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

Sotah 2~ Infidelity: Who Should be Suspecting Whom?

The new tractate that we will be studying for the next 49 days is Sotah, which outlines the ordeal of a married woman who is suspected of adultery. The ordeal outlined in במדבר (the Book of Numbers)  involves her public humiliation as she is forcibly undressed, and forced to drink a potion containing the dissolved words that describe the ceremony in the Torah. If she is guilty, she later undergoes a rather gruesome death; if she is innocent, she returns to her husband and is promised to conceive a child with him.

There is no such ceremony for a married man suspected of adultery. In fact there is no biblical prohibition for a married man to have a sexual relationship outside of his marriage. But insights from contemporary research in biology and the social sciences, together with a scandal from the sewers of the internet, have revealed (as if you needed proof for this) that married men are in fact far more likely to be the ones doing the cheating.

Rates of Infidelity

Although monogamous marriage is the norm for over 90% of humanity (with 10% practicing polygyny), up to 40% or married men and 25% of married women report having had an extramarital affair during their lifetime. Religiosity is however, negatively associated with infidelity, although there is no evidence that the religious denomination plays any role in the tendency towards philandering. Study after study have revealed that married men are more likely to be the ones doing the cheating. Here is how one recent review of the topic summed it up:

A large body of research with American samples indicated that men have a stronger desire to engage in sexual infidelity, are more likely to engage in sexual infidelity, have more extra-dyadic sexual partners, have more episodes of infidelity, including short or long term affairs and one-night stands, have more physical contact with an extra-dyadic partner (including intercourse), cite more sexual motivations for infidelity, and are less likely to fall in love with an extra-dyadic partner. 

“Gender is arguably one of the most commonly studied predictors of infidelity. Expected gender differences in infidelity are often rooted in evolutionary theory... According to this theory, women, due to internal fertilization and gestation, are more likely to benefit from long-term partner commitment and affluent partners who can provide resources that are necessary for survival; males, on the other hand, can impregnate multiple females and the desire to achieve genetic success leads men, more so than women to engage in infidelity...the literature to date suggests that men have a stronger desire to engage in infidelity… and are more likely to be unfaithful.”

— Mahalita Jackman. Understanding the Cheating Heart: What Determines Infidelity Intentions? Sexuality & Culture (2015) 19:72–84

Genes and Infidelity

New research is also suggesting that genes play a role in the complex story of infidelity.  In a study of 7,400 Finnish twins published last year in Evolution and Human Behavior, researchers found that about 10% of men and 6% of women had two or more sexual partners in the last year.  They also found a significant association with a gene for vasopressin and the likelihood of infidelity – but they only found this association in women.  This hardly makes for a compelling case that infidelity is genetically determined, but it does fit in with a body of animal evidence that supports a relationship between our genes and our ability to be monogamous. 

Some of this work comes from studies of two kinds of vole: the montane vole, which is sexually promiscuous, and the prairie vole, which is monogamous. Each of these species has vasopressin receptors that are located in different regions of the brain, and injecting the hormone vasopressin into the little vole brain causes two distinct kinds of behavioral response. When the monogamous prairie vole brain is injected with vasopressin it triggers pair bonding. Blocking of the receptors has an opposite effect – prairie voles still want vole sex, but are no longer monogamous.

Now here’s the crucial anatomical piece: The vasopressin receptors in the monogamous prairie voles lies near the brain’s reward center, so when vasopressin is released, it activates neurons in that reward center. However, the vasopressin receptors in the promiscuous montane voles is found in the amygdla, which is thought to process anxiety and fear. So releases of vasopressin in the promiscuous vole does not stimulate the reward center, and does not lead to pair bonding.  

Another team working with twins was not been able to find an association between human infidelity and the vasopressin receptor gene implicated in the sexual behavior of other mammals. However, even that team concluded that "...infidelity and number of sexual partners are both under moderate genetic influence (41% and 38% heritable, respectively) and the genetic correlation between these two traits is strong (47%)."  We are certainly very far from identifying a gene for infidelity, but there is evidence that genetics and neuroendocrine release plays some role in the expression of this behavior.

