Keritot 15b ~ Amputation and Ritual Impurity

משנה כריתות טז ,א–ב

וְעוֹד שְׁאָלָן רַבִּי עֲקִיבָא. אֵבָר הַמְדֻלְדָּל בִּבְהֵמָה, מַהוּ. אָמְרוּ לוֹ, לֹא שָׁמַעְנוּ. אֲבָל שָׁמַעְנוּ בְּאֵבָר הַמְדֻלְדָּל בְּאָדָם, שֶׁהוּא טָהוֹר. שֶׁכָּךְ הָיוּ מֻכֵּי שְׁחִין שֶׁבִּירוּשָׁלַיִם עוֹשִׂין, הוֹלֵךְ לוֹ עֶרֶב פֶּסַח אֵצֶל הָרוֹפֵא וְחוֹתְכוֹ עַד שֶׁהוּא מַנִּיחַ בּוֹ כִשְׂעֹרָה, וְתוֹחֲבוֹ בְסִירָה, וְהוּא נִמְשָׁךְ מִמֶּנּוּ, וְהַלָּה עוֹשֶׂה פִסְחוֹ, וְהָרוֹפֵא עוֹשֶׂה פִסְחוֹ. וְרוֹאִין אָנוּ שֶׁהַדְּבָרִים קַל וָחֹמֶר

Rabbi Akiva further asked: What is the status of a dangling limb of an animal [Does it impart ritual impurity like a severed limb]? They said to Rabbi Akiva: We have not heard a ruling from our teachers in that specific case, but we have heard with regard to a dangling limb of a person that it is ritually pure.

And this is what the people in Jerusalem would do, who were afflicted with boils and whose limbs were dangling due to their affliction: on the eve of Passover, each of them would go to the doctor, who would cut the affected limb almost completely off, but he would leave it connected by a hairbreadth of flesh, so that neither the doctor nor the afflicted would be rendered ritually impure by a severed limb. Then, the doctor would impale the limb on a thorn attached to the floor or the wall, and the afflicted would pull away from the thorn, thereby completely severing the limb.

Thomas Rowlandson, 'Amputation' (1793), Wellcome Library, London.

That’s quite a graphic description; I do hope it didn’t spoil your breakfast. On today’s page of Talmud we digress to resolve the important question of the ability of a partially severed animal limb to transmit ritual impurity. A completely severed limb certainly transmits impurity, but what if the limb remains partially attached? Rabbi Akiva was hoping for an answer but his colleagues could only provide a ruling regarding a partially severed human limb. Good news, they replied: it doesn’t.

And what are we to make of the historical tidbit that the Mishnah provides? Here is Rashi’s explanation as to why those afflicted with “boils” would amputate their partially severed limbs before Passover:

וחותכו : לא משום טהרה שקודם לכן נמי טהור אלא שלא יהא מאוס ברגל באבר המדולדל

They would cut it off: Not because they needed to do so to become ritually pure, because before then, when the limb was still partially attached, they were also ritually pure. Rather, they amputated the limb so that they would not appear repulsive on the Festival.

A partially attached limb looks unsightly, so the unfortunate person would remove it in order not to put the pilgrims off of their food, (in this case a Passover sacrificial lamb). But because a completely severed human limb imparts ritual impurity, they were faced with a quandary. Once the limb is amputated, it renders both the amputee and the surgeon ritually impure, since both were in contact with it. But those who are impure may not eat the Passover sacrifice. So what to do? There was a workaround. The surgeon would amputate most, but no all of the limb, and the patient would impale the limb on a hook and pull himself away. The limb would be quickly removed and since the patient was not in contact with the severed arm or leg or whatever, (and neither was the surgeon), they could go on their merry way eating the Passover lamb in a state of ritual purity.

Gangrene and Falling Limbs

One possible cause of the “boils” described in the Mishnah is leprosy. This bacterial disease was rife (and still is found in parts of) the Middle East. It causes resorption of the bone and loss of toes, fingers and the nose. However, leprosy is usually identified with tzara’at - and the leper would have already been declared ritually impure and was thus ineligible to join and eat the Passover sacrifice. So the disease described in the Mishnah - שְׁחִין (shekhin) - is likely different from leprosy.

