Yevamot 64b ~ Urinary Tract Infections, and the Class That Went On For Too Long

This is the first of two posts for Yevamot 64 that we will learn on Tuesday. The second part will be published tomorrow.

יבמות סד,ב

רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna's lectures, Rav Chelbo became sterile on account of Rav Huna's lectures and Rav Sheshet became sterile on account of Rav Huna's lectures...

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  A couple of pages ago, on Yevamot 62b, Rashi explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

Rav Huna would give a lengthy class and people needed to use the toilet. They delayed urinating, and as a result became sterile, as we learn in the tractate Bechorot

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  There is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is not a good idea.

Delayed Micturation and UTIs

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

 Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.

Bechorot 44 (Part II) ~ Urinary Tract Infections, Infertility and Other Dangers of Long Sermons

When you’ve got to go, you’ve got to go

בכורות מד,ב

אמר רבי אבא בריה דרבי חייא בר אבא משתינין מים בפני רבים ואין שותין מים בפני רבים ותניא נמי הכי משתינין מים בפני רבים ואין שותין מים בפני רבים ומעשה באחד שביקש להשתין מים ולא השתין ונמצא כריסו צבה

Rabbi Abba, son of Rabbi Ḥiyya bar Abba, says that Torah scholars may urinate in public and they need not be concerned with issues of modesty, [because holding back from urinating causes bodily harm]. But they may not drink water in public, as such conduct is unbefitting a Torah scholar. And this is also taught in a baraita: Torah scholars may urinate in public, but they may not drink water in public. And there was an incident involving one who sought to urinate, and he did not urinate, and his belly was found to be swollen.

This is one of those delightful passages in which we learn that Talmudic manners were sometimes the very opposite of our modern ones. Because of the perceived dangers of not urinating when necessary, Torah scholars were permitted, or rather encouraged, to urinate whenever the urge arose, even in public. Drinking in public, however, was not allowed, since this was considered uncouth behavior. And then we read a couple of stories in which the urgent public urination of a Torah scholar is described.

שמואל איצטריך ליה בשבתא דרגלא נגדו ליה גלימא אתא לקמיה דאבוה א"ל אתן לך ד' מאה זוזי וזיל אהדר עובדא את דאפשר לך דלא אפשר ליה ליסתכן

Shmuel needed to urinate on the Shabbat [when everyone came to hear halakhot relating to the impending Festival. In order to afford him privacy], they spread a sheet for him. Shmuel then came before his father, who said to him: I will give you four hundred dinars if you will go and retract this incident, [i.e., if you will state publicly that one may not hold back from urinating even at the expense of one’s privacy.] Since you are an important man, you can have others spread a sheet around you. But with regard to one who cannot have others spread a sheet for him, should he endanger himself by seeking privacy? You must therefore teach that no-one should hold back from urinating even in public.

Shmuel’s father was willing to pay him the massive sum of 400 dinars for Shmuel to clarify to the public that “one should not hold back from urinating even in public.” Then comes another story, (describing what must be one of the weirdest incidents in the Babylonian Talmud). While walking over a bridge, Mar Bar Rav Ashi had the urge to urinate. As he was micturating, he was told that his mother-in-law was on her way, which was presumably a suggestion that hurry up and finish. To which he replied, with a most memorable turn of phrase, emphasising just how important it was to urinate when the urge is felt: “I would have even urinated in her ear”(באודנה).

But what was it that the rabbis feared might happen if you delayed micturition? Infertility. They believed that failing to urinate frequently enough would render a person sterile. And they tell a chilling example of this happening in the tractate Yevamot.

The lecture that went on for too long

“רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna’s lectures, Rav Chelbo became sterile on account of Rav Huna’s lectures and Rav Sheshet became sterile on account of Rav Huna’s lectures...”

— Yevamot 64b

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  Rashi (Yevamot 62b) explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

Rav Huna would give lengthy sermons and [his students] would need to urinate. But they held it in, and as a result became sterile, as we read in Bechorot.

