Pesachim 113a ~ The Problem of Polypharmacy

On today’s page of Talmud there is lots of advice. Lots and lots. Live in a city which has horses that neigh and dogs that bark, because they will provide security. Don’t live in a city where the mayor is a doctor, for he will be too busy with his job to govern properly. Then comes this

פסחים קיג, א

אֲמַר לֵיהּ רַב לְחִיָּיא בְּרֵיהּ: לָא תִּשְׁתֵּי סַמָּא, וְלָא תְּשַׁוַּור נִיגְרָא, וְלָא תִּעְקַר כַּכָּא, וְלָא תְּקַנֵּא בְּחִיוְיָא

Rav said to Chiyya, his son: Do not get into the habit of drinking medications, lest you develop an addiction. And do not leap over a ditch, as you might hurt yourself in the process. And do not pull out a tooth, but try to heal it if possible. And do not provoke a snake in your house to try to kill it or chase it away…

Today we will focus on the first bit of advice on this list - the problem of taking too many medications.

The problem of polypharmacy

There is a medical word that describes taking too many medications - it is called polypharmacy. And it is a real problem, especially in the elderly, who are often prescribed one drug after another as they see different specialists and sub-specialists. There is some debate about how many drugs are considered to be polypharmacy, but most physicians have a cut off at five or more in one person.

The Rashbam and the NIH on addiction

The Rashbam (1085-1158), grandson of the famous French commentator Rashi, gave this explanation on today’s passage of Talmud:

לא תשתי סמא - אל תשתה סמים מפני שנקבע להם ווסת ויהא לבך שואלך ותפסיד מעות ואפילו לרפואה לא תישתי אם אפשר לרפואה אחרת

Do not take drugs - Don’t take drugs because you will become addicted to them, and you will constantly be looking for them and spend lots of money. Even when they are needed to cure you, do not take them if there is an alternative.

The Rashbam’s words here could not be of more relevance to us moderns. The problem of drug addiction and the abuse of some prescribed medications is one of the leading health challenges facing the US and other industrialized nations. In fact, before the COVID pandemic, it occupied much of the attention of the US National Institutes of Health, which set up a multi-million dollar investment program to address the crisis called HEAL - Helping to End Addiction Long-Term. I played a small but I hope useful role in the effort, helping to establish a program to develop effective, non-addictive treatments to reduce the burden of illness due to pain and to reduce risk of addiction. Only a few drugs we use today have the potential to become addictive, and the Rashbam’s words do not feature in the current advice we give our patients. But when we do use these useful but potentially addictive and dangerous drugs, we must do so with the utmost care.

The Dangers of Polypharmacy

The Artscroll English translation of the passage above reads “do not ingest any unnecessary drugs.” Of course what makes a drug unnecessary is often a matter of legitimate medical dispute, but there is no doubt that taking a lot of medications - polypharmacy - can lead to some serious complications. In a recent expert review of the dangers of taking too many drugs researchers noted that “in general, polypharmacy has been linked to a range of negative outcomes, including falls, frailty, and mortality.” It is hard to tease out any causation (as opposed to any association) though, and the research is complicated. Is a person taking lots of drugs more likely to be weak and fall and get infections because of the several drugs she is taken, or has she been prescribed several drugs precisely because she is frail and at risk of these and other problems?

The outcomes associated with polypharmacy can be broadly put into four categories as you can see in the figure below. “In the inner circle, closest to polypharmacy, are drug-related outcomes, such as drug-drug interactions. As we move to the outer circles, the outcomes could potentially be related to the more proximal outcomes (e.g. drug-drug interactions can contribute to hospital admissions) and are also more likely to be affected by other health-related factors.” Here are some of the problems of polypharmacy.

A framework for polypharmacy and conceptual classification of outcomes. From Jonas W. Wastesson, Lucas Morina, Edwin C.K. Tan, Kristina Johnell. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opinion of Drug Safety 2018: 17 (12); 1185-1196.

1. Adverse drug reactions. All drugs have side effects, and the more drugs you take, the more likely you are to experience some of those effects. In addition, drugs interact with each other, often in bad ways. In fact up to 10% of hospitalizations in the elderly are due to adverse drug reactions.

2. A Swedish study based on nationwide registers found that the risk of falls increased with the number of drugs used in a dose-response fashion, meaning the more drugs you take, the more likely you are to fall.

3. Physical function like getting out of a chair or gripping something is reduced in those with polypharmacy, though it is difficult to establish a causal relationship.

4. Polypharmacy has been shown to cause frailty and sarcopenia, which is a loss of muscle mass.

5. Polypharmacy has been linked to lowered cognitive functions and dementia. In a study of community-living Japanese older adults, polypharmacy was associated with lower cognitive status, and a longitudinal register-based (nested case-control) study matching incident dementia cases with dementia-free cases found that polypharmacy was associated with receiving a dementia diagnosis. 

