Nedarim 41b ~ Fever

נדרים  מא, א–ב

אמר רבא האי אישתא אי לאו דפרוונקא דמלאכא דמותא מעלי כחיזרא לדיקלי חד לתלתין יומין

Rava said about a fever: "Were it not for the fact that it is an agent of the Angel of Death, it would be beneficial for a person as a prickly foliage is for palm trees, if it is experienced once every thirty days...(Nedarim 41a-b).

As an emergency physician I've treated hundreds and hundreds of patients who came to the ER with a fever.  In fact fever is the third most common reason in the US for which people visit the ER - accounting for over 5 million visits each year. At virtually every visit they'd be given a medicine to reduce their fever, as if by doing so we were achieving something medically important. But in this page of Talmud, we read that according to Rava, fever is actually beneficial to a person (at least when it does not kill...).  How does this claim made by Rava, a Babylonian sage who died around the year 352 CE, stand up to today's medical science? Remarkably well, it turns out. Here's why.

Fever 101

Here are some basic things to know about fever. First, it is usually defined as a core temperature in humans above 38.3 C, or 101 F.  Second, there are lots of reasons why people get a fever, of which bacterial and viral infections are the most common, but not the only causes.  Third, and this is really important, not all fevers mean the same thing in terms of their seriousness.  Fever in a baby less than a month old requires an urgent and extensive evaluation. The same fever in a healthy toddler does not.  Fever in a healthy teenager is not the same as fever in an elderly patient on chemotherapy.  Finally, fever is not caused by the infection, at least not in the way you might think. It is the body's response to that infection that produces a fever.  Here's how.

The Biochemical Pathway to Fever

When bacteria infect the body, their foreign structure is recognized by white cells in the blood called macrophages. These macrophages then release a prostaglandin E2, interleukin-1, interleukin-6, and tumor necrosis factor. These act on a region deep in the brain called the hypothalamus, which acts as a thermostat for the body. Under the influence of interleukin-1 the hypothalamus releases a hormone called cyclooxygenase 2 (COX-2) which resets the body's thermostat, causing the temperature of the body to rise by a few degrees.  

How a fever is caused by a bacterial infection. From Evans, Repasky and Fisher. Fever and the thermal regulation of immunity: the immune system feels the heat. Nature Reviews Immunology June 2015: 15: 337.

It's not just people who get fevers. Dogs and cats do too, as do mice (and all mammals), reptiles, and even goldfish. Why would so many animals respond to an infection by developing a fever?

The Benefits of Fever

The reason is simple. The immune system fights infections better when the body is hotter. The way it does this is now well-understood but very complicated; here are just the highlights. 

Under what immunologists call "thermal stress" (and the rest of us call "a fever",) neutrophils, the white cells that are needed to fight infection, are released in greater numbers from the bone marrow.  These neutrophils also do a better job of fighting bacteria at the site of the infection when the body is warmer.  Fever also improves the killing ability of another group of blood cells called natural killer cells, and it increases the ability of the macrophages to ingest and destroy the invading bacteria. As last month's excellent review of fever and the thermal regulation of immunity in Nature Reviews concluded, "[t]he picture that emerges is one in which febrile temperatures serve as a systemic alert system that broadly promotes immune surveillance during challenge by invading pathogens."  

So your body does a better job of fighting bacteria when it is hotter.  Why then, do doctors give medicines that reduce a fever?  Good question. The truth is, they really shouldn't.

Don't Reach for That Tylenol/Paracetomol/AcAmol 

If you are the parent of a child with a fever, you are likely to give your sick offspring a medicine that interferes with the immune system, like Tylenol if you are in the US, Paracetamol if you are in the UK or South Africa, or Acamol in Israel (though they are different words for the same medicine.)  But if, as we have seen, the body does a better job of fighting infection when it is a few degrees hotter, might reducing the fever lead to a worse outcome for the child?