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical scientific reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  

Urinary tract infections and infertility

As it turns out, there is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is really not a good idea.

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.

[Partial repost from here.]

Bechorot 44 (Part I). The Cohen with Eye Problems - and a Pretty Bad Liver

[To understand the many conditions mentioned on Bechorott 44, you need a lot of medical information. So Part I is released today, although the daf will not be learned until tomorrow, when Part II will be released. Enjoy.]

To act as a Cohen you must look like a Cohen

“A man in whom there is a blemish from among the offspring of Aaron” (Lev. 21:21). From this verse the great Rabbi Yochanan concluded that in order to serve in the Temple, a Cohen must look like any normal descendant of Aaron, the first High Priest. Today’s page of Talmud lists a number of medical conditions, which, because they result in a recognizable deviation from normal human anatomy, would preclude a Cohen from serving in the Temple. Here is the medical science that explains some of them.

“If he looks at first floor room and an attic at the same time”

עינו אחת למעלה ועינו אחת למטה ורואה את החדר ואת העלייה כאחת או שמדבר עם חבירו ואחר אומר לי רואה

From here.

The condition that the Talmud is describing here is called vertical diplopia. As a result of a weakness in one set of eye muscles, when looking straight ahead one of the eyes wanders upwards. This is most commonly caused by damage to the fourth cranial nerve, called the trochlear nerve. The trochlear nerve supplies the superior oblique muscle of the eye, which (despite its name) causes the eye to look down and out. The nerve originates on one side of the brain stem, then crosses over to the other side and innervates the muscle. Because the trochlear nerve is unusually long it is more easily damaged. This damage can be congenital or acquired, and the most common cause is head trauma. Trochlear palsy results in that down-and-out motion of the muscle being lost, and due to the now unopposed actions of the other muscles of the eye, it wanders up. Because the eyes are no-longer in parallel the person has double-vision, or in medicalese, diplopia. To compensate, he will adopt a downward tilt of the head, which brings the eyes back into a parallel gaze. But if the person were to look straight ahead, they might certainly see both upwards and (a little bit) downwards, which is the condition described in the Talmud. This Cohen cannot serve because he has an abnormal eye gaze.

“One whose eyes are constantly moving”

זויר- דמזור עיניה

Another eye abnormality is a Cohen “whose eyes are constantly moving.” This condition is called nystagmus, and the eyes appear to dart back and forth horizontally, or more worryingly, vertically. Vertical nystagmus is always pathological, but a small degree of horizontal nystagmus is normal. It is often unnoticeable, and is called physiological nystagmus. Pathological nystagmus is caused by a host of conditions, though the ones I saw most often in the Emergency Department were caused by an attack of benign positional vertigo, or chronic alcoholism. You can see a nice video demonstration of the condition here; this one is caused by multiple sclerosis.

Liver Disease and the Cohen

The Mishnah (44b) then lists another series of physical changes that would exclude a Cohen from serving. Here it is:

בכורות מד, ב

דדין שוכבין כשל אשה כריסו צבה טיבורו יוצא נכפה אפילו אחת לימים רוח קצרה באה עליו המאושבן ובעל גבר

One who has breasts so large that they sag like those of a woman; or if one’s belly is swollen and protrudes; or if one’s navel protrudes; or if one is an epileptic, even if he experiences seizures only once in a long while; or one who is afflicted with a melancholy temper; or one whose scrotum is unnaturally long; or one whose penis is unnaturally long is disqualified from performing the Temple service.

At first, this seems to be just a random collection of anatomical blemishes. But in fact there is a single medical condition which causes all of them. It is cirrhosis of the liver, in which the cells are replaced by scar tissue. Cirrhosis has many causes, including chronic viral hepatitis, fatty build up, liver cancer, medications and genetic disorders. But the most common cause of liver cirrhosis is chronic alcohol abuse. Here is the list of symptoms from the Mishnah, with an explanation of the medical science behind them.

