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Home , Leprosy

Clinics in Dermatology (2016) 34,3–7

Leprosy in the Bible☆ Andrzej Grzybowski, MD, PhD a,b,⁎,Małgorzata Nita, MD, PhD c aDepartment of Ophthalmology, Poznan City Hospital, ul. Szwajcarska 3, 61-285 Poznań, Poland of Ophthalmology, Poznań City Hospital, Poland bDepartment of Ophthalmology, University of Warmia and Mazury, ul. Żołnierska 14 C, Olsztyn, Poland cDomestic and Specialized Medicine Centre “Dilmed”, ul. Bohaterów Monte Cassino 3, 40-231 Katowice, Poland

Abstract For many years, the biblical term tzaraat has referred to leprosy. In fact, the or described under this name have no relationship to leprosy, as was known in the Middle Ages or today; moreover, the term referred not only to skin disease, but also to the state of the ritual impurity and punishment for the sins. Although the real of tzaraat remains unknown, the differential diagnosis might include the following: , seborrheic dermatitis, , , nummular dermatitis, , , crusted , , , sycosis barbae, , furuncles, scabies, neurodermatitis, , erythematosus, et atrophicus, decalvans, , , and lichen planopilaris. Leprosy became interchangeable with the biblical leprosy due to two inaccurate translations: The Hebrew tzaraat was first translated into Greek as leprosy in the sixth century, and later, the word leprosy was translated into Arabic as lepra in the ninth century. © 2016 Elsevier Inc. All rights reserved.

Introduction political responsibilities as well) and instructs collection for the lay people, regulating and controlling all aspects of life. Chapters 13-14 of the , the third book of Chapters 13-14 relate to impurity and ritual purity, which is the Bible (the third of five books of the Torah or Pentateuch), essential for an Israelite to be able to approach and remain that is in the Old Testament of the Christian Bible, is the source part of the community.5 of biblical leprosy.1–4 The book contains material that it dates The Hebrew term tzaraat, originally used in chapter 13 of back to the time of , was created by anonymous scholars, Leviticus, is the root word and refers to collective skin diseases, and in present form was finished only in the Persian period, among them also to biblical leprosy, which, according to the 538–332 BCE. Leviticus was the divine code of proceeding Old Testament, rendered one ritually unclean. An unclean rules for Levites (in historical Judaism, they were the priestly person was physically separated from other members of the classes with exclusive rights to learn and teach Torah to others, community to prevent moral contamination rather than for served particular religious duties for the Israelites, and had medical concerns of physical contaminations.1,3 The words tzaraat in the Old Testament and lepra in the ☆ All biblical references are to the English text according to The New ⁎ appear at least 68 times.6,7, Jerusalem Bible, Garden City, New York, 1985. ⁎ ⁎ Corresponding author. Tel.: +48 505 074 224. Ex. 4:6; Lv. 13 and 14: Lv. 21:16-22:9; Nb. 5:2; Nb. 12:10; Dt. 24:8; 2 E-mail addresses: [email protected] (A. Grzybowski), S. 3:29; 2 K. 5; 2 K. 7:3-16; 2 K. 15:1-7; 2 Ch. 26, Mt. 8:2-3; Mk. 1:40-44; [email protected] (M. Nita). Lk. 5:12-13; Mt. 26:6; Mk. 24:3; Mt. 10:8, Lk. 4:27; and Lk. 17:12-19. http://dx.doi.org/10.1016/j.clindermatol.2015.10.003 0738-081X/© 2016 Elsevier Inc. All rights reserved. 4 A. Grzybowski and M.ł Nita

