Nedarim 15a ~ How Long Can You Go Without Sleep?

נדרים טו א

והא"ר יוחנן שבועה שלא אישן שלשה ימים מלקין אותו וישן לאלתר

...Rabbi Yochanan said "An oath that I will not sleep for three days" - we lash him [since he took an oath in vain] and he may sleep immediately...(Nedarim 15a)

How long can you go without sleep? If you are like me, staying awake for just one night can be very challenging.  I worked my share of night shifts in the emergency department for over fifteen years (amounting to hundreds of overnight shifts) but it never got any easier with time. We all push ourselves when we need to, but is there a physiological limit to the amount of time that you can stay awake?

The World Record for Staying Awake

The world record for staying awake is an amazing eleven days. Eleven days – that’s 264 hours (and 24 minutes to be precise) without sleep. It was set in 1965 by Randy Gardner, who was then seventeen years old. Gardner seems to have suffered little if any harm by his marathon period of sleep deprivation. But don’t try and beat the record. The Guinness Book of Records no longer has an entry for staying awake – because it is considered too dangerous an ordeal to undertake. (You can hear a review of sleep deprivation stunts in general and a wonderful interview with Gardner himself here.)

The Health Risks of Sleep Deprivation

A 1970 study of four volunteers who stayed awake for 205 hours (that’s eight and a half days!) noted some differences in how the subjects slept once they were allowed to do so, but follow-up testing of the group conducted 6-9 months after the sleep deprivation showed that their sleep patterns were similar to the pre-deprivation recordings.

Although Randy Gardner and these four volunteers seem to have suffered no long-term health consequences of staying awake for over a week, scientists have long noted that sleep deprivation is rather bad for the body. Or to be more precise, the bodies of unfortunate laboratory rats who are not allowed to sleep. In these animals, prolonged sleep deprivation causes the immune system to malfunction. This results in infection and eventual lethal septicemia. The physiologist who kept these rats awake noted that there are “far-reaching physical implications resulting from alterations in immune status [which] may explain why sleep deprivation effects are risk factors for disease and yet are not well defined or specifically localized.” In other words, sleep deprivation makes rats really sick, but we don’t know how, or why…

One possible explanation was suggested in a 2013 by a group from the University of Rochester Medical Center. They demonstrated that during sleep, the space between the cells of the brain (the interstitial space) increased by up to 60%, allowing toxic metabolites to be cleared. This raises the question of whether the brain sleeps in order to expel these toxic chemicals, or rather it is the chemicals themselves that drive the brain to switch into a sleep state.

The extracellular (interstitial) space in the cortex of the mouse brain, through which cerebral spinal fluid moves, increases from 14% in the awake animal to 23% in the sleeping animal, an increase that allows the faster clearance of metabolic waste products and toxins. From Suzana Herculano-Houzel. Sleep it out. Science 2013: 342; 316

Not having any sleep is bad for your health - but so too is going without enough sleep. Chronic restriction of sleep to six hours or less per night can produce cognitive performance deficits equivalent to up to two nights of total sleep deprivation. So be sure to get a full night's rest.

How long did the Vilna Gaon stay awake?

In his recent book on the Vilna Gaon, Eli Stern reviewed an episode in which the Gaon (d. 1797) was jailed on charges of kidnapping. (It’s a long story, but the Vilna Gaon was involved in the kidnapping of a young Jewish man who had converted to Christianity.) This episode occurred in January 1788, after which the Gaon was arrested and held for over a month.  The case was later tried, and on September 15, 1789 (sic) the Gaon of Vilna (together with others involved in the kidnapping) was sentenced to twelve weeks in jail.  Although it is unclear how long he was imprisoned, he was there over Sukkot, and the Lithuanian authorities were hardly in the practice of providing imprisoned Jews with a sukkah.  But since one is not permitted to sleep outside of the sukkah, what was the Gaon to do?  Simple.  He’d stay awake, and by doing so he would not transgress the prohibition of sleeping outside the sukkah.  Here’s how the episode is described in the work Tosefet Ma’aseh Rav published in 1892. 

Our Leader, teacher and Rabbi may he rest in peace, when he was imprisoned on Sukkot, tried with all his strength, and walked from one place to another, and held his eyelids open, and made an extraordinary effort not to sleep outside the sukkah – not even a brief nap – until the authorities released him to a sukkah.

We don’t know for how long the sixty-nine year-old Elijah stayed awake, but any suggestion that he was awake for the entire holiday of Sukkot seems to be far fetched (though as we have seen, not entirely impossible).

Hard, But Not Impossible

In today’s daf, Rabbi Yochanan ruled that since it impossible to stay awake for more than three days, any vow to do so is considered to have been a vow made in vain – and punishment follows swiftly.  Here is how the ArtScroll Talmud explains this ruling, (based on the explanation of the Ran).

