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MEDICAL RECORD OF KING DAVID THE GREAT
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MEDICAL RECORD
OF KING DAVID THE GREAT
Medical Research in Biblical Times
from the Viewpoint of Contemporary
Perspective
Liubov Ben-Nun
Ben-Gurion University of the Negev
Professor Liubov Ben-Nun
Faculty of Health Sciences, Dept. of Family Medicine
Beer-Sheva, Israel
.
The present book covers the broad field of
Family Medicine:
The roots of David's family, the battle with Goliath, David and
King Saul's family, David's family, David the King of Jehuda and
later the King of Israel, family dynamics, stressful life events and
crises, family as a social system, the mourning process, unprotected
sexual contacts, sexual abuse, decision making process, the
diseases that afflicted the old King.
NOT FOR SALE
MEDICAL RECORD
OF KING DAVID THE GREAT
Medical Research in Biblical Times
from the Viewpoint of Contemporary
Perspective
Editor : Liubov Ben-Nun
Professor of Family Medicine
Published by: B.N. Publication House, Israel
Fax: +(972) 8 6883376 Mobile 050 5971592
E-Mail: L-bennun@smile.net.il
Graphics and Cover: Ilana Ben-Nun
Distributed Worldwide
© All rights reserved
NOT FOR SALE
2009
CONTENTS
A PERSONAL ACCOUNT
5
FOREWORD………
6
SUMMARY
10
ROOTS.OF DAVID'S FAMILY
14
BATTLE WITH GOLIATH
15
DAVID AND KING SAUL' FAMILY
17
DAVID'S FAMILY
19
KING OF JEHUDA
21
KING OF ISRAEL
23
TAMAR AND AMNON
43
ABSALOM'S REBELLION
61
FATE OF CONCUBINES
65
GIBEONITES
67
BRIEF REVIEW OF STRESSFUL LIFE EVENTS AND
SUBSEQUENT CRISES
69
THE OLD KING
71
THE DISEASES THAT AFLICTED
KING DAVID
72
EYES
BONES
WEIGHT LOSS
CHRONIC WEAKNESS
HYPOTHERMIA
PRESSURE ULCERS
SEXUAL DYSFUNCTION
MENTAL DISORDER
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A PERSONAL ACCOUNT
When I arrived in Florence and saw the statue of David, I was
thrilled by the wonderful figure, and said to myself: how could a
mortal sculpt such an amazing figure, with such perfection of beauty
that seems to be alive? The sight gave me inspiration to learn more
about this giant character in the Bible, using all aspects of
contemporary medical science.
From the top of the Tower of David in Jerusalem, a symbol of the
rebirth of the Jewish people in the promised land, I set myself the
goal of diagnosing the state of health of King David, a character who
influenced the fate of the Jewish people, but solely according to the
actual text of the biblical verses, with no traditional interpretation,
from the viewpoint of contemporary medicine.
The statue of David. Michelangelo. 1504.
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FOREWORD
Every society is age graded, and every society has a system of
social expectations regarding age of appropriate behavior. The
individual passes through a socially regulated cycle from birth to
death as inexorably as he passes through the biological cycle: a
succession of socially delineated age-statuses, each with its
recognized rights, duties and obligations. There exists a socially
prescribed timetable for the ordering of major life events: a time in
the life span when men and women are expected to marry, a time to
raise children, and a time to retire. Men and women are aware not
only of the social clocks that operate in various areas of their lives,
but also of their own timing with regard to major life events. From
this perspective, time is at least a three-dimensional phenomenon in
charting the course of the life cycles, with historical time, lifetime (or
chronological age) and social time all intricately intertwined (1).
Man has survived in all societies by belonging to aggregates that
vary in different cultures in their level of organization and
differentiation. It is an inherent and basic human condition that man
survives in groups, and the family is the most enduring social form of
small group. Primitive cultures rely on large groupings with relatively
stable distributions of functions among subgroups. In more complex
societies requiring new survival skills, the social structures and
groupings are more widely differentiated (2).
Family is defined as any group of people related either
biologically, emotionally, or legally (3), and is a basic structure of
each society. This structure is the most important small social system
that has survived through generations. During long human history,
the family adapted to the norms of each society, and its functioning
depended on the norms of each specific society.
The family had undergone changes throughout history, that
parallel changes in society and has given up or taken over many of
the functions of protecting and socializing its member's response to
society's needs. Today, many people are wondering what is
happening to the family. People are troubled about many aspects of
current family life, including the divorce rate, reports of widening
child abuse, accounts of violence between spouses, and the
abundance of couples in nontraditional living and social
arrangements – contract marriages, people living in communes, and
mothers who are voluntary without husbands. Urban industrial
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society intruded forcefully in the family of the early 20th century,
taking over many of the functions that were previously the family's
duties. The old now live apart in housing homes, or housing
developments, or other arrangements, and economic support to
members of society is provided through social security and welfare
more often than it has been in the past (2).
As society changes, the family - which must adapt to society –
changes with it. Despite the disturbing aspects of current family life, a
number of observers believe that the family had demonstrated an
enormous capacity for innovation and endurance throughout the
ages, and the family is in the process of a transition reflecting the
changes in society, and it will survive because it is the best human
unit. The more flexibility and adaptability society requires of its
members, the more significantly the family becomes the matrix of
psychological development (2).
Through the application of systems theory, the family is more
than the sum of its parts. Interpersonal structures and processes that
enable to be both stable and adaptable over time organize the
family. Family change is the interpersonal process by which the
family adapts, alters, and becomes different (3).
Many changes occurred in the timing of the family life cycle over
the past several decades. For example, the pattern of post-WWII
family change has been generally similar in North America, Western
Europe, and even partly in Eastern Europe, suggesting that more
global rather than particular national explanations need to be sought.
The post-WWII years can be divided into 2 periods: 1) the period
from 1945 to 1965 that brought the unexpected marriage rush and
baby boom, and 2) the period from 1965 to the present that brought
a reversal of those trends in the form of marriage, a great increase in
no marital cohabitation, a large rise in divorce, and a sharp fall
infertility to below the replacement level. The similarity of these
large-scale trends in North America and Western Europe is striking.
The US is most like Britain and, beyond Europe, Canada, and
Australia, suggesting the influence of the common culture of the
English-speaking Western world. Yet the US has, and probably
always has had, higher rates of fertility, marriage, and divorce than
most Western European nations. The proportion of single-parent
families is unusually high, even though some nations such as Sweden
and East German have higher proportions of births to the unmarried
and cohabitating women. The level of cohabitation in the US,
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King David
although greatly increased, is still moderate by European standards.
Concern over the burden of government support for the elderly
already has prompted changes in the Social Security program. The
ability to support programs for children and for poor families is being
questioned, even though the level of government support for the
family is relatively low by Western standards (4).
From the dawn of history, the family system has been
continuously changing. In contemporary times, with the
advancements in society and the improvement of the life of many
people, health care is continuously improving, more newborn and
young children are surviving, and human life span is on the increase.
More and more people are reaching the age of eighty, ninety, or even
100 years or more. Humans are living longer due to better
sanitation, better housing, and advanced medical treatment. The
improved life style and the ongoing development of health care have
affected the composition and the behavior of the family. More
grandparents remain in the family system, and it is not uncommon
for a family to go through its life cycle with 3 and even four
generations.
In spite of the changes that have occurred in contemporary
society, the function of the family as a system, its pattern of
interaction, the relationships within it, the creation of subsystems
within the family, and the psychosocial problems experienced by
family members have changed little through the ages. Both highly
functioning and dysfunctional families, which have existed since the
dawn of human history, will continue to be part of each society. It is
important to study both ancient families and contemporary families
in order to handle many of the problems found in dysfunctional
families.
This research deals with one family, from the high socioeconomic
stratum that lived more than three thousand years ago and was
influenced by the social norms of ancient society. The behavior of
these ancient characters resembles the behavior of people who live
in contemporary times. Many ancient life cycle events within and
outside the family system were traumatic in nature. The stresses
whether minor or major were expected or unexpected events which
led the King's family to subsequent crises. We can find examples of
love and hatred, honest and disgusting behaviors, mutual respect and
betrayal, and various psychosocial problems among these family
members. The characters described were human beings with
9
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behaviors that can be observed in our society as well. Both ancient
and contemporary families go through the same life cycle, with
similar behavioral pattern among their members.
In 1974, Minuchin described the family developmental cycle as a
key component of any schema based on viewing the family as a
system (5). The family of King David the Great represents a system,
and in this paper the relationships within its internal subsystems and
with the external world are evaluated to assess how the system
affected the development of each family member. The disturbing
events that affected this family are investigated within the context of
a system having its own rules, above all obedience to the King, its
own patterns of interaction and varying abilities to handle problems
that arose. The family was confronted with a range of stressful events
and subsequent crises. Although the events described occurred
thousands of years ago, they are like a mirror reflecting the dynamics
of the contemporary family system.
In order to handle various problems found in contemporary
dysfunctional families, health care providers should understand and
recognize different problems, stressful life events and the
subsequent crises occurring in ancient families. The pattern of
interactions, the struggle for leadership, extramarital sexual relations,
sexual abuse, the structure and function of the polygamous family,
mutual affection and friendship and extreme hatred are the
dimensions that characterize this ancient family. All these behaviors
occur equally in contemporary families. The topic is fascinating, and
gives us the tools for better management of contemporary families.
The research is composed of two parts: the first studies the family
system of King David, the roots of his family, the development of this
system and its subsystems, the structure and its expansion, the
dynamics of the family, and the relationships between family
members and the external world. The second part examines the
medical record of the King that is the biblical text, evaluating the
most likely diagnoses of the diseases that afflicted the King from the
viewpoint of contemporary medicine.
References
1. Neugarten B. Adaptation and the Life Cycle. The Counseling Psychologist.
1976;6:1.
2. Ramsey CN, Lewis JM. Family structure and functioning. In: Robert E. Rakel
(ed). Textbook of Family Practice. W. B. Saunders. Philadelphia, London. Third ed.
1984, pp. 21-40.
3. McDaniel SH, Campbell TL, Seaburn DB. Basic premises of family-oriented
10
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primary care. Family systems concepts. In: McDaniel SH, Campbell TL, Seaburn DB
(eds). Springer-V, New York, Berlin. 1990, pp. 3-15, 33-39.
4. Cherlin A, Furstenberg Ff Jr. The changing European family: lessons for the
American reader. J Fam Issues. 1988;9:291-7.
5. Minuchin S. Families and Family Therapy. Cambridge: Harvard University Press.
1974.
SUMMARY
David was the second and greatest of Israel’s Kings, a true warrior
as well as a husband and father. King David's father was Jesse, who
was the son of Obed, the son of Ruth and Boaz. It follows, that King
David was a descendant of Ruth and Boaz' family.
David was born in Bet-lehem-judah, grew up in a family of eight
sons, and was the youngest son of Jesse. As a youth, David was
ruddy, good-looking, and strong. Jesse's three eldest sons were
soldiers in King Saul's army. David joined Saul's army, killed Goliath, a
terrifying giant from the area of Gat, and subsequently defeated the
Philistines. After this battle, King Saul began to hate David. The roots
of this hatred were associated with the fact that the people believed
that "..Saul hath slain his thousands, and David his ten thousands
(Philistines)".
King Saul decided to give his elder daughter Merab in marriage to
David. However, Merab was given to Adriel the Meholathite.
Meanwhile, the younger daughter Michal fell in love with David.
Subsequently, “..Saul gave him Michal his daughter to wife”. With
this marriage a new family was born.
David fought the Philistines and defeated them in another battle.
This victory had a negative impact on the King's mental state. King
Saul pursued David throughout his life in order to kill him. In the end,
David had an opportunity to kill Saul, but he did not do it. Therefore,
King Saul appointed David to succeed him as King.
Subsequently, David met a beautiful woman, Abigail whose
husband, Nabal, was a very wicked and sinful man. When Nabal died,
David took Abigail to be his wife. Later: “David also took Ahinoam of
Jezreel...”. Now David had three wives, but the family size was
reduced when King Saul took Michal and gave her to Phalti.
After Saul’s death, David and his two wives dwelt in Hebron.
David’s family entered a new phase of its life cycle when David was
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anointed as King over Judah and subsequently over Israel. At this
time David became King, and his family started a new cycle of life.
The King also had ten concubines, locked in his house in
Jerusalem, until they died. The concubines lived in an isolated
environment, depending entirely on the King. It was the King, the
ruler, the decision-making authority, who was responsible for their
fate. There was no right of dispute, disagreement or contradiction to
the King’s decision or other arrangements for these women.
Throughout his life, David was involved in endless wars against the
Philistines. He was a real warrior and fought bravely with the enemy.
He won many wars, and many Philistines were taken prisoners. He
also conquered Moab, Hadadezer, the son of Rehob, the King of
Zobah, and the Syrians of Damascus. King David’s family was
consolidated and the sons helped their father to rule the country.
David’s polygamous family, consisting of many wives and children,
changed constantly. Feelings of tension, admiration, love and hatred
characterized the internal family system. A special friendship
developed between David and Jonathan, the son of King Saul. When
Saul and his three sons, among them Jonathan, were killed, King
David found Mefivoshet, Jonathan’s son, and treated him as his own
son.
David behaved disgracefully in his sexual relations with Bathsheba
that led to her pregnancy. In order to hide his reckless action, King
David prepared a plan to destroy Uriah, Bathsheba's husband. Uriah,
a brave soldier, was sent to a fierce battle where he was killed. Uriah
was assassinated in order to hide the King’s disgraceful behavior.
When Bathsheba heard that Uriah was dead, she mourned for her
husband. In this story, we also see Bathsheba's infidelity. King David
and Bathsheba behaved immorally and both were at risk of
contracting some sexually transmitted disease.
When the days of mourning were over King David married
beautiful Bathsheba. David’s family again expanded. Two additional
members entered David’s family life cycle: Bathsheba and a newborn
son. Unfortunately, the newborn son was afflicted by an incurable
disease. The King was severely distressed; he did not sleep and did
not eat. On the seventh day, his newborn son died. After hearing
this sad news, the King washed, changed his clothes, and ate. The
King believed that if his son died, he the great King could not change
the rules of this world, he could not bring his child to life, so he had
lost his child forever.
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In other story, right at the beginning, it is written that Amnon,
King David’s son, became “..so lean, from day to day” An extensive
evaluation of the medical situation that caused Amnon to be lean
showed that there are insufficient data for a diagnosis of anorexia
nervosa. It most likely that Amnon suffered from a partial eating
disorder syndrome.
Later, Amnon sexually abused his sister Tamar. Tamar suffered
from PTSD, and/or low self-esteem, and/or anxiety, fear, depression
and anger. Because of Amnon’s disgusting behavior, hatred
developed between two brothers - Amnon and Absalom, and the
family atmosphere was poisoned. No compromise could be found in
the triangle: Amnon - Absalom - Tamar.
Absalom, Amnon’s brother, did not forgive his brother for this sin.
At the first opportunity, Absalom commanded his men to kill Amnon
and the mission was performed. The King mourned for his son
Amnon.
Absalom rebelled against his father, King David. By this behavior,
Absalom showed his extreme hatred towards his father. Fighting
broke out between the camps of Absalom and King David, and
Absalom was killed. Absalom death affected the King profoundly and
he mourned for his son.
There was a famine in the days of David. King Saul was blamed for
this famine because he killed the Gibeonites, so King David asked the
Gibeonites to end this famine. The Gibeonites demanded that the
King hand over seven men to be hanged as vengeance for their killed
people.
The King’s decision fell on two sons of Saul’s concubine
Rizpah, Armoni and Mephibosheth, and five sons of Saul’s daughter
Michal, the wife of Adriel, and son of Barzillai the Meholathite. These
seven men were taken to the Gibeonites, and were hanged.
The famine following King Saul’s murder of the Gibeonites was the
source of stress. The famine had a negative impact on the people,
making their physical and psychological demands on them. The
mediators included physical, psychological, and social resources used
by King David to end the famine. In order to resolve this stress, seven
members of King Saul’s family had to be sacrificed. David respected
King Saul all his life in spite of Saul’s wish to destroy him. Now was
the decisive moment, the moment for revenge. His vengeance
overtook the dead King Saul even in the grave. The act of revenge
encompasses physical, psychological and social aspects of human
existence.
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Hatred once again developed between two of the King’s sons,
Adonijah and Solomon, since King David anointed Solomon to
succeed him as King.
In the end, King David was an old, sick man suffering from
multiple diseases and affected by various psychosocial problems.
King David died in old age, and was buried in the city of David.
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ROOTS OF DAVID'S FAMILY
OBED - THE GRANDFATHER OF KING DAVID
The biblical events occurred in Beth-lehem and in Moab, 10001200 B.C. A family consisting of Elimelech, his wife Naomi, and their
sons, Mahlon and Chilion, left Beth-lehem-judah because of the
famine, and settled in Moab. Eventually, Elimelech died and
sometime later, his two sons married Orpah and Ruth.
Unfortunately, both couples were infertile and the two sons died, so
Naomi decided to leave Moab and return to Beth-lehem-judah.
Orpah left Naomi, but Ruth stayed with her. In Beth-lehem-judah,
Ruth met Boaz who took her to be his wife. As a result of this
marriage, a son, Obed was born, bringing happiness to Naomi. Obed
was the father of Jesse, and Jesse was the father of King David. Thus,
Obed was the grandfather of King David. In other words, King David
was a descendant of Ruth and Boaz’s family.
JESSE'S FAMILY
David, the second and greatest of Israel’s Kings, the youngest son
of Jesse, was born in Bet-lehem-judah. He grew up in a family of
eight sons. As a youth, David was ruddy and good-looking (I Samuel
17:42). He “...tended his father’s sheep at Bet-lehem” (17:15). He
was strong, he “...slew both the lion and the bear...” (17:36),
Three eldest sons of Jesse's were soldiers in King Saul's army "And
the three eldest sons of Jesse went and followed Saul to the battle:
and the names of his three sons were Eliab the firstborn, and the next
unto him Abinadab, and the third Shammah" (17:13).
King David. Berlini.
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BATTLE WITH GOLIATH
David the youth was sent to bring food from his father's house to
his older brothers at the Israelite camp. The Philistine giant,
meanwhile, was daring the Israelites to send out their best fighter.
After 40 days and no response, it was David who took up the
challenge. A devout believer in the power of God and an enthusiastic
patriot, David was also a cunning and pragmatic fellow. He knew of
King's Saul's promise that who conquered Goliath could take the
King's daughter as a wife and would be granted wealth for himself
and his family. He refused the King's proposal to don armor of heavy
metal, preferring to remain in his shepherd's garment, armed with a
mere stick, sling, and smooth stones – weapons with which he was
familiar (1).
During the battle with Goliath ".. David hastened, and ran toward
the army to meet Philistine. And David put his hand in his bag, and
took thence a stone, and slung it, and smote the Philistine in his
forehead, that the stone sunk into his forehead; and he fell upon his
face to the earth" (I Samuel 17:48,49).
Goliath, a terrifying giant from the area of Gat, was slow-moving
and ponderous (1,2-4). It is most likely that Goliath was suffering
from acromegaly. The slowness of Goliath had been attributed to
three phenomena. The first is the heavy weight. In addition to his
vast physical size, Goliath was dressed in a heavy metal suit of armor:
"And he had a helmet of brass upon his head and he was armed with
a coat of mail; and the weight of the coat was five thousand shekels,
it was of brass. And he had graves of brass upon his legs, and a target
of brass between his shoulders. And the staff of his spear was like a
weaver's beam; and his spear's head weighed six hundred shekels of
iron." (17:5-7). The second explanation is that arthropathy and
myopathy frequently appear in the late stages of acromegaly (1,5).
According to Birginer, there is no indication to suspect such
complications. The third theory claims a visual disorder. Goliath was
not blind; he saw and taunted the young boy who confronted him.
David carried a stick, yet Goliath saw "several sticks", which may be
one of the indications of his impaired vision. Thus, Goliath suffered
from visual field restriction. Bitemporal hemianopsia occurred in
large pituitary microadenoma because of optic chiasm compression
in the suprasellar region (1).
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David and Goliath. Peters Paul Rubens. 1577.
Goliath did not pass away after the stone hit his forehead.
"Therefore David ran, and stood upon the Philistine, and took his
sword, and drew it out of the sheath thereof, and slew him, and cut
off his head" (17:51). After the battle with the horrifying Goliath
"David took the head of the Philistine, and brought it to Jerusalem"
(17:54).
This was a thrilling battle, in which a cunning adolescent defeated
a frightening, clumsy giant from Gat. This victory showed that the
young David was very smart and skilful.
References
1. Berginer VM. Neurological aspects of the David-Goliath battle: restriction in
the giant's visual field. IMAJ.2000;2:725-7.
2. Prohets, Nevi'im, Samuel I,17. In: The Jewish Bible, Tanakh, a new translation
of the Holy Scriptures into English. Jerusalem: Jewish Publication Society; 1985, pp.
443-7.
3. Samuel I, 17. In: Prophets, Nevi'im (with translation into Russian), Jerusalem:
Mossad Harav Kook. 1978, 93-6.
4. The works of Flavius Josehus and the life of Josehus (written by himself and
accurately translated from the original Greek). Philadelphia: Lippincott, Crambo and
Co., 1854, vol 1, Chapter 9, pp. 106-8.
5. Lamberts SWJ. Acromegaly. In: Grossman A (ed). Clinical Endocrinology.
Oxford Blackwell Scientific Publications, 1992, pp. 154-68.
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DAVID AND KING SAUL'S FAMILY
DAVID AND KING SAUL
King Saul participated in endless wars. Later, in his life signs of
mental distress appeared " ..an evil spirit from the Lord troubled him"
(I Samuel 16:14). Consequently, Saul's servants summoned David to
play his harp, and "he (the King) loved him greatly; and he became
armourbear: (16:21). On hearing the music, the symptoms of Saul's
mental distress disappeared "David took harp, and played with his
hand: so Saul was refreshed, and was well, and the evil spirit
departed from him" (16:23).
When David killed Goliath, a terrifying giant from the area of Gat,
and subsequently defeated the Philistines, King Saul began to hate
David. The roots of this hatred were associated with the fact that the
people believed that "..Saul hath slain his thousands, and David his
ten thousands (Philistines)" (18:7).
David fought the Philistines and defeated them in another battle.
This victory had a negative impact on the King's mental state "And
the evil spirit from the Lord was upon Saul.. And Saul sought to smite
David even to the wall with his javelin…; but he slipped away out of
Saul's presence, and he smote the javelin into the wall: and David
fled, and escaped that night" (19:9,1). King Saul pursued David
throughout his life in order to kill him. In the end, David had an
opportunity to kill Saul, but he did not do it. Therefore, King Saul
appointed David to succeed him as King.
David and King Saul. Rembrandt Van Rijn.
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King David
DAVID AND JONATHAN
Later, David developed a friendship with Jonathan, King Saul’s son
“..the soul of Jonathan was knit with Jonathan, and Jonathan loved
him as his own soul” (I Samuel 18:1). So, “ ...Then Jonathan and
David made a covenant, because he loved him as his own soul” (18:3).
As a sign of their friendship “...Jonathan stripped himself of the robe
that was upon him, and gave it to David, and his garments, even his
sword, and his bow, and his girdle” (18:4).
David and Jonathan remained friends all their lives. It was a true
partnership and alliance between friends. They loved each other,
without limitation. As an expression of this love, Jonathan gave
David his garments, his sword, and even his girdle. Subsequently,
when King Saul began to hate David, Jonathan did not abandon their
friendship.
Even after Jonathan's death, their friendship continued; David,
already the King found Jonathan's son, Mefivoshet, and cared for this
child as his own. This is an example of genuine friendship, which has
lasted forever. In this situation, we see the respectful and noble
characteristics of David, who was a reliable partner, paying Jonathan
back for his special unconditional love.
David and Jonathan. Rembrandt Van Rijn.
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King David
DAVID'S FAMILY
DAVID, MERAB, AND MICHAL
King Saul decided to give his elder daughter Merab in marriage to
David. However, when “...Merab Saul’s daughter should have been
given to David,....she was given to Adriel the Meholathite to wife” (I
Samuel 18:19). Meanwhile, the younger daughter Michal fell in love
with David. Subsequently, “..Saul gave him Michal his daughter to
wife” (18:27). The personality of King Saul was unstable; he changed
his mind easily, as we see when one daughter was taken from David
and given to another man. Why was Merab given to Adriel the
Meholathite? What was behind this decision? Was Merab in love
with David? Was Merab in love with Adriel the Meholathite?
These passages do not indicate that David was in love with Merab
or with Michal. We learn that only Michal loved David. The decision
as to whom the daughters would marry was entirely in the hands of
their father, King Saul. The daughters did not express any objection
to their father's decision. It was taken for granted that only the
powerful King was responsible for the marriage and the future of his
daughters.
The family life cycle is the normal process of family development
beginning with marriage, pregnancy, launching of children,
retirement and ending with death in which specific development
tasks must be accomplished (1).
Becoming a couple is one of the most complex and difficult
transitions of the family life cycle. The positive and romanticized
view of this transition may add to its difficulty, since everyone from
the couple to the family and friends wants to see only the happiness
of the shift (2).
With David's marriage, a new family was born. The family began
its own life cycle; as a married man, David was responsible for the
well-being of his family.
References
1. McDaniel S, Campbell TL, Seaburn DB. Family systems concepts. In: McDaniel
S, Campbell TL, Seaburn DB (eds). Family-Oriented Primary Care. A Manual for
Medical providers. Springer-Verlag. New York, Berlin. 1990, pp.33-39.
2. McGoldrick M. The joining of families through marriage: the new couple. In:
Carter EA, Godrick M (eds). The Family Life Cycle: A Framework for Family Therapy
Gardner Press, New York. 1980, pp. 93-119.
20
L. Ben-Nun
King David
A NEW FAMILY
Subsequently, David met Abigail, “..a woman of good
understanding, and of beautiful countenance..” (I Samuel 25:3).
However, her husband “...Nabal was hardhearted and evil in his
doing” (25:3). When Nabal died, David took Abigail to be his wife.
Later: “David also took Ahinoam of Jezreel...” (25:43). Now David had
three wives, but the family size was reduced when Michal was taken
from David “Saul had given Michal his daughter, David’s wife, to
Phalti the son of Laish...” (25:44).
King Saul's decision indicates an unstable and light-hearted
personality. A married woman, in this case his own daughter, was
taken from one man and given to another. Why did the King take
such an extraordinary step? What was the purpose behind this
decision? Did Phalti ask for his daughter's hand? Was Laish involved
in this decision? There was no compromise, and the new couple
were not asked for their consent. As in Merab's case, the same thing
happened to Michal. This was acceptable behavior in ancient times.
Family refers to any subdivision of this kind of social unit, which
itself possesses the same attributes of affection, loyalty and
durability of membership. So a married couple without children, a
couple with several young children, three-generation units, with a
single parent and several children, and units evolved by remarriage
from parts of previously existing units, all are families (1).
David's family changed its composition, and now was composed
of two units - the husband, David, and his wives - Abigail, and
Ahinoam. After Saul’s death, David and his two wives dwelt in
Hebron.
Reference
1. Terkelsen KG. Toward a theory of the family life cycle. In: Carter EA, Goldrick
M (eds). The Family Life Cycle: A Framework for Family Therapy, Gardner Press, New
York. 1980, pp, 21-52.
21
L. Ben-Nun
King David
KING OF JUDAH
After dwelling in Hebron “...the men of Judah came, and there
they anointed David king over the house of Judah” (II Samuel 2:4). At
this time, David became the King, and his family entered a new phase
of its life. Now, David was the honored ruler over Judah. His social
position changed, from a simple man he became the new leader.
Undoubtedly, his social position had an effect on the dynamics of his
family system. Everybody had be obedient to the King, whether they
were within his family or outside the family system.
In Hebron, The King took four additional women to be his wives,
so his family once again expanded and included seven members: the
husband - the King and his six wives - Ahinoam, Abigail, Maacah,
Haggith, Abital, and Ithream. (3:2-5).
POLYGAMOUS FAMILY
In Hebron, six sons were born to King David: “And his firstborn
was Amnon of Ahinoam the Jezreelitess; And his second Chileab, of
Abigail..., and the third, Absalom the son of Maacah the daughter of
Talmai king of Geshur; And the fourth Adonijah the son of Haggith,
and the fifth, Shephatiah, the son of Abital, and the sixth, Ithream, by
Eglah David’s wife” (3:2-5). Now the King’s family consisted of a
husband, six wives and six sons.
Polygamy has been defined as "a marital relationship involving
multiple wives". There are three types: 1) polygyny occurs when one
husband is married to two or more wives and is referred as
polygamy; 2) polyandry occurs when one wife is married to two or
more husbands; and 3) polygynandry is a group marriage scenario in
which two or more wives are simultaneously married to two or more
husbands (1). King David's family can be defined as a polygamous
family consisting of 13 members: King David, the husband, his six
wives, and their six children.
Polygamous marriages engender multiple problems, for instance,
jealousy in all its forms with consequences of an explosive
confrontation, loss of self-esteem, and depression (2,3). At this time,
the Bible gives no further details about relationships, between the
wives, and children within David's extended family system. We can
surmise that the relationships in his family were typical of those
observed in any polygamous family.
22
L. Ben-Nun
King David
Holmes and Rahe (4) developed their life-event scale by asking a
random sample of the population to rank how stressful they
perceived each of 43 life events to be. Many of the events on the
Holmes and Rahe scale occur within the family, and 10 of the 15 most
stressful events are family events. Several of the most stressful life
events on this scale represent major transitions in the family life
cycle. These normative life events have powerful influences on
physical and mental health that can result in symptoms that bring the
individual to the physician's office.
On the Holmes and Rahe scale (4), marriage is given a mean value
of 50, while the birth of child is given a mean of 39. Thus, King David
certainly was in a stressful situation when he married, and
subsequently on the birth of each child.
Membership in a particular family unit once conferred through
birth, adoption, or marriage, is virtually permanent, ending only in
death. Some other types of organization grant permanent
membership, but in most organizations, membership rules dictate
routine means of termination. Two basic forms of termination can be
recognized: diminished value of individual to organization, and
diminished value of organization to individual. Regarding the first,
organizations oriented to a task value instrumental capabilities.
Members are regularly expelled either because of decreased ability
to function for the organization, or because of a change in the
instrumental priorities of the organization. As for the second, the
needs of every person change and evolve over time. Individuals
regularly drop their membership in an organization when the
organization ceases to address present needs (5).
By contrast, family membership is not subject to expiration. In the
life of the family, there is nothing like being fired or laid off. Family
members do not quit or drop their membership. In clinical practice,
one often sees families in which a member is permanently cut off
from the rest of the family, and there is an occasional family that
disowned or banished a member, or in which someone has
disappeared. However, these are extreme actions indicating serious
trouble. Disregarding the extremes, there is no routine form of
termination of family membership other than death. Like all other
organizations, families place a high value on competence in
instrumental role performance. Nevertheless, unlike all others, the
family places a still higher value on attachment, caring, and personal
loyalty (5).
23
L. Ben-Nun
King David
King David's extended family included all parameters that are
described above, with family members entering the family system
through marriage or birth and ending their membership with death.
The family included six subsystems: the husband, the King, with each
wife and her child, all of them having a definite role in this system.
The King expelled no family member from the system. All judgment,
strength of will and decision making was concentrated in his hands.
This was the usual and accepted social norm of behavior in this
society. All family members were obedient to only one person, the
head of the family, King David. In order to survive, each family
member had to obey and respect the rules of this family system. This
was the way of life and survival. The internal family system operated
according to these rules. These rules were imposed on the
surrounding external environment as well. A mutual relationship
between the internal family system and the external environment
was established.
References
1. Al-Krenavi A, Graham JR, Slonim-Nevo V. Mental health aspects of Arab-Israeli
adolescents from polygamous versus monogamous families. J Soc Psychology.
2002;142:446-60.
2.. Achte K & Schakit T. Jealousy in various cultures in the light of trancultural
psychiatry. Psychiatria Fennica. 1980;11:33-4.
3. Camara S. Femmes africaines polygamie et authorite masculines.
Ethnopsychologie. 1987;33:43-53.
4. Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J Psychosom Res.
1967;11:213.
5. Terkelsen KG. Toward a theory of the family life cycle. In: Carter EA, Goldrick
M (eds.). The Family Life Cycle: A Framework for Family Therapy. Gardner Press, New
York. 1980, pp, 21-52.
KING OF ISRAEL
Subsequently, all the tribes of Israel came to David, to Hebron.
“...and they (the elders) anointed David king over Israel. David was
thirty years old when he began to reign and he reigned forty years. In
Hebron he reined over Judah seven years and six months; and in
Jerusalem he reigned thirty and three years over all Israel and Judah”
(II Samuel 5:3-5). As we see, David’s role expanded, and each time
his family entered a new phase in their life cycle.