Severe gynecomastia in a young man. From here.

• Gynecomastia. This is an abnormal swelling of the breasts in a male. In extreme cases the breasts may be so large that they resemble those of a woman. It has many causes, one of which is cirrhosis of the liver. What happens in men with alcoholic liver cirrhosis is that they have increased serum levels of androstenedione, which is then converted into estrogens causing enlargement of the breast tissue. Since cirrhosis also causes testicular atrophy (see below), there are lower levels of circulating testosterone which also contributes to the development of gynecomastia.

Ascites and umbilical protrusion caused by liver disease. Just like it is described in the Talmud. From here.

• Abdominal swelling. When the liver fails, raised pressure in the portal vein causes a build-up of fluid in the abdominal cavity. This fluid is called ascites, and when present in a large enough volume it can cause severe abdominal distension, as you can see in the picture. It is extremely uncomfortable for the patient who has severe shortness of breath, and for whom lying flat becomes impossible. 

• Prominent umbilicus. As the volume of ascites increases, it can push against the abdominal wall and as a result the umbilicus appears to extrude.  (This is not the same as an umbilical hernia, which may look similar but is caused by a defect in the muscle of the abdominal wall.)

• Testicular and penile swelling. The ascitic fluid follows gravity and will drain caudally, that is, in the direction of the feet (or around the buttocks if the patient is lying down).  It can track through the fascial planes and settle in the scrotum where it causes swelling. The Mishnah describes swelling of the testes themselves, but the scrotal swelling is caused by the ascitic fluid, and not by any enlargement of the testes. In fact liver cirrhosis causes the testes to atrophy. Fluid that has tracked may also find its way into the penile tissue, causing it to swell, (and labial edema is seen in women with ascites).  While this is not common, there are several case reports of this in the medical literature. The Mishnah describes the penis as extending down to the knees, which is certainly far more severe than any of the published cases.

• Seizures. The ArtScroll English Talmud translates the word נכפה as epileptic seizures. This is usually close enough, but the seizures being described here are, from the context, not caused by epilepsy. Chronic alcoholics will seize if they do not keep their blood alcohol at a high enough level. These seizures, called alcohol withdrawal seizures, are common and I’ve treated dozens and dozens of them in the ED. An IV valium-like sedative usually does the trick, but giving the patient a couple of shots of whiskey will prevent them from occurring at all. Many years ago while I was a medical intern at in Boston, I would (on the orders of the attending physician) prescribe “30cc ETOH q6hrs prn” which is translated as “30cc of alcohol every six hours as needed.” By giving hospitalized patients these regular drinks, their alcohol level would remain just high enough to prevent alcohol withdrawal and the seizures that follow. They would also thus ensure a better night’s sleep for the patient, and an easier night shift for me and the nurses.

• Depression. Not surprisingly, there is a higher than usual prevalence of depression in people with liver cirrhosis. In addition, end-stage liver cirrhosis causes encephalopathy, which is a global dysfunction of the brain. It causes irritability, a slowing of cognitive function and sleepiness, which overlap with some of the symptoms of depression. As the disease advances there is increasing stupor and coma, and eventually death.

The terrible dangers of alcohol abuse 

This Mishnah appears to be the earliest recorded description of the signs of liver cirrhosis, the most common cause of which, as we have noted, is chronic alcohol abuse. It should come as no surprise that this condition was prevalent enough to be recorded. Water sources were usually contaminated, and most of the population drank beer of varying strengths.

““Since it was made using boiling water, beer was safer to drink than water which quickly becomes contaminated with human waste even in the smallest settlements…wine also made water safe. As well as being free of pathogens, wine contains natural antibacterial agents that are liberated during the fermentation process…Much of the appeal of other beverages, starting with beer in the Neolithic period, was that they were less likely than water to be contaminated.””

— Tom Standage. A History of the World in Six Glasses. Walker Publishing 2006.pp 21, 59, 266.

