Liver disease

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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