Background on Leprosy in the Bible

LEPER; LEPROSY (Heb. sara'at; Gk. lepra]. A leper suffers from a specific form of mycobacterial infection that was dreaded in antiquity and that until A. D. 1960 was regarded as intractable and incurable. To reduce the psychological trauma reported by sufferers, the condition has been renamed "Hansen's disease," after G. A. Hansen, who discovered the causative organism (see III below).

I. Terminology

II. Antiquity of Leprosy

III. Symptomatology and Diagnosis

IV. Treatment

V. In the OT

VI. In the NT

I. Terminology. Both ancient and modern writings show considerable confusion about the terminology for leprosy. Heb. sara'at is of uncertain provenance and meaning, having been related variously to the roots for "strike," "become disfigured in the skin," "erupt," and "hornet." Since the ailment is given more prominence than any other in Scripture, the inability to determine the term's derivation is very unfortunate. In Lev. 13 sara'at is evidently used in a technical sense, describing a class of pathological conditions. If related to Akk. sinnitu, "eruption," the root can describe any type of cutaneous eruptive lesion, including clinical leprosy. The comprehensive nature of sara'at is indicated by its application not only to human pathology but also to molds, mildews, and mineral efflorescence in the walls of buildings or on fabrics.

The LXX translates sara'at by the comprehensive term lepra, which for the Greeks signified an ailment that resulted in a scaly condition of the skin. Lepra was associated by Herodotus (i.138) and Hippocrates (who named it the "Phoenician disease") with leuke, a cutaneous affliction characterized by a localized absence of pigment, probably the modern leucoderma. Galen (A.D. 130-201) and some Greek medical writers before him employed elephas or elephantiasis for a more serious cutaneous disease that seems to have corresponded closely to modern clinical leprosy. The Romans generally preferred the Greek term lepra to the more cumbersome elephantiasis Graecorum ("of the Greeks"), and the Vulgate uses lepra to render Heb. sara'at. Hence "leprosy" occurs in later English versions of the Bible.

Modern versions have difficulty rendering the obscure Hebrew terms in Lev. 13, which contains diagnostic material intended for priests of the 2nd millennium B.C. In v.2. e,g., Heb, se'et (Gk. oule) is translated "rising" in the A V, "swelling" in the RSV. and "discoloration" in the NEB. For Heb. sappahat (Gk. semasia) in the same verse, the AV has "scab," the RSV "eruption," and the NEB "pustule." Heb. baheret (Gk. telaugema) is variously rendered "bright spot" (AV), "spot" (RSV), and "inflammation" (NEB). Particularly unfortunate is the NEB's use of "malignant skin disease" for sara'at, which is a comprehensive Hebrew term describing a variety of skin afflictions. Some of these were benign, and the priest could pronounce the sufferer clean. Only one form of sara'at, a chronic, spreading affliction, was deemed malignant by the diagnostic procedure and merited the strictures of vv. 45f.

II. Antiquity of Leprosy. This dreaded disease is supposed to have existed in India and China from ca. 4000 B.C., but this dating is very difficult to establish factually. Kinnier Wilson suggested that leprosy may have been the incurable skin condition mentioned in an Old Babylonian omen tablet, since the symptoms include loss of skin pigment, odor, and an apparent outbreak of papules (J. V. Kinnier Wilson, Revue d'assyriologie et d'archeologie orientale, 60 [1966], 47). Although serious skin diseases were known to both the Sumerians and the Babylonians, it is impossible to ascertain whether any of the technical terms in the various texts refer to leprosy. But probably the Mesopotamians did become familiar with leprosy during the 3rd millennium B.C.

The disease seems to have been endemic in Egypt from at least the Old Kingdom period (ca. 2700-2400 B.C.), and if the term ukhedu in the Ebers Papyrus indicates a form of clinical leprosy. then the ailment would have been familiar to the Egyptians before 1500 B.C. Ukhedu does seem to describe a malignant disease, but the identification with leprosy is not definite. A malformation in the upper jaw of an Egyptian mummy, ca, 1400 B.C.. was once thought to be an instance of leprosy but is now regarded as the result of chronic gingival infection. Some writers have expressed surprise at the paucity of cases of leprosy found in Egyptian mummies, since Lucretius (99-55 B.C.) claimed that elephas (leprosy) originated in Egypt. Most probably, however, leprous Egyptians died in some isolated place and were never mummified.

