Ketuvot 52b ~ Who Pays for Mom's Bloodletting?

“Rabbi Yochanan said: the Sages made bloodletting in Israel like a healing that has no limit.”

— Talmud Ketuvot 52b

Should you undergo therapeutic venesection - bloodletting - regularly (like using the gym) or save it for special occasions (like a birthday or anniversary)? That's a question which is addressed in today's Daf Yomi.  The question of who should pay for a widow's blood-letting session depended 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 chronically, 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, to let us know that in Israel bloodletting was performed on a regular basis, and so - at least there - the heirs were required to pay for it.  

BloodLetting Elsewhere in the Talmud

Bloodletting was a simple enough and rather brutal procedure. 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). 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.

Bloodletting is frequently mentioned in the Talmud. Most famously, in Shabbat 129a, there is an extensive discussion of some of the do's and dont's of bloodletting:

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 bloodletting 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…

Modern Medicine and the Practice of BloodLetting

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 bloodletting is hemochromatosis, in which there is a build up of iron in the body.  But other than for these rare diseases, bloodletting, (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 bloodletting may be useless, but from this is 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 associatedwith 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 bloodletting is anything other than a really bad idea.  

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

The procedure, which had been in use for at least 2,000 years, only stopped being part of standard medical practice in the late 19th century.  Writing in 1875, one Englishman could not bring himself to believe that the era of bloodletting 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.

(In fact, bloodletting was even suggested as a therapy during a severe influenza outbreak at a British Army camp in northern France in the winter of 1916-17. Amazing.)  We no-longer practice this all but useless intervention, the prayer associated with it is worth recalling. Maimonides ruled (Berakhot 10:21) that before undergoing bloodletting, the patient pray the procedure be effective,and this ruling is found as part of normative Jewish practice, recorded in the Shulchan Aruch

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 bloodletting 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 procedures have changed, but the prayers have stayed the same.

[Re-posted (with a few minor changes) for חזרה from Yevamot 72a.]

Ketuvot 50a ~ The Economic Costs of Raising Children

Kids Today

In a recent Pew study on the use of electronic media by children in the US was this remarkable finding: Nearly one-in-five parents of a child 11 or younger (17%) say that their child has their own smartphone. Here's another gem from the same report: More than one-third of parents with a child under 12 say their child began interacting with a smartphone before the age of 5. Some children have quite comfortable lives, it would seem.  But it wasn't always that way.

Kids Back Then 

Today's page of Talmud (Ketuvot 50a) reminds us of another kind of reality that children once faced. Back then, it was a much more harsh world. And not just because the kids were not given their own iPhone.  In fact, according to the Talmud, they were lucky just to get food and shelter. 

תלמוד בבלי כתובות דף נ עמוד א

אשרי שומרי משפט עושה צדקה בכל עת - וכי אפשר לעשות צדקה בכל עת? דרשו רבותינו שביבנה ... זה הזן בניו ובנותיו כשהן קטנים

““Happy are those who keep justice, who perform charity at all times” (Psalms 106:3). But is it possible to perform charity at all times? This, explained our Rabbis in Yavneh...refers to one who sustains his sons and daughters when they are minors.”

— Talmud Bavli, Ketuvot 50a.

In yesterday's Daf, we learned that a person's legal obligation to support their children ends when those children reach the age of six. From that age, the parents' obligations to give their children water, food and clothing is not a legal one, but a moral one. If a parent refuses to support a child older than six, the courts can impose pressure to do so. But there is no legal obligation to support your child once they reach the ripe old age of six.  Because of this ruling, the Talmud considers the support of minor children to be an act of charity.  (Try bringing that argument up the next time your child asks for a cellphone upgrade.)  Here is how this law is codified.  

שולחן ערוך אבן העזר הלכות כתובות סימן עא סעיף א

 חייב אדם לזון בניו ובנותיו עד שיהיו בני שש ...ומשם ואילך, זנן כתקנת חכמים עד שיגדלו. ואם לא רצה, גוערין בו ומכלימין אותו ופוצרין בו. ואם לא רצה, מכריזין עליו בצבור ואומרים: פלוני אכזרי הוא ואינו רוצה לזון בניו, והרי הוא פחות מעוף טמא שהוא זן אפרוחיו; ואין כופין אותו לזונן...במה דברים אמורים, בשאינו אמוד, אבל אם היה אמוד שיש לו ממון הראוי ליתן צדקה המספקת להם, מוציאים ממנו בעל כרחו, משום צדקה, וזנין אותם עד שיגדלו 

A person is obligated to support his sons and daughters until they reach the age of six...From that age, he is required by rabbinic decree to support them until they grow up. If he does not wish to support them, we admonish him until he complies.  If he still refuses, we announce to the public: "So-and-so is a cruel person, and does not wish to support his children. He is worse than an unclean  bird - even that bird cares for its chicks." But we cannot force him to support his children.  