Perhaps it was gangrene. Gangrene is the death of tissue, caused by a loss of the blood flow, and we discussed it when we studied Avodah Zarah. Here’s a brief recap:

Gangrene is a very serious condition. (You can see all kinds of pictures of gangrene here.) It is mostly seen on the feet, but I've seen gangrene of the hands and fingers as well. When mountain climbers (and the homeless) loose fingers and toes, it's from gangrene.  There are two kinds of gangrene. In wet gangrene, bacteria invade tissue which have little or no blood supply. They feed on the tissue and produce a great deal of pus; hence the description "wet".  Left untreated, the patient will likely become septic and die.  Amputation is often the only treatment option. 

Dry gangrene has a slower onset, and the tissue looks mummified or cracked; hence the term "dry". It does not usually cause infection or death. After several days, it becomes obvious where the black dead tissue ends and the pink health tissue begins. At that time, the tissue can be amputated; commonly, it just falls off (like here, but don't look if you are eating). The case of the Mishnah could be one of dry gangrene, but the services of a surgeon are not always needed. The healthy flesh is clearly demarcated from the dead tissue, which just…falls off.

Ancient Amputation

Depiction of amputation in ancient Egypt (Edwin Smith Papyrus, New York Academy of Medicine).

In an enticing paper published last year titled Hallmarks of Amputation Surgery, the authors point out that the earliest human remains with evidence of an amputation are dated approximately 4900 BCE. “The remains were a skeleton of a male who was lacking bones in the left forearm, wrist, and hand. Analysis of the possible site of amputation indicated a clear oblique section through the medial and lateral epicondyle consistent with the flint tools available at the time. The amputation was successful and he not only survived the amputation but lived for months or years afterward.” In ancient Egypt, amputations were performed as a retribution for a judicial punishment, and there are crimes and law offenses punished with amputation as early as the Babylonian era in the law code of Hammurabi. In addition the Egyptians performed medical amputations, but “they were feared more than death and thought to affect the amputee in the afterlife.”

“ וַיַּעַל יְהוּדָה וַיִּתֵּן יְהוָה אֶת־הַכְּנַעֲנִי וְהַפְּרִזִּי בְּיָדָם וַיַּכּוּם בְּבֶזֶק עֲשֶׂרֶת אֲלָפִים אִישׁ׃ וַיִּמְצְאוּ אֶת־אֲדֹנִי בֶזֶק בְּבֶזֶק וַיִּלָּחֲמוּ בּוֹ וַיַּכּוּ אֶת־הַכְּנַעֲנִי וְאֶת־הַפְּרִזִּי׃
וַיָּנָס אֲדֹנִי בֶזֶק וַיִּרְדְּפוּ אַחֲרָיו וַיֹּאחֲזוּ אֹתוֹ וַיְקַצְּצוּ אֶת־בְּהֹנוֹת יָדָיו וְרַגְלָיו׃
וַיֹּאמֶר אֲדֹנִי־בֶזֶק שִׁבְעִים מְלָכִים בְּהֹנוֹת יְדֵיהֶם וְרַגְלֵיהֶם מְקֻצָּצִים הָיוּ לַקְּטִים תַּחַת שֻׁלְחָנִי כַּאֲשֶׁר עָשִׂיתִי כֵּן שִׁלַּם־לִי אֱלֹהִים וַיְבִיאֻהוּ יְרוּשָׁלִַם וַיָּמָת שָׁם׃

When Judah advanced, the LORD delivered the Canaanites and the Perizzites into their hands, and they defeated ten thousand of them at Bezek. At Bezek, they encountered Adoni-bezek, engaged him in battle, and defeated the Canaanites and the Perizzites. Adoni-bezek fled, but they pursued him and captured him; and they cut off his thumbs and his big toes. And Adoni-bezek said, “Seventy kings, with thumbs and big toes cut off, used to pick up scraps under my table; as I have done, so God has requited me.” They brought him to Jerusalem and he died there.”