In the Hebrew of the period, tzaraat had a broad meaning Chapter 5 of II Kings tells the story of healing the leprosy and was related to almost all types of skin diseases and from Naaman, a non-Israelite, who came from Syria to visit the concerned four forms: prophet Eli’sha; at his order, he dipped himself in the and was cured (2 K. 5:14). The Synoptic Gospels of • on previously normal glabrous skin Mathew, Mark, and Luke (Mt. 8:1-4; Mk. 1:40-45; Lk. • lesions on previously abnormal skin 5:12-16) contain the story about healing of the Galilean leprosy • lesions in areas of diffuse alopecia sufferer, who came to , who healed him (Mk. 1:41-44) • localized alopecia. (Figures 1 and 2). Saint Luke (Lk. 17:11-19) tells the story about the healing of ten leprosy sufferers by Jesus and the To make matter more complex, each form had its own approach of the grateful Samaritan (Mk. 1:40-45) (Figure 3).11 primary and secondary characteristics.3 In the biblical Jewish culture, each of the skin diseases would Chapter 13 of Leviticus describes seven conditions which make a person culturally impure.11,12 The “Law of Purity” of could make a person unclean: ancient Israel, which refers to the set of rules concerning dealing with the sick, included regulations referring to leprosy. The • bright spot—baheret leprosy sufferer during the disease’s duration was impure and • swelling—se’et would have been totally excluded from his community in order • white —shechin not to pass his impurity to healthy people. On what was to be • that turns white or red-white—baheret considered as real leprosy was a decision for the priests. When • hair shaft breakage, yellow, and thin hair—netek the priest confirmed a diagnosis, the person suspected of having • anterior scalp hair loss—gibachat lepra was placed in a 7-day . If the clinical • posterior scalp hair loss—karachat.1 manifestations abated or disappeared after the ritual purification andanoffering,thepersoncouldreturntosociety.Whensigns Tumefaction, eruption, or spot (Lv. 13:1-8), suspicion of still were observable, the priest claimed the person to be impure, ulcers (Lv. 13:18-23), leprosy on burn (Lv. 13:24-28), leprosy and the sufferer had to abandon his family and his relatives. In on head or chin (Lv. 13:29-37), urticaria (Lv. 13:38-39), or these biblical times, the leprosy sufferers remained excluded leprosy in the bold (Lv. 13:18-23), when confirmed by a priest, from society, relegated to living outside of the villages in justified the diagnosis of tzaraat. communities of similar people.13 Medical knowledge in that era, needless to say, was limited. The term leprosy was also used in the reference to the relatively less harmful diseases, such as psoriasis and Modern interpretation of leprosy in the Bible fungal infections. The term leprosy was also applied in reference to the raiment (Lv. 13:47), which meant the fabrics being affected with some sort of mold and also to buildings It is generally assumed that the diseases which existed in 1 (Lv. 14:33), which might be moldy.4 In the Biblical sense, the biblical times are similar to the diseases known today ; leprosy was described as a swelling of the skin, with crust however, the difficulties connected with using the contem- and whitish patch, which severity might have been evaluated porary countertype of biblical leprosy ignore the fact that by the depth of the affected skin.8

Leprosy in the Biblical aspect

The early Israelites believed that illness was the punishment for sin and the particular heinous set of syndromes referred to tzaraat.2 Leprosy, then, was both a punishment for a sin (Lb. 12,10; 2 Krn. 26,19-21) and divine curse because it was a chronic and incurable disease until our times.4,8 In the Bible one can find numerous examples of the punishments for sins. Miriam was made leprous “as white as snow” (Nb. 12:9-10) by order of the Lord, because she criticized Moses, her father.2 King was stricken with tzaraat (2 Ch. 26:16-21) when discovered in the Temple by the chief priest attempting to burn incense on the altar.9 Gechazi, servant of prophet Eli’sha was punished with leprosy for his greed (2 K. 5:26-27).2 Rarely, as it was in ’s story, leprosy was cast by God, Fig. 1 Christ healing a Leper. Rembrandt, circa 1650-55; as a sort of trial of faith.10 Rijksmuseum, Amsterdam, Holland. Leprosy in the bible 5

