Sotah 20b ~ Queen Esther, Mood, and Menstruation

There is a great deal of scientific work investigating the effect of the menstrual cycle on a women's mood. There has been less examination of the effect of mood (or stress) on the cycle.  In today's page of Talmud, there is a digression into gynecology and psychology, and specifically the role of psychological stress on menstruation.  

Queen Esther's Stress

סוטה כ, א

למימרא דבעיתותא מרפיא אין דכתיב ותתחלחל המלכה מאד ואמר רב שפירסה נדה והא אנן תנן חרדה מסלקת דמים פחדא צמית ביעתותא מרפיא

Does fright loosen the womb [and causes a woman to menstruate]? Yes, as the verse states (Esther 4:4) "...and the Queen [Esther] became very afraid" about which Rav explained:" she began to menstruate."

But haven't we learned elsewhere in a Mishnah (Niddah 39a) that fear suspends the discharge of menstrual blood? In fact, fear that is not sudden contracts [the womb and prevents bleeding], but sudden fear loosens [the womb and causes early menstrual bleeding].

Here are some of the things that the rabbis of the Talmud believed could induce menstruation:

1. Carrying a heavy load (Tosefta Niddah 9:1)

2. Jumping (ibid)

3. Sudden fright (Niddah 71a, and Niddah 39a)

4. Yearning for intercourse (Niddah 20b)

5. Garlic, onions and peppers (Niddah 63b)

In today's daf, Rav opined that fear can induce menstruation. Let's take a look at the medical literature and see whether or not it supports his assertion.

“Data from both animal and human research indicate that psychological stress is associated with altered menstrual function.”

— Barsom S, et al. Association between psychological stress and menstrual cycle characteristics in perimenopausal women. Women’s Health Issues 14 (2004) 235-241

The Effect of Stress on Menstrual Function

In a review from the Department of Biological Sciences at Ohio University, researchers acknowledged that stress is difficult to define. However, one final common pathway of stressors is the low availability of dietary energy. Ovulation - which is the first part of the cascade that leads to menstruation - has been blocked in hamsters "by food restriction, pharmacological blockers of carbohydrate and fat metabolism, insulin administration (which shunts metabolic fuels into storage), and cold exposure (which consumes metabolic fuels in thermogenesis)." Women athletes frequently experience a lack of menstruation, which is found in up to 65% of competitive young runners. But what about psychogenic causes of a disturbed menstrual cycle - after all, Rav taught that it was fear that caused Esther's presumably early onset of menstruation? While not adressing this directly, the Ohio University researchers had this to say about the relationship between psychological stressors and amenorrhea (the lack of menstruation. Remember that word - it will come up again):

Associations between psychological disturbances and amenorrhea or infertility have long been interpreted as a causal relationship, but prospective studies demonstrating that psychogenic factors contribute to reproductive dysfunction in women are almost completely lacking . Early psychoanalytic conclusions that psychological conditions underlie involuntary infertility in women have been criticized recently on several grounds: first, the same psychological conditions have been found in analyses of fertile women; second, other women with very serious psychic problems conceive with ease; and third, couples with an unfulfilled desire for a child do not show psychological disorders any more frequently than do couples without fertility disorders. Even the direction of causality is questionable, because there are grounds for believing that infertility and its medical treatment cause the depression and anxiety observed in some infertility patients. These findings have led to the recommendation that the term ‘psychogenic infertility’ should be withdrawn from use because it is simplistic and anachronistic.

Menstruation and Incarceration

Some of the rabbis viewed Esther's association with King Achashverosh as being coerced: she was brought to his palace against her will, and remained there in a similar state. So with only a bit of a stretch, we might turn to a 2007 paper published in Women's Health Issues which addressed the influence of stress on the menstrual cycle among newly incarcerated women.  Researchers analyzed 446 non-pregnant women who answered a number of detailed questions about their menstrual cycles.  They found that 9% reported amenorrhea (I told you what that meant two paragraphs ago) and that a third reported menstrual irregularities.  

“Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.”

— Allsworth J. et al. The influence of stress on the menstrual cycle among newly incarcerated women. Women's Helath Issues 2007; (17) 202-209.

As might be expected, the stressors of the incarcerated women in this study included drug and alcohol problems and sexual abuse. These are not the same stressors that faced Queen Esther - who was held in such esteem by her kingly husband that he promised her (Esther 5:6) "up to half of the kingdom."  But this work does show how stress may impact the menstrual cycle.  

A Longitudinal Study of Psychological Stress and Menstruation

The final study we will review comes from a cohort of predominantly white, well educated married women of whom 505 were "invited to participate join a special survey focusing on midlife and menopause." Rather than ask about stress and current menstruation, the researchers performed a two-year analysis. Here's what they found:

In analyzing stress levels and cycle characteristics across 2 years...women with marked increases in their level of stress (n=30) are shown to have decreased length (-0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (-0.1 day/cycle) compared with increases in these measures (+2.9 days/cycle for cycle interval; +0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n=103); t-tests indicate that these differences are significant (p <0.05).

Some of the differences that the researchers found in this group were really small - "0.3 days/cycle for duration of bleeding" but if you are into statistics this difference can be significant (that's what those t-tests are all about). But these statistical associations were not powerful, and the researchers concluded that "the results of this investigation...suggest that, in the long term, stressful life events have little relationship to the length of menstrual cycle intervals and the duration of menstrual bleeding in perimenopausal women."

The three studies we've reviewed (even that last one with its weak findings) all suggest that there is indeed some relationship between psychological stress and menstruation.  Generally, the effect of stress is to increase the length of the menstrual cycle which may result in amenorrhea.  But according to Rav, stress caused Esther to menstruate sooner - the opposite of most modern research findings.  Single events should be used with caution when trying to build a general explanatory model, but Rav, and the other rabbis of the Talmud were onto something when they noted that both acute and chronic fear (which is of course just one type of stress) -  can effect a women's menstrual cycle.  

Sotah 13a ~ Metal Coffins and Green Burials

Joseph's Egyptian Coffin

סוטה יג, א

ומנין היה יודע משה רבינו היכן יוסף קבור אמרו סרח בת אשר נשתיירה מאותו הדור הלך משה אצלה אמר לה כלום את יודעת היכן יוסף קבור אמרה לו ארון של מתכת עשו לו מצרים וקבעוהו בנילוס הנהר כדי שיתברכו מימיו

הלך משה ועמד על שפת נילוס אמר לו יוסף יוסף הגיע העת שנשבע הקב"ה שאני גואל אתכם והגיעה השבועה שהשבעת את ישראל אם אתה מראה עצמך מוטב אם לאו הרי אנו מנוקין משבועתך מיד צף ארונו של יוסף

How did Moses know the place where Joseph was buried? — It is said that Serah, daughter of Asher, was a survivor of that generation. Moses went to her and asked: 'Do you know where Joseph was buried?' She answered him, 'The Egyptians made a metal coffin for him which they set in the river Nile so that its waters would be blessed'.

Moses went and stood on the bank of the Nile and said: 'Joseph, Joseph! the time has arrived about which God, swore, "I will deliver you", and the oath which you imposed on the Jewish People [to take your bones with them out of Egypt] has reached the time of fulfilment; if you show yourself, it is well and good; but if you do not show yourself, we are absolved of your oath'.  Immediately Joseph's coffin floated to the surface.

I can still recall the thrill of seeing the sarcophagus of King Tutankhamun displayed at the British Museum in 1972. The boy king had been buried inside three nested coffins: The outermost one was made of cypress overlaid with gold foil.  Inside that was another wooden coffin with a gold overlay.  And inside that was a third coffin, this time made of solid gold.   We don't have any detailed description of Joseph's coffin from the Talmud, although the tradition that it was made of metal is a fascinating, since so many of the Egyptian coffins we know of today are made of stone rather than metal.     