But this only applies when we have assessed that indeed he cannot support them financially.  But if we assessed him, and found that he has the money to give to charity and this would allow the children to live, we take the money from him by force, in the name of charity, and support the children until they grow up. (Shulchan Aruch Even Ha'Ezer 71:1)

The Economic Costs of Raising Children

Raising children is an expensive undertaking.  It requires parents to put in years and years of emotional, material and psychological effort. Those material costs can be calculated, and here they are:

So according to the USDA, it costs - on average - about $241,000 to raise a child in the US. That sounds like a bargain to me.  It cost that just to put one of my children through through twelve years of their Jewish school. And that's before I'd bought them a slice of bread. Or an iPhone.

Families Projected to Spend an Average of $233,610 Raising a Child Born in 2015. From here.

“For someone making $60,000 a year, in America, that’s middle class...But in this Orthodox community, $60,000 means you aren’t going to make it.”

— Rabbi Ilan Feldman, leader of Congregation Beth Jacob, interviewed in Tablet, July 11, 2014.

Research by the sociologists Sabino Kornrich and Frank Furstenberg has demonstrated that the way Americans spend money on their children has changed over the last several decades.  It turns out that before the the 1990s, parents spent most on children in their teen years. However, after the 1990s, spending patterns shifted, and was greatest when children were under the age of 6 and in their mid-twenties. We've also changed the where we spend on our children - and education now accounts for more than half of what US parents spend on their children. 

Average spending per child by year and percentage of expenditures in each area for all households with children age 0 to 24. From Kornrich and Furstenburg.  Investing in Children. Demography 2013. 50:1-23.

There's some good news too, for girls. In the 1970s, parents in households with only male children spent significantly more than parents in households with only female children - and nearly all of that extra money was spent on education. But by the early 2000s, the data showed a reversal: households with only female children spent more than households with only male children. 

Kronrich and Fursetnberg concluded that parents are investing more heavily in their children now than in the past. "While scholars debate exactly which resources matter most for children’s development... parents are demonstrating a substantial willingness to spend in order to better their children’s circumstances. These results mirror other shifts in parental behavior: parents are having fewer children and, through a range of activities like spending time with their children and choosing activities that impart cultural capital, are investing more intensively in the children they do have." 

Treat Your Children Well

Jewish law considers the support of a child to be an act of charity rather than a legal obligation. There is a similar ruling that shows an interesting symmetry at the other end of the spectrum. The Shulchan Aruch (הלכות צדקה סימן רנא) writes

 וכן הנותן מתנות לאביו והם צריכים להם, הרי זה בכלל צדקה

... a child who gives a gift to his parent who needs it, can include this as an act of charity

Just as you are not legally obligated to support your children when they are young, your children have no legal obligation to support you in your old age.  If they choose to do so, their act is one of charity. So treat your children well; they'll be the ones who will choose your nursing home.

“Spending on children is one of the most direct ways that parents can invest in children. Parental spending can buy children experiences that build human and cultural capital: high-quality education, residence in better neighborhoods, and potentially high-quality child care while children are young and parents are at work.”

— Kornrich and Furstenburg. Investing in Children. Demography 2013. 50:3.

Ketuvot 41 ~ Good Dog. Bad Dog.

“Az a yid hot a hunt, iz oder der hunt keyn hunt nit, oder der yid iz keyn yid nit

If a Jew has a dog, either the dog is no dog, or the Jew is no Jew”

— Sholem Aleichem. Rabtshik. Mayses far Yidishe Kinder. Ale Verk. Warsaw 1903.

On today's page of Talmud, Rabbi Natan offered the following advice:

תלמוד בבלי כתובות דף מא עמוד ב 

ר' נתן אומר: מנין שלא יגדל אדם כלב רע בתוך ביתו, ולא יעמיד סולם רעוע בתוך ביתו? שנאמר: ולא תשים דמים בביתך

Rabbi Natan said: From where do we learn that a person should not raise a bad dog in his house, and should not place a rickety ladder in his house? [From the Torah, where] it states "You shall not place blood in your house" (Deut 22:8).

[First, a disclaimer. I've owned dogs all of my married life. Still, I'll try to be as objective as possible.] 

Jews and dogs don't traditionally get along. In Bava Kamma 93a, Rabbi Eliezer does not mince his words: 

רבי אליעזר הגדול אומר: המגדל כלבים כמגדל חזירים .למאי נפקא מינה?

למיקם עליה בארור

“Rabbi Eliezer the Great said: Someone who breeds dogs is like someone who breeds pigs. What is the practical outcome of this comparison? To teach that those who breed dogs are cursed...”

— Bava Kamma 83a

The American Veterinary Medical Association estimates that in the US there are about 43 million households that own almost 84 million dogs; that means 45% of the households in the US own a dog. In the UK, an estimated 34% of all households own a dog.