24
L. Ben-Nun
King David
AFFAIR OF BATSHEBA
From the roof of his house, King David saw a beautiful woman,
Bathsheba, the wife of Uriah the Hittite, as she was taking a bath.
Therefore, the King sent messengers, took the woman, and had
sexual relations with her. As a result, Bathsheba conceived. In order
to hide this disgraceful affair, King David orchestrated a plan for
Uriah to lie with his wife and in this way, it would appear that
Bathsheba conceived by her husband.
Therefore, the King
summoned Uriah and sent him home, but Uriah did not go to his
house. Therefore, the King summoned Uriah for the second time. At
this time, Uriah “...did eat and drink before him (King David); and he
made him drunk...” (II Samuel 11:13). However, again Uriah did not
go home and did not sleep with his wife. This time, the King sent
Uriah to the front in a fierce battle, where he was killed. When
Bathsheba heard that Uriah was dead, she mourned for her husband.
Bathsheba with King David's letter. Rembrandt van Rijn.
For King David there were no limits to the deceit he practiced on
his own people to achieve his goal. In order to keep his good name
and reputation, the King tried to send Uriah home so he would sleep
with his wife. However, these efforts failed, so another disgraceful
act was planned to destroy Uriah. Uriah was assassinated in order to
hide the King’s disgraceful behavior.
A fundamental condition of survival was to develop skills of
adaptation to these rigid rules. When family members conflicted
with these rules, their fate was decided, as happened in the case of
Uriah. Decisions of life and death lay in the powerful King’s hands. In
25
L. Ben-Nun
King David
David’s internal family, there was neither autonomy nor partnership
in the decision making process. Independence was not given to any
family member. Family members’ survival depended on obedience
to the King.
In this story, we also see Bathsheba's infidelity. Was she obliged
to surrender to the King’s will? Or did she fall in love with the King?
David hands the letter to Uriah.
Pieter Lastman. 1583-1633.
UNPROTECTED SEXUAL CONTACTS
Although King David and Bathsheba both were married, they had
unprotected extramarital sexual relations. Is there any danger of such
sexual intercourse? This section evaluates sexual behavior in
different populations and examines whether there are any risks with
unprotected sexual contacts.
INTRODUCTION
The practice of prostitution has existed since the dawn of history.
If preventive measures are not taken, this practice is dangerous since
it is associated with the transmission of various sexual transmitted
diseases (STDs). STDs have existed throughout human history, with
the epidemiology of STDs changing from generation to generation.
Some STDs have disappeared, others have reappeared, and some
new diseases have developed over time. For example, the first cases
of acquired immunodeficiency syndrome (AIDS) were identified in
1978, and its diverse signs and symptoms led to its classification as a
26
L. Ben-Nun
King David
syndrome in 1980 (1). Later, the human immunodeficiency virus (HIV)
was discovered in Chennai in 1986 (2).
King David and Bathsheba behaved immorally and both were at
risk for contracting some STD. From contemporary perspective, STDs
are caused by numerous agents which include Neisseria (N.)
gonorrhea, Chlamydia (C.) trachomatis, Mycoplasma genitalium, a
new etiologic agent that causes genital infection such as nongonococcal urethritis (3-5), anaerobic bacteria including Peptococcus,
Peptostreptococcus species, Prevotella bivia, and other Prevotella
species (6), facultative aerobes such as Escherichia Coli, group B
streptococcus, or Garnerella vaginalis, Trichomonas vaginalis (7),
Chandroid (Haemophilus Ducrei) (8,9), Haemophilus influenzae (10),
genital herpes (4), human papillomavirus infection (11-13), syphilis
(4,13), hepatitis A, hepatitis B, hepatitis C and hepatitis delta viruses
(8,10-19), molluscum contagiosum virus (8) and HIV infection (20-22).
In addition, C. trachomatis, N gonorrhea (23,24), and herpes simples
virus types 1 and 2 (25,26) are risk factors for subsequent or
concurrent HIV infection.
Approximately 10% of women will develop pelvic inflammatory
disease (PID) due to STDs during their reproductive years, and a
significant number will suffer complications from the infections (5).
PID presents a spectrum of inflammatory disorders within the upper
genital tract of women including any combination of endometritis,
salpingitis, pelvic peritonitis, and tubo-ovarian abscess (27).
One out four women with PID experiences serious sequelae,
including tubal scarring, infertility, and ectopic pregnancy (28), or
chronic pelvic pain (29). In addition, genital papillomavirus infection
is associated with cervical dysplasia and may act as a cofactor in the
development of cervical cancer (30,31).
The STDs and HIV epidemics are interdependent. Some behaviors,
such as frequent unprotected intercourse with different partners,
place people at high risk of both infections, and there is clear
evidence that conventional STDs increase the likelihood of HIV
transmission. There is biological evidence, too, that the presence of
an STD increases shedding of HIV, and that STD treatment reduces
HIV shedding. Therefore, control of the sexually transmitted infection
(STI) has the potential to contribute substantially to HIV prevention
(32).
Among 2982 individuals socializing at venues in 7 Madagascar
towns, 78% of men and 74% of women reported new sexual
27
L. Ben-Nun
King David
partnership or sex-trade for money, goods or services in the past 4
weeks and 19% of men and 18% of women reported symptoms
suggestive STI in the past 4 weeks. STI symptom levels were
disproportionately high among responders reporting either sex trade
or new sexual partnership in the past 4 weeks; 24% of men and 41%
of women reported condom use during the last sex act with a new
partner (33).
STDs have accompanied humans since the long human history.
Unfortunately, these diseases have not disappeared and still are
prevalent worldwide. Forming new sexual partnerships is a prevalent
human behavior, and these partners are at risk for contracting some
STD.
This was an observational study of street-based sex workers
attending an inner-London genitourinary clinic between 2006 and
2007. The outreach team made contact with 120 street-based sex
workers in the borough, London. There were frequent reports of
recent recreational drug use, unprotected sex with clients and
unreliable contraception; 7 were pregnant, 6 were HIV positive and
12 had positive syphilis serology. A further 17 STDs were identified.
There were high frequency of HIV, syphilis, other bacterial STDs, and
unwanted pregnancies among sex workers attending this clinic (34).
This study indicates that street-based sex workers are at risk for
contracting some STI.
AIDS is one of the most important diseases of our century that is
transmitted through sexual contacts. In order to deal more efficiently
with this disease we should understand its epidemiology,
characteristics, and the sexual behavior of a variety of populations.
In 2004, 71.755 new diagnoses of HIV were reported in the (WHO)
European region, which includes all European Union countries. The
number of newly diagnosed cases was lower than the peak observed
in 2001 (113.930), but was nearly twice the number in 1999 (39.602).
For different countries, reported rates reached more than 200 new
HIV diagnoses per million population in 2004; in Estonia (568),
Portugal (280), and in the Russian Federation (212) (35).
Although the number of newly diagnosed cases in 2004 was lower
than in 2001, the rates of these infections are still high in European
countries.
In El Salvador, Guatemala, Honduras, Nicaragua, and Panama,
2466 female sex workers (FSWs) were evaluated. For FSWs, HIV
seroprevalence ranged from 0.2% in Nicaragua and Panama and 9.6%
28
L. Ben-Nun
King David
in Honduras, where estimated HIV seroincidence was also the highest
(3.2 per 100 person-years); 77% and 72% of FSWs reported using
condoms consistently with new and regular clients, respectively. The
prevalences of STDs reached: 85.3% for herpes simplex virus (HSV)-2,
9.6% for syphilis, 20.1% for C. trachomatis, 8.1% for N. gonorrhea,
11.0% for Trichomonas vaginalis, and 54.8% for bacterial vaginosis.
HSV-2 infection was associated with HIV infection (36).
Contemporary women like ancient women are at risk of infection
by various STDS.
African American women have high rates of most STIs, including
HIV. Black women (n=228) who used drugs completed a structured
questionnaire in a central Brooklyn, NY-based research center
between 2003 and 2005. Thirty-eight (17%) women were HIV
seropositive; the prevalences of STIs included HSV-2 (79%),
trichomoniasis (37%), chlamydia (11%), and gonorrhea (2%). HIVinfected women in comparison with uninfected women were
significantly more likely to have multiple positive screens and twice
more likely to report current sex work. Several STIs, including HIV,
seem to be endemic among black women who used drugs. Multiply
STIs infected individuals may unknowingly, but efficiently, contribute
to high STIs and HIV rates (37).
Women who work in sex work are at risk to be infected with STDs,
including HIV. Infected individuals may contribute unknowingly to the
high prevalence of STDs.
In Israel, despite the low sexual behavior of Israeli HIV patients,
they had a high prevalence of chronic STDs (e.g., HSV-2, HBV and
syphilis). The lower prevalence of chlamydia and gonorrhea among
HIV-immunosuppressed patients may be attributed to routine
antibiotic prophylaxis against opportunistic infections. Nevertheless,
as advocated by international health organizations, it appears
prudent to recommend the routine screening of these asymptomatic
HIV-positive patients for other STDs (38).
Syphilis, a STD, has afflicted humans since the dawn of history.
Throughout the centuries, its incidences and prevalences increased
and decreased, with recurrent epidemics spreading through the
continents. Now, we witness a recurrent upheaval of this STD
worldwide: in US (39), UK (40), France (41), Denmark (42), Germany
(43), Belgium (44), Finland (45), Russia (46), and China (47).
During 2001-2004, 7083 cases of syphilis were diagnosed in Los
Angeles. Cases of confirmed or probable neurosyphilis (NS) (n=109)
29
L. Ben-Nun
King David
occurring among persons aged 19 to 65 years were identified during
this period (1.5%). Symptomatic NS was present in 1.2% of reported
syphilis cases (86 of 7083). NS cases were inclusive of 71 (65%) men
who have sex with men. Forty-two (49%) of the symptomatic NS
cases occurred during secondary (n=28) or early latent (n=14)
syphilis. Sixty-eight percent (n=74) of the NS cases were HIV positive.
The estimated incidence of symptomatic NS among HIV-infected
persons with early syphilis was 2.1% as compared with 0.6% among
HIV-negative persons (39).
Syphilis is a prevalent disease worldwide. NS, probably due to
undiagnosed and untreated syphilis, is also prevalent, afflicting young
as well as old individuals. In addition, patients who are infected by
syphilis can contract HIV as well.
It is beyond the scope of this study to present all studies on this
topic. The studies discussed here are the most pertinent to the topic
analyzed in this research. In different populations, there are
different sexual behavior patterns and different prevalences of STDs.
The young and the old individuals, transmit STDs including syphilis
and HIV, especially those young adolescents who have begun their
sexual relations before the age 18.
CONDOMS
The Italian anatomist Fallopius first promoted the prophylactic
value of condoms in the 16th century (48). With the vulcanization of
rubber in the 1840s, condom production became both practical and
widespread (49). The correct and consistent use of latex condoms is
highly effective in preventing STDs, including HIV (50). We see that in
biblical times AIDS did not exist, nor were condoms apparently
available. However, the threat of contracting a STD always remained
whenever unprotected sexual relations took place. Men are
regarded as the agents who transmit STDs, not wives, and not
prostitutes (51).
Is unprotected sex prevalent among adolescents? In the United
States, substantial morbidity and social problems among youth result
from unintended pregnancies and STDs, including HIV infection.
Results from the 2007 survey indicate that 47.8% of students had
ever sexual intercourse, 35% of high school students were currently
sexually active, and 38.5% of currently sexually active high school
students had not used a condom during last sexual intercourse (52).
30
L. Ben-Nun
King David
We see that about third of young adolescents were involved in
unprotected sex. This figure is alarming.
Participants included 9th-12th grade rural adolescents (n=5.745)
who completed the 2003 national Youth Risk Behavior Survey.
Smoking > or = 3 days during the past 30 days was associated with
unprotected sex. Alcohol or drug use before last sexual intercourse,
having ever used marijuana, having ever used cocaine and drinking
alcohol during the past 30 days were associated with having multiple
sexual partners (53).
Among adolescents, smoking is associated with unprotected sex,
while alcohol, drug, marijuana, and cocaine usage are risk factors for
having multiple partners. The medical record, that is the biblical text,
gives no details about any of these risky behaviors in the case of
either King David or Bathsheba.
A rapid influx of Latino migrant workers came to New Orleans
after Hurricane-Katrina. Many of these men were unaccompanied by
their primary sex partner potentially placing them at high-risk for
HIV/STDs. In the last month, 68.9% engaged in sex with high-risk sex
partners, 30.0% were in potential bridge, 50.0% used condoms
inconsistently, 30.6% did not use a condom the last time they had
sex, and 21.1% were abstinent. Latino migrant workers in New
Orleans reported risky sexual behaviors and low condom use within a
potential bridge position. Although a low prevalence of C.
trachomatis and N. gonorrhea was found, there was a high percent of
self-reported HIV infection (54).
We see that in this population about half used condoms
inconsistently. This segment of population was at risk to contract
some STD, including HIV.
TO SUM UP: the features of unprotected sex today are similar to
those in ancient times. King David and Bathsheba both behaved
immorally having unprotected sexual contacts. If preventive
measures are not taken, this practice is dangerous since it is
associated with the transmission of various STDs.
Did some STDs afflict these characters? Gonorrhea? Syphilis?
Trichomonas vaginalis? Other STD?
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epidemics among men who have sex with men (MSM): neurosyphilis in Los Angeles,
2001-2004. Sex Trans Dis. 2008;35:430-4.
40. Torjesen I. Disease: a warning from history. Health Serv L. 2008;17:22-4.
41. Couturier E, Michel A, Janier M, et al. Syphilis surveillance in France, 20002003.Euro Surveill. 2004;9:8-10.
42. Cowan S. Syphilis in Denmark-Outbreak among MSM in Copenhagen, 20032004. Euro Surveill. 2004;9:25-7.
43. Marcus U, Bremer V, Hamouda O. Syphilis surveillance and trends of the
syphilis epidemic in Germany since the mid-90s. Euro Surveill. 2004;9:11-4.
44. Sasse A, Defraye A, Ducoffre G. Recent syphilis trends in Belgium and
enhancement of STI surveillance systems. Euro Surveill. 2004;9:6-8.
45. Hiltunen-Back E, Haikala O, Kostela P, et al. Epidemics due to imported
syphilis in Finland. Sex Trans Dis. 2002;29:746-51.
46. Platt L, Rhodes T, Judd A, et al. Effects of sex work on the prevalence of
syphilis among injection drug users in 3 Russian cities. Am J Public Health.
2007;97:478-85.
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47.. Wong SP, Yin YP, Gao X, et al. Risk of syphilis in STI clinic patients: a crosssectional study of 11.5000 cases in Guangxi, China. Sex Transm Infect. 2007;83:3516.
48. Oakley D, Bogue E-L. Quality of condom use as reported by female clients of
a family planning clinic. Am J Public Health. 1995;85:1526-30.
49. Murphy JC. The Condom Industry in the United States. Jefferson, NC:
McFarland & Co; 1990.
50. Cates W, Stone KM. Family planning, sexually transmitted diseases and
contraceptive choice: a literature update: Part I. Fam Plann Perspect. 1992;24:75-84.
51. Jacobson JL. The other epidemic. World Watch. 1992;5:10-7.
52. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance – United
States, 2007. 2008;57:1-131.
53. Yan AF, Chiu YW, Stoesen CA, Wang MQ. STD-/HIV-related sexual risk
behaviors and substance use among U.S. rural adolescents. J Natl Med Assoc.
2007;99:1386-94.
54. Kissinger P, Liddon N, Schmidt N, et al. HIV/STI risk behaviors among Latin
migrant workers in New Orleans pos-Hurricane Katrina disaster. Sex Transm Dis.
2008;35:924-8.
THE SYSTEM THINKING THEORY
In the system thinking theory: 1) Families (and other social
groups) are systems having properties which are more than the sum
of the properties of their parts. 2) The operation of such systems is
governed by general rules. 3) Every system has a boundary, the
properties of which are important in understanding how the system
works. 4) The boundaries are semi-permeable; some things can pass
through them while others cannot. Moreover, certain materials can
pass one way but not the other. 5) Family systems tend to reach a
relatively, but not totally, steady state. Growth and evolution are
possible. Change can occur, or be stimulated, in various ways. 6)
Communication and feedback mechanisms between the parts of a
system are important in the functioning system. 7) Events such as
behavior of individuals in a family are examples of circular causality,
rather than a linear causality. 8) Family systems, like other open
systems, appear to have purpose. 9) Systems are made of
subsystems and themselves are parts of larger suprasystems (1).
The King's family was a special system that was governed by
special rules namely full obedience to the King. There were many
subsystems in this one family system, and the behavioral and
communication patterns of each subsystem were dependent on the
decisions of the head of the family, in this case the powerful King.
The subsystems functioned by mutual consent, and were
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interconnected with open boundaries. However, all decisions flowed
only one way with full acceptance of the King's wishes, will and
choice. The family system functioned within rigid borders, and this
function was dependent on the functioning of its different
subsystems.
Reference
1. Becket JA. General system theory, psychiatry and psychotherapy. Int J
Group Psychotherapy. 1973;23:292-305.
A NEW COMPOSITION OF THE KING'S FAMILY
In any case, when the days of mourning were over "When the
mourning was past, David sent and fetched her (Bathsheba) to his
house; and she became his wife, and bare him a son” (II Samuel
11:27). David’s family again expanded. Two additional members
entered David’s family life cycle – Bathsheba and the newborn son.
Holmes and Rahe developed a standard list of events, the
Schedule of Readjustment Rating Scale (1). Several hundred
responders rated the amount of adaptation or "life change units"
(LCUs) that each event was thought to entail. According to this Scale,
marriage has a mean LCU value of 50, ranked 7th out of various life
events while 'gain a new family member' has a mean value of 39.
Thus, marriages and subsequent births of children exposed the King
to stressful events.
Reference
1. Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J
Psychosom Res. 1967;11:213.
DEATH OF THE NEWBORN SON
Unfortunately, the newborn son was afflicted by incurable
disease. Hearing this news: "David fasted, and went in, and lay all
night upon the earth" (II Samuel 12:16). The King's pain was so severe
that when: "The elders of his house arose, and went to him, to raise
him from the earth: but he would not, neither did he eat bread with
them" (12:17). Later the newborn had died: "…On the seventh
day…the child died. When David saw that his servants whispered,
David perceived that the child was dead: therefore David said unto his
servants, Is the child dead? And they said, he is dead" (II Samuel
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12:19). After hearing that his son had died "David arose from the
earth, and washed, and anointed himself, and changed his apparel,
and came into the house of the Lord, and worshipped: then he came
to his own house; and when he required, they set bread before him,
and he did eat" (12:20). Here his servants were astonished: "You did
fast and weep for the child while he was alive; but when the child was
dead, you did rise and eat bread" (12:21). King David responded that
"While the child was yet alive, I fasted and wept: for I said, Who can
tell? God may be gracious to me, and the child may live? But now he
is dead, wherefore should I fast? Can I bring him back again? I shall
go to him, but he shall not return to me" (12:22,23).
When a family member dies, it is a very stressful event. However,
when a newborn child died this is a real tragedy. According to the
Holmes and Rahe's Schedule of Readjustment Rating Scale (1) death
of close family member has a mean LCU value of 63, being in the top
5 of various life events. Thus, the death of the King's newborn son
exposed all the family to a very negative, traumatic experience.
When his newborn son was seriously ill, King David believed that
he could help to overcome this serious life-threatening disease and
thus he stopped eating and lay on the earth, and he mourned.
However, when the child died, nothing could change this unfortunate
fate on the earth, and therefore the King resumed his usual life:
broke his fasting, washed himself, changed his clothes and went to
worship to the house of the Lord. We see how the King accepted the
seriousness of illness and its subsequent fatal outcome. He had a
powerful strength to cope with the very traumatic situation – the
death of his son.
The human being needs ties to grow and develop. When some of
these ties are broken, a period of great intensity arises that we call
mourning. If the loss is radical and definitive, as in the case of death,
all the person's dimensions are affected (the physical, emotional,
cognitive, behavioral, social and spiritual) to such an extent that the
person could feel unable to overcome this and/or develop a
pathological mourning that requires professional intervention for
recovery. Many factors intervene in the mourning, such as
circumstances of the death, relation to deceased, personality,
previous experience and the socio-economic context. In order to
recover following a loss, the person passes through a series of stages
and phases: 1. Accept the reality of loss. 2. Express emotions and
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King David
pain. 3. Adapt to a setting from which the loved one is absent. 4.
Emotionally resituate the deceased and continue living (2).
The biblical words "The elders of his house arose, and went to him,
to raise him from the earth: but he would not, neither did he eat
bread with them" indicate the physical, emotional, cognitive,
behavioral, social and spiritual dimensions of the sorrow that
afflicted the King when his newborn son suffered from a devastating
disease. However, David recovered immediately after his son's death
since he accepted the reality of this death, adapted instantly to his
loss, and returned quickly to everyday life.
Coping with grief following perinatal death is a natural process
that every individual experiences in his own personal and unique
way. Parents go thorough varying emotions in the same month
following the death of their baby; they benefit from individually
focused counseling and assistance in making their own choices with
regard to saying goodbye and the way in which they will cope with
their grief in the immediate future, as parents, within the family and
in relation to the people in their surroundings (3).
The quality of dying and death construct is multidimensional, with
7 broad domains: physical experience, psychological experience,
social experience, spiritual or existential experience, the nature of
health care, life closure and death preparation, and the
circumstances of death. The quality of dying and death is subjectively
determined with numerous factors that influence its judgment,
including culture, type and stage of disease, and social and
professional roles in the dying experience. Quality of dying and death
is broader in scope than either quality of life or quality of care both at
the end of life, although there is overlap among these constructs (4).
The death of the newborn baby was a very traumatic exposure to
a negative stress. In King David's case, multidimensional parameters
such as physical, psychological, and social experiences and the
circumstances of the death all played a role in the negative
experiences and the great suffering caused by the sickness and death
of the newborn son.
Parents are attached to their unborn children, and loss around.
Parental grief is a normal response, and may last for many months.
Aspects of psychological management are associated with the time of
birth and is a serious trauma (5). Depression, anxiety disorder, posttraumatic stress disorder and somatoform disorder all have been
linked to grief reactions in response to perinatal loss (6).
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King David
In his reactions to this tragedy, King David showed a strong
character, one that was able to overcome various psychological
aspects of the grieving process. Both David and Bathsheba went
through the mourning process of the loss of their newborn son.
The purpose of this study was to understand mothers'
experiences and perspectives concerning neonatal death. Four
themes evolved: (1) Puzzlement on the brink of neonatal death:
neonatal death, as an unpredicted event, constitutes a puzzle for
mothers; they tend to seek the cause of the mishap, and in turn, fall
into a dilemma about whether to try to save the newborn. (2) Chaos
in the wake of the loss of babies: mothers' experience of physical,
mental, and behavioral changes might stymie their original positive
attitude toward the role of being the husband and wife. (3)
Adjustments in the wake of the loss: when mothers try to adjust
themselves, common approaches, such as good will with pep talk and
emotional utterance/sharing, are not ready helpful. Certain factors
also play a part, either positively or negatively, in the mental
adjustment process; they include responsibility for the household,
intentional mood-diversion, prohibiting the mother from
participating in funerals for the babies. (4) Professional guidance:
mothers expect to receive professional guidance to help them to face
the fact of death, especially in the movement of separation;
providing memorabilia and personalized follow-ups for mothers are
beneficial. In conclusion, mothers experiencing neonatal death
should be encouraged to express their grief through appropriate
emotional channels, and receive professional follow-up to rebuild
physiologically, psychologically, and spiritually, rather that
suppressing their mourning (7).
All the parameters mentioned above can be seen in Bathsheba's
reactions to the event.
The subsequent verse indicates that
Bathsheba suffered more than her husband David did: “And David
comforted Bathsheba his wife, and went in to her, and lay with her:
and she bore a son and he called his name Solomon....” (12:24). The
King calmed, reassured, and comforted her. This verse also shows
that David’s family adjusted and adapted to the death, and regained
its homeostasis.
Generally, accepted major life events include bereavement,
divorce, and job loss (8). The death of a child can be regarded and a
very stressful negative life event. The major characteristics of any
family, over its life cycle, are the changes it experiences (9,10).
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We see that the structure of David’s family changes continuously,
with new family members entering and others leaving this family
system. Positive (birth of Solomon) and negative events (death of
newborn son) are some of the changing experiences to which the
family was exposed.
References
1. Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J Psychosom Res.
1967;11:213.
2. Cabodevilla I. Loss and mourning. An Sist Sanit Navar. 2007;30 Suppl 3:163-76.
3. Geerinck-Vercammen CR, Duijvestinj MJ. Coping with grief following perinatal
death: a multifaceted and natural process. Ned Tijdschr Geneeskd. 2004;148:1231-4.
4. Hales S, Zimmermann C, Rodin G. The quality of dying and death. Arch Intern
Med. 2008;168:912-8.
5. Hudges P, Riches S. Psychological aspects of perinatal loss. Curr Opin Obstet
Gynecol. 2003;15:107-11.
6. Scheidtr CE, Waller N, Wangler J, et al. Mourning after perinatal deathprevalence symptoms and treatment – a review of literature. Psychother Psychosom
Med Psychol. 2007;57:4-11.
7. Chiang CC, Lee JT, Wang CH, Tang WR. Mothers' experiences and perspectives
of neonatal death: a qualitative retrospective inquiry. Hu Li Za Ahi. 2007;54:48-55.
8. Aldwin CM. Life events. In: Aldwin CN (ed). Stress, Coping, and Development.
An Integrative Perspective. The Guilford Press. New York, London. 1994, pp. 57-8.
9. Duvall EM. Marriage and family development, ed. 5. New York, JB Lippincott,
1977.
10. Medalie JH. The family life cycle and its implications for family practice. J
Fam Pract. 1979;9:47.
FAMILY GROWTH
After David left Hebron “And David took him more concubines and
wives of Jerusalem.....And other children were born in Jerusalem:
Shammuah, Shobab, Nathan, Solomon, Ibhar, Elishua, Nepheg,
Japhia, Elishama, Eliada, and Eliphalet” (5:13-16). The King’s
polygamous family expanded significantly, and now included many
wives, concubines and 17 children.
Families are unique in permanence of membership and in the
primacy of affectional relationship over task performance. What are
the needs that are addressed uniquely in the family unit? There are
two fundamental orders of such needs:
(a) Needs Pertinent to Survival. The family unit is uniquely
committed to the physical security of all members, hence to such
needs as food and shelter.
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King David
(b) Needs to Development. Additionally, the family is committed
to the cognitive, emotional, and spiritual development of its
members, and hence is committed to creating and sustaining the
sense of being valued, the sense of being cared about, the sense of
being accepted "as it", and the sense of permanence of
affectionalties. The family unit, in this sense is a primary context for
need-attainment (1).
All these parameters can be attributable to King David who was
responsible for the survival of his polygamous family, and for the
development of his family members.
Reference
1. Terkelsen KG. Toward a theory of the family life cycle. In: Carter EA, Goldrick
M (eds.). The Family Life Cycle: A Framework for Family Therapy, Gardner Press, New
York. 1980, pp, 21-52.
THE WARRIOR
Throughout his life, David was involved in endless wars against the
Philistines. He was a real warrior and fought bravely with the enemy.
He won many wars, and many Philistines were taken prisoners. He
also conquered Moab, Hadadezer, the son of Rehob, the King of
Zobah, and the Syrians of Damascus (8:2,3,5). “And David reigned
over all Israel; and David executed judgment and justice to all his
people” (8:15).
DAVID'S SONS THE CHIEF RULERS
King David’s family was consolidated and the sons helped their
father to rule the country “...David’s sons were chief rulers” (8:18).
We see a powerful enigmatic ruler, who conquered many countries.
His potent, authoritative and dominant character indicates a great
leader. King's special qualities helped to organize the internal family
system as well as external surrounding systems. These well-organized
systems were in mutual homeostasis, and the King's sons helped to
rule the country. The King was a perfect manager and gave the orders
to his sons, the chief rulers of the country. All these helped to build a
great empire.
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King David
MEFIVOSHET - A NEW FAMILY MEMBER
After King Saul and his three sons were killed, King David began to
seek the remaining members of Saul’s family. The son of his best
friend Jonathan, Mefivoshet, who was lame, was located and brought
to the King, who ordered that all King Saul’s property be given to
Mefivoshet. David also arranged for this boy to eat all his meals at
his table, and ordered Saul’s servant Ziba and his 15 sons, together
with 20 servants to serve Mefivoshet. Ziba agreed “As for
Mefivoshet, he shall eat at my table, as one of the king’s son” (II
Samuel 9:11). Later, however, David divided Saul’s property between
Ziba and Mefivoshet: “I have said, Thou and Ziba divide the land”
(19:30).
King David treated Mefivoshet like his own son. Finding the son of
his best friend was a positive stressful life event. In this way, King
David expressed great friendship towards his beloved Jonathan, and
another member joined the King’s family.
The pediatrician treating a child with a disability must focus not
only on the physical needs of the child but also on the emotional and
social issues associated with being disabled. This dual focus becomes
increasingly important as the child matures through adolescence and
transitions into adulthood. In addition, the pediatrician must
understand the complex interrelationships between the family and
their maturing, disabled child during the vital process of separation
from the family. This transition is particularly difficult for an
adolescent who is dependent on others for physical care and other
independent living skills. Many of transitional problems faced by
disabled adolescents and their parents have roots in early childhood.
With an awareness of the specific stressors on the parent caregivers
and an understanding of the influence of disability on the
developmental process, the pediatrician can play a major role in
easing the transition of a disabled adolescent into adulthood. By
guiding the parents of a young child through the important tasks of
childhood and adolescent, the pediatrician can set the stage for both
the parents and their disabled child to have independent, yet
supportive lives – that are focused not on the disability but on mutual
respect and life satisfaction. It is recommended that disabled teens
and young adults be given help in independence skills; personal
counseling services should be available, and physicians should give
teen's age-appropriate information about disabilities. There are
needs for sex education, preparation for parenthood, and genetic
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King David
counseling. Other issues that should be addressed are early
vocational awareness, alternatives to work, and leisure time use. Just
because an adolescent is disabled, we cannot assume that he or she
will have self-esteem and self-concept difficulties. To adjust to being
devaluated by society, the disabled person must change societal
beliefs that strength, independence, and appearance are the
essential aspects of a quality of life. The importance of being kind,
intelligence, and productive to one's capacity must become more
important (1).
The relationship between a pediatrician and a child with a
disability is important since the pediatrician accompanies such child
through childhood, and on to adolescence and adulthood. From the
contemporary perspective, the King's family urgently needed a
pediatrician in order to cope with the disability of Mefivoshet.
Since the father of Mefivoshet, Jonathan, was killed in a fierce
battle with the Philistines (we have no further details about
Mefivoshet's other family members, for example his mother), we
suppose that Mefivoshet was left alone in the world. Fortunately, the
King adopted this disabled boy, and he can be regarded as his
stepfather, while Ziba and his 15 sons can be seen as the
stepbrothers involved in raising Mefivoshet. The King's family
received the new family member with respect and saw his needs.
Here we see the humanistic features of King David's character, who
accepted the disabled son of his friend Jonathan as his own child. In
this behavior, the King expressed his loyalty to Jonathan, even after
his death.
This study used a literature review to examine the process of
parental acceptance regarding disability in a child. The results identify
two main theoretical concepts, stages of grief and chronic sorrow,
which describe the emotional responses that parents express
following the diagnosis of a child's disability. Stages of grief involve a
long-term process through which parents struggle to accept their
child's condition, eventually leading to acceptance of their child's
disability. Alternatively, chronic sorrow describes parental life-long
sadness throughout their child's lifetime, periodically repeated at
critical times in their child's development (2).
We can assume that Mevivoshet's disability caused his nuclear
family as well as the adopted family chronic sorrow and sadness.
These reactions are a natural response to a child's disability.
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Taanila et al. (3) studied how a child's physical or intellectual
disability or diabetes affected family cohesion, the parents' social life,
and leisure-time activities, and whether there was any association
between the disability and the parents' social relations and family
cohesion. The parents of 89 children aged 12-17 years returned a
questionnaire and were interviewed by a social worker. Family
cohesion increased in all the groups by an average of 27%. The effect
was smallest in the families of children with diabetes, whereas in the
families with intellectual and physical disability family cohesion
increased from 6 to 13 times more often compared to the families of
children with diabetes. The increased family cohesion was not
associated with the change in the parents' social relationship, work,
career or leisure-time activities; the importance of these activities did
not decrease even though family cohesion increased. However, a
child's chronic illness or disability affected the everyday life of the
family, for instance, 71% of the parents with diabetic children
thought that the regularity of family life increased and about a half of
the parents with physically or intellectually disabled children had to
change their hobbies because of the child.