6. Polypharmacy has been linked with hospital admission in studies including general older adults, nursing home residents, and in people diagnosed with dementia. One researcher found that the risk of unplanned hospital admissions increased with the number of medications used, though this effect was less evident for people with a high number of chronic conditions.

7. Finally, polypharmacy has been linked with increased mortality. A 2017 systematic review (with meta-analysis) estimated that the risk of death goes up by around 8% for each additional drug taken. So not good.

The authors of this review leave us with these sobering conclusions:

The prevalence of polypharmacy in older adults is increasing in most countries. This is a cause for concern given the observed association between polypharmacy and a wide spectra of negative health outcomes, including drug-related problems, adverse drug events, physical and cognitive function, hospitalization, and mortality… scalable interventions to reduce polypharmacy (by deprescribing or other interventions) is needed to revert the trend of increasing levels of polypharmacy in the older population.

Prevention is better than cure

Commenting on today’s passage of Talmud, Rabbi Yosef Chaim of Baghdad, known as the Ben Ish Chai (1860-1930), gave this advice:

לָא תִּשְׁתֵּי סַמָּא. פירוש אם ראית בעצמך התחלת מיחוש באיזה חולי לא תמהר לשתות סם דהסם עושה מלחמה עם החולי וראוי תחלת הכל וְקָרָאתָ אֵלֶיהָ לְשָׁלוֹם (דברים כ, י) שתעשה הכנות טבעיות לשמירת עצמך מן החולי הן מצד האכילה שקורין בערבי פהרי"ז הן מצד הישיבה והמנוחה והמקום וכיוצא בזה ואולי יהיה לך זה עזר לרפואה טבעית ולא תצטרך לשתות סם לגמרי

If you begin to feel unwell from some disease, do not rush to make a drug, because the drug will wage war against the illness. But it is best…if you use a natural preparation to keep yourself healthy and prevent illness, with a proper diet, and also by sitting comfortably, getting enough rest, and paying attention to where you live, and so on. In doing so, perhaps this will provide natural healing and you will not need any drugs at all.

Just like the advice of the Rashbam, the Ben Ish Chai is also spot on. Preventing disease with exercise, a proper diet, getting enough rest and living in a healthy environment are far better for you than trying to treat a disease once it has begun. This does not mean that diseases that we can and should treat with medications are best tackled with “natural interventions.” Cinnamon does not help control your blood sugar if you have diabetes. But insulin does. Still, the advice of the Rashbam and Ben Ish Chai should be played on a loop in the waiting room of doctor’s offices and clinics. And we should listen.

Pesachim 112b ~ The Causes of Epilepsy

Today’s page of Talmud discusses the etiology of epilepsy.

פסחים קיב,ב

שְׁלֹשָׁה דְּבָרִים צִוָּה רַבִּי יוֹסֵי בְּרַבִּי יְהוּדָה אֶת רַבִּי: אַל תֵּצֵא יְחִידִי בַּלַּיְלָה, וְאַל תַּעֲמוֹד בִּפְנֵי הַנֵּר עָרוֹם, וְאַל תִּכָּנֵס לְמֶרְחָץ חָדָשׁ, שֶׁמָּא תִּפָּחֵת. עַד כַּמָּה? אָמַר רַבִּי יְהוֹשֻׁעַ בֶּן לֵוִי: עַד שְׁנֵים עָשָׂר חֹדֶשׁ. וְאַל תַּעֲמוֹד בִּפְנֵי הַנֵּר עָרוֹם, דְּתַנְיָא: הָעוֹמֵד בִּפְנֵי הַנֵּר עָרוֹם — הָוֵי נִכְפֶּה. וְהַמְשַׁמֵּשׁ מִטָּתוֹ לְאוֹר הַנֵּר — הָוַיִין לוֹ בָּנִים נִכְפִּין 

Rabbi Yosei, son of Rabbi Yehuda, commanded Rabbi Yehuda HaNasi with regard to three matters: Do not go out alone at night; do not stand naked before a candle; and do not enter a new bathhouse, lest it collapse when they light the fire beneath it…

With regard to not standing naked before a candle, the Talmud comments that this is as it was taught in a baraita: One who stands naked before a candle will become epileptic, and one who engages in intimacy by candlelight will have epileptic children.

Having established one cause of epilepsy, the Talmud then add to it, and includes some nuanced qualifications.

תָּנוּ רַבָּנַן: הַמְשַׁמֵּשׁ מִטָּתוֹ עַל מִטָּה שֶׁתִּינוֹק יָשֵׁן עָלֶיהָ — אוֹתוֹ תִּינוֹק נִכְפֶּה. וְלָא אֲמַרַן אֶלָּא דְּלָא הָוֵי בַּר שַׁתָּא, אֲבָל הָוֵי בַּר שַׁתָּא — לֵית לַן בַּהּ. וְלָא אֲמַרַן אֶלָּא דְּגָנֵי לַהֲדֵי כַּרְעֵיהּ, אֲבָל גָּנֵי לַהֲדֵי רֵישֵׁיהּ — לֵית לַן בַּהּ. וְלָא אֲמַרַן אֶלָּא דְּלָא מַנַּח יְדֵיהּ עִילָּוֵיהּ, אֲבָל מַנַּח יְדֵיהּ עִילָּוֵיהּ — לֵית לַן בַּהּ. 

