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

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

כתובות קיא, א

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

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

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

Ten other causes of hemorrhoids

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

ברכות נה, א

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

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

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

THE NATURE AND ETIOLOGY OF HEMORRHOIDS

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

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

1. The Varicose Vein Theory

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

2. The Vascular Hyperplasia Theory

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

3. The Infection/Inflammation Theory

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

4. The Sliding Anal Lining Theory

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

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

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

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

So what about SITTING and Hemorrhoids? THE ISRAELI STUDY

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

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

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

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

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

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

ANd now, the Golden Vein

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

From here.

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

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

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

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

But wait; there is more:

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

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

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

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

Berachot 55~ Hemorrhoids. And Dreams.

Today’s long page of Talmud discusses lots of ideas. We will focus on two of them: Hemorrhoids and dreams. Rav Yehudah suggested that spending a long time in the lavatory promoted longevity. This prompts the following discussion:

ברכות נה, א

וְהַמַּאֲרִיךְ בְּבֵית הַכִּסֵּא: מְעַלְּיוּתָא הוּא? וְהָתַנְיָא: עֲשָׂרָה דְּבָרִים מְבִיאִין אֶת הָאָדָם לִידֵי תַּחְתּוֹנִיּוֹת: הָאוֹכֵל עֲלֵי קָנִים, וַעֲלֵי גְפָנִים, וְלוּלַבֵּי גְפָנִים, וּמוֹרִיגֵּי בְהֵמָה, וְשִׁדְרוֹ שֶׁל דָּג, וְדָג מָלִיחַ שֶׁאֵינוֹ מְבוּשָּׁל כׇּל 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.

So now the question is, what does modern medicine tell us about the cause of hemorrhoids?

The nature and etiology of hemorrhoids

Hemorrhoids are small grape-like bulges of blood vessels around the anus. They affect between 4 and 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. “The anatomist Hyrtl noted that “the golden veins of the anus” were not mentioned before the 16th century...The name denotes the typical spontaneous bleeding which, in folklore, was believed to remedy the various maladies of the ages. This provided a cure without a visit to the doctor for medicinal bloodletting, thus saving the patient from the doctor’s customary fees—hence, the name “golden veins.”

Here they some of the suggested etiologies:

1. The Varicose Vein Theory

   Varicose veins are essentially tired and weakened veins, which bulge as a result. You may have noticed them (or even have some) on your legs or 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.

2. The Vascular Hyperplasia Theory

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

3. The Infection/Inflammation Theory

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

4. The Sliding Anal Lining Theory

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

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

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

Interestingly, eating “the spine of a fish, a salty fish that is not fully cooked” or drinking wine dregs, which are suggested as causes of hemorrhoids in today’s page of Talmud, 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 itself has not a shred of evidence to support it. Now let's turn to dreams.

Dreams and the Future

In today’s page of Talmud there is the beginning of a very long discussion of the nature of dreams. Here is Rav Chisda who had a lot to say on the topic:

וְאָמַר רַב חִסְדָּא: חֶלְמָא דְּלָא מְפַשַּׁר כְּאִגַּרְתָּא דְּלָא מִקַּרְיָא. וְאָמַר רַב חִסְדָּא: לָא חֶלְמָא טָבָא מִקַּיַּים כּוּלֵּיהּ וְלָא חֶלְמָא בִּישָׁא מִקַּיַּים כּוּלֵּיהּ. וְאָמַר רַב חִסְדָּא: חֶלְמָא בִּישָׁא עֲדִיף מֵחֶלְמָא טָבָא. וְאָמַר רַב חִסְדָּא: חֶלְמָא בִּישָׁא — עֲצִיבוּתֵיהּ מִסְתְּיֵיהּ, חֶלְמָא טָבָא — חֶדְוֵיהּ מִסְתְּיֵיהּ

Rav Chisda said: A dream not interpreted is like a letter not read. [As long as it is not interpreted it cannot be fulfilled; the interpretation of a dream creates its meaning.] And Rav Chisda said: A good dream is not entirely fulfilled and a bad dream is not entirely fulfilled. And Rav Chisda said: A bad dream is preferable to a good dream, as a bad dream causes one to feel remorse and to repent. And Rav Chisda said: A bad dream, his sadness is enough for him; a good dream, his joy is enough for him. [This means that the sadness or joy engendered by the dream renders the actual fulfillment of the dream superfluous.]

