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.    

Ta'anit 27 ~ Askera, Diphtheria and the Jacobi Medical Center

Today’s page of Talmud discusses a disease called askera. We are told that each day of the week, the townsfolk that had sent their local Cohanim to serve in the Temple in Jerusalem would fast for a different reason. On Wednesday, they would fast because of askera.

תענית כז, ב

בָּרְבִיעִי — עַל אַסְכָּרָא שֶׁלֹּא תִּיפּוֹל עַל הַתִּינוֹקוֹת. בַּחֲמִישִׁי — עַל עוּבָּרוֹת וּמֵינִיקוֹת. עוּבָּרוֹת — שֶׁלֹּא יַפִּילוּ, מֵינִיקוֹת — שֶׁיָּנִיקוּ אֶת בְּנֵיהֶם. וּבָעֶרֶב שַׁבָּת לֹא הָיוּ מִתְעַנִּין מִפְּנֵי כְּבוֹד הַשַּׁבָּת, קַל וָחוֹמֶר בַּשַּׁבָּת עַצְמָהּ

On Wednesday they would fast over askera, that it should not befall the children, as on the fourth day the bodies of light [me’orot] were created, a textual allusion to curses [me’erot]. On Thursday they would fast for pregnant women and nursing women, as living beings were first created on this day. For pregnant women they would fast that they should not miscarry, while for nursing women they would fast that they should be able to nurse their children properly. And on Shabbat eve they would not fast, in deference to Shabbat, and a fortiori they would not fast on Shabbat itself…

So today we are going to discuss all things askera. Elsewhere in the Talmud there is a discussion of ways in which death can come. Which form of death is the most painful?

ברכות ח,א

Roz Chast. The New Yorker, August 6, 2001

תַּנְיָא נָמֵי הָכִי: תְּשַׁע מֵאוֹת וּשְׁלֹשָׁה מִינֵי מִיתָה נִבְרְאוּ בָּעוֹלָם, שֶׁנֶּאֱמַר: ״לַמָּוֶת תּוֹצָאוֹת״, ״תּוֹצָאוֹת״ בְּגִימַטְרִיָּא הָכִי הָווּ. קָשָׁה שֶׁבְּכֻלָּן — אַסְכָּרָא, נִיחָא שֶׁבְּכֻלָּן — נְשִׁיקָה. אַסְכָּרָא דָּמְיָא כְּחִיזְרָא בִּגְבָבָא דְעַמְרָא דִּלְאַחוֹרֵי נַשְׁרָא, וְאִיכָּא דְאָמְרִי כְּפִיטּוּרֵי בְּפִי וֶשֶׁט, נְשִׁיקָה דָּמְיָא כְּמִשְׁחַל בִּנִיתָא מֵחֲלָבָא

It was also taught in a baraita: Nine hundred and three types of death were created in the world, as it is stated: “Issues [totzaot] of death,” and that, 903, is the numerical value [gimatriya] of totzaot. The most difficult of all these types of death is askara, while the easiest is the kiss of death. Croup is like a thorn entangled in a wool fleece, which, when pulled out backwards, tears the wool. Some say that croup is like ropes at the entrance to the esophagus, which would be nearly impossible to insert and excruciating to remove. The kiss of death is like drawing a hair from milk. One should pray that he does not die a painful death.

The Koren Talmud cited above, translates askera as croup. So does the Soncino Talmud, both presumably following Marcus Jastrow’s dictionary which translates it as “choking or croup.” Jastrow cites Psalm 63:12, where another form of the work (yisoker) is used:

וְהַמֶּלֶךְ יִשְׂמַח בֵּאלֹהִים יִתְהַלֵּל כָּל־הַנִּשְׁבָּע בּוֹ כִּי יִסָּכֵר פִּי דוֹבְרֵי־שָׁקֶר׃ 

But the king shall rejoice in God; all who swear by Him shall exult, when the mouth of liars is stopped.

However the Schottenstein English (and Hebrew) Talmud leave the term untranslated, and note in a footnote that “Askera is identified with diphtheria, a disease that primarily infects the throat. In the days of the Talmud, it was feared as one of the most horrible of maladies, a disease that often leads to a ghastly death.”

There are three diseases that might fit the description of askera: diphtheria, epiglottitis and quinsy. They also fit the description of another talmudic condition called sironechi (סרונכי). The great scholar of talmudic medicine Julius Preuss wrote that “it is likely that the illness known as serunke or sirvanke is similar to the sickness askara.” We have discussed sironechi elsewhere, and Preuss was correct; from their descriptions it is simply not possible to distinguish askera from sironechi. So what are the possibilities?

Diphtheria

Child infected with diphtheria. Photo from the CDC.

Diphtheria is caused by Corynebacterium diphtheriae. Infection leads to weakness and fever, followed by swelling in the throat which gradually becomes covered in a thick grey membrane.  If the choking 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 US, 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, so it is a reasonable choice to identify this with askera.

Epiglottitis

Although none of the English translations suggest epiglottis as a possible translation for askera, 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 also a good candidate for the condition described as askera.

Quinsy

Quinsy 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 “strep throat” 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.  So this makes it a possible but unlikely candidate as the condition known as askara (or sinonechi for that matter).

BUT NOT CROUP 

One thing is certain. Askera is not croup, which is good news for those of you with young children, since it is a common disease during these winter months. Croup is a viral infection of the trachea and bronchi, and leads to a horrible barking cough and some asthma-like symptoms. It is a self-resolving condition, and the symptoms are easily treated by taking the child out into the cold air, or into the bathroom where a shower is giving off steam. Either way it is very, very, very, unlikely to lead to a life threatening condition. So askera is not croup.

“No case of diphtheria is unattended by danger. However mild the case may seem at the commencement, death may end it. Never be off your guard.”

— William Jenner. Diphtheria: Its symptoms and treatment. London: Walton & Maberly 1861. p62.

