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HEALTH AND HEALING IN THE LAND OF ISRAEL

A PALEOPATHOLOGICAL PERSPECTIVE

By Joe Zias

This article was published originally in Mikhmanim (Spring 1999)

Paleopatholgy is the study of ancient disease and its medical/historical implications for human evolution. In the millennia that humans and animals have inhabited the earth, many of the disease processes that have befallen them can be deciphered in the osteoarchaeological record. This record enables the modern paleopathologists to understand how disease affected and influenced the history of ancient peoples and how they interacted with their environment (Roberts 1990).

One of the main principles of Paleopathology is the premise that humans and animals do not exist in isolation from their environment but interact with it in various ways. Disease, therefore, is one manifestation of the stress and strain to which we are exposed, which manifest themselves in various ways, including in our genetic inheritance. Disease in antiquity (as well as today) was influenced by daily occupations, dietary habits, choice of dwellings and even clothing (Wells 1963).

Israel, along with the ancient Near East, offers a unique opportunity for research because of its ancient literary traditions, spanning four millennium, as well as having the arid climate necessary for the preservation of skeletal remains. While many of the literary traditions, such as the Code of Hammurabi (1750 BC), the Egyptian Eber’s Papyrus (1550 BC), or Smith Surgical Papyrus (1567-1320 BC) are lacking in terms of today’s medical knowledge, they still offer us a glimpse of the heroic and sometimes futile efforts made by humans to coexist with their environment. The clinical interpretation of many of these disease processes is particularly difficult as we are left with an incomplete record due to the ravages of time. Furthermore, the human skeleton can only reveal a limited range of pathological conditions, mainly those of a chronic or debilitating nature. Faced with these difficulties, one researcher noted that 'paleopathological research is like listening to one of the Beethoven symphonies, and hearing only the part played by the drums, and on this basis one is asked which symphony is being played'. While this may have been true several years ago, recent advances in the cloning (PCR) of ancient bacteria have added a much-needed diagnostic tool to aid those working in the profession Rafi (1994).

PARASITIC INFECTIONS

Parasites in humans and animals can offer insights into the diets and illness of past populations. Most of the scientific reports emanate from the desiccated fecal remains found in latrines and in both naturally and artificially mummified bodies. Here in Israel, due to unique environmental conditions, parasites are occasionally found in other contexts as well.

The Bible is replete with references to lice, the most famous being the reference to the Ten Plagues: ... 'all the dust of the earth turned to lice throughout the land of Egypt' (Exodus 8:15-17). While medical historians have long debated as to whether or not this passage actually refers to human lice, recent discoveries in the Judean and Negev deserts have shown that human head lice (Pediculus humanus capitas) have not changed morphologically over the past 9,000 years (Zias and Mumcuoglu 1991).

Combs and human hair originally found in Qumran and Masada dateable to the time of the First Revolt of the Jews against the Romans (66-73 AD) were found to contain numerous head lice along with lice eggs, many still containing the embryo. (Fig. 1, 2) Subsequent archaeological research in a Neolithic cave in the Northern Negev, C-14 dated to 9,000 BP, revealed that the hair of the deceased buried there was glued back onto the cranium using asphalt as an adhesive. Samples of this matted hair revealed 9,000-year old lice eggs, identical to those found in Israel today. Planned future research will attempt to extract human blood from the gut of these parasites found in the desert from which we hope to clone human DNA, thus giving us an opportunity to view Jewish populations in Judea in the first century AD, and to compare the DNA of these populations with those inhabiting the region today.

Whereas most parasites are found in ancient fecal matter, chance archaeological finds in Jerusalem have revealed the presence of calcified cysts (Fig. 3) and eggs of the human and animal parasite Echinococcus granulosus which is still endemic in certain parts of Israel. The parasite, which causes hydatid disease in a number of species, is mainly transmitted to humans by dogs which have consumed the flesh of infected animals. As a significant part of the economy of ancient Jerusalem involved the raising of sheep and goats, it is not surprising that these parasites were so prevalent in antiquity.

Evidence of human tapeworms along with the above parasite were recovered from sediments in an ancient toilet in the City of David dateable to the eighth century BC (Cahill et al. 1991). The human tapeworm found in these 2,800 year old fecal sediments from Jerusalem is associated with the widespread and illegal practice of irrigating fields with raw sewage, unfortunately a practice as common in antiquity as it is today in many parts of the Third World.