Likewise, the Sages taught: One who engages in intimacy in a bed upon which a baby is sleeping, that child becomes epileptic. And we said that this will occur only if the child is not yet one year old; however, if he is one year old we have no problem with it, as he is old enough not to be affected. And furthermore, we said this only concerning a baby that is sleeping near the father’s feet; but if the baby is sleeping near his head he is sufficiently far away so that we have no problem with it. And we said this only if he does not place his hand on the baby at the time, but if he places his hands on the baby to serve as a barrier between them, we have no problem with it.

What is Epilepsy?

Epilepsy is caused by inappropriate and disorderly firing of neurons in the brain. The word comes from the French épilepsie, or from the earlier Greek epilambanein ‘seize, attack’, (from epi ‘upon’ and lambanein ‘take hold of’). It describes a condition which can manifest in a number of different ways. The person can look out blankly into the distance and not respond. These are called absence seizures. Sometimes it begins with an odd sensation of smell or sounds. This is called an aura, and it may herald a more generalized seizure. Generalized seizures may begin with a shaking in one limb, and then the person falls to the ground with a generalized seizure. These are very scary to watch, but usually resolve by themselves within a couple of minutes. Following this, during the postictal period, the person typically falls into a deep sleep for some time, perhaps half an hour or so, and often has no recollection of the events. Sometimes the generalized seizures do not end; this is called status epileptics, and it is a life-threatening condition.

The Causes of Seizures

The two most commonly identified causes of seizures are a neurologic birth injury (8%) and cerebrovascular disease (11%). But lots of other things can cause seizures, like head trauma (6%), brain tumor (4%), and infections of the central nervous system (3%). In the elderly, the cause of a new seizure is more likely to be vascular (from say a stroke), or a tumor.

In addition, some toxins can cause seizures. Of these alcohol is the one most commonly associated with seizures. And some stressors like fatigue or sleep deprivation may exacerbate an underlying seizure disorder.

Scientific vs Talmudic Causes of Seizures and Epilepsy

From Harwood-Nuss’ Clinical Practice of Emergency Medicine. Kluwer 2021. Chap 159.

• Standing naked in front of a candle (Pesachim 110)

• Engaging in intimacy in a bed upon which a baby is sleeping (that child becomes epileptic) (Pesachim 110)

• Copulating in a mill (will lead to epileptic children) (Ketuvot 60b)

• After going to the bathroom, not waiting the time to walk half a mil before having sexual intercourse (Gittin 70a). This is because the demon of the bathroom accompanies the person and then attacks.

Epilepsy in the Jewish Bible

In the Bible (Numbers 24:4) the prophet Bilaam introduces himself with the following enigmatic words:

במדבר 24:3

נְאֻ֕ם שֹׁמֵ֖עַ אִמְרֵי־אֵ֑ל אֲשֶׁ֨ר מַחֲזֵ֤ה שַׁדַּי֙ יֶֽחֱזֶ֔ה נֹפֵ֖ל וּגְל֥וּי עֵינָֽיִם׃ 

The speech of he who hears God’s speech, Who beholds visions from the Almighty, who falls, but with eyes open.

In his classic work Biblical and Talmudic Medicine, Julius Preuss wrote that the expression “with open eyes” refers “to a clairvoyant soothsayer.”

I am equally certain that the term “fallen down,” is the designation for epileptics; for in Hebrew and Arabic, the verb naphal, whose present participle is nophel, always means fallen down…Who first offered this explanation (of the term nophel meaning “fallen down”)? I can certainly not be the first, for this explanation seems to be very obvious. However I have looked in vain in numerous translations and commentaries of ancient and modern times and in exegetic handbooks and dictionaries…

Preuss noted that the same word is found in the story of Saul (I Sam 19:24). “Scripture uses the expression (vayipol) in relation to Saul after he became “manitic:” and he fell down the entire day and the entire night, that is, he had frequent epileptic seizures.”

שמואל א, 19:24

וַיִּפְשַׁ֨ט גַּם־ה֜וּא בְּגָדָ֗יו וַיִּתְנַבֵּ֤א גַם־הוּא֙ לִפְנֵ֣י שְׁמוּאֵ֔ל וַיִּפֹּ֣ל עָרֹ֔ם כָּל־הַיּ֥וֹם הַה֖וּא וְכָל־הַלָּ֑יְלָה עַל־כֵּן֙ יֹֽאמְר֔וּ הֲגַ֥ם שָׁא֖וּל בַּנְּבִיאִֽם׃

Then he too stripped off his clothes and he too spoke in ecstasy before Samuel; and he fell down naked all that day and all night. That is why people say, “Is Saul too among the prophets?”