Pity the Poor Children

Whatever it is might be called today, askera was a terrible disease that was especially deadly in children. So much so that according to the Talmud, the danger from this disease is hinted at in the very opening words of the Torah that describes creation.

בראשית א, יד

וַיֹּאמֶר אֱלֹהִים יְהִי מְאֹרֹת בִּרְקִיעַ הַשָּׁמַיִם לְהַבְדִּיל בֵּין הַיּוֹם וּבֵין הַלָּיְלָה וְהָיוּ לְאֹתֹת וּלְמוֹעֲדִים וּלְיָמִים וְשָׁנִים׃ 

God said, “Let there be lights in the expanse of the sky to separate day from night; they shall serve as signs for the set times—the days and the years.”

Rashi makes the following comment on this verse:

יהי מארת. חָסֵר וָי"ו כְּתִיב, עַל שֶׁהוּא יוֹם מְאֵרָה לִפֹּל אַסְכָּרָה בַּתִּינוֹקוֹת, הוּא שֶׁשָּׁנִינוּ בְּד' הָיוּ מִתְעַנִּים עַל אַסְכָּרָה שֶׁלֹּא תִפֹּל בַּתִּינוֹקוֹת

The word is written without the ו after the א (so that it may be read מארת, cursed), because it is a cursed day when children are liable to suffer from askera. In reference to this we read (in Taanit 27b): On the fourth day of the week they used to fast to avert askera from the children

Rashi here is referencing the Talmud in Taanit (27b), which describes the tasks of the townspeople who remained behind when their local Cohanim went to serve in the Temple in Jerusalem. These non-priests had a very specific askera-oriented task:

ואנשי מעמד מתכנסין לבית הכנסת ויושבין ד' תעניות בשני בשבת בשלישי ברביעי ובחמישי בשני על יורדי הים בשלישי על הולכי מדברות ברביעי על אסכרא שלא תיפול על התינוקות 

And meanwhile, the members of the non-priestly watch remained in their towns and would assemble in the synagogue and observe four fasts: On Monday of that week, on Tuesday, on Wednesday, and on Thursday. On Monday they would fast for seafarers, that they should be rescued from danger, as the sea was created on Monday. On Tuesday they would fast for those who walk in the desert, as the dry land was created on Tuesday. On Wednesday they would fast over askera, that it should not befall the children…

Yes, children are at greater risk

Whatever the precise agent, it is interesting to note that there is good reason to especially fear these diseases in children. This is because, proportionally, the trachea of a child is of much lower diameter than it is in an adult. As a consequence, the same amount of soft tissue swelling around the trachea will threaten the airway of a child far more rapidly.  So, for example, “1 mm of swelling in the normally 4-5mm diameter of the trachea of the newborn will reduce the cross sectional area by 75% and will increase the resistance to airflow sixteen-fold. In comparison, the same 1mm of swelling in am adult would decrease the cross-sectional area of the trachea by only 44% and would increase the resistance to airflow by only threefold.” Askera was a child killer.

Askera as the punishment for Lashon Hara- and a lot else besides

Elsewhere in the Talmud, askera is described as the result of the sin of speaking gossip, known as lashon hara. But it also occurs because of many other sins:

שבת לג, א–ב

תנו רבנן אסכרה באה לעולם על המעשר רבי אלעזר ברבי יוסי אומר על לשון הרע אמר רבא ואיתימא רבי יהושע בן לוי מאי קראה והמלך ישמח באלהים יתהלל כל הנשבע בו כי יסכר פי דוברי שקר

כשנכנסו רבותינו לכרם ביבנה היה שם רבי יהודה ורבי אלעזר ברבי יוסי ורבי שמעון נשאלה שאלה זו בפניהם מכה זו מפני מה מתחלת בבני מעיים וגומרת בפה נענה רבי יהודה ברבי אלעאי ראש המדברים בכל מקום ואמר אף על פי שכליות יועצות ולב מבין ולשון מחתך פה גומר נענה רבי אלעזר ברבי יוסי ואמר מפני שאוכלין בה דברים טמאין דברים טמאים סלקא דעתך אלא שאוכלין בה דברים שאינן מתוקנים נענה רבי שמעון ואמר בעון ביטול תורה

The Sages taught: Askara comes to the world as punishment for neglecting to separate tithes. Rabbi Elazar, son of Rabbi Yosei, says: Askara comes as punishment for slander…

Rabbi Elazar, son of Rabbi Yosei, responded and said: This disease ends in the mouth because one eats non-kosher things. They immediately wondered about this: Does it enter your mind to say that askara is caused by eating non-kosher food? Are those who eat non-kosher food so numerous? Rather, it comes as a punishment for eating foods that were not ritually prepared, i.e., were not tithed. Rabbi Shimon responded and said: This disease comes as a punishment for the sin of dereliction in the study of Torah.

According to the Rav Nachman (Yevamot 62b), the 24,000 students of Rabbi Akiva who died in plague died from askera, as did the spies who brought back a bad report about the Land of Israel (Sotah 35a).

The Death of Rabbi Meir Shapira, Founder of the daF Yomi Program

In 1994, Professor Prof. Yeshayahu Nitzan from the Faculty of Life Sciences at Bar Ilan University wrote about the death of the founder of the Daf Yomi cycle, Rabbi Meir Shapira of Lublin.

כדאי להזכיר, כי הרב מאיר שפירא ז'ל מלובלין, חמייסד וראש ישיבת ’חכמי לובלין’ המפורסמת, והוגה רעיון לימוד ’הדף היומי’, נפטר לפתע בגיל 47 מדיפתריה

We should note that Rabbi Meir Shapira of Lublin, of blessed memory, who founded and led the famous Yeshivah “Chachmei Lublin,” and who established the “daf hayomi” cycle of study, died suddenly, at the age of 47, from diphtheria.

