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

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

To act as a Cohen you must look like a Cohen

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

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

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

From  here .

From here.

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

“One whose eyes are constantly moving”

זויר- דמזור עיניה

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

Liver Disease and the Cohen

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

בכורות מד, ב

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

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

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

Severe gynecomastia in a young man. From  here .

Severe gynecomastia in a young man. From here.

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

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

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

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

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

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

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

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

The terrible dangers of alcohol abuse 

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

“Since it was made using boiling water, beer was safer to drink than water which quickly becomes contaminated with human waste even in the smallest settlements…wine also made water safe. As well as being free of pathogens, wine contains natural antibacterial agents that are liberated during the fermentation process…Much of the appeal of other beverages, starting with beer in the Neolithic period, was that they were less likely than water to be contaminated.”
— Tom Standage. A History of the World in Six Glasses. Walker Publishing 2006.pp 21, 59, 266.

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

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Chullin 105b ~ The Healing Effects of Alcohol

חולין קה, ב

לכרסם דחמרא שיכרא דשיכרא מיא דמיא לית ליה תקנתא והיינו דאמרי אינשי בתר עניא אזלא עניותא

The treatment for catarrh caused by the foam of wine is beer; the treatment for catarrh caused by the foam of beer is water; and for catarrh caused by the foam of water there is no remedy. And this is in accordance with the adage that people say: Poverty follows the poor. [Not only does a pauper have nothing to drink other than water, but there also is no treatment for the disease caused by his beverage.]

Beer and Health image.png

In today’s page of Talmud we read that the disease known as karsom (כרסם) was caused by the “foam” that floats above wine, beer or water. Karsom is translated by the Soncino, Koren and ArtScroll Talmuds as catarrh, that green phlegmy discharge from our noses and mouths when we come down with a heavy cold. In his dictionary, the great philologist of rabbinic literature Marcus Jastrow notes that there is another spelling of the word, barsom, (ברסם) “a dripping like balsam, whence catarrh of the head.” And Rashi describes it as “nasal mucus” (רירין הבאין מן החוטם). In any event, the cure for one type of this mucus was beer, which raises the question - can ingesting alcohol cure disease?

We are not going to examine the ongoing debate as to whether a regular glass of wine is good for you or not. At best the evidence is mixed, with any positive effects being highly dependent on not drinking “too much.” Alcohol may be cardioprotective, but only at a moderate dose and frequency of ingestion. On the other hand, even at a low dose, alcohol does some pretty terrible things to your immune system and ability to repair damaged tissue.

...even after a single acute or binge exposure, alcohol leads to tissue damage. In gastric mucosa and in bone, alcohol exposure alters basic signaling processes. In the repair of skin damage following injury or surgery, alcohol disrupts signaling in a broader context, in multiple tissue types. The derangement of the inflammatory response by alcohol leads to altered cytokine and chemokine production by multiple cell types and this, in turn, influences the responses of other cell types.
— Jung et al. Alcohol Exposure and Mechanisms of Tissue Injury and Repair. Alcohol Clin Exp Res. 2011 ; 35(3): 392–399.
Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk.
— O'Keefe et al. Alcohol and Cardiovascular Health: The Dose Makes the Poison...or the Remedy. Mayo Clin Proc.2014;89(3):382-393.

Alcohol has been used as a medicine for over 5,000 years and when thee alternative was drinking water contaminated with bacteria, alcohol provided a safer (and certainly more enjoyable) way to remain hydrated, since it is a natural antiseptic. Juniper essential oil for example, which is obtained from Juniper berries is both antimicrobial and antifungal. It is also an essential ingredient of gin. “Juniper is such an important aspect of gin” we learn on this useful website, “that quite literally, it is not only the primary botanical used in gin but by law, it needs to be the predominant flavour in anything seeking to be classified as gin.”

alcohol and the discovery of the cause of CHolera

In the 1850s, London (and much of Europe) suffered a series of cholera outbreaks, and no-one knew what caused them. But John Snow (1813-1858), anesthesiologist to Queen Victoria had a hunch. He drew a map of the deaths around the Broad Street pump, which, he suspected was somehow involved in transmitting whatever it was that was spreading the disease.

Snow map detail.png

There were a large cluster of deaths in the immediate vicinity of the Broad Street Pump; that made sense if the pump was supplying contaminated water. However, there were far fewer deaths than would be expected at the brewery, which lay at the corner of Broad Street and Hopkin Street. Snow dug deeper, and this is what he found:

John Snow.  On the Mode of Communication of Cholera . London, John Churchill 1855. p42.

John Snow. On the Mode of Communication of Cholera. London, John Churchill 1855. p42.


The men had been saved by their allotted drinks of beer, which came from a separate well and not from the one on Broad Street. This explanation did much to bolster Snow’s suspicions. On September 8, 1854 he famously removed the pump handle which prevented the pump from being used and, so the story goes, the cholera epidemic was averted.