— Judges 1:4-7

Moving along several hundred centuries, Hippocrates (460-370 BCE) recommended amputation to stop gangrene but only as a last resort; he suggested the amputation be performed distal to the necrotic demarcation at the time, where the flesh was dead and had completely lost sensation. “In the first century Aulus Cornelius Celsus (25 BCE–50 CE) in his work De medica proposed an amputation for a gangrenous limb; he advised cutting between the living and diseased part, but not through a joint. He also proposed the ligation of vessels to control blood loss, the proximal division of bone in order to allow a “flap” of skin to cover the stump, and the packing of the wound with lint soaked in vinegar to prevent further infections.”

The French surgeon Ambroise Pare (1520-1590) is considered the father of modern surgery, and he advised amputations not only for infected or injured limbs, but for the removal of cancerous growths too. Here is how to get the job done, from an english translation (The Workes of that Famous Chirurgion Ambrose Parey) published in London in 1649:

The Religious Impulse on seeing tragedy

Today’s discussion reminds us of the desperate circumstances in which people found themselves before the advent of modern medicine. Without access to antibiotics, minor skin infections might develop into necrosis of the tissues and there would be a need to amputate an arm or a leg. But the rabbis never missed an opportunity to praise God, however awful or hopeless a situation. And so they instituted a blessing to be made “on seeing an amputee or one afflicted with boils:” “Blessed be He, the True Judge.” It’s a blessing we hope never to have to make.

“אמר רבי יהושע בן לוי הרואה את... הקטע ואת הסומא ואת פתויי הראש ואת החגר ואת המוכה שחין ואת הבהקנים אומר ברוך דיין אמת

Rabbi Yehoshua ben Levi said: One who sees ... an amputee, a blind person, a flat-headed person, a lame person, one afflicted with boils, or spotted people recites: Blessed be He, the True Judge”

— TB Berachot 58b.

Keritot 7b ~ Surviving a Cesarian Section

כריתות ז,ב

אלו שאין מביאות… יוצא דופן. ר' שמעון מחייב ביוצא דופן

These women do not bring a sin offering… a woman who gives birth by caesarean section. Rabbi Shimon deems a woman liable to bring a sin offering in the case where she gives birth by caesarean section.

Cesarean section. From here.

In a list of the women who need to bring a sacrifice after childbirth or a miscarriage, the Mishnah exludes a woman who underwent a cesarean section. She is not required to bring a sacrifice, although Rabbi Shimon disputes this ruling and opines that a sacrifice is indeed required. This is all very well, but let’s stop for a moment and think about this. The Mishnah was edited around 200 CE; there were neither antibiotics nor anesthetics (at least in any modern sense) and there was no germ theory of disease. Postpartum maternal deaths following natural childbirth common enough, but the rates of a woman surviving a cearean section must have been extremely low. Yet here is the Mishnah teaching that a woman who recovers from this operation is exempt from bringing a sacrifice, which implies that surviving a cearean section was an event so common that it required its own legal ruling.

dying by cesarean section

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

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

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

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

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

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

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

survival after cesarean section

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

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

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

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

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

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

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

Clearly this Mishanha assumes that the mother survived a cesarean and then gave birth to another child. Next, consider the explanations given by the rabbis of the Talmud who comment on our Mishnah on today’s page of Talmud:

מ"ט דר"ש אמר ר"ל אמר קרא (ויקרא יב, ה) ואם נקבה תלד לרבות לידה אחרת מאי היא יוצא דופן ורבנן מ"ט א"ר מני בר פטיש (ויקרא יב, ב) אשה כי תזריע וילדה עד שתלד ממקום שמזרעת

What is the reason of Rabbi Shimon (who obligates a sacrifice?)? Reish Lakish said that the verse states: “But if she bears a girl”(Leviticus 12:5). The term “she bears” is superfluous in the context of the passage, and it serves to include another type of birth, and what is it? This is a birth by caesarean section. And as for the Rabbis, what is their reasoning? Rabbi Mani bar Pattish said that their ruling is derived from the verse: “If a woman conceives [tazria] and gives birth to a male” (Leviticus 12:2). The word tazria literally means to receive seed, indicating that all the halakhot mentioned in that passage do not apply unless she gives birth through the place where she receives seed, not through any other place, such as in the case of a caesarean section.