It is most likely that the cohesion of King David's family increased
due to Mefivoshet's disability. Was their everyday life affected?
Since Saul’s servant Ziba and his 15 sons, together with 20 servants
served Mefivoshet, it seems that everyday life remained unaffected,
and family hobbies were not changed.
The parents of eight children (aged 8-10 years) with physical
and/or intellectual disability were interviewed twice, and the data
elicited in these interviews were analyzed quantatively using the
grounded theory method. Information and acceptance, good family
cooperation and social support were related to the coping strategies
most frequently used. Half of the families found successful ways of
coping, whereas another half had major problems. There were five
domains in which the high- and low-coping families differed most
from each other: 1) parents; initial experiences, 2) personal
characteristics, 3) effects of the child's disability on family life, 4)
acting in everyday life, and 5) social support (4).
King David's family seems to represent a family which coped
successfully with the physical disability of Mefivoshet and found ways
of dealing with this problem. Among the domains that characterize
the King's family were the personal characteristics of the King as well
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as of Ziba and his sons, the effect of Mefivoshet's disability on the
family's daily life and function, and social support.
What is the meaning of life for adolescents with disabilities?
Adolescents with physical disabilities in Korea experience meaning in
their lives when society accepts their existential problems and allows
them to live a normal live. This normality includes helping others (as
a friend or as a volunteer) and creating opportunities to achieve their
own goals in life. The main categories in the findings were
'accomplishment', 'social adaptation', improvement of the quality of
life', good deeds', 'sincerity', 'satisfaction', 'having a relationship',
'achievement of self', 'perception of one's own usefulness',
rehabilitation', and 'gain recognition by others'. Adolescent with
physical disabilities can understand the meaning of their lives when
meaning is framed in the context of being a social issue, and when
they are allowed to clarify their own values (5).
Which of these dimensions can be attributed to Mefivoshet?
References
1. Hallum A. Disability and the transition to adulthood: issues for the disabled
child, the family, and the pediatrician. Curr Prob Pediatr. 1995;25:12-50.
2. Anan A, Yamaguchi M. Process of parental acceptance of a child's disability:
literature review. J UOEH. 2007;29:73085.
3. Taanila A, Järvelin MR, Kokkonen J. Cohesion and parents; social relations in
families with a chid with disability or chronic illness. Int J Rehabil Res. 1999;22:101-9.
4. Taanila A, Syrjälä L, Kokkonen J. Järvelin MR. Coping of parents with physically
and/or intellectually disabled children. Child Care Health Dev. 2002;28:73-86.
5. Kim SJ, Kang KA. Meaning of life for adolescents with a physical disability in
Korea. J Adv Nurs. 2003;43:145-55.
TAMAR AND AMNON
Absalom, the son of David had a beautiful sister, Tamar. Another
son of David, Amnon, loved Tamar “And Amnon was so distressed
that he fell sick for his sister Tamar; for she was a virgin; and Amnon
found it hard to contrive any thing with regard to her” (II Samuel
13:2). Jonadab, Amnon’s friend, asked him “Why art thou, being the
king’s son, so lean, from day to day?” (13:4). Amnon told him that he
loved Tamar. Following Jonadab’s plan, Amnon pretended he was
sick. When the King, his father came to visit him, Amnon asked his
permission “...let Tamar my sister come, and make me a couple of
cakes in my sight, that I may eat at her hand” (13:6). With their
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King David
father’s agreement, Tamar was summoned to Amnon. So she
prepared cakes and brought them to Amnon. Meanwhile, Amnon
dismissed all the men from his room and demanded “Come lie with
me, my sister” (13:11). Tamar refused “..No, my brother do not force
me; for no such thing ought to be done in Israel: do not do this
shameful deed” (13:12). However, Amnon “...being stronger than
she, forced her, and lay with her” (13:14). After these sexual
relations, Amnon’s world turned around and he developed feeling of
hatred towards Tamar. Therefore, he called his servant who threw
her out of his room. Tamar suffered greatly: she “..put ashes on her
head, and tore her sleeved garments that was on her, and laid her
hand on her head, crying aloud as she went” (13:19). In spite of
Amnon’s disgraceful sexual behavior, Absalom advised her..”...keep
silence, my sister...So, Tamar remained desolate in her brother
Absalom’s house. But when king David heard of all these things, he
was very angry” (13:20,21). Following this disgusting sexual assault,
relations between Absalom and Amnon were destroyed, and they did
not speak with each other. An internal family system was disrupted.
SEXUAL ASSAULT
Forcible sex offences are described as any sexual act directed
against another person, forcibly and/or against that person's will; or
not forcibly or against the person's will where the victim is incapable
of giving consent because of his/her temporary or permanent mental
or physical incapacity. Forcing rape (except "statutory rape") is
described as the carnal knowledge of a person, forcibly and/or
against that person's will; or not forcibly or against the person's will
where the victim is incapable of giving consent because of his/her
temporary or permanent mental or physical incapacity. If force was
used or threatened, the crime should be classified as forcible rape
regardless of the age of the victim. If no force was used or threatened
and the victim is under the statutory age of consent, the crime should
be classified as statutory rape (1).
Most definitions of sexual assaults contain three components: the
use of threat, duress, physical force, intimidation, or deception;
sexual contact; and non-consent of the victim (2). It is a crime of
violence that puts the victim at risk of physical injury, emotional
disturbance, pregnancy, and sexually transmitted diseases (STDs) (3).
Women can be victims of unwanted touching, grabbing, oral sex, anal
sex, sexual penetration with an object, and/or sexual intercourse.
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Amnon and Tamar. Giovanni Francesco Barbieri called Guercino (Italian
painter). 1591-1666.
The words: Amnon “...being stronger than she, forced her, and lay
with her (Tamar)” indicate that sexual relations were performed
against Tamar's will. These sexual relations can be defined as rape
with Tamar as a victim.
PREVALENCE
In a stratified sample of the general population, among 941
participants, adult sexual assault is reported by 22% of women and
3.8% of men. Risk factors for adult sexual assault include a younger
age, being female, having been divorced, sexual abuse in childhood,
and physical assault in adulthood (4).
The lifetime prevalence of sexual assault is 38% among women
and 6% among men among the veteran population (5). Among a
sample of college students, roughly 30% of the women and 12% of
the men reported having been the victim of a sexual assault
sometime in their lives (6). In secondary analysis, which included a
representative population-based sample of 8080 students, 14 years
and older, at 87 New York City public high schools, lifetime history of
sexual assault was reported by 9.6% of females and 5.4% of males
(7). In Mexico, an estimated prevalence of sexual abuse in women
reached 17.3%, while half of them in youngsters under 15 years old
(8). In New Zealand's 21-year-olds, 41% experienced physical or
sexual assault in the previous 12 months (9).
46
L. Ben-Nun
King David
A retrospective study of emergency department (ED) visits for
adult female sexual assault in all Rhode Island EDs, 1995-2001, was
conducted. Of the 780 patients, 78.2% sustained anal/vaginal
penetration, 5.0% genital touching only, and 3.7% oral sex only, and
13.1% did not know what happened to them. Of those women who
were
assaulted
anal/vaginally,
83.8%
were
offered
chlamydia/gonorrhea testing, 69.4% syphilis testing, 82.9%
pregnancy testing, 77.0% chlamydia/gonorrhea prophylaxis, 47.6%
emergency contraception, and 19.2% HIV prophylaxis (10).
A total sample of 3026 women over the age of 18 attending a
consultation was included in the study, in metropolitan Melbourne,
1993-1994. Over a quarter of women in relationships had been
victims of physical or emotional partner abuse in the previous year, 1
in 10 had experienced severe physical violence. The 13% of women
had experienced rape or attempted rape, 10% had been severely
beaten during childhood and 28% had experienced childhood sexual
abuse involving physical contact. The abuse had been disclosed to the
woman's doctor by only 27% of those who had experienced partner
or childhood physical abuse and 9% of those who had experienced
sexual abuse. This study shows that there is a high prevalence of
physical, sexual and emotional violence against women as well as
poor reporting about this violence by the victims to their general
practitioners (11).
To sum up, there is a high prevalence of physical, sexual and
emotional violence against women worldwide.
This study covers information from 890 cases submitted to the
forensic science laboratory, the Republic of Ireland, in the time
between January 2004 to December 2005. The most common age
category of victim was 16-30, the most likely time of occurrence was
Saturday or night/Sunday morning during the summer months of
June, July or August. The victim most likely knew the assailant even if
only recently met. Loss of memory, mainly associated with the
consumption of alcohol, was a significant factor in many of the cases
(12).
The objective of this study was to analyze demographic and event
characteristics of patients presenting to the ED for evaluation after
sexual assault, using a Sexual Assault Nurse Examiner standardized
database. Data were collected on 1172 patients; 92% were women,
with a mean age of 27 years. The sample was 59.1% black, 38.6%
white, and 2.3% "other". Survivors of sexual assault were
47
L. Ben-Nun
King David
overwhelmingly female, relatively young, who often knew the
perpetrator of the event, and were likely to be threatened and
showed signs of physical trauma (13).
Similarly to many contemporary victims, Tamar was a young white
female who knew the perpetrator. Was she threatened?
Dating violence is an important public health concern in
adolescents. A nationally representative sample of adolescents
(n=3.614) completed a telephone-based interview that assessed
serious forms of dating violence (i.e., sexual assault, physical assault,
and/or drug/alcohol-facilitated rape perpetrated by a girlfriend,
boyfriend, or other dating partner). Prevalence of dating violence
was 1.6% (2.7% of girls, 0.6% of boys), equating to approximately
400.000 adolescents in the U.S population. Risk factors included older
age, female sex, experience of other potentially traumatic events,
and experience of recent life stressors. Dating violence was
associated with posttraumatic stress disorder (PTSD) and major
depressive episode after controlling for demographic variables, other
traumatic stressors, and stressful events (14). A person's cognitions
had a dramatic effect on the onset, severity, and progress of PTSD
following sexual assault. Sociological impacts of assault influenced
the development of PTSD through victim-blaming attitudes and the
perpetration of rape myths (14).
As in biblical times, female adolescents are the main victims of
sexual assault. Tamar most likely suffered from PTSD or major
depressive disorder. Did Tamar's cognition affect the development of
PTSD and the depression disorder?
Patients (n=1112) presented after a sexual assault to an urban
Level I trauma center, MetroHealth Medical Center Department of
Emergency Medicine, Cleveland, USA;
1.076 (97%) patients
consented to the medical and evidentiary examination and were
enrolled in the study. Age ranged from one to 85 years, with 96%
female and 4% male victims. The number of assailants was greater
than 1 in 20% of cases, and the assailant was a stranger only 39% of
the time. Force was used in 80% of reported assaults, and in 27% of
cases, a weapon was present. Vaginal intercourse was involved in
83% of female victims. Oral assault was involved in 25%, while anal
penetration in 17% of all cases. Overall, general body trauma
occurred 67% of the time, genital trauma in 53% of cases, and 20% of
patients had no trauma noted on examination (15).
48
L. Ben-Nun
King David
We see that most of the victims were females, their ages ranged
from as young as 1 year to a very old 85 years. In most cases, force
was used, with vaginal intercourse being the most prevalent type of
assault.
Forty-five girls less than 21 years of age, at Arkansas Children's
Hospital, who required surgical repair of genital injuries between
June 1986 and April 2007, were identified. Although most injuries
were due to straddle and impalement mechanisms, sexual abuse or
assault was identified in 25% of the girls. Straddle/impalement
injuries involved only the external genitalia, vestibule, perineum, or
posterior fourchette in 21 of the 28 girls (76%). The injuries in 9 of
the 11 (82%) sexually abused/assaulted girls involved the hymen,
vagina, anus, or rectum (16).
Women (n=319), aged 18-30 years, who represented a community
sample, were interviewed regarding their most recent unwanted
sexual experience. Four contexts in which adolescents were sexually
victimized emerged: Within Intimate Relationships, At Parties/Social
Gatherings, Abuse by Authority Figures, and While Alone with a
Friend. Thematic analysis revealed that inexperience with sex and
dating, lack of guardianship, substance use, social and relationship
concerns, and powerlessness contributed to adolescent vulnerability
within these contexts (17).
In Tamar's case, the most important factor (among the four
described) was: While Alone with a Friend. Other important factors in
the thematic analysis were: inexperience with sex and dating, lack of
guardianship, and powerlessness.
Sexual behavior was examined in 17-year-old girls, Sweden. Data
were collected by anonymous self-administered 2583 questionnaires.
Response rates from students were 92%, and for school nonattenders 44%. STD and pregnancy were reported by 15% of early
starters and pregnancy by 14%, p< 0.001 and 0.002, respectively,
when compared with later starters. Sexual abuse was reported by
20% of the early and 11% of later starters, p=0.002. A majority of
83% of the girls had experienced voluntary intercourse, and 49%
were early starters. Five girls were mothers. STD was reported by
19% and induced abortion by 14% (18).
In adolescents, sexual abuse was reported by 20% of the early and
11% of later starters. These adolescent girls were at risk of infection
by STD as well as of pregnancy. Thus, biblical adolescents and
contemporary adolescents faced the same risk of sexual abuse.
49
L. Ben-Nun
King David
An anonymous survey with questions on gender-based violence,
demographic and socioeconomic characteristics, and childhood
experiences with violence was administered to students at a major
public university in Santiago. Ninety percent of subjects reported that
the most severe form of undesired sexual contact they had
experienced since age 14 was rape; 6% indicated attempted rape and
16% another form of sexual victimization; 17% of subjects reported
having experienced some form of undesired sexual contacts in the
past 12 months alone. Factors associated with increased odds of
victimization included low parental education, childhood sexual
abuse, and the association between witnessing domestic violence
and victimization. A substantial proportion of young women
experienced rape, attempted rape or other forms of forced sexual
contact, indicating a need for further attention to this public health
problem in Chile (19).
The assault records and forensic examination findings of 153
consecutive women who attended a sexual assault service in
Newcastle, Australia, between 1997 and 1999, were reviewed. All
the women were examined within 72 hours of the assault. Of the
women, 111 (73.4%) were aged under 30 years and only 4% were
over 50 years. Penile-vaginal penetration was the most common type
of sexual assault (86%). Non-genital injuries were found in 46% of the
women (mostly minor) and genital injury in 22%. Genital injuries in
the absence of non-genital injury were rare (3%). Independent risk
factors for the detection of non-genital injury were reported threats
of violence. Risk factors for genital injury were the presence of nongenital injury, threats of violence and being over the age of 40 years.
If the woman knew the alleged assailant, this was protective for both
non-genital and genital injury (20).
All females who were 15 years or older presenting after sexual
assault to an urban ED Seattle, USA, underwent standardized
evaluation. Of 8199 women, 52% had general body injury and 20%
had genital-anal trauma; 41% were without injury. General body
trauma was associated with being hit or kicked, attempted
strangulation, and stranger assault. Genital-anal injury was more
frequent in victims younger than 20 and older than 49 years, virgins
and those examined within 24 hours and after anal assault. General
body injury was primarily associated with situational factors, whereas
genital-anal injury was less frequent and was related to victim age,
virginal status, and the time of examination (21).
50
L. Ben-Nun
King David
In the case of Amnon and Tamar, the victim was an adolescent
female woman. Amnon used force to sexually abuse his half-sister.
What type of force was used? What type of penetration occurred?
Was Tamar's body injured? Were her genital organs injured?
ANCIENT VICTIM
This biblical story indicates that Tamar was indeed a victim of
sexual abuse perpetrated by her half-brother. Firstly, Amnon fell in
love with his beautiful sister and consequently suffered from an
eating disorder. He dreamed about his sister but could not have
sexual relations with her. Therefore, with the help of his friend a
plan was prepared. Pretended to be sick, Amnon got permission
from his father, the King, for Tamar to visit her “sick” brother. During
this visit, Tamar was forced to have sexual relations with him. Since
the sexual relations were carried out against Tamar’s will, we can
classify them as sexual abuse. This abuse occurred within the family
system, with a brother as perpetrator.
The consequences of the biblical sexual assault were devastating.
After achieving his desire, Amnon began to hate his humiliated sister,
and threw her out of his room. In addition, the words - Tamar
remained desolate in her brother Absalom’s house, indicate that
Tamar suffered from PTSD, and/or low self-esteem, and/or anxiety,
fear, depression and anger. Because of Amnon’s disgusting behavior,
hatred developed between two brothers and the family atmosphere
was poisoned. No compromise could be found in the triangle:
Amnon - Absalom - Tamar.
PSYCHOLOGICAL CONSEQUENCES
Survivors of sexual assault display psychological sequelae
including elevated rates of suicide. Prevalence of mental health
problems of 121 forensic cases between June and August 2004 was
established. Of female clients aged over 13 years, 8% had learning
difficulties, 21% gave a history of deliberate self-harm and 20% had
psychiatric history. Vulnerable people are at increased risk for mental
health problems and deliberate self-harm following sexual violence
(22).
Adult victims of sexual assault do not generally report the abuse
because of fear of retribution by the perpetrator, the stigma attached
51
L. Ben-Nun
King David
to being a victim of a sexual crime, fear of being blamed for the
assault, history of negative outcomes following past disclosures, and
fear of the psychological consequence of disclosure such as increased
anxiety and depression (23). All these parameters can be attributed
to Tamar who in spite of suffering from a disgraceful sexual abuse
was advised to keep silent.
Survivors (n=47) of sexual abuse suffer symptoms serious enough
to require therapy (24). These include PTSD, low self-esteem and low
self-worth, distrust of others, anxiety and fear, depression, anger,
self-mutilation, interpersonal problems, sexual difficulties, substance
abuse, alcohol and drug abuse, suicidal ideation or gestures,
prostitution, promiscuity, eating disorders, personality disorder or
dysfunctional personality, significant increase in somatization scores,
and multiple sick days (24-26).
A nationally representative sample of 3015 girls in grades 5
through 12 from 265 public, private, and parochial schools (with an
oversampling of urban schools) completed an anonymous survey
conducted by the Commonwealth Fund Adolescent Health Survey.
Among the responders, 246 (8%) reported a history of physical
abuse; 140 (6%), sexual abuse; and 160 (5%), both. Those who
reported both types of abuse compared with those who did not
report any were significantly more likely to experience moderate to
severe depressive symptoms, moderate to high level of life stress,
regular alcohol consumption, use of other illicit drugs in the past 30
days, and fair to poor health status. Finally, girls who reported both
types of abuse were 2.07 more likely to report moderate to high
depressive symptoms compared with those reporting only sexual
abuse (27).
Thus, contemporary assault victims similarly to ancient victims
suffer from various psychological problems and these victims need
urgent psychiatric treatment.
FAMILY FUNCTIONING
Fleck (28) suggested five parameters of family functioning.
52
L. Ben-Nun
King David
These are:
1. Leadership: this is a result of the parents' personalities, the
characteristics of the marital coalition, the complementary of the
parental roles, and the parents' use of power – that is, their methods
of discipline.
2. Family boundaries: this covers ego boundaries, generation
boundaries, and family-community boundaries.
3. Affectivity: important in this parameter is interpersonal
intimacy, the equivalence of family triads, family members' tolerance
of each other's feelings, and unit emotionality.
4. Communication: relevant here are responsiveness of family
members to each other, the extent to which verbal and no-verbal
communications are consistent, the ways in which family members
express themselves, the clarity of the syntax of their talk, and the
nature of members' abstract and metaphorical thinking.
5. Task/goal performance: this covers the nurturance given to
members by the family, the ways in which the children master the
process of separation from the family, behavior control and guidance,
the nature of family members' peer relationships and the guidance
they are given in the leisure activities, how the family copes with
crises, and the adjustment of members after they leave the family of
origin.
Leadership in David's family was concentrated in the King's hands,
and only he could give permission to Tamar to visit her "sick" brother,
Amnon. The visit was well organized and carried out within the
family boundary. At this time, Amnon, Tamar, Absalom and the King
were strongly connected emotionally with each other. The
communication pattern was positive, and their relationships were
based on trust. The whole process went as planned: the father
permitted Tamar to visit Amnon, Tamar prepared cakes and took
them to her "sick" brother, while Absalom kept his eyes on this visit.
However, communication in this case between family members was
obstructed; Tamar had no telephone or other means to inform others
of what was happening behind the closed doors. Unfortunately, the
door was closed therefore there was no way to escape. Absalom did
not expect that his "half" brother had organized the invitation in
order to sexually abuse his "half" sister.
TO SUM UP: this research deals with one sexual abuse as
described in the Bible. Amnon, King David's son, sexually abused his
sister Tamar. Subsequently humiliated, Tamar suffered from various
53
L. Ben-Nun
King David
psychological outcomes of the abuse, including PTSD, and/or low
self-esteem, and/or anxiety, fear, depression and anger, isolation,
fear of reporting the sexual abuse because of the stigma attached to
being victim, fear of being blamed, and fear of negative outcomes
following disclosure. Just like this female victim from antiquity, any
contemporary adolescent female victim of traumatic sexual
aggression deserves appropriate assessment and treatment.
References
1. Snyder HN. Sexual assault of young children as reported to law enforcement:
victim, incident and offender characteristics. U.S. Department of Justice. Office of
Justice Programs. 2000; NCJ 182990.
2. Reynolds MW, Peipert JF, Collins B. Epidemiologic issues of sexually
transmitted diseases in sexual assault victims. Obstet Gynecol Surv. 2000;55:51-7.
3. Glasser JB, Hammerschlag MR, McCormack WM. Epidemiology of sexually
transmitted diseases in rape victims. Rev Infect Dis. 1989;11:246-54.
4. Elliott
DM, Mok DS, Briere J. Adult sexual assault: prevalence,
symptomatology, and sex difference in the general population. J Trauma Stress.
2004;17:203-11.
5. Zinzow HM, Grubaugh AL, Frueh BC, Magruder KM. Sexual assault, mental
health, and service use among male and female veterans seen in Veterans Affairs
primary care clinics: a multi-site study. Psychiatry Res. 2008;159(1-2):226-36.
6. Ellis L, Widmayer A, Palmer CT. Perpetrators of sexual assault continuing to
have sex with their victims following the initial assault: evidence for evolved
reproductive strategies. Int J Offender Ther Comp Criminol. 2008 Apr 2.
7. Olshen E, McVeigh KH, Wunch-Hitzig RA, Ricket VI. Dating violence, sexual
assault, and suicide attempts among urban teenagers. Arch Pediatr Adolesc Med.
2007;161:539-45.
8. Sam Soto S, Gayón Vera E, Garcia Pioa CA. Gynecological clinical study in girls
and adolescent victims of sexual abuse. Ginecol Obstet Mex. 2008;76:404-16.
9. Feehan M, Nada-Raja S, Martin JA, Langley JD. The prevalence and correlates
of psychological distress following physical and sexual assault in a young adult
cohort. Violence Vict. 2001;16:49-61.
10. Merchant RC, Phillips BZ, Delong AK, et al. Disparities in the provision of
sexually transmitted disease and pregnancy testing and prophylaxis for sexually
assaulted women in Rhode Island emergency departments. J Womens Health
(Larchmt). 2008;17:619-29.
11. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence
against women: a general practice-based prevalence study. Med J Aust.
1996;164:14-7.
12. McDermott SD, McBride BM, Lee-Gorman M. Sexual assault statistics from
the Republic of Ireland for 2004-2005. Med Sci Law. 20008;48:142-50.
13. Avegno J, Mills TJ, Mills LD. Sexual Assault victims in the emergency
department: analysis by demographic and event characteristics. J Emerg Med. 2008
Apr 2. [Epub ahead of print].
14. Wolitzky-Taylor KB, Ruggiero KJ, Danielson CK, et al. Prevalence and
correlates of dating violence in a national sample of adolescents. J Am Acad Child
Adolesc Psychiatry. 2008;47:755-62. 15. Chivers-Wilson KA. Sexual assault and
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King David
posttraumatic stress disorder: A review of the biological, psychological and
sociological factors and treatments. Mcgill J Med. 2006;9:111-8.
15. Riggs N, Houry D, Long G, et al. Analysis of 1.076 cases of sexual assault. Ann
Emerg Med. 2000;35:358-62.
16. Jones JG, Worthington T. Genital and anal injuries requiring surgical repair in
females less than 21 years of age. J Pediatr Adolesc Gynecol. 2008;21:207-11.
17. Livingston JA, Hequembourg A, Testa M, Vanzile-Temsa C. Unique aspects of
adolescent sexual victimization experiences. Psychol Women Q. 2007;31:331-43.
18. Edgardh K. Sexual behaviour and early coitarche in a national sample of 17
year old Swedish girls. Sex Trans Infect. 2000;76:98-102.
19. Lehrer JA, Lehrer VL, Lehrer EL, Oyarzún PB. Prevalence of and risk factors for
sexual victimization in college women in Chile. Int Fam Plan Perspect. 2007;33:16875.
20. Palmer CM, Mcnulty AM, D'Este C, Dnovan B. Genital injuries in women
reporting sexual assault. Sex Health. 2004;1:55-9.
21. Sugar NF, Fine DN, Eckert LO. Physical injury after sexual assault: findings of a
large case series. Am J Obstet Gynecol. 2004;190:71-6.
22. Campbell; L, Keegan A, Cybulska B, Forster G. Prevalence of mental health
problems and deliberate self-harm in complainants of sexual violence. J Forensic Led
Med. 2007;14:75-8.
23. Courtois C. Healing the incest wound: adult survivors in therapy. New York:
W.W. Norton & Company. 1988.
24. Briere J, Zaidi LY. Sexual abuse histories and sequelae in female psychiatric
emergency room patients. Am J Psychiatry. 1989;146:1602-8.
25. Stein MB, Lang AJ, Laffaye C, et al. Relations of sexual assault history to
somatic symptoms and health anxiety in women. Gen Hosp Psychiatry. 2004;26:17883.
26. Hegarty K, Gunn J, Chondros P, Small R. Association between depression and
abuse by partners of women attending general practice: descriptive, cross sectional
survey. BMJ. 2004;328:621-4.
27. Diaz A, Simantov E, Rickert VI. Efect of abuse on health: results of a national
survey. Arch Pediatr Adolesc Med. 2002;156:811-7.
28. Fleck S. Family functioning and family pathology. Psychiatric Annals.
1980;10:46-54
EATING DISORDER
Right at the beginning of this story, it is written that Amnon
became “..so lean, from day to day?” (II Samuel 13:4). Did he suffer
from Anorexia Nervosa (AN)?
AN and Bulimia nervosa are the main types of eating disorders
described in the International Classification of Diseases ICD-10. The
main features are eating patterns such as refusal to eat enough food
or loss of control, followed by counter-regulatory measures. In
addition, preoccupation with body shape and weight and with food is
55
L. Ben-Nun
King David
an important feature of eating disorders. Severe medical conditions
may occur because of starvation, malnutrition and purging. Patients
with AN are foremost underweight (BMI < 17.5 kg/m2). Etiological
models are multifaceted and include predisposing and sustaining
factors as well as triggers for the onset of the disorder. The course is
variable and marked by changes between remission and clinically
relevant symptoms (1).
In 1986, Morton examined a 20-year-old girl presenting with
complaints of marasmus and amenorrhea (2). He stated that her
problem was related to “sadness and anxious cares”. For centuries,
AN with its high mortality rate, and its irascible and manipulative
patients has continued to plague concerned physicians (3).
PREVALENCE
Although AN is usually considered a disorder of young women and
girls, 5% to 10% of cases occur in men and boys (4).
In the U.S Military, 1998-2006, the percentage per year of SM with
eating disorders (ED) diagnosis was 0.30%. Females were diagnosed
significantly more than males (p < 0.001). The majority of AN cases
(66%) were in Marines. Females, specifically White females, have
higher incidence of ED (5).
In Romania, the prevalence of AN was 0.6% in the female
population while clinical cases of AN were not found in the Hungarian
female sample. The prevalence of subclinical AN reached 1.9% in the
Romanian females and 0.4% in the Hungarian female sample (6).
In Tuscany, North-Central Italy, 2004-2006, the prevalence of
thinness increased with age in girls (4.9% at 9 years, and 14.1% at 15
years), while boys presented a similar low prevalence at 9 and 15
years (3.3% and 3.1%) (7).
In the city of Reus, Spain, diagnostic criteria of AN were found in
0.9% (95% CI: 0.4-2.4) of adolescent girls (n=551) between the ages
of 12 and 21 (8). In an additional study, a community sample of 1115
participants, and a risk sample of 93 participants, aged between 10.9
and 17.3 years old, from the city of Barcelona, Spain, participated in
the study. AN (of the total sample) reached 1.28% - 2.31% of girls and
0.17% of boys. Symptoms of anorexia and bulimia nervosa were
higher among girls than boys. Preoccupation with maintained low
weight, with body image and shape, and taking excessive exercise in
order to lose weight, are increasing among Spanish adolescents (9).
56
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CLINICAL CHARATERISTICS
The essential features of AN are that the individual refuses to
maintain a minimally normal body weight for his or her age and
height (Criterion A), is intensely afraid of gaining weight (Criterion B),
and exhibits significant disturbance in the perception of the shape or
size of his or her body (Criterion C) (10). AN is related to cultural,
physical, and psychological pressures on vulnerable adolescents or
young adults (11).
Of these criteria only one (Criterion A) (10) can be attributed to
Amnon. According to this definition, there are insufficient data for a
diagnosis of AN.
There are individuals, however, who do not strictly fulfill the
Diagnostic and Statistical Manual (DSM)-IV criteria (12). In 1995, The
Society for Adolescent Medicine issued a position paper on
adolescent ED, which identified a broad spectrum of ED among young
people that could lead to moderate or severe disturbance (13), while
some believe that AN is more of a dieting disorder than an eating
disorder (14). Subsequently, cases of ED were classified as AN,
bulimia, and partial syndromes (12).
According to this classification, it seems that Amnon suffered from
a partial eating disorder syndrome.
ED powerfully distorts psychological control irrespective of
culture. However, the degree, directionality, and form of the
displacement from normal control styles is culture dependent (15).
The objective of this study was to determine the distribution of
age of onset of eating disorders in males as well as the relationship
between age of onset and various clinical and demographic
characteristics. The medical records of 70 males consecutively
admitted to an inpatient eating disorders unit, 1992-2002, were
retrospectively reviewed. Age of onset did not significantly differ by
admission diagnosis and appeared to have a single peak at about age
14. Patients with older ages of onset reported lower percentage of
weight and longer duration of illness than inpatients with younger
ages of onset (16).
There are also patients who have been identified as having food
avoidance emotional disorders. These patients do not meet the
criteria for AN, and they seem to have an intermediate disorder,
somewhere between AN and food avoidance (17). Was Amnon
affected by a food avoidance emotional disorder?
57
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King David
Perhaps Amnon attempted to resolve the conflict with his sister
Tamar by focusing on food and control of food intake. Primary
depression can present with reduced food intake and weight control
(18). Was Amnon affected by depression? An evaluation of a medical
record of Amnon, that is the biblical text, did not provide evidence
for some depressive disorder.
References
1. Legenbauer T, Herpertz S. Eating disorders – diagnosis and treatment. Dtsch
Med Wochenschr. 2008;133:961-5.
2. Morton R. Phthisiologia: or treatise of consumptions. Smith and Walford
(English translation). London, 1694.
3. Silverman J. Anorexia Nervosa: clinical observations in a successful treatment
plan. J Pediatr. 1974;84:68-3.
4. Barry A, Lippmann S. Anorexia nervosa in males. Postgrad Med. 1990;98:1616.
5. Antczak AJ, Brininger TL. Diagnosed eating disorders in the U.S. Military: a nine
year review. Eat Disord. 2008;16:363-77.
6. Kovács T. Prevalence of eating disorders in the cultural context of the
Romanian majority and the Hungarian minority in Romania. Psychiatr Hung.
2007;22:390-6.
7. Lazzeri G, Rossi S, Pammolli A, et al. Underweight and overweight among
children and adolescents in Tuscany (Italy). Prevalence and short-term trends. J Prev
Med Hyg. 2008;49:13-21.
8. Olesti Baiges M, Piñol Moreso JL, Martin Vergara N, et al. Prevalence of
anorexia nervosa, bulimia nervosa and other eating disorders in adolescent girls in
Reus (Spain). An Pediatr (Barc). 2008;68:18-23.
9. Muro-Sans P, Amador-Campos JA. Prevalence of eating disorders in a Spanish
community adolescent sample. Eat Weight Disord. 2007;12:e1-6.
10. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Washington, DC, American Psychiatric Association, 1994.
11. Romeo F. Adolescent boys and anorexia nervosa. Adolescence. 1994;29:64312. Morandé G, Celada J, Casas JJ. Prevalence of eating disorders in a Spanish
school-age population. J Adolesc Health. 1999;24:212-9.
