Ketuvot 65a ~ Too Drunk To Say No

In today's daf, the Talmud is discussing the provisions that an absent husband must legally provide for his wife, at least until his return home. Wine is not to be provided - unless the woman is used to drinking it (רגילה שאני). In this case, she may be given a single cup of wine, even though her husband is not at home. And then comes this teaching:

תנא: כוס אחד יפה לאשה, שנים ניוול הוא, שלשה תובעת בפה, ארבעה אפילו חמור תובעת בשוק ואינה מקפדת

One cup of wine is good for a woman; two is a disgrace; if she drinks three cups of wine she will verbally demand marital relations. And after four cups of wine a woman will solicit even a donkey in the marketplace, and she could not care...

The Effects of Alcohol on Sexual Desire

The pharmacological effects of alcohol have been extremely well studied.  Although in popular culture alcohol is thought to be a sexual stimulant, its physiological effects actually reduce sexual arousal. Alcohol also causes disinhibition, making those who have been drinking more likely to engage both in sex, and in sexual risk-taking. Alcohol has depressant effects and caused its disinhibition in all the animals models in which it has been tested, including, most recently, the nematode, c. elegans. It is these effects that the Talmud is referencing here, in so far as they effect only women. (Men's sexual desire and sexual performance is also affected by alcohol, but since this is not the subject of the discussion in the daf, we won't go there.) 

“...alcohol specifically disinhibited these behaviors [locomotion, feeding and escape] in worms...”

— Topper SM, et al. (2014) Alcohol Disinhibition of Behaviors in C. elegans. PLoS ONE 9(3): e92965. doi:10. 1371

Too Drunk To Say No

The Talmud describes an effect of too much alcohol: it causes such a degree of sexual disinhibition that an intoxicated women looses all sense of propriety. In fact, she gets so drunk that she is prepared to commit bestiality.  In the United Kingdom three high profile court cases (the Dougal case-November 2005, the Hagan case-November 2006, and the Bree case-December 2006) illustrated the talmudic supposition in today's daf. In all cases the women who were raped were heavily intoxicated and the defendants, who admitted having had sexual intercourse but denied rape, were acquitted. If a woman is drunk, her no doesn't mean NO. 

Writing in the Stanford Law Review, Karen Kramer outlined ways which cultural myths surrounding alcohol and the place of men and women in society converge to produce a double standard. If the rapist was drunk, it reduces his culpability; if the victim was drunk, it increases her culpability.

Expectancy beliefs about alcohol - which include the beliefs that alcohol increases sexual arousal, loosens women's sexual inhibitions and increases men's feelings of power and dominance - interact with traditional notions of male aggressiveness and female submission  to set the stage for acquaintance rape. When a woman is visibly intoxicated a man may interpret friendly or flirtatious behavior an invitation to have sex. Believing that alcohol reduces a women's inhibitions, the man may read her behavior as a demonstration of her true but disguised desire for sexual activity.  Even if she fails to become physically affectionate, since alcohol is a depressant, the woman may be less able to resist unwanted sexual advances. Her lack of resistance may sound like a resounding "yes" to a man who subscribes to the tradition model of male aggression and female submission.  Moreover if the man is drinking as well, he may feel safe disregarding her will,because he knows that he can blame his aggressionon the alcohol. This is not to say that any sexual interaction between intoxicated individuals constitutes rape, but drinking does enable a man to overpower an unwilling woman while feeling confident that he can blame his own actions on the alcohol.

Over  twenty years ago, the journalist Helen Benedict in her book Virgin or Vamp described the myth of our culture in which women who drink too much are "asking for it." I had no idea that the myth could also be found embedded in our Talmud. 

Ketuvot 58b ~ Rabbi Meir on Maximizing Meaning

This post is for the page of Talmud to be studied tomorrow, Thursday.

תלמוד בבלי כתובות דף נח עמוד ב

אין אדם מוציא דבריו לבטלה

“A person does not say things without reason ”

— Ketuvot 58b

This teaching of Rabbi Meir (c.~2nd century CE) is directed towards a specific legal question: can a person's declaration containing two contradictory clauses have any legal meaning? The details of the case need not concern us, but Rabbi Meir established a hermeneutic principal that was to be widely discussed, most notably by three American philosophers Willard Quine (d. 2000),  Ronald Dworkin (d. 2013) and Donald Davidson (d. 2003).

The Principle of Charity 

The Principle of Charity asks the reader (or listener) to interpret the text they are reading (or words they are hearing) in a way that would make them optimally successful.  Here's how Moshe Halbertal from the Hebrew University explained it:

“[A]lthough a person’s words might be read as self-contradictory and thus meaningless, they should not be interpreted in that way. If someone tells us he feels good and bad, we should not take his statement as meaningless but rather understand by this that sometimes he feels good and sometimes bad, or that his feelings are mixed.
”

— Moshe Halbertal. People of the Book. Harvard University Press 1997, p27.

