Sotah 8b ~ Sironechi and Strangulation

Measure For Measure

In today's page of Talmud, we are reminded of the principal 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.

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.

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 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.