Wooden Coffins from Jericho

When a Jewish cemetery outside Jericho was excavated in the late 1970s, a team of archeologists led by Rachel Hachlili discovered both wooden and stone coffins. The wooden coffins were made of local cypress or sycamore, and "[f]rom one to three individuals were found in each coffin, usually an adult and a child but occasionally two or even three adults, each lying on a leather mattress one above the other."  These excavations revealed that there were "two distinct burial customs among the Jews of Jericho. During the 1st century B.C. they buried their dead in wooden coffins; suddenly, at the beginning of the 1st century A.D., they began to practice secondary burial in limestone ossuaries. No completely satisfactory explanation of this change has been found..."

Metal Coffins in America, and In Israel Too

The author Jessica Mitford was best probably known for her classic 1963 book The American Way of Death, an expose of the funeral industry in the US. Shortly before her death in 1996, Mitford updated the book which was later published as The American Way of Death Revisited.  In that book, Mitford noted that until the eighteenth century, few people except the very rich were buried in coffins.  "The "casket," and particularly the metal casket, is a phenomenon of modern America, unknown in past days and in other parts of the world." This statement appears not be entirely correct however, as we have seen the Talmud describe Joseph's coffin as having been made of metal.  Even if that description was based on rabbinic imagination and not archeological facts, lead coffins have in fact been found in several excavations in Israel - though they did not necessarily contain Jewish remains. These include the Netanya coffin from the 3rd-5th century C.E, and the Ashdod coffin, discovered in 1986 in dunes outside of the modern city of Ashdod. (These, and other lead coffins were described in a 1986 paper published in the Israel Exploration Journal titled, rather blandly, More Lead Coffins from Israel).  Mitford noted that the metal coffin was an innovation of the nineteenth century that caused concern. Church authorities protested that "if parishioners were to get into the habit of burying their dead in coffins made proof against normal decay, in a few generations there would be no burial space left." Good point.  

“ The ‘casket,’ and particularly the metal casket, is a phenomenon of modern America, unknown in past days and in other parts of the world.”

— Jessica Mitford. The American Way of Death Revisited. Vintage Books 2000. p146

The Simplicity of Jewish Coffins

Jewish burial practices have of course varied over time and by location.  In Israel today, most religious funerals are conducted without a coffin (military funerals are an exception), which can be a jarring experience when seen for the first time. This is a change from talmudic times, when the body was first placed in a cave and some time later the bones that remained were gathered into a box  (ירושלמי ונציה מועד קטן פרק א טור ג).      

Tom Jokinen's 2010 book Curtains: Adventures of an undertaker in training is the last place I would have looked for an endorsement of Jewish burial practices. But you'll find it right there, on page 262, at the end of a chapter on the International Cemetery, Cremation and Funeral Association trade show, held, where else, in Las Vegas. There he encounters several innovative products, including "Shiva Shades, paper blinds for Jewish families, to cover mirrors during the seven days of shiva. The paper unfurls like an accordion and sticks to the glass with an adhesive strip. "No more cumbersome bedsheets."  But Jokinen then reflects on the fancy coffins and expensive funerals that are sold to families at a time they are most vulnerable, and has this to say:

I suppose if pressed to choose one way or the other I'd have to say I'm against death...I need to face up to its absurdity, find meaning in the mess. How?..Then it comes to me: I've already seen it. A simple act without the artifice of embalming or baroque funerary product. Just a direct application of body to ground where it's left to contribute to the great cycle: ashes to ashes and all that, back to Mother Earth in a shroud and a plain wooden box. Instead of confrontation with death through commerce, you face it, fill the hole by hand and then get on with the hard work of mourning..."I've seen the future...And it's Jewish."