13. The Society for Adolescent Medicine. Eating disorders in adolescents: A
position paper. J Adolesc Health. 1995;16:
14. Beumont PJ, Russel JD, Touyz SW. Treatment of anorexia nervosa. Lancet.
1993;341:1635-40.
15. Soh N, Surgenor LJ, Touyz S, Walter G. Eating disorders across two cultures:
does the expression of psychological control vary? Aust N Z Psychiatry. 2007;41:35116. Forman-Hoffman VL, Watson VL, Andersen AE. Eating disorder age of onset in
males: distribution and associated characteristics. Eat Weight Disord. 2008;13:e2817. Higgins JF, Gooddyer IM, Birch J. Anorexia nervosa and food avoidance
emotional disorder. Arch Dis Childhood. 1989;64:346-51.
18. Fosson A, Knibbs J, Bryant-Waugh, Lask B. Early onset anorexia nervosa. Arch
Dis Childhood. 1987;62:114-8.
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REVENGE
Absalom did not forget that Amnon had defiled their sister, and
he was eager for revenge. There was no way to achieve a peaceful
reconciliation between the two brothers. The painful triangle Tamar, Absalom, and Amnon - could never achieve a peaceful
coexistence. No resources were used to solve this family crisis. Even
the King did not intervene or make any efforts to reconcile this
triangle.
After two years, at the first opportunity, Absalom commanded his
men to kill Amnon and the mission was performed "..Smite Amnon;
then kill him, fear nor.. be courageous, and be valiant.." (II Samuel
13:28). With the aid of external forces, Amnon paid with his life for
his disgusting behavior. Amnon's death affected profoundly David's
family: "..the king's sons came, and lifted their voices and wept: and
the king also and all his servants wept very sore" (13:36). Later,
"Absalom fled, and went to Talmai, the son of Ammihud, king of
Geshur. And David mourned for his son every day" (13:37).
In healthy families, the ambience is nurturing, and the
relationships are filled with love, caring, affection, and loyalty. In
dysfunctional families, the relationships take on qualities like hate,
guilt and retribution; the ambience is disjunctive. However, in both
healthy and dysfunctional families, the attachments are intense and
their vicissitudes pervade the whole life of the family. Secondly,
these interactions continue over whole lifetimes. Thirdly, the
outcome of these interactions is physical survival and personal
development for all members. The purpose of the family is to evoke
between members sequences of affectional interactions sustained
over lifetimes, thereby producing survival and development for all
family members (1).
Family change is the interpersonal process by which the family
adapts, alters, or becomes different. The family is more than the
sum of its parts. Interpersonal structures and processes that enable it
to be both stable and adaptable over time organize the family (2).
Amnon's reckless behavior led the King's family into a severe
crisis. The attachment between Absalom, Amnon and Tamar was
broken, and the stable family homeostasis was disrupted. The
relationships between the siblings reached such a level of hatred that
only the death of Amnon could calm the situation. Absalom never
accepted and never forgave Amnon for defiling his beautiful sister.
The family became unstable, it could not adjust to the consequences
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of Tamar's humiliation. Because of Amnon's behavior, the attitude
towards him changed: Amnon had to pay a price for his dreadful
action. After this unforgivable event, the King's family internal system
changed forever.
References
1. Terkelsen KG. Toward a theory of the family life cycle. In: Carter EA, Goldrick
M (eds). The Family Life Cycle: A Framework for Family Therapy, Gardner Press, New
York. 1980, pp, 21-52.
2. McDaniel S, Campbell TL, Seaburn DB. Family system concepts. Tools for
assessing the family in primary care. In: McDaniel S, Campbell TL, Seaburn DB (eds).
Family-Oriented Primary Care. A Manual for Medical Providers. Springe-Verlag. New
York, Berlin. 1990, pp. 33-39.
MOURNING FOR AMNON
King David was aware of Amnon's outrageous behavior,
” But when King David heard of all these things, he was very angry”
(II Samuel 13:20). The biblical text provides no details about any
punishment or even dialogue between the father and his son,
Amnon, concerning this disgraceful action. The internal family
system was disrupted, and a peaceful coexistence was broken.
There was no room for any compromise; the behavior of Amnon
had reached such extremely negative point that now it was only a
question of when and where Amnon would pay the price. The
internal tension and hatred between Absalom, Amnon and beautiful
Tamar led to Amnon's assassination. In spite of Amnon's dreadful
behavior that led to his death, the King mourned for his son. Here we
see a very special characteristic of the King's character – he loved his
son and was ready to forgive him for his disgusting behavior.
According to the Smilkstein's Apgar Questionnaire, at this time the
family can be defined as a severely dysfunctional (1).
Grieving a loss is a profound and universal human experience (2).
Grief is not a mental disorder; it is a painful and unexpected process
in response to the death of a family member or loved one
(bereavement), or a significant loss. Despite the fact that grief is not
a mental disorder, consultations about grief are frequent in clinical
practice, which is why clinicians must be trained for these situations.
It is important to bear in mind that not every process of grief follows
a normal development and reaches a satisfactory solution, and this is
where health care professionals must be qualified to recognize when
grief is becoming a pathological disease; they must be more alert to
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these cases and intervene in an appropriate way. It is also important
to stress that grief is not a synonym for depression, but many griefstricken people may enter a depressive state, and they therefore
require early treatment in order to avoid complications that might
arise from the unsuitable treatment of a depressive episode, such as
suicide. Finally, the relationship between grief and psychological
disorder has been demonstrated. Grief that is insufficiently
elaborated, or which follows an abnormal development, may give
rise to a psychopathological disorder, generally a major depressive
episode, just as an established mental disorder may hinder the
elaboration of a process of working through grief (3).
The process of grieving itself takes place in time in several ways:
the extent to which the death is sudden, expected, and timely; the
passage from the beginning of anticipatory grieving itself before the
actual death through the diminishing effects of the loss over an
extended period; and the age and stage in life of the grieving
persons. During the grieving process, the survivors often develop
physical and health problems, face psychological and emotional
distress, encounter difficulties with social relationships, and must
cope with numerous practical issues. The subsequent adjustment of
widows and widowers appears to be related to the extent to which
there had been the opportunity for open communication (4).
Bereavement responses were assessed in 45 parents whose
children died 6 months to 4 years earlier. Parents of boys or children
who died suddenly experienced more despair, anger, guilt, and
depersonalization. Social support and stress since the child's death
and fate-blame versus self-blame were also related to parental
responses on specific the Grief Experiences Inventory scales (5).
Amnon was not supposed to die. Following his behavior, Amnon's
relationships with his half-brother Absalom and his sister Tamar were
broken, and reached a point from where there was no way to return
to the previous level of normative affectionate relations.
On the Holmes-Rahe scale (6), the death of a close family member
receives a score of 63 and is a negative non-normative stressful life
event. Thus, in the case of Amnon, the King experienced a negative,
very stressful event.
Amnon's sudden death profoundly affected King David and other
family members. All were involved in the mourning process. The
biblical words " the King's sons came: and the King also and all his
servants wept very sore" (13:36). And David mourned for his son
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every day" (13:37) indicate the severe emotional distress that
afflicted the King, other family members, and even his servants.
These words also indicate despair, anger, and guilt. We see the very
humane reaction of the father, the King who suffered a great deal
after losing his son forever.
References
1. Smilkstein G. The Family Apgar: a proposal for a family function test and its use
by physicians. J Fam Pract. 1978;6:1231-9.
2. Pilkington FB. Grieving a loss: the lived experience for elders residing in an
institution. Nurs Sci Q. 2005;18:233-42.
3. Flórez. Grief. An Sist Sanit Navar. 2002;25 Suppl 3:77-85.
4. Kalish RA. Death and survivorship: the final transition. Ann Am Acad Pol Soc
Sci. 1982;Nov;(464):163-73.
5. Hazzard A, Weston J, Gutterres C. After a child's death: factors related to
parental bereavement. J Dev Behav Pediatr. 1992;13:24-30.
6. Holmes TH, Rahe RH. The social readjustment rating scale. J Psychosom Res.
1967;11:213.
ABSALOM'S REBELLION
Later, Absalom rebelled against his father, King David. This
rebellion led to a permanently corrosive state of disequilibrium and
the additional disruption of David’s family homeostasis. The
confrontation between Absalom and David was inevitable. Fighting
followed between the camps of Absalom and King David. In spite of
his son’s opposition to his leadership, David did not want his son to
be hurt. Therefore, he asked Joab, Abishai, and Ittai to “..Deal gently
for my sake with the young man, with Absalom” (II Samuel 18:5). In
this battle, Joab killed Absalom.
ASSESSMENT OF FAMILY
Among the several theories of family function that have been
used to study the King's family system, the Circumflex Model of
Marital and Family System was chosen. Olson, Sprenkle, and Russell
(1) described what they called a circumflex model for the assessment
of families, and later published a theoretical update of it. From an
extensive review of the literature they identified two aspects of
family behavior, cohesion and adaptability, which they believe are of
fundamental importance (2).
Cohesion is a measure of the emotional bonding that family
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members have toward one another. Family adaptability is a measure
of how the family permits change and how far it is characterized by
stability. The satisfactory functioning of a marital dyad, or a larger
family group, requires both an element of stability and the capacity
to change, and the two characteristics are balanced. Cohesion, also,
should fall somewhere in the middle ground, being neither too great
nor too little. These two dimensions are hypothesized to be related
curvilinearly to family health, that is, the extremes of cohesion –
termed enmeshment and disengagement – are theorized to be
unhealthy, while the middle range is thought to be healthy. The same
is hypothesized for adaptability, with the extremes of the continuum,
being labeled as rigid and chaotic. The circumflex model posits 16
types of family functioning based on cohesion and adaptability
continua, and there are three levels of family functioning: balanced,
midrange, and extreme dysfunction, the latter being labeled as
chaotically disengaged or chaotically enmeshed, and rigidly
disengaged or rigidly enmeshed (2).
The King's family is described at a time when the family
boundaries were shifting to accommodate a new situation, the son,
Absalom, hated his father and rebelled against his leadership. This
extreme hatred disrupted emotional bonding and a peaceful
coexistence between the father and the son. In spite of these
extreme tension and stress, neither familial nor extrafamilial nor
other environmental resources were used to resolve the problems
between the King and his son, Absalom. All this therefore led to
disequilibrium. The son hated his father extremely and decided to
destroy him; this shows that an abnormal defense mechanism was
used to resolve a severe crisis. At that time the family entered a
phase of either chaotically disengaged or chaotically enmeshed, or a
phase of rigidly disengaged or rigidly enmeshed. According to the
circumflex model, the family can be labeled as an extremely
dysfunctional.
David’s family system failed to resolve a very stressful situation,
because of the hatred that the King’s son Absalom developed
towards his father. Absalom opposed his father’s supremacy, and
two alienated camps developed, disrupting the homeostasis of the
family. The family found itself in crisis, without the resources to
resolve it. Absalom paid for his life for the struggle for leadership.
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References
1. Olson, DH, Sprenkle DH, Russel C. Circumflex model of marital and family
systems: I. Cohesion and adaptability dimensions, family types and clinical
applications. Family Process. 1979;18:3-28.
2. Olson DH, Russel C, Sprenkle DH. Circumflex model of marital and family
systems: VI. Theoretical update. Family Process. 1983;22:69-83.
MOURNING FOR ABSALOM
Following his son’s death, King David was very upset and wept
bitterly “And the King was much moved, and wept up to the chamber
over the gate, and wept: ...O my son Absalom, my son, my son
Absalom! would I had died instead of thee....And it was told to Joab,
Behold the king weeps and mourns for Absalom. And the victory that
day turned into mourning for all the people...” (II Samuel 19:1-3).
These biblical verses indicate the great suffering of a human being
who has lost his son forever. In spite of Absalom's rebellion, the King
was attached to his beloved son. The grief was so painful that the
King wished to die instead of his beloved son.
Mourning characterized the grief of a person who has lost a loved
one forever. Mourning is not a disease; it is one of the most painful
facts of life. In fact, the more we are attached to someone, the more
we will suffer his or her losses. This is unavoidable. The grief
expressing our attachment is accompanied by immediate and intense
regression with repeated need for consolation. For some people, it
can be the means of coming to terms with their own mortality (1).
There are several stages of mourning: the living person's
ambivalence toward the deceased, the recollection corresponding to
the progressive acceptance of the loss, which represents the first
phase of the mourning process. During the healing phase, the
mourner is gradually capable of recalling the good times during the
life of the deceased and then progressively of evacuating the
souvenirs and starts living and opening to others again (1).
The biblical text gives no details about the stages of mourning that
King David and his family went through although it is likely that the
whole family passed through all these stages.
Stress is an environmental event, a process, and an outcome. One
approach defines stress in terms of life events, that is, as "stimulus".
Circumstances or events that require the person to adapt produce
feelings of tension. These "stressors" may be major catastrophic
events (a flood or earthquake), major life events (the death of a loved
one), or chronic hassles (managing a chronic medical condition) (2).
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The death of beloved son acted as a severe negative stressor,
leading subsequently to a negative outcome. This negative stressor
caused the King negative feelings of despair, anxiety, and depressive
reaction.
The purpose of this study was to describe fathers' grief and the
changes the death of a child has brought to fathers' lives.
Participants included eight fathers who lost their child. The grief of
the father manifested itself individually and dynamically in various
anticipatory feelings and in physical, social, and behavioral reactions.
The death of the child brought both positive and negative changes to
the father's life (3).
We see that the death of a beloved son led to physical, social and
behavioral reactions in the King. Did the death of his beloved son
bring changes to the King's life?
The human being needs ties to grow and develop. When some of
these ties are broken, a period of great intensity arises that we call
mourning. If the loss is radical and definitive, as in the case of death,
all of the person's dimensions are affected (the physical, emotional,
cognitive, behavioral, social, and spiritual) to such an extent that the
person can feel unable to overcome that and/or develops a
pathological mourning that requires intervention for recovery. Many
factors intervene in the type of mourning such as circumstances of
the death, relation to the deceased, personality, previous experience
and the socio-family context. For there to be complete recovery
following a loss, the person affected passes through a series of stages
or phases and must carry out basic tasks: 1. Accept the reality of loss.
2. Express emotions and pain. 3. Adapt to a setting from which the
loved one is absent. 4. Emotionally resituate the deceased and
continue living (4).
All these parameters can be ascribed to King David who lost his
beloved son, Absalom, forever.
Absalom's sudden death was an unpleasant experience that the
King went through. Parents of boys or children who died suddenly
experienced despair, anger, guilt, and depersonalization (5). The
sudden, unexpected death of Absalom caused his father despair,
anger, guilt, and probably depersonalization. From a contemporary
view, David required professional psychiatric intervention.
Major stressful life events, particularly those that have chronic
hardships, create a crisis for families that often leads to disruption
the family's style of functioning (6). The death of two young
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unmarried sons, Amnon and subsequently Absalom were very
stressful negative life events causing the King's family severe
hardships and affecting the family functioning.
TO SUM UP: King David was exposed three times to the mourning
process. First, when his newborn son died, secondly, when Amnon,
his son was killed and the third time when his rebellious son,
Absalom, was killed. In the case of the newborn child, the King
mourned for the child who suffered from an incurable disease, but
recovered quickly after the child died. In the case of his two sons Amnon, who paid with his life for a disgraceful affair with his halfsister Tamar, and of Absalom, a rebellious son who decided to fight
against his father, similar grief reactions were observed.
References
1. Barbier D. Mourning. Presse Med. 2001;30:1668-71.
2. Ahmed SA, Lemkau JP. Psychosocial influences on health. In: Rakel RE (ed).
Textbook of Family Practice. Sixth ed. Saunders, Philadelphia, London. 2002, pp. 4351.
3. Aho AL, Tarkka MT, Astedt-Kurki P, Kaunonen M. Fathers' grief after the death
of a child. Issues Ment Health Nurs. 2006;27:647-63.
4. Carbodevilla I. Loss and mourning. An Sist Sanit Navar. 2007;30 Suppl 3:16376.
5. Hazzard A, Weston J, Gutterres C. After a child's death: factors related to
parental bereavement. J Dev Behav Pediatr. 1992;13:24-30.
6. Patterson JM, Garwick W. Levels of meaning in family stress theory. Family
Process. 1994;33:287-394.
FATE OF CONCUBINES
The fate of concubines indicates a subsequent verse: “And David
came to his house at Jerusalem; and the king took the ten women his
concubines, whom he had left to keep the house, and put them under
guard and fed them, but went not in unto them. So they were shut up
to the day of their death, widows of a living husband” (II Samuel 20:
3).
A family is a small social system made up of individuals related to
each other because of strong reciprocal affections and loyalties, and
compromising a permanent household (or clusters of households)
that persists over years and decades. Members enter through birth,
adoption, or marriage, and leave only by death (1).
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The King chose ten women because of their affection, but they
lived enclosed in the same household until they died, so they
belonged to the same family system. These miserable women had
only one husband, the King, and they had no right to leave this
system.
There are open and closed family systems. Closed systems are
those in which there is no interaction with the surrounding
environment, as in chemical or physical reaction in a closed
container. Such systems obey rules different from those obeyed by
open system. Closed systems, for instance show entropy, the
tendency to reach the simplest, least ordered possible state from
whatever may be starting situation. Thus, if two gases, which do not
react chemically with each other, are introduced into a closed
container, the result will be diffuse complete mixing of the two. Once
this process is completed the system is in a state of equilibrium (2).
Open systems such as families, by contrast, do not show entropy.
Instead, there is a steady inflow and outflow of relevant material
across the boundary of the system. If the characteristics of the
boundary remain the same and the outside environment is
unchanged, a steady state is reached. The environment of most open
systems is, however, liable to change. There may also be alterations
in the characteristics of the boundary. These properties of open
systems make the change and evolution possible (2).
In addition, a family system is a set of individuals with
relationships between them. This system consists of a number of
subsystems, such as the parental coalition, the parent-child, or the
sibling relationships, which may be in the forms of dyads, triads, and
so on. In addition, a membrane, or boundary that may be open,
semi-permeable, or relatively closed and impermeable surrounds the
family, like any system (3).
King David’s family system consisted of a number of subsystems.
One of these subsystems included ten concubines belonging to the
King. This particular subsystem was surrounded by an impermeable
membrane or closed boundary, isolating it from the outside world.
The concubines lived in an isolated environment, depending entirely
on the King. It was the King, the ruler, the decision-making authority,
who was responsible for their fate. There was no right of dispute,
disagreement or contradiction to the King’s decision or other
arrangements for these women. Ten concubines obeyed the rules
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coming from the ruler, the great King. The rules were permanent and
their fate was determined.
The King’s family created its own rules that governed the family as
a whole and the individual subsystems within the family. A decisionmaking process, concentrated entirely in the King’s hands,
establishing the rules of behavior. The rules were very clear and
strict, with the King as the sole authority to administer the rules. The
interaction patterns within internal family system and its interactions
with the outside world depended on these defined rules. Nobody
had a voice to decide or participate in any decision making process.
The family system was rigid and inflexible.
References
1. Berman EM. Adult Developmental stages and marital interaction. Audio-Digest
(Psychiatry). 1978;7:5.
2. Baker P. Some Basic theoretical concepts. In: Philip Barker Basic Family
Therapy. Second ed. Blackwell Scientific Publications. Oxford London Edinburg.
1981, pp. 33-54.
3. Medalie JH, Kitson GC, Zyzanski SJ. A family epidemiological model: a practice
and research concept for family medicine. J Fam Practice. 1981;12:78-87.
GIBEONITES
A subsequent story indicates an additional source of stress. There
was a famine in the days of David. King Saul was blamed for this
famine because he killed the Gibeonites, so King David asked the
Gibeonites to end this famine. The Gibeonites demanded that the
King hand over seven men to be hanged as vengeance for their killed
people. Because of his oath and friendship with Jonathan, King David
spared Jonathan’s son Mephibosheth. The King’s decision fell on two
sons of Saul’s concubine Rizpah, Armoni and Mephibosheth, and five
sons of Saul’s daughter Michal, the wife of Adriel, and son of Barzillai
the Meholathite. These seven men were taken to the Gibeonites, and
were hanged (II Samuel 21:7-9).
Model of stress includes three conceptual domains: sources of
stress, mediators of stress, and outcomes of stress (1). The sources of
stress are conceptualized as physical or psychological demands on a
system (e.g., the body), which upset its normal steady state of
functioning. The mediators are primarily resources (physical,
psychological, or social) and coping behaviors that influence whether
or not stress is experienced, how it is managed; how long it lasts, and
whether or not it prevents or reduces the outcome. The outcomes
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focus on changes in functioning of some level of the system, from the
organ (2) to the family (3).
According to this model the famine following King Saul’s murder
of the Gibeonites, was the source of stress. The famine had a
negative impact on the people, making their physical and
psychological demands on them. The mediators included physical,
psychological, and social resources used by King David to end the
famine. In order to resolve this stress, seven members of King Saul’s
family had to be sacrificed. David respected King Saul all his life in
spite of Saul’s wish to destroy him. Now was the moment of truth,
the moment for revenge. David decided to sacrifice two sons of one
of Saul’s concubines, and five sons of Michal, his former wife, who
was later given in marriage to Phalti. His vengeance overtook the
dead King Saul even in the grave. The act of revenge encompasses
physical, psychological and social aspects of human existence. The
results were obvious - revenge was achieved.
With regard to this story, there are some inconsistencies in the
Bible. Firstly, it is stated that “..Saul gave him (to David) Michal his
daughter to wife” (I Samuel 18: 27). Later, Michal, David’s wife, was
given to Phalti the son of Laish...” (25:44), while Michal’s sister Merab
was given in marriage to Adriel the Meholathite (18:19). We learn
that “And Michal the daughter of Saul had no child to the day of her
death” (II Saul 6:23). However, a subsequent verse states “… the king
took ...the five sons of Michal the daughter of Saul, whom she
brought up for Adriel the son of Barzillai the Meholathite” (21:8). In
spite of these inconsistencies, the story indicates convincingly that
King David sacrificed members of King Saul’s family in order to save
the life of others.
References
1. Patterson J. Families experiencing stress. I The Family adjustment and
adaptation response model. II Applying the FAAR Model to health-related issues for
intervention and research. Fam Systems Med. 1988;6:202-35.
2. Seley H. The stress of life. New York: McGraw-Hill, 1956.
3. Hill R. Generic features of families under stress. Social Casework. 1958;49:13950.
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BRIEF REVIEW OF STRESSFUL LIFE EVENTS
AND SUBSEQUENT CRISES
This research deals with an evaluation of King David’s family life
cycle. This family was continuously exposed to stressful life events
and subsequent crises. Crises occurring in a family are normative or
non-normative. Normative crises are expected events within the
normal life of the family, while non-normative crises are unexpected
life events. These crises may be divided into four categories: 1)
additions, e.g., birth or marriage (normative) or unexplained
pregnancy (non-normative); 2) abandonment, e.g., death of elderly
member of family, minor illness (normative), or family member being
involved in war, divorce or the sudden death of a family member
(non-normative); 3) demoralization, e.g., rebellion against social
norms (normative) or alcoholism, delinquency, or jail (nonnormative); 4) status change, e.g., moving to another community,
starting a new stage in life, change in role (normative) or physical or
emotional handicap, loss of freedom, or loss of income (nonnormative) (1).
Holmes and Rahe (2) calculated the social
readjustment value for each life event.
For, example, the
readjustment value for death of a spouse receives a score of 100,
divorce - 73, marital separation - 63.
David’s victory over Goliath was the first normative crisis. This
victory made him very popular among his people. A subsequent
crisis occurred when King Saul promised David his daughter Merab in
marriage and then broke his promise by giving Merab to Adriel the
Meholathite. Here, David was exposed to a non-normative crisis.
Later, a normative crisis followed when David married Michal. On
the Holmes-Rahe scale, marriage receives a score of 50 and can be
regarded as a positive normative stressful life event. An expansion of
the family, with a birth of a new child receives a score of 39. Thus,
each time a child was born, the King experienced a positive stressful
event.
A normative crisis also followed when David’s status was changed
and he was anointed as King over the house of Judah, and then again
when he was crowned King over Israel. From this time onwards, King
David belonged to a high socioeconomic stratum. David, the great
King of Israel, ruled all the country. The fate of his country and his
family was legally placed in his hands.
His sexual relations with Batsbeva, however, created a severe
non-normative crisis. As David exploited his royal status with
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deception and lies, culminating in the plot to destroy Uriah.
Jonathan’s death can be considered a negative stressful life event.
Since David and Jonathan were such close friends, the loss of
Jonathan should receive the maximum points - 100, on the scale
described above (2). Similarly, the discovery and adoption of
Mefivoshet, Jonathan’s son, can be regarded as a positive stressful
life event. The entry of a new family member, receives a score of 39.
The incurable illness of a newborn son was a significant source of
stress, although the King recovered and returned to everyday life
quickly. The death of Amnon and later of Absalom caused the King
significant suffering.
The story of the Gibeonites reveals an additional negative source
of non-normative stress. The King sacrificed seven men, in order to
end a dreadful famine. His decision fell on these innocent men as a
means of saving the lives of the many others.
The King was the sole leader of his society, both within his internal
family system, as well as in the external world. As the King and the
head of his family, he had the power to decide all intrafamilial and
extrafamilial problems. In this rigid system, there was no place for
confrontation or objections to the King’s will. His decisions had to be
accepted without hesitation and his family had to adjust to such
norms of life in order to survive.
Eventually the King grew old “Now king David was old, advanced
in years..” (I Kings 1:1), afflicted by various diseases and suffering
from various psychosocial problems (3). Once again, David’s family
was exposed to an another stressful event “Then Adonijah the son of
Haggith exalted himself, saying, I will be king: and he prepared him
chariots and horsemen, and fifty men to run before them” (1:5).
However, King David said nothing to his son, Adonijah. Then
Bathsheba, Solomon’s mother, intervened reminding the King that he
had promised that Solomon would reign after him. So King David
anointed Solomon to be the King after him “...Solomon thy son shall
reign after me, and he shall sit upon my throne in my stead;...I have
appointed him to be ruler over Israel and over Judah” (1:30,35).
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King David. Moretto. The Southesk Collection.
We see that two brothers struggled for the position of King. The
appointment of Solomon imposed stressful life events on the two
brothers and a poisonous atmosphere developed between them.
Eventually, Adonijah lost the crown.
References
1. Smilkstein G. The family in crisis. In: Taylor R (ed). Family Medicine-Principles
and Practices. Springer Verlag. New York. 1978, pp. 235-324.
2. Holmes TH, Rahe RH. The social readjustment rating scale. J Psychosom Res.
1967;11:213.
3. Ben-Noun L. The diseases and psychosocial problems that affected King
David. (In Hebrew). In: Ben-Noun L. (ed.). Kiryat-Gat, Israel. 2003.
THE OLD KING
In the end King David was an old, sick man suffering from multiple
diseases: "Now King David was old and stricken in years" (I Kings 1:1),
“Now the days of David drew near that he should end his life.., And
the days that David reigned over Israel were forty years: seven years
he reigned in Hebron, and thirty three years he reigned in Jerusalem”
(2:1,11). “And he died in a good old age, full of days, riches, and
honor: and Solomon his son reigned in his stead” (I Chronicles 29:28).
“So David slept with his fathers and was buried in the city of David” (I
Kings 2:10).
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THE DISEASES THAT AFFLICTED KING DAVID
EYES
The elderly have suffered from poor vision or blindness for
thousands of years. This research is unique in character, as it
combines present-day knowledge with the presentation of a patient
taken from ancient history. The main aim of this research is to
analyze the biblical description of a geriatric patient who suffered
from some visual problem. The passages “My eye is consumed…”
and “As for the light of my eyes, it is also gone from me” indicate
blindness. Among the numerous causes associated with the
blindness, either age-related neovascular macular degeneration, or
mature cataract, or asymptomatic open-angle glaucoma, or optic
atrophy caused by the end-stage open angle glaucoma are the most
likely responsible for this condition.
FOREWORD
Today’s elderly patients, like ancient patients, may suffer from
visual impairment and blindness. It is a challenge for present-day
physicians to properly diagnose and provide appropriate treatment
for these patients. In order to widen the horizon of our knowledge, it
is important that contemporary physicians be familiar with the
available literature on various visual disorders. Studying the causes
of visual impairment and blindness among the elderly in ancient texts
may help them to handle these painful situations more efficiently.
VISUAL IMPAIRMENT AND BLINDNESS
There are 37 million people who are completely blind and another
112 million whose sight is severely restricted worldwide. Of all blind
people, 85% live in developing countries. In three quarters of cases,
blindness can be prevented or treated (1).
The impact of visual loss has profound implications for the person
affected and society as a whole (2). In addition, self-reported visual
impairment is an independent factor associated with mortality (3).
The majority of blind people live in developing countries, and
generally, their blindness could have been avoided or cured. Given
the current predictions that the number of blind people worldwide
will roughly double by the year 2020, it is clear that there is no room
for complacency. As the world's population increases and as a
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greater proportion survives into late adulthood, so the number of
people with visual loss will inexorably rise. As the longevity of the
world's population increases, the visual requirements at the
workplace are also changing. People with low vision may be at a
disadvantage in many common activities, and may face
unemployment – particularly in technological societies (2).
Efforts should be made to recognize and treat those affected at an
early stage, for the benefit of the individual and society (2).
Physicians must be aware of the physical limitations and social issues
associated with vision loss to optimize health and independent living
for the visually impaired patient (4).
Of the 38 million people who are blind worldwide, 22 million are
over the age of 60 years (World Health Organization Estimate) (5).
Poor vision and blindness increase significantly with age for all races
and ethnicities (6-8). These data, combined with life expectancy that
is on the increase (9), indicate that it is essential to provide effective
ophthalmologic care for the elderly.
Cataract remains the major cause of blindness, especially in the
less developed countries, while age-related macular degeneration
(AMD) in developed countries. Substantial improvements have been
achieved in the control of blinding diseases, mainly in respect of
onchocerciasis and xerophthalmia. The WHO alliance for the
eradicating of trachoma by the year 2020 has been set up (10). The
age-related eye diseases will rapidly become the most common
causes of blindness and visual loss and, with the exception of
cataract, are the more difficult to identify, diagnose, and treat (11).
PREVALENCE
Blindness and visual impairment are among the 10 most common
causes of disability in the United States, associating with shorter life
expectancy and lower quality of life (12), and affecting more than 3
million Americans 40 years and older, and this number is projected to
reach 5.5 million by 2002 (4). The four most prevalent etiologies of
vision loss in persons 40 years and older are – AMD, cataract,
glaucoma, and diabetic retinopathy (4).
In Canada, visual impairment in the elderly is common and is
associated with increased odds of institutionalization, frequent falls,
difficulty with everyday practices, and poor health (13).
In Reykjavik, the prevalences of bilateral visual impairment and
blindness (n=1045 persons aged 50 years and older) are 0.96% (95%
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CI 0.37-1.55) and 0.57% (95% CI 0.12-1.03), respectively, using the
WHO criteria, and 2.01% (95% CI 1.16-2.86) and 0.77% (95% CI 0.241.29), respectively, using the US criteria. The prevalence rates are
4.04% and 5.5% for unilateral impairment and 1.7% and 3.1% for
unilateral blindness, using the WHO and US criteria, respectively.
AMD is the major cause of bilateral visual loss, whereas the most
common causes of unilateral visual loss are amblyopia, cataract and
glaucoma (14).
In West Africa, Mali, 828 patients were examined; unilateral
blindness accounted for 11.5% of cases (95 patients). The main
causes of unilateral blindness were trauma (60.5%), infection (26%)
and degenerative diseases (18%). Low vision accounted for 8.5% of
cases (70 patients). The main cause of low vision was ametropia.
Bilateral blindness was observed in 5.8% of cases (48 patients). The
man cause of bilateral blindness was cataract (19.2%). The third most
common cause (14.6%) was ocular manifestations of HIV infection,
confirming that the epidemiology of blindness is changing and that
HIV/AIDS should be taken into account (15).
In Brazil, Säo Paulo, the prevalence (802 individuals, 60 years and
older) of presented and best-corrected visual acuity worse than
20/400 in both eyes was 1.38% (95% CI 0.69-2.45) and 1.25% (95% CI
0.60-2.29). Cataract was the main cause of blindness - 30.0%, while
visual impairment - 54.9% (16).
In Oman, 1997, the prevalence of blindness was 7.23% (95% CI
5.91-8.55) while 8.25% (95% CI 7.14-9.36) in 2005. The prevalence of
legal blindness and low vision were 12% and 45.12%, respectively.
The prevalence of blindness due to corneal pathology declined from
1.9% to 1.1% but that of blindness due to unoperated cataract
increased from 1.8% to 2.3%. The rate of disability has declined but
the number of blind people has increased. The causes of blindness
have changed from communicable/avoidable eye diseases to noncurable/chronic eye diseases, and the number of individuals with
visual disabilities has increased (17).