There is an ambivalence about the nature of the content of dreams. Some, like Rabbi Meir (Gittin 52a) thought they were inconsequential:

גיטין נב, א

אמר, דברי חלומות לא מעלין ולא מורידין

Rabbi Meir used to say: The content of dreams is inconsequential

Earlier in Berachot (10b) Rabbi Hanan taught that even if a dream appears to predict one's imminent death, the one who dreamed should pray for mercy. R. Hanan believed that dreams may contain a glimpse of the future, but that prayer is powerful enough to changes one's fate. Later in today’s page of Talmud (55b), R. Yohanan suggests a different response to a distressing dream: let the dreamer find three people who will suggest that in fact the dream was a good one (a suggestion that is codified in שולחן ערוך יורה דעה 220:1).

He should say to them "I saw a good dream" and they should say to him "it is good and let it be good, and may God make it good. May heaven decree on you seven times that it will be good, and it will be good.

Shmuel, the Babylonian physician who died around 250 CE, had a unique approach to addressing the content of his own dreams. "When he had a bad dream, he would cite the verse 'And dreams speak falsely' [Zech. 10:2]. When he had a good dream he would say "are dreams false? Isn't it stated in the Torah [Numbers 12:6] 'I speak with him in a dream'?" (Berachot 55b).  In contrast, Rabbi Yonatan suggests that dreams do not predict the future: rather they reflect the subconscious (Freud would have been proud). "R. Yonatan said: a person is only shown in his dreams what he is thinking about in his heart..." (Berachot 55b).  

“It is of interest that two millennia separated the first detailed description of the major peripheral characteristics of dreaming from the first contemporary experimental results of brain research in this field, while only about 60 years were necessary to establish relatively solid knowledge of the basic and higher integrated neurobiological processes underlying REM sleep.”

— Gottesmann, C. The development of the science of dreaming. International Review of Neurobiology 2010. 92: 16

why do we dream?

Dreaming takes place during the REM (Rapid Eye Movement) stage of sleep, when there is brain activation similar to that found in waking, but muscle tone is inhibited and the eyes move rapidly. This type of sleep was only discovered in the 1950s, and since then it has been demonstrated in mammals and birds (but not yet in robots). Most adults have four or five periods of REM sleep per night, which mostly occur in 90 minute cycles. Individual REM periods may last from a few minutes to over an hour, with REM periods becoming longer the later it is in the night. 

Here are some theories about why we dream, all taken from this paper. (The author, J. Allan Hobson, directed the Laboratory of Neurophysiology at the Massachusetts Mental Health Center from 1968 to 2003. He also published more than 200 peer-reviewed articles and 10 books on sleep and dreaming. So he knows something about the physiology of sleep.) 

1. Sleep and dreaming are needed to regulate energy

Deprive a lab rat of all sleep and it will die. Deprive a lab rat of REM sleep so that it does not dream, and it too will die.  These sleep-and-dream deprived rats lost weight and showed heat seeking behavior. This suggests for animals which regulate their body temperature, sleep is needed to control both body temperature and weight. Importantly, only mammals and birds are homeothermic, and they are also the only animals which are known to have REM sleep.

2. Sleep deprivation and psychological equilibrium

Based on a number of experiments in healthy human volunteers, it has been shown that sleep and dreaming are essential to mental health. "The fact that sleep deprivation invariably causes psychological dysfunction" wrote Prof. Hobson in his review,  "supports the functional theory that the integrity of waking consciousness depends on the integrity of dream consciousness and that of the brain mechanisms of REM sleep." (When we studied Nedarim 15 we noted however, that eleven days of sleep deprivation seemed to have no ill effects in one man.) The relationship between dreaming and psychological health is rather more complicated though: monamine-oxidase inhibitors completely repress REM sleep, and yet are an effective class of anti-depressants.  There appears to be a relationship between dreaming and psychological well being, but its parameters require much more study.   

