Yevamot 64b~ Circumcision, death, and Hemophilia A

Today’s page of Talmud discusses the complications that may arise following a circumcision:

יבמות סו. ,ב

תניא מלה הראשון ומת שני ומת שלישי לא תמול דברי רבי רבן שמעון בן גמליאל אומר שלישי תמול רביעי לא תמול... א"ר יוחנן מעשה בארבע אחיות בצפורי שמלה ראשונה ומת שניה ומת שלישית ומת רביעית באת לפני רבן שמעון בן גמליאל אמר לה אל תמולי

It was taught: If she circumcised her first son and he died, and her second son and he too died, she should not circumcise her third son, so taught Rebbi. Rabbi Shimon ben Gamliel stated that she should indeed circumcise her third child, but [if he died] she must not circumcise her fourth...Rabbi Yochanan said that there was once a case in Zippori in which four sisters had sons: The first sister circumcised her son and he died, the second sister circumcised her son and he died, the third sister circumcised her son and he died, and the fourth sister came to Rabbi Shimon ben Gamliel and he told her, "you must not circumcise your son" (Yevamot 64:)

The Talmud here is describing a disease that is passed through the maternal line (hence the four sisters - all of whom seem to pass this disease on to their male children). The disease is X-linked Hemophilia A; the term X-linked indicates that the faulty gene is carried on the X chromosome, which is always inherited from the mother. Hemophilia A is an X-linked recessive genetic disease, first described by the American physician John Conrad Otto, who in 1803 described a bleeding disorder that ran in families and mostly affected the men. John Hay from Massachusetts published an account of a "remarkable hemorrhagic disposition" in the New England Journal of Medicine in 1813.

Hay, John. Account of a Remarkable Haemorrhagic Disposition, Existing in Many Individuals of the Same Family. New England Journal of Medicine 1813:2;3;221-225.

 If the mother is a carrier  - as were each of the four sisters in Zippori - then she has a one in four chance of passing on the disease to a child, and that affected child will always be a son:

Courtesy NHLBI

The rabbis argued over a technical point - that is, how many cases of bleeding are needed to establish a pattern. According to Rebbi (that is  Rebbi Yehuda Ha-Nasi, c. 135-217 CE.) two cases were sufficient, while Rabbi Shimon ben Gamliel insisted on three cases before ruling that there was a life-threatening pattern.  Indeed the disease in boys must have been very perplexing, because (as you can see in the diagram above) not every boy would be affected. In fact, if the mother is a carrier and the father is not, there is only a 50% chance of a boy having hemophilia.  It is this fact that perhaps explains the dispute between Rebbi and Rabbi Shimon ben Gamliel regarding how many children need to exhibit the disease before we can assume that any future male child will also have it.  If every boy born in the family would have been a hemophiliac, Rabbi Shimon's ruling would have seemed unnecessarily cruel.  But since by chance, half of the boys born might not have hemophilia, the need to demonstrate the prevalence of the disease (in a society in which its genetic foundations were not known) seems eminently sensible.

In  Hemophilia A there are various genetic mutations that result in low levels of clotting factors. These levels may be only mildly decreased, or so low that severe life-threatening hemophilia results. It is treated with transfusions of clotting factors which restore the levels to normal. Although these transfusions must be given several times a week in those with severe disease, there is hope that recombinant clotting factors can lengthen the time between the needed transfusions.

Later in Yevamot, the Mishnah records the case of a priest who was not circumcised -  because of the deaths of his brothers when they underwent the procedure. So this law was certainly practiced, and the Talmud records not only the earliest known description of hemophilia, but the emphasis on the preservation of life as a normative Jewish practice. 

Yevamot 64b ~ Urinary Tract Infections, and the Class That Went On For Too Long

This is the first of two posts for Yevamot 64 that we will learn on Tuesday. The second part will be published tomorrow.

יבמות סד,ב

רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna's lectures, Rav Chelbo became sterile on account of Rav Huna's lectures and Rav Sheshet became sterile on account of Rav Huna's lectures...

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  A couple of pages ago, on Yevamot 62b, Rashi explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

Rav Huna would give a lengthy class and people needed to use the toilet. They delayed urinating, and as a result became sterile, as we learn in the tractate Bechorot

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  There is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is not a good idea.

Delayed Micturation and UTIs

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

 Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.

Israel's Noble History

ISRAELI NOBEL PRIZE WINNERS FOR $200 PLEASE, ALEX

Quick. Name three Israelis who have won a Nobel Prize. Come on. You can do this. Still need a hint? Click here. See, I told you you'd know.  

