Medical history: Biblical texts reveal compelling mysteries

10 January 2003

Dr Azila Reisenberger

Was the Jewish patriarch, Isaac, diabetic? Why were the twins Esau and Jacob so markedly different? And why did Rachel, Jacob's wife, die in childbirth?

It was while searching for a PhD topic on women's issues in the bible that Hebrew and Jewish studies scholar Azila Reisenberger was first struck by several compelling stories of birth and in the first chapters, verses that revealed intriguing passages of early medical history. She spoke to Helen Thron.

Women in biblical times had one main function fulfil: "to be fruitful and multiply" (Genesis 1:28). "Her status and position in society, much like African cultures, depended on her ability to have children," said Reisenberger.

Studying the sparse text of the bible, Reisenberger found clues about midwives, the birthing stones women used, hints at puerperal, or "third days" blues and, more intriguingly, accounts of the first sets of monozygotic, but unidentical, twins to be born and an account of a woman dying in childbirth, with cryptic clues about what went wrong. In addition, frequent mentions of the partriarch Isaac's constant search for water widened her medical study and alerted her to another possibility: did the second of Israel's three great patriarchs (Abraham was the first and Jacob the third) have diabetes?

Reisenberger's PhD study proposal initially raised some eyebrows. "Women's issues were not so hot at UCT 17 years ago," she said wryly. But studying birth and women's issues in the bible came easily to the scholar. The pregnant Reisenberger (she breastfed in classes) was a familiar sight on campus. With each of her three babies came a degree (all cum laude) and she laughs at the memory of a former Vice-Chancellor, Harry Oppenheimer, entreating her to remain standing when he capped her for her MA. She was heavily pregnant with her third child!

For her PhD, she wanted to gain a better understanding of the ceremonies and rituals that concerned women. Who were the midwives? How did the women deliver their babies? Were there particular rites-of-passage involved? "Many of these questions would never have occurred to me had I not been a mother."

Because of her experience, Reisenberger, who is a published Hebrew poet, says she was not only interested in a literary analysis of these sacred texts. "I looked for extra things," she added. Here, she had the advantage of being able to access the original Hebrew texts.

The fact that the text had been written by men was a limiting factor. They introduced scant "woman" detail to the text, the telling elements Reisenberger sought were largely absent. "In those days, men weren't present when babies arrived. A messenger was sent to tell a father whether a son or daughter had been delivered."

But it is interesting, she notes, that in the earlier, historical parts of the bible that although there are no descriptions of women in "travail", birth is often depicted in the discourses of the prophets. Isaiah, Micah and Jeremiah, for example, when speaking of fear, desperation or great suffering. In Jeremiah 4:31 the prophet writes: "For a voice as a woman in travail have I heard, the anguish of one that brings forth her first child." Reisenberger is amused. "Jeremiah was unmarried and had no babies and in a conservative society, he probably knew nothing about birth."

Moving beyond biblical text, Reisenberger also studied thousands of hieroglyphs. "I found three hieroglyphs that depicted birth, providing the visual evidence of a verse in Exodus 1: 4, which described a woman on dual stones. The hieroglyphs showed a woman sitting over two stones to deliver, providing sufficient height for midwife to catch the baby."

There were other passages on birth that pointed to cultural practices. When Tamar delivers twin sons, the birth sequence is unusual. The text (Gen 38:27-30) says the midwife tied a scarlet thread to the first hand to appear (signalling breech babies) to mark the firstborn, with its equivalent birthright and status.

But a more compelling study was presented by the second set of twins documented in Genesis, Esau and Jacob, whose unusual appearance had Reisenberger scratching her head.

"And when her (Rebekah) days to be delivered were fulfilled, behold, there were twins in her womb. And the first came out red, all over like a hairy garment; and they called his name Esau. And after that came his brother out, his hand holding on to Esau's heel – " (Gen 25:24-26).