“The Egyptians and Babylonians recognized seizures as being associated with physical ills, particularly head trauma, but, like the Greeks and Romans, sometimes ascribed their occurrence to causes that seem rather more occult than physical. Epileptics were thus often considered unclean or evil, and Pliny advised persons to spit upon seeing an epileptic, “to throw back the contagion.” Such magical thinking about seizures persists, in altered forms, and is part of the stigma of epilepsy. The treatment of epilepsy may thus have great social importance for the patient, who may still have to contend with this view of epilepsy. ”

— Robert Gross. A brief history of epilepsy and its therapy in the western hemisphere. Epilepsy Research 1992: 12; 65-74.

And epilepsy in the Christian Bible

In Matthew (14:15) we read the story of a boy brought to Jesus because he was having seizures:

…a man came to him, knelt before him, and said, “Lord, have mercy on my son, because he has seizures and suffers terribly, for he often falls into the fire and into the water. I brought him to your disciples, but they were not able to heal him.” Jesus answered, “You unbelieving and perverse generation! How much longer must I be with you? How much longer must I endure you? Bring him here to me.” Then Jesus rebuked the demon and it came out of him, and the boy was healed from that moment.

In the original Greek the text reads “he is moonstruck,” a phrase related to our modern term “lunatic.” However, as the New English Translation notes, “now the term is generally regarded as referring to some sort of seizure disorder such as epilepsy.”

A Sacred Disease then and now

The earliest treatise to discuss epilepsy is called On the Sacred Disease. It was written around 400BCE. and attributed to Hippocrates. Here is how the book opens:

It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from the originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases. And this notion of its divinity is kept up by their inability to comprehend it, and the simplicity of the mode by which it is cured, for men are freed from it by purifications and incantations. But if it is reckoned divine because it is wonderful, instead of one there are many diseases which would be sacred; for, as I will show, there are others no less wonderful and prodigious, which nobody imagines to be sacred.

So the Greek author rejects the notion that the gods cause the disease. But despite the passage of time, some cultures retain a special respect for those who are epileptic. In her 1997 award winning book When the Sprit Catches You and You Fall Down, the reporter Ann Fadiman described the clash of cultures between Hmong immigrants from southeast Asia and western medicine. It is told through the story of a young Hmong girl Lia Lee who had a severe form of epilepsy.

Dan [a medical resident] had no way of knowing that Foua and Nao Kao had already diagnosed their daughter's problem as the illness where the spirit catches you and you fall down. Foua and Nao Kao had no way of knowing that Dan had diagnosed it as epilepsy, the most common of all neurological disorders. Each had accurately noted the same symptoms, but Dan would have been surprised to hear that they were caused by soul loss, and Lia's parents would have been surprised to hear that they were caused by an electrochemical storm inside their daughter's head that had been stirred up by the misfiring of aberrant brain cells. (p28)

The book painfully records what happens when an ancient system of belief is confronted with modern medicine. It is a reminder that different cultures interpret diseases and their origins in very different ways. The rabbis of the Talmud had no idea what caused the frightening condition we call epilepsy, but assumed that it was a punishment of some kind, and associated it with the sin of immodest behavior. We now know that it is nothing of the sort, and have medications that can usually bring the symptoms under control. Modern medicine, even with all its shortcomings, has given us that, for which we must be grateful.

Pesachim 109b ~ The Square Root of Two and the Danger of Pairs

The Mishnah established that a person must drink four cups of wine on the night of the Passover Seder. But this may pose a problem:

פסחים קט, ב

לֹא יִפְחֲתוּ לוֹ מֵאַרְבָּעָה. הֵיכִי מְתַקְּנִי רַבָּנַן מִידֵּי דְּאָתֵי בֵּהּ לִידֵי סַכָּנָה, וְהָתַנְיָא: לֹא יֹאכַל אָדָם תְּרֵי, וְלֹא יִשְׁתֶּה תְּרֵי, וְלֹא יְקַנַּח תְּרֵי, וְלֹא יַעֲשֶׂה צְרָכָיו תְּרֵי

But wasn’t it taught in a baraita: A person should not eat pairs, i.e., an even number of food items; and he should not drink pairs of cups; and he should not wipe himself with pairs; and he should not attend to his sexual needs in pairs.

The rabbis were concerned that doing things in pairs exposes a person to sorcery or demons. Why then would the Mishnah require that an even number of cups be drunk? That would place a person in great danger! Rabbi Nachman provides some reassurance. No harm will come because the night of the Passover Seder is a special night.