Since it is impossible for a person to go without sleep for three days, the man has uttered a vain oath. Hence, he receives lashes for violating the prohibition (Exodus 20:7): לא תשא את שם ה׳ אלוקיך לשוה, You shall not take the Name of Hashem, your God, in vain. And since the oath -being impossible to fulfill -has no validity, he is not bound by it at all and may sleep immediately.

We have seen however, that while it’s not a good idea to do so on any kind of regular basis, it is certainly possible to stay up for longer than three days. (Back in the 1970s, some volunteers would even do so for as little as $100). Maimonides codified this law and also assume that it is impossible to stay awake for three consecutive days. 

רמב"ם הלכות שבועות פרק ה הלכה כ

נשבע שלא יישן שלשת ימים, או שלא יאכל כלום שבעת ימים וכיוצא בזה שהיא שבועת שוא, אין אומרין יעור זה עד שיצטער ויצום עד שיצטער ולא יהיה בו כח לסבול ואח"כ יאכל או יישן אלא מלקין אותו מיד משום שבועת שוא ויישן ויאכל בכל עת שירצה

Based on what we've reviewed, Rabbi Yochanan was incorrect when he stated that it was impossible to stay awake for three days. It's certainly not impossible, but that hardly means it's a good idea to try. 

“Sleep deprivation reduces learning, impairs performance in cognitive tests, prolongs reaction time, and is a common cause of seizures. In the most extreme case, continuous sleep deprivation kills rodents and flies within a period of days to weeks. In humans, fatal familial or sporadic insomnia is a progressively worsening state of sleeplessness that leads to dementia and death within months or years. ”

— Lulu Xie et al. Sleep Drives Metabolite Clearance from the Adult Brain. Science 2013. 342.317

This may explain the teaching of Rabbi Chaninah ben Chachina'i in Masechet Avot  (3:4) who taught that one who stays awake at night "will forfeit with his life."  Now that's a warning to heed.

רבי חנינא בן חכינאי אומר הנעור בלילה ... הרי זה מתחייב בנפשו 

Nedarim 8b ~ Heliotherapy

On this page of Talmud, Abayye and Reish Lakish recommend the healing properties of sunlight:

נדרים  ח ב׳

שמש צדקה ומרפא אמר אביי ש"מ חרגא דיומא מסי ופליגא דר"ש בן לקיש דאמר אין גיהנם לעולם הבא אלא הקב"ה מוציא חמה מנרתיקה צדיקים מתרפאין בה ורשעים נידונין בה

“The sun of righteousness, with healing in its rays” (Malachi 3:20)...Abayye said: “We learn from here that the dust of the sun heals”…Rabbi Shimon ben Lakish said, “there is no hell in the world to come. Rather God takes the sun out of its canopy; the righteous are healed by it and the wicked are punished by it” (Nedarim 8b.)

A History of Heliotherapy

In 1903, the Nobel prize for Medicine was awarded to a Dane named Niels Finsen. Finsen had invented a focusable carbon-arc torch to treat – and cure – patients with lupus vulgaris, a painful skin infection caused by tuberculosis.  While this was the start of the modern medical use of phototherapy, using the sun as a source of healing is much, much older. Older even than the Talmud, which mentions it in today’s daf. 

“The Nobel Prize in Physiology or Medicine 1903 was awarded to Niels Ryberg Finsen “in recognition of his contribution to the treatment of diseases...with concentrated light radiation, whereby he has opened a new avenue for medical science”.”

Perhaps the earliest reference to heliotherapy – that is, using sunlight to heal - is found in Egyptian papyrus records from over 3,500 years ago, which record using the sun, together with ingesting a local weed, to treat skin conditions. The active ingredients of that weed, Ammi majus, were isolated in 1947. These ingredients, together with heliotherapy, were used in the first clinical trials to treat vitiligo, which were conducted, rather fittingly, in Egypt.  Further work determined that it was only a narrow part of the sun’s spectrum that was needed to treat vitiligo, psoriasis, and other skin conditions, and so lamps were developed that produced only narrow band ultraviolet light (UVB). These UVB lamps are now a mainstay of treatment for psoriasis. 

Sunlight for Healthy Bones

“For most white people, a half-hour in the summer sun in a bathing suit can initiate the release of 50,000 IU (1.25 mg) vitamin D into the circulation within 24 hours of exposure”

— Environmental Health Perspectives 2008:116;4. A162

But ultraviolet light – UVB – can also be extremely dangerous. Too much exposure to sunlight will cause skin cancer, as the light produces molecules that directly damage DNA. Here is the great paradox of sunlight – too much of it will burn and can kill – but get the dose right and it is not only curative, but essential for healthy living. Sunlight is needed to produce vitamin D in the skin, and vitamin D is needed to produce healthy bones. Without it, you will develop rickets, a skeletal deformity that is characterized by bowed legs. 

