Ta'anit 24a ~ The Ocular Manifestations of Disease

תענית כד, א

״וְהָיָה אִם מֵעֵינֵי הָעֵדָה נֶעֶשְׂתָה לִשְׁגָגָה״: מָשָׁל לְכַלָּה שֶׁהִיא בְּבֵית אָבִיהָ. כל זְמַן שֶׁעֵינֶיהָ יָפוֹת — אֵין כל גּוּפָהּ צְרִיכָה בְּדִיקָה. עֵינֶיהָ טְרוּטוֹת — כָּל גּוּפָהּ צְרִיכָה בְּדִיקָה

“Then it shall be, if it shall be committed in error by the congregation, it being hidden from their eyes” (Numbers 15:24). This verse indicates that the leaders are considered the eyes of the congregation. There is a parable that illustrates this, involving a bride who is in her father’s home and has not yet been seen by her bridegroom. As long as her eyes are beautiful, her body need not be examined, as certainly she is beautiful. However, if her eyes are bleary [terutot], her entire body requires examination. So too, if the leaders of the generation are flawed, it is a sign that the entire generation is unworthy.

In this parable, which is told by the talmudic sage Oshaya, the leaders of the Jewish people - its eyes - are a barometer of their spiritual health. If the leaders are flawed, then we can assume the people themselves are similarly flawed. Today, we will take this parable one step further, and examine in what ways the eyes do, in fact, reveal much about the health of the rest of the body.

The Eyes and Systemic Diseases

As any medical student can attest, there is a long list of ocular manifestations of systemic diseases, or in non-medical language, of how changes in the eyes reflect illness elsewhere in the body. Here are a few, taken from a useful paper published several years ago by a former colleague.

Eyelid Abnormalities

A number of dermatological problems can show up on the eyelids, which are, after all, also made up from skin. These include eczema, psoriasis, rosacea, and infections like cellulitis. Tumors that effect the eyelids include Kaposi’s sarcoma, which is found in patients with AIDS.

Dry Eyes

The list of conditions that cause dry eyes is enormous, and dry eyes may be a manifestation of many autoimmune and collagen vascular diseases. But before you self-diagnose any of these, remember also that dry eyes can also be idiopathic, meaning it is a condition that arises spontaneously, or for which the cause is unknown.

From Rothenhaus, T. Polis, A. Ocular Manifestations of Systemic Disease. Emer. Med. Clin. N. Am. 1995; 13 (8). 608.

Conjunctivitis

We have all had conjunctivitis at one time or another. It is simply an inflammation of the mucous membranes lining the inner eyelids and anterior sclera - the white part of the eyeball. It is usually caused by a viral infection and goes away after a few days. But it can also be a manifestation of systemic diseases, such as Reiter's syndrome, Wegener's granulomatosis, erythema multiforme, Stevens-Johnson syndrome, psoriatic arthritis, Kawasaki's disease, Crohn's disease and gout. As if that’s not enough, it can also be caused by systemic infections, such as Lyme disease, mononucleosis, measles, or gonorrhea. It turns out that simple conjunctivitis is a hypochondriac’s best friend.

Optic Neuritis

Optic neuritis is an inflammation of the optic nerve, and results in a rapid deterioration of vision. Causes include multiple sclerosis, sarcoidosis, syphilis, toxoplasmosis, Lyme disease (again), cat-scratch disease (it’s a real thing, look it up), and diseases related to human immunodeficiency virus (HIV), especially cytomegalovirus (CMV) and Cryptococcus. Drugs, such as ethambutol and tamoxifen, can also cause an optic neuritis.

Ptosis

Ptosis, a drooping of the eyelids, can be on one (unilateral) or both sides (bilateral). It can be a sign of neurologic disease causing a third nerve palsy (botulism, tumor, aneurysm), or a primary neuromuscular disorder, such as myasthenia gravis.

Infectious Diseases

There are many systemic infectious diseases that cause eye problems. Diphtheria (which is no-longer commonly seen since we have a vaccine against it) commonly results in a minimally purulent conjunctivitis. Botulism (which can kill you) can cause a droopy eye, an inability to focus, double vision and decreased tear formation. Farmers who are in contact with livestock might catch Brucellosis, which will cause fever, sweats, weight loss, weakness, headache, and body aches. It also causes visual field changes and a decreased visual acuity, as well as corneal lesions, conjunctivitis, and lid edema. A visit to the emergency department is recommended. The sexually transmitted disease syphilis can cause iritis, an inflammation of the colored ring around the center of the eye as well as conjunctivitis. Lyme disease, transmitted by deer ticks and increasingly common in the US can cause conjunctivitis, as well as Bell’s palsy, in which one side of the face together with the eyelid, droop.

