“The Powerful Drug:” Opium and its Derivatives in Medieval and Modern Medicine in the Light of Jewish Literature
Avraham Ofir Shemesh
Opium is a narcotic substance produced from the milky sap found in the immature capsules of the papaver somniferum plant (cultured poppy). This plant grows in a variety of climates, but in practice its growth is limited to a few countries in the East, such as India, Iran, Turkey, Yugoslavia, and China.
Opium contains around thirty psychoactive alkaloids. The best known of them are morphine, thebaine, codeine, narcotine, and papaverine. Heroine, which is addictive, is produced from morphine. In contemporary medical practice opium is used for a variety of purposes, such as anesthesia, palliative and antitussive care. There are, however, legal restrictions on its use due to the danger of addiction.
Many studies have dealt with the pharmacological aspects of opium. Few have dealt with its historical, socio-cultural, halachic and ethical aspects. The purpose of this article is to contribute two elements to the scholarly discourse by broadening the discussion to include a variety of literary sources and by discussing the halachic and ethical aspects of the medical use of opium in terms of its negative influences.
Four issues regarding opium and its form the basis of this study:
(1) We shall survey the medical uses of opium as reflected in medieval Jewish literature and we shall try to evaluate their contribution to the history of medicine. In addition, we shall try to determine the frequency of opium’s medical use and for the first time various genres of Jewish literature will be plumbed, including distinctly medical literature as well as halachic sources, responsa, lexical works, and minhag and segulla literature.
(2) Is there a characteristically Jewish approach to the use of opium?
(3) How do the halachic authorities relate to the tension between opium as an addicting substance and opium as a useful therapeutic drug?
(4) Are there sources attesting to religious use of opium or to opium addiction?
Opium: Historical Background
Opium’s medical importance has not changed since antiquity. The medical use of opium was common in ancient societies, such as Egypt and Assyria, and it is reasonable to suppose that the ancients understood its medical properties.
Poppies are mentioned in the Ebers papyrus discovered in Egypt, dating from around 1550 BCE. Some researchers think that it was used as an anesthetic during skull surgery in ancient Egypt. Others tend to identify it with the biblical herb rosh (Deut. 29:17) because of the opium capsule resembles the human head (rosh in Hebrew).
Ancient Greeks and Romans, such as Theophrastus, Pliny, and Dioscorides Pedanius, mention opium’s narcotic properties. Some called for complete abstinence from opium.
The Talmudic word peragin refers to a plant of the cereal family, apparently common sorghum. Some medieval authorities identified peragin as papaver, whose black seeds are used as a spice in baking and whose oil is pressed. But this seems unlikely. The Palestinian Talmud refers to cultured poppy as opyon, which is similar to its Arabic equivilant afyuun.
Opium as a Therapeutic Drug in Medieval Medicine
The description, properties and medical uses of opium appear in a variety of rabbinic sources. Rabbi Nathan of Rome (11th century) described the method of opium production and the danger of large-scale opium consumption in his article on the Talmudic word opyon: “Opyon… congealed juice from the seed and grass of poppies, possessing wonderful medicinal properties, which I have tested. In improper quantities, it is fatal.”
The physician Shabbetai Donolo mentioned opium together with mandrakes as a medicine that occasionally causes mania.
Another description of the plant and its parts is mentioned by R Yitshaq bar Sheshet (Spain and Algeria, 14th century): “poppy is a species of legumes, structure similar to pomegranate, in Arabic couscous, filled with seeds like sesame.”
Numerous medical sources cite the “wonderful” properties of opium in diminishing and reducing pain. Assaf the Physician refers to its various names: qusqus, miqonion, and papaver. He further mentions it efficacy in cases of sciatica, as well as its use in treating discomfort in the liver and the head and as a soporific. Shabbetai Donolo reports that it was used to treat fever and poisoning. In his medical dictionary, Maimonides defined opium as “a medicine whose power is well-known.” He presented three terms connected to the poppy plant and its products: hashhash, the poppy itself; diaqoda, the juice; and afyuun, the dried, white juice.” In one of Mainonides’ responsa regarding headache, attention deficit, and depression, he attacked those physicians who prescribed barley water (beer?) and kashkash (cultivated poppy). He claimed that opium is useful in treating sleep disorders, but the patient in question had no problem sleeping. It is interesting to note that Maimonides recommended a number of therapeutic substances to treat depression. But as far as I know, he did not recommend opium. He also recommended the milk of the kashkash for soporific purposes as well as for external treatment in the palliative care of spider bites.
The mystic R. Hayyim Vital (Israel, 17th century) recommended opium for the external treatment of hemorrhoids. He claimed that placing a bandage with a little “finely ground” opium would dry the hemorrhoids and reduce the pain.
