Maimonides and Medicine - the Movie

Last week, Dr Eddie Reichman and I presented two talks on Maimonides and Medicine at the Yeshiva University Museum in New York. The evening was part of an exhibition, The Golden Path: Maimonides Across Eight Centuries, which features manuscripts and rare books from the Hartman Family Collection.

With gratitude to the Museum, we are happy to present a video of the event. You can find the link here. Enjoy.

Jeremy Brown: The Surprising Influence of Maimonides’ Treatise on Poisons: Starts at minute 7:30.

Eddie Reichman: If the Rambam were Alive Today: Contemporary Jewish Ethics Through the Eyes of Maimonides. Starts as minute 36:30.

Bava Kamma 115b ~ Drinking Snake Venom

בבא קמא קטו, ב

והתניא מים שנתגלו הרי זה לא ישפכם ברשות הרבים ולא יגבל בהן את הטיט ולא ירבץ בהן את הבית ולא ישקה מהם את בהמתו ולא בהמת חבירו

It was taught in a Baraisa: water that was left uncovered should not be spilled out in a public area, nor should one knead clay with it, nor should one lay in the dust with it, nor should one give it to his animal, nor the animal of his friend, to drink. (Bava Kamma 115b)

Don't Drink That Water!

The rabbis of the Talmud were very worried indeed about the health effects of water that had been left uncovered.  This concern was codified by Maimonides, and later by Ya'akov ben Asher (d. 1340) in his famous halakhic work called the Arba'ah Turim. 

טור יורה דעה הלכות מאכלי עובדי כוכבים סימן קטז 

דברים האסורים משום סכנה
  יש דברים שאסרום חכמים משום סכנה כגון משקין שנתגלו שיש לחוש שמא שתה מהן נחש והטיל בהן ארס אפי' אם שתו מהן אחרים ולא הוזקו אין לשתות מהן  שיש נחש שהארס צף למעלה ויש שארס שלו מפעפע עד אמצעית המשקה  ויש שהארס שלו שוקע לשולי הכלי לפיכך אפי' שתו ממנו אחרים ולא הוזקו אין לשתות מהן דשמא ארס של הנחש ששתה מהן שוקע ואלו המשקין שיש בהן משום גילוי מים יין חלב ודבש ושום כתוש 

Tur, Yoreh De'ah 116. Things that are Prohibited Because they are Dangerous

There are things that the rabbis of the Talmud prohibited because they are dangerous. For example, liquids that were left uncovered, because of the possibility that a snake drank from the water and expelled some of its poison into them. Even if others had drunk from the liquid, and not been injured, one should not drink from them.  For some snake venom floats on the surface, and some sinks to the middle and some moves to the edges of the vessel. Therefore, even if others had drunk and had suffered no harm, one should not drink from them, for perhaps the venom from the snake that had drunk the water had sunk to the bottom. The following liquids should not be drunk if they were left overnight in an uncovered vessel: water, wine, milk, honey, and crushed garlic...

The normative Code of Jewish Law, the שולחן ערוך agreed, but added an important caveat:

שולחן ערוך יורה דעה הלכות מאכלי עובדי כוכבים סימן קטז סעיף א 

משקים שנתגלו, אסרום חכמים דחיישינן שמא שתה נחש מהם והטיל בהם ארס. ועכשיו שאין נחשים מצויים בינינו, מותר

The rabbis forbade drinking from liquids that were left uncovered,. They were concerned that a snake may have drunk from them and expelled some of its poison into them. But now that snakes are not commonly encountered, this is permitted. (Shulchan Aruch Yoreh De'ah 116:1)

So today it is permitted for us to drink from an uncovered pot, but only in a place that does not have a problem with poisonous snakes.  Which is not helpful. There are poisonous snakes in nearly every state in the US, resulting in about 2,000 human envenomations each year, and we have noted before that Israel has its own problem with snakes, including the Palestinian Viper.  The World Health Organization estimates that snakes kill between 20,000 and 94,000 people per year. So exactly where this leniency of the Shulchan Aruch might apply is not clear.

