Berachot 22b ~ Urinary Incontinence

ברכות כב,ב

תָּנוּ רַבָּנַן: הָיָה עוֹמֵד בִּתְפִלָּה וּמַיִם שׁוֹתְתִין עַל בִּרְכָּיו — פּוֹסֵק עַד שֶׁיִּכְלוּ הַמַּיִם וְחוֹזֵר וּמִתְפַּלֵּל. לְהֵיכָן חוֹזֵר? רַב חִסְדָּא וְרַב הַמְנוּנָא, חַד אָמַר חוֹזֵר לָרֹאשׁ, וְחַד אָמַר: לְמָקוֹם שֶׁפָּסַק

The Sages taught in a baraita: One who was standing in prayer when, for some reason, urine is flowing on his knees, he must interrupt his prayer until the urine ceases, and then resume praying. The Gemara, asks: To where in the prayer does he return when he resumes his prayer? Rav Chisda and Rav Hamnuna disagreed; one said: He must return to the beginning of the prayer, and the other said: He must return to the point where he stopped.

It’s OK to talk about it - The Talmud did

Worldwide, it is estimated that over 120 million men and over 300 million women have experienced a degree of urinary incontinence. And the problem is growing rapidly. We may shy away about speaking about it, but let’s take a lesson from today’s page of Talmud, which took the first step: it acknowledged that the problem exists.

Estimated numbers of those with urinary incontinence. From Irwin DE. et al. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU International 2011:108; 1132-1139.

Prevalence and Causes of Urinary Incontinence in men

Today, incontinence in men is far less common than in women, and this would have been true in talmudic times as well. According to a 2009 survey of the field, the estimated prevalence of urinary incontinence in men varies from 11% among those aged 60 to 64 years to 31% in older men, and from 16% among white men to 21% among African American men. Daily urinary incontinence was reported by 30%-47% and weekly incontinence by 15%-37% of community-dwelling men (that is, men who do not live in a nursing home). Here is what we know about the risk factors for male urinary incontinence:

Things that are associated with an increased risk of urinary incontinence:

Age, body weight, poor health, depression, diabetes, use of diuretic medications, cognitive impairment, memory problems, urinary tract infections, prostate disease, prostate surgery (which would not have been a problem during talmudic times),

Things that aren’t associated with an increased the risk:

Ethnicity, education, marital status, alcohol, smoking,

Things that are associated with an decreased risk:

Physical activity, coffee

Prevalence and Causes of Urinary Incontinence in women

Urinary incontinence (UI) is far more common in women across the age span, as you can see in the graph below. In a review of population studies from numerous countries, the prevalence of UI ranged from about 5% to 70%, with most studies reporting a prevalence of any UI in the range of 25–45%. Even in women who have not had children, about 17% have experienced UI. There appears to be a degree of genetics involved, since having a first-degree female family member with stress UI increases the risk for a woman becoming afflicted by the same disorder.

The main risk factor for women is pregnancy. According to a 2019 review of the topic, “pregnancy in itself, independent of labor and delivery practices, seems to be a risk factor for postpartum UI, especially if the incontinence started during the first trimester. During pregnancy, the prevalence of UI increases with gestational age so that more than half of all women report UI during the third trimester.” The good news is that in uncomplicated courses of pregnancy and labor, UI usually declines rapidly during the first 3months following childbirth, which suggests that most symptoms are part of a normal pregnancy and delivery.

Comparison of the prevalence of urinary incontinence in women and men of the same age resident in the same urban population. From Milso, I. Gyhaged M. The Prevalence of Urinary Incontinence. Climacteric 2019: 22 (3); 217-222.

Can you Pray while attached to a Urinary Catheter?

From here.

A Foley catheter is a tube that extends from the bladder through the urethra and into a bag. There are many reasons that a person might need to be attached to one, like following abdominal surgery or a complication of childbirth. May a Jew pray but while attached to this device?

Among the first rabbis to consider the question of the Foley catheter and prayer was the late Eliezer Waldenberg, (d. 2006) who was the head of the Jerusalem Rabbinic Court (Bet Din). In a 1964 responsa he ruled that a person may indeed pray while attached to a Foley and a urine collection bag, and he cited today’s page of Talmud. Among his reasons was a sensitivity to the need of the patient to be able to pray, and the fact that the Talmud did not forbid prayer within four amot of urine, (unlike the ruling regarding excrement or a bad smell, which we will address in the next installment of Talmudology). In his responsa he reviewed multiple possible objections to his ruling, which is why it stretched to twelve pages (!), and he concluded that so long as the collection bag was covered during prayer, the patient may not only pray, but wear a prayer shawl and phyalcteries (a tallit and tefillin). Rav Waldenberg’s ruling is a reminder that urinary incontinence and a prayerful life can peaceably co-exist.