Infectious Disease

Infectious disease was undoubtedly the single greatest threat to life in antiquity, with epidemics killing half or more of the populations of the world’s cities (Ortner and Putschar 1985). Most epidemics were acute, and decimated the population in a short time, thus leaving little or no skeletal evidence for the modern paleopathologist. However, chronic disease processes of long duration do on occasion leave skeletal evidence on which one can provide a clinical diagnosis. Chronic debilitating diseases such as syphilis, tuberculosis and leprosy therefore are prime candidates for an appearance in the osteoarchaeological record.

LEPROSY. One area of agreement among scholars is that Biblical leprosy, particularly that referred to in the Old Testament as sara’at, has no connection with modern day leprosy (Lendrum 1952). For decades medical historians have known that Levitical leprosy as described in chapters 13-14 is a generic disease covering a wide range of skin diseases (such as psoriasis) which were regarded as being ritually unclean. Due to complicated semantic issues and errors in translation of the Old Testament into other languages, the lay public today continues to view the millions sufferers of true leprosy (Hansen’s disease) with horror and approbation. Unfortunately the Biblical command that sufferers should reside outside the camp of Israel (Leviticus 13: 46) is still taken literally despite the fact that the Bible was not referring to modern leprosy, thus the 12-15 million estimated (World Health Organization) sufferers of the disease are still shunned by many people throughout the world.

Osteoarchaeological evidence suggests that true leprosy entered the Mediterranean basin around the 200 BC, for it was in this era that the first direct evidence of the disease appears in Nubia (Egypt.) Here in a Black Nubian cemetery were found the remains of several Caucasians, all of whom were suffering from the disease. The fact that only the Caucasians were infected with leprosy implies that those individuals suffering from the affliction were ostracized and forced to live among strangers as early as the Hellenistic period.

Despite the ongoing concern for this issue in ancient Israel, no skeletal evidence for true leprosy had been recovered by archaeologists until the mid 1980’s, when it was first noticed by Paleopathologists in a Judean Desert monastery east of Bethlehem (Fig. 4) Literary evidence (Usener 1890) mentioned that this monastery, the Monastery of Theodosius, had separate facilities for those suffering from the disease as early as the Byzantine period, therefore it would appear that the individual found there, showing unmistakable signs of the disease, may have been one of those mentioned in the ancient sources. Subsequent research in the monasteries of the Judean Desert eventually turned up an additional two find sites, both along the Jordan River, the traditional site, according to Christian sources, for the ‘washing of the leper’. Anthropological evidence at one of the sites, the Monastery of Saint John the Baptist, suggests that the mass grave C-14 dated to 900 AD contained the bodies of people who were not indigenous to the Holy Land but who were probably drawn to the site because of the alleged curing powers of the Jordan River. During the Byzantine period there existed a centuries-old tradition that Na'aman, the commander of the Syrian army, was healed of his ‘leprosy’ in the Jordan River (2 Kings: 5); therefore this site, along with others (Hamat Geder, Beit Shean) along the Jordan River valley, was reputed to have curative powers for those suffering from skin diseases.

Tuberculosis. Osteoarchaeological evidence for tuberculosis is rare in the ancient east. This is puzzling, as the disease may have originated in this region, where cattle were first domesticated in the seventh-sixth millennium BC (Bokonyi 1977). Tuberculosis, according to most medical historians, originally became a medical problem when man began domesticating cattle and other mammals which carry a form of the disease known as bovine tuberculosis. The consumption of infected meat and milk products eventually let to the transmission of the disease to the human population perhaps several thousand years later, as cattle were primarily domesticated as work animals and not for their milk products. This fundamental shift in dietary habits in the fourth millennium BC, with cattle now being bred for meat and milk as well as for work, may have ushered in a new form of the disease which infected humans for the first time. Supporting this hypothesis is evidence that the human form of the disease appeared for the first time in skeletal remains from Israel, (Zias 1998, in press), Egypt (Morse, Brothwell and Ucko 1964) and Italy (Formicola, Milanesi and Scarsini 1987) in the fourth millennium BC.