understanding of Hansen’s disease and is not similar to any well-known dermatologic disease.4 There is a growing consensus that the term leprosy used in the Bible for a group of diverse cutaneous disorders bears no resemblance to Hansen’s disease, as it is known today.3,4 Leprosy takes its name from the Latin word lepra, which means "scaly," while the term “Hansen's disease” was coined for the disease later,15,16 after identification of its , leprae, in the year 1873, by the Norwegian physician Gerhard Henrik Armauer Hansen (1841-1912).17 There are several arguments against considering Hansen’s disease as biblical leprosy. Leprosy is one of the least contagious human disease, children are more susceptible than adults, is transmitted probably by respiratory droplets, it has slow progression (changes can be seen just after 5 or even 20 years), and the symptoms of the disease do not ever regress or show remission without the treatment.1,15,16,18,19 Tzaraat, on the other hand, was very contagious and might have undergone complete remission in 1 to 2 weeks.2 Skin lesions of Hansen’sdisease16 do not have the biblical features of netek (presence of golden hair in an area of localized alopecia), and even the skin patches of mycobacterial leprosy are poorly pigmented, they are neither pruritic nor painful (the affected areas are anesthetic to heat and ), and redness, inflamma- Fig. 2 Cleansing of the ten lepers. Unknown author, circa tion, or induration of the skin are associated with secondary skin 1035-1040; from: Codex Aureus Epternacensis (ie, an 11th-century 1,3 illuminated Gospel Book created in the approximate period infections. 1030-1050); The Germanisches National Museum, Nuremberg, Potential countertypes of biblical leprosy include psori- Germany. asis, seborrheic dermatitis, favus, dermatophyte infections, nummular dermatitis, atopic dermatitis, pityriasis rosea, none of the contemporary disease or diseases meet the crusted scabies, syphilis, impetigo, sycosis barbae, scabies, criteria for the diagnosis of biblical tzaraat.1 In addition, the neurodermatitis or scarlet fever (although in both cases there term tzaraat referred to a group of skin diseases and not to are no hair color changes), lupus erythematosus, lichen one particular disease.1,8 sclerosus et atrophicus, , morphea, Modern leprosy (ie, Mycobacterial leprosy or Hansen’s sarcoid and lichen planopilaris, and psoriasis.2,3,8,20-29 It disease) has long been thought to be the disease referred in was suggested that the leprosy of Israelites entirely the Bible as to tzaraat,14 but tzaraat differs from our present disappeared and depended on some which attached

Fig. 3 Christ cleanses the Leper. Instalment in the series of 12th century new roman mosaics of the Basilica Cattedrale di Santa Maria Nuova di Monreale. Monreale, Sicily, Italy. 6 A. Grzybowski and M.ł Nita

elephantiasis graecorum (Hansen’s disease) was called lepra graecorum.23,39 For some unknown reason, the term elephantiasis was discontinued and lepra was applied to both tzaraat and mycobacterial leprosy8; moreover, in ancient times, many scaling diseases were wrongly diag- nosed as leprosy (in Greek language lepo means to scale); the most spectacular is psoriasis, which was called lepra (lepra vulgaris, lepra alphoides, and lepra nigra) until the 19th century.1 The term lepra was also used in the Vulgate40 as the equivalent of tzaraat, and transliterated into the first English version of the Bible in 1382 CE as leprosie, so leprosy became firmly the English equivalent for tzaraat.2