Other philosophers of language, like the late American analytical philosopher Donald Davidson developed this Principle of Charity. “We make maximum sense of the words of others,” wrote Davidson, “when we interpret in a way that optimizes agreement.” But sometimes The Principle of Charity requires that the reader change the meaning of the text in order to maximize the likelihood of agreement with the author’s words, as long as such a rational or coherent interpretation is available to the reader. It is the attempt to read the text in the “best” possible light.

We could include in this discussion Ludwig Wittgenstein (d. 1951). In his Philosophical Investigations he claimed that there is no single correct way that language works. Instead, there are "language games" - with the rules of the game changing as the needs of the speaker change. Or the American philosopher John Searle's important work Speech Acts, in which speech follows certain rules, and it is the context of the words that determine which rules are in force.  Or the father of deconstruction, the French Sephardi philosopher Jacques Derrida (d. 2004) who believed that once they are cut off from their author, words can mean something other than what they meant in their original context. Or J.L Austin or Paul Ricoeur or.... Let's stop here.

Just remember that it was Rabbi Meir who introduced us to the hermeneutic Principle of Charity. Now can you please fix that Wiki article so that Rabbi Meir gets his just recognition?

Ketuvot 60b ~ Everything is Bad For You

On this page of Talmud we read of a number of things that, if done by a pregnant mother, may injure (or rarely, improve) her unborn child.

תלמוד בבלי כתובות דף ס עמוד ב - סא עמוד א

דמשמשא בי ריחיא - הוו לה בני נכפי, דמשמשא על ארעא - הוו לה בני שמוטי, דדרכא על רמא דחמרא - הוו לה בני גירדני, דאכלה חרדלא - הוו לה בני זלזלני, דאכלה תחלי - הוו לה בני דולפני, דאכלה מניני - הוו לה בני מציצי עינא, דאכלה גרגושתא - הוו לה בני מכוערי, דשתיא שיכרא - הוו לה בני אוכמי, דאכלה בישרא ושתיא חמרא - הוו לה בני בריי, דאכלה ביעי - הוו לה בני עינני, דאכלה כוורי - הוו לה בני חינני, דאכלה כרפסא - הוו לה בני זיותני, דאכלה כוסברתא - הוו לה בני בישרני, דאכלה אתרוגא - הוו לה בני ריחני. ברתיה דשבור מלכא אכלה בה אמה אתרוגא, והוו מסקי לה לקמיה אבוה בריש ריח

A woman who copulates in a mill will have epileptic children. [A woman] who copulates on the ground will have children with long necks. [A woman] who treads on the excrement of a donkey will have children who lose their hair.  [A woman] who eats mustard will have children who are gluttons. [A woman] who eats cress will have children with teary eyes.  [A woman] who eats small fish will have children with fluttering eyes.  [A woman] who eats clay will have ugly children.  [A woman] who drinks beer will have dark children.  [A woman] who eats meat and drinks beer will have children who are healthy.   [A woman] who eats eggs will have children with large eyes.  [A woman] who eats fish will have charming children.   [A woman] who eats celery will have radiant children.  [A woman] who eats coriander will have fat children.  [A woman] who eats an esrog will have fragrant children...

Everything is Bad For You. Or Good For You.

In their highly entertaining 2013 paper, Schoenfeld and Ioannidis looked at 50 common ingredients from random recipes found in The Boston Cooking-School Cook Book.   Then they searched for any recent scientific studies that evaluated the relation of each ingredient to the risk of cancer. And what did they find?

Eighty percent of ingredients from these randomly selected recipes had been studied in relation to malignancy.  (Those ingredients that had not been studied tended to be more obscure, like hickory or terrapin.)

Thirty-nine percent of studies concluded that the studied ingredient conferred an increased risk of malignancy; 33% concluded that there was a decreased risk, 5% concluded that there was a borderline statistically significant effect, and 23% concluded that there was no evidence of a clearly increased or decreased risk. In most (80%) of the studies, the statistical effect was weak.  As you can see in the table, the same ingredient (like tomatoes, tea, carrots and coffee) was found in different studies to both increase and decrease the risk of cancer. 

Effect estimates by ingredient. From Schoenfeld and Ioannides. Is everything we eat associated with cancer? Am J. Clin. Nutrition 2013:97;127-34. 

The authors concluded that:

“Nutritional epidemiology is a valuable field that can identify potentially modifiable risk factors related to diet. However, the credibility of studies in this and other fields is subject to publication and other selective outcome and analysis reporting biases, whenever the pressure to publish fosters a climate in which “negative” results are undervalued and not reported. Ingredients viewed as “unhealthy” may be demonized, leading to subsequent biases in the design, execution and reporting of studies.”

