Yevamot 75a~ Voltaire, Rabbi Yishmael, and the Man with One Testicle

VoltaIre’s Count

In 1587, Pope Sixtus V decreed that all marriages in which the man did not have two testicles in the scrotum should be dissolved.  Voltaire (1694-1778) felt the need to share some further observations on the testes and the Pope's edict, which he did in his Philosophical Dictionary:

This word [testes] is scientific, and a little obscure, signifying small witnesses. Sixtus V... declared, by his letter of the 25th of June, 1587, to his nuncio in Spain, that he must unmarry all those who were not possessed of testicles. It seems by this order...that there were many husbands in Spain deprived of these two organs...We have beheld in France three brothers of the highest rank, one of whom possessed three, the other only one, while the third possessed no appearance of any, and yet was the most vigorous of the three.

...[The] Parliament of Paris, on the 8th of January, 1665, issued a decree, asserting the necessity of two visible testicles, without which marriage was not to be contracted.

Which brings us to tomorrow’s daf, Yevamot 75a. To catch up quickly: The Mishnah (on 70a) listed the circumstances under which a Cohen is not allowed to eat terumah. Among those banned from this edible delight is a Cohen with an injury to his testicles - and this same injury, the Mishnah continues, when found among other Jewish men, may prevent that man from marrying. 

In discussing the details of what kind of testicular injury results in a ban on marriage, we read the following:

יבמות עה, א

אמר רבי ישמעאל בנו של ר' יוחנן בן ברוקה שמעתי מפי חכמים בכרם ביבנה כל שאין לו אלא ביצה אחת אינו אלא סריס חמה וכשר סריס חמה

Rabbi Yishmael the son of Rabbi Yochanan ben Berokah said: I heard from the sages in the vineyard at Yavneh that whoever has only one testicle [at birth] is called "sterile from the sun" [i.e. naturally sterile] and is allowed to marry...

So according to this report of Rabbi Yishmael, the sages in Yavneh allowed a man born with one testicle to marry.  The Talmud is describing a condition known as cryptorchidism in which one or sometimes both of the testes remains undescended and hide somewhere within the abdomen.

Cryptorchidism 

To understand all this, there's some embryology involved. Here is what you need to know:

The testes develop in the abdominal cavity and migrate southwards into the scrotum. Usually they land there by birth, or soon after, if they behave themselves.  Which they don't always do. Sometimes one of the pair (and very rarely both) fail to migrate. Sometimes they descend and then, apparently disappointed by their new cool accommodations, bolt back north to the warmth of the abdomen.

Which brings us to the question, just how common is cryptorchidism?

The best answer will be an educated guess because the data is not great. One of the few studies of the epidemiology of this condition comes from the medical examination of English schoolboys published in 1941. It reported that the incidence of cryptorchidism in 3,300 boys under 15 was almost 10%, but that this number dropped to less than 1% in boys older than 15.

And then in this paper comes this memorable line:

“Sir Robert Hutchison tells me that he knew a man in whom descent occurred while he was an undergraduate at Oxford (an event duly celebrated by a party).”

— Smith RE. The undescended testicle. The Lancet 1941;14: 747-751

A more recent  study from 2007 put the incidence of undescended testes at 1-4.6% at birth (depending on the infant birthweight), while at age 11 the incidence is anywhere from 1.6-2.2%. The incidence is higher in low birth-weight and premature boys.

What is clear is that there is an association between fertility and cryptorchidism, even when the testicle that went AWOL is retrieved and secured in the scrotum.

“The incidence of azoospermia in men with unilateral cryptorchidism is 13% regardless of the fate of the testis”

— Canadian Urological Association Journal, 2011

Which brings us back to the prohibition against a man with injured testes (or penis- as in Deut. 23:2:   לא יבא פצוע דכא וכרות שפכה בקהל) marrying. It is related to his presumed inability to father a child.   Voltaire seems to have been unsure of the role of the testes (whether one, two, or in one lucky case "three,") but Rabbi Yishmael's  סריס חמה, a man with only one visible testicle, while certainly less fertile than a normal man, is capable of fathering a child.  Hence his marriage, while not encouraged, is recognized, and this is codified as normative Jewish law.