Berachot 20a ~ Rabbi Yochanan, Maternal Imprinting, And The Woman Who Gave Birth To Rabbits

In today’s page of Talmud we meet the great Rabbi Yochanan where you would have least expected him: sitting outside the mikveh (ritual bathhouse), waiting for the married women who used it to pass him by. And notice him.

ברכות כ,ב

רַבִּי יוֹחָנָן הֲוָה רְגִיל דַּהֲוָה קָא אָזֵיל וְיָתֵיב אַשַּׁעֲרֵי דִטְבִילָה. אֲמַר: כִּי סָלְקָן בְּנוֹת יִשְׂרָאֵל וְאָתְיָין מִטְּבִילָה, מִסְתַּכְּלָן בִּי, וְנֶהֱוֵי לְהוּ זַרְעָא דְּשַׁפִּירֵי כְּווֹתִי

Rabbi Yochanan would go and sit by the entrance to the ritual bath. He said to himself: When Jewish women come up from their immersion [after their menstruation,] they should see me first so that they have beautiful children like me

Rabbi Yochanan’s actions were not really as bizarre as it might first seem. He believed that what a mother sees around the time she conceives will affect her offspring. This belief is called maternal imprinting or psychic maternal impressions, or mental influence, or maternal imagination, or (my favorite) maternal fancy. It was widespread in the ancient world, and not uncommon in the early modern one. (Maternal imprinting also has a very modern use, when it refers to the way in which an individual phenotype is determined by the environment and genotype of its mother. But that’s most certainly not the phenomena alluded to in the Talmud.)

“A surprising large number of people, in different cultures and over many centuries, have believed that a woman who imagines or sees someone other than her sexual partner at the moment of conception may imprint that image upon her child- thus predetermining its appearance, character or both.”

— Doniger W. Spinner G. Female Imaginations and Male Fantasies in Parental Imprinting. Daedalus 127 (1), No. 1, Science in Culture (Winter, 1998). 97-129

OTHER Maternal Imprinting in jewish sources

The earliest mention of maternal imprinting is the story of Yaakov and his division of the goats he watched for his uncle Lavan (Gen 30:25-43, 31:1-12).  Yaakov asked for all the speckled goats as wages, while Lavan would get to keep the plain ones.  Yaakov then took several wooden rods from which he peeled the bark, and left these now speckled rods in front of a water trough.   The female goats stared at the rods while they are drinking and mating, and this in turn caused them to give birth to speckled kids, all of which Yaakov got to keep. That's how maternal imprinting works. And that's what Rav Yochanan was doing.  

The Midrash and Talmud are replete with examples of maternal imprinting. Here is another example, this one to do with cows.

The Parah Adumah

The Parah Adumah, the red heifer, was used in several ceremonies in the Temple. It was, however, a rare animal. In the Talmud (Avodah Zarah 24a) there is a discussion as to whether a red heifer born to an idol-worshipper could be used. The concern was that the heifer, or one of its ancestors, might have been used by the idol-worshipper for beastiality. Should this have happened, it was forbidden to use the red heifer as a sacrifice. The Talmud relates that in fact an idol-worshipper called Daba ben Natina had sold a red heifer to his Jewish neighbors. To insure that the heifer's mother had not been the object of beastiality, the pregnant cow had been watched "משעה שנוצרה" – from the moment it was impregnated. Then comes an obvious question: how could anyone be sure that the cow was indeed pregnant with a red calf which would warrant safeguarding her? Perhaps the calf would be born another color? 

Here is the answer: "כוס אדום מעבירין לפניה בשעה שעולה עליה זכר" -"while the mother was copulating, the farmer would show her a red cup." That would insure that she would give birth to a little red calf that would grow into a bigger red heifer. 

Rabbi Akiva and the King of Arabia

Here is another example, in which Rabbi Akiva used maternal imprinting to save a king from a rather embarrassing situation:

מדרש תנחומא נשה, ז

מַעֲשֶׂה בְּמֶלֶךְ הָעַרְבִים שֶׁשָּׁאַל אֶת רַבִּי עֲקִיבָא, אֲנִי כּוּשִׁי וְאִשְׁתִּי כּוּשִׁית וְיָלְדָה לִי בֵּן לָבָן, הוֹרְגָהּ אֲנִי, שֶׁזָּנְתָה תַּחְתַּי. אָמַר לוֹ: צוּרוֹת בֵּיתְךָ שְׁחֹרוֹת אוֹ לְבָנוֹת. אָמַר לוֹ: לְבָנוֹת. אָמַר לוֹ: כְּשֶׁהָיִיתָ עוֹסֵק עִמָּהּ, עֵינֶיהָ נָתְנָה בְּצוּרוֹת לְבָנוֹת וְיָלְדָה כַּיּוֹצֵא בָּהֶם. וְאִם תָּמֵהַּ אַתָּה בַּדָּבָר, לְמַד מִן צֹאנוֹ שֶׁל יַעֲקֹב, שֶׁמִּן הַמַּקְלוֹת הָיוּ מִתְיַחֲמוֹת, שֶׁנֶּאֱמַר: וְיִחֲמוּ הַצֹּאן אֶל הַמַּקְלוֹת (בראשית ל, לט). וְהוֹדָה מֶלֶךְ הָעַרְבִים וְשִׁבַּח לְרַבִּי עֲקִיבָא