פסחים קט, ב

אָמַר רַב נַחְמָן, אָמַר קְרָא: ״לֵיל שִׁמּוּרִים״ — לַיִל הַמְשׁוּמָּר וּבָא מִן הַמַּזִּיקִין

Rav Nachman said that the verse said: “It was a night of watching to the Lord” (Exodus 12:42), which indicates that Passover night is a night that remains guarded from demons and harmful spirits of all kinds. [Therefore, there is no cause for concern about this form of danger on this particular night.]

Additional, or perhaps alternative reasons for reassurance are provided by the great Babylonian sage Rava (c.280-352), and Ravina, who lived several generations later:

רָבָא אָמַר: כּוֹס שֶׁל בְּרָכָה מִצְטָרֵף לְטוֹבָה, וְאֵינוֹ מִצְטָרֵף לְרָעָה. רָבִינָא אָמַר: אַרְבָּעָה כָּסֵי תַּקִּינוּ רַבָּנַן דֶּרֶךְ חֵירוּת, כׇּל חַד וְחַד מִצְוָה בְּאַפֵּי נַפְשַׁהּ הוּא

Rava said: The cup of blessing for Grace after Meals on Passover night is used in the performance of an additional mitzva and is not simply an expression of freedom. Therefore, it combines with the other cups for the good, i.e., to fulfill the mitzva to drink four cups, and it does not combine for the bad. [With regard to the danger of drinking pairs of cups, it is as though one drinks only three cups.]

Ravina said: The Sages instituted four separate cups, each of which is consumed in a manner that demonstrates freedom. Therefore, each and every one is a distinct mitzva in its own right.[In other words, each cup is treated separately and one is not considered to be drinking in pairs.]

The Danger of Pairs

Over the next few pages of Talmud (Pesachim 109-111) the rabbis explain some of the issues around pairs.

פסחים קי, א

תָּנוּ רַבָּנַן: שׁוֹתֶה כִּפְלַיִם — דָּמוֹ בְּרֹאשׁוֹ. אָמַר רַב יְהוּדָה: אֵימָתַי — בִּזְמַן שֶׁלֹּא רָאָה פְּנֵי הַשּׁוּק, אֲבָל רָאָה פְּנֵי הַשּׁוּק — הָרְשׁוּת בְּיָדוֹ. אָמַר רַב אָשֵׁי: חֲזֵינָא לֵיהּ לְרַב חֲנַנְיָא בַּר בִּיבִי, דְּאַכֹּל כָּסָא הֲוָה נָפֵיק וְחָזֵי אַפֵּי שׁוּקָא. 

The Sages taught in another baraita: If one drinks in pairs his blood is upon his head [i.e., he bears responsibility for his own demise]. Rav Yehuda said: When is that the case? When one did not leave the house and view the market place between cups. However, if he saw the marketplace after the first cup, he has permission to drink another cup without concern. Likewise, Rav Ashi said: I saw Rav Chananya bar Beivai follow this policy: Upon drinking each cup, he would leave the house and view the marketplace.

The great Babylonian sage Abaye (d~337 CE.) was raised never to drink precisely two cups.

פסחים קי, א

וְאַבָּיֵי, כִּי שָׁתֵי חַד כָּסָא, מְנַקֵּיט לֵיהּ אִימֵּיהּ תְּרֵי כָסֵי בִּתְרֵי יְדֵיהּ

When Abaye would drink one cup, his mother would immediately place two cups in his two hands so that he would not inadvertently drink only one more cup and thereby expose himself to the danger of drinking in pairs.

Rav Nachman, who was a contemporary of Abaye, apparently had a personal butler, and followed a similar practice:

 וְרַב נַחְמָן בַּר יִצְחָק, כִּי הֲוָה שָׁתֵי תְּרֵי כָסֵי, מְנַקֵּיט לֵיהּ שַׁמָּעֵיהּ חַד כָּסָא, חַד כָּסָא — מְנַקֵּיט לֵיהּ תְּרֵי כָסֵי בִּתְרֵי יְדֵיהּ

 And similarly, when Rav Nachman bar Yitzchak would drink two cups, his attendant would immediately place one more cup in his hand, and if he would drink one cup, the attendant would place two cups in his two hands. These reports indicate that one should be concerned for his safety after drinking an even number of cups, even when he remains at home.

Isaac Baer Levinsohn On the origins of the Suspicion

Isaac Baer Levinsohn (1788-1860) was a Ukrainian Hebrew scholar and leader of the Haskalah. In a collection of his essays and letters called Yalkut Rival published in Warsaw in 1878 he addressed the origin of the Talmudic concern about pairs of things. Here it is:

Yalkut Riva’l, Warsaw 1878, p59-60.