And on and on

The list continues. Other infectious diseases that cause ocular problems are herpes, chlamydia, tuberculosis, and leprosy, as well as fungal infections and HIV. Autoimmune diseases, in which the body’s own immune system turns against itself also cause eye problems. The list of these diseases includes systemic lupus erythematosus, sarcoidosis, Sjogren's Syndrome, Behcet's Disease, polyarteritis nodosa and giant cell arteritis. And diabetes, hyperthyroidism and gout can cause a number of different eye problems, as will sickle cell disease.

“Knowledge of the characteristic ophthalmologic manifestations of systemic disease can aid the physician in diagnosing a particular disorder, limit the progression of more common diseases, and prevent further visual loss or blindness in patients with serious ophthalmologic complications.”

— Rothenhaus, T. Polis, A. Ocular Manifestations of Systemic Disease. Emer. Med. Clin. N. Am. 1995; 13 (8), 627.

So Oshaya’s parable was, medically speaking, spot on. Let us hope that the leaders of the Jewish people have fewer ocular problems than these.

---

Want more about talmudic eye diseases? The read our post on the Cohen with eye problems.

Ta'anit 21b ~ Pandemics in Pigs

On today’s page of Talmud we continue the discussion of pandemics, and one of Jewish responses to them, which is to fast. But in this passage of Talmud the victims of the pandemic are not human. They are pigs.

תענית כא, ב

אֲמַרוּ לֵיהּ לְרַב יְהוּדָה: אִיכָּא מוֹתָנָא בַּחֲזִירֵי. גְּזַר תַּעֲנִיתָא. נֵימָא קָסָבַר רַב יְהוּדָה מַכָּה מְשׁוּלַּחַת מִמִּין אֶחָד מְשׁוּלַּחַת מִכל הַמִּינִין? לָא, שָׁאנֵי חֲזִירֵי — דְּכמְיָין מְעַיְיהוּ לִבְנֵי אִינָשֵׁי

On one occasion, they said to Rav Yehuda: There is pestilence among the pigs. Rav Yehuda decreed a fast. The Gemara asks: Let us say that Rav Yehuda maintains that a plague affecting one species will come to affect all species, and that is why he decreed a fast. The Gemara answers: No, in other cases there is no cause for concern. However, pigs are different, as their intestines are similar to those of humans. Consequently, their disease might spread to people.

Rav Yehuda’s ruling became normative Jewish practice, and is codified in the Shulhan Arukh:

שולחן ערוך אורח חיים 576:2-3

היה דבר במדינה ושיירו' הולכו' ובאו' ממנה למדינה אחר' שתיהן מתענו' אע"פ שהן רחוקו' זו מזו

ואם היה דבר בחזירים מתענין מפני שמעיהם דומים לשל בני אדם וכל שכן אם היה דבר בעכו"ם ולא בישראל שמתענים

…If there was an outbreak in one area and those who escaped were able to flee to another, both places must fast, even though they may be far apart.

If there was an outbreak of disease among pigs, we declare a fast because their intestines are similar to those of humans, and certainly if there was an outbreak among idolators that spared Jews we must still declare a fast.

Influenza in Pigs and People

Jews are required to fast in response to an epidemic, regardless of whether it had spread in their own particular community. They also have to do so even if the disease remained within the animal reservoir.

This requirement was ominously prescient, because one strain of influenza, the A strain, infects not only humans, but several other mammalian species, as well as some birds. The animal strains may pass from one mammalian species to another, sometimes gaining virulence as they do so. The 1918 influenza pandemic, which killed at least 50 million people, is thought to have originated as a bird virus which then passed through a mammalian host, most likely pigs, before infecting humans. In 1975, swine flu threatened the US and led the federal government to undertake an enormous – and very controversial – mass vaccination program. And in 2009 there was another outbreak of swine flu, which originated in Mexico. The Jewish requirement to fast in response to an outbreak of swine flu, is, medically speaking, spot on.