3. Sleep, Dreams and Learning

In 1966, it was first suggested that REM sleep is related to the brain organizing itself.  This suggestion was later supported by studies which showed that the ability of an animal to learn a new task is diminished their REM sleep is interrupted.  Other studies show that REM sleep in humans is increased following an intensive learning period. 

“...dreaming could represent a set of foreordained scripts or scenarios for the organization of our waking experience. According to this hypothesis, our brains are as much creative artists as they are copy editors.”

— Hobson, JA. REM sleep and dreaming: towards a theory of protoconsciousness. Nature Reviews 2009.807.

Nightmares and Fasting

We've all had dreams that frighten or upset us. The major code of Jewish law take bad dreams seriously. While fasting is absolutely forbidden on Shabbat, it is permitted in two instances: when Yom Kippur falls on Shabbat and when you've had a bad dream and need to undertake a fast "to tear up the heavenly decree." Here is the ruling:

שולחן ערוך אורח חיים הלכות שבת סימן רפח 

סעיף ד
 מותר להתענות בו תענית חלום כדי שיקרע גזר דינו. וצריך להתענות ביום ראשון, כדי שיתכפר לו מה שביטל עונג שבת 

It is permitted to fast on Shabbat because of a bad dream, in order for the bad ruling to be torn up. However he must then also fast on Sunday, in order to atone for the fact that he ruined his Shabbat enjoyment by fasting...  

There are several psychological definitions of a nightmare. One describes nightmares, as "characterized by awakenings primarily from REM sleep with clear recall of disturbing mentation." These bad dreams are common, occurring in 2-6% of the population at least once a week. They seem to be more prevalent in children and less prevalent in the elderly, but in all age groups women report having nightmares more often than men. Nightmares are also more frequent in patients with psychiatric disorders such as anxiety, neuroticism, schizophrenia, sociality and post traumatic stress disorder. And in all populations they are more frequently reported during episodes of stress.  

There are a number of psycho-analytical models of nightmare formation, but little empirical evidence to support any of them.  They are shown in the table below.

Psychoanalytic and neo-psychoanalytic models of nightmare formation
Authors	Core mechanism producing nightmares
Freud 1900	Transformation of libidinal urges into anxiety that punishes the self (masochism); analogous to the neurotic anxiety underlying phobias
Jones 1951	Expression of repressed, exclusively incestuous, impulses
Jung 1909-1945	Residues of unresolved psychological conflicts.Individuation or development of the personality
Fisher et al. 1970	Attempts to assimilate or control repressed anxiety stemming from past or present conflicts
Greenberg 1972	Failure in dream function of mastering traumatic experience
Lansky 1995	Transformation of shame into fear (post-traumatic nightmares only)
Solms 1997	Epileptiform (seizure) activity in the limbic system (recurring nightmares only). Activation of dopaminergic appetitive circuits in mediobasal forebrain and hallucinatory representation by occipito-temporal-parietal mechanisms (nonrecurring nightmares and normal dreaming)
From Nielsen T and Levin, R. Nightmares: A new neurocognitive mode. Sleep Medicine Reviews 2007:11 (4); 295-310.

A recent review paper from researchers in Montreal and Yeshiva University summarizes the research in this way:

In sum, although clinical and, to some extent, empirical evidence supports different psychoanalytic models of nightmare formation, for the most part such models have not been subjected to rigorous empirical scrutiny. Rather, their central tenets have been integrated with more recent nightmare models, where empirical evidence is less scarce.

These same researchers suggest that nightmares "result from dysfunction in a network of affective processes that, during normal dreaming, serves the adaptive function of fear memory extinction." Fear memory occurs when an innocuous stimulus (like a door bell ringing) is paired with an unpleasant experience (like an electric shock).  Fear memory may be useful if it saves the individual from repeating a dangerous error. Extinction memories override the original fear memories and allow the individual to hear that ringing door bell without fearing an electric shock. The suggestion is that nightmares occur when the brain does not properly process fear extinction memories, For this reason nightmares are more prevalent in those with stress or psychiatric disorders. It's an interesting theory, but one that has not yet gathered much empirical evidence for its support.  But there is no doubting the relationship between psychiatric disorders, stress, and nightmares, and we noted earlier that  R. Yonatan claimed "a person is only shown in his dreams what he is thinking about in his heart..." (Berachot 55b). Perhaps this is why it is permitted to fast on Shabbat after a nightmare.  