Although Professor Nitzan is an expert in infectious diseases, he did not cite any supporting evidence, and other sources (also without citing supporting evidence) claim that Rabbi Shapira died from typhus. There is an apparent eyewitness account of the death of Rabbi Shapira, which was written by his student, Yehoshua Baumol. Baumol, who was murdered in the Holocaust, wrote his account in Yiddish in 1934, a year after the episode. The manuscript was translated into English by Charles Wengrow and published by Feldheim in 1994 as A Blaze in the Darkening Gloom: The Life of Rav Meir Shapiro. Here is an excerpt.

The hour of night grew later and later. On a piece of paper he asked that he be shown all the prescriptions which the doctors had written. When they were handed him, he went through them and selected the one for a preparation to cleanse the throat and the respiratory organs and he asked that a new supply be gotten for him. Every few minutes he kept washing his hands while his mind was obviously immersed in distant thoughts. The evident struggle that he had to make to draw breath was heartbreaking. One could feel the frightful, racking agony that he had to undergo to try to get a bit of air into his lungs, and try as he would, he kept failing, because the channels were blocked.

The respiratory distress that Rabbi Shapira experienced could have been due to any number of conditions and there is nothing in this account that points to any specific etiology. It could have been pneumonia, or typhus, of diphtheria, or even influenza. If it were diphtheria, that would mean that the founder of the Daf Yomi movement died from a disease that the Talmud associates with a punishment for lashon hara or eating non-tithed foods, or, most inappropriately of all, a dereliction in the study of Torah.

There is a lesson here. Ascribing a spiritual meaning to personal difficulties is a long Jewish tradition. But one should never ascribe such meaning to explain tragedies that may befall others. Rabbi Shapira might have agreed.

Even More on Askera

As we have noted, diphtheria is caused by a bacterium called Corynebacterium diphtheriae. Infection leads to weakness and fever, followed by swelling in the throat which gradually becomes covered in a thick grey membrane. It is this membrane that gave us the word diphtheria, from the Greek diphthera, meaning a skin or hide.   But the Spanish called the disease by what it did do its victims: El garrotillo -The Strangling Disease. 

The thick grey membrane that develops in the throat is pathognomonic for diphtheria and is likely the origin of the word askara. While Rashi identified it as related to the Hebrew word miskar or misgar meaning closed, it is more likely derived from the Greek word eschara (εσχαρα) meaning a scab, and it is from this root that we derive the English word scar. Diphtheria was certainly widespread during the talmudic era, as the first century Greek physician Aretaeus of Cappadocia made clear in his important work De causis et signis acutorum morborum [The Causes and Symptoms of Acute Diseases. This translation is from http://data.perseus.org/citations/urn:cts:greekLit:tlg0719.tlg001.perseus-eng1:1.9]

Ulcers occur on the tonsils; some, indeed, of an ordinary nature, mild and innocuous; but others of an unusual kind, pestilential, and fatal. Such as are clean, small, superficial, without inflammation and without pain, are mild; but such as are broad, hollow, foul, and covered with a white, livid, or black concretion, are pestilential. Aphtha is the name given to these ulcers. But if the concretion has depth, it is an Eschar and is so called: but around the eschar there is formed a great redness, inflammation, and pain of the veins, as in carbuncle; and small pustules form, at first few in number, but others coming out, they coalesce, and a broad ulcer is produced. And if the disease spread outwardly to the mouth, and reach the columella (uvula) and divide it asunder, and if it extends to the tongue, the gums, and the alveoli, the teeth also become loosened and black; and the inflammation seizes the neck; and these die within a few days from the inflammation, fever, fetid smell, and want of food. But, if it spread to the thorax by the windpipe, it occasions death by suffocation within the space of a day. For the lungs and heart can neither endure such smells, nor ulcerations, nor discharges, but coughs and dyspnea supervene.

The cause of the mischief in the tonsils is the swallowing of cold, rough, hot, acid, and astringent substances…wherefore children, until puberty, especially suffer, for children in particular have large and cold respiration; for there is most heat in them; moreover, they are intemperate in regard to food, have a longing for varied food and cold drink; and they bawl loud both in anger and in sport; and these diseases are familiar to girls until they have their menstrual purgation. The land of Egypt especially engenders it, the air thereof being dry for respiration, and the food diversified, consisting of roots, herbs of many kinds, acrid seeds, and thick drink;  

This Greek account is especially important because was written during the talmudic era, and corroborates many of the Talmud’s observations about this terrible infectious disease – its origins in the back of the mouth, its epidemic nature, how it suffocates, and how it had a predilection for children.

 Because diphtheria kills its victim by suffocation, identifying this disease with askera is certainly reasonable.  And because of a rabbinic enthusiasm to percieve illness as a punishment that was meted out “measure for measure,” the disease was associated with transgressions of the mouth and throat. It was the punishment for failing to tithe food, for eating foods that are not kosher, and for speaking ill of others (Shabbat 33a). It was also identified as the biblical epidemic which broke out after a group of spies returned from a clandestine mission and gave a grim report about the chances for conquering the Land of Israel. “As for the men whom Moses sent to scout the land, those who came back and caused the whole community to mutter against him by spreading calumnies about the land - those who spread such calumnies about the land died of plague, by the will of the Lord, and Rav Nahman bar Yitzhak says: They died of askara.”(Numbers 14: 36-37. T.B. Sotah 35a.)

The deaths of the 24,000 Students of Rabbi Akiva -from Askera

Askera was also the cause of a pandemic said in the Talmud (Yevamot 62b) to have killed twenty-four thousand students of the great sage Rabbi Akiva (c. 50-135 C.E.):

Rabbi Akiva had twelve thousand pairs of students in an area of land that stretched from Gevat to Antipatris in Judea, and they all died in one period of time, because they did not treat each other with respect….It is taught that all of them died in the period from Passover until Shavuot. Rav Hama bar Abba said (and some say it was Rabbi Hiyya bar Avin): They all died a bad death. What is it that is called a bad death? Rav Nahman said: Askara.