A king of Arabia once asked Rabbi Akiva, “I am black and my wife is black, yet she gave birth to a white child. Shall I have her executed for infidelity?” Rabbi Akiva responded by inquiring if the statues in his house where white or black. He said to Rabbi Akiva that they were white.  Rabbi Akiva explained to the king that during conception his wife's eyes were fixed on the white statues and so she bore a white child...the king agreed and praised Rabbi Akiva

Maternal Imprinting in Greek Thought, and Beyond

In 1998 Professors Wendy Doniger and Gregory Spinner published perhaps the most comprehensive review of imprinting, in a paper titled Misconceptions: Female Imaginations and Male Fantasies in Parental Imprinting. They noted Empedocles, who lived in the fifth century BCE, wrote that 

the fetuses are shaped by the imagination of the women around the time of conception. For often women have fallen in love with statues of men, and with images, and have produced offspring which resemble them.

Soranus of Ephesus, another Greek physician who lived in Rome and Alexandria (and who was a contemporary of Rabbi Yochanan) firmly believed in imprinting, both for animal husbandry and in humans:

Some women, seeing monkeys during intercourse, have borne children resembling monkeys. The tyrant of the Cyprians, who was misshapen, compelled his wife to look at beautiful statues during intercourse and became the father of well-shaped children; and horse-breeders, during covering, place noble horses in front of the mares.

Jumping forward a millennium, in 1282 it was reported that an infant was born with hair and claws like a bear. The Pope at the time "straightway ordered the destruction of all pictures of bears in Rome." This story is from John Ballantyne, a Scottish physician who in 1897 published Teratogenesis: an Inquiry into the Causes of Monstrosities. According to Ballantyne, in the seventeenth century, the belief in maternal impressions "reigned supreme."  Here is another example of the kind of thing it led to:

And then things get even weirder:

In 1726 the matter of maternal impressions was brought still more prominently before the profession and the public in England in connexion [sic] with the notorious case of an "Extraordinary Delivery of Rabbets" which was alleged to have occurred in the case of Maria Tofts of Godlyman in Surrey; she had a great longing for 'Rabbets"in early pregnancy.

Pregnancy and the fetus

Maternal imprinting is a rather extreme form of what we all know to be true; that what happens to a pregnant mother affects the fetus she is carrying. Here are two of the countless examples of this.  If a mother drinks enough alcohol while pregnant, the fetus will be born with Fetal Alcohol Syndrome. This syndrome includes facial abnormalities, growth delays, abnormal development of organs, and reduced immunity.  If a mother is infected with measles (rubella) early in pregnancy, the baby will likely be born with congenital rubella syndrome, which includes cataracts, congenital heart disease and brain damage.  But these examples do not imply that a woman who eats eggs will have children with large eyes or that a woman who eats an esrog will have fragrant children, as the Talmud (Ketuvot 60b) declares. Some things a pregnant mother does will have a huge effect on the fetus she carries. Some won't have any affect at all.  

John Ballantyne, the Scottish physician concluded his book noting, as we have, that of course there are some things a mother does that will affect fetal outcome. "To this extent" he wrote, "I believe in the old doctrine of maternal impressions; this is, I think, one grain of truth in an immense mass of fiction and accidental coincidence."

“The history of the belief in maternal impressions is one of great antiquity...it is also one of practically world-wide distribution. [It can be found in] such far apart lands as India, China, South America, Western Asia and East Africa..the Esquimaux, the Loango negros, and the old Japanese.”

— John William Ballantyne. Teratogenesis: an Inquiry into the Causes of Monstrosities. Edinburgh, Oliver & Boyd 1897. 24

More on Rabbi Yochanan’s Beauty

In tractate Bava Metziah (84a) the Talmud notes that Rabbi Yochanan was indeed a very handsome man - both by his own account, and that of others:

אמר רבי יוחנן אנא אישתיירי משפירי ירושלים האי מאן דבעי מחזי שופריה דרבי יוחנן נייתי כסא דכספא מבי סלקי ונמלייה פרצידיא דרומנא סומקא ונהדר ליה כלילא דוורדא סומקא לפומיה ונותביה בין שמשא לטולא ההוא זהרורי מעין שופריה דר' יוחנן 

Rabbi Yochanan said: I alone remain of the beautiful people of Jerusalem. 