Leprosy was already becoming globally distributed in the 7th cent. B.C., and by ca. 250 B.C. it was being reported by Greek physicians. It spread slowly west across Europe. and by ca, 40 B.C. it had entered the British Isles.

In view of the lengthy tradition attaching to the existence of the disease, it seems ill-advised to suppose that the Hebrews became acquainted with the affliction only after they had been in sedentary occupation of Canaan for some time. Liberal writers who accept a post-exilic date for Leviticus to demonstrate that sara'at had nothing to do with clinical leprosy are actually working against their own theoretical postulates, since the later that Leviticus is dated, the more probable it is that the chronic form of sara'at was Hansen's disease, which was unquestionably in Palestine by the 4th cent. B.C

III. Symptomatology and Diagnosis. The cause of leprosy fits the minute rod-shaped organism Mycobacterium leprae, identified by the scientist G. A. Hansen in 1871-1873.(As his terminology indicates; Hansen thought that the infecting agent is a fungus, but it is now known to be a bacillus or bacterium.) Hansen's organism is similar to Koch's bacillus Mycobacterium tuberculosis (which causes' tuberculosis); indeed, "the two bacilli are possibly of common origin, having become different through mutation.

To speak of leprosy symptomatology is to raise some fundamental philosophical issues related to all of human pathology. In the strictest sense there are no such entities such as "diseases"; a disease is actually a collection of symptoms that are given a designation for convenience. One must realize that the designation may describe only the principal symptoms, and that a person need not have all the attributed symptoms to have the disease. An equally significant observation is that the pattern, distribution, and character of some diseases have changed: over the centuries. Thus Browne (p. 8) properly warned about the dangers of retrospectively diagnosing diseases mentioned in ancient literature, especially if the terminology is indeterminate.

As already noted, Heb sara'at in Lev: 13-14, although technical and obscure, is known to denote a variety of related conditions (cf. the broad pathological and metaphorical uses of "cancer").The symptoms of sara'at are detailed in Lev. 13 so that the Hebrew priest-physician could make a differential diagnosis. Since medical legislation in the Torah has a preventative nature, the priest as diagnostician functioned as a health officer more than the Babylonian or Egyptian priest-physician did. The affliction that the Hebrew priest would carefully inspect could have arisen spontaneously (vv. 2.6), or after a prodromal interval of unspecified length (vv. 7f.). It could have succeeded a furuncle, a carbuncle (vv. 18~23), or a burn (vv. 24-28), or it could have developed upon the beard, the head or elsewhere on the body (vv. 29-44). Preliminary symptoms could include the presence of subcutaneous swellings, or nodules (se'et), a cuticular scab (sappahat), and whitish-red spots or reddish areas of skin (baheret)

If a person with one or more of these symptoms that had turned into a leprous disease presented himself to a priest (13:2); the priest pronounced him leprous after inspection if the local hair had turned white (leucotrichia) and the affliction seemed to have penetrated the skin (v. 3). If the person did not have the last two symptoms, he was quarantined seven days and then seven more if the symptoms showed no development (vv, 4-6); his condition was diagnosed as an eruption (Heb. mispahat). Mispahat appears to be a general term for the slight pustulation occurring in many of the dermatoses.

Another nonmalignant form of sara'at covered the person from head to foot (13:13). This condition could not have been Hansen's disease, which seldom covers the entire body and never makes the skin white. The condition would probably have been psoriasis, in which round reddish patches covered with whitish scales erupt on the scalp, elbows, knees, and back. This common affliction manifests itself in several forms and is sometimes extremely resistant to treatment. Even more probably, the sufferer was the victim of vitiligo (acquired leucoderma), a condition marked by white patches on the skin characterized by deficiency of pigment. The body chemistry involved has not yet been explained satisfactorily, but the affliction, like psoriasis, is neither infectious nor harmful.