Data From a Website You Should Not Visit

There is new data to support the assertion that married men are more likely to cheat than are married women, and that data came from the Ashley Madison breach. (Now for those of you who did not read about this from the sewers of the Internet, here’s what you need to know. Ashley Madison is a website that offers to pair up married people – men and women – who want to cheat on their spouse and have an affair.  In August of 2015 it was revealed that the website had been hacked and some of the data of the subscribers to the service was leaked. OK, that’s the background. No read on to the more important part of the story.)

In a report published in Gizmodo, it was revealed that out of a database of 37 million Ashley Madison users, only about 5.5 million were marked as female.  While acknowledging that some of these users are not real, the raw numbers show that for every married woman looking to have an affair, there were more than five married men.  The report goes on to note that

...out of 5.5 million female accounts, roughly zero percent had ever shown any kind of activity at all, after the day they were created...The men’s accounts tell a story of lively engagement with the site, with over 20 million men hopefully looking at their inboxes, and over 10 million of them initiating chats. The women’s accounts show so little activity that they might as well not be there….we’re left with data that suggests Ashley Madison is a site where tens of millions of men write mail, chat, and spend money for women who aren’t there.

Jewish Adultery In the Middle Ages

In his essay on rabbinic attitudes towards nonobservance, Ephriam Kanarfogel pointed out that "[s]exual promiscuity and even adultery were never absent from any region on the medieval Jewish world." These adulterous relationships were "widespread", but, continues Kanerfogel, "...the presence of even more objectionable possibilities (i.e., relations with married Jewish women) also had to be considered…" As evidence of just how widespread was the practice of married Jewish men having affairs, Kanarfogel cites R. Moses of Coucy of Spain who preached "at length" in 1236 about the sins of sexual relations outside of marriage. The issue of sexual promiscuity was so widespread  that in Toledo a herem (communal ban) was issued against it in 1281. Remarkably, "many who had vowed to honor the ban could not retain themselves and either openly flouted the ban or attempted to circumvent it." It was the widespread promiscuity of married Jewish men that, according to Kanarfogel, led the Ramban to accept the institution of pilagshut (concubines) as an alternative.  Married Jewish men have been cheating for rather a long time.  

“In the second half of the fifteenth century, R. Judah Mintz of Padua acknowledged that there were those in the Jewish community who approved the presence of prostitutes as a means of preventing men from committing adultery with married women...R. Judah Mintz did not himself condone this policy, but could do nothing to dislodge it.”

— Ephraim Kanerfogel. Rabbinic Attitudes towards Nonobservance. In Schachter JJ. (ed.) Jewish Tradition and the Nontraditional Jew. Jason Aronson 1992. p25

The Double Standard for Married Women

The fact is that while the Torah only mandated the Sotah ordeal for a married woman suspected of adultery but not for a married man, it is married men who are far more likely to be the ones doing the cheating.  This bias represents another way in which women are objectified – and we have observed this while studying Ketuvot.  Indeed, as several scholars have noted, the Talmud speaks to men, but it speaks about women. And nearly always the statements about women represent nothing more than the faulty perspectives of the men who uttered them. A final example of the way in which adultery is only of concern when it is committed by a woman will be encoutntered in tomorrow’s daf, Sotah 3b. Here's a sneak preview:

Rav Hisda said: Adultery in a house is like a karya worm to sesame. [Just as the worm eats and destroys the sesame, adultery destroys the family structure.] And Rav Hisda said: Anger in a house is like a karya worm to sesame. [Just as the worm eats and destroys the sesame, so anger destroys the family structure.] Both of these statements were said with respect to the behavior of the woman; however with respect to the man, we have no concern about it.

Why Was the Ritual Abolished? 

The ordeal of the Sotah was abolished sometime during the Second Temple period, although there are three separate Tannaitic sources that describe why this occurred. The most well known is in the Mishnah in Sotah (9:9):

משרבו המנאפין, פסקו המים המאררים; רבן יוחנן הפסיקן, שנאמר לא אפקוד על בנותיכם כי תזנינה, ועל כלותיכם כי תנאפנה  

When adulterers increased the waters of bitterness ceased. Raban Yohanan ben Zakkai discontinued them. For it is written (Hos.4:14): I shall not punish your daughters wine they fornication nor tour daughters-in-law when they commit adulery..."