In Malay, Australia, in the population-weighted (n=3280) the
prevalence of bilateral blindness was 0.3% and 4.4% of bilateral low
vision. Cataract was the main cause of unilateral (38.9%) and bilateral
(65.2%) blindness, whereas under corrected refractive error was the
main cause of unilateral (68.5%) and bilateral (52.2%) low vision.
Diabetic retinopathy, AMD, and glaucoma were the other leading
causes of blindness and low vision (18).
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In Pakistan, a nationally representative sample of 16.507 adults
aged 30 years or above (95.3% responsive rate) was studied.
Blindness was associated with poverty in Pakistan; lower access to
eye care services was one contributory factor (19). Cataract still
accounts for over half of the cases of blindness followed by corneal
opacity, uncorrected aphakia and glaucoma (20).
In Nantong, China, the prevalence of blindness and low vision
(n=3040) based on the pinhole visual acuity was 1.35% (presenting
1.32%) and 1.84% (presenting 6.05%), respectively. The prevalence of
blindness and low vision grew up exponentially with age. Blindness
and low vision were prevalent in the urban area of China, especially
in the elderly women, with cataract as the most common cause in the
Chinese elderly (21).
Visual impairment and blindness either unilateral or bilateral are
prevalent conditions worldwide. In the elderly, the most common
causes of vision loss are AMD, cataract, glaucoma, optic atrophy,
diabetic retinopathy, and refractive error (22-26). The prevalence of
these conditions increases with age and vary in different populations.
My previous research indicates that vision problems in the elderly
have existed for thousands of years. Isaac (the second of the three
biblical Patriarchs of the Jewish people), Jacob (the third of the
Patriarchs later called Israel), and Eli (the priest who judged Israel for
forty years) all suffered from a gradual impairment of vision (27).
THE BIBLICAL DESCRIPTION
King David, the second and greatest of Israel’s Kings who ruled the
country 3531 years ago, was about 70 years old at the end of his
reign. When the King reached old age he, similarly to the three
biblical characters mentioned, suffered from some type of visual
disorder as indicated by the subsequent passages “My eye is
consumed…” (Psalm 6:8; 31:10) and “As for the light of my eyes, it is
also gone from me” (38:11). Severe visual impairment is categorized
as blindness or poor vision (28). Since the King could not see even
light, it follows that he was blind.
What was the cause(s) of the blindness that afflicted the old King
David, a member of the highest socioeconomic stratum? This
research aims to answer these questions by evaluating this patient’s
medical record, which is the biblical text.
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AGE–RELATED MACULAR DEGENERATION
AMD is a degenerative disorder of the retinal macula that results
in loss of central vision needed for tasks such as reading, watching
TV, driving, and recognizing faces, with some people feeling suicidal
(29-31). AMG is the most common cause of severe vision loss in
people over 50 years of age in the western world (32). AMD
threatens independence, especially when comorbidity exacerbates
functional limitations (31). Neovascular form of AMD is especially
associated with decreased functional abilities and quality of life,
which result in an increase in healthcare resource utilization (33).
AMD is the first cause of blindness in industrialized countries in
patients over the age of 55. Its prevalence increases with age,
affecting up to 25% of the population aged over 75 (34). Based on
demographics from the 2000 US Census, an estimated 937.000
(0.78%) Americans older than 40 years are blind (US definition). The
leading cause of blindness among white persons is AMD (54.4% of
the cases) (35). The overall prevalence of neovascular AMD and/or
AMD with geographic atrophy in the US population 40 years and
older is 1.47% (95% CI 1.38-1.55) (36), 3.7% (95% CI 3.2-4.2) of those
75 years or older, and 14.4% (95% CI 11.6-17.2) in the population
aged 90 years or older (37).
AMD is responsible for 54% of legal blindness, in Iceland, 2006,
(38); 23.1% in Baden, Germany, 1980-1999, (39); 20.1% in Israel
(n=21.585), 1998-2003, (40); 2.6% in Osun State, Nigeria, (n=3204)
(41); 2.0%/7.7% of low vision/blindness (n=8816 eyes of 4409
subjects) in Beijing, China (42); and in Tehran, 2002, 1.95 per 100
(95% CI 1.55-2.34) of the population (n=6497) (43).
Advanced AMD is more likely to be present in whites than blacks,
despite the similar prevalence of soft drusen in both groups.
Neovascular AMD is more frequent than geographic atrophy in most
population-based studies in whites in America, Australia, and the
Netherlands than in similar population-based studies in Iceland and
Norway. The relationship of smoking, hypertension, and cataract
surgery to advanced AMD has been consistent (44). Genetic factors
such as complement factor H are strongly associated with AMD (45).
Abu Asleh et al. (46) suggested that AMD is less common in Arabs
than in Jews in the city of Jerusalem. They compared the number of
patients eligible for certification of blindness and the number of
patients who underwent photodynamic therapy for neovascular
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AMD, providing additional evidence that ethnic background plays an
important role as a risk factor for advanced AMD.
Different ethnic groups can have significantly different genetic
patterns and can vary considerably in their lifestyles in terms of diet,
cigarette smoking, alcohol consumption, etc. All these may explain, in
part, the differences in the prevalence of AMD between Jews and
Arabs in Jerusalem (47).
AMD is classified into two types: non-neovascular (non-exudative
or atrophic AMD) and neovascular (exudative or serous AMD) (29).
Non-neovascular AMD accounts for approximately 80% of all AMD
and is associated with the formation of drusen (48). Neovascular
AMD accounts for only about 20% of all AMD, but is responsible for
90% of cases of severe, irreversible central vision loss. Progression
from non-neovascular AMD to neovascular AMD occurs in
approximately 10%-20 % of people with AMD (48).
AMD pathogenesis is multifactorial, involving a complex of
interactions of various factors such as metabolic, functional, genetic
and environmental (34,48,49).
Arterial sclerosis in the retina is associated with 2-fold increased
risk (OR=1.96) of exudative AMD. No association was found between
iris color, use of sunglasses, work conditions and AMD. The
coexistence of arterial sclerosis in the retina suggests that vascular
disorders take part in pathogenesis of exudative type of AMD (50).
Eyes with AMD are more likely to have cataract and nuclear
sclerosis. The concomitance of cataract (especially nuclear sclerosis)
and AMD supports the theory of common pathogenesis in both
pathologies. There is increased risk of exudative type of AMD in eyes
after cataract surgery (51).
In addition, middle-aged persons who have a 3% or greater
reduction in waist-hip-ratio overtime were less likely to have AMD,
particularly among those who are initially obese (52).
Non-neovascular AMD is characterized by blurred or distorted
vision, central scotoma and slow decline or no change in visual acuity,
while the neovascular type is recognized by central scotoma, image
distortion, increased glare sensitivity, decreased color perception,
photopsias, formed hallucinations, blindness, and rapid, steady
decrease in visual acuity (29).
Typical symptoms of AMD include decreased central vision,
central scotoma, and metamorphopsia (28). Examination of the
fundus shows: drusen (located deposits of lipids and lipoproteins)
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and alterations in retinal pigment epithelium (RPE) (hypo- or
hyperpigmentation). Two forms of complications are atrophic (or
"dry") and exudative (or "wet"). The atrophic form is characterized by
the presence of degeneration in the central RPE, choriocapillaris and
photoreceptors, resulting from the enlargement and/or coalescence
of small areas of peri-foveal atrophy (or "geographic" atrophy). The
exudative form, responsible for the majority of cases of blindness due
to AMD, is characterized by the appearance of choroidal new vessels,
identifiable on fluorescein angiography and responsible for serous
retinal detachment, edema and hemorrhage, leading to the
destruction of the macular photoreceptors. RPE progressively
degenerates, which results in an irreversible degeneration of
photoreceptors (53).
Diagnosis of AMD requires an ophthalmoscopic examination.
Although data for such an evaluation are unavailable in King David's
case, the presence of blindness seems to hint at neovascular AMD.
There is also a possibility that non-neovascular AMD progressed to
neovascular AMD in the King's case.
CATARACT
Cataract is the leading cause of blindness, accounting for 50% of
blindness worldwide. Although significant progress has been made
toward identifying risk factors for cataract, there is no proven
primary prevention or medical treatment (54). Age-related cataracts
are by far the most common type of cataracts (55). Most cataracts
are bilateral (55) although cataract may occur in only one eye and
may mature more rapidly in one eye than in the other (55,56).
Cataract, namely subscapular cataract in elderly subjects, is
associated with an increased mortality risk (57). Cataract, which is a
lens opacity that interferes with visual function, is the leading cause
of blindness in the world today (5), and accounts for approximately
16 million cases of blindness (visual acuity <20/400, Snelen
equivalent) worldwide (World Health Organization 1997 estimate)
(29). An estimated 20.5 million (17.2%) Americans older than 40
years have a cataract in either eye (58). The prevalence of vision loss
caused by cataract increases with age, rising from 4.5% in people
aged 52-64 years to 45% in people aged 75-85 years (59).
The incidence of age-related cataract over a 15-year interval in the
Beaver Dam Eye Study reached 29.7% for nuclear cataract, 22.9% for
cortical cataract, and 17.7% for cataract surgery (60). In Lódź, the
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mean age of patients operated for cataract, 1997–2004, increased
and there was a tendency of performing operations in cases with
better visual acuity (61).
In Pakistan, 2002-2003, 16.402 adults were included to investigate
the prevalence and evaluate risk factors for lens opacity. Almost a
fifth of the adult population had lens opacity. Significant positive
associations were age, smoking status, hypertension, diabetes, and
increased deprivation level (62).
The chief symptom of acquired cataract is a gradual decrease of
vision that is not associated with pain or inflammation of the eye.
Double vision in one eye (monocular diplopia) is caused by the lens
opacity splitting light bundles, but this disappears with further
decrease in vision. In the early stages, lights may be surrounded by a
collar halo (63).
Dilatation of the pupil that occurs in dim illumination improves
vision. Glare and constriction of the pupil in bright illumination
reduce vision, particularly in patients with posterior subcapsular
cataracts that obstruct the visual axis. Patients may complain of
spots in the visual field that, unlike those caused by vitreous floaters
remain fixed. In nuclear cataracts, there is often an increase in the
refractive power of the lens so that patients are able to read without
glasses (63).
Paradoxically, in the incipient stage of cataract distant vision is
blurred, but near vision may improve slightly, so the patient will read
better without glasses ("second sight"). This artificial myopia is due to
the greater refractive index of the lens in the incipient stage. The
gradual decrease of vision is not associated with pain or
inflammation of the eye (64). Opacity of the lens can vary from a
small local opacity to a diffuse general loss of transparency (29).
Since the King was elderly, it is very likely that he was afflicted by
mature cataract responsible for a slow and painless deterioration in
the King’s visual function, progressing subsequently to blindness.
Cataract may be also associated with inflammation, trauma,
diabetes mellitus, ultraviolet radiation, and metabolic or nutritional
disorders (65,66). Since King David suffered from anorexia, fasting,
extreme weight loss, and subsequent cachexia (67), he suffered from
malnutrition, which is an identifiable risk factor for cataract in this
particular geriatric patient. There is no reason to suspect diabetes
mellitus when evaluating King David’s medical record (the biblical
text), on the whole.
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Cataracts may be located in the nuclear, posterior polar, posterior
cortical, posterior subscapular, coronary, lamellar, anterior
subscapular or anterior pyramidal area (63). Where was the cataract
located in King’s case?
Since there are no data from an
ophthalmoscopic examination, this question remains open.
In summary, it is very likely that the King suffered from cataract
that led to blindness, with malnutrition as a risk factor for cataract
development.
GLAUCOMA
The glaucomas are a range of disorders with a characteristic type
of optic nerve damage. These diseases are the second commonest
cause of blindness in the world, and the commonest cause of
irreversible blindness (68). The glaucomas are associated with an
increased rate of mortality, particularly angle-closure glaucoma, in
elderly subjects (69).
There are two main types of glaucoma: open angle glaucoma
(OAG) and closed angle glaucoma (CAG). If the cause is evident,
glaucoma is designated as secondary, but if the cause is unknown, as
primary (70).
Approximately 6.4 million people worldwide are affected by
blindness due to glaucoma (World Health Organization 1997
estimate) (29). Of those people who are legally blind (visual acuity of
20/200 or worse in the better-seeing eye) because of glaucoma, 75%
are older than 65 years of age (71).
In the United States, the prevalence of glaucoma reached 2.0%
(n=31.044) (6), in adult Latinos (n=6142) the prevalence of OAG was
4.7% (72), among Eskimos, the prevalence of primary glaucoma with
angle-closure (PACG) was 2%-8%, and among Caucasians 0.1% (73), in
Northern Italy, the overall PACG reached 0.6% (n=4287) (74), in
Chennai, India, the prevalence of PACG was 0.88% (n= 3850) and
2.75% were diagnosed to have primary angle closure (75). In Tajimi,
Japan, (n=3870) the prevalence of primary OAG was 0.6%, secondary
glaucoma 0.5%, and 5.0% for all glaucomas in subjects over 40 years
(76), in China, an estimated 9.4 million people aged 40 years and
older have glaucomatous optic neuropathy. Approximately 5.2
million people (55%) would be blind in at least one eye, and around
1.7 million (18.1%) would be blind in two eyes (77).
In OAG, the resistance to outflow through the trabecular
meshwork gradually increases for reasons not fully understood, and
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the pressure in the eye slowly increases. There may be other damage
mechanisms, particularly ischemia of the optic nerve (78).
OAG is usually asymptomatic. It is a silent, surreptitious process
leading to a gradual loss of vision (68). Halos around lights and
blurring of vision do not occur unless there has been a sudden
increase in intraocular pressure and many patients never have visual
difficulties. Because the visual loss is gradual, patients do not usually
present until damage has occurred. The disease can be detected by
screening high risk groups for the signs of glaucoma. At present time,
optometrist at routine examinations detects most patients with
primary open angle glaucoma (79).
In primary CAG, relative pupillary block is the mechanism of angle
closure. This means that there is relative resistance to fluid flow of
aqueous humor between the posterior iris surface and lens due to
their close approximation at the pupil. This relative papillary block
increases the pressure of aqueous in the posterior chamber, forcing
the peripheral iris forward over the trabecular meshwork (79).
The symptoms of PACG are mainly related to a sudden increase in
intraocular pressure. There may be repeated attacks of ocular pain
and blurred vision occurring after a prolonged time in darkness, after
emotional upset, or after similar situations that cause papillary
dilation. The rapid increase in intraocular pressure causes an
epithelial edema of the cornea that results in blurred vision and halos
surrounding streetlights. The eye becomes red and painful, and
patients may be systemically unwell with nausea, vomiting, and
severe pain or headache. Vision is blurred, and patients notice haloes
around light. They may have a history of similar attacks that were
aborted by going asleep. During sleep, the pupil constricts and may
pull peripheral iris out of the angle (79). Severe prostrating pain,
usually unilateral, may be confused with migraine, impending rupture
of a carotid aneurism, and similar causes of hemicrania (70).
The degree of increased pressure that causes organic change is
not the same in every eye, and some individuals may tolerate for long
periods a pressure that would rapidly blind another. There are two
major factors involved in the visual loss of glaucoma: 1) the
intraocular pressure, which depends on the rate of reduction of
aqueous humor and its rate of exit through the trabecular meshwork,
and 2) the resistance of the intraocular portion of the optic nerve to
the development of optic atrophy (70).
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Glaucoma-caused blindness is associated with an advanced stage
of glaucoma at diagnosis, fluctuation of intraocular pressure during
treatment, the presence of exfoliation syndrome, and poor patient
compliance (80).
Recently, the association between thyroid problems and
glaucoma was evaluated in a population-based cross-sectional
sample with 12.376 participants from the 2002 National Health
Interview Survey. Odds ratios (OR) and 95% confidence intervals (CIs)
were used to quantify the association between a self-reported
diagnosis of glaucoma and a self-reported history of thyroid
problems, controlling for demographic characteristics and smoking
status. The overall prevalence of glaucoma was 4.6%; 11.9%
reported a history of thyroid problems. The prevalence of glaucoma
among those who did not report thyroid problems was 6.5% and
4.4%, respectively (p=0.0003). Following adjustment for differences
in age, gender, race and smoking status, the association between
glaucoma and thyroid problems remained (OR 1.38, 95% CI 1.08 1.76). The results of this study lend support the hypothesis that
thyroid disorders may increase the risk of glaucoma (81).
Was King David afflicted by glaucoma? It seems likely that OAG
with its asymptomatic, slowly deteriorating course led to damage of
his optic nerve and eventual blindness. The diagnosis of CAG can be
excluded because of the absence of the above-mentioned associated
symptoms.
OPTIC ATROPHY
Optic atrophy is the result of diseases or injuries to retinal
ganglion cells or their axons that produces degeneration of axons
anterior to the lateral geniculate body. The chief symptom of optic
atrophy is loss of central and peripheral vision. Etiological
classification of optic atrophy includes glaucoma, diabetes mellitus,
brain tumor, retinal ganglion cell or nerve fiber disease (pigmentary
degeneration of retina, chorioretinal degeneration, inflammation,
and atrophy), inflammation (demyelinating disease, meningitis,
encephalitis, abscess), tabes dorsalis, optic neuritis, metastatic
septicemia, optic neuropathy, papiledema, toxicity (chemical:
arsenic, lead, methanol, ethanol, quinine, cigarette smoking, tobacco,
chloroquine, ethambutol, chlorphenicol), vitamin B deficiency
(beriberi, pellagra, pernicious anemia), sarcoidosis, glioma, hereditary
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and trauma (82-85). Ischemic optic neuropathy can be related to
atherosclerosis or giant cell arteritis (86). Giant cell arteritis can
produce an ophthalmic catastrophe and occurs exclusively in the
elderly. It most commonly produces ischemic optic neuritis (75% of
ocular events) due to arteritis of the posterior ciliary artery (87).
Hereditary causes of progressive optic nerve or retinal degeneration
can be excluded, since the loss of vision occurred at an advanced age.
Of the factors listed above, OAG can be identified as the probable
cause of optic nerve atrophy in the King’s case. Was the King
afflicted by nutritional optic atrophy since he suffered from
malnutrition?
REFRACTIVE ERROR
Refractive error is prevalent among the causes of impaired vision
among the elderly (88). It may be defined as a state in which the
optical system of the non-accommodating eye fails to bring parallel
rays of light into focus anterior or posterior to the fovea, respectively,
resulting in blurred vision (88). Since in this disorder vision is only
blurred, it can be excluded as a cause of King David’s blindness.
OCULAR MANIFESTATIONS OF CANCER
Ocular manifestations of systemic malignancy are important for
both the ophthalmologist and the internist to recognize because they
may precede the diagnosis of cancer (89).
Cancer may affect the eye and orbit as a direct result of
metastatic neoplastic infiltration, compression, or circulating
antibodies involving paraneoplastic retinal degeneration.
A
metastatic tumor to the uvea is the most common form of an
intraocular metastatic process. The choroid is the most common site
for uveal metastasis; metastasis to the ciliary body, iris, retina, optic
disc, and vitreous are rare. Approximately one-third of patients have
no history of primary cancer at the time of ocular diagnosis. Breast
and lung carcinomas for women and lung and gastrointestinal
carcinomas for men most commonly metastasize to the eye and
orbit. The visual paraneoplastic syndromes encompass several
distinct clinical and pathological entities including carcinomaassociated retinopathy (CAR), melanoma-associated retinopathy and
bilateral diffuse melanocytic uveal proliferation (90).
The CAR is a paraneoplastic retinopathy in which an antigenantibody reaction, due to retinal antigens, also expressed in tumors,
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leads to degeneration of retinal photoreceptor cells. The CAR is most
frequently associated with small cell lung and ovarian carcinomas.
Clinical symptoms (phosphenes, progressive loss of eyesight)
sometimes occur before the diagnosis of primary cancer (91).
The term "Masquerade Syndrome" was first used in
ophthalmology in 1967 by Theodore to describe a case of
conjunctival carcinoma that manifested as chronic conjunctivitis. The
Uveitis Masquerade Syndromes are a group of various ocular
diseases that mimic chronic intraocular inflammation. Most common
malignant conditions, which may be considered masquerades,
include primary intraocular lymphoma, leukemias, uveal melanoma,
retinoblastoma, metastatic lesions, and paraneoplastic syndromes
(92).
Renal cancers metastasize to the eye and the orbit. As these
tumors can be confused with other amelanotic or vascular tumors, a
high index of suspicion is required for early detection and
management of the primary tumor (93).
Prostate carcinoma, when metastatic, typically involves bones and
produces both osteoblastic and osteolytic changes. Orbital
involvement is uncommon and extraocular muscle enlargement is a
rare presentation of metastatic adenocarcinoma (94). Prostate
cancer may metastasize to an extraocular muscle many years after
treatment of the primary tumor and may not be accompanied by
elevated serum PSA (95). Clinicians should be aware that, although
rare, prostate cancer could involve the extraocular muscles (94).
Ophthalmic manifestations of multiple myeloma may appear at
the initial presentation of the disease or occur late in the disease
process (96). Ocular findings include: proptosis, diplopia, lid
ecchymosis, xanthomatosis, conjunctival and corneal crystalline and
non-crystalline deposits, scleritis, episcleritis, secondary glaucoma,
ciliary body cysts, ciliochoroidal effusion, uveal plasmocytoma,
hyperviscosity retinopathy, and retinal vasculitis, detachment of
sensory retina and retinal pigment epithelium, and neuro-ophtalmic
manifestations (97).
A 47 year-old man with a history of lung adenocarcinoma
presented a red and painful right eye with loss of visual acuity after
the fifth course of chemotherapy. The ophthalmologic examination
showed visual acuity at 3/1 and diffuse iris nodular lesions in the
same eye. The ocular scan demonstrated iris tumors without
choroidal metastasis (98).
85
L. Ben-Nun
King David
Furuichi et al. (99) reported a case of small cell carcinoma of the
lung with metastasis to the iris during a stage of complete remission
obtained with chemotherapy and radiation therapy.
Reddish/orange color is a commonly observed feature of the
uveal metastasis of thyroid carcinoma. Although ocular and skin
metastases from thyroid carcinoma are rare, this possibility should be
considered in the differential diagnosis of reddish-colored iris and
choroidal masses (100).
A 47-year-old healthy man sought treatment for a three-week
history of a progressively enlarging red spot on the left iris. Iris biopsy
revealed the lesion represented metastasis, and a systemic
evaluation revealed the primary source of esophageal
adenocarcinoma (101).
In 26 of 227 patients with carcinoma metastatic to the eye or
orbit, metastasis to the anterior uveal tract was the predominant
feature. There was a definite propensity for the tumor to involve the
horizontal meridian of the iris or ciliary body, rather than the upper
or lower portion. The site of the primary tumor in the 26 patients was
as follows: lung, 14; breast, 9; kidney, 2; and rectum, 1. Ocular
symptoms and signs produced by the metastatic tumor at onset or
during the course of the disease included a decreased vision (80%), a
visible mass (72%), redness of the eye (56%), pain (56%), glaucoma
(56%), iridocyclitis (44%), and hyphema (24%). The median survival of
the 26 patients with metastasis to the anterior segment of the eye
was only 5.4 months from the time of ocular surgery. This is poorer
than the median survival (7.2 months) of the patients with metastasis
confined to the posterior segment, and much worse than the median
survival (15.6 months) of the patients with orbital involvement (102).
Thus, the main symptom in the case of ocular metastasis is a
decreased vision.
Various types of cancers may affect eyes. As previously shown
(67,103), it is most likely that the King had suffered from some
malignant disease. Among these neoplastic diseases, it is most likely
that the King was afflicted by multiple myeloma, or renal and/or
prostate cancer, see the section below. Did one of these diseases
spread to the eye/eyes? The passages “My eye is consumed…” and
“As for the light of my eyes, it is also gone from me” gives us an
answer; the verses indicate blindness (not decreased vision).
Although data on any ophthalmoscopic examination are unavailable,
metastatic ocular disease seems unlikely in King David's case.
86
L. Ben-Nun
King David
OTHER CAUSES
Other causes of vision loss include trachoma, leprosy,
onchocerciasis, xerophthalmia, herpes simplex keratitis, retinal
detachment, and inherited retinal degenerative disorders (104).
Although these diseases cannot be entirely excluded, the King’s
medical history on the whole makes these diagnoses very unlikely.
TO SUM UP: this research describes the eye disease that afflicted
King David the Great. The passages “My eye is consumed…” and “As
for the light of my eyes, it is also gone from me” indicate blindness.
Among the numerous conditions associated with blindness, either
AMD, or mature cataract, or asymptomatic OAG, or optic atrophy
caused by OAG were the most likely causes in King David’s case.
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pp. 396-400.
BONES
Elderly people have suffered from pain in their bones, which may
be associated with various diseases, for thousands of years. This
report analyzes the disease that affected the biblical King David, the
second and greatest of Israel’s Kings, who ruled the country 3531
years ago. 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,
which are associated with osteoporosis, the most likely are senile
osteoporosis, hyperparathyroidism, or malignant disease. Among
these diseases, the diagnosis of malignancy is the most acceptable.
Among malignant diseases, the most likely are either multiple
myeloma, or renal carcinoma and/or prostate cancer.
INTRODUCTION
Patients have suffered from pain in their bones, which may be
associated with various diseases, for thousands of years. Did King
David suffer from some disease of the bones? If so, what are the
characteristics of the disease of the bones? What was the most likely
diagnosis? This article aims to answer these questions by evaluating
a disease of the bones in the King as described in the Bible.
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King David
THE BIBLICAL DESCRIPTION
King David, the second and greatest of Israel’s Kings who ruled
that country 3531 years ago, suffered from a disease of the bones
“...my strength failed..., and my bones are consumed” (Psalm 31:11),
“My bones wasted away through my anguished roaring all day long”
(32:3). The first sentence indicates that the King’s bones were used
up, his strength decreased, and he had become very weak. In the
second sentence, the King’s bones have reached a stage where they
are extremely thin and weak, causing him severe pain.
What does the phrase “...my bones wasted away... ” mean? The
1990 Consensus Development Panel defined osteoporosis as a
“disease characterized by low bone mass and micro architectural
deterioration of bone tissue, leading to enhanced bone fragility and a
consequent increase in fracture risk” (1). In recent years,
osteoporosis is defined as a skeletal disorder characterized by
compromised bone strength predisposing to an increased risk of
fracture. Bone strength reflects integration of bone density and bone
quality (2).
Taking into consideration a multifactorial nature of bone fragility
in osteoporosis, we do not diagnose "osteoporosis" but a total,
individual 10-year fracture risk (AR-10) based on independent and
self-sufficient risk factors. These are: advanced age, previous
osteoporotic fracture, parental history of proximal femur fracture,
low body weight or low bone mineral density (BMD), low bone mass,
weight loss, physical inactivity, glycocorticosteroid treatment,
androgen deprivation therapy, rheumatoid arthritis, smoking, and
overuse of alcohol (3,4).
Osteoporosis is a severe public health problem. For example,
there are approximately 700.000 vertebral body compression
fractures in the United States each year with approximately 70.000 of
these resulting in hospitalization, with an average hospital stay per
patient of eight days (5).
Because the King’s bones were “...wasted away...,” they became
very weak, that is, the bone mass decreased. The decreased bone
mass indicates that the King was suffering from osteoporosis. For the
King, risk factors for bone fragility were: advanced age, low bone
mass, and low BMI. Low BMI indicates the subsequent verses: “My
knees are weak through fasting; and my flesh failed of fatness”
(Psalm 109:24) and “....my bones (the King’s) cleave to my skin”
(102:6).
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King David
Contemporary medicine measures reduced bone mass by various
techniques including conventional radiographs, computerized
tomography, single or dual photon absorption densitometry,
radiographic measurements of cortical width (radiogrammetry),
resonance frequency of the ulna, total body neutron activation
analysis, and X-ray micro densitometry (6). Dual energy x-ray
absorptiometry (DXA) scans to measure BMD at the spine and hip
have an important role in the evaluation of individuals at risk of
osteoporosis, and in helping clinicians' advice patients about the
appropriate use of antifracture treatment. Compared with alternative
bone densitometry techniques, hip and spine DXA examinations have
a number of advantages that include a consensus that BMD results
can be interpreted using the WHO T-score definition of osteoporosis,
a proven ability to predict fracture risk, proven effectiveness at
targeting antifracture therapies, and the ability to monitor response
to treatment (7). At present, severe osteoporosis is considered BMD
below a t-score of -2.5 existing together with a prevalent fragility
fracture. This is a rough categorization of a wide range of clinical
conditions. In osteoporotic patients, two different severities include:
prognostic severity, i.e., the risk of the occurrence of other fragility
fractures and clinical severity, i.e. the degree of pain and disability
experienced by the patient (8).
Osteoporosis
Because there is no word in the biblical text about any of the
methods listed above, one can speculate that no methods of
evaluating osteoporosis were in use at that time. Nevertheless, the
biblical sentences quoted above indicate convincingly that the King
suffered from osteoporosis.
The possible pathologies that cause the loss of bone mass include:
endocrinological, digestive, genetic, hematological, rheumatic, posttransplant, pharmacological and a wide miscellaneous group (9). We
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King David
see that various diseases can be associated with osteoporosis. What
was the disease that affected the King?
Involutional or age-dependent senile osteoporosis occurs in men
aged 70 or older and is characterized by trabecular and cortical bone
loss leading to hip, vertebral, proximal humerus, proximal tibia, and
pelvis fractures (10). It can be assumed that senile osteoporosis may
have affected King David’s bones. However, this does not entirely
explain what kind of disease “...consumed...” his bones.
Cushing’s syndrome refers to metabolic disorders that result from
high levels of glucocorticoids. Osteoporosis related to glucocorticoids
may be so severe that collapse of vertebral bodies and pathological
fractures of other bones may occur (11). Did Cushing’s syndrome
affect the King’s bones? In the absence of truncal obesity,
hypertension, hirsutism, plethoric face, purplish abdominal striae,
edema, and glucose intolerance (11) this disease is very unlikely.
Were hyperthyroidism or hypothyroidism associated with
osteoporosis? In hyperthyroidism, the bone loss is solely due to
elevated thyroid hormone level (12), occurring as a direct
consequence of thyroid hormone excess acting on bone (13) more on
axial than appendicular (14). Some studies showed that bone loss in
thyrotoxicosis is independent on circulating TSH levels, and mediated
predominantly by thyroid hormone receptor alpha, thus identifying
thyroid hormone receptor as a novel drug target in the prevention
and treatment of osteoporosis (15).
Hypothyroidism is common, potentially serious, often clinically
overlooked, readily diagnosed by laboratory testing, and eminently
treatable. The condition is particularly prevalent in older women, in
whom autoimmune thyroiditis is common. Other important causes
include congenital thyroid disorders, previous thyroid surgery and
irradiation, drugs such as lithium carbonate and amiodarone, and
pituitary and hypothalamic disorders. Worldwide, dietary iodine
deficiency remains an important cause. Hypothyroidism can present
with nonspecific constitutional and neuropsychiatric complains, or
with hypercholesterolemia, hyponatremia, hyperprolactinemia, or
with hyperhomocysteinaemia (16).
Subclinical hypothyroidism (SHT) or subclinical hyperthyroidism
(SCH) are defined as normal free T4 and T3 levels associated with
elevated serum TSH levels (SHT) or subnormal serum TSH levels
(SCH), respectively. Symptoms and signs of thyroid dysfunction are
scare. In SHT, total cholesterol and LDL-C are modestly elevated and
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levothyroxine may influence the lipid levels. There is decreased
cardiac contractility and increased peripheral vascular resistance that
improve with treatment. SCH is associated with atrial fibrillation,
increased cardiac contractility and left ventricular mass, diastolic and
systolic dysfunction that can be reversed with beta-adrenergic
antagonists (17,18). Depression, panic disorders and alterations in
cognitive testing are frequent in SHT (17).
Since bone density is
reduced in SCH (17), SCH is a risk factor for osteoporosis (19).
Individuals with SCH demonstrate a 41% increase in relative
mortality from all causes versus euthyroid control subjects. Absolute
excess mortality depends on age, with an increase beyond the age of
60, especially in aging men. For patients with SHT, the relative risk of
all-cause mortality is increased only in patients with comorbid
conditions (20).
Measurement of the serum TSH concentration with an assay of
adequate sensitivity is the cornerstone of thyroid function testing; for
untreated population at risk of primary thyroid dysfunction, a normal
TSH concentration rules out an abnormality with a high degree of
certainty (21).
Thus, osteoporosis is mainly associated with hyperthyroidism
either overt or subclinical. This diagnosis as a cause of osteoporosis
should be ruled out in all patients who have bone demineralization
(22).