In his medical dictionary, Tuvia the Kohen (Metz, 17th century) referred to labdanus, a compound of opium juices and “honorable drugs”.
The known sources support the conclusion that opium was administered even in cases where according to contemporary medical science it is injurious. Explanations for this will be proposed later. An example of this would be the advice of the European physician Tuvia Katz (17th century) to administer opium to women suffering from various physiological symptoms, especially sleep disorders, during the first months of pregnancy: “Hyper-wakefulness – she should bath her feet in hot water at night and drink papoir water and papoir and violet syrup.
Other European physicians mentioned the use of opium. For example, the father of homeopathy, Samuel Friedrich Hahnemann (1755-1843) claimed that minimal doses of opium are aid in sleeping.
Another use of opium was as a palliative for toothaches. The Jewish scholar, R. Avraham Sperling (19th century), wrote in the medical appendix to his comprehensive work on Jewish practices: “Buy opium pills at the chemist shop and put one into the cavity in the tooth. Be careful not to swallow your saliva.” Although Sperling indeed recommended this treatment, he qualified it by warning against swallowing saliva so as to avoid influencing mental function.
Sperling also recommended morphine, which is derived from opium, as an ingredient in cough syrup. But in this case as well he advises using a minimal dose: “For coughing and hoarseness of voice – soda mixed with Senegal gum, sugar, well ground liquorice, magnesium, and a little acid salt of morphine”.
Nowadays most morphine undergoes a chemical process to produce codeine, which is widely used as a palliative and cough remedy.
It should be noted that these narcotic substances were mentioned infrequently in Sperling’s medical compilation among hundreds of substances and prescriptions for treating a wide spectrum of medical problems. This might be because opium was relatively rare in European folk medicine due to the great distance to the areas of cultivation in the East. Alternatively, it is possible that Sperling purposely refrained from mentioning it because of its narcotic characteristics.
Opium was used in a number of places in the East to put babies to sleep. A North African scholar, R. Refael Ohana, lists the medical characteristics of the various parts of the plant. Among other points, he mentions the use of a narcotic substance for inducing sleep in the Land of Israel: kaskas, i.e. adurimidiras – its juice is mixed with oil darkens and strengthens the hair; chewing its root purifies the fluids of the head through the nostrils. In the Land of Israel they put part of the plant that resembles pomegranate under an infant’s head to induce sleep. I have heard that intoxicating afyuun is derived from it.
It seems that opium powder was not administered to children internally. Rather, it was placed under their heads externally. Used in this manner, it is hard to believe that it had much effect. Use of opium as a soporific for infants was common in other Eastern countries such as Morocco, Tunis, and Iraq.
Opium in Halachic Literature
Opium is mentioned in a limited number of passages in rabbinic-halachic literature. R. Yosef Karo (Israel, 16th century) mentioned it while discussing the permissibility of accepting non-Jewish medical services and while discussing therapeutic substances like alcohol and theriac, which can be purchased without fear that any poison has been added. In his Beit Yosef he wrote:
Nachmanides wrote in his Torat ha-Adam: Opium is afyuun, a kind of medicine made from poppies. It is dangerous to acquire it from a non-expert. But theriac is permitted because it is expensive and it is made expertly.
R.Y. Karo distinguishes between opium and theriac. The first was sold in the markets without any supervision, leading to possible injury to the patient. Theriac, on the other hand, was expensive and only experts compounded it. Therefore, there was no fear that poisonous ingredients might be added or that the dosage would be incorrect.
In the halachic literature of the twentieth century, use of opium is discussed in the context of Passover. In a letter sent to R. Moshe Yehuda Jakobowitz (Austria 1889 – New York 1950) we find the following question:
What is the status of opium on Passover?
(1) Is an alcohol tincture permitted? Surely not
(2) If it is finely ground into a powder, may it be used even though the workers touched flour before working? Since the flour is nullified before Passover, it is of no consequence on Passover (eino hozer ve-ne’or).
The two issues are as follows:
(1) Use of Flour in Preparing Therapeutic Drugs – In the production of opium pills, the pharmacists used flour to prevent the material from sticking to their hands. R. Jakobowitz is of the opinion that the finished product is permitted on Passover because the flour was mixed in before the festival and its quantily is so small that it is nullified. In this case he relies on those authorities who hold that such a mixture is of no consequence on Passover because both the flour and the opium are powders. It follows that the resulting mixture is evenly mixed (lah be-lah).
