What Was the Disease of the Bones That Affected King David?

Liubov (Louba) Ben-Noun

Department of Family Medicine, Faculty for Health Sciences, Soroka Hospital, Ben-Gurion University of the Negev, Downloaded from https://academic.oup.com/biomedgerontology/article/57/3/M152/550372 by guest on 28 September 2021 Beer-Sheva, Israel.

Background. Elderly people have suffered from pain in their bones, which may be associated with various diseases, for thousands of years.

Methods. This report analyzes the disease that affected the Biblical King David, the second and greatest of Israel’s Kings, who ruled the country 3000 years ago.

Results. The sentences “My strength failed. . .and my bones are consumed,” and “My bones wasted away through my anguished roaring all day long” indicate that King David suffered from osteoporosis, which affected his bones. Among the various diseases that may be associated with osteoporosis, the most likely are senile osteoporosis, hyperparathyroidism, or malignant disease. Among these diseases, the diagnosis of malignancy is the most acceptable.

Conclusion. This report demonstrates that the roots of contemporary modern gerontology can be traced to Biblical times.

ATIENTS have suffered from pain in their bones, which no word in the Biblical text about any of the methods listed P may be associated with various diseases, for thousand above, one can speculate that no methods of evaluating os- of years. Who suffered from bone pains in Biblical times? teoporosis were in use at that time. Nevertheless, the Bibli- What were the characteristics of the disease of the bones? cal sentences quoted above indicate very convincingly that What was the most likely diagnosis? This article aims to an- King David suffered from osteoporosis. swer these questions by evaluating a disease of the bones as There are various diseases that can be associated with os- described in the Bible. teoporosis. What was the disease that affected King David? Involutional or age-dependent senile osteoporosis occurs DISEASE OF BONES AS DESCRIBED IN THE BIBLE in men aged 70 or older and is characterized by trabecular King David, the second and greatest of Israel’s Kings and cortical bone loss leading to hip, vertebral, proximal hu- who ruled that country 3000 years ago, suffered from a dis- merus, proximal tibia, and pelvis fractures (3). It can be as- ease of the bones: “My strength failed. . .and my bones are sumed that senile osteoporosis may have affected King consumed” (Psalm XXXI:11); “My bones wasted away David’s bones. However, this does not entirely explain what through my anguished roaring all day long” (Psalm XXXII: kind of disease “consumed” his bones. 3). The first sentence indicates that the king’s bones were Cushing’s syndrome refers to a metabolic disorder that re- used up, his strength was decreased, and he had become sults from high levels of glucocorticoids. Osteoporosis re- very weak. In the second sentence, the king’s bones had lated to glucocorticoids may be so severe that collapse of ver- reached a stage where they were extremely thin and weak, tebral bodies and pathological fractures of other bones may causing him severe pain. occur (4). Did Cushing’s syndrome affect King David’s What does the phrase “my bones wasted away” mean? bones? In the absence of truncal obesity, hypertension, hirsut- The 1990 Consensus Development Panel defined os- ism, plethoric face, purplish abdominal striae, edema, and teoporosis as a “disease characterized by low bone mass and glucose intolerance (4), this disease is very unlikely. microarchitectural deterioration of bone tissue, leading to Did the king suffer from thyrotoxicosis? In thyrotoxico- enhanced bone fragility and a consequent increase in frac- sis, demineralization of bones may occur, considerably ture risk” (1). Because King David’s bones were “wasted more in axial than in appendicular bone (5). This diagnosis away,” they became very weak; that is, the bone mass de- as a cause of osteoporosis should be ruled out in all patients creased. The decreased bone mass indicates that King David who have bone demineralization (6). In the absence of ner- was suffering from osteoporosis. Contemporary medicine vousness, emotional lability, tremors, hyperhydrosis, heat measures reduced bone mass by various techniques includ- intolerance, weight loss, palpitations, eye symptoms (such ing conventional radiographs, computerized tomography, as lid lag or exophthalmos), a wide pulse pressure, sinus tachy- single or dual photon absorption densitometry, radiographic cardia, atrial arrhythmias (especially atrial fibrillation), sys- measurements of cortical width (radiogrammetry), reso- tolic murmurs, cardiac enlargement, heart failure, and data nance frequency of the ulna, total body neutron activation on the level of thyroid stimulating hormone in serum, this analysis, and x-ray microdensitometry (2). Because there is disease seems very unlikely.