The Gemara continues: One who wishes to see something resembling the beauty of Rabbi Yochanan should bring a new, shiny silver goblet from the smithy and fill it with red pomegranate seeds and place a diadem of red roses upon the lip of the goblet, and position it between the sunlight and shade. That luster is a semblance of Rabbi Yochanan’s beauty.

And never shying away from calling things as he saw them, Rav Pappa had this to say about another beautiful feature of Rav Yochanan

אמר רב פפא איבריה דרבי יוחנן כחמת בת חמשת קבין ואמרי לה בת שלשת קבין

The organ of Rabbi Yochanan was the size of a jug of five kav, and some say it was the size of a jug of three kav.

Well thanks for that. Rabbi Yochanan’s beauty was so great that it attracted Reish Lakish, then a highwayman, to abandon his ways and turn to the study of Torah.

יומא חד הוה קא סחי ר' יוחנן בירדנא חזייה ריש לקיש ושוור לירדנא אבתריה אמר ליה חילך לאורייתא אמר ליה שופרך לנשי א"ל אי הדרת בך יהיבנא לך אחותי דשפירא מינאי קביל עליה בעי למיהדר לאתויי מאניה ולא מצי הדר 

The Gemara relates: One day, Rabbi Yochanan was bathing in the Jordan River. Reish Lakish saw him and jumped into the Jordan, pursuing him. At that time, Reish Lakish was the leader of a band of marauders. Rabbi Yochanan said to Reish Lakish: “Your strength is fit for Torah study.” Reish Lakish said to him: “Your beauty is fit for women.” Rabbi Yochanan said to him: “If you return to the pursuit of Torah, I will give you my sister in marriage, who is more beautiful than I am.”

Passing on what is really important

The story of Rabbi Yochanan sitting outside the mikveh doing some maternal imprinting is told twice in the Babylonian Talmud: once in today’s page of Talmud and a second time in Bava Metziah. In that second telling the Talmud adds an additional phrase, one not found in today’s passage.

בבא מציעא פד, א

ר' יוחנן הוה אזיל ויתיב אשערי טבילה אמר כי סלקן בנות ישראל מטבילת מצוה לפגעו בי כי היכי דלהוו להו בני שפירי כוותי גמירי אורייתא כוותי

Rabbi Yochanan would go and sit by the entrance to the ritual bath. He said to himself: When Jewish women come up from their immersion [after their menstruation,] they should see me first so that they have beautiful children like me, and as learned of the Torah as I am…

In this other version of the story, Rav Yochanan was not only interested in passing on his physical beauty. He was just as interested in passing on the Torah wisdom that he had accumulated. And despite what he and others believed, passing that on takes a lot more than a glancing look at a rabbi. However attractive he might have been.

---

[Special thanks to Rabbi Dr. Eddie Reichman, medical historian and Talmudology reader who has been researching maternal imprinting for years, and was kind enough to share his material. Mostly a repost from here.]

Berachot 10b ~ The Snake as a Symbol of Healing

In much of the Talmud snakes are associated with coma, convulsions and death.  But occasionally - and paradoxically -  they are sometimes associated with those healing, and those who heal. Let’s begin with today’s page of Talmud.

ברכות י, א

תָּנוּ רַבָּנַן: שִׁשָּׁה דְבָרִים עָשָׂה חִזְקִיָּהוּ הַמֶּלֶךְ, עַל שְׁלֹשָׁה הוֹדוּ לוֹ, וְעַל שְׁלֹשָׁה לֹא הוֹדוּ לוֹ 

עַל שְׁלֹשָׁה הוֹדוּ לוֹ: גָּנַז סֵפֶר רְפוּאוֹת — וְהוֹדוּ לוֹ. כִּתֵּת נְחַשׁ הַנְּחשֶׁת — וְהוֹדוּ לוֹ. גֵּירַר עַצְמוֹת אָבִיו עַל מִטָּה שֶׁל חֲבָלִים — וְהוֹדוּ לוֹ

The Sages taught: King Hezekiah performed six innovative actions. With regard to three the Sages agreed with him, and with regard to three they did not agree with him.