So that's the lesson: Be really careful when ascribing risk or benefit to commonly found ingredients. And with that warning, let’s analyze the passage in today’s daf:

THE RISK OF EPILEPSY

According to the Talmud, copulating in a mill is a risk factor for epilepsy.  Although there has not been a significant attempt to categorize the causes of epilepsy, one recent paper suggested that the etiology of this condition be broken down into four types:

Idiopathic (predominantly genetic or inherited in a complex way)

Symptomatic (acquired or genetic, together with gross anatomical or clinical features)

Provoked (the predominant cause is environmental)

Cryptogenic (cause has not been identified)

The Talmud is describing the mill as one of the environmental causes of epilepsy. While no such link has ever been suggested outside of the Talmud, the claim that epilepsy has an environmental cause is certainly plausible.

OTHER PRE-CONCEPTION ENVIRONMENTAL ASSOCIATIONS WITH CHILDHOOD OUTCOMES

It is increasingly clear that some major diseases in later life – like diabetes, high blood pressure and heart disease- have a basis in the impaired growth of the fetus. For example, a long-term British study showed that those infants who had low birth weights had relatively high death rates from coronary heart disease in adult life. Low birth rate has also been associated with the later development of diabetes, high cholesterol, and high blood pressure. In today’s daf, the Talmud claims an association between some foods ingested by a woman and certain characteristics or health traits in the later development of children she may carry. Again, there is no evidence that the details here are correct, but there is no reason to exclude such an association ab initio.

PICA – clay makes you ugly

Pica is the medical term for the craving and ingestion of foods or substances that have no nutritious value. Pregnant women engage in pica behavior all over the world. One study found that three-quarters of pregnant women in Kenya ate soil on a regular basis, and that this practice had a strong relationship to fertility and reproduction. In a study of 128 pregnant women conducted in a rural America, about a third practiced pica and clay was sometimes eaten together with other substances –a practice called polypica. Although women reporting daily pica practice were significantly more likely to have lower prenatal hematocrits than women who did not practice pica, no specific pregnancy complication was associated with the practice of pica. Although the authors did not report on whether the children were more likely to be ugly, the evidence suggests this is not related to pica, and so this claim of Talmud is unlikely to be true.

Pica Frequency. From Corbett et al. Pica in Pregnancy. Does it affect pregnancy outcomes? American Journal of Maternal Child Nursing. 2003: 28 (3); 183-189.

Fetal Alcohol Syndrome

The relationship between the ingestion of a pregnant woman’s ingestion of alcohol and the growth of the fetus is clear. It is a terrible idea to drink when you are pregnant. If you drink while pregnant, the fetus will be born with Fetal Alcohol Syndrome, which includes facial abnormalities, growth delays, abnormal development of organs, and reduced immunity.  The Talmud suggests that drinking beer before (or during?) pregnancy leads to “dark children” while drinking beer and eating meat will lead to healthy children. Do not follow this advice.  Drinking beer while pregnant is a  really bad idea, at pretty much any dose.

“Despite the many gains in knowledge, we still do not know if there is a “safe” dose of alcohol that can be consumed by pregnant women without risking damage to their unborn children. Until such a safe dose, if it exists, can be determined, the only responsible advice to women who wish to become pregnant and to those who are pregnant is to avoid alcohol use entirely. ”

— Enorch Gordis MD, Then Director of The National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert #50, 2000

Eggs and Etrogs

The final intriguing association that is made is between eggs and large eyed children, and etrogs and fragrant children. Here the assumed mechanism is clear. You are what you eat – literally. Eggs have big yellow yolks, so if a woman eats them, her children’s eyes will mimic the egg – and appear to have large pupils surrounded by the white of the conjunctiva. Similarly, by eating a fragrant etrog, the body literally becomes fragrant. It’s a lovely theory really, but totally without of any basis in fact. “Like causes like” is as unlikely as “that which causes the same symptoms leads to a cure.” The latter is called homeopathy, and there is no scientific basis to it whatsoever. (Before you send me that angry email, read the sentence again. I did not say that it is not effective. It is indeed effective; as effective as placebo – and no more. But there is no scientific evidence that homeopathy is any better than sham treatment, that is, a placebo). The latest evidence to show that there is no benefit of homeopathy comes from a lengthy report (actually a series of reports) from the Australian National Health and Medical Research Council. We’ve wasted enough money on chasing the scientific study of homeopathy; let’s not waste still more seeing if eggs make your kids eyes larger because “like causes like”…

The Talmud's list of possible environmental causes is a joy to read, but is it true? Without a doubt yes. And certainly no.

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.]