Another version is found in the Tosefta (Sotah 14:1-2):

תוספתא מסכת סוטה פרק יד הלכה ב 

משרבו המנאפין פסקו מי מרים לפי שאין מי מרים באין אלא על הספק עכשיו כבר רבו הרואין בגלוי 

When adulterers increased the water of bitterness ceased, for the waters of bitterness functions only to clarify a doubt, but now many see adultery in the open...

A third version is found in the Sifrei 21 (25):

ספרי במדבר פרשת נשא פיסקא כא 

כשהאיש מנוקה מעון האשה ההיא תשא את עונה... (הושע ד יד) אמר להם הואיל ואתם רודפים אחר הזנות אף המים לא יבדקו את נשיכם

...Only when the man is free of that sin will "the woman bear her iniquity" [ie. be punished by the ritual of the Sotah]...(Hos.4:14): I shall not punish your daughters when they fornicate nor your daughters-in-law when they commit adultery..." [Hosea] said to them: since you keep the company of whores, the water will not examine your wives...

As the scholar Ishay Rosen-Zvi notes, the Sifrei attributes the end of the ritual "to the failure to apply its moral standard to both men and women equally." Evidence from the social sciences, genetics, and even from Jewish history have demonstrated that (Jewish) men were, and are, far more likely to be the ones cheating. We know this today, but perhaps the Sifrei, (a work of halakhic midrash likely composed in Israel some time after the end of the fourth century CE.) understood this long ago. 

“Sotah stands out in its description of particularly extreme and violent gestures:intentional defacement of the female body; its exposure before an audience; and finally its mutilation to the point of death. These gestures have no trace in the biblical ritual or in sources from the Second Temple period, and they appear to be an innovation of Tannaitic discourse. Furthermore, rabbnic literature itself hardly contains parallels of these gestures, which in fact contravene this literatures’s ethos of punishment and modesty, according to which the body, especially the female body, should be protected from physical damage or the public gaze as much as possible. Thus, in any scholarly analysis of rabbininic attitudes towards questions of modesty, punishment and gender, Tractate Sotah is an anomaly that doesn’t quite fit into the overall picture.”

— Ishay Rosen-Zvi. The Mishnaic Sotah Ritual: Temple, Gender and Midrash. Brill 2012.

Nazir 65b ~ The Zov, and Gonorrhea

The Zov in The Torah...

In Leviticus chapter 15 the laws of the זב – Zov - a man who experiences a discharge from his penis - are outlined. If a man experiences this discharge on two days he becomes impure (טמאי), and must undergo a process of spiritual recovery that includes isolation from others and immersion in running water. If he has a third day of penile discharge he is required to bring an offering to the Temple. (The laws differ in their application to a woman who is infected, but the basic idea is the same. To keep it simple, we'll just focus on the male Zov.)

...And in the Talmud

The rabbis of the Mishnah thought that if the discharge was due to an external factor, then the person so afflicted did not become a Zov. Here is the list of those external causes of genital discharge, as outlined in today’s daf, (Nazir 65b):

נזיר סה, ב

בשבעה דרכים בודקין את הזב עד שלא נזקק לזיבה במאכל ובמשתה במשא ובקפיצה ובחולי ובמראה ובהירהור

A Zov is examined in seven ways…about food and drink [certain foods such as cheese and wine could have caused the discharge], about carrying a load, jumping and illness [strenuous physical activity could also do so], sight and thought [he is asked whether he has been thinking about or looking at women, which could have caused his discharge]…

In modern Hebrew, zivah (זיבה) is the term for gonorrhea, a sexually transmitted disease caused by the bacterial species Neisseria gonorrhoeae.  Preuss, in his famous Biblical and Talmudic Medicine has this to say about the Zov:

“It is clear forthwith that the only illness we know that can be referred to here is gonorrhea” (354).