With regard to three actions the Sages agreed with him:  He suppressed the Book of Remedies, and they agreed with him.  He ground the copper snake through which miracles were performed for Israel (Numbers 21:9), destroying it because it had been used in idol worship (II Kings 18:4), and they agreed with him…

You might have heard that the symbol for healing, that snake (or is it two snakes?) wrapped around a central pole, came from the episode to which today’s page of Talmud is referring. In Numbers 21 the Children of Israel complain that “there is no bread and no water, and we have come to loathe this miserable food.” So God sends fiery snakes “that bit the people and many of the Israelites died.” Let’s let the Good Book tell the rest:

7-10 :במדבר כא

וַיָּבֹא הָעָם אֶל־מֹשֶׁה וַיֹּאמְרוּ חָטָאנוּ כִּי־דִבַּרְנוּ בַיהוָה וָבָךְ הִתְפַּלֵּל אֶל־יְהוָה וְיָסֵר מֵעָלֵינוּ אֶת־הַנָּחָשׁ וַיִּתְפַּלֵּל מֹשֶׁה בְּעַד הָעָם׃

וַיֹּאמֶר יְהוָה אֶל־מֹשֶׁה עֲשֵׂה לְךָ שָׂרָף וְשִׂים אֹתוֹ עַל־נֵס וְהָיָה כָּל־הַנָּשׁוּךְ וְרָאָה אֹתוֹ וָחָי׃

וַיַּעַשׂ מֹשֶׁה נְחַשׁ נְחֹשֶׁת וַיְשִׂמֵהוּ עַל־הַנֵּס וְהָיָה אִם־נָשַׁךְ הַנָּחָשׁ אֶת־אִישׁ וְהִבִּיט אֶל־נְחַשׁ הַנְּחֹשֶׁת וָחָי׃

וַיִּסְעוּ בְּנֵי יִשְׂרָאֵל וַיַּחֲנוּ בְּאֹבֹת׃ 

The people came to Moses and said, “We sinned by speaking against the LORD and against you. Intercede with the LORD to take away the serpents from us!” And Moses interceded for the people.

Then the LORD said to Moses, “Make a seraph figure and mount it on a standard. And if anyone who is bitten looks at it, he shall recover.” 

Moses made a copper serpent and mounted it on a standard; and when anyone was bitten by a serpent, he would look at the copper serpent and recover.

The Israelites marched on and encamped at Oboth.

But you’d be wrong. In fact the episode in the Bible and the fiery snakes that cured has nothing to do with this medical symbol of healing.

“From the beginning of the 17th century, the figure of Asklepios began appearing on medical medals and calling cards. The same pattern seen in antiquity emerged: The symbol was used only in a medical context, whereas the caduceus, although used by some medical organizations, was associated with other fields, especially commerce, communications, chemistry, and pharmacy”

— Robert A. Wilcox. Emma M. Whitham. The Symbol of Modern Medicine: Why One Snake Is More Than Two. Ann Intern Med. 2003;138:673-677.

SNAKES THAT HEAL

Here is the cover of Fred Rosner's book; notice what looks like two snakes wrapped around a winged pole.  Compare that image with the insignia of the US Army Medical Corps below.

The image you see is the caduceus, the rod carried by the Greek god Hermes (known as Mercury when he was in Rome). But in fact this double-snake flying-rod has nothing to do with healing, and is erroneously -though very widely- used as a medical emblem.  As an article in the Annals of Internal Medicine points out, the adoption of the double-snaked caduceus of Hermes - at least in the US - is likely due to its having been used as a watermark by the prolific medical publisher John Churchill.   

The correct mythological association is with the Staff  of Asklepios, the ancient Greco-Roman god of medicine. The opening lines of the Hippocratic Oath clearly reveal the central role occupied by Asklepios (and his mythologic daughters, Hygieia and Panakeia,) in the hearts and minds of the ancients: “I swear by Apollo Physician and Asklepios and Hygieia and Panakeia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgement this oath and this covenant . . .”

In one legend, a snake placed some herbs into the mouth of another serpent that Asklepios had killed, and the dead snake was restored to life.  As a mark of respect, Asklepios adopted as his emblem a snake coiled around his staff.  While the US Army Medical Corps uses the caducues as its badge, on its regimental flag the US Army Medical Command uses the more appropriate single snaked staff. Oh, and a rooster.  

U.S. Army Medical Command Regimental Flag. Don't ask about the rooster...

Fortunately, the Israel Defense Forces clearly know a caduceus from an Asklepios. They adopted the correct Greco-Roman mythological symbol for the medical unit of the first Jewish army in 2,000 years.

The Greeks may have had their tradition, but we have ours. And as the Midrash notes, in ours, it is never the snake that heals.

“עשה לך שרף ושים אותו על נס, והיה כל הנשוך וראה אותו וחי. וכי נחש ממית או נחש מחיה? אלא בזמן שישראל מסתכלין כלפי מעלה ומשעבדין את לבם לאביהן שבשמים היו מתרפאים, ואם לאו היו נימוקים...