Boss notes that the rabbis “make no comment on the implied survival of the mother after the operation, neither explaining away the implication of the Mishnah nor treating it as remarkable.”

In another mishnaic discussion about postpartum ritual uncleanliness (Niddah 5:1) the rabbis again argue with Rabbi Shimon about the obligations of a woman who had given birth by c-section.

נידה מד,א

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

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

Again, there is no discussion as to whether this could have occurred. It is simply taken as fact. In his commentary on this Mishnah, Maimonides wrote:

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

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

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

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

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

Maimonides didn’t believe a woman could survive

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

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

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

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

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

Cesarean Section Today

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

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

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

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.

Temurah 16a ~ Transient National Amnesia

תמורה טז, א

אמר רב יהודה אמר שמואל שלשת אלפים הלכות נשתכחו בימי אבלו של משה

Rav Yehuda says that Shmuel says: Three thousand halakhot were forgotten during the days of mourning for Moses.

Three thousand laws were forgotten when Moses died. Gone. Or maybe it was only seventeen hundred:

אלף ושבע מאות קלין וחמורין וגזירות שוות ודקדוקי סופרים נשתכחו בימי אבלו של משה 

One thousand and seven hundred a fortiori inferences, and verbal analogies, and minutiae of the scribes were forgotten during the days of mourning for Moses.

Or maybe it was only a thousand:

תשש כחו של יהושע ונשתכחו ממנו שלש מאות הלכות ונולדו לו שבע מאות ספיקות

Joshua’s strength weakened, and three hundred halakhot were forgotten by him, and seven hundred cases of uncertainty needed to be resolved.

Whatever the number, the rabbis of the Talmud identified the death of Moses with a period of transient national amnesia. And the rabbis were correct. Psychological trauma and memory are intricately linked.

Psychological Trauma and Memory

As Professor Kristin Samuelson points out in her review of the relationship between memory and psychological trauma, patients with post traumatic stress disorder (PTSD) “often complain of experiencing everyday memory problems with emotionally neutral material.” In other words stress can make you forget things that have little or nothing to do with the stressful event itself. However, “PTSD most significantly impacts the initial acquisition and learning phases of memory, as opposed to the retention phase.” Two psychologists from the University of Bergen in Norway analyzed no fewer than 28 clinical studies and concluded there was marked verbal memory impairment in the PTSD groups compared to healthy controls. And while we commonly associate PTSD with combat, child abuse, rape and political violence, the everyday grief of losing a loved one can also mess with your mind. Here is Helen Macdonald, in her New York Times bestseller H is for Hawk describing what happened to her after her father’s sudden and unexpected death.

I started crashing my father’s car. I didn’t mean to do it: it just happened. I backed up against bollards, scraped wings against walls, heard the sound of metal squealing in agony over and over again…I couldn’t keep the dimensions of the car in my head. Or my own, for I kept having accidents. I cracked cups. I dropped plates. Fell over. Broke a toe on a door-jamb. I was as clumsy as I had been as a child…

The effect of stress on brain chemistry

Although as many as 8% of Americans will have PTSD at some point in their lives, we are only just beginning to understand the ways in which that stress interferes with the functioning of the brain. The hippocampus, which is involved in verbal declarative memory, is very sensitive to the effects of stress. For example, Vietnam veterans with PTSD have a smaller right hippocampal volume based relative to controls, and combat severity is correlated with volume reduction. Interestingly, hippocampal atrophy and hippocampal-based memory deficits might be reversed with treatment with anti-depressants such as the selective serotonin reuptake inhibitor (SSRI) paroxetine, which has been shown to promote the growth of neurons in the hippocampus. Stress also interferes with the release of brain transmitters such as norepinephrine. It will take many more decades of research to figure it all out, but there is no doubt that stress causes very real changes in both the anatomy and the function of the brain.