OK, those were easy. How about this one.  Which Israel won a Nobel Prize for literature? Need a hint? He was awarded it in 1966 for "his profoundly characteristic narrative art with motifs from the life of the Jewish people" and his photo is shown here. Still not sure? You may have read his work on Rosh Hashanah and Yom Kippur which was translated into English as Days of Awe...Of course; it was Shai Agnon, who was born in Galicia, moved to what was then Palestine (twice) and died in Jerusalem in 1970.

As of this year there have been twelve Israeli winners of the Nobel Prize. We've noted Agnon as the single winner for literature, and (as you may have answered correctly) there have been three winners of the Nobel Peace Prize: Menachem Begin (1978), Yizhak Rabin and Shimon Peres (both in 1994). That leaves eight more prizes. In honor of Yom Ha'atzmaut, Israel's Independence Day, we will pause from our analysis of science in the Talmud and reflect on the Israeli winners of this prize, given each year (in accordance with the will of Alfred Nobel) "to those who, during the preceding year, shall have conferred the greatest benefit on mankind."

DANIEL KAHNEMAN, ECONOMICS, 2002

Following at an eight year prize-drought, Israel picked up her fifth Nobel in 2002, when Daniel Kahneman was awarded the 2002 Prize in Economics. In his biographical sketch, Kahneman credits his early days in the IDF with the first cognitive illusion he discovered.

““… after an eventful year as a platoon leader I was transferred to the Psychology branch of the Israel Defense Forces….We were looking for manifestations of the candidates’ characters… we felt…we would be able to tell who would be a good leader and who would not. But the trouble was that, in fact, we could not tell... The story was always the same: our ability to predict performance at the school was negligible...I was so impressed by the complete lack of connection between the statistical information and the compelling experience of insight that I coined a term for it: “the illusion of validity.” Almost twenty years later, this term made it into the technical literature. It was the first cognitive illusion I discovered.”

— Daniel Kahneman, Biographical sketch at Nobelprize.org

(I was about two-thirds of the way through Kahneman's recent best-seller Thinking Fast and Slow, when I left it on a flight from Tel Aviv. Please let me know if you find it.) 

CIECHANOVER AND HERSHKO, CHEMISTRY 2004

Ubiquitin-mediated Proteolysis.

In 2004 Aaron Ciechanover and Avram Hershko, both from the Technion in Haifa (together with Irwin Rose), were awarded the Nobel Prize in Chemistry for their discovery of how cells breaks down some proteins and not others. They discovered ubiquitin-mediated proteolysis, a process where an enzyme system tags unwanted proteins with many molecules of another protein called ubiquitin. The tagged proteins are then transported to the proteasome, a large multi-subunit protease complex, where they are degraded.

ROBERT AUMANN, ECONOMICS, 2005

Robert Aumann from the Hebrew University won the 2005 Nobel Prize in Economics for his work on conflict, cooperation, and game theory (yes, the same kind of game theory made famous by John Nash, portrayed in A Beautiful Mind). Aumann worked on the dynamics of arms-control negotiations, and developed a theory of repeated games in which one party has incomplete information.  The Royal Swedish Academy of Sciences noted that this theory is now "the common framework for analysis of long-run cooperation in the social science." The kippah-wearing professor opened his speech at the Nobel Prize banquet with the following words (which were met with cries of אמן from some members of the audience):

ברוך אתה ה׳ אלוקנו מלך העולם הטוב והמיטב

The four-minute video of his talk should be required viewing for every Jewish high school student (and their teachers).

ADA YONATH, CHEMISTRY, 2009

Remember ribosomes from high school? They are the machines inside all living cells that read messenger RNA and link amino acids in the right order to make proteins.  In 2009, Ada Yonath from the Weizmann Institute shared the Nobel Prize in Chemistry for her work on the structure and function of the ribosome. Specifically, she reported their three-dimensional structure and her work in the 1980s was "instrumental for obtaining the robust and well diffracting ribosome crystals that eventually led to high resolution structures of the two ribosomal subunits." Why is this important?  Well, many antibiotics target the ribosomes of bacteria, and so knowledge of how antibiotics bind to the ribosome may help in the design of new and more efficient drugs.  

Available structures of antibiotics targeting the small ribosomal subunit (30S). From Franceschi and Duffy. Structure-based drug design meets the ribosome. Biochemical Pharmacology 2006; 71; 1016-1025.