In the absence of nervousness, emotional lability,
hyperhydrosis, heat intolerance, eye symptoms (such as lid lag or
exophtalmus), a wide pulse pressure, sinus tachycardia, atrial
arrhythmias (especially atrial fibrillation), systolic murmurs, cardiac
enlargement, heart failure, and data on TSH level in serum, the
diagnosis of hyperthyroidism seems unlikely.
It has been reported that acromegaly may be associated with
osteoporosis (23). A cross-sectional study was carried out in Division
of Endocrinology, Catholic University, Rome. Patients included 40
males with acromegaly (25 patients with controlled disease and 15
patients with active disease) and 31 control males, with age and
gonadal status comparable to the patients. Although BMD was not
significantly different between acromegalic patients and control
subjects, the prevalence of vertebral fractures was higher in
acromegalic patients as compared with the control subjects (57.5%
vs. 22.6%, p=0.003). Fractured and non-fractured acromegalic
patients showed insignificant difference in age and BMD Z-score.
Patients with fractures showed significantly longer untreated
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hypogonadism as compared to patients without fractures. The
duration of active acromegaly was the only risk factor that
significantly correlated with the occurrence of fractures. This study
reported a high prevalence of osteoporotic vertebral fracture in an
unselected acromegalic male population generally considered at low
risk of osteoporosis suggesting that complicated osteoporosis is an
important comorbidity of acromegaly (24).
Did the King suffer from acromegaly? In the absence of coarse
facial features as the result of overgrowth of frontal, malar and nasal
bones, enlarged mandible, separated teeth, overgrowth of soft tissue
producing widening of the nose and protrusion of the lips, enlarged
hands and feet, thickened skin, enlarged sebaceous glands, and other
clues that suggest this disease (e.g., carpal tunnel syndrome, diabetes
mellitus, headache [sellar enlargement], and visual field defects) (25),
the diagnosis of acromegaly unlikely. It would also be ironic if David
who as a youth had slain the pituitary giant, Goliath (26), was visited
by the same disorder in his old age.
Hypogonadism may be associated with osteoporosis (10,23). In
the absence of hypospadias, cryptorchism in childhood, delayed
puberty, gradual loss of male secondary sex characteristics and libido,
impotence, and signs or symptoms of a disease that can produce
hypogonadism (e.g., severe headache, indicating intracranial tumor)
(25), this diagnosis is unlikely. However, recent longitudinal studies
have demonstrated that the majority of older men develop
hypogonadism that can be reversed by testosterone replacement
(27-29).
Primary hyperparathyroidism is a generalized disorder of calcium,
phosphate, and bone metabolism that results from an increased
secretion of parathyroid hormone (PTH).
The excessive
concentration of PTH usually leads to hypercalcemia and
hypophosphatemia. Symptoms are usually associated with the
degree of hypercalcemia; however, the patient may be
asymptomatic. In advanced cases manifestations of hypercalcemia
include: central nervous system - lassitude, fatigability, poor memory,
depression, and obtundation, ophthalmic-band keratopathy,
cardiovascular - hypertension, digestive - anorexia, vomiting,
constipation, ulcers, and pancreatitis; genitourinary - renal stones,
decreased urine - concentrating capacity, and renal insufficiency,
muscular - weakness, skeletal - osteoporosis, fractures, bone pain,
brown tumors, bone cysts, and joints - pseudogout (30,31).
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All patients (n=48), afflicted by primary hyperparathyroidism,
Sanata Crisitina, Madrid, had elevated PTH levels and 87% had
normal or moderately increased hypercalcaemia. The most common
clinical presentation was renal colic (34%), while 22.8% was
asymptomatic. In 70.4% of patients osteopenia was found, and
osteoporosis in 81.3%. Fractures developed in 21.8% of the patients.
Osteoporosis was a common finding (32).
In primary hyperparathyroidism, PTH is produced by an adenoma
in 80% of patients. Ectopic adenomas occur in a small proportion of
cases. A 72-year-old woman with a delayed diagnosis of primary
hyperparathyroidism, produced by an intrathoracic adenoma with a
longstanding course, presenting with severe osteoporosis, multiple
fractures, bone deformities, and neurological impairments. Persisted
hypercalcaemia, high levels of alkaline phosphatase, and PTH were
documented and a paratracheal mass was found on a helicoids
tomography of the thorax. After surgical removal, the
histopathological examination confirmed an ectopic adenoma of the
parathyroid gland and the patient achieved some improvement in
her clinical course (33).
Did the King suffer from hyperparathyroidism? It can be
speculated that he may have suffered from this disease leading to
osteoporosis, subsequent fractures and severe bone pain. Did the
King suffer from asymptomatic renal stones, renal failure, or other
asymptomatic manifestations of this disease? There are insufficient
data to answer these questions. If this diagnosis is accepted,
however, there is still no explanation for the disease, which
“...consumed ...” the King’s bones.
Paget’s disease is a relatively common disorder, resulting from a
primary overactivity of osteoclasts, which leads to excessive
resorption of bone and the formation of disorganized, structurally
defective bone. Commonly affected areas include the skull, spine,
pelvis, femur, and tibia. The usual presenting symptoms are
deformity and pain, the latter probably arising from periostal
stretching, microfractures, degenerative joint disease, or direct
neural compression. The skull may become enlarged and bowing of
the femur and tibia are frequently seen. Increased warmth and
sweating of the skin overlying affected bones are common. In
addition, a high output cardiac failure may develop (34).
A retrospective review evaluated the medical records of 51
patients with Paget's disease, at a tertiary referral centre in Southern
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India, 1995-2003. The symptoms included bone pain (65%), low
backache (37%), skeletal deformities (33%), pathological fractures
(20%), neurogenic claudication (4%), deafness and head enlargement
(7%), and renal stones (4%) of the subjects. Five patients (9.8%) were
asymptomatic and were incidentally diagnosed during evaluation of
an elevated alkaline phosphatase. Two patients had neurological
symptoms (root pains in one and cauda equina in the other) (35).
Hypocalcemia is rare in Paget's disease, usually occurring as a
consequence of therapy with biphosphonates (36 ).
Was this disease responsible for the King’s bone pain? In the
absence of the deformity of bones, bowing of the femur or tibia,
enlargement of the skull, or warmth and sweating skin over the
affected bones, this diagnosis seems very unlikely.
Persons with a lifelong low intake of dairy products because of
lactase deficiency have an increased incidence of osteoporosis (37).
In the absence of abdominal pain, bloating and diarrhea after lactose
ingestion (38), this diagnosis seems very unlikely.
Biliary cirrhosis results from injury to or obstruction of either the
intrahepatic or the extrahepatic biliary system. It is associated with
impaired biliary excretion, destruction of hepatic parenchyma, and
progressive fibrosis (39). Liver cirrhosis at an advanced stage can
lead to osteoporosis due to diminished vitamin D absorption, while
deficiency of vitamin K contributes to bone fragility (39,40). In the
absence of pruritus, jaundice, hyperpigmentation of the exposed skin
areas, xanthelasmas and tendinous and plantar xanthomas,
hepatomegaly, splenomegaly, clubbing of the fingers, steatorrhea,
easy bruising related to the malabsorption of vitamin K, night
blindness due to vitamin A deficiency, and dermatitis due to vitamin
E and/or essential fatty acid deficiency (6,39), this diagnosis is very
unlikely.
Whipple's disease is a rare, chronic multisystem disease
characterized by the presence of fever, diarrhea, weight loss and
malabsorption, abdominal pain and arthralgia.
Arthritis and
arthralgia may be the only presenting symptom, predating other
manifestations by years. The causative organism is the bacterium
Tropheryma whipplei. Although Whipple's disease usually includes
involvement of the small intestine with the presence of
malabsorption, it commonly affects other organs, especially the
heart, brain, eyes and joints. The disease is fatal unless patients are
treated with antibiotics. The characteristic histopathological features
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are found most often in the small intestine. These are variable villous
atrophy and distension of the normal villous architecture by an
infiltrate of foamy macrophages with a coarsely granular cytoplasm,
which stain a brilliant magenta with PAS. These pathognomonic PAS
positive macrophages may also be present in the peripheral and
mesenteric lymph nodes and various other organs (41-45).
In the absence of fever, diarrhea, abdominal pain, arthralgia and
arthritis, and the characteristic histopathological findings in the small
intestine this diagnosis is very unlikely.
The prevalence of malnutrition, particularly under nutrition,
increases with age (40). Deficiencies in micronutrients such as
calcium and vitamin D can accelerate age-dependent bone loss (10),
while a deficiency in vitamin K can accelerate bone fracture. A
deficiency in macronutrient (protein) leads to lower femoral neck
mineral density (40). Several factors can cause weight loss and lead
to a state of malnutrition in elderly persons. Most of them act by
reducing spontaneous food intake, although malabsorption and
increased metabolism can also be implicated in some situations (46).
Reduction in food intake occur physiologically with aging (47), and
this can be aggravated by various physical and mental disorders, poor
appetite due to consumption of drugs, loss of taste and smell,
inadequate access to foods due to poverty or to impairment of
cognitive or physical functions, and chronic alcohol abuse (46,48).
Did the King suffer from malnutrition or under nutrition? It is
possible that for some reason the intake of food was reduced.
However, it seems very unlikely that osteoporosis and possible
subsequent fractures developed solely because of reduced food
intake. Thus, it seems unlikely that malnutrition or under nutrition
per se were the cause of the King’s bone disease.
Chronic obstructive lung disease has been found to be associated
with osteoporosis (23). In the absence of a history of cough and
sputum production (sometimes with wheezing) over many years,
dyspnea, and signs of right ventricular failure (49), this diagnosis
seems unlikely.
Rheumatoid arthritis (RA) is a chronic multisystemic disease of
unknown cause characterized by persistent inflammatory synovitis,
usually involving wrists, metacarpophalangeal joints, knees, and feet
in a symmetric distribution. A prodrome of fatigue, weakness, joint
stiffness, arthralgias and myalgias may precede the joint swelling.
Constitutional manifestations include malaise, anorexia, low-grade
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fever and an elevated sedimentation rate (50). Juxta-articular
osteoporosis develops in early stages of RA; later bony erosions
appear at the joint margins with the destruction of subchondral
bone, and diffuse osteoporosis develops at an advanced stage (51).
In the absence of joint involvement accompanied by constitutional
symptoms, this diagnosis is very unlikely in King David.
The aim of this study was to analyze the clinical characteristics
and etiological factors related to osteoporosis in patients attending
an outpatient rheumatology department during an 11-year period
(1995-2006), as well as to compare them with the observed
characteristics in a previous study performed 12 years ago,
Barcelona, Spain. Males (n=232) aged 21-88 years (mean 56.1 +/-14)
with osteoporosis were included in the study. Of the patients, 67%
had previous skeletal fractures and 51% had vertebral fractures; 57%
had idiopathic and 43% had secondary osteoporosis. The most
frequent causes of secondary osteoporosis were corticosteroid
therapy, hypogonadism and alcoholism; 38% of the patients with
idiopathic osteoporosis had associated hypercalciuria. Patients with
secondary osteoporosis were older, shorter, had lower femoral neck
T score and lower serum values of 25-OH vitamin D and testosterone,
as well as higher gonadotrophin and PTH values than patients with
idiopathic osteoporosis,
whereas patients with idiopathic
osteoporosis had higher urinary calcium and more frequently family
history of osteoporosis. Back pain, frequently associated with
vertebral fractures, was the most common cause of referral in all age
groups of patients. Idiopathic osteoporosis was the most frequent
cause of male osteoporosis in this clinical study (52).
It can be assumed that idiopathic osteoporosis may have affected
King David’s bones. However, this does not entirely explain what
kind of disease “...consumed...” his bones.
Some medications are associated with osteoporosis.
Glucocorticoid-induced osteoporosis is the leading cause of
medication-induced osteoporosis (53,54). The incidence of new
fractures after one year of glucocorticoid therapy can be high as 17%,
and observational studies suggest that fractures, which are often
asymptomatic, occur in 30%-50% of chronic glucocorticoid-treated
patients (55). Other medications include antiepileptic drugs (56,57),
thyroid hormone which is used to suppress TSH because of thyroid
cancer, goiters, or nodules (58), and neuroleptics (59).
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In the absence of appropriate anamnesis, it seems unlikely that
the King took any of the above-mentioned medications.
Metastatic bone disease constitutes a major clinical problem.
Skeletal complications are common and lead to significant morbidity;
patients live with metastatic bone disease for several years,
increasing the prevalence of this problem. Effective management
aims to reduce the incidence of complications and relieve symptoms,
such as severe bone pain, which adversely affects patient mobility
and quality of life (60).
The presence of bone metastases predicts the presence of pain
and is the most common cause of cancer-related pain. Although bone
metastases do not involve vital organs, they may determine
deleterious effects in patients with prolonged survival. Bone
fractures, hypercalcaemia, neurological deficits, and reduced activity
associated with bone metastases result in an overall compromise in
the patient's quality of life. A metastasis is a consequence of a
cascade of events including a progressive growth at the primary site,
vascularization phase, invasion, detachment, embolization, survival in
the circulation, arrest at the site of a metastasis, extravasation,
evasion of host defense and progressive growth. Once cancer cells
establish in the bone, the normal process of bone turnover is
disturbed. The different mechanisms responsible for osteoclast
activation correspond to typical radiological features showing lytic,
sclerotic or mixed metastases, according to the primary tumor. The
possible mechanisms of malignant bone pain include: the release of
chemical mediators, the increased pressure within the bone,
microfractures, the stretching of periosteum, reactive muscle spasm,
nerve root infiltration and compression of nerves by the collapse of
vertebrae. Pain is often disproportionate to the size or degree of
bone involvement (61,62).
Bone metastases produce pain because of periostal irritation,
medullar pressure, and fractures. Pain may be produced by the
growth of tumor in a closed area richly supplied with pain receptors
(nocireceptors). Chest pain occurs when tumor of the lung or the
mediastinum invades the pleura. Certain tumors produce
characteristic types of pain. For example, back pain occurs in multiple
myeloma, while shoulder pain in patients afflicted by Pancoast's
tumor (63).
Bone metastases represent a devastating clinical problem in the
most frequent malignancies, especially in multiple myeloma, tumors
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of the breast, prostate, and lungs. The consequences include pain,
which is refractory to conventional analgesics, osteolysis that often
leads to bone-marrow compression, pathological fractures, and
metabolic disorders (64).
Were any of the above-mentioned mechanisms involved in King
David's case?
Biochemical bone markers, such as bone isoenzyme, form of
alkaline phosphatase, have been used to assess the bone formation
phase of bone turnover in health and disease. Bone markers could be
valuable clinical tools for the management of patients with
metastatic bone disease. Serum levels of BAP, along with serum
levels of beta-CrossLap, were measured in a large group (n=200) of
patients with newly diagnosed or progressive cancer of the prostate,
breast, colon, liver and pancreas. Tumor markers such as CEA, PSA,
CA 19-9, AFP, CA 15-3 and bone marker levels were correlated with
the presence or absence of bone scan documented metastases.
Markers of biochemical bone remodeling can be used in assessing
and managing patients with malignancies that metastasize to the
bone (65).
We see that the modern approach requires performing of various
malignancy marker tests. These examinations are useful in
establishing the diagnosis of the tumor. It is understandable that
such tests were not performed in the King's case.
IMMUNOSECRETORY DISORDERS
The immunosecretory disorders are a diverse group of diseases
associated with proliferation of an abnormal clone of
immunoglobulin (Ig) synthesizing, terminally differentiated B cells.
These disorders include multiple myeloma (MM) and its variants,
plasmacytoma,
Waldenström's
macroglobulinemia
(WM),
monoclonal gammopathy of undetermined significance, and
monoclonal Ig deposition diseases, the latter includes amyloidosis
and nonamyloidotic types. The disorders are histologically composed
of plasma cells, or plasmacytoid cells, which produce Ig that is
synthesized and is usually secreted and can be deposited in some
diseases. The Ig can be complete or can be composed of either heavy
or light chains and is termed M-(monoclonal) protein (66).
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MULTIPLE MYELOMA
MM is the second most common hematologic malignancy, with
approximately 16.000 new cases per year, and accounts for 11.000
deaths in the USA. It is the most common cancer to metastasize to
the bone, with up to 90% of patients developing bone lesions (67).
MM is a tumor of terminally differentiated plasma cells that home
to and expands in the bone marrow (67). It is a hemato-oncologic
disease in the elderly population, with a peak incidence in the eight
decade, and represents a malignant bone marrow neoplasia in which
a monoclonal strain of atypical plasma cells proliferates and may
result in bone destruction. Skeletal metastases represent the most
common malignant bone tumor and are the third most common
location for distant metastases. They occur predominantly in adults,
especially in the elderly population (68,69).
MM is characterized by the accumulation more than 10% of
monoclonal plasma cells in the bone marrow and the production of
large amounts of a monoclonal immunoglobulin or paraprotein
(70,71); in MM enhanced bone loss is commonly associated with a
diffuse osteopenia, or osteoporosis, focal lytic lesions, pathological
fractures, cord compression, severe bone pain, malaise,
hypercalcaemia, anemia, and renal insufficiency (68,72-75).
Osteolytic bone disease is the most debilitating manifestation of
MM (76). The disease of the spine is a growing problem, affecting
70% of patients with metastatic disease or multiple myeloma. Tumorinduced osteolysis may lead to pain, dysfunction, and ultimately
vertebral collapse. If left untreated, vertebral body compression
fractures take place with progressive kyphosis over multiple levels,
cord compression, and intractable pain (77).
Although bone pain related to multiple lytic lesions is the most
common clinical presentation, up to 30% of patients are diagnosed
incidentally while being evaluated for unrelated problems, and one
third of patients are diagnosed after a pathological fracture,
commonly in axial skeleton (71).
Diagnosis of MM should be based on the following tests:
*Detection and evaluation of the monoclonal (M-) component.
*Serum and urine protein electrophoresis (concentrate of 24-h
urine); quantification of IgG, IgA and IgM immunoglobulins.
*Characterization of the heavy and light chain by immunofixation.
Serum free light chain measurement for identifying and monitoring
non secretory MM; evaluation of bone marrow plasma cell
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infiltration; bone marrow aspiration and biopsy to detect quantitative
and/or qualitative abnormalities of bone marrow plasma cells.
*Evaluation of lytic bone lesions.
*Biological assessment is required to differentiate symptomatic
and asymptomatic MM: hemoglobin (and full blood cell count),
serum creatinine and calcium level (68,78).
Multiple myeloma
Skeletal radiographs are important in staging MM and revealing
lytic lesions, vertebral compression fractures, and osteoporosis.
Magnetic resonance imaging (MRI) and positron emission
tomography or computed tomography emerged as useful tools in the
evaluation of patients with myeloma; MRI is preferred for evaluating
metastatic spinal disease (79) and acute spinal compression. Nuclear
bone scans and dual energy x-ray absorptiometry have no role in the
diagnosis and staging of MM (68).
Was the King afflicted by MM? We have two parameters: the King
was an elderly person and he had severe intractable bone pains.
Bone pain related to multiple lytic lesions is the most common
presentation of MM. Although in King David's case no contemporary
diagnostic evaluation was performed, the biblical words "My bones
wasted away through my anguished roaring all day long” may
indicate MM.
Did King David suffer from smouldering myeloma? Smouldering
(asymptomatic) MM is characterized by having a serum IgG or IgA
monoclonal protein of 30 g/l or higher and/or 10% or more plasma
cells in the bone marrow but no evidence of end organ damage –
hypercalcaemia, renal insufficiency, anaemia, and bone lesions (80).
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Since the King suffered from severe bone pains as well as from
anemia, as shown in a subsequent section, the diagnosis of
smouldering myeloma seems unlikely.
OTHER TYPES
MM must be differentiated from other causes of monoclonal
gammopathy, including monoclonal gammopathy of undetermined
significance (MGUS), WM, heavy chain
diseases (HCD),
osteomyelofibrosis, amyloidosis, plasmacytoma, and small
lymphocyte cell disorders (68,69,71,81).
MGUS denotes the presence of a monoclonal protein (M protein)
in patients, without evidence of MM, macroglobulinemia,
amyloidosis or other related diseases (82). MGUS is characterized by
the serum M-protein less than 3 g/dl; fewer than 10% plasma cells in
the bone marrow; no, or only small amounts of M protein in the
urine; absence of bone lesions, anemia, hypercalcaemia, and renal
insufficiency; and, most importantly stability of the M-protein and
failure of development of other abnormalities (83).
MGUS is found in approximately 3% of persons older than 70
years and in 1% of those 50 years and older. During long-term followup, approximately one fourth of patients develop MM, amyloidosis,
macroglobulinemia, or a similar malignant lymphoproliferative
disorder (80).
Was old King David afflicted by MGUS? Although MGUS is mostly
a disease of the elderly, the absence of the bone pains and anemia
from which the King suffered makes it unlikely that the King was
afflicted by MGUS.
WM is a B-cell neoplasm characterized by lymphoplasmacytic
infiltration of the bone marrow and/or other tissues. The symptoms
of WM are attributable to the extent of tumor infiltration and
elevated IgM levels (81,84). The most common symptom is fatigue
attributable to anemia (85). Aside from uncommon patients with
idiopathic IgM peaks, most patients have evidence of an underlying
lymphoma, which is characterized by bone marrow infiltration,
enlargement of lymph nodes and/or spleen, chronic lymphocytic
leukemia, or a combination of these features (86).
The presenting symptom in WM disease is that of lymphoma
including fatigue due to anemia. Thus, although the King suffered
from severe anemia (see the section below), his severe intractable
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bone pains cannot be related to WM. For this reason, the diagnosis of
WM seems unlikely
HCD are immunoproliferative disorders characterized by the
production of monoclonal immunoglobulin molecules composed of
deleted heavy chains devoid of light chains by the malignant B-cells
(87,88). The diagnosis is established by immunoelectrophoresis or
immunofixation (88).
There are three types of HCD defined by the class of
immunoglobulin (Ig) heavy chain (HC) produced: IgA (alpha-HCD), IgG
(gamma-HCD), and IgM (mu-HCG). Alpha-HCD is the most common
and occurs most commonly as intestinal malabsorption in a young
adult from a country bordering the Mediterranean Sea (87,88). In its
usual digestive form, the clinicopathologic pattern is typical. The
main clinical features are chronic diarrhea and severe malabsorption
syndrome (88).
The clinicopathologic features of gamma HCD are heterogeneous
often somewhat similar to macroglobulinemia. Some patients show
no evidence of underlying malignant lymphoproliferation. Gamma
HCD most often presents as a lymphoproliferative disorder,
characterized by lymphadenopathies, splenomegaly, constitutional
symptoms, and the absence of bone lesions (89,90).
mu-HCD is a rare monoclonal lymphoid disorder characterized by
the failure to assemble a complete IgM immunoglobulin (91). muHCD often presents as chronic lymphocytic leukemia with
hepatosplenomegaly and vacuolated plasma cells on bone marrow
smears (87), and thrombocytopenia (92). Renal failure is a rare
disease in mu-HCD (93). The prognosis for patients with mu-HCD is
poor (92).
Did some type of HCD afflict the King? In alpha-HCD, the main
symptoms are those of chronic diarrhea and severe malabsorption
syndrome, in gamma HCD the clinical presentation is that of a
lymphoproliferative disorder, characterized by lymphadenopathies,
splenomegaly, and constitutional symptoms, while in mu-HCD the
principal symptoms are those of hepatosplenomegaly and vacuolated
plasma cells on bone marrow smears. Bone pain is not the
characteristic symptom of all these types of HCD. Thus, it seems
unlikely that any type of HCD afflicted the King.
Osteomylofibrosis and sclerosis are chronic myeloproliferative
diseases of the elderly, with a peak incidence in the sixth and seventh
decade of life (69), in which fibrosis and sclerosis finally lead to bone
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marrow obliteration (94). Bone marrow fibrosis, anemia,
splenomegaly and a leuko-erythrobastic blood picture generally
characterize idiopathic myelofibrosis. Apart from minor hemorrhage
and peripheral thrombosis, patients with early stage of idiopathic
myelofibrosis present with non-specific symptoms including varying
degrees of leukocytosis (51%), anemia (38%), a platelet count
exceeding 600 x 10(9)/l (86%), splenomegaly (15%), increase in
leukocyte alkaline phosphatase (24%) and serum lactate
dehydrogenase (LDH) (20%) (95).
Did osteomylofibrosis affect the old King? Although the disease is
prevalent in the elderly, the disease is mainly manifests with nonspecific symptoms. Since the King suffered from severe bone pains,
the diagnosis of osteomyelofibrosis seems unlikely.
Among small lymphocyte cell disorders, B-chronic lymphocytic
leukemia (B-CLL), small lymphocytic lymphoma (SLL), and
lymphoplasmacytic lymphoma/Waldenström's macroglobulinemia
(LPL/MW) are included (96).
B-CLL patients always have blood and bone marrow involvement
by a CD5+ B lymphocyte. They frequently present with
lymphadenopathy and/or hepatosplenomegaly, although in a
considerable number of patients, no abnormal physical findings are
found. They are prone to develop hypogammaglobulinemia,
autoimmune hemolysis, or autoimmune thrombocytopenia (96).
SLL patients present with lymphadenopathy, usually generalized.
Lymphocytosis is by definition absent and bone marrow involvement,
usually nodular, is found in 25% to 50% of patients. LPL/WM patients
may present either with an accidental discovery of IgM gammopathy,
symptoms related to paraproteinemia, or lymphadenopathy and/or
splenomegaly. The bone marrow is frequently involved and a
leukemic picture may be found (96). Some patients have an indolent
leukemia, with long survival while others experience an aggressive
disease, with early and frequent need of treatment (97).
Was the King afflicted by some disorder as mentioned above? In
the absence of severe bone pains from which suffered the King, the
diagnosis of some type of small lymphocyte cell disorder seems
unlikely.
The fibrils of primary amyloidosis consist of kappa or lambda
monoclonal light chains. Weakness, fatigue, and weight loss are the
most frequent symptoms. Macroglosia occurs in 10%. An M-protein is
found in the serum or urine in 90%. The presence of nephritic
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syndrome, renal insufficiency, congestive heart failure, orthostatic
hypotension, or sensorimotor peripheral neuropathy, and an Mprotein in the serum or urine suggest the possibility of primary
amyloidosis. The diagnosis depends upon the demonstration of
amyloid in tissues (98).
Did primary amyloidosis afflict the King? Amyloidosis is mainly
characterized by nephritic syndrome, renal insufficiency, peripheral
neuropathy, and orthostatic hypotension. Since the King suffered
from severe bone pains, the diagnosis of amyloidosis seems unlikely.
Was the King afflicted by plasmacytoma, solitary or multiple?
Intracranial plasmacytomas are a rare abnormality in a
neurosurgeon's practice. The plasmacytomas may originate from the
skull bones or soft tissue intracranial structures; they may be solitary
or occur as a manifestation of MM, this type being typical of most
intracranial plasmacytomas. Progression of solitary plasmacytoma to
MM is observed in a number of cases. The final diagnosis of
plasmacytoma is based on a morphological study (99-102).
A case of multiple plasmacytoma in a woman is described, with a
several-year radicular syndrome and recently, with numerous
pathologic fractures and tumor formation on the head and sternum.
Bone pains, pathologic fractures and tumours – osseous
manifestations characterized this disease (103).
Since the King suffered from severe bone pains, the diagnosis of a
solitary plasmacytoma seems unlikely. In the case of multiple
plasmacytomas, numerous pathological fractures may indicate this
disease. However, although this diagnosis cannot be absolutely
ignored, the formation of tumors on the head and sternum makes
the diagnosis of multiple plasmacytomas unlikely in the King's case.
During 1990 at the Mayo Clinic, 787 patients were found to have
monoclonal gammopathy. IgG accounted for 61% of the cases,
followed by IgM (18%), IgA (11%), Bence Jones proteinemia (6%),
biclonal gammopathy (3.5%), and IgD (0,5%). MGUS accounted for
approximately two thirds of patients. This denotes the presence of
monoclonal protein in persons without evidence of MM,
macroglobulinemia, amyloidosis, or other related diseases. During
the long-term follow-up of patients with MGUS, one fourth
developed MM or related disorders. The interval from recognition of
the monoclonal gammopathy to the development of MM ranged
from two to 29 years (median, 10 years). WM developed in seven
patients 4 to 20 years (median, 8.5 years) after recognition of the
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King David
monoclonal protein. Systemic amyloidosis was found in eight patients
6 to 19 years (median, 9 years) after the diagnosis of a serum
monoclonal protein. Five patients developed a malignant
lymphoproliferative process 6 to 22 years (median, 10.5 years) after
the recognition of a monoclonal protein. Minimal criteria for the
diagnosis of MM include the presence of at least 10% abnormal
plasma cells in the bone marrow or histological proof of a
plasmacytoma, the usual clinical features of MM, and at least of the
following abnormalities: monoclonal serum protein (usually greater
than 3 g/dL), monoclonal protein in the urine, or osteolytic lesions.
No single technique differentiates benign from malignant plasma cell
proliferation. The most dependable means is serial measurement of
the monoclonal protein in the serum and urine and periodic
reevaluation of pertinent clinical and laboratory features to
determine whether MM, systemic amyloidosis, macroglobulinemia,
or other lymphoplasma cell proliferative disease have developed
(104).
This study indicates that one fourth of the patients with MGUS
developed MM or other related disorders. Was King David afflicted
by MGUS that later developed into MM or other related disorders?
The diagnosis of MM or other immunosecretory disorders
requires an extensive evaluation including laboratory, radiological,
and histopathological. This is a contemporary approach to
establishing an appropriate diagnosis of the disease that afflicted the
patient. We can assume that such evaluation was not performed in
the King's case.
TO SUM UP: the medical record of the King, that is the biblical
text, documents the patient's complains: “...my strength failed..., and
my bones are consumed” (Psalm 31:11), “My bones wasted away
through my anguished roaring all day long” (32:3). The anamnestic
findings indicate a very serious and lethal disease that caused the
King severe intractable bone pain and a great suffering. Among the all
diagnoses, as presented above, the most likely is MM.
OTHER MALIGNANCIES
In Turkey, of 945 patients with non-small cell lung cancer, 377
(39.9%) had metastases. Of the 224 patients with the stage I and II of
the disease, 73 had 73 metastases, including bone metastases, with a
rate of 10.9% silent metastases (105).
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Did lung cancer with metastases to the bones affect the King? In
the absence of dyspnea, chronic cough, and sputum production
(sometimes with wheezing), the diagnosis of lung cancer seems
unlikely.
Gastric carcinoma is the third most common gastrointestinal
malignancy after colon and pancreatic carcinoma. A 46-year-old
female woman patient was presented with a thoracic vertebral
wedge fracture and widespread vertebral metastatic deposits with
marrow infiltration. An acute bleeding into the extradural space
causing spinal cord compression complicated the infiltration and
suppression of marrow function. Gastric cancer, although far less
common than breast, kidney, thyroid, prostate and bronchial cancers,
was a cause of metastases to the bones. It highlights the
complications of bone metastases, marrow suppression,
leukoerythroblastic anemia, spinal canal hematoma and cord
compression (106).
Did the King suffer from gastric carcinoma? In the absence of
upper abdominal pain association with stomach dysfunction,
gastroscopic evaluation and histopathological evaluation this
diagnosis seems unlikely.
Patients with metastatic colorectal cancer (CRC) evaluated from
1993 to 2002 at the Fox Chase Cancer Center, Philadelphia, were
identified. The records of 1020 patients were reviewed. Incidence of
bone and brain metastases were 10.4% (95% CI 8.6-12.4) and 3%
(95% CI 2.2-4.5), respectively. Patients with primary rectal versus
primary colon cancer were more likely to develop bone metastases
(16% vs. 8.6%; p = 0.01). Patients with lung metastases were more
likely to have bone metastases (16.1% vs. 6.4%; p < 0.001) or brain
metastases (6.2% vs. 1.2%; p < 0.0001) than those without it (107).
Did the King suffer from CRC? In the absence of abdominal pain,
rectal bleeding, occult stool examination, colonoscopic evaluation,
and histopathological findings this diagnosis seems unlikely.
In Japan, the clinical records of 482 patients who had been
diagnosed as having hepatocellular carcinoma (HCC) were reviewed,
1995-2001. Extrahepatic metastases had been detected in 65
patients. The frequent metastatic sites were lung (53.8%), bone
(38.5%), and lymph node (33.8%). Other metastatic sites were the
adrenal gland, peritoneum, skin, brain and muscle (108). Spinal cord
compression was an unusual cause of metastatic HCC (109,110).
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A 65-year old man presented with bone pain and anemia. Skull Xray revealed multiple osteolytic lesions. The patient was evaluated
for MM but detailed workup revealed the diagnosis of primary HCC
with osteolytic bone metastases (111).
Did the King suffer from HCC, which spread to the bones? In the
absence of abdominal pain, and jaundice, and appropriate
investigation – laboratory, ultrasound, CT of the abdomen and
histopathological findings this diagnosis seems unlikely.