Despite its long history, little skeletal evidence for the presence of tuberculosis among the peoples of ancient Israel exists. In those few isolated instances where it is found, the reported finds, aside from one, are temporally and spatially from a non-Israelite/Jewish contex. The startling lack of skeletal evidence for this highly contagious disease among the Jewish population of ancient Israel is noticeable in several epidemiological studies which have shown that, with minor exceptions, Jews world-wide have relatively low rates of morbidity and mortality from tuberculosis (Fishberg 1916; Btesh 1958). This low incidence of the disease among the Jewish people in poorly understood and may be the result of a number of factors, including the biological (genetic) makeup of the Jewish people as a whole. One interesting theory put forth for this low rate of infection around the turn of the century, when tuberculosis was rampant in the Western World may, according to Diamond (1988) be attributable to one in 30 Jews being carriers of the Tay-Sachs gene. While being homozygotic for the gene leads to Tay-Sachs disease which is ultimately fatal, heterozygotic individuals may actually be resistant to tuberculosis which could account for the low rates of morbidity and mortality found among American and British Jews at the turn of the century.

Venereal disease. For decades it has been widely believed that syphilis originated in the New World and was brought to the Old World by returning sailors who sailed with Christopher Columbus (Dennie 1962). Epidemics of the disease ravaged Europe in 1500, thus giving rise to the belief that the disease was unknown in Europe prior to 1492. Current osteoarchaeological evidence, however, supports the theory that the disease existed in both the Old and the New worlds prior to Columbus’ voyage and that syphilis was probably the adaptive transmutation of a New World non-venereal disease brought back to Europe by returning sailors. When it reached Europe, nonvenereal syphilis transmuted and became a particularly virulent venereal disease (Baker and Armelagos 1988). In the eastern Mediterranean Basin, nonvenereal syphilis, or what is commonly refereed to as bejel, was endemic among certain populations until recently (Hudson 1958). Like venereal syphilis, skeletal involvement is extensive and ultimately fatal; however, its mode of transmission is quite different. The venereal form of the disease is transmitted by sexual contact, while the nonvenereal from of the disease is transmitted by skin contact, occurring mostly in childhood (Ortner and Putschar 1985).

The few cases of nonveneral syphilis that do occur in the archaeological record of the Holy Land come exclusively from Bedouin and Arab populations during the Turkish period (Goldstein, Arensburg and Natan 1976; Eakins 1989). The improved hygiene and living conditions of the Bedouin populations of the Middle East have practically eliminated the disease today; however areas exist where the nonvenereal form of the disease can still be found.

Surgery. Trephination, the oldest medical procedure in which human intervention in the form of surgery is known, dates to approximately 10,000 BC (Ferembach 1962). Ever since the description of ancient skull surgery during the 1867 meetings of the Parisian Anthropological Society, the modern world has been entranced by the fact that thousands of operations of this type, whereby a portion of the skull is removed, had been performed in antiquity in both the Old and the New Worlds. In Israel 29 trephinated crania, ranging in time from the pre-pottery Neolithic at Jericho (8350-6000 BC; Kurth and Rohrer-Ertl 1981) to the early Arab Period (8th century CE) have been recovered. The survival rate for this form of cranial surgery in ancient Israel, based upon inflammatory response or bone remodeling indicative of post operative survival, is 77 percent whereas in the late Middle Ages few individuals survived the operation (performed in hospitals) due to post-operative infection.

While it is relatively easy to determine the survival rate, the question of why the operation was performed at all in antiquity is exceedingly difficult to answer. Numerous theories have been put forth ranging from ritual to medical are commonly found in the literature on the subject, however one can rarely be certain why ancient cranial surgery was performed at all.

A recent find (Fig. 5) from the Chalcolithic period (carbon-14 dated to 3500 BC at the Weitzman Institute) northwest of Jericho has provided evidence for determining why the operation was performed on this particular individual. The patient, a male of 20-30 years, underwent three separate operations over a period of several weeks prior to his death. Endocranically, an extensive inflammatory response is indicated which was the result of a severe infection of the frontal sinus which burst the posterior wall of the sinus. As a result of this intercranial infection, three separate surgical attempts were made to drain the infection. If our assumptions are correct, this operation was carried out for the same medical reasons that would dictate a similar operation today. This case would then be the oldest known cranial surgery for a known medical reason (Zias and Pomeranz 1992).