(2) The Prohibition of Legumes (kitniyyot) on Passover – Kitniyyot are prohibited on Passover according to Ashkenz practice. Poppy seeds are called in mon (cf. modern German Mohn) or sumsumin in European responsa. In some Ashkenazi communities these were not eaten on Passover. On this basis, R. Jakobowitz prohibits opium made from poppies except for patients who need it:
But in any event opium made from mon should not be permitted because it is a kind of kitniyyot. Therefore, most authorities prohibit it. But it is permitted even if the patient is not in a life threatening condition as long as he is ill in his whole body and the physician says that he needs the opium immediately. In our case, it is not going to be cooked. So it can be permitted without cooking. Simply swallow the pill whole for the custom not to eat poppies on Passover is not applied to sick people. But care must be taken to swallow it dry.
R. Jakobowitz bases the prohibition on the fact that the authorities identify poppies with the peragin mentioned in Talmudic literature as being kitniyyot. Of course he is not referring to the seeds themselves, only a derivative of them. But this too is prohibited just as the authorities prohibited oil derived from sesame seeds (sesanum orientale or sesanum indicum).
Aware of the medical need for opium, R. Jakobowitz permitted its use even for patients not in life threatening situations as long as they are suffering through their whole body and a physician prescribed the opium He indicates that although some authorities requires boiling (halita) kitniyyot, in this case the requirement of boiling is irrelevant because of the nature of the mixture. R. Jakobowitz is nonetheless concerned that the flour in the mixture might become prohibited. Therefore, he advises not allowing the pills to come into contact with water.
In my opinion, the problem of kitniyyot might not be relevant because there is no connection between poppy seeds and opium. Opium is a powder produced from the capsule, not the seeds.
Opium: Therapeutic or Dangerous Substance?
As we have seen, opium was considered an important therapeutic substance in the Middle Ages. On the other hand, there is also historical evidence regarding its dangers. A tragic story of an infant’s death resulting from the use of opium as a soporific is described in detail in the responsa of a well-known Baghdad rabbi, R Yosef Hayyim (1883-1909). The background is the ethical question: if administering a medicine to a patient causes his death, is repentance (teshuva) required?
A baby boy was born. Day and night he cried and screamed. They took him to the physicians to find a cure. No cure was found. Every day his health declined until he was mere skin and bones. He still cried and the family could not stand it any longer. The father asked a physician, who told him that he should administer a little bit of opium in the morning and at night. This would quiet the baby. The father told his mother-in-law. She did it… One night, after eighteen days of treatment, she came to administer the opium as usual. But the baby did not wake up. She looked and saw that he had died. The woman is upstanding and righteous and is concerned for her soul. Perhaps the opium she administered killed the baby. If so, she caused the death.
It is apparent that the infant’s illness, accompanied as it was by great pain, caused a precipitous decline in his physical condition. The physician prescribed a small dose of opium, to be administered twice a day, in order to lessen the infant’s suffering. The infant received the prescribed medicine, but died shortly thereafter. His grandmother took care of him and she had pangs of conscience fearing that the opium she had administered caused the death. Therefore, she asked R. Yosef Hayyim for his opinion.
In the course of the responsum, R. Yosef Hayyim encouraged the grandmother by claiming that she acted on the physician’s instructions intending to aid the infant who apparently died as a result of his illness. His position implies that even when it is known in advance that administering opium might be fatal in certain circumstances, administering it in accord with the instructions of a qualified physician exempts the grandmother from the need of atonement. This is because she acted in the best interests of the infant with no malicious intent.
It is reasonable to suppose that other fatalities resulted from the medical use of opium. For various reasons, however, no other cases have appeared in halachic literature. We have no pre-modern statistics regarding the death rate resulting from the use of opium. It seems reasonable that the rate depended on various factors such as the patient’s state of health and the dose administered.
R. Hayyim dealt with a case where the patient had already died as a result of administering opium. The case under discussion raises the question of how halacha relates to a case where opium treatment has a 50% chance of improving the condition of a living patient and a 50% chance causing his death. This will be discussed later.
The story of the infant’s death due to opium treatment illustrates the tension that exists between a substance having vital medical properties on the one hand and having addicting or even fatal properties on the other. The dangers of using opium were without doubt known in antiquity. It seems reasonable that the ancients were familiar with such dangers on the basis of personal experience.
As indicated above, there were medical authorities in the Greek and Roman period who recommended complete abstinence because of opium’s addictive properties. Evidence of the negative impact of addictive drugs can be found in medieval literature as well.
Note too that Maimonides’ general approach regarding everything touching upon the use of strong drugs was extremely cautious. He was of course concerned with their danger.