Prognosis of pancreatic cancer is one of the worst among other
cancers; however, the incidence of the bone metastases has been
increased in recent years. Among 13 patients diagnosed with
pancreatic cancer, at National Kyushu Cancer Center Japan,
pancreatic cancer was located at pancreatic body to tail in 10 cases,
and at pancreatic head in three cases. Liver metastases were noted in
seven of 13 patients with bone metastases. Radiographical imaging
of bone lesions revealed osteolytic bone destruction, and serum
levels of bone resorption marker, 1CTP, were elevated (112).
Did the King suffer from pancreatic carcinoma? In the absence of
intractable abdominal pain, appropriate laboratory tests, radiological
investigations, and pathological data this diagnosis seems unlikely.
Although epithelial malignancies can have bone metastases,
involvement of small bones is exceedingly rare, representing either
first manifestation of an occult carcinoma or late disseminated
disease. Small bone metastases may mimic primary skeletal diseases
leading to misdiagnosis and delayed treatment. Three cases of
metastatic epithelial malignancies were diagnosed by computed
tomography (CT)-guided fine-needle aspiration (FNA) biopsy in two
patients with lytic calcaneal lesions and a patellar lesion in a third
patient; all with a histological confirmation. Case 1, a 63-year-od
female, presented with heel pain. FNA and tissue biopsy of the
calcaneous revealed a clear cell malignancy consistent with a renal
primary carcinoma. Case 2, a 37-year-old man with squamous cell
carcinoma of esophagus, presented with foot pain; FNA and tissue
biopsy of the calcaneous revealed metastatic squamous cell
carcinoma. Case 3, a 52-year-old man with a history of squamous cell
carcinoma of the floor of the mouth, presented with knee pain and
swelling. FNA and tissue biopsy of the patella revealed metastatic
squamous cell carcinoma (113).
Was the King afflicted by metastatic squamous cell carcinoma? All
patients described suffered from the pain in a solitary bone, the first
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King David
had heel pain, the second foot pain, and the third knee pain. In the
absences of the bones involvement (not only solitary bone), the
diagnosis of epithelial malignancy, although it cannot be ignored
absolutely, seems unlikely.
Over 20 years, 470 cases of giant cell tumor of bone diagnosed at
a tertiary cancer hospital, India, were analyzed. Tumors measured 6
to 20 cm and, in 402 cases, showed "usual" histology comprising
uniformly scattered multinucleate giant cells amidst mononuclear
stromal cells, together imparting a syncitium-like appearance. The
presence of osteoid, hemorrhage, and aneurismal bone cyst-like
areas; spindle cells in sheets (devoid of giant cells); or storiform
pattern and intravascular osteoclasts were less common (114).
Did the King suffer from a giant cell tumor of bone? Since the King
suffered from pain in his bones, but not in one bone the diagnosis of
giant cell tumor seems unlikely.
Leptomeningeal carcinomatosis is a rare complication of solid
tumors, e.g., breast, lung and gastrointestinal carcinomas. Clinical
manifestations are variable with radicular pains with or without
neurological deficiencies as well as headache and hallucinations. The
rare case of a 57-year-old patient with urological symptoms caused
by a leptomeningeal carcinomatosis and a spinal metastasis of an
asymptomatic signet-ring cell gastric carcinoma was reported (115).
Did the King suffer from leptomeningeal carcinomatosis? In the
absence of severe headache and hallucinations, radiological
evaluation such as CT and MRI of the brain, bone scan evaluation,
and bone histopathological studies this diagnosis seems unlikely.
In Europe, renal cancer (that is neoplasia of the kidney, renal
pelvis or ureter) ranks as the seventh most common malignancy in
men amongst whom there are 29.000 new cases each year (3.5%) of
all cancers. Renal carcinoma may remain clinically occult for most of
its course. The classic presentation of pain, hematuria and flank mass
occurs in only 9% of patients and is often indicative of advanced
disease. Approximately 30% of patients with renal carcinoma present
with metastatic disease, 25% with locally advanced renal carcinoma
and 45% with localized disease. Metastases are typically found in the
lung, soft tissue, bone, liver, cutaneous sites, and central nervous
system (116).
In Japan, Nagasaki, bone scan was performed at presentation in
205 patients with confirmed renal cell carcinoma. Overall, bone
metastasis was present in 34 (17%) patients (117).
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King David
We see that renal carcinoma is a malignant disease, which spreads
to the bones. Renal carcinoma may remain clinically occult for most
of its course, and even in the advanced stages of the disease the
classical presentation of pain, hematuria and flank mass occur in only
9% of patients. Since renal carcinoma may manifest itself without
overt clinical symptoms, severe intractable bone pains in the King's
case may indicate renal carcinoma with metastases to the bones.
The British Association of Urological Surgeons Cancer Registry
2000 and 2001 data were used to identify the clinical features and
outcome of 33 patients with metastatic prostate carcinoma who
presented with serum PSA levels <10 ng/mL. Seventeen patients
(51%) presented with urinary symptoms and/or pelvic pain, 6% with
cachexia and 21% with bone pain. Characteristic bone metastases
were found in 81% of patients, similarly to the men with high serum
PSA levels (118).
Was prostate carcinoma responsible for the bone metastases in
the King? The medical record of the King, that is the biblical text, did
not mention any urinary complaints. However, only 51% of patients
afflicted with prostate carcinoma may suffer from urinary symptoms
and/or pelvic pain. Thus, the absence of urinary complains cannot
point to the absence of the disease, in this case the prostate cancer.
For this reason, the diagnosis of prostate cancer is still possible for
King David.
The clinical data of 91 patients with bone metastases, Warsaw,
Poland, were reviewed. The renal carcinoma and prostatic carcinoma
were diagnosed respectively in 53% and 47% of the patients; 21% of
the patients presented a bone pain (119).
We see that a combined diagnosis of renal cancer and prostate
cancer is possible in King David's case.
METASTATIC BONE DISEASE
Skeletal metastases represent the most common malignant bone
tumor. They occur mainly in adults and even more frequently in the
elderly (120). Tumor infiltration of bones is cited as the most
common cause of cancer pain, and is most often secondary to the
primary disease in the prostate, breast, thyroid, lung or kidney (121,
122).
One hundred and forty-one cases of metastatic carcinoma in bone
encountered at the People's Hospital Peking University, 1998–2004,
were retrospectively reviewed. Skeletal metastases occurred more
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King David
commonly in males (male to female ratio = 1.7:1). The age of patients
ranged from 23 to 86 years (mean age = 56.5). The presenting
symptoms included pain and dysfunction of the affected bones. The
locations of skeletal metastases were as follows: spine (58), pelvic
bone (46), long bone (34) and others (3). Twenty-three cases
suffered from multiple bone lesions. The primary sites were
identified in 130 cases (92.2%), which included lung (37), female
genital system and breast (25), kidney (18), gastrointestinal system
(17), liver (12), thyroid (11), prostate (7), bladder (2) and skin (1).
Skeletal metastases occurred more often in elderly males. Axial
bones (spine and pelvis) were usually affected (123).
Metastatic cancer
According to Scutellari et al. (119), the most common metastases
in men are from prostate cancer (60%) while in women from breast
cancer (70%). Other tumors responsible for bone metastases are:
lung, kidney, thyroid, alimentary tract, bladder, and skin. The spine
and pelvis are the most common metastatic sites, due to the
presence of red (hematopoietic active) bone marrow in a high
amount. Generally, the radiographic pattern is lytic type; other
aspects are osteosclerotic, mixed, lytic vs. mixed and osteosclerotic
vs. lytic patterns. The main symptom is pain, although many bone
metastases are asymptomatic. The most severe consequences are
pathological fractures and cord compression. Clinical evaluation of
patients with skeletal metastases needs multimodal diagnostic
imaging, able to detect lesions, to assess their extension and location,
and eventually to perform the biopsy (for histo-morphological
diagnosis). These techniques give different performances in terms of
sensitivity and specificity; but none of the modalities alone seems to
be adequate to yield a reliable diagnostic outcome. Therefore,
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King David
multidisciplinary cooperation is required to optimize the screening,
clinical management and follow-up of the patients (120).
The King suffered from severe intractable bone pains, which point
towards metastatic disease. Where were the metastases located?
What was the radiographic pattern of the lesions? Osteolytic?
Osteosclerotic? Did pathological fractures occur? Did cord
compression take place?
There were 124,655-fracture cases and 373,962 ages and gender
matched controls. An increased risk of fractures, primarily within the
first year after diagnosis occurred in patients with primary bone
cancer, multiple myeloma, metastases to the bones, metastases to
other organs than bone, lung cancer, and cancer of the liver, gall
bladder and pancreas. For patients with prostate cancer an increase
in the risk of fractures occurred with time. Other cancer types were
not associated with an increased risk of fractures. A high-risk group
regarding fractures included cancers primarily affecting the bone
(primary bone cancer, multiple myeloma, metastases to the bone,
metastases to other organs than bone, lung cancer, and cancer of the
liver, gall bladder, and pancreas, and prostate cancer). The main
increase in risk of fractures in this group occurred within the first year
following diagnosis. A low risk group for fractures included all other
cancer types (e.g. cancer of the breast, colon, and skin) (124).
Metastatic bone disease
Tumor registry data were collected between 1994-1996 on 11
primary tumor sites and 15 metastatic sites from 4399 patients.
Three primary tumors had single, dominant metastatic sites: ovary to
abdominal cavity (91%), prostate to bone (90%), and pancreas to liver
(85%). The liver was the dominant metastatic site for gastrointestinal
(GI) primary tumors (71% of patients), whereas bone and lung
metastases were noted most frequently in non-GI primary tumors,
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King David
43% and 29%, respectively. In a study of combinations of liver,
abdominal cavity, and bone metastases, 86% of prostate primary
tumors had only bone metastases, and 74% of pancreas primary
tumors had only liver metastases (125).
Clinical charts of 100 cancer patients (70 women and 30 men were
studied; mean age 63 years, range: 55-87). The primary lesions
responsible for bone metastases were located in the breast (51
cases), colon (30 cases), lung (seven cases), stomach (4 cases), skin (4
cases), kidney (2 men), pleura (1 woman), and liver (1 men). The
most frequent radiographic pattern was lytic type (52%), followed by
osteosclerotic, mixed, lytic vs. mixed and osteosclerotic vs. lytic
patterns. Skeletal metastases were the most common malignant
bone tumors: among these metastases the spine and the pelvis were
the most frequent. Pain was the main symptom, even though many
bone metastases were asymptomatic. Pathological fractures were
the most severe consequences. Bone scintigraphy remain the
technique of choice in asymptomatic patients in whom skeletal
metastases are suspected. However, this technique though very
sensitive is poorly specific, and thus a negative bone scan finding is
double-checked with another physical examination: if the findings
remain negative, the diagnostic workup is over. On the contrary, in
patients with a positive bone scan or with local symptoms and pain,
radiography and CT are used for screening of metastatic lesions:
results may be negative (for low sensitivity of conventional radiology)
or questionable (in which case bone biopsy is necessary), or
symptoms may be due to the different causes than metastatic lesions
(i.e., osteoarthritis). Before bone biopsy MRI must be performed,
because it is the only technique that allows to distinguish between
bone marrow components (126).
We see that pain is the main symptom in metastatic bone disease,
even though many bone metastases are asymptomatic; pathological
fractures are the most severe consequences. Skeletal metastases are
the most common signs of malignant bone tumors, and the spine and
the pelvis are the most frequent locations for metastases.
It seems very likely that the King was afflicted by some neoplastic
disease, such as multiple myeloma, or renal cancer and/or prostate
cancer which metastasized to the bones. Did pathological fractures
occur?
Other neoplastic diseases such as lung, stomach, CRC,
hepatocellular carcinoma, pancreatic cancer and other types, as
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King David
mentioned above, were excluded from the differential diagnostic list
since it seems unlikely that they afflicted the elderly King David.
The diagnoses of various thyroid disorders can be excluded, since
there are no insufficient data to prove their existence, and it would
be very ironic if the King had been affected by carcinoma of the
thyroid. The diagnosis of breast cancer is unlikely because there are
insufficient signs to indicate the presence of this disease.
HAS THIS PATIENT CANCER?
"Has this patient a cancer?" is a question we frequently ask
ourselves in front of some symptoms, signs of laboratory results like
weight loss, anemia, and high erythrocyte sedimentation rate (ESR).
A retrospective study of the records of 5500 patients admitted in the
Department of Internal Medicine, Bucharest, Romania, during 1998,
selecting those patients with weight loss, anemia (Hb < 10.5 g/dl) and
ESR > = 50 mm/h. The main conclusion of this study was that any
patient admitted to this department had a 4% probability of having a
cancer. Among those with weight loss, anemia and high ESR, one
patient out of two had cancer; among those with weight loss and
anemia 44% had a cancer; and among those with weight loss and
high ESR, one of three had a cancer (127).
If the King had been admitted to the Department of Internal
Medicine, he had only 4% probability of having a cancer. However if
we look at the other considerations, then a significant loss of weight
combined with anemia increases the probability of having cancer to
44%. This research reinforces the conclusion of the previous
research that some type of cancer afflicted King David (128), adding
that there is a 44% probability that he was afflicted by a neoplastic
disease.
Due to the lack of space, it was impossible to discuss about other
neoplastic diseases. Nevertheless, the main types of disease, which
may have afflicted the King are presented in this brief report.
The contemporary diagnosis requires an extensive evaluation
including modern evaluation such as laboratory evaluation, CT, MRI,
bone scan, gastrointestinal tract evaluation, and histopathological
findings. Although these investigations were not performed on King
David, the most likely diagnosis is based on the description given in
the medical record, that is the biblical text.
We learn that in spite of his great suffering, pain-killing
medications were not used in the King's case. By comparison,
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King David
contemporary patients who suffer from severe bone pains would
receive some medication and therefore their quality of life is much
better than those of the patients in ancient times, in this case King
David the Great.
In conclusion: this report analyzes the most likely disease
affecting King David. 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 many
diseases which could have been associated with osteoporosis, senile
osteoporosis, hyperparathyroidism, or malignant disease can be
taken into account. Of these possible diagnoses, malignancy is the
most likely. Among neoplastic diseases, MM, or kidney carcinoma
and/or prostate cancer are the most likely diagnoses.
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Gerontol A Biol Med Sci. 2001;57(3):M152-4.
WEIGHT LOSS
“My knees are weak through fasting,. my flesh failed of fatness,...my
bones cleave to my skin” (Psalm, Bible)
Older people have suffered from loss of weight since the dawn of
history. This research is unique in character, as it combines
contemporary medical knowledge with presentation of a case taken
from ancient history. The main objective of this research was to
analyze from a modern perspective the biblical description of a
geriatric patient who suffered from weight loss. Biblical texts
associated with the aged were examined and passages relating to
geriatric patients who suffered from loss of weight were closely
studied. Passages such as: “... I forget to eat my bread” and “My
knees are weak through fasting; and my flesh failed of fatness” and
“....my bones cleave to my skin” indicate anorexia, fasting, extreme
loss of weight and subsequent cachexia. Among the numerous
causes associated with weight loss, malignancy, social problems such
as loneliness, social isolation and neglect by others, and psychological
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causes including depressed mood, were most likely responsible.
With regard to malignancy, it seems that the King was affected either
by multiple myeloma, or primary carcinoma of the kidney and/or by
prostate cancer with subsequent metastases to the bones.
INTRODUCTION
Elderly patients have suffered from decrease in weight that may
be associated with various diseases for thousands of years. By
studying the causes of weight loss in geriatric persons from ancient
history, modern physicians can expand their knowledge thereby
improving their professional skills.
Who suffered from loss of weight in biblical times? What is the
most likely diagnosis? What are the characteristics of the diseases
that caused weight loss? This report aims to answer these questions
by evaluating weight loss in geriatric patient as described in the Bible.
WEIGHT LOSS AS DESCRIBED IN THE BIBLE
King David, the second and greatest of Israel’s Kings who ruled
that country 3531 years ago, suffered from an eating disorder. A
passage in Psalm 102:4 “..I (the King) forget to eat my bread” tells us
about lack of food intake. This condition indicates anorexia [from Gk,
a + orexis, no appetite]. Anorexia is defined as lack or loss of
appetite, resulting in the inability to eat (1). A subsequent passage
“My knees are weak through fasting; and my flesh failed of fatness”
(Psalm 109:24) shows that David’s anorexia led to fasting and
consequently to unintentional weight loss. The weight loss was so
extreme that “....my bones (the King’s) cleave to my skin” (Psalm
102:6). The condition is compatible with cachexia.
CACHEXIA
The word "cachexia" comes from the Greek words "kakos" and
"hexis", meaning bad condition (2). Cachexia is a complex metabolic
status with progressive weight loss and depletion of host reserves of
adipose tissue and skeletal muscle. Cachexia should be suspected if
involuntary weight loss of greater than five percent of premorbid
weight occurs within a six-month period. Cachexia represents the
clinical consequence of a chronic, systemic inflammatory response,
with high hepatic synthesis of acute-phase proteins resulting in
depletion of essential amino acids. By contrast, in starvation only fat
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metabolism is increased while the organism tries to conserve body
mass (2).
Cachexia – sometimes refers to as devastating disease,
malnutrition, or hypercatabolism – has been described for centuries
and has always raised ominous thoughts that "the end is near". The
disease is encountered in many malignant and nonmalignant chronic,
and ultimately fatal illnesses. Cachexia is associated with exceedingly
high mortality once the syndrome has fully developed, irrespective of
the definition, and is associated with weakness, weight loss, muscle
wasting, and inflammation. It is not simply an ancillary event, it may
contribute to the death of the patients either through effects on
neuroendocrine and immune defense mechanisms or through
protein calorie malnutrition (3,4).
Cachexia indicates general ill health and malnutrition, marked by
weakness and emaciation, usually associated with a severe disease
such as tuberculosis or cancer (1). What was the disease responsible
for anorexia, fasting, extreme loss of weight and subsequent cachexia
in this particular geriatric patient, who was a member of the highest
socioeconomic stratum?
WEIGHT LOSS IN THE ELDERLY
Aging is generally accompanied by weight loss of both fat mass
and fat-free mass. As more people, including elderly, are overweight
or obese, weight loss improves health. Rapid unintentional weight
loss in elderly is usually indicative of underlying disease and
accelerates the muscle loss, which normally occurs with aging (5).
Unintentional weight loss is a relatively common problem in
clinical practice (6). Low body weight and unintentional loss of
weight predict increased morbidity and mortality, especially in the
elderly population (7-10). A retrospective review of 8428 hospital
admissions shows that underweight is a strong predictor of inhospital mortality in patients over 60 years of age (11). The
Framingham Heart Study demonstrates that the relative risk of death
in persons over age 65 who are at the lower extreme of body mass
index is twice than that of other individual (12). Data for persons in
their seventies and eighties also suggest that higher mortality rates
occur in those with low body weights (13). Thus, it is very likely that
cachexia damaged the old King’s health and even accelerated his
death.
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PHYSIOLOGICAL ANOREXIA OD AGING
Most men reach maximum body weight in their forties and most
women in their early fifties. Beyond these ages, declining lean body
mass normally accounts for the majority of weight lost. Weight
distribution shifts from muscle mass in the extremities to fat stores in
the trunk (14). Despite the increase in body fat and obesity that
occurs with aging, there is a linear decrease in food intake over the
life span. This conundrum is explained by decreased physical activity
and altered metabolism with aging (15). Since older persons fail to
regulate food intake adequately, they develop a physiological
anorexia of aging (15,16).
Anorexia is a frequent and complex symptom occurring
physiologically in older persons and during acute and chronic
pathology (17). Energy intake is reduced in older individuals, with
several lines of evidence suggesting that both physiological
impairment of food intake regulation and non-physiological
mechanisms are important. Non-physiological causes of the anorexia
of aging include social (e.g. poverty, and isolation), psychological (e.g.
depression, and dementia), medical (e.g. edentulism, and dysphagia),
and pharmacological factors (18).
Healthy aging is associated with decreased appetite and energy
intake and this is generally associated with weight loss after about 70
years of age. Many sensory and social factors, including olfactory
changes and economic status, contribute to under-nutrition in older
people; however, normal ageing is associated with a number of
significant changes in gastrointestinal function. The control of
appetite is complex but it is clear that gastrointestinal signals are
important in the regulation of appetite and food intake (19).
Physiological anorexia is related to the decreased hedonic
qualities of feeding, altered hormonal and neurotransmitter
regulation of food intake (15), alterations in energy metabolism, loss
of calories in the urine or stools (14), poor absorption from the
gastrointestinal tract (20), abnormal gastrointestinal contraction and
secretion, altered perceptions of taste or smell, satiety, nausea
(14,18,21), poor oral hygiene, ill-fitting dentures (22), and aversion to
specific foods because these foods no longer seem palatable (14). As
many sensory systems decline with aging, these declines influence
food choice and acceptability and may manifest conditions such as
geriatric anorexia (23).
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Was King David afflicted by physiological anorexia of aging? The
subsequent words “... I forget to eat my bread” indicate lack of
appetite, absence of caloric intake, and altered perceptions of taste,
smell and satiety (24). All these factors can be attributed to
physiological anorexia of aging.
However, the diagnosis of
physiological anorexia of aging seems very unlikely in this case,
because the King’s anorexia led to fasting and subsequent cachexia.
An excessive loss of weight may point to a serious and even fatal
disease (25). What was the disease that caused cachexia in King
David’s case?
PATHOLOGICAL CAUSES OF WEIGHT LOSS
Weight loss in older persons can be ascribed to one or more of
three major sets of causes: 1) social, 2) psychological, and 3) medical
(15). Social causes include poverty, functional impairment limiting
the ability to perform activities of daily living, social isolation, poor
nutritional knowledge, and institutional factors such as ethnic food
preferences, inability to tolerate other residents’ behavior, the
monotony of institutionalized food, loss of mate, fear of old age and
changing roles, feelings of rejection, all resulting in emotional stress,
strain, and deprivation (15,26,27).
Were social causes, as mentioned above, responsible for loss of
weight in King David’s case? Subsequent passages in Psalm 22:7,12
“..I am a worm, and not a man; a reproach of men, and despised of
the people”...and “..trouble is near ; for there is none to help” indicate
loneliness, social isolation and neglect by others. It seems,
therefore, that these social problems were associated with the loss of
appetite that led to subsequent loss of weight.
Psychological causes of weight loss include depression,
bereavement, alcoholism, late-life mania, late-life paranoia, anorexia
tardive or nervosa, sociopathy, excessive life burden, cholesterol
phobia, choking phobia, and globus hystericus (15,28). Was any
psychological cause responsible for the King’s weight loss? The
subsequent passages “..a broken and depressed heart (the King’s)
and “I am feeble and depressed...” (Psalms 51:19; 38:9) indicate a
depressed mood. In older persons, depression is associated with
anorexia and weight loss more than in younger individuals (29).
Thus, depression probably also contributed to King David’s anorexia,
fasting and subsequent loss of weight. His social problems can be
associated with social isolation, loneliness, and neglect by other
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people, while his psychosocial problems included his depressed
mood (30).
Many medical conditions cause weight loss. Unintentional weight
loss (UWL) was documented in 154 patients (2.8%) admitted to an
internal medical department during two-year period. More than onethird (36.3%) had a neoplasm, involving preponderantly the
gastrointestinal tract. Patients with neoplasia were older and more
frequently had abnormal physical findings and significantly lower
values of serum albumin as well as higher values of alkaline
phosphatase than other patients did. Despite extensive
investigations, in 36 patients (23.3%) UWL remained unexplained
even after prolonged follow-up periods. The remaining 62 patients
had a variety of disorders, preponderantly gastrointestinal tract (26
patients) and psychiatric (16 patients) diseases. Endocrine disorders
such as diabetes mellitus and hyperthyroidism were relatively
uncommon (3.8%). Thus, UWL is relatively common problem in
clinical practice (8).
The cause of weight loss was established in 132 (84%) patients,
Lünenberg, Germany, and remained unclear in 26 (16%). Reasons
were non-malignant (60% of patients) and malignant (24%) diseases.
Psychological disorders represented 11% of the non-malignant group.
A gastrointestinal disease caused weight loss in 50 (30%) patients. Of
malignant diseases, 53% were gastrointestinal. Amongst the nonmalignant group, 39% had somatic disorders. The prognosis for
unknown causes of weight loss was the same as for non-malignant
causes. Contrary to common belief, weight loss was not usually due
to a malignant disease. A gastrointestinal tract disorder accounted
for weight loss in every third patient (31).
Weight loss of 101 patients, [age, interquartile range): 64 (51-71)
years, 46% male], at University Hospital Gasthuisberg, Leuven,
Belgium, was evaluated. Organic causes were found in 57 patients
(56%), including malignancy in 22 (22%). In 44 patients without
obvious organic cause for the weight loss (44%), a psychiatric
disorder was implicated in 16 (16%) while no cause was established
in 28 (28%), despite vigorous effort and follow-up of at least 6
months (32).
In Spain, at University Hospital Marqués de Valdecilla, 328
patients were studied. There were 236 in-patients (72%) and 92 outpatients (28%). Malignancies were the most frequent cause of
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involuntary weight loss (35%), followed by psychiatric disorders
(24%) (33).
Patients with hyperthyroidism may experience increased appetite
that leads to increased food consumption.
However,
hyperthyroidism, especially in the elderly, may present without
obvious change in appetite, and anorexia as well as loss of weight
may be the predominant symptoms (10,34,35). Hypothyroidism may
cause weight gain. However, this disorder may also lead to anorexia
and apathy resulting in weight loss, especially in the elderly people
(14).
The original Whickham Survey documented the prevalence of
thyroid disorders in a randomly selected sample of 2779 adults,
which matched the population of Great Britain in age, sex and social
class. Outcomes in terms of morbidity and mortality were
determined for over 97% of the original sample. The mean incidence
of spontaneous hypothyroidism in women was 3.5/1000
survivors/year (2.8-4.5) rising to 4.1/1000 survivors/year (3.3-5.0) for
all causes of hypothyroidism and in men 0.6/1000 survivors/year
(0.3-1.2). The mean incidence of hyperthyroidism in women was
0.8/1000 survivors/year (0.5-1.4) and was negligible in men. An
estimate of the probability of the development of hypothyroidism
and hyperthyroidism at a particular time, i.e. the hazard rate, showed
an increase with age in hypothyroidism but no age relation in
hyperthyroidism. The presence of goiter was not associated with any
clinical or biochemical evidence of thyroid dysfunction. Increased
values of TSH above 2 mu/l increased the probability of developing
hypothyroidism, which was further increased in the presence of antithyroid antibodies (36).
We see that hypothyroidism is increasing with age. Was the King
afflicted by hypothyroidism or hyperthyroidism? We have insufficient
data to suspect the presence of hypothyroidism. The diagnosis of
hyperthyroidism as a condition that led to extreme weight loss in the
absence of appropriate physical and laboratory findings seems
unlikely. Other endocrine and metabolic diseases such as diabetes
mellitus, Addison’s disease, pheochromocytoma, panhypopituitarism
and hypercalcaemia (14,15) can be excluded, since there are
insufficient data to prove their existence. For the same reason,
various infections such as tuberculosis, fungal disease, amebic
abscess, and subacute bacterial endocarditis (14) can be removed
from the list. The use of medications that can interfere with appetite
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by causing abdominal discomfort, anorexia, nausea, diarrhea, and
inhibition of gastric emptying seems unlikely (14). Although various
gastrointestinal diseases such as peptic ulcer, gastroesophageal
reflux, cholelithiasis, inflammatory bowel disease, hepatitis,
pancreatitis, gluten enteropathy, pancreas insufficiency, Helicobacter
pylori infection, cardiac disease (congestive heart failure), respiratory
diseases (end-stage lung disease, chronic bronchitis), renal disease
(uremia), connective tissue diseases (rheumatoid arthritis, systemic
lupus erythematosus), and neurological diseases (Parkinson’s
disease, stroke) (14,15,37) may cause anorexia and subsequent loss
of weight, there are insufficient data to prove their presence.
Malignancy is probably the most common cause of weight loss,
especially when major signs and symptoms are absent (6,34,38,39).
The sentences “My strength failed...and my bones are consumed”
and “My bones wasted away through my anguished roaring all day
long” (Psalm 32:11, 32:3), analyzed in a previous section, indicate
that King David suffered from osteoporosis, which afflicted his bones.
Among the various diseases that may be associated with
osteoporosis, the most likely are senile osteoporosis,
hyperparathyroidism, or malignant disease, and the diagnosis of
malignancy is the most acceptable.
A combination of two factors, cachexia and intractable bone
pains, reinforces a previous conclusion that the King was indeed
afflicted by a neoplastic disease (40). It is most likely that the King
was affected either by multiple myeloma, or by primary carcinoma of
the kidney and/or prostate cancer with subsequent metastases to
the bones.
Cancer cachexia describes a syndrome of progressive weight loss,
anorexia, and persistent erosion of host body cell mass in response to
a malignant growth. Although often associated with preterminal
patients bearing disseminated disease, cachexia may be present in
the early stages of tumor growth before any signs or symptoms of
malignancy. A decline in food intake relative to energy expenditure
(which may be increased, normal, or decreased) is the fundamental
physiologic derangement leading to cancer-associated weight loss. In
addition, abnormalities of host carbohydrate, protein, and fat
metabolism lead to continued mobilization and ineffective repletion
of host tissue, despite adequate nutritional support. Cachectin/TNF
or other host-derived cytokines (produced as a defense against
malignancy) have been implicated as signal molecules in cachexia,
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based upon similar metabolic derangements produced by these
cytokines in other chronic wasting illnesses (41).
Cancer cachexia is a complex syndrome that includes host tissue
wasting, anorexia, asthenia, and abnormal host intermediary
metabolism. It is present in approximately 50% of cancer patients
during treatment and nearly 100% of treated cancer patients at
death. The central problem of cancer cachexia is that energy balance
is not maintained, and the host has a relative hypophagia which
results in host tissue wasting (41).
Cachexia is the most common paraneoplastic syndrome of
malignancy and is characterized by anorexia, early satiety, and severe
body compositional change with weight loss, adipose and muscle
loss, weakness (asthenia), anemia, and edema. Cause of death in as
many as 20% of patients with cancer is associated with tumorinduced and treatment-related malnutrition and inanition (42).
Muscle wasting during cancer and ageing share many common
metabolic pathways and mediators. Due to the size of the population
involved, both cancer cachexia and ageing sarcopenia may represent
targets for future promising clinical investigations. Cancer cachexia is
a syndrome characterized by a marked weight loss, anorexia,
asthenia and anemia. In fact, many patients who die with advanced
cancer suffer from cachexia. The degree of cachexia is inversely
correlated with the survival time of the patient and it always implies
a poor prognosis. In recent years, age-related diseases and disabilities
have become a major health interest and importance. This holds
particularly for muscle wasting, also known as sarcopenia that
decreases the quality of life of the geriatric population, increasing
morbidity and decreasing life expectancy. The cachectic factors
(associated with both depletion of fat stores and muscle tissues) can
be divided into two categories: of tumor origin and humoral factors
(43,44).
What factors were involved in the King's cachexia?
TO SUM UP: this article analyzes the most likely diseases
associated with loss of weight in King David. The passages “... I forget
to eat my bread” and “My knees are weak through fasting; and my
flesh failed of fatness” and “....my bones cleave to my skin” indicate
that the King suffered from anorexia, fasting, and extreme loss of
weight leading to cachexia. Multiple causes may be responsible for
weight loss in a single patient. For King David, a combination of
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multivariate causes such as neoplastic, social and psychological
played a role in the development of cachexia. It is most likely that
the King was affected either by multiple myeloma, or by primary
carcinoma of the kidney and/or cancer of prostate with subsequent
metastases to the bones. His social problems can be associated with
social isolation, loneliness, and neglect by other people, while his
psychological problems included his depressed mood.
References
1. Hamerman D. Molecular-based therapeutic approaches in treatment of
anorexia of aging and cancer cachexia. J Gerontol Med Sci. 2002;57A(8):M511-8.
2. Tisdale MJ. Biology of cachexia. J Natl Cancer Inst. 1997;89:17631773.doi:10.10993/jnci/89.23.1763.
3. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2:862-871.
Doi:10.1038/nrc927.
4. Lainscak M, Filippatos GS, Gheorghiade M, et al. Cachexia: common, deadly,
with an urgent need for precise definition and new therapies. A, J Cardiol.
2008;101(11A):8E-10E.
5. Miller SL, Wolfe RR. The danger of weight loss in the elderly. J Nutr Health
Aging. 2008;12:487-91.
6. Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A
retrospective analysis of 154 cases. Arch Intern Med. 1986;146:186-7.
