Niddah 41 ~ Surviving a Cesarean Section

In today’s page of Talmud there is an argument about whether a mother who had a cesarean section is ritually impure.

נדה מא, א

ת"ר המקשה שלשה ימים ויצא ולד דרך דופן הרי זו יולדת בזוב ורבי שמעון אומר אין זו יולדת בזוב ודם היוצא משם טמא ורבי שמעון מטהר

The Sages taught in a baraita:… And if the offspring emerged by cesarean section, she is considered one who has given birth during a period of ziva. But Rabbi Shimon says: She is not considered one who has given birth during a period of ziva. And the blood that emerges from there is ritually impure, but Rabbi Shimon deems it pure.

This discussion revolves around the Mishnah that we learned yesterday.

נדה מ, א

יוֹצֵא דֹפֶן, אֵין יוֹשְׁבִין עָלָיו יְמֵי טֻמְאָה וִימֵי טָהֳרָה, וְאֵין חַיָּבִין עָלָיו קָרְבָּן. רַבִּי שִׁמְעוֹן אוֹמֵר, הֲרֵי זֶה כְיָלוּד

For a child born from its mother's side, she does not sit the prescribed days of uncleanness nor the days of cleanness, nor does one incur on its account the obligation to bring a sacrifice. Rabbi Shimon says: it is regarded as a regular birth.

This is all very well, but let’s stop for a moment and think about this. The Mishnah was edited around 200 CE; there were neither antibiotics nor anesthetics (at least in any modern sense) and there was no germ theory of disease. Postpartum maternal deaths following natural childbirth common enough, but the rates of a woman surviving a cesarean section must have been extremely low. Yet here is the Mishnah teaching that a woman who recovers from this operation is exempt from bringing a sacrifice, which implies that surviving a cesarean section was an event so common that it required its own legal ruling.

Cesarean section. From here.

“Death borders upon our birth
And our cradle stands in the grave
”

— Joseph Hall, Bishop of Exeter (1564–1656)

Dying by cesarean Section

Precisely because it was so unlikely for a woman to survive a cesarean section, historians believe that despite his name, Julius Caesar could not have been born as a result of this procedure. “Caesar’s mother Aurelia survived childbirth and outlived her son to bury him 55 years later” wrote one reviewer of a history of cesarean section. “The fact that she lived and gave birth successfully rules out the possibility that Caesar was born in this way.” In fact the first recorded case of a mother and baby both surviving a cesarean section was only in 1500 (that’s 1,300 years after the Mishnah). It occurred in Switzerland,  

where Jacob Nufer, a pig gelder, reportedly performed the operation on his wife after a prolonged labour. She spent several days in labour and had assistance from 13 midwives but was still unable to deliver her baby. Her husband received permission from the religious authorities to perform a caesarean section. Miraculously, the mother lived and subsequently gave birth to five other children by vaginal deliveries including twins. The baby lived to the age of 77 years.

But even this story may not be accurate, since it was only reported some eighty years after the event. It was only with the introduction of chloroform as an anesthetic and hand-washing as means of reducing maternal mortality (both around 1847) that the cesarean became a viable means of saving the life of either mother or infant. So why did the Talmud bother to record the dispute as to whether a woman who survived a c-section brings a sacrifice?

“Hitherto it has commonly been concluded or assumed that there is no sound evidence for caesarean section with maternal survival before 500 A.D. If, however, the rabbinical reports are accepted as implying familiarity with the mother’s recovery from the operation, the date for the earliest practice of caesarean section with a successful outcome for both mother and child must be advanced by almost a millennium and a half.”

— Boss, J. The Antiquity of Caesarean Section with Maternal Survival: The Jewish Tradition. Medical History 1961; 5: 17-31.

survival after cesarean section

It turns out that contrary to expectations, during the time of the Talmud in the second century, “Jews practiced caesarean section not only to rescue an infant from a dead mother, but also to rescue both mother and baby from a prolonged labour. The mother's survival is implicit in written passages which are unambiguous on the matter, serious in purpose, and certainly not the subjects of modern amendment.” At least that is the claim made by Jeffrey Boss, in a 1961 paper published in the journal Medical History. There are several examples of post c-section survival.

Let’s start with animals. The Mishnah in Bechorot (2:9) describes a dispute between Rabbi Tarphon and Rabbi Akivah regarding the special status of an animal born by cesarean section, and its sibling, born naturally later on. In his commentary, Maimonides wrote:

יוצא דופן הוא שיקרע כסל הבהמה ויצא הוולד משם ועושים זה כמו כן באשה שתקשה ללדת והגיעה לשערי מות

Through the wall: this means that the animal is cut open and the calf removed. This is also done to a dying woman who is unable to deliver her baby naturally.