But is drinking snake venom indeed dangerous? Maybe not. In 2012 India Today reported that police in New Delhi had seized about half a liter of snake venom to be used "in high-end raves planned for Valentine's Day in and around the national capital." Apparently the venom, when ingested, produces a euphoric state. Who knew?

Video evidence - Drinking Cobra Venom

It is really hard to find any peer-reviewed scientific studies about people drinking snake venom, because, um, it's a silly thing to do.  But that doesn't mean it hasn't been done. So where could we turn to find people doing silly things? YouTube of course. This video involves drinking the venom directly from spitting snake. Apparently, these kind of human interest stories are popular in India. 

Why it is safe to drink snake venom

If you are a diabetic and take insulin, or know someone who does, you may have wondered why the drug has to be injected. It would, after all, be much less bothersome to swallow an insulin pill than to inject insulin several times a day.  The reason is that insulin is a protein, and like all proteins, it is easily broken down by heat and, more importantly, by the acid environment in the stomach.  Our gastrointestinal tracts evolved to break down proteins into their building blocks - and they perform a wonderful job doing precisely that.

Like insulin, snake venom is a complex protein. And so, like insulin, it too is easily broken down in the very acidic environment of your stomach.  Of course, if intact venom gets into your bloodstream, it could kill you. But if you drink venom, then the intact protein never does get into your bloodstream. You don't need to be an Indian snake charmer to safely drink snake venom. You just need a working digestive system.

HOW SNAKES DRINK

 In case you were wondering how we know how snakes drink, here is a diagrammatic view of the apparatus used to record the kinematics and water transport during drinking. The video camera was placed to the left. LED, light-emitting diode. From Cundall, D. Drinking in snakes: kinematic cycling and water transport. The Journal of Experimental Biology. 2000; 203, 2171–2185.

The Talmud was concerned that snakes leave venom in water from which they drank, and that a person drinking from that water would then suffer from envenomation. As we have seen, this concern has no biological basis, although theoretically, if there was an open cut or ulcer in the mouth, ingested venom could get into the bloodstream and then cause its havoc.  But there is another reason why the talmudic concern is overstated.  Snakes, you see, don't leave any venom when they drink water.  As you may have noted from watching the first video, it takes a lot to get a snake to expel its venom - like sticking a blue pen in its mouth.  Venom is a snake's most precious commodity, and it has evolved to protect that commodity. Snakes only release venom when they are in danger, or ready to strike their prey, and not otherwise. Want a great example? The venomous rattlesnake. That species has evolved a warning rattle to tell would-be predators that if they get any closer, they will be bitten. This only makes evolutionary sense if it was in the snake's best interest to do everything possible to conserve its venom.

In a fascinating article on how snakes drink published in The Journal of Experimental Biology, David Cundall notes that a snake's tongue does not carry or move water, and that "in many snakes, the tongue does not visibly move during drinking." That leads to the conclusion that snakes are suction drinkers. And that makes them even less likely to leave any venom behind in the water.

“As far as is known, all snakes are suction drinkers, and the only critical structural variations that might be predicted to influence drinking performance are the relative dimensions and shapes of the mandibles and their suspensorial elements and the arrangements of intermandibular muscles and connective tissues.”

— Cundall, D. Drinking in snakes: kinematic cycling and water transport. The Journal of Experimental Biology. 2000; 203, 2171–2185.

So let's put this all together:

1. Snakes don't release their venom unless they are threatened or hunting. 

2. Snakes use suction when they drink water. Their mouths are not open, which is needed when they are expelling venom.

3. Snake venom is not dangerous when drunk.

4. (If somehow venom did get into the water, it would be greatly diluted.)

So there is no danger if you were to drink from water from which a venomous snake had drunk. None.