”Make a fiery snake and place it on a pole, and it will be that anyone who is bitten will look at it and live” [Numbers 21:8] But is a snake the source of life and death? Rather, the verse means that when Israel looked up and submitted their heart to their Father in Heaven, they were healed, but if they did not do so, they perished.”

— Mishnah Rosh Hashanah 3:8

[A repost from here.]

Berachot 8a ~ What is Askera (And Did It Kill Rabbi Meir Shapiro of Lublin?)

In this page of Talmud there is a discussion of ways in which death can come. Which form of death is the most painful?

ברכות ח,א

Roz Chast. The New Yorker, August 6, 2001

תַּנְיָא נָמֵי הָכִי: תְּשַׁע מֵאוֹת וּשְׁלֹשָׁה מִינֵי מִיתָה נִבְרְאוּ בָּעוֹלָם, שֶׁנֶּאֱמַר: ״לַמָּוֶת תּוֹצָאוֹת״, ״תּוֹצָאוֹת״ בְּגִימַטְרִיָּא הָכִי הָווּ. קָשָׁה שֶׁבְּכֻלָּן — אַסְכָּרָא, נִיחָא שֶׁבְּכֻלָּן — נְשִׁיקָה. אַסְכָּרָא דָּמְיָא כְּחִיזְרָא בִּגְבָבָא דְעַמְרָא דִּלְאַחוֹרֵי נַשְׁרָא, וְאִיכָּא דְאָמְרִי כְּפִיטּוּרֵי בְּפִי וֶשֶׁט, נְשִׁיקָה דָּמְיָא כְּמִשְׁחַל בִּנִיתָא מֵחֲלָבָא

It was also taught in a baraita: Nine hundred and three types of death were created in the world, as it is stated: “Issues [totzaot] of death,” and that, 903, is the numerical value [gimatriya] of totzaot. The most difficult of all these types of death is croup [askara], while the easiest is the kiss of death. Croup is like a thorn entangled in a wool fleece, which, when pulled out backwards, tears the wool. Some say that croup is like ropes at the entrance to the esophagus, which would be nearly impossible to insert and excruciating to remove. The kiss of death is like drawing a hair from milk. One should pray that he does not die a painful death.

The question we will address is what, precisely, is the condition known as askera?

The Koren Talmud cited above, translates askera as croup. So does the Soncino Talmud, both presumably following Marcus Jastrow’s dictionary which translates it as “choking or croup.” Jastrow cites Psalm 63:12, where another form of the work (yisoker) is used:

וְהַמֶּלֶךְ יִשְׂמַח בֵּאלֹהִים יִתְהַלֵּל כָּל־הַנִּשְׁבָּע בּוֹ כִּי יִסָּכֵר פִּי דוֹבְרֵי־שָׁקֶר׃ 

But the king shall rejoice in God; all who swear by Him shall exult, when the mouth of liars is stopped.

However the Schottenstein English (and Hebrew) Talmud leave the term untranslated, and note in a footnote that “Askera is identified with diphtheria, a disease that primarily infects the throat. In the days of the Talmud, it was feared as one of the most horrible of maladies, a disease that often leads to a ghastly death.”

There are three diseases that might fit the description of askera: diphtheria, epiglottitis and quinsy. They also fit the description of another talmudic condition called sironechi (סרונכי). The great scholar of talmudic medicine Julius Preuss wrote that “it is likely that the illness known as serunke or sirvanke is similar to the sickness askara.” We have discussed sironechi elsewhere, and Preuss was correct; from their descriptions it is simply not possible to distinguish askera from sironechi. So what are the possibilities?

Diphtheria

Child infected with diphtheria. Photo from the CDC.

Diphtheria is caused by Corynebacterium diphtheriae. Infection leads to weakness and fever, followed by swelling in the throat which gradually becomes covered in a thick grey membrane.  If the choking doesn't kill the victim, toxins released by the bacteria may finish him off.  According to the Centers for Disease Control and Prevention, in 1921 there were over 200,000 cases of diphtheria in the US, and over 15,000 deaths. Diphtheria is still found in the developing world, especially in parts of Africa and India, and the World Health Organization estimates that there were over 7,000 cases worldwide in 2014.

Like most physicians in the US, I've never seen a case (or met someone who has seen a case, or met someone who has met someone...) because, thanks to widespread vaccination, the disease here has been almost completely eradicated.  Diphtheria may certainly kill its victim by suffocation, so it is a reasonable choice to identify this with askera.

EPIGLOTTITIS

Although none of the English translations suggest epiglottis as a possible translation for askera, it is an infection that certainly may fit.  The disease is most commonly caused by Haemophilus influenzae type b, and results in swelling of the epiglottis, which is a flap of tissue that covers the larynx (also known to non-medically trained personnel as the voice box). It is your epiglottis that moves over the voice box every time you swallow, preventing food from entering your trachea and lungs. In acute epiglottitis, that flap of skin and the surrounding tissues may become swollen to such a degree that breathing becomes impossible, and the victim suffocates.  Thankfully, this disease is now extremely unusual in developed countries since there is an effective vaccine against it. In fact I can't recall having seen a single case of it. Because of the way in which the disease causes the airway to become occluded, epiglottis is also a good candidate for the condition described as askera.