(The identical passage also appears in Kohelet Rabbah 11:6, but in a third passage, found in Bereshit Rabbah 61:3 the time period is not mentioned. For an analysis of the early rabbinic sources see Aaron Amit, "The Death of Rabbi Akiva’s Disciples: A Literary History," Journal of Jewish Studies 56 (2005), 265-284.)

Diphtheria in recent history

Because of its predilection for the airway, askera was a child killer. “No case of diphtheria is unattended by danger” wrote the British physician William Jenner in 1861. “However mild the case may seem at the commencement, death may end it. Never be off your guard.”

Diphtheria was an equal opportunity killer, taking princes and paupers alike. In 1878, Queen Victoria’s daughter, Princess Alice, died from the disease aged 35, as did Alice’s youngest child, four year old Marie. So did the daughter of U.S. President Grover Cleveland; her name was Ruth, and she was twelve years old. In Spain, the youngest sister of Pablo Picasso named Conchita died of diphtheria aged seven. Diphtheria was one of the reasons that before there were modern vaccines, the infant mortality rate was so high. At the beginning of the nineteenth century almost half of all children died before reaching their fifth birthday; by its end, still, a quarter did so. Epidemics of diphtheria were a fact of life. Paul de Kruif, the author of the famous 1926 book Microbe Hunters wrote that “several times each hundred years [diphtheria] seems to have violent ups and downs of viciousness.” 

The wards of the hospitals for sick children were melancholy with a forlorn wailing; there were gurgling coughs foretelling suffocation; on the sad rows of narrow beds were white pillows framing small faces blue with the strangling grip of an unknown hand. Through these rooms walked doctors trying to conceal their hopelessness with cheerfulness; powerless they went from cot to cot—trying now and again to give a choking child its breath by pushing a tube into its membrane-plugged windpipe….

Five out of ten of these cots sent their tenants to the morgue.

 (Paul De Kruif, Microbe Hunters. New York: Harcourt, Brace and Company, 1926.185.)

Abraham Jacobi, 1912. from here.

Abraham Jacobi and the fight against Diphtheria

There is a coda to the story of the Jews and diphtheria, and it is in the figure of Abraham Jacobi (1830-1919), one of the most important personalities in the modern battle against the disease.  Jacobi was born in the German region of Westphalia and as a young man had studied medicine and became involved in Berlin’s politics of revolution.  He spent about two years in prison, and fled before further charges could be brought against him. He then made his way to New York City in 1853.  His rise through the medical ranks there was meteoric; The New York Times reported that “credit has been given to him by famous physicians for having given more to the science of pediatrics in this country than any other physician…His writings were accepted everywhere as authoritative.” He became Chair of Children’s Diseases at New York Medical College, which was the first position of its kind in the country, and he spent much of his clinical effort in diagnosing and treating diphtheria. In early 1860 he presented a case series of over one-hundred and twenty children in whom he had diagnosed the illness, and in 1880 he published his Treatise on Diphtheria, which built on his by then having diagnosed thousands. In a telling sign of the times, diphtheria killed one of his own two children, a boy named Ernst, aged seven. He had been powerless to stop it. 

Still, learned as he was, Jacobi was wrong when he wrote that “at present, it seems altogether improbable that bacteria have any direct function in diphtheria.” In 1883, the same year that his son died from the illness, a Prussian pathologist named Edwin Klebs identified a bacterium that was associated with the feared pseudo-membrane that grew over the back of the child’s throat, blocking the airway. A year later a German microbiologist named Friedrich Loeffler was able to grow the bacteria in his lab, and demonstrated that it caused diphtheria in guinea pigs and rabbits.   But Jacobi brought attention to the disease, and a disciplined approach to its diagnosis and therapy, even though, in that era before antibiotics, there were almost no effective medical interventions of which to speak. Jacobi also emphasized the importance of hygiene, bathing and cleanliness, which were perhaps the most important tools in preventing diphtheria. Today, Jacobi Hospital in the Bronx, named in his honor, is a 460 bed level one trauma center, serving the 1.2 million residents of the Bronx and New York City. It stands as a reminder of the contribution that this Jewish immigrant from Germany made to the field of pediatrics, and to the fight against a killer childhood disease that was mentioned in the Talmud.

Pesachim 105a ~ What is Askara?

During a talmudic discussion of the havdalah (separation) ceremony that concludes the Sabbath, we read the following:

פסחים קה, א

דְּתָנָא מִשְּׁמֵיהּ דְּרַבִּי עֲקִיבָא: כׇּל הַטּוֹעֵם כְּלוּם קוֹדֶם שֶׁיַּבְדִּיל — מִיתָתוֹ בְּאַסְכָּרָה

It was taught in the name of Rabbi Akiva that whoever tastes anything before he recites havdalah, will die from askara.

In explaining the reason why this form of death is an appropriate punishment, Tosafot (a medieval collection of commentaries on the Talmud) makes this observation:

ומיתתו באסכרה מדה כנגד מדה הוא משביע גרונו יחנק

He will die from askara because it is measure for measure: He satisfied his throat [inappropriately] and so he will choke…

So askara has something to do with choking. The question we will address is what, precisely, is the condition known as askera?