If, however, the Hebrew sufferer, had basar hay (presumably to be translated "raw flesh"), then the condition would no longer have been thought benign (13:14). Apparently ulceration was occurring, as in developed cases of nodular leprosy. If the ulceration or inflammation was local and transitory, the sufferer could be pronounced free of sara'at and therefore would be ceremonially clean again. The extent of cuticular penetration governed the seriousness of the condition, as though the developing pathology was being viewed from inside rather than from outside the skin. This perspective would help explain the decision that any pale or reddish swelling' beneath the skin was malignant. The RV translation "deeper than the skin" may thus indicate cutaneous nodules, that were about to erupt and form the fetid sores seen in modern lepromatous leprosy. Persistently bright-pink patches of skin: (Heb. baheret) were a symptom of leprosy; they are sometimes seen on modern lepers.

If the site of a previous, staphylococcal infection was ulcerated or inflamed (13;18t), the symptoms of leucotrichia, cuticular penetration, and the spread of infection determined the seriousness of the condition. The swelling in question (Heb. se'hin; RSV "boil", NEB "fester") is of uncertain nature but it could have been a furuncle a carbuncle, an ulcer, a keloid, or erysipelas on the site of a boil.

The mention of a burn on the skin (13:24-28) is interesting in view of the medical contention that anesthetic patches are not recorded in this chapter. Burns occur commonly among lepers when cutaneous nerve endings have been made insensitive by the disease. Infection resulting in pus formation or ulcers can have serious consequences if left untreated. Verses 24-28 seem to refer to infection of a burn, perhaps sustained because of the occurrence of macula-anesthetic leprosy; the condition was pronounced malignant if the reddish-white area had spread and the local hair had changed color.

The seriousness of a disease, of the scalp or beard (Heb. neteq; Gk, thrausma) was governed by the degree of skin penetration as well as by the amount of hair lost and a change in hair color from dark to coppery (RSV: "yellow" 13:29-37). These conditions incidentally are seen periodically in modern lepers and are attributed by some medical authorities to vitamin or protein deficiency. The condition in vv. 29--37, however, seems to be ringworm. (This fungus attacks various areas of the skin and is extremely irritant in nature. It can be contracted from cattle. Hair loss accompanied by a pinkish disease spot indicates chronic leprosy, however.

Dull white spots on the body(13:38f.) were not regarded as malignant; eruption, (Heb. bohaq; Gk. alphos) was probably vitiligo. In a well-developed case of vitiligo the skin exhibits complete loss of pigment, in contrast to leprosy the lesions of which are never white.

Leviticus 13:47-59 treats "leprous diseases" in cloth and leather garments. The expression "warp or woof" probably refers to the woven or fabricated material as a whole, which was judged diseased if it appeared greenish or reddish. Fungi; mildew, iron mold, or dampness could be the responsible or facilitating agents. Even buildings could be affected by "leprosy" (14:34-53), which was apparently dry rot or mineral efflorescence affecting stone walls.

The diagnostic principles in Leviticus were deemed sufficient both to establish the nature of the various types of sara'at and to provide for malignant cases. Such sufficiency was very important if only because the malignant sara'at resembled other dermatoses in so many respects; especially in the initial stages of the ailment, just as Hansen's disease does today. Modern clinicians have similarly established cardinal signs of leprosy, namely, localized hypopigmented patches; loss of sensations particularly of temperature or touch, and the presence of M.leprae bacilli taken from skin lesions. If a person has more than one of these signs he or she is deemed to be a leper. Other experts reduce these signs to two, namely, loss or impairment of cutaneous sensation regardless of the presence or absence of a skin patch, and the thickening of nerves. These basic signs indicate the two, principal types of leprosy--lepromatous and nonlepromatous; the latter including tuberculoid, maculo-anesthetic, and polyneuritic varieties. In addition, an intermediate leprosy group accommodates borderline and indeterminate cases.

The prodromal symptoms include vague pains in limbs and joints with intermittent fever. The incubation period can vary between a few months and thirty years, according to some leprologists, but when the eruptive stage occurs the disease begins to assume its special character. In the severe form, lepromatous leprosy, a hypopigmented patch of skin or numbness of skin occur first, although ulcers, nasal blockage, and other symptoms may anticipate the morbid skin changes. Lepromatous (nodular)leprosy is the most severe form, with the nodules occurring in the skin, mucous membranes, and perhaps subcutaneous tissues. Sometimes the nodules ulcerate and discharge bacilli in large quantities. Many of the peripheral nerves are affected, as are internal organs such as the spleen, liver, lymph nodes, and adrenal glands. Lesions often occur in the nasal mucosa, the larynx, and the eyes. In diffusely infiltrated lepromatous leprosy the skin of almost the entire body may thicken and redden; some hair loss commonly occurs too. The hypopigmented lesions of macular leprosy have smooth, reddish surfaces with little loss of sensation and poorly defined margins. By comparison, nonlepromatous leprosy is milder in character. Tuberculoid leprosy has few lesions which may be hypopigmented or erythematous, with dry, rough surfaces generally occurring. The lesions often affect peripheral nerves causing a loss of tactile sensation except occasionally on facial patches. Like sufferers from tuberculoid leprosy, maculoanesthetic patients are normally noninfective but exhibit hypopigmented skin lesions that are more or less insensitive to touch. Polyneuritic leprosy only involves peripheral nerves which thicken and sometimes necrose when nodules form and become abscesses. Frequently in advanced stages motor paralysis occurs.