In Roman medical manuals describing the procedure and the reasons for skull surgery when trauma was involved, one is impressed by the sophisticated techniques used by the attending surgeon to ascertain the extent of the injury (Celsus). According to Celsus, after making the initial incision and preparing the flap of skin which would eventually be sewn back, the surgeon would pour black ink over the affected area and then wait a few minutes before wiping the area clean. The ink would seep down into those areas of the skull which were fractured, the end result being similar to a modern-day radiograph which would then permit the surgeon to see the full extent of the fracture before the surgical procedure was performed. It is clear that the ancient profession was unaware of the fact that, if the procedure was done to relieve intercranial pressure which was the result of some traumatic event such a depressed fracture, not all the affected area had to be removed, but rather only a small portion, as the damaged area would repair itself in time.

Along with trephination, medical historians have noted that Byzantine physicians were able to perform over 120 operations, including several complicated invasive surgical procedures, such as mastectomy, operations for hernias, tumors, removal of bladder stones and embyrotomy, all of which attest to the skill of ancient medical practitioners (Bliquez 1981).

Dentistry. Dentistry in the Old World is perhaps one of the earliest known medical specialization's for which we have literary evidence. Ancient Egyptian texts refer to an established dental profession called 'toothers' as early as 3000 BC (Weinberger 1948). Archaeological finds do not always mirror the literary evidence for dental intervention, as many of the so called ’cures’ were in the form of incantations or the use of substances which would not survive the passage of time. Until recently there was very limited evidence in the archaeological record of dentistry: one case of oral surgery, four prosthetic devices fashioned from gold and silver from ancient Egypt and two retentive prosthetic devices from a Sidonian cemetery (Zias and Numeroff 1986) comprise the total number of finds from the Eastern Mediterranean. In Israel and its neighboring countries, excluding the finds in Sidon, no finds were reported until 1985 when Israeli anthropologists reported finding a second century BC skeleton in which the individual had had rudimentary root canal work done (Zias and Numeroff 1986). Radiographs (Fig. 6) showed that a bronze wire 2.5 mm. in length had been inserted in the root canal of the upper right lateral incisor. The radiograph suggests that the root canal was widened prior to the insertion of the wire, implying that the procedure was carried out by a dental practitioner. An ancient (650 BC) Assyrian text (Heidel 1963) dealing with dental problems which contains the following brief instruction may indicate why the bronze pin was found in the canal (Instructions to dentist):

Drive in a pin and seize its foot.

'Because you have spoken thus, O Worm,

May Ea strike you with all the strength of his hand!'

If our reasoning is correct, the dental practioner was following the widely accepted theory that dental disease, particularly caries, were the result of ‘tooth worms’ burrowing into the teeth.

Although the Talmud refers to artificial teeth of silver and the Mishnah to those of gold, their absence from the archaeological record may be partially attributable to the fact that tooth replacement appears in the Talmudic chapter on woman’s ornaments, inferring that false teeth were considered cosmetic devices (Preuss 1978). As men, by Talmudic law, were forbidden to wear women’s jewelry, it is doubtful if false teeth and retentive devices, appearing in Roman Etruscan tombs, would halakhically be permitted for Jewish males, despite their obvious dental advantages.

Drugs

While drugs used for medicinal purposes are seldom found in the archaeological record due to their poor chances of being preserved, their use, according to literary sources, was widespread. The famed Egyptian Eber medical papyrus dating to the early second millennium BC contains numerous references to the use of drugs for healing, although today many are known to have no medical efficacy whatsoever. There are, however, drugs such as Cannabis sativa (what is popularly referred to as hashish) which were mentioned in the papyrus and are known today to be of therapeutic value (Mechoulam 1986).

