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.    

Chagigah 16b ~ Wrongful Executions

On today’s page of Talmud we read about Rabbi Yehuda ben Tabbai, who, was rather pleased with himself. In order to make a point of law against the Sadducees, he had sentenced a conspiring false witness to death. Except that he was mistaken. Shimon ben Shetach pointed out that a single conspiring witness cannot be executed. That punishment is reserved when there are two conspiring witnesses.

חגיגה טז, ב

אֵין עֵדִים זוֹמְמִין נֶהֱרָגִין עַד שֶׁיִּזּוֹמּוּ שְׁנֵיהֶם, וְאֵין לוֹקִין עַד שֶׁיִּזּוֹמּוּ שְׁנֵיהֶם, וְאֵין מְשַׁלְּמִין מָמוֹן עַד שֶׁיִּזּוֹמּוּ שְׁנֵיהֶם

Conspiring witnesses are not executed unless they are both found to be conspirators; if only one is found to be a conspirator, he is not executed. And they are not flogged if they are liable to such a penalty, unless they are both found to be conspirators. And if they testified falsely that someone owed money, they do not pay money unless they are both found to be conspirators.

Rabbi Yehuda stood corrected and from then on he would only rule on a matter of law when he was in the presence of Shimon ben Shetach. But what of the innocent person he had executed?

כל יָמָיו שֶׁל יְהוּדָה בֶּן טָבַאי הָיָה מִשְׁתַּטֵּחַ עַל קִבְרוֹ שֶׁל אוֹתוֹ הָרוּג, וְהָיָה קוֹלוֹ נִשְׁמָע. כִּסְבוּרִין הָעָם לוֹמַר שֶׁקּוֹלוֹ שֶׁל הָרוּג הוּא. אָמַר לָהֶם: קוֹלִי הוּא. תֵּדְעוּ, שֶׁלְּמָחָר הוּא מֵת, וְאֵין קוֹלוֹ נִשְׁמָע

All of Yehuda ben Tabbai’s days, he would prostrate himself on the grave of that executed individual, to request forgiveness, and his voice was heard weeping. The people thought that it was the voice of that executed person, rising from his grave. Yehuda ben Tabbai said to them: It is my voice, and you shall know that it is so, for tomorrow, [i.e., sometime in the future,] I will die, and my voice will no longer be heard.

Today, capital punishment is still legal in 55 countries, including Bangladesh, China, Egypt, Ethiopia, India, Indonesia, Iran, Japan, Nigeria, Saudi Arabia, South Korea, Sri Lanka, Taiwan, and the United States. And so today on Talmudology we will look at the terrible phenomenon of wrongful executions.

Edouard Manet. The Execution of Emperor Maximilian (1868–69).

The earliest wrongful executions

Shimon ben Shetach lived around 150 BCE, which is the era in which Rabbi Yehuda’s miscarriage of justice would have taken place. About three hundred years earlier there was another wrongful execution. Or nine, to be more precise. Around the year 440 BCE, nine Hellenotamiai were tried and executed. The Hellenotamiai were a board of ten treasures of the Athenian empire who oversaw the funds and taxes that were paid by members of the empire as tributes. Apparently they miscalculated, and were accused of embezzlement, making them perhaps the earliest white collar criminals in history. Except that they were innocent, as Antiphon recorded.

. . . οἱ Ἑλληνοταμίαι οἱ ὑμέτεροι, ἐκεῖνοι μὲν ἅπαντες ἀπέθανον ὀργῆι μᾶλλον ἢ γνώμηι, πλὴν ἑνός, τὸ δὲ πρᾶγμα ὕστερον καταφανὲς ἐγένετο. τοῦ δ’ ἑνὸς τούτου—Σωσίαν ὄνομά φασιν αὐτῶι εἶναι—κατέγνωστο μὲν ἤδη θάνατος, ἐτεθνήκει δὲ οὔπω· καὶ ἐν τούτωι ἐδηλώθη τῶι τρόπωι ἀπωλώλει τὰ χρήματα, καὶ ὁ ἀνὴρ ἀπήχθη ὑπὸ τοῦ δήμου τοῦ ὑμετέρου παραδεδομένος ἤδη τοῖς ἕνδεκα, οἱ δ’ ἄλλοι ἐτέθνασαν οὐδὲν αἴτιοι ὄντες.