Interestingly the Shulchan Aruch records an opinion that such Shabbat fasting is not permitted for a nightmare that appears only once; rather it is only allowed if it appears three times or more ( י"א שאין להתענות תענית חלום בשבת אלא על חלום שראהו תלת זימני). This is now more readily understood in light of the relationships we have noted between nightmares and psychological wellbeing; a recurrent nightmare may be associated with a more deeply felt stressful situation, and so it is only these recurrent bad dreams that allow for a Shabbat fast. One-off nightmares are not reflective of this stress, and so fasting  on their account is not permitted on Shabbat.    

The Realism and Bizarreness of 365 Dreams
Category	Frequency (%)
Possible in waking life, everyday experiences	29
Possible in waking life, uncommon elements	50
One or two bizarre or impossible elements	27
Several bizarre elements	4
From M. Schredl, et al. Dream content and personality. Dreaming 1999. (9): 257–263

In Summary

At best, we can say that contemporary science has a poor understanding of why we dream.  Hobson concludes his review stating that dreaming is "the subjective experience of a brain state with phenomenological similarities to - and differences from - waking consciousness, which is itself associated with a distinctive brain state." Well thanks for that Professor.  But not very helpful.

Dreams are very important to how we function as humans but we seem to have no idea how dreams serve to keep us from dying or getting very sick. That we must dream in order to function seems to be certain; but why we dream about what we do is far less known. And don't trust every scientific paper you read on the subject. Publication and peer review is no guarantee of veracity. Let's end with a good example of scientific nonsense from this recently published paper in the journal Sleep and Hypnosis, which seeks to explain why some dreams portend the future. (Well, um, actually they don't. But do go on.)  Just its title alone should make you run for the hills: Dreams, Time Distortion and the Experience of Future Events: A Relativistic, Neuroquantal Perspective. And it only gets better:

“If dreams and related altered states are actually the experiences of biophotons within the brain...then the temporal discrepancies between precognitive experiences and subsequent verified events may reflect the relativistic and quantum properties of minute differential velocities in electromagnetic phenomena. The average discrepancy of about two to three days between the experience and the event in actual cases supported this hypothesis.
The moderately strong correlation between the global geomagnetic activity at the time of precognitive experiences, primarily during dreams, and the geomagnetic activity during the two days before the event in those cases where the discrepancy is more than 6 days suggests a variant of entanglement between photons emitted during the event and those experienced before the event. The marked congruence of gravitational waves, geomagnetic activity, the Schumann resonance and the peak power of brain activity during different states, particularly when the sensitivity of the right hemisphere is considered, indicates a physical substrate by which prescience could occur.”

— Dotta BT. Persinger MA. Dreams, Time Distortion and the Experience of Future Events: A Relativistic, Neuroquantal Perspective. Sleep and Hypnosis 2009;11(2):29-39)

Rabbi Meir, the great sage of the Talmud, believed that the content of dreams was of no consequence whatsoever.  He may well said that same about some of the contemporary scientific explanations of dreaming.  

“אמרו לו בחלום מעשר שני של אביך שאתה מבקש הרי הוא במקום פלוני, אף ע”פ שמצא שם מה שנאמר לו אינו מעשר, דברי חלומות לא מעלין ולא מורידין
If a man was told in a dream that Ma’aser Sheni [a tithe on produce] belonging to his father was to be found in a certain location, even if he found some produce in that same location, it is not to be considered set aside for this tithe. For the content of dreams is of no consequence.”

— רמב"ם הלכות מעשר שני ונטע רבעי פרק ו הלכה ו

Keritot 5b ~ Hemorrhoids, Plague, and the Ark of the Covenant

כריתות ה,ב

משנגנז ארון נגנז צנצנת המן וצלוחית שמן המשחה ומקלו של אהרן שקדים ופרחים וארגז ששגרו פלשתים דורון לאלהי ישראל

When the Ark was hidden, along with it was sequestered the jar of manna, and the flask of the anointing oil, and Aaron’s staff with its almonds and blossoms. And also hidden with the Ark was the chest that the Philistines sent as a gift to the God of Israel [after they captured the Ark and were stricken by several plagues].