QUINSY

Quinsy is an uncommonly used word that refers to an inflammation of the tonsils.  It is a complication of what Americans tend to call Strep throat, and what I grew up in London calling tonsillitis. It is most commonly caused by a bacteria known as Group A beta-hemolytic Streptococcus, and most of you reading this will have had “strep throat” or seen it in a family member. Today it is easily treated with antibiotics, but one of its rare complications  is a peri-tonsillar abscess, sometimes called quinsy.  In this condition an abscess forms at the back of the mouth in the tonsils, which bulge forward.  When this occurs, the treatment is to lance the abscess.  I've treated hundreds of cases of strep throat and many cases of peri-tonsillar abscess, and the condition never causes suffocation - though it could in theory.  So this makes it a possible but unlikely candidate as the condition known as askara (or sinonechi for that matter).

BUT NOT CROUP 

One thing is certain. Askera is not croup, which is good news for those of you with young children, since it is a common disease during these winter months. Croup is a viral infection of the trachea and bronchi, and leads to a horrible barking cough and some asthma-like symptoms. It is a self-resolving condition, and the symptoms are easily treated by taking the child out into the cold air, or into the bathroom where a shower is giving off steam. Either way it is very, very, very, unlikely to lead to a life threatening condition. So askera is not croup.

“No case of diphtheria is unattended by danger. However mild the case may seem at the commencement, death may end it. Never be off your guard.”

— William Jenner. Diphtheria: Its symptoms and treatment. London: Walton & Maberly 1861. p62.

Pity the Poor Children

Whatever it is might be called today, askera was a terrible disease that was especially deadly in children. So much so that according to the Talmud, the danger from this disease is hinted at in the very opening words of the Torah that describes creation.

בראשית א, יד

וַיֹּאמֶר אֱלֹהִים יְהִי מְאֹרֹת בִּרְקִיעַ הַשָּׁמַיִם לְהַבְדִּיל בֵּין הַיּוֹם וּבֵין הַלָּיְלָה וְהָיוּ לְאֹתֹת וּלְמוֹעֲדִים וּלְיָמִים וְשָׁנִים׃ 

God said, “Let there be lights in the expanse of the sky to separate day from night; they shall serve as signs for the set times—the days and the years.”

Rashi makes the following comment on this verse:

יהי מארת. חָסֵר וָי"ו כְּתִיב, עַל שֶׁהוּא יוֹם מְאֵרָה לִפֹּל אַסְכָּרָה בַּתִּינוֹקוֹת, הוּא שֶׁשָּׁנִינוּ בְּד' הָיוּ מִתְעַנִּים עַל אַסְכָּרָה שֶׁלֹּא תִפֹּל בַּתִּינוֹקוֹת

The word is written without the ו after the א (so that it may be read מארת, cursed), because it is a cursed day when children are liable to suffer from askera. In reference to this we read (in Taanit 27b): On the fourth day of the week they used to fast to avert askera from the children

Rashi here is referencing the Talmud in Taanit (27b), which describes the tasks of the townspeople who remained behind when their local Cohanim went to serve in the Temple in Jerusalem. These non-priests had a very specific askera-oriented task:

ואנשי מעמד מתכנסין לבית הכנסת ויושבין ד' תעניות בשני בשבת בשלישי ברביעי ובחמישי בשני על יורדי הים בשלישי על הולכי מדברות ברביעי על אסכרא שלא תיפול על התינוקות 

And meanwhile, the members of the non-priestly watch remained in their towns and would assemble in the synagogue and observe four fasts: On Monday of that week, on Tuesday, on Wednesday, and on Thursday. On Monday they would fast for seafarers, that they should be rescued from danger, as the sea was created on Monday. On Tuesday they would fast for those who walk in the desert, as the dry land was created on Tuesday. On Wednesday they would fast over askera, that it should not befall the children…

Yes, children are at greater risk

Whatever the precise agent, it is interesting to note that there is good reason to especially fear these diseases in children. This is because, proportionally, the trachea of a child is of much lower diameter than it is in an adult. As a consequence, the same amount of soft tissue swelling around the trachea will threaten the airway of a child far more rapidly.  So, for example, “1 mm of swelling in the normally 4-5mm diameter of the trachea of the newborn will reduce the cross sectional area by 75% and will increase the resistance to airflow sixteen-fold. In comparison, the same 1mm of swelling in am adult would decrease the cross-sectional area of the trachea by only 44% and would increase the resistance to airflow by only threefold.” Askera was a child killer.