. . . your own Hellênotamiai, they all perished out of anger rather than sound judgment, except one, because the facts of the matter became clear too late. This one—his name, they report, was Sosias—had already been condemned to be executed, but had not yet died. And just in time it was revealed how the money had been lost and the man, even though he had already been delivered to the Eleven, was forcibly rescued by the people, but the others had already died although quite innocent.

Wrongful executions in the early modern era

In 1661 two brothers and their mother were hanged and their bodies placed in iron cages near Campden in England. They had been convicted of the murder of a seventy year old man named William Harrison. But a few years later Harrison showed up, claiming he had been attacked on the night of his disappearance and pressed to serve on a sailing ship. The wrongful execution changed the minds of no-one, and it was later claimed that the mother had been a witch and had orchestrated the events, which were taken to be “signs of Satan's evil designs and of God's overwhelming mercy."

But over the next couple of centuries British judges tried to do better by tightening the requirements for corroboration, especially for the testimony of those who had turned “state’s evidence.” In the 1790s, wrote Bruce Smith, a historian of the law, “British judges increasingly instructed jurors concerning what came to be known as the "beyond-reasonable-doubt" standard of proof-initially, it appears, by instructing jurors to acquit if they had "any rational doubt" as to a defendant's guilt.”

Wrongful executions in TWENTIETH century america

Wrongful executions were also ignored in the United States, as events that could never happen. In 1912 the American Prison Congress published a report claiming to have found not a single case of wrongful execution in American history, though their methodology hardly inspired confidence. They simply asked prison wardens if they had “personal knowledge of the execution of any person on conviction of murder whom you believe, from subsequent developments, to have been innocent?” And there was at least one warden, R. W. McClaughry, of the government prison at Fort Leavenworth, who said: "I know of one or two who may, in my opinion, have been executed wrongfully.”

A couple of decades later, writing in The New Yorker in March 1935, the crime writer Edmund Pearson (1880–1937) was certain that there had been no wrongful executions, at least in the US. Here it is, in the original:

And that’s how things remained until the 1980s, when a philosopher and a sociologist published a paper in the Stanford Law Review in which they identified 350 people who had been wrongfully convicted of capital crimes from 1905 to 1974. Here is a table of their findings:

And here are the executions that were carried out on people that were, according to the authors, innocent of their crimes:

“
Eighteen people have been proven innocent and exonerated by DNA testing in the United States after serving time on death row. They were convicted in 11 states and served a combined 229 years in prison – including 202 years on death row – for crimes they didn’t commit.”

— The Innocence Project

Exonerations after a death sentence today

According to the Death Penalty Information Center, there are now 185 people who have been exonerated after being wrongfully convicted and sentenced to death. And an analysis of theses cases reveals “disturbing patterns of official misconduct and racial bias:”

Nearly 70% of the exonerations involved misconduct by police, prosecutors, or other government officials. 80% of wrongful capital convictions involved some combination of misconduct or perjury/false accusation and more than half involved both. Cases that involved misconduct took longer, on average, to reach exoneration. Misconduct was implicated in all 8 of the exonerations that took more than 30 years and 88% of exonerations that took 21-30 years. Misconduct occurred more often in cases involving Black exonerees (78.8%) than white exonerees (58.2%). Black exonerees spent an average of 4.3 more years waiting for exoneration than white exonerees.