Rescue excavations carried out by the Israel Antiquities Authority in 1989 near the ancient city of Beit Shemesh uncovered a Roman burial tomb dated to the late fourth century AD in which were found the remains of a young girl of 14 years who died in childbirth (Zias 1995) Along with the body of the mother and unborn child were 7 grams of organic material which was originally believed to be incense. Subsequent microscopic analysis of the material by the Forensic laboratories of the Israel Police and a gas chromatography analysis performed by chemists at Hadassah Medical School showed the unmistakable presence of Tetralydrocannabinol, a component a cannabis, which indicated the presence of Cannabis sativa in the sample (Zias et al 1993) Ancient Egyptian literary sources provide the first written evidence (1600 BC) the this plant was used in association with 'mothers and children', which Mechoulam (1986) assumes was probably used in the prevention of hemorrhage in childbirth. Extensive research on the medicinal history of the plant by Mechoulam (1986) and others has shown that the use of the plant for a variety of purposes was widespread in the Old World for twelve millennia (Abel 1980). Studies done by British medical researchers (Christison 1851) on the medical efficacy of Cannabis sativa in the mid-19th century showed that the plant was medically effective for women in the final stages of pregnancy in 'increasing the force of uterine contractions along with a significant reduction of labour pain', thus explaining its extensive use in the fields of health, healing and childbirth.

The opium poppy (Papaver somniferum), like Cannabis sativa, appears frequently in the archaeological record as a medicament. According to scientists, its use in the Old World can be traced as far back as the Neolithic period in Europe (Merlin 1984). As is the case with many drugs, the distinctions between their recreational and medicinal uses are blurred and therefore it would seem likely, based on the literary evidence, that hashish and opium were used for both purposes. Archaeological and numismatic evidence also show that the plant was well known in ancient times in the Holy Land as King Herod depicted the opium poppy along with ears of wheat on his coinage in honor of the local cult of Demeter and Kore at Samaria (Meshorer 1982).

Recent paleo-botanical evidence of opium usage predates the finding of the opium poppy on coinage by over a thousand years. The former Australian Ambassador to Israel and Biblical scholar, R. Merrillees, speculated that small ceramic juglets dating to the Late Bronze period, or what are commonly referred to as Buckaroo jugs of 'base ring 1' type, are morphologically similar to the bulb of the poppy which produces the narcotic. If one inverts the jug (Fig. 7) and removes the handle, it closely resembles the head of the plant. Even more convincing is the relief decoration in the form of painted slits and/or indentations on the shoulder and body of the jug, which were believed to depict the incisions on the head itself in order to extract the resins. While the close morphological relationship between the two is strikingly similar, it was not until two samples were tested chemically in 1989 using gas chromatography, that the hypothesis could be shown to be correct (Merrilles 1989).

It is perhaps interesting to note that while archaeological evidence attests to the presence of both hashish and the opium poppy in the Holy Land, religious sources are noticeably silent on the subject, leading some observers to speculate that the religious establishment was more concerned with mortals seeking solace through spiritual means rather than through narcotic forms of religious experience which, anthropologically speaking, is the norm in many cultures.

The fact that traces of opium residues were found in these small, 14-12th century poppy- shaped Cypriote juglets, traded throughout the Levant, reminds one of the oft repeated phrase of Marshall McLuen, 'the medium is the message', as the manufacturers of this ancient drug fashioned containers similar to those in which the drug was found in its natural state, i.e., the poppy itself. In pre-literate societies, such an decision certainly makes sense with regard to marketing, whether it be that the drug was used for healing or for religious and recreational use as well.

Interpersonal violence

Reading the ancient literature, particularly Josephus Flavius, would lead one to believe that interpersonal violence was endemic in the region, whereas the osteoarchaeological record shows scant evidence of its actual occurrence. For example, in one incident alone Josephus mentions the killing of 3,000 Jews. When anthropological evidence for interpersonal violence does occur in the archaeological record, it is confined mainly to the Roman period.

Cut marks on bone, indicative of interpersonal trauma, particularly those appearing on the cranium and in the region of the cervical vertebrae, have appeared almost exclusively within what can be described as the period when interpersonal violence was rife. Jewish ossuaries from Jerusalem have yielded three find sites in which there is clear evidence of beheading or fatal blows to the head (Fig. 8) (Zias 1983; Smith 1977), while the site of Ein Gedi yielded three more individuals who were decapitated during the late Roman period (Rak 1976).

