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:
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:
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).
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.
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.
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.”
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.”
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.