This question was recently examined by a group from McMaster University in Canada. They looked at the side effects of reducing a fever in those who are sick from a population level . What happens in a large group of people when some of them - infected with, say, influenza - take medicines to reduce their fever? The answer is that more of them transmit the virus and so more of them fall ill.  On a population level the effect is rather drastic:

Putting together our estimates of the treatment probability p and the individual transmission enhancement factor fi ...we conclude that the current practice of frequently treating fevers with antipyretic medication has the population-level effect of enhancing the transmission of influenza by at least 1% (95% CI: 0.04–3%)...This estimate does not take into account the known effect that the infectious period of influenza is also increased by antipyresis, nor does it take into account the potentially large effect of increasing the rate of contact among infectious and susceptible individuals because antipyresis makes infectious individuals feel better...To put our lower bound...into perspective, consider that approximately 41,400 ...deaths per year are attributed to seasonal influenza epidemics in the United States (and an order of magnitude more worldwide). Taken at face value, our results indicate, for example, that...at least 700 deaths per year ... could be prevented in the US alone by avoiding antipyretic medication for the treatment of influenza...

“In the absence of meaningful evidence for the beneficial effects of fever reduction, the commonplace reduction of fever in critically ill patients must be called into question.”

— Ryan and Levy. Clinical Review: Fever in intensive care patients. Critical Care 2003, 7:224.

The Canadian investigators concluded that "...the use of antipyretics can have subtle and potentially important negative effects at the population level. Any medical intervention that aims to relieve the symptoms of an infectious disease in an individual should also be evaluated in light of potentially harmful effects at the population level..." And it's not just populations that can suffer; individual patients are at risk too. In a 2011 paper looking at the treatment of fever in very ill patients with sepsis in the ICU,  a French team looked at the beneficial and detrimental effects of fever, and concluded that "...the widespread use of antipyretic methods in ICU patients is not supported by clinical data and fever control may be harmful, particularly when an infectious disease is progressing..."

From Lainey Y. et al. Clinical review: Fever in septic ICU patients - friend or foe? Critical Care 2011:15:222

The Death of Rav Assi - from Fever

So Rava's teaching in tomorrow's daf, Nedarim 41b appears to be spot on.  Fever is indeed beneficial for the body, though it is a sign that something bad is going on.  Elsewhere in the Talmud (Niddah 36b, which we will learn on November 28, 2019, הבא עלינו לטובה) we read that another Babylonian Amora, Rav Assi, died from a fever accompanied with chills - the classic description of sepsis (and a lot else besides, too). It is interesting to note that Rav Assi's attendants tried to reduce his fever.  Perhaps they not aware of the tradition that Rava - who was born two generations later - would later teach.

R. Assi fell ill and they had to put him in hot [blankets] to relieve him from chills, and in cold [compresses] to relieve him from heat,[but] his soul departed to its eternal rest. (Niddah 36b.)

Fever may be beneficial, but the underlying infection of which it is a sign never is.  Which is why,in the next daf  (Nedaraim 42,) Rava's teaching was not accepted by by Rav Nachman bar Yitzchak who retorted: לא היא ולא תירייקה:  "Give me neither fever, nor its antidote!"

Gittin 19a ~ Mishnaic Inks

משנה גיטין יט, א

בכל כותבים בדיו בסם בסיקרא ובקומוס ובקנקנתום ובכל דבר שהוא של קיימא אין כותבין לא במשקין ולא במי פירות ולא בכל דבר שאינו מתקיים 

A get may be written with any material, with ink, with paint, with red pigment, with gum, or with shoe blackening, or with anything which lasts. It may not be written with liquids or with fruit-juice or with anything that is not lasting...

Which international best-seller was set in the middle ages and featured a poisonous ink used to illuminate manuscripts? Click here for the answer.