Conclusions Fig. 4 Cauterization of leprosy lesions. Charaf-ed-Din, 1466; Bibliotheque Nationale, Paris, France. Leprosy has long been thought to be the disease referred in the Bible to tzaraat, which referred to a variety of itself to the hair of people and animals, produced a crust inflammatory with pigmentary disturbances or similar to favus, only of a white color, and was found not only to a spiritual concept of moral and ritual cleanliness. only on men, but also on the skin of animals worn as Tzaraat (the disease or diseases) have no relationship to garments and on the walls of the houses.21 leprosy as it was known in the Middle Ages or today (ie, to Confirmation of the thesis that the biblical tzaraat was not Mycobacterial leprosy or Hansen’s disease); however, a few leprosy in the contemporary meaning can also be made by may have been originally leprosy. Mistranslation of the looking at the chronology of the historic events and the biblical term tzaraat as “leprosy,” without regard to the double mistake in the translation work of both the Old and modern medical terminology, led to not only a lack of the New Testament, done by the Greek translators. medical knowledge and the therapeutic possibilities (Figure 4), The latest date of the final Leviticus redaction is during or but also to the multicentury discrimination of the leprosy- just after the Jewish exile in Babylon 587-538 BCE.1,2 The affected persons, in agreement to the concept of tzaraat, ancient roots of the leprosy derive from either Central Asia or understood as the punishment for the sins. Eastern Africa30–32; however, according to the classic concept, According to the above, biblical leprosy was defined as “a the cradle of the worldwide leprosy epidemics is India.32–34 comedy of errors,”2 and other authors suggest that a more Mycobacterial leprosy was described in India around appropriate translation of tzaraat would be “sign of ” “ ”1 600 BCE,35 but there is no historical, osteo-archaeological, impurity or spiritual uncleanliness, and they postulate literary, or artistic evidence of Hansen’s disease existence in that in modern Bible translations, the term leprosy should be Palestine or Syria before the return of Alexander the Great's replaced again by the term tzaraat, which should prove that armies from India in Society of 325-324 BCE,36 which means we do not know what this term meant, or use the literary term that the Old Testament was written before the introduction of "plaque," which indicates an infectious disorder of great the Mycobacterial leprosy (true leprosy) on the territory concern for the person, for his or her clothes, and home.4 inhabited by Hebrews, and the skin disorders described in Leviticus could not possibly be modern leprosy (Hansen’s Acknowledgments disease) as it is known now.1 Hansen’s disease became interchangeable with biblical Tomasz M. Dąbek, a Biblicist, from Tyniec Abbey of leprosy also as a result of two inaccurate translations, since Benedictines, in Kraków, reviewed the manuscript to insure Hebrew tzaraat was first translated into Greek as leprosy, the correctness of the biblical references and their substance. and then leprosy was translated into Arabic as lepra.1,2 The story of the mistranslation is quite a complex one. In the first translation of original Hebrew Bible scriptures References from 587-538 the word tsaarth was translated as lepra (a generic term for skin disease),1,8,37,38 because there was not equivalent for tsaarath in Greek. Mycobacterial leprosy 1. Kaplan DL. Biblical leprosy: An anachronism whose time has come. was known in Greece at that time and called elephantiasis J Am Acad Dermatol. 1993;28:507-510. 2,8,39 2. Lloyd Davies M, Lloyd Davies TA. Biblical leprosy: A comedy of graecorum, due to the thickening of the skin. errors. J R Soc Med. 1989;82:622-623. The second mistranslation was made in ninth century, 3. Freilich AR. Tzaraat-biblical leprosy. J Am Acad Dermatol. 1982;6: when the Arabic texts were translated into Latin, and 131-134. Leprosy in the bible 7