A Jewish Prayer for cattle

This sensitivity to zoonotic infections was not just theoretical; there is at least one example of a prayer specifically composed to save animals during a pandemic. It is a beautifully printed prayer sheet titled “A Prayer to End an Outbreak of Disease among the Cattle” and may have been composed in Italy in the late eighteenth century., but there are no further details of its origins. I am grateful to Sharon Hurwitz and Ann Brener of the Library of Congress for bringing this remarkable document to my attention. (The reference to it is Library of Congress Hebrew Broadside Collection, Hebrew Cage no. 21.)

A Prayer to End an Outbreak of Disease among the Cattle. Library of Congress Hebrew Broadside Collection, Hebrew Cage no. 21

Here is a flavor of the prayer:

Master of the Universe, Creator of the heavens who spread them out in the celestial sky and over the land, who bestowed a soul in the people that dwell on land and a spirit in those who walk on it!

You created all the animals, beasts, creatures, and birds of flight. What is humanity that you should remember it? What are people that you should visit them, that your divinity should pity them, that your honor and glory should crown them?…

You have made him master over your handiwork, laying the world at his feet. Flocks in their thousands, God’s creatures, the birds of the skies and the fish in the oceans, so that the poor may have food and be satiated. Let all who seek God speak his praises, may their hearts endure forever. 

As a result of our sins [these animals] were smitten, and our sins prevented good for them. The disease has started to attack animals and birds. How the animals sighed, how the flocks despaired, for God’s hand afflicted them and scattered a plague in their midst... 

Grant a complete cure and healing to all all flesh through your goodness and through your mercy, as it is written God is good to all, his mercy extends over all his creations.We beseech you, let your mercy be stronger than your justice. See our poverty and our burden, and accept our repentance and our prayers with pity…

Please God, please heal all the creatures with a heart, heal, turn away your anger, annul all the evil decrees for us and for all Israel with abundant mercy, and end the plague that attacks all the animals and the beasts in the fields…

The Anglican and Catholic Churches Also Prayed for Cattle

Unusual though this prayer may seem at first, it was not a uniquely Jewish expression. As Alasdair Raffe noted in his excellent paper on the topic, in England the Anglican Church added a prayer for the relief of cattle mortality in 1748 which was used daily for the next eleven years. And when bovine disease recurred during an outbreak of cholera in 1865, three new prayers were composed for the Anglican service.

Still, these prayers could be controversial. “In 1754 a clerical correspondent of the London Evening Post complained that the prayer for the relief of disease in cattle had 'nothing of the Spirit of the Gospel in it’ and was an invitation to the congregation 'to be carnally minded,' though this probably says more about the state of mind of the correspondent than it does of the clerics who composed these prayers.

In 1866 Alexander Goss, the Roman Catholic Bishop of Liverpool wrote a series of prayers for cattle “whether presented to you in droves or in their stalls.”

Let us pray
O God, our refuge and strength, hear the pious prayers of thy church, thou, author of piety, and grant that we obtain speedily what we are asking for full of confidence. …
Let us pray
May these animals receive thy blessing, O Lord: may their bodies be saved and be delivered from all evil through the intercession of the blessed Antony. Through Christ our Lord. Amen.
Let us pray
We humbly beseech thy mercy, o Lord, and pray that thou mayst grant protection to these cattle and (other) animals from all the devil’s deception and power, as well as from any illness, through the power of the blessing with your name. Be thou, O Lord, their defense, their support in life and their remedy in illness, and multiply thy mercy and kindness, so that thy holy name will be glorified forever. Amen.

[The priest then sprinkles holy water. ]

In Jewish law, we are to pray for others who are suffering in a pandemic, whether or not we ourselves are also affected. We are to pray for Jews, Gentiles, “idolators” and yes, even for pigs.

Ta'anit 19a ~ On the Definition of a Pandemic

What, exactly, is a pandemic? Perhaps you think this is an easy question, because, after all, we have been living through a pandemic for almost two years. So surely we must all know what we mean by the term. So before we go on, write down your definition of a pandemic (and don’t Google it first). All done? Let’s see how you did.

The World Health Organization and Its Definitions

In its discussions of what constitutes a pandemic (in this case, of influenza,) the World Health Organization went through various iterations:

1999

There was no real definition in use. According to Peter Doshi, the closest the WHO came to was this:

At unpredictable intervals, however, novel influenza viruses emerge with a key surface antigen (the haemagglutinin) of a totally different sub-type from strains circulating the year before. This phenomenon is called “antigenic shift”. If such viruses have the potential to spread readily from person-to-person, then more widespread and severe epidemics may occur, usually to a similar extent in every country within a few months to a year, resulting in a pandemic.”