The Babylonian Talmud, Chapter Arve Pesachim, (109–110), expounds at length on the matter of concern about zugot, even numbered events…

In early general literature, I found that both the Greek philosopher Pythagoras and his student Plato were most particular about the number two. They believed that it indicates very bad omen. During the era of Pythagoras, this belief was prevalent over the entire Italian region. The Romans also believed in the terrible powers of the number two. Since they customarily consecrated all evil things to the god Pluto, we find in mythological books of the early Romans that the second month of the year and the second day of that month were consecrated to this god…

Our Sages (who generally sought scriptural hints at established customs) noted [in Gen. Rab. 4:7] that the second of the six days of creation is the only one in which ki tov, “that it is good” [Gen 1:6–8], is not written. We also treat the fourth day of the week like the second day, and do not begin projects on it…

However, it is distinctly possible that the number four is considered to not be good because of zugot, as it is a double pair. Tractate Pesachim of the Babylonian Talmud [112b] also states that on the eve of the fourth day [= Tuesday night] Agrat bat Machlat ventures out (see my Bet Yehudah for speculation as to the original identity of Agrat, the qelipah “shell”). Finally, to defuse these primitive beliefs from the hearts of the masses, our sages maintained elsewhere that Monday and Wednesday are, in fact, excellent days to begin projects, with a mnemonic: Ba”D qodesh, “holy Monday and Wednesday,” literally “holy fabric.”

The fear of √2

It is not clear to which writings attributed to Pythagorus Levinsohn was referring, but it may be connected to the Pythagorean discovery (if it was indeed discovered by him) that the square root of two is an irrational number. In his sweeping history of mathematics The Universal History of Numbers: From Prehistory to the Invention of the Computer Georges Ifrah wrote (p.596) that the discovery that √2 is irrational (meaning it goes on and on forever without a repeating pattern, like π) “greatly perturbed the Pythagoreans, who believed that number ruled the Universe…”

The new numbers were called “unmentionable” and the existence of these monsters was not to be divulged to the profane. According to the Pythagorean conception of the world, this inexplicable error on the part of the Supreme Architect must be kept secret, lest one incur divine wrath.

Could this explain the origin of the fear of the number two, and from that the fear of doubles in general?

The Code of Jewish Law on auspicious days

In general, Jews are forbidden to pay any attention to superstitions, although as those of you who have spent time studying the Talmud will know, Jews are a superstitious lot. Here is the Shulchan Aruch, the Code of Jewish Law, on the topic:

שולחן ערוך יורה דעה 179

שלא לכשף לעונן ולנחש. ובו י"ט סעיפים
אאין שואלין בחוזים בכוכבים ולא בגורלות: הגה משום שנאמר תמים תהיה עם ה' אלהיך (ב"י בשם תוספות דע"פ ובשם ספרי) וכ"ש דאסור לשאול בקוסמים ומנחשים ובמכשפים (פסקי מהרא"י סי' צ"ו):

It is forbidden to turn to astrologers or those who forecast using lotteries. For it is written “You shall be perfect with the Lord your God”

So far so good. But then comes this:

נהגו בשאין מתחילין בב' ובד' גואין נושאין נשים אלא במילוי הלבנה: הגה ולכן נהגו ג"כ להתחיל ללמוד בר"ח כי אע"פ שאין ניח

We have the custom not to begin a project on the second day of the week, or the fourth day of the week

Superstition in our Modern World

Our modern, rational world is still filled with superstitions. In the US, at lest 85% of buildings using an Otis elevator do not have a thirteenth floor. Actors still say to one another “break a leg” right before a show, reflecting a superstition that wishing an actor “good luck” was…bad luck. And there are any number of superstitions around boats and boating. Pairs and irrational numbers may no longer frighten us but just like our ancestors, we remain, sadly, a superstition-wary people.

“אָמַר רַב פָּפָּא, אָמַר לִי יוֹסֵף שֵׁידָא: בִּתְרֵי קָטְלִינַן, בְּאַרְבְּעָה לָא קָטְלִינַן, בְּאַרְבְּעָה מַזְּקִינַן. בִּתְרֵי, בֵּין בְּשׁוֹגֵג בֵּין בְּמֵזִיד. בְּאַרְבְּעָה, בְּמֵזִיד — אִין, בְּשׁוֹגֵג — לָא

Rav Pappa said: Yosef the Demon said to me: “If one drinks two cups, we demons kill him; if he drinks four, we do not kill him. But this person who drank four, we harm him. There is another difference between two and four: With regard to one who drinks two, whether he did so unwittingly or intentionally, we harm him. With regard to one who drinks four, if he does so intentionally, yes, he is harmed; if he does so unwittingly, no, he will not be harmed.””

— פסחים קי, א -Pesachim 110a

For more on the fifth cup and magical pairs, see the excellent paper by Leor Jacobi from where the translation of Levinsohn’s paragraph on the origin of the suspicion was taken.