 שולחן ערוך אבן העזר הלכות קידושין סימן מד, ד

   סריס שקדש, בין סריס חמה בין סריס אדם, וכן אילונית שנתקדשה, הוי  קדושין

If a man with one testicle married, whether this condition is from birth or later acquired, he is legally married.

Today, an undescended testicle is surgically brought into the scrotum at an early age, so that the cryptorchidism described by Rabbi Yishmael has been virtually eliminated, as have been some very interesting parties at the University of Oxford.

Yevamot 72 a ~ Blood Letting and Permissive Anemia

יבמות עב, ב

א”ר פפא הלכך יומא דעיבא ויומא דשותא לא מהלינן ביה ולא מסוכרינן ביה והאידנא דדשו בה רבים שומר פתאים ה

Rav Pappa said...we should not circumcise on a cloudy day or on a day of severe south winds, and we should not let blood on these days. But now that so many people do in fact do these procedures on these days we can apply the principle “God protects the simple”

Blood-letting 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.

Blood-letting 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 blood letting:

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 reduce it to [just] a revi’it,  and the wind comes and drains him [still further], and thus he is in danger.

Samuel was accustomed to be bled in a house [whose wall consisted] of seven whole bricks,  and a half brick [in thickness]. One day he bled and felt himself [weak]; he examined [the wall] and found a half-brick missing.

Rab and Samuel both say: He who is bled must [first] partake of something and then go out; for if he does not eat anything, if he meets a corpse his face will turn green; if he meets a homicide he will die; and if he meets swine, it [the meeting] is harmful in respect of something else.

Rab and Samuel both say: One who is bled should tarry awhile and then rise, for a Master said: In five cases one is nearer to death than to life. And these are they: When one eats and [immediately] rises, drinks and rises, sleeps and rises, lets blood and rises, and cohabits and rises.

Samuel said: The correct interval for blood-letting is every thirty days. Samuel also said: The correct time for bloodletting is on a Sunday, Wednesday or Friday, but not on Monday or Thursday…

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

Blood Letting - a practice whose time has certainly not come

There is absolutely no place for this intervention today, other than for the rare illness called 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.  But other than for this disease, and another one called hemochromatosis, in which the body absorbs too much iron, blood-letting, (called today phlebotomy or venepuncture, which do sound a whole lot more palatable but describe the same procedure) is harmful. Do not try this at home.  

Having made this very clear, let's introduce some nuance. Palliative blood-letting may be useless, but from this 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 associated with increased risk, when compared with those in whom the hemoglobin level was lower. And when tiny premature babies get anemic, there does not seem to be an advantage to keeping the hemoglobin in a higher range (though to be fair, more research needs to be done). But these two examples do not in any way lend support to the notion that blood-letting is anything other than a bad idea.  

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 blood-letting was really over. "Is the relinquishment of bleeding final?" he wrote, 

or shall we see by and by, or will our successors see, a resumption of the practice? This, I take it, is a very difficult question to answer; and he would be a very bold man who, after looking carefully through the history of the past, would venture to assert that bleeding will not be profitably employed any more.

(In fact, blood letting 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.) 

“Venesection has likewise failed to benefit the patient for more than a very short time, though possibly we have not resorted to this treatment sufficiently early.”

— Hammond, JAB. Rolland, W. Shore, TGHG. Purulent Bronchitis. The Lancet, July 14, 1917, 42.

While 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 blood-letting, the patient should 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 blood letting say: May it be your will Lord my God, that this procedure will heal me, for you are an unconditional healer. And when it is finished he says: Blessed are you God, healer of the sick.

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

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.