The death penalty inflicted by Rabbi Yehuda ben Tabbai is typical of the errors that involve the death penalty today, in that it involved what we might call “official misconduct.” How hard, really, was it for Rabbi Yehuda to have checked with his colleagues before passing sentence? And it’s not as if Shimon ben Shetach was a bleeding heart liberal. According to the Talmud Yerushalmi, he executed eighty witches in a single day, even though it is forbidden to carry out more than one judicial execution per day. His reasoning was simple: “the times called for it” (אָֽמְרוּ. שְׁמוֹנִם נָשִׁים תָּלָה. וְאֵין דָּנִין שְׁנַיִם בְּיוֹם אֶחָד. אֶלָּא שֶׁהָֽיְתָה הַשָּׁעָה צְרִיכָה לְכָךְ).

Perhaps, fearing such miscarriages of justice, Rabbis Akiva and Tarfon made it clear that they would never vote to convict a person for a capital crime.

משנה מכות 1:10

סַנְהֶדְרִין הַהוֹרֶגֶת אֶחָד בְּשָׁבוּעַ נִקְרֵאת חָבְלָנִית. רַבִּי אֶלְעָזָר בֶּן עֲזַרְיָה אוֹמֵר, אֶחָד לְשִׁבְעִים שָׁנָה. רַבִּי טַרְפוֹן וְרַבִּי עֲקִיבָא אוֹמְרִים, אִלּוּ הָיִינוּ בַסַּנְהֶדְרִין לֹא נֶהֱרַג אָדָם מֵעוֹלָם. רַבָּן שִׁמְעוֹן בֶּן גַּמְלִיאֵל אוֹמֵר, אַף הֵן מַרְבִּין שׁוֹפְכֵי דָמִים בְּיִשְׂרָאֵל

A Sanhedrin that executes a transgressor once in seven years is characterized as a destructive tribunal. Rabbi Elazar ben Azarya says: This categorization applies to a Sanhedrin that executes a transgressor once in seventy years. Rabbi Tarfon and Rabbi Akiva say: If we had been members of the Sanhedrin, we would have conducted trials in a manner whereby no person would have ever been executed…

“No matter how careful courts are, the possibility of perjured testimony, mistaken honest testimony, and human error remain all too real. We have no way of judging how many innocent persons have been executed, but we can be certain that there were some.”

— Thurgood Marshall. Furman v. Georgia, 408 U.S. 238, 367-68 (1972) (Marshall, J., concurring)

Sanhedrin 45 ~ Stoning and the Height of a Lethal Fall

In today's page of Talmud we continue with the rather gruesome details of judicial execution. Here the Mishnah details the procedure for execution by stoning:

סנהדרין מה, א

 בית הסקילה היה גובה שתי קומות אחד מן העדים דוחפו על מתניו נהפך על לבו הופכו על מתניו ואם מת בה יצא ואם לאו השני נוטל את האבן ונותנו על לבו אם מת בה יצא ואם לאו רגימתו בכל ישראל 

The elevation of the stoning grounds was twice the height of a man. One of the witnesses to the crime pushes him by his hips [so that he falls on his side]. If he falls onto his chest he is turned onto his hips. If he dies [from the fall] the court has fulfilled its obligation. If he is still alive the second witness takes a stone and places it on his chest. If the condemned man dies, the court has fulfilled its obligation.  If he is not dead, he is stoned by all of Israel...

The Talmud states that condemned is standing when he is pushed.  But why push him from twice the height of a person?  According to the Mishnah in Bava Kamma (50b), a fall into a pit that is only ten handbreadths deep is lethal. If this is case, why not push the condemned from that smaller height? Rav Nahman in the name of Rabbah bar Avuha explained that pushing from the greater height insures a quicker and less painful death, thereby fulfilling the biblical requirement of loving your neighbor by choosing a more swift execution. Still, it seems rather improbable that the condemned would be killed merely by falling from a twelve foot platform.  