Sotah 8b ~ Sironechi and Strangulation

Measure For Measure

In Thursday’s page of Talmud, we are reminded of the principle of "measure for measure", or as the Mishnah teaches: במדה שאדם מודד בה מודדין לו.  Rav Yosef teaches that this principal applies to the offenses that were capital crimes; although court imposed executions are no longer carried out,  במידה לא בטיל - "measure for measure remains in force."

מי שנתחייב סקילה או נופל מן הגג או חיה דורסתו ... מי שנתחייב חניקה או טובע בנהר או מת בסרונכי

One who deserved death by stoning, either falls from a roof or is trampled by a wild animal...one who deserved death by strangulation [one of the four types of biblical capital punishment] either drowns in a river or dies of sironechi (Sotah 8b)

The question that we need to answer is, of course, just what is סרונכי - sironechi ? Rashi explains that it means חולי בגרנו  "he becomes sick in his throat" but as we will see, this rather general explanation became more specific among later commentators. 

Marcus Jastrow's dictionary (published 1886-1903) defines sironechi as "choking" or "suffocation." The origins of the word, Jastrow claims, is from the root סרך meaning to clutch or hold fast.  This seems reasonable, and Jastrow's understanding of this Mishnah would be that a person who would have been liable to judicial execution by strangulation will meet his end by choking or suffocation.

Soncino, Schottenstein and Koren

The English translations of the Talmud are more specific than was Jastrow, and suggest that the condition is due to an infectious disease. The Soncino Talmud translates sironechi as quinsy, and the Schottenstein Talmud does the same.  The Koren Talmud takes a different approach, and translates the condition as diphtheria. In a side note, the Koren Talmud states that sironechi may have a semitic origin, or it may be derived from the Greek sunnakhe "referring to a form of strangulation that results from complications of diphtheria due to the trachea being blocked by pus." So let's understand what each of these conditions is, and how it may mimic execution by strangulation.

Quinsy

Peritonsillar abscess at the back of the mouth.  But even this does not occlude the airway, and breathing is not usually affected.

Quincy is an uncommonly used word that refers to an inflammation of the tonsils.  It is a complication of what Americans tend to call Strep throat, and what I grew up in London calling tonsillitis. It is most commonly caused by a bacteria known as Group A beta-hemolytic Streptococcus, and most of you reading this will have had it, or seen it in a family member. Today it is easily treated with antibiotics, but one of its rare complications  is a peri-tonsillar abscess, sometimes called quinsy.  In this condition, an abscess forms at the back of the mouth in the tonsils, which bulge forward.  When this occurs, the treatment is to lance the abscess.  I've treated hundreds of cases of strep throat and many cases of peri-tonsillar abscess, and the condition never causes suffocation - though it could in theory.  This makes it a very unlikely candidate to be the condition known as sironechi. Sorry Soncino. And sorry, Schottenstein.  

Diphtheria

Child infected with diphtheria. Photo from the CDC.

Diphtheria is a disease caused by Corynebacterium diphtheriae. Infection causes weakness and fever, followed by swelling in the throat, which gradually becomes covered in a thick grey membrane.  If that doesn't kill the victim, toxins released by the bacteria may finish him off.  According to the Centers for Disease Control and Prevention, in 1921 there were over 200,000 cases of diphtheria in the US, and over 15,000 deaths. Diphtheria is still found in the developing world, especially in parts of Africa and India, and the World Health Organization estimates that there were over 7,000 cases worldwide in 2014.

Like most physicians in the west, I've never seen a case (or met someone who has seen a case, or met someone who has met someone...) because, thanks to widespread vaccination, the disease here has been almost completely eradicated.  Diphtheria may certainly kill its victim by suffocation, and while there is no other reason to identify this with sironechi, it's a reasonable choice. So one point to Koren.

“Classical respiratory diphtheria is characterized by formation of a gray-white pseudomembrane in the throat that is firmly adherent. A swollen, bull-neck appearance caused by inflammation and edema of soft tissues surrounding lymph nodes is associated with severe illness and higher death rates...”