Bad Dogs

There are some really bad dogs. In a 10 year period from 2000-2009, one paper identified 256 dog-bite related fatalities in the US. Of course that's a tiny number compared to the overall number of dogs owned, but that's still 256 too many; the tragedy is compounded when you read that over half the victims were less than ten years old. 

Partaken, GJ. et al. Co-occurrence of potentially preventable factors in 256 dog bite–related fatalities in the United States (2000–2009). Journal of the American Veterinary Medical Association 2013. 243:12: 1726-1736.

Fatalities from dog bites are rare. Dog bites are not. Over my career as an emergency physician I must have treated hundreds of patients with dog bites. And my experience is pretty typical. One recent study estimated that more than half the population in the US will be bitten by an animal at some time, and that dogs are responsible for 80-90% of these injuries. 

Good Dogs

Although Jews are thought not to have a historical affinity for dogs, one theologian has reassessed the evidence. In his 2008 paper Attitudes toward Dogs in Ancient Israel: A Reassessment, Geoffrey Miller  suggests that in fact dogs were not shunned in Israelite society. He notes that the remains of over a thousand dogs were discovered in a dog cemetery near Ashkelon dating from about the 5th century BCE. It was described as "by far the largest animal cemetery known in the ancient world" by Lawrence Stager who also pointed out that during this period, Ashkelon was a Phoenician city - not a Jewish one. Miller surveys several mentions of dogs in the Bible and the Book of Tobit, and concludes that at least some Israelites "valued dogs and did not view them as vile, contemptible creatures." Joshua Schwartz from Bar-Ilan University surveyed Dogs in Jewish Society in the Second Temple Period and in the Time of the Mishnah and Talmud (a study that marked "...the culmination of several years of study of the subject of dogs...").  He found that while "most of the Jewish sources from the Second Temple period and the time of the Mishnah and Talmud continue to maintain the negative attitude toward dogs expressed in the Biblical tradition" there were some important exceptions. There were sheep dogs (Gen. Rabbah 73:11) and hunting dogs (Josephus, Antiquities 4.206) and guard dogs (Pesahim 113a), and yes, even pet dogs (Tobit, 6:2), though Schwartz concedes that "it is improbable that dogs in Jewish society were the objects of the same degree of affection as they received in the Graeco-Roman world or the Persian world."  

“תלמוד ירושלמי (ונציה) מסכת תרומות פרק ח דף מו טור א /ה”ג

זמין חד רבן ואייתיב כלבא גביה אמר ליה ביזיון אנא חייב לך אמר ליה רבי טיבו אנא משלם ליה שביין עלון לקרתא עאל חד מינהון בעא מינסב איתתי ואכל ביציו

A certain person invited a sage to his home, and [the householder] sat his dog next to him. [The sage] asked him, ‘How did I merit this insult?’ [The house-holder] responded, ‘My master, I am repaying him for his goodness. Kidnappers came to the town, one of them came and wanted to take my wife, and the dog ate his testicles.’”

— PT Terumot 8:7

Whatever your feeling about dogs, let’s be sure to remember that they serve alongside soldiers in the IDF, where they save lives. In 1969, Motta Gur (yes, the same Mordechai "Motta" Gur who commanded the unit that liberated the Temple Mount in the Six Day War, and who uttered those amazing words "The Temple Mount is in our hands!" הר הבית בידינו‎,) wrote what was to become a series of children's books called Azit, the Canine Paratrooper (later turned into a popular feature film with the same title. It was once available on Netflix.

But IDF dogs don't just feature in fiction. They are a fact, and an amazing addition to the IDF, where they make up the Oketz unit.  Here's a news report (in Hebrew) about the amazing work these dogs - and their handlers - perform. Keep them in your prayers.

Ketuvot 36 ~ The Aylonit Syndrome and Turner's Syndrome

“ איילונית - אין לה לא קנס ולא פיתוי
​ There is no fine for the rape or seduction of an Aylonit

”

— Ketuvot, 36a

Aylonit Syndrome

An Aylonit is a woman who is congenitally unable to have childern.  In the fifth chapter of Niddah (47b) the Mishnah describes the signs which suggest that a woman is an Aylonit:

תלמוד בבלי נדה דף מז עמוד ב 

...בת עשרים שנה שלא הביאה שתי שערות, תביא ראיה שהיא בת עשרים שנה - והיא איילונית, לא חולצת ולא מתיבמת

A woman who is twenty years old and has not grown two pubic hairs..is classified as an Aylonit...