“ואהבת לרעך כמוך ברור לו מיתה יפה
Love your fellow as yourself, by choosing for him a better way to die”

— Sanhedrin 45a

Let's take another look at what science says about the height of lethal falls, starting with that Mishnah cited from Bava Kamma:

החופר בור ברה"ר ונפל לתוכו שור או חמור חייב אחד החופר בור שיח ומערה חריצין ונעיצין חייב א"כ למה נאמר בור מה בור שיש בו כדי להמית עשרה טפחים אף כל שיש בו כדי להמית עשרה טפחים היו פחותין מעשרה טפחים ונפל לתוכו שור או חמור ומת פטור ואם הוזק בו חייב

If a man digs a pit on public ground and a bull or a donkey falls into it, he is liable for damages. Whether he dug a pit, or a ditch, or a cave, trenches, or wedge-like ditches, he is liable for damages that his digging caused. If so why is pit mentioned in the Torah? It is to teach the following: just as a standard pit can cause death because it is ten tefachim [handbreadths] deep, so too for any other excavation to have sufficient depth to cause death, it must be ten tefachim deep. Where, however, they were less than ten tefachim deep, and a bull or a donkey fell into them and died, the digger would be exempt.  But if then animal was only injured by falling into them, the digger would be liable. (Mishnah, Bava Kamma 50b.)

THE HIGHEST FALL SURVIVED (WITHOUT A PARACHUTE)

According to The Guinness Book of Records, Vesna Vulovic  holds the world record for the highest fall survived without parachute. And how high was that? Really, really high:

Vesna Vulovic (Yugoslavia) was 23 working as a Jugoslavenski Aerotransport hostess when she survived a fall from 10,160 m (33,333 ft) over Srbsk, Kamenice, Czechoslovakia (now Czech Republic), on 26 January 1972 after the DC-9 she was working aboard, blew up. She fell inside a section of tail unit. She was in hospital for 16 months after emerging from a 27 day coma and having many bones broken...She never suffered any psychological trauma as a result of the incident, and never experienced any fear of flying. She is still alive today, and flies with some regularity. However, Vulovic does not consider herself lucky. Thirty years after the crash, in an interview she said:  ''I'm not lucky. Everybody thinks I am lucky, but they are mistaken. If I were lucky I would never have had this accident and my mother and father would be alive. The accident ruined their lives too."

In my years as an emergency physician I saw countless patients with injuries from falls. Most injuries were relatively minor, but several of my patients died. Is there really a minimum height below which a fall would result in a trivial, or at least a non-fatal injury? Based on my experience, the answer is an unequivocal no.  A fall from any height, however low, can result in a serious or fatal injury, and that includes a fall from standing. But that's just my experience. What does the medical literature say? Does it agree with the assertion of the Mishnah that a fall below 10 tefachim (about 76 cm or 30 inches) cannot result in a fatal injury? Let's take a look...

““At autopsy, classic findings in falls from height include aortic lacerations and vertebral compression fractures, as well as ring fractures of the skull base...Severe head injuries most frequently occurred in falls from heights below 10m and above 25m, whereas in the group that fell from 10 to 25m, few head injuries were seen and they rarely were the cause of death.”

— Turk, EM. Tsokos, M. American Journal of Forensic Medical Pathology 2004;25: 194–199

THE EPIDEMIOLOGY OF FALLS

Falls are very common. In the US they make up about a third of the injuries that lead to an ED visit in the each year - that's close to eight million visits.  In keeping with my experience, national data shows that only about 1% of all fall injuries that come to the ED are serious.  And here's another interesting finding that is in keeping with my own clinical experience: it's close to impossible to predict what kind of injury a person will have based on the height of the from which the victim falls. In a paper that examined over six-hundred fatal falls that occurred in Singapore, the authors noted that  

...there was much variability in the injury severity scores, in relation to the height of fall... Thus, a subject who had fallen through a height of 10 m, with primary feet impact, could have sustained complete traumatic transection of the thoracic aorta, with haemorrhage into the pleural cavities but little else by way of serious injury; while another, similar, subject could have fallen through 20 m and had sustained multiple head, thoracic and abdominal injuries...