Abraham Steinberg, in his more recent three volume Encyclopedia of Jewish Medical Ethics, also identifies the disease described in Leviticus as gonorrhea, (though he notes that some rabbis identified the discharge as being sperm, rather than pus. More on that below).  If a Zov is indeed a man suffering from gonorrhea, that would explain “the laws of isolation and impurity in regard to people with flux [=discharge] as being hygienic rules to prevent the spread of the disease” (Vol  II, p452).

Neisseria gonorrhea - a Gram-negative, oxidase positive, aerobic, nutritionally fastidious, bacterium, which appears as pairs under the microscope. From here.

 According to the Centers for Disease Control and Prevention, there are about 330,000 new cases of gonorrhea in the US. That makes it the second most common sexually transmitted disease, with first place going to chlamydia- and the two are frequently found together. The World Health Organization estimated a global total of  106 million cases in 2008 (and that’s an increase of 21% compared to 2005).  Gonorrhea is most common in women age 15-19, and infections in women are usually asymptomatic. In contrast, gonorrheal infection in men is nearly always symptomatic, with the most common symptoms being pain on urination (dysuria) and purulent penile discharge. (Think of what comes out of your nose when you get a bad cold. Now think of that coming out of another orifice.)   But gonorrhea is not just a disease of the genital tract. It may involve the eyes, pharynx and anus, and if it is not treated it may (rarely) progress to disseminated disease that includes endocarditis and meningitis. In women, untreated gonorrhea can cause pelvic inflammatory disease and sterility.

While the Zov in Temple times had to remove himself society and hope for an end to the symptoms, in the era of antibiotics things are different. Gonorrhea is generally easy to treat – a single shot of ceftriaxone in the muscle and a swig of oral azithromycin and you are on the mend. The problem is that drug resistant gonorrhea is now emerging worldwide, and consequently some infections are difficult to treat. 

Don't Touch That Chair...

As outlined in the Torah, the Zov imparts ritual impurity to the bed on which he lies and the chair on which he sits. Preuss wrote that “the hygienic value of these regulations… is obvious.” If the disease that is described in the Torah is indeed gonorrhea, well, then today we understand enough to say that the hygienic value of these regulations is, contra Preuss, really not that obvious at all. We now know that you cannot catch gonorrhea from sitting on a chair or lying on a bed that an infected person had touched.  But in fairness, such beliefs were not uncommon even a century age. We’ve had occasion to review the theories prevalent in early twentieth century America about the transmission of gonorrhea. Back then, doctors claimed girls were susceptible to infection from gonorrhea “from everyday nonsexual objects, including their mothers’ hands, bed linens…and toilet seats.” It is hardly surprising, therefore, to read in the Torah, that the Zov contaminates all he touches. But it is not so. You need sexual or oral contact to transmit the disease, (which can also be caught by the innocent new-born baby passing through its mother's infected genital tract).  

Maimonides on the Nature of the Zov

In his Mishneh Torah, Maimonides identified the Zov as suffering from a physical disease – and not a spiritual one [הלכות מחוסרי כפרה 2:1]:

The Zov that is described in the Torah, is a form of semen that results from an infection in the tubes [of the genital tract]. When the discharge of the Zov flows, it does not do forcefully like ejaculate, and there is no pleasure associated with it. Rather it flows passively like dough…

(Maimonides was following the best medicine of his time when he described the discharge as a form of semen. The word gonorrhea is from the Greek roots gone meaning seed and rhein, meaning flow.)

In an era that did not have antibiotics, removing the infected person and isolating him was really all that could be done. Today, we have alternatives: antibiotics to treat the infection, and condoms to prevent its spread.   But we lack the self-reckoning that the infection might encourage. I’ve treated many, many cases of gonorrhea, and every patient encounter was centered on diagnosing and treating the infection. I do not recall any discussions about changing the behaviors that allowed infection. Perhaps I bear responsibility for not having had that conversation, and perhaps I should have followed the example of the biblical text. That text was mistaken in some of the details of how the disease is spread, but possibly accurate in requiring the Zov to leave his social network, and perhaps reflect on the kind of behaviors that led to his infection in the first place.