While decapitation is infrequently observed in the archaeological record in the Eastern Mediterranean, traumatically-caused multiple injuries are even rarer. One such case is that of a male found in a late Second Temple family burial tomb atop Mount Scopus in 1989 (Zias 1989). A young man 18-21 years of age presented multiple traumatic injuries showeing signs of having been struck by a sharp instrument at least five times (Fig. 9), probably by an axe or saber. The type and severity of the trauma inflicted on this individual suggest punitive action against a captive or mutilation of the body after death, rather than wounds inflicted in warfare. This is indicated by the bilateral nature of the trauma to the upper arms, as opposed to any evidence in the forearm where blows are usually parried, along with wounds fatal to the head, spine and pelvis. The fact that these parts of the body, including the severed left arm, were retrieved and placed in the ossuary indicates the respect for the deceased shown by the family and strict adherence to Jewish law governing burial practices..

Tumors

Modern medicine is based upon populations which survive twice as long of those in antiquity, thus diseases of old age, such as secondary bone tumors, are relatively infrequent in ancient populations (Ortner 1985). Furthermore, many malignant tumors are due to environmental causes such as tobacco smoking, asbestosis and other biological hazards which were unknown in antiquity. As a result of these two factors (low average life expectancy and fewer bio/environmental hazards), tumors both malignant and benign rarely occur in the archaeological record.

Recent excavations carried out by building contractors inadvertently discovered beneath the living room floor of a 20th century Jerusalem household unexpectedly revealed that the house had been built decades earlier over a Byzantine (4^th cent.) tomb. Subsequent tomb clearance by archaeologists and physical anthropologists provided the rare discovery of an adult male, 30-40 years of age, with a large epidermoid tumor appearing only on the skull, which had perforated the outer table (Photo 11, 12). This rare and unusual benign tumor is usually congenital in nature but may also result from a penetrating wound (Lodge 1975). Surrounding the tumor are ten circular defects which have perforated the calvarium. These lesions are sometimes erroneously reported as multiple trephinations (Yassine 1984) or as myeloma multiplex, but they are in fact postmortem, the result of tree roots which penetrated the burial chamber from outside. These taphonomic changes, commonly found in the archaeologiocal excavation of ancient tombs, are but one form of pseudopathology commonly reported at true pathology by inexperienced investigators.

DNA amplification

The extraction and amplification of genetic material from ancient human and animal remains is one of the most significant breakthroughs in the discipline. Not only will this research enable the scientist to determine genetic relationships between individuals and species (Paabo 1993), but it will clarify many of the outstanding problems connected with correctly diagnosing certain paleopathological conditions. Recent scientific advances using PCR (polymerase chain reaction) have enabled scientists to correctly identify tuberculosis (Salo et al 1994) and leprosy (Rafi et al 1994) in dry bone specimens, thus proving scientifically what was previously suspected on the basis of gross pathology.

Conclusion

One of the major research objectives of paleopathology is to understand the forces responsible for mankind's cultural and biological responses to disease throughout the ages (Ortner and Putschar 1985). Is human disease environmentally caused, or is it a result of our daily habits and genetic makeup? By understanding the processes which have affected our biological history over the millennia, we can perhaps devise strategies for coping with disease in the future. Disease, like living organisms, evolves through time. Only through the science of paleopathology are we able to view these processes diachronically and to determine the course of their evolution. Leprosy research is a prime example of this. Through international cooperation, we can now view the disease over an extended period of time , beginning in Nubia around 200 BC and tracing it across the Judean Desert to medieval Europe and Great Britain (Manchester 1984). Additionally, paleopathology can contribute to the study of the history of cancer, particularly those forms of the disease which metastasize to the bone. By examining the skeletal remains of ancient populations we can provide inferences as to whether these diseases are the direct result of our environment, genetic make-up or our habits and customs.

Lastly, the skeletal remains of all people are extremely valuable scientific-medical resources for knowledge dealing with the biological history of mankind. This information should and must be studied in an effort to promote better understanding of our ancestors, our health and the present world. Health is, after all, a primary concern for all of us.

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· Zugibe, F.T. (1984). Death by Crucifixion. Canadian Society of Forensic Science 17 (1): 1-13.

· Zugibe, F. T. (1989). Two Questions About Crucifixion. Bible Review 2: 35-43.