The Talmud relates that when King Josiah hid the Ark of the Covenant, he also hid, among other things “the gifts to the God of Israel.” And what were these gifts? Golden Hemorrhoids. To understand why, you need some some background.

How Israel lost their Ark

In one of the many battles between the Philistines and the People of Israel, the latter were routed, losing “four thousand men on the field of battle” (I Sam 4:2). The Israelites then came up with a plan: “Let us fetch the Ark of the Covenant of the Lord from Shiloh, so that He will be present among us and will deliver us from the hands of our enemies.” This turned out to be a terrible idea. The Ark was quickly captured, taken to Ashdod and “ put into the temple of Dagon where they set it up beside Dagon.”

But watching the Ark of the Covenant comes with a lot of responsibility, which the Philistines had not really factored in. The very next day “they woke to find Dagon lying face down on the ground in front of the Ark of the Lord. They picked Dagon up and put him back in his place.” Next day, same thing, except this time “the head and both hands of Dagon were cut off, lying on the threshold; only Dagon’s trunk was left intact.”

The priests in Ashdod got the message and decided to move the Ark to Gath. And what happens next is critical to our story:

וַיְהִי אַחֲרֵי הֵסַבּוּ אֹתוֹ וַתְּהִי יַד־יְהוָה בָּעִיר מְהוּמָה גְּדוֹלָה מְאֹד וַיַּךְ אֶת־אַנְשֵׁי הָעִיר מִקָּטֹן וְעַד־גָּדוֹל וַיִּשָּׂתְרוּ לָהֶם עפלים [טְחֹרִים]׃

And after they had moved it, the hand of the Lord came against the city, causing great panic; He struck the people of the city, young and old, so that hemorrhoids broke out among them.

The Philistines had enough of the Ark, and decided to send it back to Israel, but they were warned by their priests, “If you are going to send the Ark of the God of Israel away, do not send it away without anything; you must also pay an indemnity to Him.”

וַיֹּאמְרוּ מָה הָאָשָׁם אֲשֶׁר נָשִׁיב לוֹ וַיֹּאמְרוּ מִסְפַּר סַרְנֵי פְלִשְׁתִּים חֲמִשָּׁה עפלי [טְחֹרֵי] זָהָב וַחֲמִשָּׁה עַכְבְּרֵי זָהָב כִּי־מַגֵּפָה אַחַת לְכֻלָּם וּלְסַרְנֵיכֶם׃

They asked, “What is the indemnity that we should pay to Him?” They answered, “Five golden hemorrhoids and five golden mice, [corresponding to the number of lords of the Philistines;] for the same plague struck all of you and your lords.

The Plague of Ashdod 1630 by Nicolas Poussin (1594–1665). Louvre, Paris. The picture was on the front cover of the January 2018 edition of the journal Emerging Infectious Diseases.

So “they placed the Ark of the Lord on the cart together with the chest, the golden mice, and the figures of their hemorrhoids” and sent them on their merry way. The Ark was taken briefly to Bet Shemesh, where the Bible tells us more than 50,000 people were killed “because they looked into the Ark” before it finally found a resting place in Kiryat Ya’arim, where, for the first time, no-one who came into contact with the Ark died.

Those “Five Golden Hemorrhoids” were the gifts that were kept with the Ark, and which were later hidden by King Josiah. And I hear you ask “what on earth is going on in this story?” That’s where science, and a bit of Latin come in.

It wasn’t hemorrhoids. it was plague.

The story about the “hemorrhoids” seems to be somehow related to mice - for why did else did the Philistines send back golden mice? And what’s with hemorrhoids as a divine reaction to removing the Ark? The author of a Letter to the Editor that appeared in the Journal of the Royal Society of Medicine, noted something important.