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It has been reported that acromegaly may be associated Was this disease responsible for King David’s bone pain? with osteoporosis (7). Did King David suffer from this dis- In the absence of the deformity of bones, bowing of the fe- ease? In the absence of coarse facial features as the result of mur or tibia, enlargement of the skull, or warmth and sweat- overgrowth of frontal, malar, and nasal bones, enlarged ing skin over the affected bones, this diagnosis seems very mandible, separated teeth, overgrowth of soft tissue produc- unlikely. ing widening of the nose and protrusion of the lips, enlarged Persons with a lifelong low intake of dairy products be- hands and feet, thickened skin, enlarged sebaceous glands, cause of lactase deficiency have an increased incidence of and other clues that suggest this disease (e.g., carpal tunnel osteoporosis (15). In the absence of abdominal pain, bloat- syndrome, diabetes mellitus, headache [sellar enlargement], ing, and diarrhea after lactose ingestion (16), this diagnosis and visual field defects) (8), this diagnosis seems very un- seems very unlikely. Downloaded from https://academic.oup.com/biomedgerontology/article/57/3/M152/550372 by guest on 28 September 2021 likely. It would also be ironic if David, who as a youth had Biliary cirrhosis results from injury to or obstruction of slain the pituitary giant Goliath (9), was visited by the same either the intrahepatic or extrahepatic biliary system. It is disorder in his old age. associated with impaired biliary excretion, destruction of Hypogonadism may be associated with osteoporosis hepatic parenchyma, and progressive fibrosis (17). Liver cir- (3,7). In the absence of hypospadias, cryptorchism in child- rhosis at an advanced stage can lead to osteoporosis due to hood, delayed puberty, gradual loss of male secondary sex diminished vitamin D absorption, whereas deficiency of vi- characteristics and libido, impotence, and signs or symp- tamin K contributes to bone fragility (17,18). In the absence toms of a disease that can produce hypogonadism (e.g., se- of pruritus, jaundice, hyperpigmentation of the exposed skin vere headache, indicating intracranial tumor) (8), this diag- areas, xanthelasmas and tendinous and plantar xanthomas, nosis may be unlikely. However, recent longitudinal studies hepatomegaly, splenomegaly, clubbing of the fingers, steat- have demonstrated that the majority of older men develop orrhea, easy bruising related to the malabsorption of vitamin hypogonadism and that this can be reversed by testosterone K, night blindness due to vitamin A deficiency, and derma- replacement (10–12). titis due to vitamin E and/or essential fatty acid deficiency Primary hyperparathyroidism is a generalized disorder of (2,17), this diagnosis is very unlikely. calcium, phosphate, and bone metabolism that results from The prevalence of malnutrition, particularly undernutri- an increased secretion of parathyroid hormone (PTH). The tion, increases with age (18). Deficiencies in micronutrients excessive concentration of PTH usually leads to hypercalce- such as calcium and vitamin D can accelerate age-depen- mia and hypophosphatemia. Symptoms are usually associ- dent bone loss (3), and a deficiency in vitamin K can accel- ated with the degree of hypercalcemia; however, the patient erate bone fracture. A deficiency in macronutrient (protein) may be asymptomatic. In advanced cases, manifestations of leads to lower femoral neck mineral density (18). Several hypercalcemia include: central nervous system—lassitude, factors can cause weight loss and lead to a state of malnutri- fatigability, poor memory, depression, and obtundation; tion in elderly persons. Most of them act by reducing spon- ophthalmic—band keratopathy; cardiovascular—hyperten- taneous food intake, although malabsorption and increased sion; digestive—anorexia, vomiting, constipation, ulcers, metabolism can also be implicated in some situations (19). and pancreatitis; genitourinary—renal stones, decreased Reduction in food intake occurs physiologically with aging urine-concentrating capacity, and renal insufficiency; mus- (20), and this can be aggravated by various physical and cular—weakness; skeletal—osteoporosis, fractures, bone mental disorders, poor appetite due to consumption of pain, brown tumors, and bone cysts; and joints—pseudo- drugs, loss of taste and smell, inadequate access to foods gout (13). due to poverty or to impairment of cognitive or physical Did King David suffer from hyperparathyroidism? It can functions, and chronic alcohol abuse (19,21). be speculated that he may have suffered from this disease, Did King David suffer from malnutrition or undernutri- which leads to osteoporosis, subsequent fractures, and se- tion? It is possible that for some reason the intake of food vere bone pain. Did he suffer from asymptomatic renal was reduced. However, it seems very unlikely that os- stones, renal failure, or other asymptomatic manifestations teoporosis and possible subsequent fractures developed of this disease? There are insufficient data to answer these solely as a result of reduced food intake. Thus, it seems very questions. If this diagnosis is accepted, however, there is unlikely that malnutrition or undernutrition per se were the still no explanation for the disease that “consumed” King cause of the king’s bone disease. David’s bones. Chronic obstructive lung disease has been found to be as- Paget’s disease is a relatively common disorder, resulting sociated with osteoporosis (7). In the absence of a history of from a primary overactivity of osteoclasts, which leads to cough and sputum production (sometimes with wheezing) excessive resorption of bone and the formation of disorga- over many years, dyspnea, and signs of right ventricular nized, structurally defective bone. Commonly affected areas failure (22), this diagnosis seems very unlikely. include the skull, spine, pelvis, femur, and tibia. The usual Rheumatoid arthritis (RA) is a chronic multisystemic dis- presenting symptoms are deformity and pain, the latter ease of unknown cause characterized by persistent inflam- probably arising from periosteal stretching, microfractures, matory synovitis, usually involving wrists, metacarpopha- degenerative joint disease, or direct neural compression. langeal joints, knees, and feet in a symmetric distribution. A The skull may become enlarged, and bowing of the femur prodrome of fatigue, weakness, joint stiffness, arthralgias, and tibia are frequently seen. Increased warmth and sweat- and myalgias may precede the joint swelling. Constitutional ing of the skin overlying the affected bones are common. In manifestations include malaise, anorexia, low-grade fever, addition, a high-output cardiac failure may develop (14). and an elevated sedimentation rate (23). Juxta-articular os-