This delivery is mentioned in detail probably because of two peculiarities, Reisenberger noted: Esau was red and very hairy and his brother was holding his heel.

Though they were markedly different in appearance (which meant they should have been dizygotic, or from separate amniotic sacs), if the one followed holding the other's heel, their emergence from the womb together suggested to Reisenberger that they were monozygotic.

As he grew older, says Reisenberger, Jacob was able to plan ahead and delay gratification, unlike Esau who wanted immediate satisfaction, selling his birthright to his brother for food (Gen 25:29-32). "In one episode, Jacob covers his smooth neck and arms with goatskins in order to fool his sight-impaired father into believing he is Esau.

"Although there is much controversy about the nature/nurture theories of personality development, the marked differences in the boys' personalities could support the dizygotic hypothesis. 'And the boys grew: and Esau was a cunning hunter, a man of the field; and Jacob was a plain man, dwelling in tents' (Gen 25:27)."

The personality differences pose a bigger problem to scholars who suggest the twins were monozygotic. Reisenberger proposes that they were indeed and that their physical differences were due to a lesser-known twin-twin transfusion syndrome, a condition in which identical twins who share an amniotic sac have an abnormal blood circulation. To arrive at this conclusion, she the biblical scholar went to work with medical doctors, one a professor from Stellenbosch University and others at Groote Schuur Hospital.

It was after a lecture to the gynaecology department that a doctor approached Reisenberger, calling her to his antenatal ward. "Look, I'll show you Esau and Jacob," he told her.

He had delivered (prematurely) twin boys; the one red and hairy, the other smaller and pale. He confirmed they had been delivered from the same amniotic sac.

"They were monozygotic but completely different," Reisenberger confirmed. He challenged her to solve the mystery, giving her access to the medical library and putting her in touch with a medical centre in Stockholm. It was there that she found the reasons for the twins' dissimilar appearance; Esau and Jacob, and the twins at GSH, had transfusion syndrome.

"In normal twins, each draws oxygenated blood from the mother and expels deoxygenated blood separately back into the mother's bloodstream. With transfusion syndrome, connections between the circulation of the twins are detected," she explained.

"The artery from the one foetus distributes blood into a placental cotyledon, which, in turn, is drained by the vein of the next foetus. As a result, one twin is born with too many red blood cells and may suffer from hypertension and an enlarged heart, while the other twin will have hypotension and be anaemic and dehydrated."

There can also be a 20% body weight difference between the twins. "The recipient twin is redder and bigger at birth and may be of somewhat lower intelligence and may display more aggressive traits, which fits the biblical description of Esau. The second twin is usually smaller and paler, which describes the biblical description of Jacob.

What fascinated Reisenberger is that, after a hostile relationship in their youth, Esau and Jacob were separated for many years. But as they matured they became more similar; both in personalities and aspirations. "They married, had many children and fulfilled themselves. Their reunion, however, was anticipated with anxiety, but is described in the bible as a warm meeting between two long-lost brothers. 'And Esau ran to meet him and embraced him and fell on his neck and kissed him and they wept –' (Gen 33:4).

"It has been noted that the visible dissimilarity of twins born with transfusion syndrome diminishes as they mature and their similar features become more conspicuous with passing years. Esau and Jacob's behaviour as adults also supports the transfusion syndrome theory."

Rachel, the mother of Joseph, dream diviner of a pharaoh, died while giving birth to her last child, Benjamin. Reisenberger combed the ancient texts for clues to her death. "The bible said she had travelled far and had 'hard travail'. 'And it came to pass, when she was in hard labour, that the midwife said unto her: Fear not; for this child also is a son for thee. And it came to pass, as her soul was departing, for she died, that she called his name Ben-Oni, but his father called him Benjamin' (Gen 35:16-18)."

The cause, according to medical experts, may have been hypertonic uterine contractions. A breech birth complicated things (in the text the midwife announces "it is a son" before the delivery is complete). The Hebrew text also says Rachel (whom Reisenberger maintains was 40 years old and had last given birth 10 years previously) became "hard", indicating some form of uterine paralysis. "In this case, women often die, even in our time," Reisenberger added. "They often bleed to death."