The table may assist in comparing the malignant condition described in Lev. 13 with some forms of modern clinical leprosy.

Malignant sara'at

Hansen's Disease

Papules or nodules on shiny or erythematous skin patch. Hypopigmentation and spreading of patch. Pinkish-white patches. Cuticular crusts. Subcutaneous nodules. Loss of scalp hair associated with a cutaneous lesion. (Scalp lesions rare?) _ Leucotrichia. A sore on the site of a burn. Coppery-colored hair in a facial or scalp lesion. Skin ulcers. Disease "deeper than the skin." "Quick raw flesh." White, spreading eruption, "no deeper than the skin." "Appearance of leprosy."

Typical of lepromatous leprosy. Skin patch may also exhibit edema. Seen in maculo-anesthetic leprosy, tuberculoid leprosy, and the indeterminate group of leprosy. Diffuse cutaneous erythema. Low-grade pustulation common. Seen in nodular lepromatous leprosy. Seen in diffusely infiltrated lepromatous leprosy. Hair loss can occur in different areas of the body. Not reported in modern leprosy. Anesthetic skin patches sometimes become infected. Hair-color changes from black to coppery reported both in children and adults with some forms of leprosy. Scaly lesions rare. Lepromatous ulcers. Subcutaneous nodules either ready to ulcerate or erupting, seen in lepromatouS leprosy. Ulceration or inflammation of lepromatous nodules? Hypopigmented, slightly raised lesions seen in minor tuberculoid leprosy. Leonine facies, indurated skin typical of diffusely infiltrated lepromatous leprosy.

The comparison in the" table suggests more correspondence between the malignant sara'at of Lev. 13, and some forms of clinical leprosy than has been conceded by medical, practitioners (e,g., Browne, p, 14; R.G. Cochrane, p. 9) and some biblical commentators. But it is true, that some features of leprosy are unmentioned in Scripture, e.g., the fetid smell of gangrenous ulcers, the thickening of nerves, contractures of joints, osseous changes and clawing of the fingers.

The fourteen-day quarantine for suspected malignant sara'at has been quite correctly regarded as much too short for clinical leprosy to develop. But it would have allowed certain differential diagnoses, such as scabies or ringworm, to be made. Thus the quarantine would have helped to safeguard the interests of priests and patients alike, since the diagnosis of leprosy even today can be difficult in the early stages of the disease. No doubt ancient lepers, like. many of their modern counterparts usually concealed themselves when they suspected their illness. They probably would have sought diagnosis only when the symptoms were already well advanced; note that in Lev. 13:2 the patient, his friends, or his relatives seem already to have made a tentative diagnosis. The abysmal terror associated with leprosy from ancient times was an Eastern rather than a Western phenomenon; the modern reductionists who fail to find any connection between Hansen's disease and the malign conditions of Lev. 13~14 have been unable to suggest any substitute ailment that would have inspired such abject dread.

IV. Treatment. In contrast to modern practice, no herbal remedies or therapeutic measures were prescribed by the Hebrew priest-physicians. Instead, the person diagnosed as having malignant sara'at was banished from society (Lev. 13:45f.) as a hygienic precaution. He had to proclaim by his appearance and actions his social and religious uncleanness thus he was prevented from returning and communicating the infection to members of what was meant to be a holy community. There is no record from the ancient Near East of any effort to determine whether leprosy was communicable.

Only if divine healing occurred:(cf. Numbers 12:9-15) could the sufferer apply to the priest for a medical discharge. When his healing had been established; he still had to satisfy certain social and religious requirements to be pronounced clean; An appropriate ritual was provided (14:10-32); the elaborate detail suggests that it was indeed used on occasion.