Earlier in our current tractate, Ketuvot (11a), the Talmud suggested the etymology of the word Aylonit:  "איילונית - דוכרנית דלא ילדה - an Aylonit [is given this name] as if she is a ram [דכר is the Aramic translation of the Hebrew word איל– a ram] which [being a male] cannot give birth"

In the last tractate that we studied (Yevamot 80b) the Talmud gives four other signs of this condition, which are codified by Maimonides:

רמב"ם הלכות אישות פרק ב הלכה ו 

ואלו הן סימני אילונית, כל שאין לה דדין, ומתקשה בשעת תשמיש, ואין לה שיפולי מעיים כנשים, וקולה עבה ואינה ניכרת בין איש לאשה

These are the signs that a woman is an Aylonit: She has not developed breasts, she has difficulty during sexual intercourse [that is, she has a diminished libido], the mons pubis is lacking, and she has such a deep voice that it is indistinguishable from that of a man...(Mishneh Torah, Hil. Ishus, 2:6)

There are many reasons for a woman to be infertile, but because the Talmud lists a number of signs other than infertility, we are able to narrow down the possible causes in the special case of the Aylonit. As many have previously noted, the cause of the Aylonit is likely to be what, (since 1938) we now call Turner's Syndrome.  

Turner's Syndrome

In 1938 an American endocrinologist names Henry Turner published a paper describing a newly observed syndrome in seven female patients. (A syndrome is a series of medical abnormalities which occur together.) It consisted of a triad of infantilism, a webbed neck, and a deformity of the elbow. It was found only in female patients, and was associated with delayed or absent sexual development. We now know (and Turner did not) that it is caused by a genetic aberration in which the patient has a missing X chromosome. Instead of carrying 44 regular and two X chromosomes, a woman with (what we now call) Turner's Syndrome has one missing X chromosome. (It gets a little more complicated: in some cases of Turner's Syndrome the woman has only part of one of the X chromosomes missing. And in others, the women's cells contain a mixture of both normal - 45XX - and abnormal - 45X - chromosomes. This is called mosaicism. But let's keep our focus.)

Sex chromosome analyses in Turner's Syndrome.  Here the 22 pairs of autosomes are grouped according to size and the sex chromosomes placed at the end; in this case, there is only one X chromosome.  From Saenger and Bondy. Turner Syndrome. In Sperling M. (ed.) Pediatric Endocrinology. Pittsburgh PA, Elsevier 2014.

Turner's Syndrome occurs in about 1 out of every 2,000 live-born girls. In addition to infertility in most, there are liver problems, high blood pressure, cardiac disorders and various metabolic disorders. Most of the girls with Turner's Syndrome have skeletal abnormalities and a short stature. In girls with the 45X variant, there is ovarian failure and hence infertility, although the cause is not yet clear.    

The variable appearance of Turner syndrome. Both of these 7-year-old girls with short stature have the 45X variant of Turner syndrome. The girl on the left was diagnosed at birth due to prominent neck webbing and low-set and posteriorly rotated ears. She also has micrognathia and a low posterior hairline. In contrast, the girl on the right was diagnosed at age 7 due to short stature without “classical” stigmata of Turner syndrome, and she is more typical of the clinical presentation of the majority of girls with Turner syndrome diagnosed in the 21st century.  From Saenger and Bondy. Turner Syndrome. In Sperling M. (ed.) Pediatric Endocrinology. Pittsburgh PA, Elsevier 2014. 

“Girls and women with Turner syndrome may have low self-esteem and more shyness and social anxiety than controls. In a population-based study of 566 French women with Turner syndrome, low self- esteem was associated with hearing impairment and limited sexual experience, whereas age at first sexual intercourse was related to age at puberty and paternal socioeconomic class.”

— Levitsky, L. Turner Syndrome. Current Opinion Endocrinology, Feb 2015

A study of Polish women with Turner's Syndrome, found that these women had less "...interest in males, less frequent sexual activity, later initiation of sexual life and a less frequent orgasm rate." Other studies found that women with this syndrome were less likely to establish a relationship with a partner, and were less sexually active than women from the general population. All this suggests that the Talmud's description in which they suffer from "difficulties during intercourse" (מתקשה בשעת תשמיש) may be correct.   

Let's remember that behind these scientific findings are real women with the same range of  sensitivities, feelings, hopes and aspirations as those of us who have two functioning sex chromosomes.  Let's give the last word to Harley Gould, a researcher at the National Institutes of Health:

“Moreover, it is important to remember that society continues to dis- criminate against people that are different, and that being short, or infertile, or looking different impose quite a social burden on individuals... Our demonstration of very similar academic, employment...suggests that genomic imprinting of X-linked genes has little to do with functioning in school or socially...We would like to add to that concept the positive observation that many individuals with Turner Syndrome display excellent coping skills, including perseverance in the face of adversity and equability of temperament.”

— Harley Gould et al. High Levels of Education and Employment Among Women with Turner Syndrome. Journal of Women's Health 2013. 22:(3) 230-235.