Jewish sources also warn against using opium improperly. To these concerns we must add the classic halacha from the Talmudic period which permits buying opium from qualified people who are expert in preparing it in accord with quality standards. It is quite possible that this halacha was established following classical Greek and Roman standards. The halacha was established for all future generations and is mentioned in medieval rabbinic literature. This indicates the relevance of the halachic norms over long periods of time in accord with historic reality.
Jewish sages were aware that opium possesses contradictory medical properties. However, there seems to be no Jewish source which entirely rejects the use of opium due to its dangers. It seems that the sages chose to resolve the “tension” between the uses of opium by cautiously permitting it.
It is reasonable to suppose that the ancients tried to administer opium to patients in a controlled way (dose, etc.). The impression remains, however, that, at least from the point of view of modern medical practice, it was used too broadly (e.g. for headache and toothache). Similarly, there was insufficient caution in its use. For example, Eastern sources report that it was used as a soporific in relatively dangerous cases such as for infants and pregnant women.
With respect to the fairly broad medical use of opium in the Middle Ages, the following explanations might be proffered:
1. First it must be assumed that due to the absence of any legal restrictions on opium in many countries, especially in the East, it was more readily available. Therefore, its medical use was more common.
2. Opium’s broad use for medical purposes was part of accepted medical concepts, according to which it had great medical efficacy. This fact is mentioned by various Jewish personalities, such as the author of Sefer ha-Aruch, who ascribed “amazing medical properties” to opium. Similarly, Maimonides defined it as “a drug of well-known power”.
It may be assumed that opium’s image as an effective drug was due to its palliative characteristics, despite the many cases in which it did nothing to cure the underlying disease.
3. Ancient medicine was limited in its ability to find substitutes with less dangerous side effects. At times there was no alternative to using dangerous substances. In other words, cases of serious illness presented to approaches: (a) to suffer greatly and at times to die; or (b) to administer opium or another drug to attenuate the pain despite its negative side effects. Such patients had no choice; of course they chose to use the drug.
Today the attitude toward opium is stricter. Current scientific knowledge has supplied us with better tools to understand the physiological and psychological ramifications of drug use. It seems that the contribution of the ancient sources to the contemporary discussion is in documenting the “tension” which exists between opium’s properties (curative and palliative) and undesirable side effects that can result from improper use.
Jewish Sources: The Halachic Approach to the Medical Use of Opium
Jewish sources are a sensitive indicator of opium use at that time. Jewish literature includes compositions and writings produced in quite a broad geographical area from the East to the West. This literature therefore provides a relatively broad picture of opium use.
On the other hand, it seems that these sources merely reflect the general knowledge embedded in contemporary Arabic and European medical literature. It must be emphasized, however, that Jewish literature (aside from clearly medical literature) is religious in nature. The medical information contained in Jewish literature is therefore indirectly embedded and occasionally incidental.
Is there a uniquely Jewish approach to the use of opium? The sources create an ambivalent impression regarding drugs in general and opium in specific. This was representative of general medicine in the Middle Ages.
On the other hand, it is clear that the halachic norm requiring caution to prevent improper use of opium derives from the overarching Jewish principle of guarding one’s health (ve-nishmartem le-nafshoteichem).
It seems that there is nonetheless a characteristically Jewish approach to opium use. Jewish literature reports no religious use of opium, no massive addiction to narcotic substances, and no use of opium among closed mystical groups although this was common in other religions. Further, the sources reflect reticence in these matters.
In Rabbinic literature there are indeed not a few reports of drunkenness and alcoholism and heavy smoking and tobacco dependence. But we know of no sources reflecting addiction to opium or other drugs.
It must be assumed that there were addicts in the old Jewish society. The impression remains, however, that the phenomenon was quite rare. At the moment we have insufficient data to evaluate the dimensions of the phenomenon. Further research is a clear desideratum.
On the other hand, medieval Arabic literature presents a clearer picture. Several sources report, for example, exaggerated use of hashish (cannabis) among Sufi fakirs and among the masses throughout the Mediterranean area. This phenomenon, which created a severe social problem as it spread, led Muslim religious and secular leaders to wage war against addicts.
The Halachic and Ethical Attitude to the Medical Use of Opium
Although this article focuses on the use of opium in the Middle Ages, it is appropriate to observe the change which has occurred in more recent attitudes.
As is well known, the law of the land prohibits narcotic drugs. Use of opium and its derivatives is permitted only in medical contexts and with the approval of a qualified physician. Recent responsa literature deals with the halachic and ethical question of administering palliative substances (morphine, etc.) that endanger the patient or hasten his death.