Rashi's Two Explanations of Today's Passage

In today's page of Talmud, we are warned not to drink water left standing, because of the danger of a venomous snake having drunk from it.  That danger, as we have seen, does not exist.  But the Talmud also warns us not to use this water to sprinkle on a dirt floor to keep the dust down. According to Rashi, the concern is that a person might cut her foot on a sharp stone left on the floor, which would then allow the venom that was in the water that was sprinkled on that floor to enter the bloodstream. Now that is an incredibly unlikely event, but it is certainly possible, and Rashi's point is absolutely correct. The danger is only if there is an open wound that would allow the venom to enter the blood stream. (שלא יעבור עליהם אדם יחף ויכנס ארס של נחש ברגלו ע"י מכת צרור וימות.)  It is fascinating to compare Rashi's explanation here with his explanation of the the identical passage found in Avodah Zarah (30b).  

 לא ישפכם: שמא יעבור אדם יחף ויעמוד הארס בין קשרי אצבעותיו וכיון שנכנס מעט ונוקב   בבשר שוב אין לו רפואה. רשי, עבודה זרה ל, ב

There, Rashi notes that if "venomous" water was sprinkled on the floor, a person might step on it and absorb the venom through the skin of his toe joints. Once that happens, "שוב אין לו רפואה" - there is no medical treatment. What Rashi may not have known is that snake venom is not dangerous if it gets on your skin, because it is not absorbed from there into the bloodstream.  So his explanation in Avodah Zara is not correct, unlike his explanation of the passage in today's daf.

Bye Bye Bava Kamma

And that brings us to the end of Talmudology on Bava Kamma, which we will finish learning this Thursday. We've discussed all kinds of topics:

Whether wolves can be tamed

Whether donkeys could break pottery with their braying

The talmudic and legal liability for dog bites

Whether a man is liable for injuring his wife during intercourse

How animals feel pain

Liability in bullfighting

Deaths from falling

Whether a goose has a scrotum

Whether kosher and non-kosher animals might cross-breed

Whether garlic is good for you

Whether honey is bad for you

How animals faced trial

And more besides.  Now it is time to turn to the next tractate. I'll see you on the opening page of Bava Metziah,  when we will discuss game theory and the work of the Israeli Nobel prize winner Robert Aumann.

Talmudology on the Parsha, Tetzaveh: Lux et Veritas

שמות 28:30

וְנָתַתָּ֞ אֶל־חֹ֣שֶׁן הַמִּשְׁפָּ֗ט אֶת־הָאוּרִים֙ וְאֶת־הַתֻּמִּ֔ים וְהָיוּ֙ עַל־לֵ֣ב אַהֲרֹ֔ן בְּבֹא֖וֹ לִפְנֵ֣י יְהֹוָ֑ה וְנָשָׂ֣א אַ֠הֲרֹ֠ן אֶת־מִשְׁפַּ֨ט בְּנֵי־יִשְׂרָאֵ֧ל עַל־לִבּ֛וֹ לִפְנֵ֥י ה׳ תָּמִֽיד׃       

And thou shalt put in the breastplate of judgment the Urim and the Tummim; and they shall be upon Aharon’s heart, when he goes in before the Lord: and Aharon shall bear the judgment of the children of Yisra᾽el upon his heart before the Lord continually.

In this week’s parsha are the long and detailed lists of what the Priests (the Cohanim) and the High Priest (Cohen Gadol) should wear, and instructions for producing them. Once he (it is alway a he) is suited up, the High Priest puts on a breastplate of 12 stones, and then two additional somethings called the Urim and the Tummim.

No one is quite sure what these were or how they were supposed to work. Rashi, following the Talmud (Yoma 73b) explains them this way:

רשי, שמות 28:30

את האורים ואת התמים. הוּא כְּתָב שֵׁם הַמְפֹרָשׁ, שֶׁהָיָה נוֹתְנוֹ בְּתוֹךְ כִּפְלֵי הַחֹשֶׁן, שֶׁעַל יָדוֹ הוּא מֵאִיר דְּבָרָיו וּמְתַמֵּם אֶת דְּבָרָיו

את האורים ואת התמים — This was an inscription of the Proper Name of God which was placed between the folds (i. e. the two pieces forming the front and back) of the breast-plate through which it (the breast-plate) made its statements clear (lit., illuminated its words; מאיר from אור, light, this being an allusion to the אורים) and its promises true (מתמם from the root תמם, an allusion to תמים).