2005

The WHO still didn’t really have a definition, but said that a pandemic will be said to have begun when a new influenza virus subtype is declared to have reached Phase 6. Phase 6 is defined as “Increased and sustained transmission in the general population.”

2009

Ibn 2009 the WHO stated that “Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different [second] WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.”

These definitions have important consequences, as I pointed out in my book on the history of influenza. Most people think of a pandemic as a disease that spreads and kills thousands of people. That description is echoed in the WHO’s official definition of the word as an infectious disease that causes “enormous numbers of deaths and illness.” But in talking about the 2009 outbreak, the WHO used a more academic and narrow definition that focused only on how much diesease was out there (called its prevalence,) not severity. After this was pointed out by an astute CNN reporter, a WHO spokeswoman announced that the organization had erred in using the more apocalyptic definition. “It was a mistake, and we apologize for the confusion,” she said, noting that the word painted “a rather bleak picture and could be very scary.” Quite so.

Some other definitions of a pandemic

Here is a comparison of the WHO and the CDC definitions of a (n influenza) pandemic, taken from Doshi’s helpful (though now dated) 2011 paper The elusive definition of pandemic influenza. As you can see, they are different.

From Doshi, P. The elusive definition of pandemic influenza. Bull World Health Organ. 2011;89:532–538 | doi:10.2471/BLT.11.086173

More recently, the CDC has defined a pandemic as an event in which a disease spreads across several countries and affects a large number of people. Fine, but how many countries exactly? It is not defined. Writing on a patient information page in the influential Journal of the American Medical Association, Dana Grennan defined a pandemic as an epidemic that spreads globally - and an epidemic is an outbreak that spreads over a larger geographical area than an “outbreak.” As you will note, none of these definitions address how deadly the disease is. In fact, by this standard you can have a pandemic of a completely mild and clinically unimportant disease, though no-one would really pay it any attention.

“It is ironic that part of the recent problem with pandemic terminology arose not because of inherent vagueness but because of well-meaning attempts to eliminate ambiguities.”

— D. Morens, G. Folkers and A. Fauci The Journal of Infectious Diseases 2009 Vol. 200 Issue 7 Pages 1018-1021.

The definition of a Pandemic in the Talmud

All of this is by way of introducing today’s page of Talmud, which takes a stab at defining a pandemic:

תענית יט, א

אֵיזֶהוּ דֶּבֶר? עִיר הַמּוֹצִיאָה חֲמֵשׁ מֵאוֹת רַגְלִי, וְיָצְאוּ מִמֶּנָּה שְׁלֹשָׁה מֵתִים בִּשְׁלֹשָׁה יָמִים זֶה אַחַר זֶה — הֲרֵי זֶה דֶּבֶר, פָּחוֹת מִכָּאן — אֵין זֶה דֶּבֶר

What is considered a plague? If a city that sends out five hundred infantrymen, [i.e., it has a population of five hundred able-bodied men, and three dead are taken out of it on three consecutive days,] this is a plague of pestilence, which requires fasting and crying out. [If the death rate is lower than that, this is not pestilence.]

In a couple of pages the Talmud will further define the definition we have in the Mishnah:

תענית כא,א

. תָּנוּ רַבָּנַן: עִיר הַמּוֹצִיאָה חֲמֵשׁ מֵאוֹת וְאֶלֶף רַגְלִי, כְּגוֹן כְּפַר עַכּוֹ, וְיָצְאוּ הֵימֶנָּה תִּשְׁעָה מֵתִים בִּשְׁלֹשָׁה יָמִים זֶה אַחַר זֶה — הֲרֵי זֶה דֶּבֶר

The Sages taught: If a city that sends out fifteen hundred infantrymen, i.e., one that has a population of at least fifteen hundred men, e.g., the village of Akko, and nine dead are removed from it on three consecutive days, i.e., three dead per day, this is considered a plague of pestilence.