Pesachim 108a ~ The Passover Seder and the Heimlich Maneuver

In describing the regulations for the proper performance of the Passover Seder, the Talmud concludes that the celebrant must recline while drinking each of the Four Cups of wine.Then comes this discussion of how, exactly, one reclines:

פסחים קח, א

פְּרַקְדָּן לָא שְׁמֵיהּ הֲסִיבָּה. הֲסִיבַּת יָמִין לָא שְׁמַהּ הֲסִיבָּה. וְלֹא עוֹד, אֶלָּא שֶׁמָּא יַקְדִּים קָנֶה לְוֶושֶׁט, וְיָבֹא לִידֵי סַכָּנָה

Lying on one’s back is not called reclining. Reclining to the right is not called reclining [as free people do not recline in this manner. People prefer to recline on their left and use their right hand to eat, whereas they find it more difficult to eat the other way]. And not only that, perhaps the windpipe will precede the esophagus. [The food will enter the windpipe, and one will come into danger of choking].

Rashi, the great medieval commentator explains that the last comment “perhaps the windpipe will precede the esophagus” refers to lying flat on ones’s back:

רש׳י פסחים קח, א

שמא יקדים - אפרקדן קאי שמתוך שצוארו שוחה לאחריו שיפוי כובע הסותם את פי הקנה נפתח ומתקפל למעלה והקנה פושט למעלה והמאכל נכנס לתוכו ונחנק

This refers to lying on the back. For then the neck is stretched backwards, and the covering that blocks the trachea is open and the trachea is thrust upwards. Food can enter and cause choking.

However Rashi had a prodigious grandson called Shmuel, who also wrote a commentary on this passage. Rabbi Shmuel ben Meir (c.1085-1158) or Rashbam, as he is known, disagreed with the explanation of his grandfather, and offered this instead:

רשב׳ם פסחים קח,א

שמא יקדים - … וקשיא לי אמאי לא סמכיה להאי ולא אהסיבת ימין ורבותי פירשו שמא יקדים קנה לושט דושט הוי על (דרך) ימין ונפתח הכובע שעל פי הקנה מאיליו כשהוא מטה כלפי ימין ואם יכנס בו המאכל הרי סכנה שאין אוכלין ומשקין נכנסין אלא דרך הושט ולכך נראה בעיני דאהסיבת ימין קאי מדסמכיה לדידיה

Anatomy of the upper airway. The esophagus (or oesophagus, as it is written in the UK) lies behind the trachea, and not to its right.

Rashi’s explanation is difficult to understand. Why did he not explain that [the danger] is when you lean to the right [while drinking]? My teachers explained that “perhaps the windpipe will precede the esophagus” refers to leaning, because the esophagus is on the right side. The covering that covers the trachea will open when he leans to the right, and if food gets into the trachea there is a danger [of choking], because food and drink should usually only be found in the esophagus. This is why I believe the Talmud is referring to the [danger of] leaning to the right…

The Rashbam’s Anatomy is incorrect

The anatomy described by the Rashbam is wrong. The trachea lies directly in front of the esophagus; one is not to the right of the other. If you reach up and put your fingers around your trachea now (go on, do it) you will not feel the esophagus because it is lying behind the trachea (and because it is essentially a long fleshy tube with no internal rings for support). This is true in us, and it is true in animals like cows, sheep and chickens, which are kosher and which, presumably, the Rashbam could have used as a model to figure this out. Had he taken a look at freshly slaughtered chicken, he would have seen this.

From Yaakov Dovid Lach, Chullin Illuminated. Brooklyn New York. Hamesivta Publications 5771(2011). p35.

The trachea clearly lies directly in front of the esophagus, though in the image the latter is slightly off center because of the pressure of the thumb.

What happens when we swallow?

The Rashbam did not have access to YouTube, which is a shame, because there are many great videos that explain the process. Here is one, for example. The key bits are at 1:44.

Deglutition: anatomy of a swallow. This video is available for instant download licensing here: https://www.alilamedicalmedia.com/-/galleries/all-animations/...

So the epiglottis acts as a trapdoor, closing off the entrance to the trachea each and every time you swallow. Of course when you talk and try to swallow your food, you are forcing air down into the into your larynx while at the same time hoping that no food gets in. When it does, you will cough at best, and choke at worst. Which is why we were always taught never to talk with our mouths full. It’s good advice.

When you choke, a piece of food is stuck around the epiglottis or top of the trachea. This stimulates our coughing reflex, in an attempt to use the force of air to dislodge the food and expel it up and out. If food gets past this sensitive area and enters the lungs, there is no more choking. It is too late for that.

But does leaning to one side or another increase the likelihood of choking on food? Not at all. First, because if you listen to your mother’s advice and don’t try and talk while swallowing, you won’t choke. And second, because the trachea, the esophagus and the epiglottis are all midline structures. Leaning to one side makes you no more or less likely to choke than does leaning to the other.

But what about the Right Main Bronchus?