The function of the Urim Vetummim becomes more evident from an episode in the First Book of Shmuel in which Saul inquires of them as to whether he should continue a series of battles with the Philistines:

שמואל א, 14:37-42

וַיִּשְׁאַ֤ל שָׁאוּל֙ בֵּֽאלֹהִ֔ים הַֽאֵרֵד֙ אַחֲרֵ֣י פְלִשְׁתִּ֔ים הֲתִתְּנֵ֖ם בְּיַ֣ד יִשְׂרָאֵ֑ל וְלֹ֥א עָנָ֖הוּ בַּיּ֥וֹם הַהֽוּא׃ וַיֹּ֣אמֶר שָׁא֔וּל גֹּ֣שֽׁוּ הֲלֹ֔ם כֹּ֖ל פִּנּ֣וֹת הָעָ֑ם וּדְע֣וּ וּרְא֔וּ בַּמָּ֗ה הָ֥יְתָ֛ה הַחַטָּ֥את הַזֹּ֖את הַיּֽוֹם׃ כִּ֣י חַי־יְהֹוָ֗ה הַמּוֹשִׁ֙יעַ֙ אֶת־יִשְׂרָאֵ֔ל כִּ֧י אִם־יֶשְׁנ֛וֹ בְּיוֹנָתָ֥ן בְּנִ֖י כִּ֣י מ֣וֹת יָמ֑וּת וְאֵ֥ין עֹנֵ֖הוּ מִכל־הָעָֽם׃ וַיֹּ֣אמֶר אֶל־כל־יִשְׂרָאֵ֗ל אַתֶּם֙ תִּֽהְיוּ֙ לְעֵ֣בֶר אֶחָ֔ד וַֽאֲנִי֙ וְיוֹנָתָ֣ן בְּנִ֔י נִהְיֶ֖ה לְעֵ֣בֶר אֶחָ֑ד וַיֹּאמְר֤וּ הָעָם֙ אֶל־שָׁא֔וּל הַטּ֥וֹב בְּעֵינֶ֖יךָ עֲשֵֽׂה׃וַיֹּ֣אמֶר שָׁא֗וּל אֶל־יְהֹוָ֛ה אֱלֹהֵ֥י יִשְׂרָאֵ֖ל הָ֣בָה תָמִ֑ים וַיִּלָּכֵ֧ד יוֹנָתָ֛ן וְשָׁא֖וּל וְהָעָ֥ם יָצָֽאוּ׃ וַיֹּ֣אמֶר שָׁא֔וּל הַפִּ֕ילוּ בֵּינִ֕י וּבֵ֖ין יוֹנָתָ֣ן בְּנִ֑י וַיִּלָּכֵ֖ד יוֹנָתָֽן׃

And Sha᾽ul asked counsel of God, Shall I go down after the Pelishtim? wilt Thou deliver them into the hand of Yisra᾽el? But he answered him not that day. And Sha᾽ul said, Draw near, all you chiefs of the people: and know and see wherein this sin has been this day. For, as the Lord lives, who saves Yisra᾽el, though it be in Yonatan my son, he shall surely die. But there was not a man among all the people that answered him. Then said he to all Yisra᾽el, Be you on one side, and I and Yonatan my son will be on the other side. And the people said to Sha᾽ul, Do what seems good to thee.Therefore Sha᾽ul said to the Lord God of Yisra᾽el, Give a perfect lot. And Sha᾽ul and Yonatan were picked: but the people escaped. And Sha᾽ul said, Cast lots between me and Yonatan my son. And Yonatan was picked.