As far as I know, no similar question was ever raised in ancient or medieval sources. It is possible that the recent discussions of this question is connected to two central factors: (1) opium derived substances play an important role in modern medicine; and (2) developments in the field of ethics.
Causing death is of course discussed in ancient ethical literature. Some halachic authorities prohibit palliative medicines that hasten death. In their opinion, administering such medicines is tantamount to murder. Many other halachic authorities tend to permit such treatment under certain limited conditions.
One example of such a permissive ruling is that of R. Eliezer Yehuda Valdenberg, one of the greatest authorities in the field of medical halacha. Rabbi Professor Avraham Steinberg addressed the following question to R. Valdenberg:
An incurable patient in a life threatening condition is suffering in great pain. Is it permitted to increase the amount of pain relief medicine, such as morphine, which is injected into him even though the morphine does not treat the underlying disease and is liable to hasten death?
Answer: In my humble opinion it seems that as long as the medicines are administered in the form of pills or injections and are prescribed by a physician for the purpose of reducing great pain, they are permitted even though they might injure the patient and are liable to hasten his death. This is because it seems that this is part of the permission that the Torah grants to physicians to heal. As Nachmanides explained in his Torat ha-Adam this permission is needed because all therapeutic procedures are dangerous. If so, the principle applies in this case as well and injecting morphine or similar substances is permitted under the rubric of the Torah’s permission to heal even though the morphine is solely intended to reduce the patient’s suffering. There is nothing worse than suffering, may we be protected. Therefore, when administering the morphine to reduce pain, the physician is indeed treating the patient. This is permitted even if it is liable to hasten the patient’s death.
R. Valdenberg permitted increasing the dose of morphine to reduce strong pain in terminal patients even if such treatment might hasten death. His central claim is that halacha permits the physician to apply dangerous therapies that in his medical opinion will help the patient. Administering morphine is part of the therapeutic program because the patient suffers not only from his underlying disease. He is also suffering great pain that needs to be treated.
His second claim is that in the case under discussion there was no hope that the patient would survive. Therefore, administering morphine would not alter his medical condition.
He further notes that although the morphine might hasten the patient’s death, it is clear that his great pains alone might also hasten death. It follows that palliative treatment impedes death.
Summary and Conclusions
Medieval Jewish sources reflect a fairly clear picture indicating that opium occupied a prominent position in the pharmacological armamentarium. Opium was broadly used in treating external and internal conditions. The spectrum of medical problems mentioned in Jewish texts include: toothache, headache, depression, cough, fever, poisoning, stings and bites, and others.
These therapeutic procedures appear in non-Jewish medical sources as well. It therefore seems that the contribution of rabbinic literature consists of consolidating and broadening the medical knowledge they possessed.
Jewish writings preserve warnings against improper use of opium. The sages were aware of the fact that opium possesses contradictory medical characteristics with dangers of addiction and even death. Since there were no good substitutes for opium and indeed there was occasionally no other way to relieve the patient’s pain, the sages did not prohibit opium. Rather, they recommended caution. This might explain the use of opium for patients at high levels of risk.
Jewish sources express an ambivalent attitude toward drugs in general and opium in specific. This ambivalence was common in medieval medicine. The phenomenon of religious or social use of opium, well documented in various Islamic chronicles, was unknown in Jewish communities.
The use of opium or its derivatives for pain relief in cases where it is liable to hasten death is first discussed in modern times. There is no hint of such a discussion in earlier Jewish sources. It is possible that this is due to the importance of these substances in modern medicine and to developments that have occurred in the field of ethics.
 For poppies and the method of producing drugs, see M. Zahai, Olam ha-Tsmahim (Tel Aviv, 1969), p 321; A. Fahan et al., Magdir le-Tsimhe ha-Tarbut be-Yisra’el (Tel Aviv, 1998), p. 138; A. Alon, ed., Ha-Hay ve-ha-Tsomeah shel Erets Yisra’el (Ministry of Defense, 1990), vol. 12, p. 87; L.S. Cobley, An Introduction to the Botany of Tropical Crops (London, 1956), pp. 248-249; R.S. de Rop, Samim Meshakkerim ve-Nefesh ha-Adam (Tel Aviv, 1952), p. 115; A.F. Hill, Economic Botany: Textbook of Useful Plants and Plant Products, (Toronto, 1952), pp. 260-261. England was among the countries that imported opium from Turkey in the Middle Ages. Jewish merchants participated in that trade. See A. Bashan, “Pe’ilut ha-kalkalit shel Yehude Izmir,” in Yehudim be-kalkala – Kovets Ma’amarim, ed. N. Gross (Jerusalem, 1975), pp. 153-154. For the medical uses of the poppy in the Middle Ages, see D. Palwitz, “Tsimhe Marpe ve-Erkam be-Refu’ah ha-Modernit,” in Madda 22:6, pp. 264-269.