It is a challenge to identify each of the materials mentioned in this Mishnah, but that hasn't stopped people from trying. In a 1964 paper published in Chymia (that would be the International Journal for Chemistry), Martin Levey from Yale University suggested that דיו – diyo is a black ink whose color is due to soot particles.  Based on prior work (by Low and others) he wrote that that the best soot came from olive oil, which was then mixed with balsam. קנקנתום -Kankantum is translated in the Schottenstein Talmud as copper sulfate. How the editors arrived at this translation is not clear. Perhaps they are basing it on אורח חיים הלכות תפילין לב, ג where the משנה ברורה suggests that it is "קופער וואסער" - "copper water".  Levey claims that in Babylonia, kankantum was green and contained not copper but ferrous sulfate. In a more recent paper on the ink content of middle Persian documents, the author found that they too contained lamp soot which was gathered from inside a chimney that burned linseed oil. The soot was then sieved to produce a fine powder that was bound with Gum Arabic, made from the sap of the acacia tree.

“...He dictated all these words to me, and I wrote them with ink in the book.”

— Jeremiah 36:18

Dead Sea Ink

A group of German scientists recently analyzed the ink on one of the Dead Sea Scrolls and reported their findings in Dead Sea Discoveries. They used x-ray spectroscopy, in which an electron beam is bounced over the sample, and the spectrum of radiation that is given off is measured. As you can see in the figure below, the spectrum of the Dead Sea Scroll ink is similar to Gum Arabic, but it contains peaks that suggest other compounds, including a gum produced by the Acacia Raddiana, known in Hebrew as שיטה סלילנית. Not surprisingly this tree is only found in very dry or desert climates.   

Spectroscopy results of the ink from a Dead Sea Scroll (1QHa) marked as TG ink, compared with Gum Arabic, Gum Rasdsiana and ink prepared according to Maimonides' recipe.  From Ira Rabin, Oliver Hahn, Timo Wolff, Admir Masic and Gisela Weinberg. On the Origin of the Ink of the Thanksgiving Scroll (1QHodayot). Dead Sea Discoveries, 2009: 16 (1)97-106.

But the German team made an amazing discovery. No, really, it was amazing.  They compared the spectrum given off by the Dead Sea Scroll ink to a recipe for ink that Maimonides details in his Mishneh Torah,  and which is shown in the lowermost line in the Figure above.  You can see how it resembles TG sample that is the scroll ink. Here is what they wrote:  

To our astonishment the best correspondence was found when comparing the spectra of the ink from the scroll with a sample of ours prepared according to Maimonides' recipe, dating from the 12th century.

Analysis of the spectrum of the scroll ink also suggests the presence of tannins -a group of chemicals naturally found in many trees and plants. The authors note that Maimonides' recipe uses gall-nuts, which contain tannins.  

Maimonides' prescription could indicate the survival of an ancient use, whose actual reason had been forgotten. In this case the tannins would chemically bind the ink to the parchment collagen, explaining the surprising durability of the scroll inks as compared to the usual, physisorbed, carbon-based ink.   

Let's conclude with that recipe from the Rambam's Mishneh Torah, which is almost identical to the ink used on a Dead Sea Scroll that was written around 100 CE. Today there are several recipes for ink, but for those who use the Rambam's, they are following a recipe that has been in continuous use for at least 1,900 years. That what the science in this daf tells us.   

רמב"ם הלכות תפילין ומזוזה וספר תורה פרק א 

כיצד מעשה הדיו, מקבצין העשן של שמנים או של זפת ושל שעוה וכיוצא בהן וגובלין אותן בשרף האילן ובמעט דבש ולותתין אותו הרבה ודכין אותו עד שיעשה רקיקין ומיבשין אותו ומצניעין אותו, ובשעת כתיבה שורהו במי עפצים וכיוצא בו וכותב בו, שאם תמחקנו יהיה נמחק, וזהו הדיו שמצוה מן המובחר לכתוב בו ספרים תפילין ומזוזות

How is the ink made? One collects lamp-black obtained from oil or from pitch, wax  or similar substances; one binds them with wood resin and a little honey, and they are kneaded well and flattened into cakes.  Then they are dried and put away. When they are used to write, they are soaked in gall-nut water or something similar and he writes with it.  And if the writing needs to be erased, it may be erased.  This is the finest ink used for writing a Sefer Torah, Tefillin, and Mezuzot. (Hil. Tefillin 1:4).