DAN SHECHTMAN, CHEMISTRY, 2011

in 1982, Shechtman was working at the US. National Institute of Standards and Technology. As he was looking through an electronic microscope at the structure of new material that he was studying, and noted that the atoms had arranged themselves "in a manner that was contrary to the laws of nature." 

אין חיה כזו – There is no such entitiy" was how he recalled responding to what he had seen. Shechtman double checked his findings and submitted them for publication; the paper was rejected immediately, not worthy even of being sent on for peer review. But Shechtman did manage to get his work published, work that the Nobel Committee found questioned a fundamental truth of science: that all crystals consist of repeating, periodic patters. Shechtman's discovery of what were later to be called quasicrystals  was important not only because of what he found. It was important that he found. Here's why:

“Over and over again in the history of science, researchers have been forced to do battle with established “truths”, which in hindsight have proven to be no more than mere assumptions. One of the fiercest critics of Dan Shechtman and his quasicrystals was Linus Pauling, himself a Nobel Laureate on two occasions. This clearly shows that even our greatest scientists are not immune to getting stuck in convention. Keeping an open mind and daring to question established knowledge may in fact be a scientist’s most important character traits.”

— The Swedish Academy of Sciences. The Nobel Prize in Chemistry 2011. Information for the Public

ARIEH WARSHEL AND MICHAEL LEVITT, CHEMISTRY 2013

Israelis continued with a winning streak at chemistry. In 2013 Arieh Warshel and Michael Levitt shared the prize in, yes, Chemistry, (together with Marin Karplus, a Jew, but not yet an Israeli). Working together in the 1970s on GOLEM, the supercomputer at the Weizmann Institute, they developed computer programs that could simulate chemical reactions with the help of quantum physics.  These programs, and their offshoots, are used in a variety ways, from optimizing solar panels to designing new drugs.

Joshua Angrist, Economics 2021

The most recent Israeli Nobel laureate is Joshua Angrist, who was awarded the 2021 Nobel Prize in Economics. Angrist, who is a professor at The Massachusetts Institute of Technology, was born in the US but lived in Israel in the 1980s, where he served as a paratrooper. He holds dual US-Israeli nationality, and has spent much of his career analyzing the economics of schooling and the effect of class size on academic achievement. One of his papers looks at the “Maimonides Rule,” named for, well, Maimonides, who apparently noted a correlation between class size and student achievement.

THE LAST WORD

There you have it. Thirteen remarkable Israelis who have contributed to peace efforts, science and literature, and whose efforts were recognized by a Nobel Prize. As we celebrate Yom Ha'atzmaut, let's give the last word to the 2005 winner Robert Aumann, who noted in his banquet speech just what is really important in life. 

“We have participated in the human enterprise – raised beautiful families. And I have participated in the realization of a 2000-year-old dream – the return of my people to Jerusalem, to its homeland.”

— Robert Aumann, Nobel Prize banquet speech, 2005.

Yevamot 54a ~ Bizarre Talmudic Scenarios

On this page of Talmud we read of a very bizarre case:

יבמות נד, א

 אָמַר רַבָּה: נָפַל מִן הַגָּג וְנִתְקַע — חַיָּיב בְּאַרְבָּעָה דְּבָרִים, וּבִיבִמְתּוֹ לֹא קָנָה. בְּנֵזֶק, בְּצַעַר, בְּשֶׁבֶת, בְּרִפּוּי. אֲבָל בּוֹשֶׁת לָא מִיחַיַּיב, דְּאָמַר מָר: אֵין חַיָּיב עַל הַבּוֹשֶׁת עַד שֶׁיִּתְכַּוֵּון

Rabba said: One who fell from a roof and was inserted into a woman due to the force of his fall is liable to pay four of the five types of indemnity that must be paid by one who damaged another, and if she is his yevama he has not acquired her in this manner. He is liable to pay for injury, pain, loss of livelihood, and medical costs. However, he is not liable to pay for the shame he caused her, as the Master said: One is not liable to pay for shame unless he intends to humiliate his victim…

As weird Talmudic cases go, this is among the weirdest. It is entirely impossible, and not least because this would happen. Did the rabbis of the Talmud really believe that such a case could occur? To answer this, let’s consider come other rather implausible cases from across the Babylonian Talmud.

 The AMAZING Shechita Knife

We begin with a fanciful question that is somewhat analogous to tomorrow’s falling Yibbum case. What happens if a person throws a knife across the room, but in doing so the flying knife somehow manages to cut the neck of an animal in just the correct fashion to perform a kosher shechita (ritual slaughter). Is the meat of this slaughtered animal kosher?