The New International Version (NIV) in its footnotes records that the Septuagint (a translation from the Hebrew to Greek done in Alexandria for Ptolemy Philadelphus) and Vulgate (a translation by St Jerome into Latin from the Septuagint) texts elaborate on the fact that Philistines were smitten with tumours as follows. In 1 Samuel 5 v6 the NIV states the Philistines were afflicted with tumours and the Septuagint and Vulgate expand this point with the words `and rats appeared in their land, and death and destruction were throughout the city' and in v 9 of the same chapter the Septuagint versions expand `He afflicted the people, both young and old with an outbreak of tumours' by specifying the site of the tumours as being `in the groin.’

A bubo, a swelling of the lymph nodes of the groin.

As a result, the letter suggests it was bubonic plague that struck the Philistines, and it was the associated swelling of the lymph nodes - called buboes- that the Book of Samuel was describing. It wasn’t hemorrhoids at all.

Bubonic plague is caused by a nasty bacteria called Yersinia Pestis. It first causes a flu-like illness with fevers and muscle cramps, followed by severe swelling of the lymph nodes (but not hemorrhoids). Then things get really bad: there is secondary pneumonia, sepsis, gangrene of the fingers and toes, bleeding and death. Lots of death. The Black Death of 1347 killed one-third of the population of Europe. And it still kills; the World Health Organization reports a couple of thousand cases each year, and the actual number of cases is far higher. Fortunately it can usually be treated with antibiotics if they are started early enough.

The Role of the Mice and the rats

The bacteria that causes plague is carried inside fleas that feed primarily on rats. While the Hebrew Bible doesn’t mention the role of rats, the Septuagint does. Here is the verse in the Hebrew Book of Samuel (I Sam 6:1)

וַיְהִי אֲרוֹן־ה’ בִּשְׂדֵה פְלִשְׁתִּים שִׁבְעָה חֳדָשִׁים׃ - The Ark of the Lord remained in the territory of the Philistines seven months.

And here is the Greek Septuagint: “And the ark was seven months in the country of the Philistines, and their land brought forth swarms of mice.”It was theses swarms of mice (or really rats, which are the primary host for the rat flea that carries the plague bacteria Yersinia) that were responsible for the spreading the plague among the Philistines, causing the lymphatic swellings, the buboes, that were later (mis)translated as hemorrhoids.

So which is it, hemorrhoids or swellings?

It was with this same Septuagint translation that the hemorrhoids thing began: “According to the number of the lords of the Philistines, πέντε έδρας χρυσάς five buttocks of gold, for the plague was on you, and on your rulers" (I Sam 6:5). From this Greek version of the Hebrew we move to the Latin. In the late fourth century Jerome produced a Latin translation of the Hebrew Bible known as the Vulgate, which is still used by the Catholic Church. This translation gave us the quinque anos aureos, “five golden behinds,” which was then translated by the King James Bible as “five golden emerods.”

The Koren Jerusalem Bible translates the phrase as “five golden swellings,” but there is ambiguity as to the meaning in the very text of the Hebrew Bible itself. The text has the word ophalim, עפלים, but the traditional way of pronouncing this word is techorim טְּחֹרִים, which in both the Talmud and modern Hebrew means hemorrhoids. So the different ways of translating the text is embedded in the Hebrew text itself. But one thing is certain: although they may be painful, hemorrhoids won’t kill you, but bubonic plague certainly will. And that should certainly enter into any consideration of an appropriate translation.

From Panagiotakopulu E. Pharaonic Egypt and the origins of plague. Journal of Biogeography 2004:31; 269–275.

“The Vulgate says that they offered five golden images of mice and ‘quinque aureos anos’. It would seem, therefore,that the compilers of the Vulgate were satisfied that the word opalim meant haemorrhoids ,and that the Philistines made golden replicas of the anal ring with a haemorrhoid,or a cluster of piles, protruding from it, not a difficult matter for a reasonably expert goldsmith.”

— Shrewsbury, J.F.D. The Plague of the Philistines.The Journal of Hygiene Vol. 47, No. 3 (Nov., 1949), pp. 244-252.