Typical presentation of 2 children with rickets. The child in the middle is normal; the children on both sides have severe muscle weakness and bone deformities, including bowed legs (right) and knock knees (left). From Holick M. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004;80(suppl):1678S–88S.

Sunlight for a Healthy Immune System

The sun’s light has been shown to have effect the immune system, although many of these effects are only poorly understood. 

When some nerve fibres are exposed to sunlight, they release a chemical called neuropeptide substance P. This chemical seems to produce local immune suppression.  Exposure to the ultraviolet wavelengths in sunlight can change the regulation of T cells in the body which can also modulate autoimmune diseases.

Sunlight to Treat Melanoma?

While sunlight can cause skin cancer, it has been shown to release a hormone called alpha melanocyte-stimulating hormone. This hormone appears to limit the damage to DNA damage from sunlight and so may actually reduce the risk of melanoma (but don't try this as a treatment yet. It's certainly not ready for prime time.)

Sunlight for Your Mood

Then there’s sunlight for your mood. Seasonal affective disorder – SAD – is caused by a lack of exposure to sunlight, which most affects those living in the northern latitudes in the winter.  SAD was first described in 1984 by Norman Rosenthal working at the National Institute of Mental Health but why it happens is still something of a mystery.  Rosenthal went on to write several best selling books on SAD and how to beat it. The answer appears to be something to do with sitting in front of a lamp that mimics sunlight (but the evidence that this works is still controversial).

 Sunlight for Babies with Jaundice

Sunlight is also a great treatment for babies with neonatal jaundice. This condition is very common and is caused when the baby breaks down the fetal hemoglobin with which it was born. A product of that breakdown is bilirubin, and if this is allowed to build up in the tissues it can cause lethargy, difficultly feeding, and in rare and extreme cases, brain damage. However, sunlight (or more precisely, the blue band of the spectrum at 459nm)  breaks down this dangerous bilirubin molecule into a harmless one called biliverdin.  So the best treatment for a newborn baby with mild jaundice is to put them out in the sun.  (Failing that, or if the degree of jaundice is not mild, you can consider phototherapy in the hospital.) 

The absorbance spectrum of bilirubin bound to human serum albumin (white line) is shown superimposed on the spectrum of visible light. Clearly, blue light is most effective for phototherapy, but because the transmittance of skin increases with increasing wavelength, the best wavelengths to use are probably in the range of 460 to 490 nm. Term and near-term infants should be treated in a bassinet, not an incubator, to allow the light source to be brought to within 10 to 15 cm of the infant (except when halogen or tungsten lights are used), increasing irradiance and efficacy. For intensive phototherapy, an auxiliary light source (fiber-optic pad, light-emitting diode [LED] mattress, or special blue fluorescent tubes) can be placed below the infant or bassinet. If the infant is in an incubator, the light rays should be perpendicular to the surface of the incubator in order to minimize loss of efficacy due to reflectance. From Maisels and McDonagh. Phototherapy for Neonatal Jaundice. New England Journal of Medicine 2008.358;920-928.

Sunlight for Infectious Diseases

 We don't treat infectious diseases with sunlight any more. But it wasn't always that way. Less than eighty years ago sunlight was recommended as a therapy for some patients with tuberculosis. The authors, writing in the journal Diseases of the Chest were cautious:

Even in those cases where the sun can be of great value, it is in no sense a specific cure for any manifestation of tuberculosis. Rest, good food, and fresh air, are still the fundamentals in treating all forms of the disease; and the sun, where it should be used, is only a valuable adjutant...Heliotherapy is not indicated in all cases of tuberculosis. The majority of patients with this disease should never use it...It is not a sure cure for any type of tuberculosis, but is often, especially in some of the extrapulmonary cases, a very valuable—or even necessary—aid.

In today's daf, Abaye noted that the sun can heal, and Rabbi Shimon ben Lakish (a.k.a Resh Lakish) taught that the sun can both reward and punish. Their insights were more correct than they could ever have guessed.  

“Bright light therapy and the broader realm of chronotherapy remain underappreciated and underutilized, despite their empirical support. Efficacy extends beyond seasonal affective disorder and includes nonseasonal depression and sleep disorders, with emerging evidence for a role in treating attention-deficit/hyperactivity disorder, delirium, and dementia.”

— Schwartz and Olds. The Psychiatry of Light. Harvard Review of Psychiatry 2015. 23 (3); 188.

What's Love Got To Do With It?