Maimonides, - himself a physician of great repute - does not dispute whether an animal could survive a c-section. He just accepts it as fact. Now let’s consider another Mishnah in the same tractate Bechorot (8:2), that deals with the special obligations surrounding a first-born child.

יוֹצֵא דֹפֶן וְהַבָּא אַחֲרָיו, שְׁנֵיהֶם אֵינָן בְּכוֹר לֹא לַנַּחֲלָה וְלֹא לַכֹּהֵן. רַבִּי שִׁמְעוֹן אוֹמֵר, הָרִאשׁוֹן לַנַּחֲלָה, וְהַשֵּׁנִי לְחָמֵשׁ סְלָעִים: 

A baby extracted by means of a caesarean section and one that follows is not a first-born for inheritance or a first-born to be redeemed from a priest. Rabbi Shimon says: the first is a first-born for inheritance and the second is a first-born as regards [the redemption] with five selas.

Clearly this Mishanha assumes that the mother survived a cesarean and then gave birth to another child. Next, consider the dispute in today’s page of Talmud (and elsewhere). Boss notes that the rabbis “make no comment on the implied survival of the mother after the operation, neither explaining away the implication of the Mishnah nor treating it as remarkable.”

In his commentary on the Mishnah (on Niddah 40a), Maimonides wrote:

רבי שמעון אומר שאמרו תלד לרבות יוצא דופן והוא שישוסע חלצי האשה אם תקשה עליה הלידה ויצא העובר משם

Rabbi Shimon said: When the Torah wrote “if she bears” it includes a child that comes from the side of the belly. This means that because the child will not emerge naturally the loins of the woman are cut open and the child is delivered.

“Maimonides does not here demur to her being well enough to make her purificatory offering” wrote Boss. Another famous commentator on the Mishnah, the fifteenth century Italian Rabbi Ovadiah ben Abraham of Bertinoro also makes the case for surviving a c-section:

יוצא דופן. אשה שפתחו [מעיה] ע״י סם והוציאו העובר לחוץ ונתרפאה:

Through the side of the belly: This means a women whose belly was opened by means of a medicine (סם) and the child was delivered and she survived…

Maimonides didn’t believe a woman could survive

But in fact Maimonides did demur. He demurred a lot. Let’s go back to the back to that Mishnah in Bechorot (8:2) that we cited above: “A baby extracted by means of a caesarean section and one that follows neither is a first-born for inheritance or a first-born to be redeemed from a priest.” (וֹצֵא דֹפֶן וְהַבָּא אַחֲרָיו, שְׁנֵיהֶם אֵינָן בְּכוֹר לֹא לַנַּחֲלָה וְלֹא לַכֹּהֵן). Here is Maimonides:

מה שאפשר להיות בזה שתהא האשה מעוברת משני וולדות ונקרע דופנה ויצא א' מהן ואח"כ יצא השני כדרך העולם ומתה אחר שיצא השני אבל מה שאומרים המגידים שהאשה חיה אחר שקורעים דופנה ומתעברת ויולדת איני יודע לו טעם והוא ענין זר מאד ואין הלכה כרבן שמעון

It may happen that a woman is pregnant with twins, one is delivered by cesarean section, and then the other is delivered normally, and the first child dies after the second is born. But what some say, that a woman can live after her side is cut open and then bear a child, is contrary to reason and utterly absurd…

Notwithstanding the opinion of the great Maimonides, Boss reaches this conclusion:

The texts quoted indicate that the Tannaim assumed that a woman could be fit to offer a sacrifice forty or eighty days after undergoing caesarean section, and that she might be delivered of an infant by a subsequent pregnancy. Internal evidence dates the texts to the second century A.D. and indicates that they were discussions of known possibilities and not of fantasies; the evidence of manuscripts shows that the texts must precede the development of the operation in Europe…The mother's survival is implicit in written passages which are unambiguous on the matter, serious in purpose, and certainly not the subjects of modern amendment.

Cesarean Section Today

You can read the Boss paper here, and decide for yourself if the evidence is persuasive. What is certain is that the cesarean section began as a veterinary procedure. It was once an extremely unusual operation only undertaken as a last ditch effort to save a baby from inside the womb of its dead or dying mother. How things have changed; there are now an estimated 30 million cesarean sections performed around the world each year. In the Dominican Republic, almost 60% of all births are by C-section, and overall they are almost five times more frequent in births in the richest versus the poorest countries. As one news report concluded, when it comes to cesarean section, it’s either too little too late, or too much too soon.