4. Goldman L, Moraites R, Kitzmiller K. White spots in biblical times. 23. Glickman FS. Lepra, psora, psoriasis. J Am Acad Dermatol. 1986;14: Arch Dermatol. 1966;93:744-753. 863-866. 5. Brown RE, Fitzmyer JA, Murphy RE, eds. The Jerome Biblical Commentary. 24. Cochrane RG. Biblical Leprosy-A Suggested Interpretation. London, London: Geoffrey Chapman; 1984:75-76,142-143,431-432. England: Tyndale Press. 1963:13-14. 6. Baillie RA, Baillie EE, Anderson SC. Biblical leprosy as compared to 25. Levin S. Job’s syndrome. S Afr Med J. 2004;94:398. present-day leprosy. South Med J. 1982;75:855-857. 26. Browne SG. Leprosy in the Bible. London, England: Christian Medical 7. Mac Arthur W. Medieval Leprosy in the British Isles. Lepr Rev. Fellowship. 1979:11-13. 14-16. 1953;24:8-19. 27. Mellanby K. Scabies. Oxford War Manuals. London, England: Oxford 8. Appelboom T, Cogan E, Klastersky J. Job of the Bible: Leprosy or University Press. 1943:37. scabies? Mt Sinai J Med. 2007;74:36-39. 28. Lloyd Davies M. Leprosy and Leviticus: Uncleanness and the Psyche. 9. Bennett R. Diseases of the Bible. London, England: Religious Tract Oxford, England: Pusey House Library. 1985. Society. 1887:19-37. 29. Danby H. The Mishnah. Translated from the Hebrew with Introduction 10. Habel NC. The Book of Job. A Commentary. Philadelphia, PA: The and Brief Explanatory Notes. Oxford, England: Oxford University Press. Westminster Press. 1985. 1933:679. 11. Levin S. Bacteriology in the Bible. Practitioner. 1964;192:820-827. 30. Robbins G, Tripathy VM, Misra VN, et al. Ancient skeletal evidence for 12. Lewis G. A lesson from Leviticus: Leprosy. Man. 1987;22:593-612. (2000 B.C.). PLoS One. 2009;4:e5669. 13. Mathew SK, Pandian JD. Newer insights to the neurological diseases 31. Grimm D. Global spread of leprosy tied to human migration. Science. among biblical characters of old testament. Ann Indian Acad Neurol. 2005;308:936-937. 2010;13:164-166. 32. Monot M, Honoré N, Garnier T, et al. On the origin of leprosy. Science. 14. Rosner F. Julius Preuss' Biblical and Talmudic Medicine. New York, 2005;308:1040-1042. NY: Hebrew Publishing Company. 1978:323-339. 33. Jacob JT, Franco-Paredes C. The stigmatization of leprosy in India and 15. Leprosy fact sheet N 101". World Health Organization. Jan 2014. its impact on future approaches to elimination and control. PLoS Negl 16. Suzuki K, Akama T, Kawashima A, Yoshihara A, Yotsu RR, Ishii N. Trop Dis. 2008;2:e113. Current status of leprosy: Epidemiology, basic science and clinical 34. Browne SG. The . In: Hastings RC, ed. Leprosy. perspectives. J Dermatol. 2012;39:121-129. Edinburgh, Scotland and New York, NY: Churchill Livingstone; 1985: 17. Hansen GHA. Undersøgelser Angående Spedalskhedens Årsager 1-14. (Investigations concerning the etiology of leprosy in Norwegian). 35. Beckett DW. The striking hand of God: Leprosy in history. N Z Med J. Norsk Mag Laegervidenskaben. 1874;4:1-88. 1987;100:494-497. 18. Nations MK, Lira GV, Catrib AMF. Stigma, deforming metaphors and 36. Browne SG. How old is leprosy? Br Med J. 1970;3:640-641. patients’ moral experience of multibacillary leprosy in Sobral, Ceará 37. Bubenik V. The rise of Koiné. In: Christidis AF, ed. A History of State, . Cad Saude Publica. 2009;25:1215-1224. Ancient Greek: From the Beginnings to Late Antiquity. Cambridge, 19. Mull DJ, Wood CS, Gans LP, Mull DS. Culture and “compliance” England: University Press; 2007:342-345. among leprosy patients in Pakistan. Soc Sci Med. 1989;29:799-811. 38. Browne SG. Some aspects of the history of leprosy: The leprosie of 20. Hulse EV. The nature of biblical “leprosy” and the use of alternative yesterday. Proc R Soc Med. 1975;68:485-493. medical terms in modern translations of the Bible. Palestine Exploration Q. 39. Hulse EV. Leprosy and ancient Egypt. Lancet. 1972;1:1024-1025. 1975;107:87-105. 40. The Latin version of the Bible. The Old Testament translated from the 21. Walker AD. The Leprosy of the Bible. BMJ. 1873;22:313. Hebrew by Jerome c. 400 AD. Current edition Biblia Sacra juxta 22. Stein S, Bolchman LG. Alone no Longer. New York, NY: Funk and latinam vulgatem versinem ad codicum fidem. Rome, Italy: Vatican Wagnall. 1963. Press. 1926.