Today we will end our study of Ketuvot. This tractate addresses, in the words of the Koren Talmud, "matters that constitute the relationship between husband and wife: Conjugal relations, mutual obligations, and monetary arrangements between them. In a general sense it addresses the entirety of marital life."   Except it doesn't. There's one rather important part of the entirety of marital life that is not addressed at all. Love.  So as we turn the last page of Ketuvot, now is a good time to ask: what happened to that crazy little thing called love? 

LOVE IN KETUVOT

How often does the word "love" appear in Ketuvot, a tractate about the obligations of a husband towards his wife (and some of her obligations too)?  For those who've learned it as part of Daf Yomi, how often did you come across the word? For those who have not learned it, how often would you guess it appears in a talmudic volume of 112 pages? And you can't count the name of רב אדא בר אהבה - (though his name appears thirteen times).

I counted, and the answer is....six. Just six. (And don't look to מסכת קידושין for help. Love, or one of its conjugates appears there twenty-four times. Only one was in the context of spousal love - and that was a quote from משלי 9:9.) Here then, are the appearances of "love" in מסכת כתובות:

1-2.  Two of them are a quote from the ברכות  recited at the wedding.

(שמח תשמח ריעים האהובים and דיצה חדוה אהבה ואחוה)

3. One is used in conjunction with the choice of the method of judicial execution 

(דף מ: ואהבת לרעך כמוך ברור לו מיתה יפה)

4. One is used to claim that women prefer jewelry to wine 

דף סח: אלכה אחרי מאהבי נותני לחמי ומימי צמרי ופשתי שמני ושקויי! דברים שהאשה משתוקקת עליהן, ומאי נינהו? תכשיטין

5.  One is a quote from  משלי א, to claim that the study of Torah protects the scholar against a weird parasitic disease. 

(דף עז: "אילת אהבים ויעלת חן" - אם חן מעלה על לומדיה, אגוני לא מגנא)

6. The final mention of love is a quote from the Torah (דברים ל)  to prove that marrying your daughter to a תלמיד חכם (or going into business with such a person) is a sign of loving God.

דף קיא: לאהבה את ה' אלהיך ולדבקה בו ... כל המשיא בתו לתלמיד חכם, והעושה פרקמטיא לתלמידי חכמים, והמהנה תלמידי חכמים מנכסיו, מעלה עליו הכתוב כאילו מדבק בשכינה

So all in all, love is kinda absent. But should we be surprised by this?

A (REALLY BRIEF) HISTORY OF THE INSTITUTION OF MARRIAGE

As the historian Stephanie Coontz points out in her fascinating book, for most of history, marriage was not primarily about individual needs. Instead it was about "getting good in-laws and increasing ones's family labor force."  In ancient Roman society "something akin to marriage was essential for the survival of any commoner who was not a slave...A woman needed a man to do the plowing.  A man needed a woman to spin wool or flax, preserve food, weave blankets and grind grain, a hugely labor-intensive task." Marriage was essential to survive. So it comes as no surprise that historically, love in marriage was seen as a bonus, not as a necessity. In many societies (including that described in the Talmud), a woman's body was the property first of their fathers, and then of their husbands. A woman had to follow, as Confucious put it, the rule of three obediences: "while at home she obeys her father, after marriage she obeys her husband, after he dies she obeys her son."  

This pattern existed for centuries. Here's a rather graphic, but certainly not isolated example.  In the 1440s in England, Elizabeth Paston, the twenty-year old daughter of minor gentry, was told by her parents that she was to marry a man thirty years her senior. Oh, and he was disfigured by smallpox.  When she refused, she was beaten "once in the week, or twice and her head broken in two or three places." This persuasive technique worked, and reflected a theme in Great Britain, where Lord Chief Baron Matthew Hale  declared in 1662 that "by the law of God, of nature or of reason and by the Common Law, the will of the wife is subject to the will of the husband." Things weren't any better in the New Colonies, as Ann Little points out (in a gloriously titled article "Shee would Bump his Mouldy Britch; Authority, Masculinity and the Harried Husbands of New Haven Colony 1638-1670.) The governor of the New Haven Colony was  found guilty of "not pressing ye rule upon his wife." 

“Marriage was not fundamentally about love. It was too vital an economic and political institution to be entered into solely on the basis of something as irrational as love.”

— Stephanie Coontz 2005. Marriage, a History, p7.

Coontz concludes that marriage for political and economic advantage was the norm for some five thousand years, and only started to change in the eighteenth century. And throughout, the husband was the owner of his wife. Love had nothing whatsoever to do with it.

““For most of recorded history, people married for logical sorts of reasons: because her parcel of land adjoined yours, his family had a flourishing business, her father was the magistrate in town, there was a castle to keep up, or both sets of parents subscribed to the same interpretation of a holy text. And from such reasonable marriages, there flowed loneliness, infidelity, abuse, hardness of heart and screams heard through the nursery doors. The marriage of reason was not, in hindsight, reasonable at all; it was often expedient, narrow-minded, snobbish and exploitative.