 Partial discussions regarding the medical use of opium in view of Jewish sources can be found in I. Low, Die Flora der Juden (Vienna, 1924-1934), vol. 2, pp. 363-370; A Lev, Homre ha-Marpe be-Erets Yisra’el u-be-Surya (Doctoral Diss., Ramat Gan, 1989), pp. 249-250; N. Krispil, Yalkut ha-Tsemahim (Jerusalem, 1953-59), vol. n-ts, s.v. pereg, pp. 1061 ff.
 For opium in antiquity in view of archeological findings such as Cyprus (12th-14th cent. BCE), see R.S. Merrillees, “Highs and Lows in the Holy Land: Opium in Biblical Times,” in Eretz Israel, 20 (1889), pp. 148-153. See P.G. Kritikos and S.N. Papadaki, “The History of the Poppy and of Opium and their Expansion in Antiquity in the Eastern Mediterranean Area,” in Bulletin on Narcotics, XXI (3), 1067, pp. 17 ff. and D.M. Merlin, On the Trail of the Ancient Opium Poppy, (London, 1984).
 Jer. 8:4; see Y. Felix, Olam ha-Tsomeah ha-Mikra’i (Ramat Gan, 1976), p. 197; the identification with conium maculatum seems more likely as the ancient Greeks used this as a poison.
 For opium use among the masses in antiquity, see de Rop, p. 114; Krispil, p. 1063.
 For peragin, see for example Mishna Shevi’it 2:7; Halla 1:4. For the identification in medieval sources, see Y. Felix, “Perek Zera’im,” in M. Margoliot, Hilchot Erets Yisra’el min ha-Geniza (Jerusalem, 1954), p. 165.
 A.Z. 2:2 (ed. Venice, fol. 40d). On the poppy in Jewish literature, see Low, vol. 2, pp. 363 ff.
 Aruch ha-Shalem (ed. Kohut, New York, 1935), s.v. opium.
 Shabbetai Donolo (ed. Muntner), p. 122.
 Resp. Rivash, no. 442.
 S. Muntner, “Sefer Asaf ha-Rofe” in Korot 4, p. 415. Note too that the poppy flower symbolized Morpheus, the Roman god of dreams.
 S. Muntner, R. Shabbetai Donolo (Jerusalem, 1939), p. 15.
 Maimonides, Comm., p. 23, no. 35.
 Maimonides, Comm., p. 110, no. 110; p. 40, no. 109; p. 23, no. 35.
 For the medical use of opium in the Middle Ages with emphasis on the Land of Israel and Syria, see Lew, Homre, p. 249-250
 “Medical Responsa,” in S. Muntner, ed., Rambam Ketavim Refu’iyim (Jerusalem, 5725), p. 141, resp 9.
 For example, “oksimal and hidrumal mixed with ox tongue” (Medical Responsa, p, 140, par. 8; p. 143, par. 6) or “quality wine increases joy and eliminates black gall, brings sleep, cleans the blood, and neutralizes the injurious vapors therein” (p. 138, par 2). For this plant and its names in medieval Arabic, see Maimonides, Comm., no. 211.
 Maimonides, Same ha-Mavet ve-ha-refu’ot ke-negdam (ed. Muntner, Jerusalem, 5702), p. 93.
 M. Benyahu, “Likkutim mi-Sefer ha-Refu’ot ve-ha-Segullot shel R. Hayyim Vital”, in Korot 9 (5747), p. 102 and p. 110.
 Ma’ase Tuvya (Venice ed.), fol. 122b.
 See R. Marguta, Toledot ha-Refu’ah, (Jerusalem, 5761), p. 129. The use of opium in European medicine is embedded in modern literary works. For the use of tincture of opium, see for example S. Agnon, Sippur Pashut (Jerusalem, 5735), p. 189.
 A.I. Sperling, Ta’ame ha-Minahgim u-Mekore ha-Dinim (Jerusalem, 5717), p. 588).
 Morphine was one of the first medicines isolated from a plant. It was first discovered by a German researcher, Friedrich Wilhelm Adam Sertuemer, in 1803 while he was growing white crystals from opium. See A Panlopi, Tsimhe Marpe (Tel Aviv, 5754), p 23.
 Sperling, p. 596.
 ha-Hay ve-ha-Tsomeah, p, 87.
 The use of opium as a soporific is clear in its Arabic name abu num, meaning “father of sleep”. See G.E. Post and J.E. Dinsmore, Flora of Syria, Palestine and Sinai (Beirut, 1932-33), vol. 1, p 36; Low, Flora, vol. 2, p. 363.