The Bible prohibits a drunk Cohen from serving, but alcoholic liver cirrhosis is most certainly not a disease of Cohanim. In the US there are about 630,000 adults with liver cirrhosis, and chronic alcohol abuse is the cause of at least 60% of cases. This Mishnah should be a warning to everyone: before it eventually kills you, alcohol abuse leads to some very nasty conditions.

Yevamot 64b ~ Urinary Tract Infections, and the Class That Went On For Too Long

יבמות סד,ב

רב גידל איעקר מפרקיה דרב הונא רבי חלבו איעקר מפרקיה דרב הונא רב ששת איעקר מפרקיה דרב הונא

Rav Gidel became sterile on account of Rav Huna's lectures, Rav Chelbo became sterile on account of Rav Huna's lectures and Rav Sheshet became sterile on account of Rav Huna's lectures...

Rav Huna had a lot to answer for.  His lectures went on, and on, and on, and on and on and on.  A couple of pages prior, on Yevamot 62b, Rashi explained the relationship between these lengthy classes and infertility:

איעקר מפרקיה דרב הונא.שהיה מאריך בדרשיו וצריכים למי רגלים ומעמידים עצמן ונעקרים כדתניא בבכורות 

The suggestion here is that holding-it-in can lead to problems of fertility, and there is a least a theoretical reason why Rav Huna's lengthy classes had the unintended consequence of lowering the reproductive rates of his students.  There is a clear relationship between male infertility and repeated infections of the genitourinary tract. Here, for example, is  how one urology textbook opens its chapter on male genital tract infections and infertility:

Male Genital Tract Infections and Infertility. Neal, DE, Weinstein, SH. In Male Reproductive Dysfunction ed Kandeel FR. Informa Healthcare 2007

Any male GU infection such as prostatitis, urethritis or epididymo-orchitis can reduce both sperm count and the quality of the seminal fluid. OK, but what does that have to do with not urinating when you feel the urge? Well here's the thing: that not-going-when-you-need-to is not a good idea.

It's quite a challenge to determine scientifically the effect of holding-it-in (and hereafter referred to as delayed micturition, because it sounds nicer) on the risk of getting a urinary tract infection.  You can't very easily randomly assign one large group of healthy volunteers to urinating whenever they want, and a second to urinating only three times a day.

However, there are a couple of observational studies that may be able to tell us something about the risk of delayed micturition.  A 1968 study of 112 women with a documented UTI reported that further UTIs could be reduced by voiding  every two hours during the day (which sounds rather too good to be true). And a 1979 study from the (not-very-widely-read-but-it-really-is-a-journal) Scandinavian Journal of Urology and Nephrology reported that the frequency of UTI was significantly higher among women with three or less voidings per day compared with those who have to go four or more times per day. (Whether this is true for women outside of northern Jutland where the study was conducted remains unclear.)

So a decreased voiding frequency is associated with an increased number of infections, and urinary tract infections are associated with decreased fertility. Thus by the rule of transitive relations (or something clever like it) decreased voiding may indeed be associated in a causative way with decreased fertility.  

All this is highly speculative, and it would certainly be unusual for male sterility to directly result from delayed micturition.  But here's the weird thing: teachers are slightly more likely to suffer urinary tract infections when compared with the general population. Is that because they too, like their students, hold-it-in? (Yes, I know it didn't reach statistical significance, but the authors thought it was important to note, and so do I.)   

Kovess-Masféty, V. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health 20066:101;1-13

Poor Rav Huna, talking on and on and on, while his miserable students had to sit there with their legs crossed and could likely only think of only one thing. We will give the last word to Rav Acha bar Yaakov, another hapless student of Rav Huna. 

אמר רב אחא בר יעקב שיתין סבי הוינא וכולהו איעקור מפרקיה דרב הונא לבר מאנא

Rav Acha bar Yaakov said, we were a group of sixty students, and all of us became sterile because of Rav Huna's lectures - except me (Yevamot 64b).

Students be warned.