So the Urim and the Tummim (or at least the Tummim) were a device used to cast lots. They were used for (and this is going to be the word of the week) cleromancy - divination by means of casting lots.

How did Yale end up with that Seal?

Why did the Urim and Tummim end up in Hebrew on the Seal of Yale University? And what are those Latin words underneath the Hebrew ones?

In October 1722 the trustees of Yale College voted to have the colonial General Assembly grant the college its own seal. If you think that it bears a resemblance to the seal of its slightly older brother Harvard University, you are correct. Other universities too, have seals that show open books. Harvard’s was apparently used since the end of the seventeenth century, but Veritas - “Divine Truth”was not used as the centerpiece of its seal until around 1843. Prior to 1736, Yale diplomas did not show the seal, and while Harvard’s then had three Latin Words In Christi Gloriam, Yale inscribed Lux et Veritas “Light and Truth” underneath the Hebrew Urim and Tummim.

Yale likely chose the Hebrew Urim and Tummim because its scholars had access to a 1578 edition of the Genevan Bible which gives this explanation of the mysterious Hebrew words:

Urim signiheth light and Thummim perfection: declaring that the stones of the brestplate were most cleare, and of perfect beautie: by Urim also is ment knowledge & Thummim holiness, shewing what vertues are required in the Priests.

“If the early Yale graduates left the college both holy and knowledgeable,” wrote Dan Oren in his 1958 book Joining the Club: a history of Jews at Yale, and from where all this information is taken “Yale’s leaders would have been pleased.” But he continues,

Unfortunately, the 1742 Yale Library is a poor reflection of the theological character of education at Yale. As historian Richard Warch pointed out, the 1742 Library, containing a wide spectrum of authors, was far more broad-minded than the curricular fare.Therefore the above explanations remain, by themselves, unsettling. That Yale was long dedicated to producing men of knowledge and character (“holinesse”) is unquestioned. In that sense the Urim and Thummim were appropriate for the Yale mission. Placing these words in the original Hebrew testified both to their biblical origins and tied Yale to the ancient Israelites, whose position Yale theologians saw themselves as imitating. But the 1742 Library does not tie these words particularly to Yale.

Oren therefore suggested another explanation, and points to a basic theology text that was available at the time called (in translation from the original Latin title) The Abridgement of Christian Divinitie. The original Latin reads “Urm & Thummim, h.e. lumina & perfectiones, Christum designabant, Verbum & Interpretem Patris, Lucem & Perfectionem nostram,” which in the 1660 translation became “Urim and Thummim, that is, light and perfection, did signify Christ the Word and Interpreter of the Father, our light and perfection.” Just as Harvard’s motto celebrated the glory of Jesus, so did Yale’s. And by translating Urim as Lux, Light, Yale was following the interpretation of the Talmud as cited by Rashi. How Tummim became Veritas, Truth is less clear. It was translated as Veritas in the 4th century Latin translation of the Bible known as Vulgate, and, Oren concludes, “by choosing to translate אורים ותמים as Lux et Veritas, perhaps, Yale insisted that its college offered the essentials of proper learning: the “light” of a liberal education and the “truth” of an old New England religious tradition.” Or perhaps this translation too, followed the explanation of Rashi: שֶׁעַל יָדוֹ הוּא מֵאִיר דְּבָרָיו וּמְתַמֵּם אֶת דְּבָרָיו -through it, it illuminates the statements made by the Breastplate, and made its words true.

Whatever Yale has recently been doing wrong, its translation of Urim VeTummim as Lux et Veritas is perfectly sensible. If only the same could be said for all of its faculty.

Join us in NYC - Maimonides and Medicine, Wednesday Feb 21, 6.30p

For those in the NY area, please join me and my colleague Dr. Eddie Reichman at the Yeshiva University Museum this Wednesday. Details are below, and no, the event is not available remotely. Anyway, you should come see the books on display. They are spectacular.