Askara is discussed elsewhere in the Talmud. For example there is this passage, about which form of death is the most painful:

ברכות ח,א

Roz Chast. The New Yorker, August 6, 2001

תַּנְיָא נָמֵי הָכִי: תְּשַׁע מֵאוֹת וּשְׁלֹשָׁה מִינֵי מִיתָה נִבְרְאוּ בָּעוֹלָם, שֶׁנֶּאֱמַר: ״לַמָּוֶת תּוֹצָאוֹת״, ״תּוֹצָאוֹת״ בְּגִימַטְרִיָּא הָכִי הָווּ. קָשָׁה שֶׁבְּכֻלָּן — אַסְכָּרָא, נִיחָא שֶׁבְּכֻלָּן — נְשִׁיקָה. אַסְכָּרָא דָּמְיָא כְּחִיזְרָא בִּגְבָבָא דְעַמְרָא דִּלְאַחוֹרֵי נַשְׁרָא, וְאִיכָּא דְאָמְרִי כְּפִיטּוּרֵי בְּפִי וֶשֶׁט, נְשִׁיקָה דָּמְיָא כְּמִשְׁחַל בִּנִיתָא מֵחֲלָבָא

It was also taught in a baraita: Nine hundred and three types of death were created in the world, as it is stated: “Issues [totzaot] of death,” and that, 903, is the numerical value [gimatriya] of totzaot. The most difficult of all these types of death is croup [askara], while the easiest is the kiss of death. Croup is like a thorn entangled in a wool fleece, which, when pulled out backwards, tears the wool. Some say that croup is like ropes at the entrance to the esophagus, which would be nearly impossible to insert and excruciating to remove. The kiss of death is like drawing a hair from milk. One should pray that he does not die a painful death.

The Koren Talmud cited above, translates askera as croup. So does the Soncino Talmud, both presumably following Marcus Jastrow’s dictionary which translates it as “choking or croup.” Jastrow cites Psalm 63:12, where another form of the work (yisoker) is used:

וְהַמֶּלֶךְ יִשְׂמַח בֵּאלֹהִים יִתְהַלֵּל כָּל־הַנִּשְׁבָּע בּוֹ כִּי יִסָּכֵר פִּי דוֹבְרֵי־שָׁקֶר׃ 

But the king shall rejoice in God; all who swear by Him shall exult, when the mouth of liars is stopped.

However the Schottenstein English (and Hebrew) Talmud leave the term untranslated, and note in a footnote that “Askara is identified with diphtheria, a disease that primarily infects the throat. In the days of the Talmud, it was feared as one of the most horrible of maladies, a disease that often leads to a ghastly death.”

There are three diseases that might fit the description of askara: diphtheria, epiglottitis and quinsy. They also fit the description of another talmudic condition called sironechi (סרונכי). The great scholar of talmudic medicine Julius Preuss wrote that “it is likely that the illness known as serunke or sirvanke is similar to the sickness askara.” We have discussed sironechi elsewhere, and Preuss was correct; from their descriptions it is simply not possible to distinguish askara from sironechi. So what are the possibilities?

Diphtheria

Child infected with diphtheria. Photo from the CDC.

Diphtheria is caused by Corynebacterium diphtheriae. Infection leads to weakness and fever, followed by swelling in the throat which gradually becomes covered in a thick grey membrane.  If the choking 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 US, 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, so it is a reasonable choice to identify this with askara.

EPIGLOTTITIS

Although none of the English translations suggest epiglottis as a possible translation for askara, 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. (We will do a deep dive into topic of the epiglottis next week.) 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 also a good candidate for the condition described as askara.

QUINSY

Quinsy 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 “strep throat” 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.  So this makes it a possible but unlikely candidate as the condition known as askara (or sinonechi for that matter).

BUT NOT CROUP 

One thing is certain. Askara is not croup, which is good news for those of you with young children, since it is a common disease during these winter months. Croup is a viral infection of the trachea and bronchi, and leads to a horrible barking cough and some asthma-like symptoms. It is a self-resolving condition, and the symptoms are easily treated by taking the child out into the cold air, or into the bathroom where a shower is giving off steam. Either way it is very, very, very, unlikely to lead to a life threatening condition. So askara is not croup.

“No case of diphtheria is unattended by danger. However mild the case may seem at the commencement, death may end it. Never be off your guard.”

— William Jenner. Diphtheria: Its symptoms and treatment. London: Walton & Maberly 1861. p62.

Pity the Poor Children

Whatever it is might be called today, askara was a terrible disease that was especially deadly in children. So much so that according to the Talmud, the danger from this disease is hinted at in the very opening words of the Torah that describes creation.

בראשית א, יד

וַיֹּאמֶר אֱלֹהִים יְהִי מְאֹרֹת בִּרְקִיעַ הַשָּׁמַיִם לְהַבְדִּיל בֵּין הַיּוֹם וּבֵין הַלָּיְלָה וְהָיוּ לְאֹתֹת וּלְמוֹעֲדִים וּלְיָמִים וְשָׁנִים׃ 

God said, “Let there be lights in the expanse of the sky to separate day from night; they shall serve as signs for the set times—the days and the years.”

Rashi makes the following comment on this verse:

יהי מארת. חָסֵר וָי"ו כְּתִיב, עַל שֶׁהוּא יוֹם מְאֵרָה לִפֹּל אַסְכָּרָה בַּתִּינוֹקוֹת, הוּא שֶׁשָּׁנִינוּ בְּד' הָיוּ מִתְעַנִּים עַל אַסְכָּרָה שֶׁלֹּא תִפֹּל בַּתִּינוֹקוֹת

The word is written without the ו after the א (so that it may be read מארת, cursed), because it is a cursed day when children are liable to suffer from croup. In reference to this we read (in Taanit 27b): On the fourth day of the week they used to fast to avert croup from the children

Rashi here is referencing the Talmud in Taanit (27b), which describes the tasks of the townspeople who remained behind when their local Cohanim went to serve in the Temple in Jerusalem. These non-priests had a very specific askara-oriented task:

ואנשי מעמד מתכנסין לבית הכנסת ויושבין ד' תעניות בשני בשבת בשלישי ברביעי ובחמישי בשני על יורדי הים בשלישי על הולכי מדברות ברביעי על אסכרא שלא תיפול על התינוקות 