The Steinsaltz (Koren) English Talmud has a nice diagram of the upper trachea and esophagus, but unfortunately it fails to label the all important epiglottis, and nor does it address the issue of the mistaken anatomy of the Rashbam. The Schottenstein (ArtScroll) English Talmud goes into a little more detail. It notes that “actually the esophagus is directly behind the windpipe…which makes it unclear what Rashbam means when he writes that the esophagus is ‘on the right side.’” So far, so good. But then comes this:

There are, though, anatomical differences between the left side and and the right side (e.g the right bronchus branches off the windpipe into the right lung at a far more gradual angle than the left one does into the left lung) that might account for why leaning on the right side presents a choking hazard whereas leaning on the left side does not.

Here is what the ArtScroll explanation is getting at:

From here.

As you can see, the trachea ends at a sort of T-junction with the right and left main bronchi. And if you pay attention to the diagram, you will see that the right main bronchus comes off at a more gentle angle than does the left. Here is another diagram, this time just of the trachea and bronchi, where you can see this a little more clearly:

From here.

Do you see how, when compared to the left, that right main bronchus comes off at a more gentle angle? Now, if you were a piece of bread, or better yet, a piece of matzah that had snuck past the epiglottis and you were making your way down into the lungs, which direction would you be more likely to go, all things being equal, when you reached that junction with the right and left main bronchi? You would be more likely to continue in a straight line, rather than take a sharp left turn. And so you would be more likely to end up in the right main bronchus. Which is exactly what happens when people aspirate food into their lungs: it generally ends up in the right lung rather than the left. And, by the way you now know the answer to a common question thrown at medical students on the first day of their pulmonary rotations. You are welcome.

But what does this have to do with leaning to the right, as noted in the ArtScroll commentary? In a word, nothing. In two words, absolutely nothing. Leaning to one side or another might theoretically change the side into which the food might lodge of you are unlucky enough to aspirate it, but food in the right lung is as undesirable as food aspirated on the left. Neither is good for you, and if left untreated will lead to aspiration pneumonia and its complications, none of which are good. It’s an easy fix for ArtScroll to make to its excellent product. Could you please let them know?

What about a left-handed person?

When the Talmud addresses issues to do with sides, it assumes that the person is right-handed, since this is true of the majority. But there are differences for left-handed people. For example, a left-handed person puts tefillin on the right arm, while right-handers do so on the left. Might there be a difference for left-handers when it comes to this business of leaning on the Seder night?

Rabbi David ben Solomon ibn Zimra (1479-1573, known by his acronym Radbaz, was one of the leading rabbinic leaders of his generation. In one of his three thousand (!) responsa he addressed the question of whether a person who is left-handed should recline on his right side. In his answer he wrote that he too failed to understand the anatomy described by the Rashbam.

תשובות רדב׳ז ג: 1012

ועוד ראיתי כי הסימנים שוכבין זה על זה ולא ידעתי אם סימני אדם נשתנה

Furthermore, I have seen that the trachea and the esophagus lie one behind the other (although I do not know if this is the same as in people)

Radvaz wrote that for a left-handed person, leaning to the left would be uncomfortable, and since the entire point of the act of leaning is to replicate a feeling of freedom, for a left-handed person this cannot be the correct thing to do:

ועוד הרי תקנו הסיבה זכר לחירות ואם הוא מסב על ימינו ואוכל בשמאלו מצטער הוא ואין זה דרך חירות

Therefore, he concluded that a left-handed person should lean rightwards, though not because of anything to do with a danger of choking, which, as we have seen, does not depend on leaning one way or the other. (Bonus content - for more on left-handedness in the Talmud see here.)

A Yiddish Bonus

Dr Avi Rockoff of Newton, Massachusetts is a longtime friend and Talmudology reader. He noted a fascinating linguistic twist to today’s daf. “When I was a kid and choked on something,” he told me via email, “my mother would clap me on the back, commiserate, and tell me that I had to take care so food wouldn't enter die linke keyli [lit. the left vessel].” And then he added this:

Yiddish has its fair share of Talmudic references, part of traditional cultural knowledge of even unlearned Jews. This one is more than a quotation--it's a bit of lomdus [learning], referring to a dispute between Rashbam, whose view prevailed over even that of his famous zeyde, and seems to have made it into Yiddish anatomical folklore.

How to save a choking person

According to the National Safety Council, about 5,000 people die in the US each year from choking. About half are over 74, and food is often responsible. This is why each of us should know how to perform abdominal thrusts, also known as the Heimlich maneuver:

1. Stand behind the person. Place one foot slightly in front of the other for balance. Wrap your arms around the waist. Tip the person forward slightly. If a child is choking, kneel down behind the child.

2. Make a fist with one hand. Position it slightly above the person's navel.

3. Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust — as if trying to lift the person up.

4. Perform between six and 10 abdominal thrusts until the blockage is dislodged.

And here is a useful video of how to save a choking person. So go on, watch the 2 minutes and 19 second video. Who knows? You might save a life on Seder night.