Gittin 2a ~ A Very Determined Envoy

המביא גט ממדינת הים צריך שיאמר בפני נכתב ובפני נחתם

If an envoy brings a Get to Israel from abroad, he must declare "it was written in my presence and signed in my presence" (Gittin 2a)

In the first chapter of Gittin, we address the laws that apply to an envoy (שליח) who is charged with bringing a Get, a Jewish Bill of Divorce, to a woman living overseas.  Such cases were clearly prevalent, so much so that they open this tractate, devoted to the rules of divorce.

For many hundreds of years, these messengers carried out their religious duties and delivered the Get, but did so without much recognition in our literature.  Today, one such envoy will be recognized for perhaps the most arduous trip ever undertaken to deliver a Get. That trip, which began in 1830, was from London to Sydney, Australia, and back again. It covered over 27,000 nautical miles and took close to thirteen months. The trip is detailed in Jeremy Pfeffer's book From One End of the Earth to the Other, from where the following information is taken. 

Rabbi Aaron Levy of Lissa

The envoy who undertook this daunting trip was Aaron Levy, born in 1795 in western Poland. He arrived in London in 1811, where he taught in cheder and worked as a calligrapher and sofer. At the time, many convicted of crimes were sentenced to exile in Australia. Of the Jewish population of Australia, which numbered about 1,550, about 44%  - some 684 (!) - were convicts. Rabbi Levy was to find one of those convicts - a serial counterfeiter who used many aliases - by the name (or rather a name) of  Samuel Levi. Levi had been sentenced to death in London for repeated crimes of  counterfeiting, but the sentence had been commuted to transportation for life in 1808.  Samuel had left behind his wife in London, and now, after some 29 years of marriage, she wanted to obtain a Get and divorce him. Here is the charge to Levy, as recorded in the notes of the London Bet Din:

On 23rd Mencachem Av 5590 [August 12, 1830] there appeared before us...a woman Mindela who is commonly known as Minka bat Yehuda Leib, and she appointed R. Aaron ben R. Yehuda of Lissa to be her agent to receive a Get from her husband Samuel who is commonly known as Long Zanvil ben Mordechai ben Meir who lives in Sydney on the sea coast in the State of South Wales...And let it be known that after discussing the matter the Gaon, Head of the Bet Din, and the Bet Din determined that the above R. Aaron, who is the agent for receipt (שליח לקבלה) of the above woman, will first effect the Get as an agent of accept acceptance before a Bet Din and witness to the handing over [of the Get].  And after he has received the Get from him with the intent of receiving, he will instruct the man to appoint him as his agent of delivery (שליח להולכה) and execute the Get as is required for an agent for transmission.

The kind of agency that Rabbi Levy used was not common. Usually the envoy was acting on the husband's behalf to deliver a Get to his wife. Here however, Levy was acting on the wife's behalf to receive the Get from her husband. Once Levy received the Get, it would immediately take effect, even if the good rabbi never made it back to London. In addition Rabbi Levy would have to act as a Sofer and write the Get, and convene a Bet Din in Australia to verify the procedure.  But first he would have to find Long Zanvil.

R. Levy left for Australia on August 17, 1830 and arrived some three months later, on December 21, 1830.  While there, he managed to track down Long Zanvil and convinced him to give a Get to his estranged wife. He then wrote the Get, and found five Jewish laymen: three to to act as a Bet Din and two to witness the handing over of the Get from the husband to the Rabbi. Rabbi Levy stayed in Sydney for five months, during which time his skills as a Sofer were put to good use. He sold a new Sefer Torah to the community, which he likely wrote himself, and repaired mistakes in several others.  