And meanwhile, the members of the non-priestly watch remained in their towns and would assemble in the synagogue and observe four fasts: On Monday of that week, on Tuesday, on Wednesday, and on Thursday. On Monday they would fast for seafarers, that they should be rescued from danger, as the sea was created on Monday. On Tuesday they would fast for those who walk in the desert, as the dry land was created on Tuesday. On Wednesday they would fast over croup, that it should not befall the children…

Yes, children are at greater risk

Whatever the precise agent, it is interesting to note that there is good reason to especially fear these diseases in children. This is because, proportionally, the trachea of a child is of much lower diameter than it is in an adult. As a consequence, the same amount of soft tissue swelling around the trachea will threaten the airway of a child far more rapidly.  So, for example, “1 mm of swelling in the normally 4-5mm diameter of the trachea of the newborn will reduce the cross sectional area by 75% and will increase the resistance to airflow sixteen-fold. In comparison, the same 1mm of swelling in am adult would decrease the cross-sectional area of the trachea by only 44% and would increase the resistance to airflow by only threefold.” Askara was a child killer.

Askera as the punishment for Lashon Hara- and a lot else besides

Elsewhere in the Talmud, askara is described as the result of the sin of speaking gossip, known as lashon hara. But it also occurs because of many other sins:

שבת לג, א–ב

תנו רבנן אסכרה באה לעולם על המעשר רבי אלעזר ברבי יוסי אומר על לשון הרע אמר רבא ואיתימא רבי יהושע בן לוי מאי קראה והמלך ישמח באלהים יתהלל כל הנשבע בו כי יסכר פי דוברי שקר

כשנכנסו רבותינו לכרם ביבנה היה שם רבי יהודה ורבי אלעזר ברבי יוסי ורבי שמעון נשאלה שאלה זו בפניהם מכה זו מפני מה מתחלת בבני מעיים וגומרת בפה נענה רבי יהודה ברבי אלעאי ראש המדברים בכל מקום ואמר אף על פי שכליות יועצות ולב מבין ולשון מחתך פה גומר נענה רבי אלעזר ברבי יוסי ואמר מפני שאוכלין בה דברים טמאין דברים טמאים סלקא דעתך אלא שאוכלין בה דברים שאינן מתוקנים נענה רבי שמעון ואמר בעון ביטול תורה

The Sages taught: Askara comes to the world as punishment for neglecting to separate tithes. Rabbi Elazar, son of Rabbi Yosei, says: Askara comes as punishment for slander…

Rabbi Elazar, son of Rabbi Yosei, responded and said: This disease ends in the mouth because one eats non-kosher things. They immediately wondered about this: Does it enter your mind to say that askara is caused by eating non-kosher food? Are those who eat non-kosher food so numerous? Rather, it comes as a punishment for eating foods that were not ritually prepared, i.e., were not tithed. Rabbi Shimon responded and said: This disease comes as a punishment for the sin of dereliction in the study of Torah.

According to the Rav Nachman (Yevamot 62b), the 24,000 students of Rabbi Akiva who died in plague died from askara, as did the spies who brought back a bad report about the Land of Israel (Sotah 35a).

The Death of Rabbi Meir Shapira, Founder of the daF Yomi Program

In 1994, Professor Prof. Yeshayahu Nitzan from the Faculty of Life Sciences at Bar Ilan University wrote about the death of the founder of the Daf Yomi cycle, Rabbi Meir Shapira of Lublin.

כדאי להזכיר, כי הרב מאיר שפירא ז'ל מלובלין, חמייסד וראש ישיבת ’חכמי לובלין’ המפורסמת, והוגה רעיון לימוד ’הדף היומי’, נפטר לפתע בגיל 47 מדיפתריה

We should note that Rabbi Meir Shapira of Lublin, of blessed memory, who founded and led the famous Yeshivah “Chachmei Lublin,” and who established the “daf hayomi” cycle of study, died suddenly, at the age of 47, from diphtheria.

Although Professor Nitzan is an expert in infectious diseases, he did not cite any supporting evidence, and other sources (also without citing supporting evidence) claim that Rabbi Shapira died from typhus. There is an apparent eyewitness account of the death of Rabbi Shapira, which was written by his student, Yehoshua Baumol. Baumol, who was murdered in the Holocaust, wrote his account in Yiddish in 1934, a year after the episode. The manuscript was translated into English by Charles Wengrow and published by Feldheim in 1994 as A Blaze in the Darkening Gloom: The Life of Rav Meir Shapiro. Here is an excerpt.

The hour of night grew later and later. On a piece of paper he asked that he be shown all the prescriptions which the doctors had written. When they were handed him, he went through them and selected the one for a preparation to cleanse the throat and the respiratory organs and he asked that a new supply be gotten for him. Every few minutes he kept washing his hands while his mind was obviously immersed in distant thoughts. The evident struggle that he had to make to draw breath was heartbreaking. One could feel the frightful, racking agony that he had to undergo to try to get a bit of air into his lungs, and try as he would, he kept failing, because the channels were blocked.

The respiratory distress that Rabbi Shapira experienced could have been due to any number of conditions and there is nothing in this account that points to any specific etiology. It could have been pneumonia, or typhus, of diphtheria, or even influenza. If it were diphtheria, that would mean that the founder of the Daf Yomi movement died from a disease that the Talmud associates with a punishment for lashon hara or eating non-tithed foods, or, most inappropriately of all, a dereliction in the study of Torah.

There is a lesson here. Ascribing a spiritual meaning to personal difficulties is a long Jewish tradition. But one should never ascribe such meaning to explain tragedies that may befall others. Rabbi Shapira might have agreed.

[Mostly a repost from Berachot 8.]

Berachot 8a ~ What is Askera (And Did It Kill Rabbi Meir Shapiro of Lublin?)

In this page of Talmud there is a discussion of ways in which death can come. Which form of death is the most painful?