 Sefer Mar’e le-Yeladim by R Refael Ohana (ed. S. Katz; reprt.: Jerusalem, 5750), p 216. Compare Krispil, p. 1075 according to whom children in the villages in Shomron were put to sleep with pills made from crushed capsules, honey and dough. Note that other recipes quoted by Ohana indicate that opium was an ingredient in creams used externally for hemorrhoids. See p. 115-116 and compare note 17.
 For the use of opium in Tunis, see Krispil, p 1073. For the opium trade in Iraq, see Resp. Zivhe Tsedek by R. Abdulla Somekh (Jerusalem, 5741), pt. 3, Y.D. 37, p 50. This source indicated that the opium trade was unsupervised by the Iraqi authorities.
 A bluish black mineral used for coloring the eyes and treating eye problems. For this material, its sources, and uses, see M. Gil, Erets Yisra’el ba-tequfa ha-muslamit ha-rishona, vol. 1, p. 353; H.Z. Hirshberg, Toledot ha-Yehudim be-Afrika ha-Tsefonit (Jerusalem, 5755), p. 233; Z. Dori, Ha-Pukh ve-ha-Kofer (Jerusalem, 5743).
 Medicine for animal bites, prepared from the flesh of various reptiles. See Z. Amar, “Yitsu ha-Teriak” in Korot 12, pp. 17-18; Lev, Homre, pp. 322-323.
 Bet Yosef Y.D. 155. Note especially that the reference is to an idolatrous healer unqualified in the preparation of the medicines. In antiquity there was concern that he would not properly care for the patient. This is no longer the case today.
 Resp. Zikhron Moshe, no. 6.
 See Shulchan Aruch, O.H. 447:4.
 See the adduced sources.
 Several European authorities mistakenly identified peragin in Rabbinic literature with poppies. This mistake appears in the Aruch s.v. pragin: “mago in the language of the gentiles; khashkhaash in Arabic; papavero in Italian”. Rashi followed the Aruch (see Katan, Lo’aze Rashi, no. 922). Maimonides in his commentary on the Mishna translated the term with the Arabic khashkhaassh (see Felix, Perek Zera’im, p. 165). This identification must be rejected for two reasons: (1) papaver is typically a winter growth; (2) the Mishnaic peragin are discussed in the context of halla and hamets. It is improbable the small papaver seeds could be used to make bread.
 R. David Zvi Hoffmann pointed out that European authorities called poppies by the name of sumsumin (Resp. Melammed le-Ho’il, no. 87). Compare Bi’ur Halacha 168 s.v. she-ki-me’at and see Shemesh, Ma mesammelot, p. 55-56.
 See Zevin, ha-Mo’adim, pp. 255-262.
 For the controversy regarding the use of sesame on Passover, see Zevin, op. cit.
 For the concern of the medieval Sages that kitniyyot might turn into hamets, see Shemesh, Shorshav, p. 111 and the sources in note 44.
 Resp. Rav Pe’alim, Pt. 3, no. 36. Note too the famous poisoning of Napoleon’s soldiers who were victims of epidemic during the siege of Jaffa in the 18th century. The poisoning was caused by opium administered by military physicians. See N. Shor, Massa’ Napoleon le-Erets Yisra’el (Tel Aviv, 5744), p. 113.
 See note 5 above.
 For example, ibn al-Bitaar, the Spanish herbalist (Spain, 1197 – Damascus, 1248), dealt with the influences of Indian cannabis. He reported that consuming one or two dirhams of this plant causes intoxication. Consuming a larger dose brings the patient to the brink of madness and can even be fatal. He indicated that Muslim fakirs processed cannabis leaves into special pills that they would chew for extended periods. This use of cannabis caused emotional elevation and joy, but many of them became intoxicated and even went mad, or almost mad. See ibn al-Bitaar, al-Jaami’, Pt. 4, p. 39.
 See Maimonides, Pirke Moshe (ed. Muntner, Jerusalem, 5721), 21:49.
 See notes 8 and 25 above.
 See note 22 above.
 For example, R. Y. Karo, the author of the Shulchan Aruch. See note 21 above.
 The sources do not discuss addiction to drugs in a detailed manner. At the moment we have no sources dealing with the question of actual danger.
 Aruch ha-Shalem (ed. Kohut, New York, 5715), s.v. opyon.
 Maimonides, Bi’ur, p. 23,note 35.
