Bava Metzia 85b ~ Rebbi's Ailments

בבא מציעא פה, ב 

שמואל ירחינאה אסייה דרבי הוה חלש רבי בעיניה א"ל אימלי לך סמא א"ל לא יכילנא אשטר לך משטר [א"ל] לא יכילנא הוה מותיב ליה בגובתא דסמני תותי בי סדיה ואיתסי

Shmuel Harchina'ah was Rebbi's physician. One day Rebbi was suffering from an eye ailment. Shmuel said to him, "I will insert this medication into your eyes." Rebbi told him "I cannot endure that treatment." Shmuel said to him "I will gently put a salve on the surface of your eyes." Rebbi replied "I cannot endure that either." So Shmuel put a tube of medicine under Rebbi's pillow, and he was cured." [Bava Metzia 85b]

RABBI YEHUDAH HANASSI, EDITOR EXTRAORDINAIRE

Rebbi, (Teacher) was the moniker of  Rebbi Yehudah Hanassi, Judah the Prince (~135-217 CE). Rebbe edited the Mishnah, and so had a pivotal role in the formation of Jewish practice and indeed the evolution of Judaism itself.  According to the great scholar of the Talmud David Halivni, the Mishnah came into being 

...as a result of the exigencies of the post-Temple era...towards the second half the of century with the termination of the oppressive Roman regimens, the Mishnah continued to flourish through the activities of the enormously prestigious R. Judah Hanassi...only to collapse of its own weight soon after R. Judah Hanassi's death.  
As a result, relatively few additions entered the Mishnah; it basically remained much the same as it was when compiled by the editor-anthologist.  This is why the Mishnah is the only classical rabbinic book about whose editor we are relatively certain.  We have no idea who the editors were of any of the other classic rabbinic texts (including the Talmud) but the evidence clearly indicates that R. Judah Hanassi was the editor-anthologist of the Mishnah.  This evidence is based on two sources: the occasional cross reference by R. Yochanan to R. Judah as editor-anthologizer and, above all, the fact that no one who lived after R. Judah Hanassi is mentioned in the Mishnah. 

Even though Rebbi was on very good terms with the leader of the Roman occupiers of Israel, the Emperor Macrus Aurelius Antoninus, he was not a healthy man, and suffered from a great many ailments. You may recall some of them when we studied Ketuvot. There we read that he suffered with an intestinal disorder, and Rebbi’s maid noted that he needed to use the latrine very often. This was causing him great distress –although apparently the distress was not because he needed to move his bowels so often, but rather that as a result of his condition, he could not wear tefillin. 

THE MEDICAL HISTORY OF RABBI YEHUDAH HANASSI

Recent scholars have been tempted to diagnose the many illnesses from which Rebbi suffered. In her Hebrew paper The Illnesses of Rabbi Yehudah HaNassi in Light of Modern Medicine, the historian Esther Divorshki  from the University of Haifa noted that more is known about the ailments of Rebbi than about any other talmudic sage. Some think that Rebbi suffered from painful hemorrhoids, to such a degree that his cries could be heard when he used the latrine (and as described in today's page of Talmud). Rebbi was so distressed by this illness that he ascribed to it a religious meaning, and proclaimed: “The righteous die though intestinal diseases.” But as Divorshki correctly notes, hemorrhoids are not painful to the degree described in the Talmud (– unless complicated by anal fissures). She therefore suggests that Rebbi’s illness - the one from which he died - was an inflammatory bowel disease.

Rebbi suffered from a number of other diseases throughout his life. In Nedarim  we learn that he had episodes of temporary memory loss. He was also afflicted with צמירתא and צפרנא (that's in taday's daf, Bava Metziah 85a). Divorshki the historian notes that some have suggested that צמירתא is kidney stones, perhaps complicated with urinary tract infections. As for צפרנא, (or, in variant forms, צפדנא) Avraham Steinberg from Sha'arei Tzedek Hospital suggests that since this disease was characterized by bleeding from the gums, “it seems reasonable to identify this illness with scurvy.” Julius Preuss had a similar suggestion, one he offered with great certainty: “There can be no doubt that tzafdina refers to stomatitis, perhaps scorbutic stomatitis which also occurs sporadically.” And if these were not enough, today we leaned that Rebbi also had an eye ailment, which his personal physician Shmuel was able to cure, as well as inflammation of his joints, (Yerushalmi Shabbat 16:1) that suggests the illness we call gout. 

A UNIFYING DIAGNOSIS?

Can a wise clinician put all this together and come up with a single unifying diagnosis that can explain all of Rebbi’s terrible symptoms? In 1978, Ari Shoshan suggested in Korot, The Israel Journal of the History of Medicine and Science, that Rebbi suffered from a psychosomatic disease. However, Divorshki suggests that the rapidly advancing field of genetics can provide a more satisfying solution. She posits that Rebbi had a seronegative spondyloarthritis associated with a specific tissue type called HLA (Human Leukocyte Antigen) B-27. (Don't be afraid. Seronegative means that the condition is not associated with rheumatoid factor, and spondyloarthritis is a group of conditions that causes inflammation of the joints - and other tissues.)  This tissue disorder –a kind of autoimmune disease - is associated with gout (Rebbi had that) and inflammation of the mouth (check) and uveitis – a painful inflammatory eye condition (that's the passage in today's daf with which we opened.). Perhaps, Divorshki notes, צמירתא was not in fact kidney stones or a urinary infection, but an inflammation of the bladder wall or referred pain from an inflammation of the intestines, caused by the same nasty tissue disorder. For reasons that are still not known, this autoimmune disease can flare up and then, just as mysteriously, become dormant for months or years, which could explain how Rebbi appeared to have been cured.

 

Schematic ribbon diagram of the HLA-B27 molecule’s peptide-binding cleft with a bound peptide (light blue); the letters N and C indicate, respectively, the amino and carboxy termini of the bound peptide. HLA-B*27:06, one of the two subtypes that seem to have no association with ankylosing spondylitis, and the disease-associated subtype HLA-B*27:04 (from which Rebbi may have been suffering) differ from each other by two residues at positions 114 and 116. From Khan, MA.  Polymorphism of HLA-B27: 105 Subtypes Currently Known.  Current Rheumatology Reports. (2013) 15:362

Schematic ribbon diagram of the HLA-B27 molecule’s peptide-binding cleft with a bound peptide (light blue); the letters N and C indicate, respectively, the amino and carboxy termini of the bound peptide. HLA-B*27:06, one of the two subtypes that seem to have no association with ankylosing spondylitis, and the disease-associated subtype HLA-B*27:04 (from which Rebbi may have been suffering) differ from each other by two residues at positions 114 and 116. From Khan, MA.  Polymorphism of HLA-B27: 105 Subtypes Currently Known.  Current Rheumatology Reports. (2013) 15:362

We now have identified at least 105 subtypes of HLA-B27, and the list continues to grow.  Today, seronegative spondyloarthitis, of the sort that may have afflicted Rebbi, can often be managed with medications that suppress the immune response. But without these, damage to the host tissues slowly builds until the organ systems start to fail, offering no respite from the painful symptoms of this disease. Perhaps now we are in a position to better understand Rebbi’s dying words, which appear on Ketuvot 104a.

“May it be Your will that there will be peace when I rest in eternity.”

Rebbi wanted nothing more than respite from his pain, and his wish was granted: ‘A voice from heaven emerged and said: “He will come with peace, they will rest on their resting places.”

[Repost from here.]