But pandemics don’t follow linear rules, or recognize neat periods of 24 hours, and the Talmud delves a little further:

בְּיוֹם אֶחָד אוֹ בְּאַרְבָּעָה יָמִים — אֵין זֶה דֶּבֶר. וְעִיר הַמּוֹצִיאָה חֲמֵשׁ מֵאוֹת רַגְלִי, כְּגוֹן כְּפַר עֲמִיקוּ, וְיָצְאוּ הֵימֶנָּה שְׁלֹשָׁה מֵתִים בִּשְׁלֹשָׁה יָמִים זֶה אַחַר זֶה — הֲרֵי זֶה דֶּבֶר

If all nine died on a single day, while none died on the other days, or if the nine died over a period of four days, this is not a plague of pestilence. And a city that sends out five hundred infantrymen, for example, the village of Amiko, and three dead are removed from it on three consecutive days, this is a plague of pestilence.

Now this might sound a little confusing. First we are told that three people need to die each day for three consecutive days for a pandemic to be declared. But then we learn that if all nine die on one day, or over four days rather than three, then there is no pandemic declaration. And then comes this:

בְּיוֹם אֶחָד אוֹ בְּאַרְבָּעָה יָמִים — אֵין זֶה דֶּבֶר

If all three died on one day or over four days, this is not a plague of pestilence.

Rashi explains that if all three die on a single day, or over four days - אין זה דבר, דאקראי בעלמא הוא - this does not meet the definition of a pandemic, but rather it is a chance occurrence. The point here is that for a pandemic to be declared, we need a pattern of disease over a unit of time. The Talmud is trying to find the best pattern over the best unit of time that would make the declaration of a pandemic meaningful. We might argue that a better definition might be found, but as we have seen, even today the definition of a pandemic is elusive and changes frequently.

BONUS CONTENT: Even More on how we measure Pandemic Deaths

In 1854 in London there was a deadly outbreak of cholera. The British physician John Snow determined that it was caused by a contaminated water supply, and, so the famous story goes, when he removed the handle to the pump that supplied the dangerous water, the epidemic ended.

But what exactly was the effect of removing that handle? Well, it depends on how we measure things. Here for example is one way of visualizing that effect:

This and the following images are from From Edwin Tufte, Visual Explanations, pp. 27-37

It’s pretty impressive, right? But now let’s visualize the same data in another way:

Now the effect of removing the handle seems even more impressive. The deaths dropped from about 500 per week to about 100. But all we have done here is to slightly change the way in which the dates are grouped together. In the first chart the x-axis had August 20-26, then August 27-September 2 and so on. In the second chart the x-axis was August 18-24, August 25-31, and so on. Same deaths, different way to display the data. Now let’s take one last look at the same data, but this time the x-axis does not display periods of seven days. Instead, it displays day-by-day.

When the data is displayed in this way, the effect of the removal of the handle from the Broad Street pump seems to disappear entirely, because the cholera epidemic was already waining. In fact, the result of Snow’s intervention will depend on the arbitrary choice of time periods and the way we display the data. And we can also generalize to all pandemics. Any method to count pandemic deaths will be arbitrary, but that does not make it useless. We just have to be clear about why we decided to count the way that we did, and explain that decision. That is true whether you are the World Health Organization, The Centers for Disease Control, of the rabbis of the Talmud.

Talmudology field trip to the Broad Street Pump in London, July 2007.

Ta’anit 17b ~ Alcohol Metabolism

In today’s page of Talmud there is an interesting discussion of how to dissipate the intoxicating properties of alcohol:

תענית יז ,ב

דְּאָמַר רָמֵי בַּר אַבָּא: דֶּרֶךְ, מִיל, וְשֵׁינָהכל שֶׁהוּא — מְפִיגִין אֶת הַיַּיִן! לָאו מִי אִיתְּמַר עֲלַהּ, אָמַר רַב נַחְמָן אָמַר רַבָּה בַּר אֲבוּהּ: לֹא שָׁנוּ אֶלָּא בְּשֶׁשָּׁתָה שִׁיעוּר רְבִיעִית, אֲבָל שָׁתָה יוֹתֵר מֵרְבִיעִית — כל שֶׁכֵּן שֶׁדֶּרֶךְ מַטְרִידָתוֹ וְשֵׁינָה מְשַׁכַּרְתּוֹ

Rami bar Abba said: Walking a distance of a mil, and similarly, sleeping even a minimal amount, will dispel the effect of wine that one has drunk. But wasn’t it stated about this halakha that Rav Nahman said that Rabba bar Avuh said: They taught this only with regard to one who has drunk the measure of a quarter-log of wine, but with regard to one who has drunk more than a quarter-log, walking this distance will preoccupy and exhaust him all the more, and a small amount of sleep will further intoxicate him.