“The skill needed for such an operation implies some general tradition of surgery, and surgery was in fact considerably developed in Talmudic times among the Jews. From the Tannaitic period, the material on surgery is indicative but scanty, but among the Amoraim, who taught between 100 and 300 years later...there was considerable anatomical knowledge and surgical skill...”

— Boss, J. The Antiquity of Caesarean Section with Maternal Survival: The Jewish Tradition. Medical History 1961: 5; 17-31

Niddah 38a ~ How Long Does A Pregnancy Last?

If you have ever stayed up all the way to the end of a Pesach Seder, you will have sung the following:

תשעה מי יודע
תשעה אני יודע
תשעה ירחי לידה

Who knows Nine?

I know nine.

Nine are the months of a Pregnancy.

Well I have some news - it ain’t necessarily so. It all begins on today’s page of Talmud:

נדה לח,א

 אמר שמואל אין אשה מתעברת ויולדת אלא למאתים ושבעים ואחד יום או למאתים ושבעים ושנים יום או למאתים ושבעים ושלשה 

Shmuel says that a woman becomes pregnant and gives birth only after 271 days, which is a full nine months, or after 272 days or after 273 days.

As Rashi explains, nine (thirty day) months is 270 days following intercourse. On day 271, the start of the tenth month of pregnancy, the baby is born. Sometimes though, the egg is not fertilized for 24 or even 48 hours, in which case birth happens on day 272 or 273 after intercourse.

Today’s question is, was Shmuel, the famous second century Babylonian physician-rabbi (and head of the yeshiva of Negardea) actually correct?

“
The length of human gestation varies considerably among healthy pregnancies, even when onset of pregnancy is measured by an accurate marker of ovulation. This variability is greater than suggested by the clinical assignment of a single ‘due date’.”

— Jukic A.M. et al. Length of human pregnancy and contributors to its natural variation Human Reproduction 2013. 28 (10): 2848–2855

The length of gestation calculated by the time from the last menstrual period

Generally speaking, studies that examined the length of gestation have estimated gestational age either by the mother’s last menstrual period (LMP) or by ultrasound, both of which are imperfect measures. Based on the first date of the LMP, the end of gestation is 280 days later. But that is not the length of time to which Shmuel referred. He was very precise, and calculated the duration (or received a tradition that was) based on the number of days post conception, Shmuel assumed conception would be on the date of intercourse, or no no more than two days later.

Estimated Due Date (EDD) Calculator. Based on the standard 280 days after the first day of the mother’s last menstrual period.

The actual median length of gestation

In 2013 a study funded by the National Institutes of Health measured things a little differently. It calculated the length of gestation beginning at ovulation or conception in 125 naturally conceived, singleton live births, and determined the exact date of ovulation and implantation by measuring urinary hormone measurements. What they found was very close to Shmuel’s length of gestation. The median time (which is not the average time) from ovulation to birth was 38 weeks and 2 days, or 268 days. That’s a difference of only two days! That’s strong work from Shmuel, who figured it out without the resources of the National Institutes of Health (annual budget, about $32 billion).

Smoothed distribution of length of gestation (accounting for medical interventions that shortened gestation) derived from 125 singleton live births. Solid line: ovulation-based length of gestation. Dashed line: LMP-based length of gestation. From Jukic A.M. et al. Length of human pregnancy and contributors to its natural variation Human Reproduction 2013. 28 (10): 2848–2855.

There is an important caveat, however. The study found that the gestational length varied by 37 days (even after excluding preterm births or pregnancies with medical conditions). This means that the length of human pregnancies can vary naturally by as much as five weeks, and - this is important- that much of this reflects natural variation.

But other factors can influence the length of a pregnancy. For example, older women deliver later on average, with each year of age adding roughly one day to their pregnancy. And women who had themselves been heavier at their own births had longer gestations, with each 100g in the mother's own birth weight corresponding roughly to a one-day longer pregnancy.

The practice of early pious ones

All of which leads us to question the practice of the early pious ones, as they are called by the Talmud. Today’s page of Talmud describes how this group was so convinced by the tradition that gestation was exactly 270 days that they would only have intercourse on a Wednesday, Thursday or Friday. They did this to avoid the risk of the baby being delivered on the Shabbat, and any desecration of it, albeit legally permitted, that might occur to care for the infant or its mother.

