted the strange effects of yet gene discovered in the 1980s. This sex-determining gene on a tiny bit of the male Y chromosome is called the sry gene. That gene tells the body to develop into a male or female appearing body. Sometimes the sry gene sneaks off of the Y gene and makes its way into the DNA of an XX female. As a result, she will develop male anatomy while genetically remaining an XX female. (Please read that sentence again, just to be sure you have understood it.) And sometimes the sry gene on an XY genetic male can mutate and not work. In that case, the genetic male appears to have the organs of a female, which is what occurs in Swyer syndrome. (You can hear more about the amazing sex-changing effects of sry in this fascinating podcast.)

And then there is the small community in the Dominican Republic where there have been a number of cases in which little girls grow a penis and turn into little boys. These observations were first reported to the scientific community in 1974, and are caused by a deficiency of the steroid 5α-reductase. Here is how the BBC explained what is going on when they reported about it in 2015.

When you are conceived you normally have a pair of X chromosomes if you are to become a girl and a set of XY chromosomes if you are destined to be male. For the first weeks of life in womb you are neither…Then, around eight weeks after conception, the sex hormones kick in. If you're genetically male the Y chromosome instructs your gonads to become testicles and sends testosterone to a structure called the tubercle, where it is converted into a more potent hormone called dihydro-testosterone. This in turn transforms the tubercle into a penis. If you're female and you don't make dihydro-testosterone then your tubercle becomes a clitoris…the reason [some genetic males] don't have male genitalia when they are born is because they are deficient in an enzyme called 5-alpha-reductase, which normally converts testosterone into dihydro-testosterone.

So the boys, despite having an XY chromosome, appear female when they are born. At puberty, like other boys, they get a second surge of testosterone. This time the body does respond and they sprout muscles, testes and a penis.

So gender identity is very complicated. James Parsons, that physician who wrote the book on hermaphrodites in 1797 tackled some of the difficult questions that were addressed in Mishnah Bikkurim: can a hermaphrodite get married? (yes, but to which gender varies by case); can they be a witness? (only if the “predominating sex” is male); can they be ordained as a minister? (no); The rabbis were puzzled as to the “true” gender of the androgyne, and so classified them as sometimes male, and sometimes female. It was the best they could do at the time, and Parsons, writing 1,500 years later did the same. Thanks to modern medicine we have learned why these intersex cases occur, but as a society we have still a long way to go to help make their lives easier.

[Mostly a repost from Arachin, but well worth the read.]

Shabbat 134a ~ The Imperforate Anus and the Skills of the Midwife

During a discussion about the permissibility of healing on Shabbat, we read the following:

שבת קלד,א

אָמַר אַבָּיֵי, אֲמַרָה לִי אֵם: הַאי יָנוֹקָא דְּלָא יְדִיעַ מַפַּקְתֵּיהּ, לְשַׁיְיפֵיהּ מִישְׁחָא וְלוֹקְמֵיהּ לַהֲדֵי יוֹמָא, וְהֵיכָא דְּזִיג — לִיקְרְעֵיהּ בִּשְׂעָרְתָּא שְׁתִי וָעֵרֶב. אֲבָל בִּכְלִי מַתָּכוֹת — לָא, מִשּׁוּם דְּזָרֵיף

Abaye said: my nurse told me: In the case of a baby whose anus cannot be seen, [as it is obscured by skin,] let one rub it with oil and stand it before the light of the day. And where it appears transparent, let one tear it with a barley grain widthwise and lengthwise. However, one may not tear it with a metal implement because it causes infection and swelling.

This is a fascinating piece of Talmud for a number of reasons.  First, the medical knowledge Abaye shared comes from the nurse who raised him (for he was an orphan). Since women were the ones who helped in childbirth, it was they who were most experienced in identifying neonatal disorder.  

Second, the problem that is described is a congenital defect, one that is the result of a malformation during the development of the growing fetus. We have encountered these before; it would seem that the Cohanim had a high rate of polydactyly, or extra digits on their hands.

Third, the intervention is one of the earliest descriptions of neonatal surgery of any sort (perhaps with the exception of circumcision). Fourth, it describes in detail the surgical steps to be taken to fix the problem. Fifth, it demonstrates that the operation had evolved over time, and that earlier techniques using metal probes were associated with poor outcomes. The women had used their observation and experience to perfect the procedure.

Finally, the fact that there was a procedure for this congenital problem at all, and that it had been perfected through trial and error, means that what is today called an imperforate anus must have been fairly prevalent, and not something seen only once in a lifetime.

The spectrum of anorectal malformations 

From here.

The abnormality described in this page of Talmud is one of several anorectal malformations which occur in about one in 4,000 births. Some, like the mild case described by Abaye, are mild. A small skin flap covers the opening of the anus and can be fixed with a simple incision, in this instance with a barley seed. Others are far more serious and are associated with other malformations in the urogenital system and lower spine. Because of their different genital anatomy, boys and girls have different associated complications. For example, boys may have a connection to the prostate gland, while girls may have malformation in which rectum, vagina, and urethra are fused together into a single common channel that opens into a single orifice. These may be corrected with surgery, some of it simple, much of it complicated. Other congenital defects associated with this condition are gastrointestinal, and about 30% of these neonates have additional cardiac defects.  In short, there is a wide spectrum of problems that may be associated with a neonate born with an imperforate anus.

The technique described by Abaye’s nurse would only be of benefit in the very mildest cases, in which a simple skin plug covers the opening.  For the majority of babies born in Talmudic times with an anorectal disorder, the procedure sadly, would not have helped. They would have required complex surgery that has only been around in the last fifty years or so. Even today, about a third of the children who undergo surgical repair have associated fecal incontinence.  

The skills of Abaye’s nurse 

Abaye’s nurse was not only knowledgeable about the imperforate anus. In the same page of Talmud she offers other medical advice, all of it to do with the period immediately following childbirth. She gave advice as to the bandage to be used after circumcision, how to encourage a neonate to suckle, how to resuscitate a baby that has stopped breathing, and under what medical conditions a circumcision must be postponed. Childbirth and care of the neonate has long been the provenance of women, starting with the Hebrew midwives Shifrah and Pu’ah who lied to Pharaoh in order to save the male Jewish babies from certain death. The knowledge that midwives passed down to each other saved countless babies from the complications of childbirth or the rigors immediately following it. While some of their advice was certainly in error from our modern perspective (Abaye’s nurse recommended placing a baby in a sieve and shaking her in order to get her to urinate,) their knowledge and skills often worked. Otherwise we would not be here to tell about it.

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]