How alcohol is metabolized

Alcohol, or really ethanol ,which is the specific kind of alcohol found in our alcoholic drinks, is metabolized in the liver. This is why, if you drink too much of it for too long, you will irreversibly damage that organ. The liver first breaks down ethanol into acetaldehyde; that is then broken down into acetic acid and a molecule called acetyl coenzyme, or acetyl-CoA. Once acetyl-CoA is formed, it is further used in the citric acid cycle, ultimately producing cellular energy and releasing water and carbon dioxide.

The amount of ethanol that the liver can break down per hour varies greatly between individuals. Here are some of the factors at play:

Gender

Men and women generally have similar alcohol elimination rates when results are expressed as grams per hour, but per unit of lean body mass, women are faster at breaking down ethanol.

Age

As we age we get slightly slower at eliminating ethanol.

Race

Native American men and women appear to eliminate alcohol faster than whites. There is also evidence that people of Asian descent have a slightly faster rate of metabolism, owing to a polymorphism in the Class I hepatic ADH enzyme. But overall, racial and ethnic differences in rates of ethanol elimination are small compared with many other factors.

Alcoholism

Heavy drinking increases alcohol metabolic rate. But advanced liver disease will decrease the rate of ethanol metabolism.

Nutritional state

Alcohol metabolism is slower in people with a poor nutritional state. Kinda like drinking on an empty stomach.

Here is the bottom line. Although rates vary widely, the “average” metabolic capacity to remove alcohol is about 7 gm/hr which translates to about one drink per hour. In the graph below, you can see the blood alcohol concentration in an average man at hourly intervals after drinking one, two, four, or six ounces of spirits containing 50 percent alcohol. A person who drink alcohol frequently might metabolize his drinks more quickly, because (among other things) alcohol induces the production of more alcohol dehydrogenase, which is needed to break alcohol down. Conversely, a person who rarely drinks might metabolize it more slowly. This is the reason that when I worked in the emergency department, it was the young drunks, especially those of college age, who worried me more than the older, chronic drunks. The chronic drinkers will metabolize their alcohol much faster.

Image from here.

Another measure to remember is that in general, the elimination rate is around 10-15mg/dL/hr in alcohol naive people and around 20mg/dL/hr or higher in those with chronic alcohol use. Try as you might, there is really nothing you can do to speed up this rate of elimination. Which brings us to…

Exercise and alcohol metabolism

According to Rami bar Abba on today’s page of Talmud, exercise can increase the elimination of alcohol.

אמר רמי בר אבא דרך מיל ושינה כל שהוא מפיגין את היין

Rami bar Abba said: Walking a path of a mil, and similarly, sleeping even a minimal amount, will dispel the effect of wine that one has drunk. 

Does exercise help, as Rami bar Abba suggested? Well, there is one study that looked at this very question. It studied rats, which were fed alcohol mixed into their liquid diet “with use of a kitchen wire whisk and bowl.” They were then made to run on a little rodent treadmill, and blood was removed from their tails at various time intervals. The researchers, from the University of Texas at Austin, concluded that “…running exercise for periods of at least 60 min will increase rates of ethanol clearance compared with rates measured at rest.” So if you are a rat with a hangover, a vigorous run for an hour might help you feel better. But what about us?

Well, it depends how much you exert yourself. A study published in 1982 tested the rates of alcohol elimination in a very small group of volunteers, who got drunk and hopped on an exercise bike. It found that

prolonged physical exercise produces an enhanced ethanol elimination if the intensity and duration of exercise are sufficient. But this finding has hardly any pathological meaning.The reasons for the enhanced elimination of blood alcohol are probably to be found in the elevated body temperature caused by physical exercise and in a supplementary loss of alcohol by perspiration and exhalation. The muscles are not able to utilize ethanol either directly or indirectly.

TIME-DEPENDENT ELIMINATION OF ALCOHOL

Sleep does nothing to speed up the metabolism of alcohol either. But what if Rami bar Abba was not suggesting an activity, but rather a length of time? Perhaps he is in effect saying that the alcohol wears off in about the time it takes to walk a mil, or have a short nap. That certainly makes physiological sense. To which Rav Nachmun pointed out that this time period only applied after a small amount of wine (“a quarter log”). Any more than that could not be eliminated in such a short period. Also physiologically correct.

But as Rami bar Avuha (not the same Rami as before) noted, if you are really intoxicated, you would need more time to sober up.