In early May 1831, Levy set sail to London, with a cow, a gift from the Jewish community of Sydney, which would provide him with fresh milk during his long voyage.  He arrived home after four months at sea, and a couple of weeks later the London Bet Din convened a session to formally hand over the Get to Minka. Here is what happened, as recorded in the notes of the London Bet Din: 

On the 27th of Tishrei 5592 [October 4, 1831], further to what is written above, the Gaon, Head of the Bet Din, executed the Get in accordance with the law of an agent for transmission...And when the agent gave the Get to the woman Mindela, who is commonly known as Minka bat Yehuda Leib, he declared "I wrote the Get with intent (לשמה) and the witnesses also signed it before me with the intent for the purpose of divorce.

Some Questions about the Voyage

A number of questions remain about the trip.  Here are a few of them:

1. Why did Mindela wait for over twenty years before asking for a Get?

2. Who financed the voyage, which cost about 100 pounds, which is over $15,000 today?

3. Why did Rabbi Levy undertake the voyage without knowing where Long Zanvil was living, and whether he was prepared to give a Get? 

Jeremy Pfeffer, the author of the book that details the trip, believes that there had to have been some communication between the couple, and that the voyage was likely financed by Rabbi Levy himself. Pfeffer writes:

To the best of our knowledge, he was not related to any of the parties involved nor did he receive any great monetary renumeration for the mission. Putting our contemporary cynicism aside, we may believe that his motives were simply altruistic; there was a wrong that needed to be corrected and he alone could do so. And so we may fairly conclude that he undertook the mission to Australia simply for its own sake and for the sake of Heaven, לשמה ולשם שמים.

Two years after his return from Australia, Rabbi Levy was appointed to the London Bet Din where he served as Dayan and Secretary. His mission, now all but forgotten, is a wonderful example of a rabbi doing the right thing to help a women obtain a Get. יהי זכרו ברוך.

Gittin ~ On Divorce, Then and Now

From Salon.com

Today, those learning in the one-page-of-talmud-a-day daf yomi cycle begin a new tractate, called Gittin. As its title suggests, it is focussed on the laws of divorce. So let's look at divorce in the western world.    

Divorce in the Western WOrld

As you can see in the chart below, the current average rate of divorce in the countries that make up the Organization for Economic Co-operation and Development (OECD) is about two per thousand people; in the US the figure is almost three per thousand, while in Israel the figure is just below the OECD average. In many countries the rate is lower than it was in 1995, but in nearly all it is much higher than it was way back in 1970.

Crude divorce rate, 1970, 1995 and 2012. From OECD Family Database.  

THE CHANGING RATES OF DIVORCE IN THE US

 In the 1970s there was a surge in the divorce rates in the US (and throughout the industrialized world), and in 1977 the sociologist Amir Etzioni issued a dire prediction. If the rates of divorce continued to rise as they had done over the preceding years, "not one American family" would be left intact by the 1990s. But by 1981 the divorce rates levelled off (and more couples were choosing to live together without getting married). By 1998 the divorce rate was 26% lower than it had been in 1979. (This data is found in Marriage, A History by Stephanie Coontz.)

“No party can oblige continuance in contradiction to its end and design.”

— Thomas Jefferson, in Norma Basch, Framing American Divorce. University Of California Press 2001.

In the US, statistics on rates of marriage and divorce are published by the National Center for Health Statistics, which is a branch of the Centers For Disease Control and Prevention.  The latest data for the US were published in 2021. It shows that the probability of divorce depends on the length of the marriage. Sadly the probability of divorce increases as the duration of the marriage increases.  The probability of a marriage of five years or less ending in divorce is about 20%; the probability of a marriage of twenty years ending in divorce is a massive 48%.  And second marriages fare a little worse: by ten years of marriage 32% of those married for the first time will have divorced in the US, compared to 46% of those in their second marriage.

There is some good news. The US divorce has been falling fast in recent years, and it hit a record low in 2019. For every 1,000 marriages in the last year, only 14.9 ended in divorce. This is the lowest rate we have seen in 50 years. It is even slightly lower than 1970, when 15 marriages ended in divorce per 1,000 marriages. 