ברכות ח,א

Roz Chast. The New Yorker, August 6, 2001

תַּנְיָא נָמֵי הָכִי: תְּשַׁע מֵאוֹת וּשְׁלֹשָׁה מִינֵי מִיתָה נִבְרְאוּ בָּעוֹלָם, שֶׁנֶּאֱמַר: ״לַמָּוֶת תּוֹצָאוֹת״, ״תּוֹצָאוֹת״ בְּגִימַטְרִיָּא הָכִי הָווּ. קָשָׁה שֶׁבְּכֻלָּן — אַסְכָּרָא, נִיחָא שֶׁבְּכֻלָּן — נְשִׁיקָה. אַסְכָּרָא דָּמְיָא כְּחִיזְרָא בִּגְבָבָא דְעַמְרָא דִּלְאַחוֹרֵי נַשְׁרָא, וְאִיכָּא דְאָמְרִי כְּפִיטּוּרֵי בְּפִי וֶשֶׁט, נְשִׁיקָה דָּמְיָא כְּמִשְׁחַל בִּנִיתָא מֵחֲלָבָא

It was also taught in a baraita: Nine hundred and three types of death were created in the world, as it is stated: “Issues [totzaot] of death,” and that, 903, is the numerical value [gimatriya] of totzaot. The most difficult of all these types of death is croup [askara], while the easiest is the kiss of death. Croup is like a thorn entangled in a wool fleece, which, when pulled out backwards, tears the wool. Some say that croup is like ropes at the entrance to the esophagus, which would be nearly impossible to insert and excruciating to remove. The kiss of death is like drawing a hair from milk. One should pray that he does not die a painful death.

The question we will address is what, precisely, is the condition known as askera?

The Koren Talmud cited above, translates askera as croup. So does the Soncino Talmud, both presumably following Marcus Jastrow’s dictionary which translates it as “choking or croup.” Jastrow cites Psalm 63:12, where another form of the work (yisoker) is used:

וְהַמֶּלֶךְ יִשְׂמַח בֵּאלֹהִים יִתְהַלֵּל כָּל־הַנִּשְׁבָּע בּוֹ כִּי יִסָּכֵר פִּי דוֹבְרֵי־שָׁקֶר׃ 

But the king shall rejoice in God; all who swear by Him shall exult, when the mouth of liars is stopped.

However the Schottenstein English (and Hebrew) Talmud leave the term untranslated, and note in a footnote that “Askera is identified with diphtheria, a disease that primarily infects the throat. In the days of the Talmud, it was feared as one of the most horrible of maladies, a disease that often leads to a ghastly death.”

There are three diseases that might fit the description of askera: diphtheria, epiglottitis and quinsy. They also fit the description of another talmudic condition called sironechi (סרונכי). The great scholar of talmudic medicine Julius Preuss wrote that “it is likely that the illness known as serunke or sirvanke is similar to the sickness askara.” We have discussed sironechi elsewhere, and Preuss was correct; from their descriptions it is simply not possible to distinguish askera from sironechi. So what are the possibilities?

Diphtheria

Child infected with diphtheria. Photo from the CDC.

Diphtheria is caused by Corynebacterium diphtheriae. Infection leads to weakness and fever, followed by swelling in the throat which gradually becomes covered in a thick grey membrane.  If the choking 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 US, 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, so it is a reasonable choice to identify this with askera.

EPIGLOTTITIS

Although none of the English translations suggest epiglottis as a possible translation for askera, 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 also a good candidate for the condition described as askera.

QUINSY

Quinsy 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 “strep throat” 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.  So this makes it a possible but unlikely candidate as the condition known as askara (or sinonechi for that matter).

BUT NOT CROUP 

One thing is certain. Askera is not croup, which is good news for those of you with young children, since it is a common disease during these winter months. Croup is a viral infection of the trachea and bronchi, and leads to a horrible barking cough and some asthma-like symptoms. It is a self-resolving condition, and the symptoms are easily treated by taking the child out into the cold air, or into the bathroom where a shower is giving off steam. Either way it is very, very, very, unlikely to lead to a life threatening condition. So askera is not croup.

“No case of diphtheria is unattended by danger. However mild the case may seem at the commencement, death may end it. Never be off your guard.”

— William Jenner. Diphtheria: Its symptoms and treatment. London: Walton & Maberly 1861. p62.

Pity the Poor Children

Whatever it is might be called today, askera was a terrible disease that was especially deadly in children. So much so that according to the Talmud, the danger from this disease is hinted at in the very opening words of the Torah that describes creation.

בראשית א, יד

וַיֹּאמֶר אֱלֹהִים יְהִי מְאֹרֹת בִּרְקִיעַ הַשָּׁמַיִם לְהַבְדִּיל בֵּין הַיּוֹם וּבֵין הַלָּיְלָה וְהָיוּ לְאֹתֹת וּלְמוֹעֲדִים וּלְיָמִים וְשָׁנִים׃ 

God said, “Let there be lights in the expanse of the sky to separate day from night; they shall serve as signs for the set times—the days and the years.”

Rashi makes the following comment on this verse:

יהי מארת. חָסֵר וָי"ו כְּתִיב, עַל שֶׁהוּא יוֹם מְאֵרָה לִפֹּל אַסְכָּרָה בַּתִּינוֹקוֹת, הוּא שֶׁשָּׁנִינוּ בְּד' הָיוּ מִתְעַנִּים עַל אַסְכָּרָה שֶׁלֹּא תִפֹּל בַּתִּינוֹקוֹת

The word is written without the ו after the א (so that it may be read מארת, cursed), because it is a cursed day when children are liable to suffer from askera. In reference to this we read (in Taanit 27b): On the fourth day of the week they used to fast to avert askera from the children

Rashi here is referencing the Talmud in Taanit (27b), which describes the tasks of the townspeople who remained behind when their local Cohanim went to serve in the Temple in Jerusalem. These non-priests had a very specific askera-oriented task:

ואנשי מעמד מתכנסין לבית הכנסת ויושבין ד' תעניות בשני בשבת בשלישי ברביעי ובחמישי בשני על יורדי הים בשלישי על הולכי מדברות ברביעי על אסכרא שלא תיפול על התינוקות 

And meanwhile, the members of the non-priestly watch remained in their towns and would assemble in the synagogue and observe four fasts: On Monday of that week, on Tuesday, on Wednesday, and on Thursday. On Monday they would fast for seafarers, that they should be rescued from danger, as the sea was created on Monday. On Tuesday they would fast for those who walk in the desert, as the dry land was created on Tuesday. On Wednesday they would fast over askera, that it should not befall the children…

Yes, children are at greater risk

Whatever the precise agent, it is interesting to note that there is good reason to especially fear these diseases in children. This is because, proportionally, the trachea of a child is of much lower diameter than it is in an adult. As a consequence, the same amount of soft tissue swelling around the trachea will threaten the airway of a child far more rapidly.  So, for example, “1 mm of swelling in the normally 4-5mm diameter of the trachea of the newborn will reduce the cross sectional area by 75% and will increase the resistance to airflow sixteen-fold. In comparison, the same 1mm of swelling in am adult would decrease the cross-sectional area of the trachea by only 44% and would increase the resistance to airflow by only threefold.” Askera was a child killer.

Askera as the punishment for Lashon Hara- and a lot else besides

Elsewhere in the Talmud, askera is described as the result of the sin of speaking gossip, known as lashon hara. But it also occurs because of many other sins:

שבת לג, א–ב

תנו רבנן אסכרה באה לעולם על המעשר רבי אלעזר ברבי יוסי אומר על לשון הרע אמר רבא ואיתימא רבי יהושע בן לוי מאי קראה והמלך ישמח באלהים יתהלל כל הנשבע בו כי יסכר פי דוברי שקר

כשנכנסו רבותינו לכרם ביבנה היה שם רבי יהודה ורבי אלעזר ברבי יוסי ורבי שמעון נשאלה שאלה זו בפניהם מכה זו מפני מה מתחלת בבני מעיים וגומרת בפה נענה רבי יהודה ברבי אלעאי ראש המדברים בכל מקום ואמר אף על פי שכליות יועצות ולב מבין ולשון מחתך פה גומר נענה רבי אלעזר ברבי יוסי ואמר מפני שאוכלין בה דברים טמאין דברים טמאים סלקא דעתך אלא שאוכלין בה דברים שאינן מתוקנים נענה רבי שמעון ואמר בעון ביטול תורה

The Sages taught: Askara comes to the world as punishment for neglecting to separate tithes. Rabbi Elazar, son of Rabbi Yosei, says: Askara comes as punishment for slander…

Rabbi Elazar, son of Rabbi Yosei, responded and said: This disease ends in the mouth because one eats non-kosher things. They immediately wondered about this: Does it enter your mind to say that askara is caused by eating non-kosher food? Are those who eat non-kosher food so numerous? Rather, it comes as a punishment for eating foods that were not ritually prepared, i.e., were not tithed. Rabbi Shimon responded and said: This disease comes as a punishment for the sin of dereliction in the study of Torah.

According to the Rav Nachman (Yevamot 62b), the 24,000 students of Rabbi Akiva who died in plague died from askera, as did the spies who brought back a bad report about the Land of Israel (Sotah 35a).

The Death of Rabbi Meir Shapiro, Founder of the daF Yomi Program

In 1994, Professor Prof. Yeshayahu Nitzan from the Faculty of Life Sciences at Bar Ilan University wrote about the death of the founder of the Daf Yomi cycle, Rabbi Meir Shapiro of Lublin.

כדאי להזכיר, כי הרב מאיר שפירא ז'ל מלובלין, חמייסד וראש ישיבת ’חכמי לובלין’ המפורסמת, והוגה רעיון לימוד ’הדף היומי’, נפטר לפתע בגיל 47 מדיפתריה

We should note that Rabbi Meir Shapiro of Lublin, of blessed memory, who founded and led the famous Yeshivah “Chachmei Lublin,” and who established the “daf hayomi” cycle of study, died suddenly, at the age of 47, from diphtheria.

Although Professor Nitzan is an expert in infectious diseases, he did not cite any supporting evidence, and other sources (also without citing supporting evidence) claim that Rabbi Shapiro died from typhus. There is an apparent eyewitness account of the death of Rabbi Shapiro, which was written by his student, Yehoshua Baumol. Baumol, who was murdered in the Holocaust, wrote his account in Yiddish in 1934, a year after the episode. The manuscript was translated into English by Charles Wengrow and published by Feldheim in 1994 as A Blaze in the Darkening Gloom: The Life of Rav Meir Shapiro. Here is an excerpt.

The hour of night grew later and later. On a piece of paper he asked that he be shown all the prescriptions which the doctors had written. When they were handed him, he went through them and selected the one for a preparation to cleanse the throat and the respiratory organs and he asked that a new supply be gotten for him. Every few minutes he kept washing his hands while his mind was obviously immersed in distant thoughts. The evident struggle that he had to make to draw breath was heartbreaking. One could feel the frightful, racking agony that he had to undergo to try to get a bit of air into his lungs, and try as he would, he kept failing, because the channels were blocked.

The respiratory distress that Rabbi Shapiro experienced could have been due to any number of conditions and there is nothing in this account that points to any specific etiology. It could have been pneumonia, or typhus, of diphtheria, or even influenza. If it were diphtheria, that would mean that the founder of the Daf Yomi movement died from a disease that the Talmud associates with a punishment for lashon hara or eating non-tithed foods, or, most inappropriately of all, a dereliction in the study of Torah.

There is a lesson here. Ascribing a spiritual meaning to personal difficulties is a long Jewish tradition. But one should never ascribe such meaning to explain tragedies that may befall others. Rabbi Shapiro might have agreed.