One last candidate: Tularemia

There is another possible etiology of the disease that plagued the Philistines. It is a bacterial disease called tularemia, which most commonly kills rabbits and rodents, but may rarely pass into humans. It causes fever and pneumonia as well as swelling of the lymph nodes in the neck and groin. In a 2007 paper published in the journal Medical Hypotheses, Siro Igino Trevisanato suggested that bubonic plague was not known in the area, tularemia was a better candidate for the outbreak described in the Book of Samuel:

The biblical data appear to center around the box as a vehicle for the disease, as well as the rodents that appear shortly thereafter, and are depicted in the ‘‘settlement’’ paid in gold. The Hebrew word akhbar for the rodents fails to distinguish between mice and rats. Rats would have carried Y. pestis, but bubonic plague fails to adequately explain the epidemic. Mice are a better option: they can carry diseases, and fit the other data relative to the historical text, i.e., box, idol, and settlement payment.

Mice nesting in the [gold plated wooden] box would have explored their new habitat upon each the transfer of the box, thus offering an explanation for the box transmitting the disease.

Mice also explain the otherwise odd detail of a small Philistine idol falling on the floor. Once the box was hosted in the Philistine temple, the animals exiting the box from the same aperture, would have tipped over the statuette, eventually breaking the extremities after repeated falls (1Sa.5.2-5)…

Linking mice to the box and to the disease singles out tularemia as the disease portrayed by the biblical text: mice are known to carry Francisella tularensis, the etiological agent for tularemia. Moreover, the text calls for a disease which originated from animals, can be communicated, can form tumors, and is deadly. Tularemia is a zoonotic disease that can be transferred to humans, manifests ulceroglandular formations, which tend to be misdiagnosed for signs of bubonic plague, and carries a 15% fatality rate when untreated, thus fitting all the criteria in the text.

Nicolas Poussin’s Plague at Ashdod

The French Baroque painter Nicolas Poussin (1594–1665) depicted the Plague at Ashdod in a painting that now hangs in the Louvre. He drew the Philistines dying from what appears to be bubonic plague, a disease with which he was well acquainted, since there was an outbreak of bubonic plague in Italy in 1630, where Poussin painted the work. “By including recognizable signs in his picture of the disease that was at that time a grave concern or all of Italy” wrote Sheila Barker, a specialist in southern Baroque painting, “Poussin coaxed his contemporary audience to identify their own friends’ and relatives’ suffering with the plight of the ancient Philistines.” She continues:

Ostensibly, Poussin's depiction accords with the biblical reference to a plague of "tumors in secret parts," since no tumors can be seen on the victims' bodies. In other respects however, he took great liberty with his laconic source, supplementing one "secret" attribute with a veritable catalogue of the bubonic plague's recognized symptoms. One of these, the telltale darkening of the victim's skin, is detectable in the old woman collapsed against a fallen column, the deceased mother and infant in the foreground, and the make cadaver being carried away by two men in the middle ground at right….Though the bubonic plague's namesake buboes are not visible in the picture, their painful presence can be intuited from the victims' postures. Both the dead mother in the central foreground and the male victim to the far left have raised the right arm away from the body, as if to avoid contact with the inflamed, tumescent, and pus-filled lymph glands in the armpit area….

Beyond the symptoms of bubonic plague, Poussin provides another identifying feature of the disease: its much-disputed means of propagation. Several figures in the painting pinch their noses or cover their faces in proximity to Ashdod's dead and dying. They are protecting themselves from one of the many mechanisms of contagion recognized by seventeenth- century physicians: the breath of the plague victims (rightly so, as today it is recognized that Yersinia pestis occasionally develops into a pulmonary plague transmitted through human sputum). More widely recognized by laymen and physicians alike, however, was the danger of breathing in the vicinity of putrefying corpses, since the foul odors they released were assumed to be the essence of the disease's poison, and of death itself…

Poussin's picture accommodates advanced plague etiologies in other ways as well-particularly in its depiction of the rats scurrying about the city of Ashdod, a detail that has intrigued modern viewers who recognize them as vectors of the plague-causing bacillus Yersinia pestis, discovered in 1894.

Whatever the true etiology of this curious plague, it was frightening enough for a memorial of it to be displayed at the epicenter of religious worship, as a constant reminder that pain and suffering will follow if the Ark of the Covenant is ever removed from its rightful place in Israel.