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teoporosis develops in early stages of RA; later, bony ero- bolic bone diseases. In: Schrier RW, ed. Geriatric Medicine. St. Louis, sion appears at the joint margins with the destruction of sub- MO: W.B. Saunders; 1990:324–340. 8. Gregerman RI. Selected endocrine problems: disorders of pituitary, chondral bone, and diffuse osteoporosis develops at an adrenal, and parathyroid glands; pharmacologic use of steroids; hy- advanced stage (24). In the absence of joint involvement ac- pocalcemia and hypercalcemia; water metabolism; hypoglycemia; and companied by constitutional symptoms, this diagnosis is hormone use of unproven value. In: Barker LR, Burton JR, Zieve PD, very unlikely in King David. Finucane TE, eds. Principles of Ambulatory Medicine. 5th ed. Balti- Malignancies of various types, particularly multiple my- more, MD: Williams & Wilkins; 1999:1096–1121. 9. Berginer VM. Neurological aspects of the David-Goliath battle: re- eloma, lymphoma, leukemia, systemic mastocytosis, and striction in the giant’s visual field. IMAJ. 2000;2:725–727. carcinomatosis, may result in diffuse loss of bone and sub- 10. Morley JE. Andropause: is it time for the geriatrician to treat it? J Ger- sequent fractures leading to severe bone pain (13). Because ontol Med Sci. 2001;56A:M263–M265. Downloaded from https://academic.oup.com/biomedgerontology/article/57/3/M152/550372 by guest on 28 September 2021 the king’s bones were “wasted away” and “consumed,” it is 11. Morley JE, Kaiser FE, Perry P, et al. Longitudinal changes in testosterone, luteinizing hormone, and follicle-stimulating hormone in healthy very likely that he suffered from one type of the malignant older men. Metabolism. 1997;46:410–413. diseases listed above. The disease was severe enough to 12. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR. Longitu- cause the king “anguished roaring all day long.” What type dinal effects of aging on serum total testosterone levels in healthy of malignancy? There are insufficient data to answer this men. J Clin Endocrinol Metab. 2001;86:724–731. question. 13. Moore TJ. Hypercalcemia. In: Branch WT, ed. Office Practice of Med- icine. 2nd ed. St. Louis, MO: W.B. Saunders; 1987:752–763. This article and others on biblical affections (25–27) 14. Brown EM. Osteoporosis and Paget’s disease of bone. In: Branch WT, show that the roots of contemporary gerontology go back to ed. Office Practice of Medicine. 2nd ed. St. Louis, MO: W.B. Saun- biblical times. We have not included any commentaries but ders; 1987:952–964. referred to the words of the Bible just as written. 15. Newcomer AD, Hodgson SF, McGill DB, Thomas PJ. Lactase deficiency: prevalence in osteoporosis. Ann Intern Med. 1978;89:218– 220. SUMMARY 16. Scheuner M, Yang H, Totter JI. Gastrointestinal manifestations of This report analyzes the most likely disease affecting specific genetic disorders. In: Yamada T, ed. Textbook of Gastroenter- King David. The sentences “my strength failed. . .and my ology. 