”

— Alain de Botton. Why You Will Marry the Wrong Person. The New York Times, May 29, 2015.

It is with this historical perspective that the attitudes of the rabbis in Ketuvot (and in the Talmud in general) should be judged.  Marriage was an economic arrangement, and so it required economic regulation.  For example (and there are dozens,) the Mishnah ruled that a widow may sell her late husband's property in order to collect the money owed to her in the ketuvah without obtaining the permission of the court.  This leniency was enacted, (according to Ulla) "משום חינה" - so that women will view men more favorably when they understand that the ketuvah payment does not require the trouble of going to court. Consequently (and as Rashi explains) women will be more inclined to marry. Which leaves the reader to wonder just for whom this law was really enacted. 

““Jews and Asians in their home cultures used arranged marriages, in which overt economic bargaining and kinship networks beyond the marrying pair played acknowledged parts....Chinese and Japanese parents regularly took the decisive part in arranging marriages for their children...often well in advance of the marriage date. These traditions did not ignore considerations of affection and sexual satisfaction, but considered them alongside economic and family stability.”

— Nancy Cott. Public Vows. A History of Marriage and the Nation. Harvard University Press 2008. 149-150.

LOVE, ACTUALLY

It is also with this historical background that the exceptions should be noted. Like the earliest record of love as a reason to marry, found in Bereshit 29:18. "ויאהב יעקב את רחל" - "Jacob loved Rachel" and for this reason he agreed to work in Laban's house for seven years, which "seemed to him but a few days because of his love for her."  

And then there's this odd exception, found where you'd least expect it - in Rashi's discussion on Ketuvot 86b. There, the Talmud is discussing when a husband can make his wife - who is acting as his business manager  - swear that she has not taken anything of his.  The Talmud puts limits on a husband's suspisions that his wife is embezzling him, and she may claim: כיון דקדייקת בתראי כולי האי, לא מצינא דאדור בהדך – "since you are checking up on me to this degree, I can no longer live with you." This seems to be a fair: when one business partner has an unreasonable degree of suspicion about another, the partnership should be ended. But Rashi's explanation of this phrase adds in the aspect of love - or rather, a lack of it:

וקא דייקת בתראי - אינך אוהב ומאמין אותי ולא מצינא דאידור בהדך

Since you are checking up on me: [She claims that] you don't love or believe me - so I can no longer live with you.

Rashi's explanation suggests (at least as far as he understood marriage), love was, if not essential, then certainly highly desirable.  Without a wife feeling loved and trusted, the marriage is in deep trouble.  

Today of course, most of us believe that love is the only reason to marry. Economics should have nothing to do with it. And although this is a thoroughly modern (and western) idea, if you look carefully, soft echoes of it can be heard in our tradition. Although love has almost nothing to do with marriage in Ketuvot, it is in fact mentioned near the start of the tractate. There, we learn that seven blessings - שבע ברכות – are said for a week after the wedding. And in the text of the sixth of these blessings, the bride and groom are called "beloved companions" -ריעים האהובים -  or as Rashi explains it, "companions who love each other." 

The Business of Marriage

We should not judge the Talmud's business-like approach to the institution of marriage, because for thousands of years, and for the vast majority of those who entered into it, that's all it was. Business. One aspect of the business is even codified in the more recent Arukh Shulkhan, written by by Yechiel Michel Epstein (1829–1908). It is a commentary on the Shulkhan Arukh, the Code of Jewish Law, and was first published between 1884–1893:

ערוך השולחן אבן העזר סימן ב

אבל אם נושא אשה כשירה לשם ממון שאלמלא ממונה היה נושא אחרת אין בזה עון ואדרבא ראוי לעשות כן אם הוא ת”ח דעי”ז לא יצטרך להיות טרוד הרבה בענייני העולם וכן נוהגין אנשים ישרים ליקח ת”ח לבתו וליתן לה ממון הרבה ולהחזיקו על שולחנו כמה שנים שישב וילמוד ואין לך מצוה רבה מזה ובשכר זה מצליחים בעסקיהם

If a man married an upstanding woman just for her money - and if she did not have that money, he would choose to marry another woman - this is not a sin. On the contrary, if the man is a wise scholar (talmid hakham) it is good to do this, for by doing so he no longer needs to be focussed on business matters. Indeed, this is exactly how many upstanding fathers acted, and took a scholar to marry their daughter, and gave her a large sum of money. This would support the scholar for several years, during which time he could sit and learn, and there is no greater mitzvah than this. And in the merity of this he will be successful in his business ventures…

But western society has changed its beliefs about the nature of marriage, and so have we.  Still not convinced? Then answer this. Did your parents marry for love or money? If you are married - did you marry for love or for economic advancement (and how did that work out)? If you are not married, but want to be, what is driving you? The search for the love of your life, or the search for physical security? And if you have children - or grandchildren, would you want them to marry because they loved their significant other, or because it would be a good way to unite two families and ensure financial stability? If your answers were like mine, they were closer to contemporary secular values about marriage than they were to the models of marriages described in Ketuvot. And that's probably a very good thing.