Lasting effects of trauma on the brain, showing long-term dysregulation of norepinephrine and cortisol systems, and vulnerable areas of hippocampus, amygdala, and medial prefrontal cortex that are affected by trauma. GC, glucocorticoid; CRF, corticotropin-releasing factor; ACTH, adrenocorticotropin hormone; NE, norepinephrine; HR, heart rate; BP, blood pressure; DA, dopamine; BZ, benzodiazapine; GC, glucocorticoid. From Bremner J.D.Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience 2006; 8 (4): 445-461.

Transient Global Amnesia

One of the most fascinating clinical conditions I have encountered working as a physician in the emergency room is called transient global amnesia, or TGA. It is uncommon, but once you’ve seen it it is hard to forget. In its classic presentation, the syndrome consists of the abrupt onset of a temporary, severe inability to form new memories (called in medicalese an anterograde amnesia), usually accompanied by repetitive questioning, in the absence of any focal neurologic features that would suggest other problems like a stroke. Behavior is otherwise normal; the patient remains alert and cognition is not impaired, but he or she is often disoriented to time and place. The vast majority of attacks last between 1 and 8 hours and after the attack the patient's the ability to form new memories gradually returns, although she remains amnestic to events that took place during the episode. Patients may feel "something is wrong," but in many cases there is a profound lack of insight and the patient may have had to be coaxed by a worried observer into coming to the ED. That’s what happened with one particularly memorable (sorry) case I saw: a man who raced his sail boat around the island on Nantucket while being observed to have what turned out to be TGA. His daughters finally got him to agree to go to the ER, where I diagnosed, reassured and discharged the patient. I am still waiting for the boat trip he promised me.

Detailed neuropsychologic examination of patients during an attack of TGA shows that personality, complex cognition, problem-solving, semantic knowledge, language, and visuospatial function are all normal. Patients can learn a list of words and retain them when they are able to rehearse but rapidly forget when distracted. Although distant memories tend to be preserved, semantic memory (long-term memory responsible for the storage and integrity of knowledge about the world, including the meaning of words and objects) and "metamemory" (the awareness of what one should know) are usually preserved.

Bad news wipes out memory

No one knows why it occurs, but as one brilliant physician explained in a paper on the Emergency Department treatment of TGA “in approximately one third of cases TGA is precipitated by an emotional experience, intense pain or cold, or strenuous physical activity. Well-described precipitating factors include…emotionally taxing episodes such as being robbed, hearing bad news, or experiencing painful medical procedures.” Transient global amnesia is often caused by emotionally taxing episodes, including hearing bad news, like, presumably, the death of a loved one. And in today’s page of Talmud, it is as if transient global amnesia followed the death of Moses on a national level. Thousands of rulings in Jewish law were forgotten, only to be restored some time later:

אמר רבי אבהו אעפ"כ החזירן עתניאל בן קנז מתוך פלפולו

Rabbi Abbahu says: Even so, Othniel, son of Kenaz, restored them through his sharp mind

Never Forget

In his seminal work on Jewish Memory Zachor, Yosef Chaim Yerushalmi (d. 2009) noted that the command to remember -zachor - is repeated one-hundred and sixty-nine times in the Bible. Remember the Sabbath day, remember what Amalek did to you; remember what God did to Miriam; remember the exodus from Egypt, and on and on. “And as Israel is enjoined to remember” he wrote, “so it is adjured not to forget. Both imperatives have resounded with enduring effect among the Jews since biblical times.” We are one week from Tisha Be’Av the Fast of the Ninth of Av, the day on which Jewish calamities are re-membered, the day on which Jews are reminded: Never Forget. But if grief can cause us to forget parts of our national heritage, it can also spurn us to recall them too. The laws that were forgotten when Moses died were restored through hard work. The amnesia was transient. The rebuilding began once the period of mourning was over. And that is the story of the Jews writ large.