It was miraculous that the midwife had managed to deliver Benjamin alive, despite Rachel's uterine paralysis. "I looked for indications of bleeding in the text, but couldn't find it," Reisenberger recalled. "Suddenly it struck me; the bible says 'when her soul was departing'. In Judaism the blood is the soul. If the soul was departing it was clear she was bleeding to death."

The third preoccupying account of medical history in the early passages of the bible concerns the possibility that Isaac was a diabetic. "Diabetes mellitus and its complications encompass a multiplicity of signs, symptoms and secondary conditions which include a constant need for water, increased appetite, lethargy and chronic fatigue, visual deficit and sexual dysfunction, including impotence," said Reisenberger.

Isaac and Rebekah had their twin sons Esau and Jacob 20 years after they were married. The Bible says he was 100 years old and when "his eyes were too dim to see", he called his eldest son, Esau, to give him his last blessing recognising his birthright.

"Given that blessings like these were usually given from the deathbed, Isaac must have felt very sick and it seems reasonable that, having reached a century, Isaac should think about his mortality and bestowing his assets. But Isaac went on the live another 80 biblical years (Gen 35: 28-29)." Reisenberger questions whether he was 100 years old at all.

Some scholars believe that the calendar of the Patriarchal Era counted seasons as years, which would have made Isaac 20 when he married Rebekah, 30 when she fell pregnant and almost blind at 50. The afflictions of infertility, visual deficit and chronic illness are strongly supportive of the hypothesis that he was diabetic.

Reisenberger says that other textual evidence supports this. Though the bible purports Rebekah to be barren, the infertility may have stemmed from Isaac. "In biblical times, the survival and continuity of family line were fundamental to society and formed the foundation of marriage. Patriarchs whose wives were barren took concubines or coupled with their slave maidens to produce heirs. (Abraham produced through Hagar when Sarah could not conceive and through Ketura after Sarah's death.)"

If his wife was barren, why did Isaac not take a concubine? Did Isaac perhaps know the fault lay with him? Did Rebekah remain silent because she knew Isaac did not always function adequately due to impotence? "The couple may have shared a painful secret which they kept to themselves to preserve the husband's honour. Even the writer of Genesis does not share this secret with the reader, but the fact that the couple made no effort to bring another woman to Isaac's bed speaks more loudly than words." Instead, they called on God:

"– and the Lord was entreated of him, and Rebekah his wife conceived." (Gen 25:21)

There are other pointers to diabetes, for example, Isaac's constant search for water. Though she admits this preoccupation was not unnatural, given that Isaac lived in the hot, dry Negev desert, he stands out among the three patriarchs in respect of his obsession with water. "He is the only one whose search for water is extensively recorded; his servants seem always to be building wells."

Through the text we also learn that he loved food. "His appetite receives more attention than that of Abraham and Jacob," Reisenberger said. In Gen 27:3-4, he commands: "Now therefore hunt for me – and make me savoury food, such as I love –". The words "food" and "eat" are mentioned more often in relation to Isaac and with no other biblical character.

Sifting through the information, Reisenberger discovered texts that indicated Isaac needed a guaranteed source of water, was chronically weary and lethargic, had no noteworthy physical accomplishments, was fond of food, later suffered from impaired vision and sexual dysfunction.

"The Hebrew text tells you much more than the translations, which enabled me to decipher texts 4 000 years later."

Reisenberger's research has been incorporated into a science module at the Yeshiva University in New York, and Jewish and Hebrew scholars from the world over have engaged her in further debate in the arena. "At first, many people don't believe my field is literature and the bible and not medicine." For her, the studies have revealed new and engrossing aspects to the bible. "One shouldn't stop when you analyse the texts from a medical point of view, or from a literary point of view, or for the religious message. It's an all-encompassing book."

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