Alcohol and Influenza

The Talmud had suggested wine would fight some infections. In the last century physicians had a similar idea. In 1913 in New York, a physician named John Hopkirk published a small book: Influenza. Its History, Nature, Cause and Treatment. To cure some of the many complications of influenza (including pneumonia and otitis media) Hopkirk wrote that “it will always be necessary…to administer port or champagne…there is no finer pick-me-up after an attack of influenza than good “fiz”.” During the Great Flu Epidemic of 1918 a few years later, physicians reverted to a similar strategy. Writing in the London Times on November 1, 1918, Britain’s chief medical officer had limited advice: wear small face masks, eat well, and drink a half bottle of light wine.

Purim in next week

When celebrating the festival of Purim, the Talmudic sage Rava recommends (Megillah 7b) that a person drink until they are so inebriated that they cannot distinguish between the phrases “cursed is Haman” (the enemy of the Jews), and “blessed be Mordechai” (one of the key figures in their salvation). Perhaps in doing so, we can remain sober enough to remember that from the time of the Talmud until today alcohol was thought to prevent and cure all manner of disease. But only in moderation.

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Ketuvot 65a ~ Too Drunk To Say No

In today's daf, the Talmud is discussing the provisions that an absent husband must legally provide for his wife, at least until his return home. Wine is not to be provided - unless the woman is used to drinking it (רגילה שאני). In this case, she may be given a single cup of wine, even though her husband is not at home. And then comes this teaching:

תנא: כוס אחד יפה לאשה, שנים ניוול הוא, שלשה תובעת בפה, ארבעה אפילו חמור תובעת בשוק ואינה מקפדת

One cup of wine is good for a woman; two is a disgrace; if she drinks three cups of wine she will verbally demand marital relations. And after four cups of wine a woman will solicit even a donkey in the marketplace, and she could not care...

The Effects of Alcohol on Sexual Desire

The pharmacological effects of alcohol have been extremely well studied.  Although in popular culture alcohol is thought to be a sexual stimulant, its physiological effects actually reduce sexual arousal. Alcohol also causes disinhibition, making those who have been drinking more likely to engage both in sex, and in sexual risk-taking. Alcohol has depressant effects and caused its disinhibition all the animals models in which it has been tested, including, most recently, the nematode, c. elegans. It is these effects that the Talmud is referencing here, in so far as they effect only women.  (Men's sexual desire and sexual performance is also affected by alcohol, but since this is not the subject of the discussion in the daf, we won't go there.) 

...alcohol specifically disinhibited these behaviors [locomotion, feeding and escape] in worms...
— Topper SM, et al. (2014) Alcohol Disinhibition of Behaviors in C. elegans. PLoS ONE 9(3): e92965. doi:10. 1371

Too Drunk To Say No

The Talmud describes an effect of too much alcohol: it causes such a degree of sexual disinhibition that an intoxicated women looses all sense of propriety. In fact, she gets so drunk that she is prepared to commit bestiality.  In the United Kingdom three high profile court cases (the Dougal case-November 2005, the Hagan case-November 2006, and the Bree case-December 2006) illustrated the talmudic supposition in today's daf. In all cases the women who were raped were heavily intoxicated and the defendants, who admitted having had sexual intercourse but denied rape, were acquitted. If a woman is drunk, her no doesn't mean NO

Writing in the Stanford Law Review, Karen Kramer outlined ways which cultural myths surrounding alcohol and the place of men and women in society converge to produce a double standard. If the rapist was drunk, it reduces his culpability; if the victim was drunk, it increases her culpability.

Expectancy beliefs about alcohol - which include the beliefs that alcohol increases sexual arousal, loosens women's sexual inhibitions and increases men's feelings of power and dominance - interact with traditional notions of male aggressiveness and female submission  to set the stage for acquaintance rape. When a woman is visibly intoxicated a man may interpret friendly or flirtatious behavior an invitation to have sex. Believing that alcohol reduces a women's inhibitions, the man may read her behavior as a demonstration of her true but disguised desire for sexual activity.  Even if she fails to become physically affectionate, since alcohol is a depressant, the woman may be less able to resist unwanted sexual advances. Her lack of resistance may sound like a resounding "yes" to a man who subscribes to the tradition model of male aggression and female submission.  Moreover if the man is drinking as well, he may feel safe disregarding her will,because he knows that he can blame his aggressionon the alcohol. This is not to say that any sexual interaction between intoxicated individuals constitutes rape, but drinking does enable a man to overpower an unwilling woman while feeling confident that he can blame his own actions on the alcohol.

Over  twenty years ago, the journalist Helen Benedict in her book Virgin or Vamp described the myth of our culture in which women who drink too much are "asking for it." I had no idea that the myth could also be found embedded in our Talmud. 


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