Kenneth M.Prager, M.D.
Columbia Presbyterian Medical Center, New York

When I was an elementary school student in yeshiva - a Jewish parochial school with both religious and secular studies - my classmates and I used to find amusing a sign that was posted just outside the bathroom. It was an ancient Jewish blessing, commonly referred to as the asher yatzar benediction, that was supposed to be recited after one relieved oneself. For grade school children, there could be nothing more strange or ridiculous than to link to acts of micturition and defecation with holy words that mentioned God's name. Blessings were reserved for prayers, for holy days, or for thanking God for food or for some act of deliverance, but surely not for a bodily function that evoked smirks and giggles.

It took me several decades to realize the wisdom that lay behind this blessing that was composed by Abayei, a fourth-century Babylonian rabbi.

Abayei's blessing is contained in the Talmud, an encyclopedic work of Jewish law and lore that was written over the first five centuries of the common era. The Jewish religion is chock-full of these blessings, or brachot, as they are called in Hebrew. In fact, an entire tractate of Talmud, 128 pages in length, is devoted to brachot.

On page 120 (Brachot 60b) of the ancient text it is written: "Abayei said, when one comes out of a privy he should say: Blessed is He who has formed man in wisdom and created in him many orifices and many cavities. It is obvious and known before Your throne of glory that if one of them were to be ruptured or one of them blocked, it would be impossible for a man to survive and stand before You. Blessed are You that heals all flesh and does wonders."

An observant Jew is supposed to recite this blessing in Hebrew after each visit to the bathroom. We young yeshiva students were reminded of our obligation to recite this prayer by the signs that contained its text that were posted just outside the restroom doors.

It is one thing, however, to post these signs and it is quite another to realistically expect preadolescents to have the maturity to realize the wisdom of and need for reciting a 1600-year-old blessing related to bodily functions.

It was not until my second year of medical school that I first began to understand the appropriateness of this short prayer. Pathophysiology brought home to me the terrible consequences of even minor aberrations in the structure and function of the human body, At the very least, I began to no longer take for granted the normalcy of my trips to the bathroom. Instead, I started to realize how many things had to operate just right for these minor interruptions of my daily routine to run smoothly.

I thought of Abayei and his blessing. I recalled my days at yeshiva and remembered how silly that sign outside the bathroom had seemed. But after seeing patients whose lives revolved around their dialysis machines, and others with colostomies and urinary catheters, I realized how wise the rabbi had been.

And then it happened: I began to recite Abayei's bracha. At first I had to go back to my siddur, the Jewish prayer book, to get the text right. With repetition - and there were many opportunities for a novice to get to know this blessing well - I could recite it fluently and with sincerity and understanding.

Over the years, reciting the asher yatzar has become for me and opportunity to offer thanks not just for the proper functioning of my excretory organs, but for my overall good health. The text, after all, refers to catastrophic consequences of the rupture or obstruction of any bodily structure, not only those of the urinary or gastrointestinal tract. Could Abayei, for example, have foreseen that "blockage" of the "cavity," or lumen, of the coronary artery would lead to the commonest cause of death in industrialized countries some 16 centuries later?

I have often wondered if other people also yearn for some way to express gratitude for their good health. Physicians especially, who are exposed daily to the ravages that illness can wreak, must sometimes feel the need to express thanks for being well and thus well-being. Perhaps a generic, nondenominational asher yatzar could be composed for those who want to verbalize their gratitude for being blessed with good health.

There was one unforgettable patient whose story reinforced the truth and beauty of the asher yatzar for me forever. Josh was a 20-year-old student who sustained an unstable fracture of his third and fourth cervical vertebrae in a motor vehicle crash. He nearly died from his injury and required emergency intubation and ventilatory support. He was initially totally quadriplegic but for weak flexion of his right biceps.

A long and difficult period of stabilization and rehabilitation followed. There were promising signs of neurological recovery over the first few months that came suddenly and unexpectedly: movement of a finger here, flexion of a toe there, return of sensation here, adduction of a muscle group there. With incredible courage, hard work, and an excellent physical therapist, Josh improved day by day. In time, and after what seemed like a miracle, he was able to walk slowly with a leg brace and a cane.

But Josh continued to require intermittent catheterization. I know only too well the problems and perils this young man would face for the rest of his life because of a neurogenic bladder. The urologists were very pessimistic about his chances for not requiring catheterization. They had not seen this occur after a spinal cord injury of this severity.

Then the impossible happened. I was there the day Josh no longer required a urinary catheter. I thought of Abayei's asher yatzar prayer. Pointing out that I could not imagine a more meaningful scenario for its recitation, I suggested to Josh, who was also a yeshiva graduate, that he say the prayer. He agreed. As he recited the ancient bracha, tears welled in my eyes.

Josh is my son.