Askera as the punishment for Lashon Hara- and a lot else besides

Elsewhere in the Talmud, askera is described as the result of the sin of speaking gossip, known as lashon hara. But it also occurs because of many other sins:

שבת לג, א–ב

תנו רבנן אסכרה באה לעולם על המעשר רבי אלעזר ברבי יוסי אומר על לשון הרע אמר רבא ואיתימא רבי יהושע בן לוי מאי קראה והמלך ישמח באלהים יתהלל כל הנשבע בו כי יסכר פי דוברי שקר

כשנכנסו רבותינו לכרם ביבנה היה שם רבי יהודה ורבי אלעזר ברבי יוסי ורבי שמעון נשאלה שאלה זו בפניהם מכה זו מפני מה מתחלת בבני מעיים וגומרת בפה נענה רבי יהודה ברבי אלעאי ראש המדברים בכל מקום ואמר אף על פי שכליות יועצות ולב מבין ולשון מחתך פה גומר נענה רבי אלעזר ברבי יוסי ואמר מפני שאוכלין בה דברים טמאין דברים טמאים סלקא דעתך אלא שאוכלין בה דברים שאינן מתוקנים נענה רבי שמעון ואמר בעון ביטול תורה

The Sages taught: Askara comes to the world as punishment for neglecting to separate tithes. Rabbi Elazar, son of Rabbi Yosei, says: Askara comes as punishment for slander…

Rabbi Elazar, son of Rabbi Yosei, responded and said: This disease ends in the mouth because one eats non-kosher things. They immediately wondered about this: Does it enter your mind to say that askara is caused by eating non-kosher food? Are those who eat non-kosher food so numerous? Rather, it comes as a punishment for eating foods that were not ritually prepared, i.e., were not tithed. Rabbi Shimon responded and said: This disease comes as a punishment for the sin of dereliction in the study of Torah.

According to the Rav Nachman (Yevamot 62b), the 24,000 students of Rabbi Akiva who died in plague died from askera, as did the spies who brought back a bad report about the Land of Israel (Sotah 35a).

The Death of Rabbi Meir Shapiro, Founder of the daF Yomi Program

In 1994, Professor Prof. Yeshayahu Nitzan from the Faculty of Life Sciences at Bar Ilan University wrote about the death of the founder of the Daf Yomi cycle, Rabbi Meir Shapiro of Lublin.

כדאי להזכיר, כי הרב מאיר שפירא ז'ל מלובלין, חמייסד וראש ישיבת ’חכמי לובלין’ המפורסמת, והוגה רעיון לימוד ’הדף היומי’, נפטר לפתע בגיל 47 מדיפתריה

We should note that Rabbi Meir Shapiro of Lublin, of blessed memory, who founded and led the famous Yeshivah “Chachmei Lublin,” and who established the “daf hayomi” cycle of study, died suddenly, at the age of 47, from diphtheria.

Although Professor Nitzan is an expert in infectious diseases, he did not cite any supporting evidence, and other sources (also without citing supporting evidence) claim that Rabbi Shapiro died from typhus. There is an apparent eyewitness account of the death of Rabbi Shapiro, which was written by his student, Yehoshua Baumol. Baumol, who was murdered in the Holocaust, wrote his account in Yiddish in 1934, a year after the episode. The manuscript was translated into English by Charles Wengrow and published by Feldheim in 1994 as A Blaze in the Darkening Gloom: The Life of Rav Meir Shapiro. Here is an excerpt.

The hour of night grew later and later. On a piece of paper he asked that he be shown all the prescriptions which the doctors had written. When they were handed him, he went through them and selected the one for a preparation to cleanse the throat and the respiratory organs and he asked that a new supply be gotten for him. Every few minutes he kept washing his hands while his mind was obviously immersed in distant thoughts. The evident struggle that he had to make to draw breath was heartbreaking. One could feel the frightful, racking agony that he had to undergo to try to get a bit of air into his lungs, and try as he would, he kept failing, because the channels were blocked.

The respiratory distress that Rabbi Shapiro experienced could have been due to any number of conditions and there is nothing in this account that points to any specific etiology. It could have been pneumonia, or typhus, of diphtheria, or even influenza. If it were diphtheria, that would mean that the founder of the Daf Yomi movement died from a disease that the Talmud associates with a punishment for lashon hara or eating non-tithed foods, or, most inappropriately of all, a dereliction in the study of Torah.

There is a lesson here. Ascribing a spiritual meaning to personal difficulties is a long Jewish tradition. But one should never ascribe such meaning to explain tragedies that may befall others. Rabbi Shapiro might have agreed.