חולין לא, א

דתני אושעיא זעירא דמן חבריא זרק סכין לנועצה בכותל והלכה ושחטה כדרכה ר' נתן מכשיר וחכמים פוסלים הוא תני לה והוא אמר לה הלכה כר' נתן

Oshaya, the youngest of the company of Sages, taught a baraita: If one threw a knife to embed it in the wall and in the course of its flight the knife went and slaughtered an animal in its proper manner, Rabbi Natan deems the slaughter valid and the Rabbis deem the slaughter not valid. Oshaya teaches the baraita and he says about it: The halakha is in accordance with the opinion of Rabbi Natan that there is no need for intent to perform a valid act of slaughter.

 The Fish That Pulled a Plough

The Bible (Deuteronomy 22:10) forbids a farmer to plough his land using an ox and a donkey together. While no reason for this law is given, we might suppose it has something to do with the concern that doing so might cause unnecessary pain to the smaller (or perhaps the larger?) animal. Regardless of the reason, the Talmud explains that this law applies to any kind of work and any two different species of animal. Then comes this fantastic question: “What is the law if someone pulls his wagon using a goat and a fish?” 

בבא קמא נה, א

בעי רחבה המנהיג בעיזא ושיבוטא מהו מי אמרינן כיון דעיזא לא נחית בים ושיבוטא לא סליק ליבשה לא כלום עביד או דלמא השתא מיהת קא מנהיג

The Sage Rachava raised a dilemma: With regard to one who drives a wagon on the seashore with a goat and a shibbuta, a certain species of fish, together, pulled by the goat on land and the fish at sea, what is the halakha? Has he violated the prohibition against performing labor with diverse kinds, in the same way that one does when plowing with an ox and a donkey together, or not?

This turned out to be such a hard question that the Talmud could not answer it. The Rosh concludes though that just to be sure, best not to hitch up your wagon to a fish, if you also intend for it to be pulled by a goat (ולא איפשיטא ואזלינן לחומרא). Don’t say you weren’t warned.

The Bird that built her nest on a person’s head

The Bible also demands that the mother bird must be shooed away before collecting the eggs upon which she is brooding. But what happens if a bird makes her nest in a person’s hair? Must this mother be driven away before her eggs are collected? (Chullin 139b)

חולין קלט, ב

אמרי ליה פפונאי לרב מתנה מצא קן בראשו של אדם מהו? אמר (שמואל ב טו, לב) ואדמה על ראשו

The residents of Pappunya said to Rav Mattana: If one found a nest on the head of a person, what is the halakha with regard to the mitzva of sending away the mother? Is the nest considered to be on the ground, such that one is obligated in the mitzva? Rav Mattana said to them that one is obligated in the mitzva in such a case because the verse states: “And earth upon his head” (II Samuel 15:32), rather than: Dirt upon his head, indicating that one’s head is considered like the ground. 

(And just to be clear - the Talmud is not discussing a case like this one, in which a woman allowed an abandoned fledgling to nest in her long har for 84 days, though it is, I will admit, a very touching story.)

One hypothetical too many

Sometimes, even bizarre questions can go too far. If a baby pigeon is found within 50 cubits of a coop, it is presumed to belong to the owner of that coop. If it is found further away than 50 cubits, it belongs to the finder. Ever keen to push the limits of rabbinic law, Rabbi Yirmiyah asked “if one foot of the pigeon is within the fifty cubits and one foot is outside, to whom does it belong?” This apparently was one question too many. The rabbis (rather unfairly in my opinion) expelled Rabbi Yirmiyah from the Yeshivah for asking it.

בבא בתרא כג, ב

בָּעֵי רַבִּי יִרְמְיָה רַגְלוֹ אַחַת בְּתוֹךְ חֲמִשִּׁים אַמָּה וְרַגְלוֹ אַחַת חוּץ מֵחֲמִשִּׁים אַמָּה מַהוּ וְעַל דָּא אַפְּקוּהוּ לְרַבִּי יִרְמְיָה מִבֵּי מִדְרְשָׁא

Rabbi Yirmeya raises a dilemma: If one leg of the chick was within fifty cubits of the dovecote, and one legwas beyond fifty cubits, what is the halakha? The Gemara comments: And it was for his question about this far-fetched scenario that they removed Rabbi Yirmeya from the study hall, as he was apparently wasting the Sages’ time. 