However, the rate of marriage in the US also reached an all-time low in 2019. For every 1,000 unmarried adults in 2019, only 33 got married. This number was 35 a decade ago in 2010 and 86 in 1970. So on balance, maybe things are basically the same.

Divorce rates in the US. Source: The New York Times.

Divorce in Christianity, The UK and the Colonial US

The Church essentially forbade divorce for most of its history, basing itself mostly on Mark 10:9: "what therefore God has joined, let no man put asunder." This left its mark on attitudes towards divorce. (We came across one example of the difficulty in obtaining a divorce when we examined King Henry VIII and his plight to get one of his marriages annulled.)  In the United Kingdom of 400 years ago, a divorce required a special Act of its Parliament; this, and its cost made it available only to those with money and privilege. It was only in 1857 that a new law was passed that removed divorce from the control of the Church and made it a civil affair. But husbands and wives were treated very differently by this new law. A husband could obtain a divorce on the grounds of his wife's adultery. But for a wife to obtain a divorce, she had to prove both adultery and an additional "matrimonial offense". The early colonists in the US had similar laws; divorce was allowed only in cases of adultery, habitual drunkenness, desertion, cruelty, or impotence. What we call today "no-fault" divorces have only been around since the 1970s.

JEWISH DIVORCE, THEN AND NOW

It is challenging to get a good count of the rates of divorce in the Jewish communities around the world.  One of the rare examples of such data can be found in Jeremy Pfeffer's book From One End of the Earth to the Other, which examines the London Bet Din in the first half of the nineteenth century, and its relationship to the Jewish convicts deported to Australia. (We will return to this fascinating book in our next post.) Pfeffer examined in great detail the marriage and divorce records of the London Bet Din, and discovered that between 1805 and 1855 there were 347 divorces. This turns out to be about one divorce per thousand married Jews, and he notes that the current rate of divorce is "an order of magnitude greater." In fact the current divorce rates in England and Wales are about twelve per thousand married persons, "and there is no reason to suppose that it is significantly lower amongst present day English Jews." 

“The indissolubility of marriage is a main principle of English law, asserted without any exception or reserve in the formularies of the Church, in which the parties pledge themselves, either to other, that they will live together so long as they both shall live, and until death shall part them.”

— Hector Davies Morgan (of Trinity College Oxford). The Doctrine and Law of Marriage, Adultery and Divorce. 1826. p214

Divorce Rates and Religious Committment

Another study published over 30 years ago reviewed the relationship between rates of divorce and levels of religious commitment. It was based on the 1981 Greater New York Population study which sampled over 4,000 Jewish households, and it made the following observation:

As one might expect, we see the lowest rate of divorce among the Orthodox. In comparison, we see a slight rise among the Conservative, a doubling among the Reform, and a quadrupling for those who do not identify themselves as members of the major denominations. It is the Orthodox community that is most frequently held up as the most effective transmitter of traditional Jewish family values, and these results are consistent with our thesis of a relationship between Jewish commitment and divorce. 

Further support for these findings can be found in more recent work from Focus on the Family ("a global Christian ministry dedicated to helping families thrive"). They report the following relationships between faith affiliation and divorce rates:

From Focus on the Family

Of course we have no idea about whether the lower rate of divorce among active Protestants, Catholics and Jews is because religious practice increases marital harmony or, as a cynic might claim, peer pressure makes those who are more actively religious are reluctant to divorce. Still, a 97% reduction in the divorce rate in those who are "actively Jewish" is pretty impressive.

As we have noted, it took many centuries for secular societies (even in countries that are deeply Catholic) and the church to allow for more equitable divorce laws. For most of that time, Jewish divorce law was in some aspects the most enlightened of any society.  It allowed for divorce on the grounds of incompatibility, but at the same time allowed only the husband to control the process. If he did not wish to divorce, no divorce could take place.   But the last great change to Jewish divorce law was over 900 years ago, when Rabbenu Gershom forbade a man from divorcing his wife against her will. It is probably time for orthodox Judaism to take another look at the issue.