 For example, treating fever with opium as indicated by Shabbetai Donolo (note 11 above) is mentioned also by Marie Elise Rogers, who describes Arab medicine in Israel in the 19th century (Hayye Yom Yom be-Erets Yisra’el, ed. R. Ze’evi, Ministry of Defense, Tel Aviv, 5744, p. 133). Similarly, treatment of toothache mentioned by R. Sperling (note 25 above) is documented in a memoir written by A. Piaroti, an Italian architect and civil engineer who visited Jerusalem during the same century (Minhagim u-Masorot, tr. A. Arbel, Ministry of Defense, Tel Aviv, 5745, p. 186).
 Much has been written about the difficulty of historical analysis based on halachic sources and Jewish exegesis. See M. ben Sasson, Tsemihat ha-hekehila ha-Yehudit be-Artsot ha-Islam (Jerusalem, 5757), p. 20, note 12.
 In the course of history a number of religious cults used drugs and intoxicating substances in order to reach “spiritual heights”. This is exemplified by trance and ecstasy. For example, American Indians used peyotl, Mexicans used mushrooms, and Muslims used hashish. See de Rop, pp. 30-32; ben David and S. Ran, “ha-Kombamla be-Hodu” in Teva’ ha-Devarim 65, pp. 42-43.
 Jewish Kabbalists indeed used certain mystical techniques (meditation, mental concentration, color imagery, etc.) to arrive to para-normal states of consciousness. But they did not use psychedelic substances. See M. Idel, ha-Kabbbala: Hebbetim Hadashim (Jerusalem, 5753), pp. 92-127.
 For the attitude toward drunkenness, see Midrash Tanhuma, Par. Noah, 13.
 See, for example, Resp. R. Eliahu Mizrahi, no. 72; Resp. Nose ha-Efod, no. 32; Resp. Maharitats ha-Hadashot, no. 205.
 The dependence of smokers on tobacco is indicated in a number of responsa. See Sheyyare Keneset ha-Gedola (Benveniste), O.H. 547; Resp. Admat Kodesh (Mizrahi), Pt. 1, O.H. no. 4; Y.Z. Kahana, Mehkarim be-Sifrut ha-Shut (Jerusalem, 5733), 317-329.
 For example, Krispil, p. 1073, reports that the use of opium as a soporific in children caused dependence when the patient grew up.
 See Z. Amar, Giddule Erets Yisra’el be-Yeme ha-Benayyim (doctoral diss., Ramat Gan, 5756), pp. 241-242.
 It is interesting to note that R. Y. Hayyim (19th century) ex post facto justified treating a patient with opium although it killed him (see above). Other authorities discussed the initial permissibility of administering opium for palliative purposes in terminal patients despite the danger of hastening death.
 For example, actively or passively causing death (euthanasia) within a medical or non-medical framework. Summary of Hebrew sources from the Middle Ages and modern times can be found in A. Steinberg, Enc. Hilchatit Refu’it 4:359-370 and 398-419.
 See, for example, R. A. Nebenzahl in ASSIA 4:260-262. He, however, cites the opinion of R. Sh.Z. Auerbach who held that each individual injection does not shorten the patient’s life. Only several injections do.
 For example, R. M. Feinstein (Russia-New York, 20th century) permitted this with the condition that the patient’s life not be shortened and that the medicine not be administered to a moribund patient (goses; Iggerot Moshe H.M. 2:73a). Compare Resp. Bet Avi by R. Y.I. Liebes (New York, 5731-5750) H.M. 103; A.A. Sofer, Nishmat Avraham Y.D. 339:4; R. Y.M. Lau, “Retsah mi-tokh Rahamim”, in Torah she-ba’al Pe 25:58-63.
 This is the text of the question that Prof. Steinberg proposed to R. Valdenberg: “If a patient is in a life threatening condition, the attending physicians despair of effectuating a cure, and he is suffering greatly from his disease, is it permitted to increase the injections of pain relieving medicine like morphine even though this does not act to cure the patient and is even liable to hasten his death?” See Resp. Tsits Eliezer 13:87. An identical responsum to Prof. L. Vislicki is mentioned there at 14:103.
 It is obligatory to treat human suffering even by means of intoxicating substances as mentioned in Talmudic literature with respect to convicts who are to be executed: “R. Hayya bar R. Ashi said in the name of R. Hisda that the convict about to be executed is given some frankincense in a cup of wine to numb his senses, as it is said: Give an intoxicant to him who is lost, and wine to the bitter of soul (Prov. 31:6; Sanh. 43a). For the attitude of halacha towards suffering and pain, see A. Steinberg, Enc. Hilchatit Refu’it 3, s.v. yissurin, pp. 143-182.
 The negative impact of palliatives in hastening death is especially common in opiates, which suppress respiration.