2nd ed. Philadelphia, PA: J.B. Lippincott; 1995:2381–2419. bones are consumed” and “My bones wasted away through 17. Podolsky DK, Isselbacher KJ. Cirrhosis and alcoholic liver disease. In: Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison’s Princi- my anguished roaring all day long” indicate that King ples of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; David suffered from osteoporosis, which affected his bones. 1998:1704–1709. Among the many diseases that could have been associated 18. Bonjour J-P, Schurch M-A, Rizzoli R. Nutritional aspects of hip frac- with osteoporosis, senile osteoporosis, hyperparathyroid- tures. Bone. 1996;18:139S–144S. ism, or malignant disease can be taken into account. Of 19. Lipschitz DA. Nutritional assessment in interventions in the elderly. In: Buerhardt P, Heaney RP, eds. Nutritional Aspects of Osteoporosis these possible diagnoses, malignancy is the most likely. 94. Challenges of Modern Medicine. Vol. 7. Rome: Ares-Seromo Symposia Publications; 1995:177–191. 20. MacIntosh C, Morley JE, Chapman IM. The anorexia of aging. Nutri- Acknowledgments tion. 2000;16:983–995. Address correspondence to Dr. Liubov Ben-Noun, P.O.B 572 Kiryat- 21. Munro HN, Suter PM, Russell RM. Nutritional requirements of the el- Gat 82104, Israel. E-mail: [email protected] derly. Ann Rev Nutt. 1987;7:23–49. 22. Nicholson D, Bower AD. Pulmonary medicine. In: Rakel RE, ed. Textbook of Family Practice. 3rd ed. St. Louis, MO: W.B. Saunders; References 1984:363–400. 1. Consensus Development Conference. Prophylaxis and treatment of os- 23. Branch WT. Monoarticular arthritis and acute polyarticular synovitis. teoporosis. Am J Med. 1991;90:107–111. In: Branch WT, ed. Office Practice of Medicine. 2nd ed. St. Louis, 2. Rosenblum AL. Connective tissue disorder in diabetes. In: Alberti MO: W.B. Saunders; 1987:829–853. KGMM, Zimmet P, DeFronzo RA, Keen H, eds. International Text- 24. Gilliland BC, Mannik M. Rheumatoid arthritis. In: Petersdorf RG, Ad- book of Diabetes. Vol. 2. 2nd ed. New York, NY: John Wiley & Sons; ams RD, Braunwald E, Isselbacher KJ, Martin JB, Wilson JD, eds. 1997:1517–1529. Harrison’s Principles of Internal Medicine. 2nd ed. St. Louis, MO: 3. Riggs BL, Melton LJ. Medical progress: involutional osteoporosis. N W.B. Saunders; 1987:829–853. Engl J Med. 1986;314:1676–1686. 25. Ben-Noun L. What was the disease of the legs that afflicted King Asa? 4. Baker C, McFarland KF. Endocrinology. In: Rakel RE, ed. Textbook Gerontology. 2001;47:96–99. of Family Practice. 3rd ed. St. Louis, MO: W.B. Saunders; 1984:949– 26. Ben-Noun L. What diseases of the eyes affected biblical men? A re- 997. view of age-associated visual impairment. Gerontology. In press. 5. Seeman E, Wahner HW, Offord KP, Kumar R, Johnson WJ, Riggs 27. Ben-Noun L. Speech disorder in biblical times: Moses—A heavy BL. Differential effects of endocrine dysfunction and the appendicular mouth and a heavy tongue. Harefuah. 1999;136:69–71. skeleton. J Clin Invest. 1982;69:1302. 6. Smith TJ. Connective tissue in thyrotoxicosis. In: Braverman LE, Uti- ger RD, eds. Werner and Ingbar’s The Thyroid. A Fundamental and Clinical Text. 6th ed. Philadelphia, PA: J.B. Lippincott; 1991:738– Received June 11, 2001 741. Accepted July 9, 2001 7. Miller PD. Musculoskeletal diseases. Osteoporosis and other meta- Decision Editor: John E. Morley, MB, BCh