אָמַר רַב נַחְמָן אָמַר רַבָּה בַּר אֲבוּהּ: לֹא שָׁנוּ אֶלָּא שֶׁשָּׁתָה כְּדֵי רְבִיעִית, אֲבָל שָׁתָה יוֹתֵר מֵרְבִיעִית — כל שֶׁכֵּן שֶׁדֶּרֶךְ טוֹרַדְתּוֹ וְשֵׁינָה מְשַׁכַּרְתּוֹ

Rav Nachman said that Rabba bar Avuh said: They only taught this with regard to one who has drunk a quarter-log of wine, but with regard to one who has drunk more than a quarter-log, this advice is not useful. In that case, walking a path of such a distance will preoccupy and exhaust him all the more, and a small amount of sleep will further intoxicate him.

Of course so long as you stop drinking, there is no way that a nap will further raise your alcohol level, but again, if you have consumed a lot of alcohol and take a nap, you may wake with an awful hangover, which may make you feel as if you were intoxicated.

How to drink the Four Cups of Wine at the Seder

In tractate Shekalim there is a lengthy excursus into the laws of the Four Cups of wine that must be drunk on the night of the Seder. May one drink the four cups little by little, sip by sip, or must they be drunk in large gulps?

שקלים ח, ב

מָהוּ לִשְׁתוֹתָן בְּפִיסָקִין. כְּלוּם אָֽמְרוּ שֶׁיִּשְׁתּוּ לוֹ כְּדֵי שֶׁיִּשְׁתַּנֶּה וְלֹא יִשְׁתַּכֵּר. אִם שָׁתָה בְפִסָקִין אַף הוּא אֵינוֹ מִשְׁתַּכֵּר

What is the halakha with regard to drinking the four cups of wine little by little, with interruptions? The Gemara answers: When the Sages said that one must drink four cups of wine, didn’t they institute that he must drink them, and not that he should become intoxicated from drinking them? Therefore, if he drank them little by little, with intervals, he too is acting in accordance with the will of the Sages, as he is not becoming intoxicated, and therefore he need not drink the entire quarter-log at once.

In other words, because the rabbis specifically wanted to avoid the Seder celebrants becoming intoxicated, they did not allow additional wine to be drunk between the Third and Fourth cups of wine. Hence, the Talmud concludes that sipping wine a little at a time is certainly permitted. And now that we have reviewed the way in which alcohol is metabolized, this ruling makes physiological sense. You are less likely to become intoxicated if you sip your cup slowly over some time, rather than finish it in one or two gulps. It’s all about the alcohol dehydrogenase.

On the other effects of alcohol

The Talmud has a few conflicting statements about wine and its intoxicating effects. In another tractate (Eruvin 65a) Rav Chaninah claimed that the relaxed feeling a person gets after drinking wine puts him in the same mindset as the Creator of the universe:

עירובין סה, א

אמר רבי חנינא כל המתפתה ביינו יש בו מדעת קונו שנאמר וירח ה׳ את ריח הניחוח וגו׳ 

Rabbi Chanina said: Whoever is appeased by his wine, i.e., whoever becomes more relaxed after drinking, has in him an element of the mind-set of his Creator, who acted in a similar fashion, as it is stated: “And the Lord smelled the sweet savor, and the Lord said in His heart, I will not again curse the ground any more for man’s sake” (Genesis 8:21).

And according to Rav Chanan bar Papa, it is a sign of prosperity if “wine flows like water” in the house (Eruvin 65a).

But rabbis also pointed out the dangers of drinking to excess. One explanation for the deaths of the sons of Aaron the High Priest (described in Lev.10) is that they were drunk when they performed in the Mishkan. Elsewhere we have discussed how the Talmud described alcoholic liver disease, and how it precluded a Cohen from service in the Temple. Like many things, wine should be taken in moderation. That lesson, taught in Avot D’Rabbi Natan, was true in talmudic times, and remains so in ours too.

אבות דרבי נתן 37:5

ח׳ דברים רובן קשה ומיעוטן יפה. יין מלאכה שינה ועושר ודרך ארץ ומים חמין והקזת דם 

There are eight things which are dangerous in excess but good in moderation: wine, work, sleep, [having] wealth, sexual relations, [bathing in] hot water, and bloodletting.

---

Want more? Here are some other Talmudology posts that also discuss alcohol and its effects:

Cohanim and alcoholic liver disease

The healing effects of alcohol

Too drunk to say no

Alcohol and cognitive function