  תם ולא נשלם, וברוך משדך שידוכים בעולם

NEXT TIME ON TALMUDOLOGY: HELIOTHERAPY.

Ketuvot 111a~Sitting and Learning. And Hemorrhoids. And the Golden Vein

On the penultimate page of Ketuvot, we learn of a letter that the brothers of the great sage Rabbah had sent. These brothers were living in Israel, while Rabbah who died around the year 320, lived in Babylon, far from his siblings. They pleaded for Rabbah to join them in the Holy Land, where he could study with renowned Rabbi Yohanan. But they also told their brother to be careful, and not sit for too long while studying. Here is their advice:

כתובות קיא, א

וְאִם אֵין אַתָּה עוֹלֶה — הִזָּהֵר בִּשְׁלֹשָׁה דְּבָרִים: אַל תַּרְבֶּה בִּישִׁיבָה — שֶׁיְּשִׁיבָה קָשָׁה לְתַחְתּוֹנִיּוֹת, וְאַל תַּרְבֶּה בַּעֲמִידָה — שֶׁעֲמִידָה קָשָׁה לַלֵּב, וְאַל תַּרְבֶּה בַּהֲלִיכָה — שֶׁהֲלִיכָה קָשָׁה לָעֵינַיִם. אֶלָּא שְׁלִישׁ בִּישִׁיבָה, שְׁלִישׁ בַּעֲמִידָה, שְׁלִישׁ בְּהִילּוּךְ.

And if you do not ascend to Eretz Yisrael, be careful in three matters: Do not sit excessively, as sitting is harmful with regard to hemorrhoids; do not stand excessively, as standing is harmful with regard to heart trouble; and do not walk excessively, as walking is harmful with regard to eye problems. Rather, divide your time: One-third for sitting, one-third for standing, and one-third for walking.

Today we ask the important question: does excessive sitting really increase the likelihood of developing hemorrhoids?

Ten other causes of hemorrhoids

Let’s start by noting that elsewhere, the Talmud lists ten other causes of this affliction:

ברכות נה, א

וְהַמַּאֲרִיךְ בְּבֵית הַכִּסֵּא: מְעַלְּיוּתָא הוּא? וְהָתַנְיָא: עֲשָׂרָה דְּבָרִים מְבִיאִין אֶת הָאָדָם לִידֵי תַּחְתּוֹנִיּוֹת: הָאוֹכֵל עֲלֵי קָנִים, וַעֲלֵי גְפָנִים, וְלוּלַבֵּי גְפָנִים, וּמוֹרִיגֵּי בְהֵמָה, וְשִׁדְרוֹ שֶׁל דָּג, וְדָג מָלִיחַ שֶׁאֵינוֹ מְבוּשָּׁל כל צָרְכּוֹ, וְהַשּׁוֹתֶה שִׁמְרֵי יַיִן, וְהַמְקַנֵּחַ בְּסִיד וּבְחַרְסִית. וְהַמְקַנֵּחַ בִּצְרוֹר שֶׁקִּנַּח בּוֹ חֲבֵרוֹ, וְיֵשׁ אוֹמְרִים: אַף הַתּוֹלֶה עַצְמוֹ בְּבֵית הַכִּסֵּא יוֹתֵר מִדַּאי.

With regard to what Rav Yehuda said in praise of one who prolongs his time in the bathroom, the Gemara asks: Is that a virtue? Wasn’t it taught in a baraita: Ten things bring a person to suffer from hemorrhoids: One who eats the leaves of bulrushes, grape leaves, tendrils of grapevines, the palate and tongue of an animal, as well as any other part of the animal which is not smooth and which has protrusions, the spine of a fish, a salty fish that is not fully cooked, and one who drinks wine dregs, and one who wipes himself with lime and clay, the materials from which earthenware is made, and one who wipes himself with a stone with which another person wiped himself. And some say: One who suspends himself too much in the bathroom as well. This proves that prolonging one’s time in the bathroom is harmful.

This list does not include all prolonged sitting, but only lengthy sitting on the toilet, which presumably has something to do with the act of straining for a bowel movement rather than being in the sitting position. There is something to this, but first, I know what you are thinking: what exactly are hemorrhoids?