Their thinking went like this: 270 days is 38 complete weeks and four days. This meant that delivery would occur four days later in the week than had conception. So if the baby was conceived on a Wednesday, it would be delivered on a Sunday, or a Monday (if fertilization was delayed by 24 hours) or a Tuesday (if fertilization was delayed by 48 hours.) Similarly, a baby conceived on a Thursday could only be born on a Monday, Tuesday or a Wednesday. A baby conceived on a Friday could only be born on a Tuesday, Wednesday or a Thursday. But if the baby was conceived on a Sunday, Monday or Tuesday, they ran the risk of it being born on a Shabbat.

דתניא חסידים הראשונים לא היו משמשין מטותיהן אלא… מרביעי ואילך

As we know, nature does not always cooperate; gestation may on average be about 270 days after conception, but that is an average (or more precisely a median). Some pregnancies are naturally shorter and some longer. Dr Jukic, the lead author of the paper that recalculated the length of human gestation noted that “natural variability may be greater than we have previously thought.” And that is certainly the case for Shmuel and the early pious ones, who calculated the length of gestation with great precision, but alas, not great accuracy.

Niddah 36 ~ Fever

נדה לו, ב

חלש רב אסי עיילוה בחמימי אפקוה מקרירי עיילוה בקרירי אפקוה מחמימי נח נפשיה דרב אסי

Rav Assi became ill. When he had a fever his chills were relieved, and when he had chills his fever ended. Eventually, Rav Assi died.

We have previously discussed fevers in the Talmud, when we read the tractate Nedarim.

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 here we read that according to Rava, fever is actually beneficial to a person (at least when it does not kill you as it did poor Rav Assi).  Was Rava, a Babylonian sage who died around the year 352 CE, correct when he claimed that a fever might be good for you? He was, as 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 found on Nedarim 41b is scientifically accurate.  Fever is indeed beneficial for the body, though it is a sign that something bad is going on.  Which is what happened on today’s page of Talmud when 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 according to the Soncino translation of today’s passage of Talmud, 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.

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

[Mostly a repost from here.]

Niddah 35b ~ The Zov, and Gonorrhea

נדה לה, ב

אמר רב הונא זוב דומה למי בצק של שעורים זוב בא מבשר המת שכבת זרע בא מבשר החי זוב דיהה ודומה ללובן ביצה המוזרת שכבת זרע קשורה ודומה ללובן ביצה שאינה מוזרת

Rav Huna says: The discharge of ziva is similar to water of barley dough. Whereas the discharge of ziva comes from dead flesh, i.e., when one’s penis is flaccid, semen comes from living flesh, when one’s penis is erect. Moreover, the discharge of ziva is runny, and is similar in appearance to the white of a unfertilized egg. By contrast, semen is viscous, and it is similar in appearance to the white of an egg that is not unfertilized, i.e., a fertilized egg.

The Zov in The Torah...

In Leviticus chapter 15 the laws of the זב – Zov - a man who experiences a discharge from his penis - are outlined.

ויקרא טו, ב–ג

אִישׁ אִישׁ כִּי יִהְיֶה זָב מִבְּשָׂרוֹ זוֹבוֹ טָמֵא הוּא. וזֹאת תִּהְיֶה טֻמְאָתוֹ בְּזוֹבוֹ רָר בְּשָׂרוֹ אֶת־זוֹבוֹ אוֹ־הֶחְתִּים בְּשָׂרוֹ מִזּוֹבוֹ טֻמְאָתוֹ הִוא

When any man has a discharge issuing from his member, he is unclean. The uncleanness from his discharge shall mean the following—whether his member runs with the discharge or is stopped up so that there is no discharge, his uncleanness means this…

If a man experiences this discharge on two days he becomes impure (טמאי), and must undergo a process of spiritual recovery that includes isolation from others and immersion in running water. If he has a third day of penile discharge he is required to bring an offering to the Temple. (The laws differ in their application to a woman who is infected, but the basic idea is the same. To keep it simple, we'll just focus on the male Zov.)

“ אין כל צורך להביא ראיות ומופתים להוכיח, כי במחלה מתדבקת ידועה
Gonorrhoe הכתוב מדבר, במחלה הנקראת אצלינו היום

There is no need to bring any proofs to prove that the verse in the Bible is referring to a well known infection, which today we call Gonorrhoe [sic]...”