In fact these authors had a very hard time coming up with a model that describes the height of fall and indicators of injury severity other than to give this rather useless nugget: "Our findings suggested that the height of the fall was significantly associated with ... the extent of injury." Well thanks. But it's one thing to fall 10m or more (that's over 30 feet for those if you not on the metric system). What about falls from less lofty heights?

FALLS DOWN THE STAIRS, AND FALLS FROM STANDING

Let's start with falls down the stairs. German forensic pathologists published a paper in Forensic Science International that addressed this aspect of falls in 116 fatal cases.  The most frequent victim was a man between 50 and 60 years old, and brain and skull injuries were the most common cause of death. About 8% broke their spines as they fell and (shocker) many were intoxicated. So stairs can kill.  

What about falls from standing? Well back to the German forensic pathologists, who this time published a retrospective analysis of 291 fatal falls. Of these, 122 -that's 42% - were falls from standing. About 80% of these ground-level falls were not immediately fatal, and the victim survived anywhere from three hours to almost a year post injury. Almost 60% of the men and 11% of the women who sustained a fatal ground-level fall were (shocker again) intoxicated.  So there we have it. The medical literature demonstrates that falls from standing can certainly be lethal.  Especially after kiddush.

From Thierauf A. et al. Retrospective analysis of fatal falls. Forensic Science International 2010. 198. 92–96. Forgive the English. It wasn't their first language

The US federal government has also weighed in on the matter. OSHA, the Occupational, Safety and Health Administration has a ruled that a duty to erect fall barriers to protect employees only applies when the fall will be more than 6 feet (1.8m).  

“Each employee who is constructing a leading edge 6 feet (1.8 m) or more above lower levels shall be protected from falling by guardrail systems, safety net systems, or personal fall arrest systems.”

— 29 CFR 1926.501

Back to Stoning

How likely then, is it that executing a person by pushing him from a height of about 12 feet will result in his instant death? Not likely at all. We know (and the those German pathologists have shown) that a fall from standing can be lethal, but it doesn't happen very often, and is certainly not likely to be immediate. Remember, the pathologists found that of all lethal falls, about 42% were from a standing position. Which is not the same as saying that 42% of falls from a standing position are lethal.

There is another interesting data source that may help us, and it comes from a 1995 paper titled Fatal Work Related Falls from Roofs, published in the Journal of Safety Research.  It examined 288 falls from roofs and showed that falls from as low as 6-15 feet may be fatal. Again, this is an analysis of fatal falls, not of all falls. 

From Suruda A. Fosbroke D. Braddee R. Fatal work related falls from roofs. Journal of Safety Research 1995;26: 1-8

The LD50 for falls

The LD50 is used to describe toxins or medications, and is the dose which would kill 50% of those who ingested it.  The LD50 can also be used to describe falls, and is the height from which at least 50% of those who fell would die.  According to this medical text, the median lethal distance (LD50) for falls is four stories, which is about 48 feet, or 15 meters. Mortality increases to 90% when the fall is greater than seven stories.  

The Role of Alcohol

In considering the first step of the judicial process of stoning, there is one more factor to consider: the role of alcohol. The Talmud (Sanhedrin 43a) relates that when the convict was taken out to be executed, he would be given a drink of wine and frankincense, כדי שתטרף דעתו – in order to dull his senses. Perhaps this would make the twelve foot fall more likely to be lethal? It turns out not to be so.

While you may be more at risk from a fall if you are drunk, drunk people who fall are not more likely to sustain a lethal injury when compared with those who are sober. Pushing a drunk person off a platform is not more likely to result in their death compared to pushing a sober person, though neither is recommended.

In conclusion, the first part of the penalty of stoning - that push of a twelve foot platform - would only very rarely result in the instant death of the criminal.  This meant that the execution would proceed to the second step - in which a heavy stone was placed on the chest to cause suffocation. The details are horrific, and thankfully have not been practiced in our legal system for nearly two thousand years.   

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.

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 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.