THE NATURE AND ETIOLOGY OF HEMORRHOIDS

Hemorrhoids are small grape-like bulges of blood vessels around the anus. They affect between 4 -30% of the population, (though no one really knows). In most people they are completely painless and asymptomatic, and only a minority will require medical attention, though in my experience that attention was always expected in the emergency department at 4am. The most common symptoms are painless rectal bleeding or pain and swelling.

You would have thought that by now we knew for sure what causes hemorrhoids. But there is in fact some medical controversy about the whole thing. According to William Cirocco of the Department of Surgery at the University of Missouri, Galen, writing in the 2nd century, believed that that “unsound juices” were discharged from the body through hemorrhoids. Here are some of the other suggested etiologies:

1. The Varicose Vein Theory

   Varicose veins are essentially tired and weakened veins, which bulge as a result. You may have some on your legs noticed then on the legs of others. An increase in local venous pressure combined with a localized weakness in the vein wall were thought to result in hemorrhoidal disease. This leads to the medical advice to use stool softeners. These supposedly reduce the need for straining when defecating, and so reduce the pressure on those tired veins (see below).

2. The Vascular Hyperplasia Theory

   Anatomists noted that there were communications between the veins and arterioles (little arteries) within the hemorrhoid. This should explain the bright red bleeding typical of symptomatic hemorrhoids rather than dark, venous bleeding which would otherwise be expected if this were purely venous disease.

3. The Infection/Inflammation Theory

   This was popular in the early nineteenth century, when it was suggested the “there is always an infectious process associated with hemorrhoids . . . a condition which may properly be termed ‘phlebitis’.” This infection was thought to “come from outside the lumen of the vessels” and weaken the venous walls. Today, it is not a widely held explanation.

4. The Sliding Anal Lining Theory

   This interestingly named theory, based on the microscopic pathology of hemorrhoids, suggested that they are caused by a  “giving away of the supportive structures rather than a weakening and thinning out of the vessel walls as the initial pathologic change.” This sliding anal lining theory held that the cause of hemorrhoids was due to the gradual reduction of supportive elastic tissues due to aging, and abetted by the daily trauma of straining at the time of a bowel movement.

“The year 1975 was a watershed year for studies regarding the origin and explanation of hemorrhoids.”

— William C. Cirocco. Why are hemorrhoids symptomatic? the pathophysiology and etiology of hemorrhoids. Seminars in Colon and Rectal Surgery 2018: 29; 160-166

Interestingly, eating “the spine of a fish, a salty fish that is not fully cooked” or drinking wine dregs, which are suggested as causes of hemorrhoids in Berachot 59 have not been explored as possible etiologies. Neither has “wiping with a stone with which another person wiped himself,” though it’s probably a good idea to follow the Talmud’s suggestion on this one. Like many Talmudic medical theories, the suggestion here is that “like causes like”: so spiny fish cause the bulging of hemorrhoids, or grape leaves cause hemorrhoids - which may bulge out like little grapes. It’s an attractive theory, but like homeopathy - the theory that “like cures like” it has not a shred of evidence to support it.

So what about SITTING and Hemorrhoids? THE ISRAELI STUDY

There is no known relationship between hemorrhoids and sitting, and a study randomizing the population to minimal or maximal sitting would be all but impossible to do. The factor that does seem to be a risk is prolonged sitting on the toilet, and not sitting in other settings. This is exactly what the Talmud is getting at when it suggests not squatting for too long: “הַתּוֹלֶה עַצְמוֹ בְּבֵית הַכִּסֵּא יוֹתֵר מִדַּאי”

In fact it is not just prolonged sitting on the toilet, but straining to have a bowel movement while sitting. And would you believe it, but last year a group from Israel published a study in which they randomized 68 patients with (internal) hemorrhoids to either sitting on the toilet as usual, or squatting to have a bowel movement. Why did they do this, you may ask? Well, when you squat, the angle between the rectum (the bit before the anal canal, the most southerly part of our alimentary canal) and the anal canal itself straightens out. There is usually a 90 degree bend at that point, but squatting reduces that, as the researchers show in their helpful diagram:

From Sikirov, B. et al. Symptoms of Hemorrhoids Diminished Significantly or Ceased Completely by Changing from the Sitting to the Squatting Defecation Position. Israel Medical Association Journal 2021. 23: 264

By encouraging patients with hemorrhoids to squat rather than sit when defecating, the doctors found that

switching from the sitting defecation position to the squatting (test group) reduced the intensity of the bleeding and pain significantly greater than the medical treatment (control group). A paired analysis revealed that changing from the sitting to the squatting defecation position in the crossover trial caused a significant diminishment in the intensities of the bleeding, pain, and prolapse compared to the control. The percentage of patients with the complete cessation of the symptoms was significantly higher in the trial and crossover groups than in the controls.