The Role of Bizarre cases

In a 2004 paper published in Thalia: Studies in Literary Humor, Hershey Friedman, a Professor of Business at Brooklyn College, suggested that “whether a situation is possible or not is immaterial when the Talmud is trying to establish legal principles.”  

Purely theoretical (at least in their days) cases are discussed because the sages felt that principles derived from these discussions would clarify the law and thus provide a more thorough understanding of it. Discussions of theoretical cases in the Talmud have allowed scholars of today to use the Talmudic logic and principles to solve current legal questions 

The theoretical questions make a legal point, and it is that legal point that is the real object of the discussion. Whether or not the case could actually happen is immaterial. Friedman also suggests that these unusual cases serve to keep the material interesting, and also act as brain teasers, which don’t necessarily make a legal point but serve to sharpen the minds of both the students and the teachers who ask them.

“There was a time, not many years ago, when a lawyer could feel reasonably confident as he approached oral argument in the United States
Supreme Court if he had thoroughly absorbed the record in his case and
had obtained a working knowledge of all relevant cases. No longer. Today, an advocate must, more than ever before, prepare himself for a
stream of hypothetical questions touching not only on his own case but on
a variety of unrelated facts and situations.”

— E. Barrett Prettyman Jr., The Supreme Court's Use of Hypothetical Questions at Oral Argument, 33 Cath. U. L. Rev. 555 (1984). 555.

 Hypothetical Cases in the US Legal System

It may help to understand the role that these weird cases have in the Talmud by understanding that hypothetical cases have an important role to play in many legal systems, including that of the United States. Consider this series of questions that were asked in the famous 1984 case of California vs Carney. Police officers entered a motor home without a search warrant, and found marijuana. The question before the court was whether this motor home was a more like a car, which should not require a search warrant, or more like a home, which would. There were various appeals, and the case ended up being heard in front of the US Supreme Court, which is where the following hypothetical questions were raised:

Q: Well, what if the vehicle is in one of these mobile home parks and hooked up to water and electricity but still has its wheels on?

Q: Suppose somebody drives a great big stretch Cadillac down and puts it in a parking lot, and pulls all the curtains around it, including the one over the windshield and around all the rest of them. Would that be a home?

Or how about this exchange back in 1982, (and the subject of which is once again a hot topic of debate in the US). In Board of Education v.Pico, the question before the Court was whether a public school board could remove books which it found to be objectionable from the shelves of junior and senior high school libraries, in order to promote the community's "moral, social, and political values." 

Q: Suppose they [the Board] barred the St. James version of the New Testament, and the Constitution of the United States, and the Declaration of Independence?

Q: Suppose some of these books were assigned as outside reading, and the children were told, you can get it in the public library?

Q. Suppose you had a book, counsel, that had been the subject of criminal proceedings, and conviction of someone in connection with that book had been sustained, a criminal conviction. Would you say that the book comes under this broad authority you suggest? 

(By the way, the Court, in a 5-to-4 decision, held that as centers for voluntary inquiry and the dissemination of information and ideas, school libraries enjoy a special affinity with the rights of free speech and press. Therefore, the School Board could not restrict the availability of books in its libraries simply because its members disagreed with their content. That might be useful to remember.)

There are many, many similar examples. Here is one of my favorites. It comes from United States v. Ross, in which the defendant’s lawyer argued that a small brown paper bag should not have been searched for narcotics because it was protected under the Fourth Ammendment, the right against unlawful search. Here is one of the hypotheticals:

Q: Suppose what they were hunting for was, say, a waffle iron, a stolen waffle iron, or something else that couldn't go in the paper bag. You might have probable cause to search the car for the waffle iron, but if you got to the paper bag, you wouldn't be searching it, would you?

Commenting on this case, the late American lawyer Elijah Barrett Prettyman Jr. (d. 2016) wrote that “one cannot help but be impressed with how far removed some hypotheticals are from the facts before the Court. In Ross, the brown paper bag case, one Justice had the police hunting for a waffle iron.”

Why we need Hypotheticals

Hypothetical cases are really important when the Supreme Court is trying to figure out the difficult cases that come before it. And they are all difficult cases, because if they were easy, the Supreme Court wouldn’t be considering them. The rabbis of the Talmud needed to do the same, which is why they often consider outlandish, implausible or downright fanciful cases to ponder.

The best way to think about these cases is to add in the following missing words: “Hypothetically, what would happen if…” Then, as if by magic, they cease to be silly and start to be really important.