It must be noted that concepts of cleanness or uncleanness have no real bearing upon the meaning, etiology, or pathology of the term sara'at. The covenant community of Israel was essentially a religious one (Ex. 19:6), and any form of uncleanness or defilement, including that of malignant sara'at, was expressly prohibited, Accordingly, specific cleansing and purifying procedures were followed for mildewed or rotting garments (Lev. 13:47-58) and for buildings similarly affected (14:33.53). These rituals were mandatory when prescribed by the priests, because they carried the full sanction of the law (14;54~57).

Although the leper was regarded under the law as ceremonially unclean, in Scripture leprosy was never considered a sin. To that extent leprosy was merely one of a class of conditions that rendered a person ritually unclean, the main differences being the social abhorrence of the condition and its duration. As with all other forms of healing, the leper's restoration to health was regarded in Scripture as a token of God's grace, and thus the concept of spontaneous remission independent of divine activity had no place in biblical thought.

V. In the OT. The affliction that God imposed upon Moses as a sign (Ex. 4:6) was evidently not chronic sara'at, which, as has been noted, is never white. It may have been leucoderma or psoriasis and was possibly the same affliction as Miriam's (Nu. 12:9~16). In both texts the gloss "white as snow" (Heb. kassaleg, lit. "like snow") differentiates this sara'at from the chronic form. Naaman (2 Kings 5) also does not seem to have been afflicted with Hansen's disease, since he lived and worked among his own people. After Naaman's healing the affliction was transferred to Gehazi (vv. 19-27), a gloss again occurs in the Hebrew text to show that the disease was not Hansen's disease, but perhaps scabies or vitiligo (leucoderma), In the early stages of the latter hypopigmented patches or" skin develop and can easily be mistaken for lepromatous leprosy, particularly if the observer has no desire for close contact with the sufferer.

The four leprous men at the gate of Samaria most probably constituted a small "leper colony" living together for mutual support (2 Kings 7:3-10); there seems no reason for doubting that they had Hansen's disease. Uzziah (2 Ch. 26:19.21) was "smitten" (Heb. naga'; the related noun nega' is sometimes used synonymously with sara'at with an ailment that the priests judged to be leprosy, and accordingly he remained in isolation until his death. Browne (p. 13) dismissed the suggestion that Uzziah had sudden hyperemia in a leprous lesion of the forehead that was otherwise inconspicuous. The perpetual quarantine strongly implies chronic sara'at.

Sara'at could also be invoked as a curse upon someone (cf. 2 S. 3:28f).

VI. In the NT. Although medical and other writers have doubted that OT references to sara'at ever indicate Hansen's disease, it is clear that in Palestine during the NT period clinical leprosy was a reality. The Israelite priests still used the diagnostic criteria of Leviticus (Mt. 8:1-4; Mk. 1:40-44; etc.), and thus "cleansing" is often mentioned in connection with healings recorded in the Gospels. The Gospels' use of "leper" and "leprosy" seems less technical than that of the law, but there is little doubt even from the scanty NT descriptions of the personal and social plight of the sufferers that they were predominantly victims of Hansen's disease.

Jesus and His disciples healed persons with leprosy, but the symptoms associated with that disease are mentioned only in Luke. On their mission of witness the Twelve (cf. Mt. 10:1, 8) were to anticipate the priesthood of all believers by cleansing lepers. The account of the ten lepers (Lk. 17:11,19) uses "cleanse" and "heal" interchangeably, and the believing Samaritan appears as much under the covenant of divine grace as his Jewish companions were. This coterie was most probably a small colony of people suffering from Hansen's disease; doubtless several such groups were scattered about Palestine in NT times. The leper of Lk. 5:12-15 has been considered a victim of a dermatosis other than Hansen's disease, possibly vitiligo, but the description "full of leprosy" (Gk. pleres lepras) seems instead to indicate a chronic condition, quite possibly clinical leprosy. Simon the leper (Mt. 26:6 par. Mk. 14:3) perhaps had only vitiligo or patches of hypopigmented macules, since he was in close contact with society. [Bibliography omitted]

R. K. HARRISON, International Standard Bible Encyclopedia. Eerdmans, Grand Rapids 1986.