— י.ל קצנלסון. התלמוד והכמת הרפואה. הוצאת חיים ברלין תרפ׳ח. 378

...And in the Talmud

The rabbis of the Mishnah thought that if the discharge was due to an external factor, then the person so afflicted did not become a Zov. Here is the list of those external causes of genital discharge, as outlined in Nazir 65b:

נזיר סה, ב

בשבעה דרכים בודקין את הזב עד שלא נזקק לזיבה במאכל ובמשתה במשא ובקפיצה ובחולי ובמראה ובהירהור

A Zov is examined in seven ways…about food and drink [certain foods such as cheese and wine could have caused the discharge], about carrying a load, jumping and illness [strenuous physical activity could also do so], sight and thought [he is asked whether he has been thinking about or looking at women, which could have caused his discharge]…

In modern Hebrew, zivah (זיבה) is the term for gonorrhea, a sexually transmitted disease caused by the bacterial species Neisseria gonorrhoeae.  Preuss, in his famous Biblical and Talmudic Medicine has this to say about the Zov:

“It is clear forthwith that the only illness we know that can be referred to here is gonorrhea” (354).

Abraham Steinberg, in his more recent three volume Encyclopedia of Jewish Medical Ethics, also identifies the disease described in Leviticus as gonorrhea, (though he notes that some rabbis identified the discharge as being sperm, rather than pus. More on that below).  If a Zov is indeed a man suffering from gonorrhea, that would explain “the laws of isolation and impurity in regard to people with flux [=discharge] as being hygienic rules to prevent the spread of the disease” (Vol  II, p452).

More than you wanted to know about gonorrhea

According to the Centers for Disease Control and Prevention, there are about 330,000 new cases of gonorrhea in the US. That makes it the second most common sexually transmitted disease, with first place going to chlamydia- and the two are frequently found together. The World Health Organization estimated a global total of  106 million cases in 2008 (and that’s an increase of 21% compared to 2005).  Gonorrhea is most common in women age 15-19, and infections in women are usually asymptomatic. In contrast, gonorrheal infection in men is nearly always symptomatic, with the most common symptoms being pain on urination (dysuria) and purulent penile discharge. (Think of what comes out of your nose when you get a bad cold. Now think of that coming out of another orifice.)   But gonorrhea is not just a disease of the genital tract. It may involve the eyes, pharynx and anus, and if it is not treated it may (rarely) progress to disseminated disease that includes endocarditis and meningitis. In women, untreated gonorrhea can cause pelvic inflammatory disease and sterility.

While the Zov in Temple times had to remove himself society and hope for an end to the symptoms, in the era of antibiotics things are different. Gonorrhea is generally easy to treat – a single shot of ceftriaxone in the muscle and a swig of oral azithromycin and you are on the mend. The problem is that drug resistant gonorrhea is now emerging worldwide, and consequently some infections are difficult to treat. 

Don't Touch That Chair...

As outlined in the Torah, the Zov imparts ritual impurity to the bed on which he lies and the chair on which he sits. Preuss wrote that “the hygienic value of these regulations… is obvious.” If the disease that is described in the Torah is indeed gonorrhea, well, then we now understand enough to say that the hygienic value of these regulations is, contra Preuss, really not that obvious at all. We now know that you cannot catch gonorrhea from sitting on a chair or lying on a bed that an infected person had touched.  But in fairness, such beliefs were not uncommon even a century age. We’ve had occasion to review the theories prevalent in early twentieth century America about the transmission of gonorrhea. Back then, doctors claimed girls were susceptible to infection from gonorrhea “from everyday nonsexual objects, including their mothers’ hands, bed linens…and toilet seats.” It is hardly surprising, therefore, to read in the Torah, that the Zov contaminates all he touches. But it is not so. You need sexual or oral contact to transmit the disease, (which can also be caught by the innocent new-born baby passing through its mother's infected genital tract).  

Maimonides on the Nature of the Zov

In his Mishneh Torah, Maimonides identified the Zov as suffering from a physical disease – and not a spiritual one [הלכות מחוסרי כפרה 2:1]:

The Zov that is described in the Torah, is a form of semen that results from an infection in the tubes [of the genital tract]. When the discharge of the Zov flows, it does not do forcefully like ejaculate, and there is no pleasure associated with it. Rather it flows passively like dough…

(Maimonides was following the best medicine of his time when he described the discharge as a form of semen. The word gonorrhea is from the Greek roots gone meaning seed and rhein, meaning flow.)

In an era that did not have antibiotics, removing the infected person and isolating him was really all that could be done. Today, we have alternatives: antibiotics to treat the infection, and condoms to prevent its spread.   But we lack the self-reckoning that the infection might encourage. I’ve treated many, many cases of gonorrhea, and every patient encounter was centered on diagnosing and treating the infection. I do not recall any discussions about changing the behavior that allowed infection to take place in the first place. Perhaps I bear responsibility for not having had that conversation, and perhaps I should have followed the example of the biblical text. That text was mistaken in some of the details of how the disease is spread, but accurate in requiring the Zov to leave his social network, and perhaps reflect on the kind of behaviors that led to his infection in the first place.

[Repost from here.]