— Wagner K. et al. Diphtheria in the Postepidemic period, Europe, 2000-2009. Emerging Infectious Disease. 2012 18 (2):218.

EpiglottiTis

Although none of the English translations suggest epiglottis as a possible translation for sironechi, it is an infection that certainly may fit.  The disease is most commonly caused by Haemophilus influenzae type b, and results in swelling of the epiglottis, which is a flap of tissue that covers the larynx (also known to non-medically trained personnel as the voice box). It is your epiglottis that moves over the voice box every time you swallow, preventing food from entering your trachea and lungs. In acute epiglottitis, that flap of skin, and the surrounding tissues, may become swollen to such a degree that breathing becomes impossible, and the victim suffocates.  Thankfully, this disease is now extremely unusual in developed countries since there is an effective vaccine against it. In fact I can't recall having seen a single case of it. Because of the way in which the disease causes the airway to become occluded, epiglottis is good a candidate for the condition described in the Mishnah as sironechi. It's certainly as likely as quinsy or diphtheria.  

Did George Washington Die of Sironechi?

It is generally agreed that when George Washington died in December 1799, it was from some kind of throat infection, although the precise cause remains unclear. Two of the physicians who treated Washington published an account of the president's last hours. Here's an excerpt:

George Washington was attacked with an inflammatory affection of the upper part of the windpipe, called in technical language, cynanche trachealis. The disease commenced with a violent ague, accompanied with some pain in the upper and fore part of the throat, a sense of stricture in the same part, a cough, and a difficult rather than painful deglutition, which were soon succeeded by fever and a quick and laborious respiration.

Interestingly, each of the three diseases we have reviewed here have been suggested as the one that killed Washington. Writing in The New England Journal of Medicine, David Morens noted that the culprits include "inflammatory quinsy" and the relatively new diagnostic entity called cynanche trachealis ("dog strangulation"), a term likely to include "the modern diagnosis of bacterial epiglottis...[as well as other conditions such as] laryngeal diphtheria and viral croup." Morens acknowledged that historians do not agree on the cause of Washington's death, but he thought that  "the signs and symptoms point to acute bacterial epiglottitis."

Blood Letting for Sironechi, and for the President

There is more to the relationship between Washington's death and sironechi. In Masechet Yoma, the tractate that deals with the laws of Yom Kippur, a treatment for sironechi is mentioned: מקיזין דם לסרונכי בשבת - "one may let blood on shabbat to alleviate sironechi"(84a). We've addressed the issue of blood letting in the Talmud elsewhere, and noted that it was a widely used therapy until the late nineteenth century.  And as George Washington lay dying from an occluded airway, his doctors decided the best therapy was to let his blood. This they did four times, the last just a few hours before Washington died. It would appear that the medical practice to let blood for a patient with sironechi was found not only in the Jews of Babylon, but among the physicians of Washington's home at Mount Vernon too.   

Washington's death by choking was carefully documented and published, but the infectious agent behind it remains uncertain. If a single infectious agent is behind the talmudic condition of sironchi,  it remains similarly unknown. But most likely, sironechi just means choking or suffocation - (as Rashi and Jastrow suggested) a condition that could be caused by any of the diseases we've reviewed - and more besides. To identify one disease as the cause of sironechi is to miss a larger point - that it is likely caused by many infections.  Today, vaccinations make many of these diseases so rare that most physicians will never see a case. Like the form of judicial execution that it mimicked, sironechi has become a feature of a past that we are all better without.    

The 2023 Talmudology Passover Reader

Pesach (Passover) begins this Wednesday evening, April 5th, 2023.

For your delight we present The 2023 Talmudology Passover Reader. It may be downloaded at the links below.

The 2023 edition includes a new essay on the Ten Plagues in Science and History, and material for discussion at the Seder.

Read, share, and enjoy.

And a Happy Passover from Talmudology