This study was published as a letter and contained no statistics, so beware. But still, if it is correct, that’s a win for the patient, and for the Start-Up Nation that discovered it. By the way, Dr. Sikirov, the first author of this letter, has published on this topic before. Who can forget his classic 2003 paper “Comparison of Straining During Defecation in Three Positions; Results and Implications for Human Health”? You can read that here, if you need to. (In case you are wondering how to squat over a western toilet, you can buy the apparatus here. Talmudology receives no compensation from and does not guarantee the work of this company.)

ANd now, the Golden Vein

In June 1766 a physician by the name of John Petertseg published this advertisement for his services in his local colonial newspaper, the Pennsylvania Gazette.

From here.

Petersteg was offering to cure “without fail” consumption (the old name of tuberculosis) and the “Golden Vein,” which was the name once used to describe hemorrhoids. To understand this moniker, recall that for a couple of thousand years the prevailing theory was that all disease was caused by an imbalance of the four humors: black bile, yellow bile, phlegm and blood. As readers of Talmudology will recall from several previous posts, blood was often drained via an incision in the arm, neck or leg, in order to re-equilibrate those four humors, and blood-letter could charge a great deal for their “skills.” But hemorrhoids often bleed, sometimes even profusely, which meant that those who suffered with them would undergo a sort of constant blood-letting. Therefore, they would save the money that would have needed to be spent to have the procedure. Hence the “Golden Vein.”

Now here comes the really interesting bit: the suggestion that prolonged sitting may cause hemorrhoids could be found in a specific kind on anti-Jewish rhetoric published at the end of the 18th century. It claimed that Jews - specifically Jews - were more prone to suffer from hemorrhoids, for they typically sat while engaged in lengthy intellectual pursuits like the study of Talmud . Here is how Susan Kassouf of Vassar College described the association in her 1998 paper, The Shared Pain of the Golden Vein: The Discursive Proximity of Jewish and Scholarly Diseases in the Late Eighteenth Century:

…hemorrhoids were considered a classic Jewish disease, stemming from male Jews' scholarly lifestyle and the requisite hard benches, but it quickly became a disease they shared with all those bookishly inclined. As early as 1305, the Lilium Medicinae had reported that Jews suffer from hemorrhoids "because they are generally sedentary and therefore the excessive melancholy humors collect." The author of the Lilium Medicinae, Bernard de Gordon, further attributes the supposedly Jewish predisposition toward hemorrhoids to the constant fear and anxiety in which the persecuted people lived, a state that led to the collection of melancholy juices, and to a psalmic bit of divine revenge in which Jews were whacked on their collective posterior.

The explicit connection with scholarship reemerges in the eighteenth century among writers such as Johann Adolf Behrends who continue to propagate a connection between too much Talmud study and hemorrhoids: "the consequence of their lifestyle is that nowhere are more inhabitants plagued with hemorrhoids than in the Judengasse." In Von den Krankheiten der Juden (On the Diseases of the Jews, 1777), the Mannheimer Jewish physician Elcan Isaac Wolf constructs a similar relation between the stationary life of the Jewish scholar and his posterior afflictions.

But wait; there is more:

Discussions about a Jewish predisposition to hemorrhoids were part of a larger medical discourse that understood the golden vein to be peculiarly endemic to late eighteenth-century culture in general. Franz Anton May begins his study (The Hemorrhoids, 1780) with the question: "Why is the flow of the golden vein so common in our time?" He and his medical colleagues posit a dramatic increase during the last twenty years. Among the reasons May offers are: frequent bloodletting, too little physical activity, indulgence in warm drinks, over-refined meals, wine, and the sedentary scholarly life. To construct a patient from this etiology, it seems the sufferer is sickly, slothful, gluttonous, and intellectual; not surprisingly, hemorrhoids were seen by many doctors as a deserved moral punishment for culinary and physical excess and decadence.Hemorrhoids were also understood to stem from a deviant sexuality, alternately denoting "pederasty" or simply lasciviousness.

“While the topos of the menstruating and/or hemorrhoidal Jewish man appears to reach back to the thirteenth century in Europe, in which his condition was related to both melancholia and sexual excess, the feminization connected with bleeding continued to shape the eighteenth-century discourse on hemorrhoids.”

— Kassof, S. The Shared Pain of the Golden Vein: The Discursive Proximity of Jewish and Scholarly Diseases in the Late Eighteenth Century Eighteenth-Century Studies , 1998; 32, (1): 101-110.

It is fascinating to note on this page of Talmud how Rabbah’s siblings advised their scholarly brother not to sit for too long, lest he develop hemorrhoids. Some 1,400 years later, hemorrhoids came to be associated with Jews and their incessant habit of sitting and studying. And not in a good way. So be careful, and please stand when you read Talmudology.