7. Hardy C, Wallace C, Khansur T, et al. Nutrition, cancer and aging. An
annotated review. J Am Geriatr Soc. 1986;24:219-28.
8. Schiffman S, Pasternak M. Decreased discrimination of food odors in the
elderly. J Gerontol. 1979;34:79.
9. Liu LJ, Bopp MM, Roberson PK, et al. Undernutrition and risk of mortality in
elderly patients within 1 year of hospital discharge. J Gerontol Med Sci.
2002;57A(11):M741-6.
10. Lee IB, Blair SN, Allison DB, et al. Epidemiologic data on the relationships of
caloric intake, energy balance, and weight gain over the life span with longevity and
morbidity. J Gerontol Med Sci. 2001;56A(Special Issue SI):7-19.
11. Potter JF, Schafer DF, Bohi RL. In-hospital mortality as a function of body
mass index: An age-dependent variable. J Gerontol. 1988;43:M59-63.
12. Harris T, Cook EF, Garrison R, et al. Body mass index and mortality among
nonsmoking older persons: The Framingham Heart Study. JAMA.1988;259:1520-4.
13. Fischer DW. Low body weight and weight loss in the aged. Am Diet Assoc.
1990;90:1697-705.
14. Reife C. Involuntary weight loss. Med Clin North Am. 1995;79:299-313.
15. Morley J. Decreased food intake with aging. J Gerontol Med Sci. 2001;56
(Special Issue 2):81-8.
16. Roberts SB, Fuss P, Heyman MB, et al. Control of food intake in older men.
JAMA. 1994;272:1601-6.
17. Bertrand PC, Roulet M. Anorexia and malnutrition. Rev Prat. 2003;53:259-62.
18. Hays NP, Robers SB. The anorexia of aging in humans. Physiol Behav.
2006;88:257-66.
19. Parker BA, Chapman IM. Food intake and ageing – the role of the gut. Mech
Ageing Dev. 2004;125:859-66.
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20. Geokas MC, Haverback BJ. The aging gastrointestinal tract. Am J Surg.
1969;117:881-92.
21. Mathey MFAM, Siebelink E, de Graaf C, et al. Flavor enhancement of food
improves dietary intake and nutritional status of elderly nursing home residents. J
Gerontol Med Sci. 2001;56A(4):M200-5.
22. Langan MJ, Yaerick ES. The effect of improved oral hygiene on taste
perception and nutrition of the elderly. J Gerontol. 1976; 31:413-8.
23. Elsner RJ. Changes in eating behavior during the aging process. Eat Behav.
2002;3:15-43.
24. Reynish W, Andrieu S, Nourhashemi F, et al. Nutritional factors and
Alzheimer’s disease. J Gerontol Med Sci. 2001;56(11):M675-80.
25. Gazewood JD, Mehr DR. Diagnosis and management of weight loss in the
elderly. J Family Pract. 1998;47:19-25.
26. Kamath SK. Taste acuity and aging. Am J Clin Nutr. 1982; 36:766-75.
27. McIintosh WA, Shifflett PA, Picou JS. Social support, stressful events, strain,
dietary intake, and the elderly. Med Care. 1989;27:140-53.
28. Morley JE. Anorexia and weight loss in older persons. J Gerontol Med Sci.
2003; 58A(2):131-7.
29. Fitten LJ, Morley JE, Gross PL, et al. Depression. J Am Geriatr Soc.
1989;40:365-9.
30. Ben-Noun L. The disease that caused weight loss in King David the Great. J
Gerontol A Biol Med Sci. 2004;59(2):143-5.
31. Lankish P, Gerzmann M, Gerzmann JF, Lehnick D. Unintentional weight loss:
diagnosis and prognosis. The first prospective follow-up study from a secondary
referral centre. J Intern Med. 2001;249:41-6.
32. Metalidis C, Knockaert DC, Bobbaers H, Vanderschueren S. Involuntary
weight loss. Does a negative baseline evaluation provide adequate reassurance? Eur
J Inten Med. 2008;19:345-9.
33. Henández JL, Matorras P, Riancho JA, González-Macías J. Involuntary weight
loss without specific symptoms: a clinical prediction score for malignant neoplasm.
QJM. 2003;86:649-55.
34. Morley JE, Slag MF, Elson MK, et al. The interpretation of thyroid function
tests in hospitalized patients. JAMA. 1983; 249:2377-9.
35. Foster DW. Gain and loss in weight. In: Isselbacher KJ, Braunwald E, Winson
JD, et al (eds). Harrison’s Principles of Internal Medicine, ed 13. New York: McGrawHill. 1994, pp. 221-4.
36. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid
disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin
Endocrinol (Oxf). 1995;43:55-68.
37. L. Ben-Noun. Was the biblical King David affected by hypothermia? J
Gerontol Med Sci. 2002; 57:M364-7.
38. Martignoni ME, Kunze P, Friess H. Cancer cachexia. Mol Cancer. 2003;2:36.
Doi:10.1186/ 1476-4598-2-36.
39. Marton KI, Sox HC, Krupp JR, et al. Involuntary weight loss: diagnostic and
prognostic significance. Ann Intern Med. 1981;95:568-74.
40. L. Ben-Noun. What was the disease of the bones that affected King David ? J
Gerontol Med Sci. 2002;57:M152-4.
41. Kern KA, Norton JA. Cancer cachexia. JPEN J Paenter Enter Nutr. 1988;12:28698.
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42. Norton JA, Peacock JL, Morison SD. Cancer cachexia. Crit Rev Oncol Hematol.
1987;7:289-327.
43. Ottery FD. Cancer cachexia: prevention, early diagnosis, and managemet.
Cancer Pract. 1994;2:123-31.
43. Argilés JM, Busquets S, Felipe A, López-Soriano FJ. Muscle wasting in cancer
and ageing: cachexia versus sarcopenia. Adv Gerontol. 2006;18:39-54.
CHRONIC WEAKNESS
Older people have suffered from weakness, associated with
various diseases, since the dawn of history. This research is unique in
character, as it combines present-day knowledge with the
presentation of a case taken from ancient history. The main aim of
this research was to analyze from a modern perspective the biblical
description of a geriatric patient who suffered from weakness.
Biblical texts associated with the aged were examined and passages
relating to geriatric patient who suffered from weakness were closely
studied. Passages “My strength fails…, My heart palpitates, my
strength fails me,….My heart fails me, and My strength is dried up like
a potsherd” indicate generalized weakness. Among the numerous
causes associated with generalized weakness, cancer related fatigue,
intractable bone pain, malnutrition leading to cachexia, severe
anemia of chronic diseases, psychosocial problems associated with
loneliness, social isolation, and neglect by others, and depression are
the most likely.
INTRODUCTION
Patients have suffered from chronic weakness, which may be
associated with various diseases, for thousands of years. Who
suffered from this condition in biblical times? What were the causes?
What was the most likely diagnosis? This research aims to answer
these questions by evaluating diseases that caused chronic weakness
as described in the Bible.
WEAKNESS AS DESCRIBED IN THE BIBLE
King David, the second and greatest of Israel’s Kings who ruled
that country 3531 years ago, suffered from diminished strength “My
strength fails…, My heart palpitates, my strength fails me” (Psalms
31:11; 38:11), “My heart fails me” (Psalms 38:13), and “My strength
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is dried up like a potsherd” (Psalms 22:16). These passages show that
the King became very weak, and was afflicted by the loss of energy.
DEFINITION
Weakness is defined as a reduction in the strength of one or more
muscles (1). It may be generalized (total body weakness) or localized
to a specific area, side of the body, limb or muscle (1,2). Thus,
according to the contemporary definition, the passages mentioned
above indicate a generalized weakness.
GENERALIZED WEAKNESS
Since David suffered from generalized weakness, all conditions
associated with local weakness were not analyzed. Causes for
generalized weakness include electrolyte disturbances, e.g.,
hypokalemia, hypercalcemia, hypernatremia, hypophosphatemia,
hypermagnesemia,
endocrine
disorders
such
as
hypo/hyperthyroidism, Addison’s disease, muscle disorders channelopathies (periodic paralyses), metabolic defects of muscle
(impaired carbohydrate or fatty acid utilization; abnormal
mitochondrial function), neuromuscular junction disorders myasthenia gravis, Lambert-Eaton myasthenic syndrome, central
nervous system disorders - transient ischemic attacks, transient
global ischemia, multiple sclerosis, toxic myopathy, fibromyalgia, any
infection, such as infectious mononucleosis, flu, poliomyelitis,
botulism, pneumonia, any serious disease, such as congestive heart
failure, cirrhosis, chronic renal failure, cancer, and psychiatric
conditions, especially depression (1-4).
Did any of the factors listed above play a role in the development
of David’s weakness? As previously shown, King David suffered from
mild hypothermia (5). It seems unlikely that this condition led to a
generalized weakness. King David also suffered from intractable
bone pains due to osteoporosis. Among the various diseases that
may be associated with osteoporosis, the most likely are senile
osteoporosis, hyperparathyroidism, or malignant disease, and of
these causes malignant disease is the most likely (6). David was also
afflicted by anorexia, fasting and extreme weight loss that led to
cachexia (7).
A combination of two factors, cachexia and
osteoporotic, intractable bone pains points towards a diagnosis of a
metastatic bone disease (6,7).
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With regard to malignancy, it seems that the King was affected
either by multiple myeloma, or by primary carcinoma of the kidney
and/or prostate cancer with subsequent metastases to the bones (7).
In addition to physical diseases, David suffered from various
psychosocial problems such as loneliness, social isolation and neglect
by others, and depression (7,8).
Among the numerous causes which may be associated with
weakness, two conditions can be identified in David’s case malignancy and depression. There are insufficient data to verify the
presence of other conditions, e.g., electrolyte imbalance.
FATIGUE IN CANCER PATIENTS
Fatigue occurs commonly in general practice. Approximately 20%
of men and 30% of women in the general population complain of
frequent tiredness (9). Labeling it as healthy fatigue, Glaus found
that 55% of healthy individuals identified a physical sensation of
fatigue/tiredness, 21% complained of an affective sensation of
fatigue, and 24% identified cognitive fatigue (10). However, when
cancer patients experience fatigue, it is different and more extreme
than that experienced by healthy individuals (11).
Fatigue is the most common unrelieved symptom of cancer (1215). Fatigue, as a symptom, is a subjective sensation of weakness,
lack of energy, or tiredness (16). As a syndrome, fatigue has been
defined as an overwhelming, sustained sense of exhaustion and
decreased capacity for physical and mental work (17). Criteria for
cancer-related fatigue include diminished energy and mental capacity
and increased need to rest that is disproportionate to any recent
change in activity level and is evident nearly every day during any 2week period in the past month (13). Fatigue presents at the time of
cancer diagnosis in approximately 50%-75% of patients (18).
Fatigue is a frequent symptom in tumor patients. Although the
phenomenon is well known, there is no homogenous definition.
Decreased quality of life, exhaustion, fatigability, tiredness, malaise,
and asthenia are synonymous and overlapping terms used for this
syndrome. Fatigue and exhaustion are present in at least 75% of all
tumor patients. Fatigue and exhaustion are enhanced by chemo-,
radiation- and immunotherapy as well as surgery. Fatigue in tumor
patients has many reasons and comprises physical, mental and
emotional facets. Cancer anemia, atrophy of the skeleton muscles
and cancer cachexia are the decisive factors for exhaustion (19).
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According to the contemporary definition, the biblical verses “My
strength fails…, My heart palpitates, my strength fails me”, “My heart
fails me” and “My strength is dried up like a potsherd” indicate
chronic fatigue most likely due to cancer. The following verse “…I am
in trouble, my eye is consumed with grief, my soul and my body”
demonstrates a decreased mental capacity.
The body wasting known as cancer cachexia is a complex
syndrome characterized by progressive tissue depletion and
decreased nutrient intake that is manifested clinically as inexplicable,
recalcitrant anorexia, and inexorable host weight loss. Decreased
nutritional intake, increased metabolic expenditure and dysfunctional
metabolic processes, including hormonal and cytokine-related
abnormalities, all appear to play roles in the development of cancer
cachexia. Although this condition of advanced protein-calorie
malnutrition, sometimes is described as the cancer anorexia-cachexia
syndrome, it is not entirely understood. The syndrome appears to be
multifactorial, and is a major cause of morbidity and mortality in
cancer patients that ultimately leads to death. The pathogenesis of
cancer cachexia appears to be related to proinflammatory cytokines,
alterations in the neuroendocrine axis and tumor-derived catabolic
factors (20). Several other possible causes of cancer-related fatigue
consist of altered muscle metabolism, sleep deprivation, stress, and
depression (12,13,20-25).
The identifiable causes for cancer-related fatigue in King’s David
case include malnutrition that led to cachexia, intractable bone pains,
persistent stress associated with various psychosocial problems, such
as loneliness, social isolation, neglect by others, and depression (6,7).
It seems unlikely that mild hypothermia was associated with the
development of cancer-related fatigue.
King David also suffered from insomnia “..All the night make I my
bed to swim; I water my couch with my tears” (Psalms 6:7). According
to DSM-IV, insomnia or hypersomnia is one of the symptoms of
depression (25). Thus, insomnia too can be related to cancer-related
fatigue, and it seems likely that in King David’s case, insomnia was
associated with depression.
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ANEMIA OF CHRONIC DISEASES
One of many causes of cancer-related fatigue is the anemia that
accompanies the disease, or the anemia of chronic disease (11).
Anemia is a decrease in circulating red blood cells that contributes to
a complex group of symptoms. Anemia may be present in more than
half of all patients with cancer but often is assessed, documented,
prevented, and treated inadequately. Individuals with cancer are
living longer, and the number of cancer treatment options provided
at various points in the cancer continuum is growing; however, many
treatments contribute to anemia. Because anemia can develop from
multiple causes, treatment must be tailored to the underlying
etiology. Cancer-related anemia can significantly affect therapeutic
outcomes and patients' quality of life (26).
Anemia that is common in patients with cancer is often underdiagnosed and under-treated. Fatigue is frequently associated with
cancer-related anemia and has a significant impact on patients'
quality of life. Many patients regard the treatment of fatigue as more
important than the treatment of pain, in contrast with the opinions
of many physicians. Accurate assessment of anemia and fatigue is
essential to understand the reality of living with cancer-related
anemia and to provide optimal treatment (27).
Symptoms associated with anemia include fatigue, loss of
stamina, breathlessness, and tachycardia, particularly associated with
physical exertion, and depend on age of the patient and the
adequacy of blood supply to critical organs (28).
The words “My heart palpitates, my strength fails me” indicate
tachycardia, most probably sinus tachycardia, while the words "… my
strength fails me" indicate fatigue. These two symptoms –
tachycardia and fatigue point anemia. It follows, that the King
suffered from anemia of chronic diseases.
A large European survey of cancer patients (n=15.367) reported
that 67% had anemia at some point during the survey, and that 60%
of these patients did not receive any treatment for anemia. Two
other surveys (the FATIGUE surveys) showed that over 75% of cancer
patients experienced fatigue at least monthly, with over 30%
reporting this symptom on a daily basis. Significantly more patients
regarded fatigue as having a greater negative impact on their daily
lives than many other cancer- or treatment-related complications,
with important emotional and mental consequences including lack of
self-motivation, sadness, frustration, and mental exhaustion. Indeed,
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King David
fatigue was so debilitating that 12% of patients felt their quality of
life was so reduced that they did not wish to continue living. Anemia
is also an independent predictor of poor prognosis in cancer patients.
A systematic review evaluating survival showed a 65% overall
increase in the risk of mortality in cancer patients with anemia (29).
Anemia in cancer-related fatigue can be defined as mild –
hemoglobin (Hgb) level between 10.00-11.99 g/dL, moderate (8.009.90 g/dL), and severe (<8.00 g/dL). Severity of anemia, using
standard criteria for mild, moderate and severe anemia, is associated
with the degree of reported fatigue among the anemic cancer
patients (11).
What level did the King’s anemia reach? The words “My heart fails
me” are compatible with a severe condition, in which the
cardiovascular system has failed. The situation indicates severe
anemia.
TO SUM UP: the present research analyzes the most likely
conditions associated with the decreased strength that afflicted the
King David. The passages “My strength fails…, My heart palpitates,
my strength fails me, My heart fails me, and My strength is dried up
like a potsherd” indicate a generalized weakness. Among the
numerous causes associated with generalized weakness, cancerrelated fatigue, malnutrition leading to cachexia, intractable bone
pain, severe anemia of chronic diseases, persistent stress associated
with various psychosocial problems such as loneliness, social
isolation, neglect by others, and depression are the most likely in this
case.
References
1. Aminof MJ. Weakness and paralysis. In: Fauci A, Kasper DL, Longo DL,
Braunwald E, et al. (eds). Principles of Harrison's Internal Medicine. 17th ed. New
York: McGraw-Hill. 2008, pp. 147-150.
2. Plum F. Disorders of motor function. Weakness, asthenia, and fatigue. In:
Benet JC, Plum F. (eds). Cecil Textbook of Medicine. Saunders. Philadelphia, London.
1991, pp. 2027-8.
3. Olney RK, Aminoff MJ. Weakness, myalgias, disorders of movement and
imbalance. In: Braunwald E, Fauci AS, Kasper DL, et al. (eds). Harrison’s Principle of
Internal Medicine. 15th ed. New York: McGraw-Hill. 2001, pp. 118-348.
4. Fietta P. Fibromyalgia: state of art. Minerva Med. 2004;95:37.
141
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King David
5. Ben-Noun L. Was the biblical King David affected by hypothermia? J Gerontol
Med Sci. 2002;57A:M364-7.
6. Ben-Noun L. The disease that caused weight loss in King David the Great. J
Gerontology Med Sci. 2004 59A(2):143-5.
7. Ben-Noun L. What was the disease of bones that affected King David? J
Gerontol Med Sci. 2002;57A:M152-4.
8. Ben-Noun L. Mental disorder that afflicted King David the Great. Hist
Psychiatry. 2004;15:467-76.
9. Hjermstad MJ, Fayers PM, Bjordal K, et al. Health-related quality of life in the
general Norwegian population assessed by European Organization for Research and
Treatment of Cancer Core Quality-of-Life Questionnaire: the QLQ-C30 (+3). J Clin
Oncol 1998;16:188-96.
10. Glaus A. Fatigue in patients with cancer: analysis and assessment. Heidelberg:
Springer-Verlag, 1998.
11. Cella D, Jin-shei L, Vhang C-H, et al. Fatigue in cancer patients compared with
fatigue in the general United States population. Cancer. 2002;94:528-38.
12. Cella D. The functional Assessment of Cancer Therapy-Anemia (FACT-An): a
new tool for the assessment of outcomes in cancer anemia and fatigue. Semin
Hematol. 1997;34(Suppl):13-9.
13. Cella D, Peretman A, Passik S, et al. Progress toward guidelines for the
management of fatigue. Oncology 1998;12:369-77.
14. Mooney K, Ferrel B, Nail L, et al. Oncology Nursing Society research priorities
survey. Oncol Nurs Forum. 1991;18:1381-8.
15. Stetz K, Haberman M, Holcombe J, et al. 1994 Oncology Nursing Society
research priority survey. Oncol Nurs Forum. 1995;22:785-9.
16. Stone P, Richards M, Hardy J. Fatigue in patients with cancer. Eur J Cancer.
1998;34:1670-6.
17. North American Nursing Diagnosis Association. Nursing diagnoses: definition
and classification, 1987-1998. Philadelphia: McGraw-Hill. 1996.
18. Stasi R, Abriani L, Beccaglia P, et al. Cancer-related fatigue: evolving concepts
in evaluation and treatment. Cancer 2003;98:1786-801.
19. Zahner J. Fatigue and exhaustion in tumor patients. Etiology, diagnosis and
treatment possibilities. Med Klin (Munich). 2000 95:613-7.
20. Palesty JA, Dudrick SJ. What we have learned about cachexia in
gastrointestinal cancer. Dig Dis. 2003;21:198-213.
21. Portenoy RK, Itri LM. Cancer-related fatigue: guidelines for evaluation and
management. Oncologist. 1999;4:1-10.
22. Irvine DM, Vincet L, Bubela N, et al. A critical appraisal of the research
literature investigating fatigue in the individual with cancer. Cancer Nurs.
1991;14:188-99.
23. Portenoy RK, Miaskowaki C. Assessment and management of cancer-related
fatigue. In: Berger A, Portenoy RK, Weissman DE, eds. Principles and practice of
supportive oncology. Philadelphia: Lippincott-Raven. 1998, pp. 109-18.
24. Visser MRM, Smets ERA. Fatigue, depression and quality of life in cancer
patients: How are they related? Support Care Cancer. 1998;6:191-8.
25. APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Washington, DC: American Psychiatric Association, 1994.
26. Hurter B, Bush NJ. Cancer-related anemia: clinical review and management
update. Clin J Oncol Nurs. 2007;11:349-59.
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27. Fubert J. Cancer-related anemia and fatigue: assessment and treatment. Nurs
Stand. 2006;20:50-7.
28. Adamson JW, Longo DL. Anemia and polycythemia. In: Braunwald E, Fauci
AS, Kasper DL, et al. (ed). Harrison’s Principles of Internal Medicine. 15th ed. 2001.
New York: McGraw-Hill. 2001, pp. 348-51.
29. Harper P, Littlewood T. Anaemia of cancer: impact on patient fatigue and
long-term outcome. Oncology. 2005;69 Suppl 2:2-7.
HYPOTHERMIA
The elderly have suffered from hypothermia for thousands of
years. This research analyses the first documented case of
hypothermia as described in the Bible. The sentence “Now king
David was old and stricken in years, and covered him with clothes, but
he gained no warmth” indicates hypothermia that afflicted the
biblical King David, the second and the greatest of Israel’s Kings, who
ruled the country 3531 years ago. Environmental factors did not play
a significant role in the development of hypothermia. Among various
diseases, the most likely to cause immobility and subsequent
hypothermia are senile osteoporosis, hyperparathyroidism, or
malignancy. Among these diseases, malignancy is the most
acceptable. Viewed by a modern physician, the story of King David
unfolds as possibly the earliest description of patient affected by
hypothermia, features of which have changed little through the ages.
INTRODUCTION
Elderly patients have suffered from hypothermia for thousands of
years. It is defined as a core (rectal, esophageal, tympanic) body
temperature equal to or less than 350 C (950 F) (1-5).
The causes of hypothermia are either primary or secondary.
Primary, or accidental, hypothermia occurs in healthy individuals with
inadequately clothing and who are exposed to severe cooling (6).
The term accidental hypothermia is used to imply that the low body
temperature is unintentional (7), environmentally induced, and
distinguished from hypothermia that develops secondary to medical
conditions or surgical treatment (2,4,7-9). Who was the person who
suffered from hypothermia as described in the Bible? What were the
characteristics of this hypothermia? This report aims to evaluate this
subject using the biblical description of hypothermia.
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HYPOTHERMIA AS DESCRIBED IN THE BIBLE
King David, the second and greatest of Israel’s Kings, who ruled
the country 3531 years ago, was about 70 years old “David was thirty
years old when he began to reign, and he reigned forty years” (II
Samuel 5:4). When the King reached old age, he suffered from a low
body temperature “Now king David was old and stricken in years, and
covered him with clothes, but he gained no warmth” (I Kings 1:1).
Thus, David’s servants summoned Abishag to warm the King “...let
her cherish him, and let her lie in thy bosom, that my lord the king get
heat” (1:2). Do these words indicate hypothermia? According to the
biblical text, King David was a very old man. Although the King was
covered with clothes, his body gained no warmth. Therefore, the
King’s body temperature was lower than normally accepted, that is,
equal to or even less than 950 F. Thus, it is clearly stated that the
King was suffering from hypothermia.
ABNORMAL PHYSIOLOGICAL MECHANISMS
Man adapts to cold in a variety of ways: vasoconstriction reduces
peripheral blood flow and maintains the temperature of the body
core, shivering increases heat production, and modification of
behavioral patterns results in better tolerance of abnormally low
temperatures (8). When these mechanisms fail, hypothermia
develops (10,11). Its symptoms include impairment of increased heat
production and decreased heat loss (12), impaired recognition of
decreased temperature allowing patients to tolerate cold conditions
without discomfort (9), decreased activity of the autonomous
nervous system, decreased resting peripheral blood flow, decreased
vasoconstriction, decreased ability to alter respiratory response to
changes in environmental temperature, decreased mobility,
decreased muscle mass, and decreased or absent shivering (10).
Severe cold affects all organ systems and especially the central
nervous and cardiovascular systems; many biochemical reactions and
pathways become distorted or slowed at low body core
temperatures (13).
Did any of the mechanisms, mentioned above, play a role in the
old King’s hypothermia? This question remains open, since there are
insufficient documented data to evaluate it.
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TYPES OF HYPOTHERMIA
Etiologically, there are three types of hypothermia: immersion,
exhaustion, and subclinical (14).
Immersion or accidental
hypothermia may result from exposure to prolonged or extreme cold
from immersion or atmospheric conditions that lead to a body heat
deficit and a fall in the core temperature to 950 F (15). Mountain
climbers inadequately clothed in cold weather and long distance
swimmers exposed to hot and cold waters are prone to this type of
hypothermia (14). Exhaustion hypothermia results from depletion of
the body’s readily available energy sources. It occurs in long distance
runners, miners, steel workers, manual laborers, and so on.
Subclinical hypothermia is usually found in the elderly, resulting from
an impairment of their temperature-regulating center. Often, older
patients are unable to adjust their body temperatures readily to
extremes. They may have consistently low core body temperatures
due to impaired ambient temperature perception, impaired capacity
to shiver, decreased total body water, and inability to conserve heat
by vasoconstriction (10,14).
How can King David’s hypothermia be classified? Obviously, the
King was not a mountain climber, nor a long distance swimmer, nor a
runner, nor a manual laborer. Thus, immersion and exhaustion
hypothermia can be excluded. Because the King represents the
elderly person, it is most likely that he suffered from subclinical
hypothermia.
ENVIRONMENTAL HYP[OTHERMIA
A variety of environmental factors such as poor heating facilities,
particularly during winter, a lack of indoor plumbing, living alone, and
being housebound contribute to hypothermia (16-19). Fox et al. (20),
however, were unable to correlate any environmental factors with
low body temperatures in the elderly. Similarly, Davidson and Grant
show that accidental hypothermia was not confined to the elderly
people, nor it was a winter phenomenon. They found that the
eventual outcome was determined more by the underlying medical
condition than by the severity of hypothermia (3).
Exposure to cold can produce a variety of injuries that occur
because of man's inability to adapt to cold. These injuries can be
divided into localized injury to a body part, systemic hypothermia, or
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a combination of both. Body temperature may fall because of heat
loss by radiation, evaporation, conduction, and convection (6).
Did any of the environmental factors play a role in the
development of King David’s hypothermia? Because the King did not
belong to the lower socioeconomic strata, hypothermia related to
poor housing seems very unlikely. Apparently, the King’s house was
not poor heated. Thus, this type of hypothermia seems unlikely.
More than 650 deaths from hypothermia occur each year in the
United States. Even minor deviation from normal temperature leads
to important symptoms and disability. The most significant risk
factors are advanced age, mental impairment, substance use, and
injury (21).
This retrospective study (1995-2995) in a 1200-bed tertiary care
hospital in southern Israel examined patients' data and weather
conditions (including mean day and low temperatures, humidity,
wind velocity and precipitation) within 48 hours before admission.
Patients (n=169) with hypothermia were admitted. The mean highest
environmental temperature over 48 hours before admission was 15.3
degrees C in the severe hypothermia (9 cases, 5.3%), 21.4 degrees C
in the moderate (40 cases, 23.7%), and 29.3 C in the mild group (120
cases, 71%). Major medical conditions associated with decreased
body temperature were sepsis (65, 38.5%), trauma (34, 30.1%),
endocrine disorders (19, 11.2%), and substance abuse (15, 8.8%). The
inhospital mortality rate was 47.3%. A risk score based on 5
admission variables (age > or = 70 years, mean arterial pressure < 90
mm Hg, pH < 7.35, creatinine > 1.5 mg/dL, and confusion) was
generated, predicting inhospital mortality with area under the
receiver operating characteristic curve of 0.8. A prognostication
system based upon clinical and laboratory variables may identify
hypothermic patients with increased risk of death (22).
We see that hypothermia is a significant public health problem
and even may cause death.
Did King David suffer from sepsis,
trauma, some endocrine disorder, or substance abuse? In the
absence of appropriate anamnestic, physical, and laboratory findings,
these diagnoses seem unlikely.
URBAN HYPPOTHERMIA
Urban hypothermia is characterized by a poor temperature
discrimination and lack of precision in adjusting the thermal
environment (11). In Zagreb, University Hospital Rebro, Croatia, 18
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elderly patients, 11 women and 7 men, aged 66-87 years, were
afflicted by urban hypothermia. Ten patients suffered from moderate
hypothermia (rectal temperature 32-35 degrees C), and eight from
severe hypothermia (rectal temperature < 32 degrees C). In the
group of patients suffering from moderate hypothermia, three were
somnolent and six in various degrees of comatose states. In the
group of patients with severe hypothermia, three patients were
somnolent or stuporous and five were in comatose states of various
degrees. In the group with severe hypothermia, three presented with
arterial hypotension and five were in a state of shock (23).
Did the King suffer from urban hypothermia? Apparently, the
King's house was not poorly heated. Thus, the question arises of
whether he suffered from poor temperature discrimination and lack
of precision in adjusting to his thermal environment?
CLINICAL STAGES
In mild hypothermia or the responsive stage, body temperatures
range between 32.2 and 350 C (90 to 95 F) (3,10). Patients tend to
generate and retain body heat, hence the term “responsive” phase.
The body’s metabolic rate, blood pressure (20), cardiac rate, cardiac
output, and respiratory rate increase. The patient shivers unless this
response is lost because of aging. Cutaneous vasoconstriction occurs
and renders the skin pale and cold to the touch. Diuresis ensues as
vasoconstriction increases the volume of the central circulation. In
moderate hypothermia or the slowing phase, body temperature
reaches 32.1 to 240 C. The ability to generate heat is seriously
impaired. Muscles tend to stiffen and shivering decreases. The
respiratory rate declines, hypoventilation, hypotension, arrhythmia,
and central nervous system dysfunction such as disorientation,
confusion and hallucinations occur, pupils dilate; and coma may
develop (8,10,24). The lower the body temperature, the more likely
the victim is to become unconscious (1,4). Severe hypothermia or
the poikilothermic phase occurs when body temperature is below 240
C (75 F). At this stage a rigor mortis-like appearance is evident, and
patients have been mistaken for dead (3,4,10). Finally, death may
occur (4).
ADDITIONAL SIGNS
Hypothermia should be suspected if any of these signs are
evident: bloated face, pale and waxy skin color (at times oddly pink),
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trembling on one side of the body or in one arm or leg, irregular and
slowed heartbeat, slurred speech, shallow, very slow breathing, low
blood pressure, absence of chilliness due to diminished alertness,
lessened reflexes, clumsiness, drowsiness, poor coordination, poor
judgment, slips and falls (4,24-26).
What stage did King David’s hypothermia reach? The King was
not warmed in spite of covering with clothing, but he was warmed by
Avishag’s body heat. Because other signs of hypothermia did not
develop, it is most likely that King’s hypothermia reached only a mild
stage. The absence of shivering can be explained by an impaired
thermoregulation mechanism due to the King’s advanced age.
Although absence of shivering may also indicate moderate or even
severe hypothermia, the occurrence of these two stages is very
unlikely.
WAS THE KING'S TEMPERATURE TAKEN?
The thermometer, first invented four hundred years ago by
Galileo and refined for clinical use by Sir Clifford Allbutt in 1866, is
one of the most simple and useful tools available in medicine. The
measurements show the body’s response to a myriad of stresses (2).
King David lived three thousand years ago, before the thermometer
was known. Was temperature measured by another means? Or was
it was not measured at all? This question remains open.
EKGCHANGES
There is a pathognomonic EKG pattern - the lengthening of the
RR, PR, QRS, and corrected QT (QTC) intervals, the presence of the
typical J deflection, with or without inversion of T, in leads related to
the left ventricle (17,27, 28), and lethal cardiac arrhythmias
(ventricular fibrillation and asystole) (29).
HYPOTHERMIA IN KING DAVID
The passages “My strength failed.. and my bones are consumed”
(Psalm 31:11) and “My bones wasted away through my anguished
roaring all day long” (Psalm 32:3), analyzed in previous report (30),
indicate the osteoporosis which affected the King’s bones. Among
various diseases associated with osteoporosis, senile osteoporosis,
hyperparathyroidism, or malignancy were the most likely to cause
immobility and subsequent hypothermia in King David. Because the
diagnosis of malignancy is the most acceptable (30), it is very likely
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that this disease led to malnutrition and subsequent hypothermia
(30,31). Did he suffer from diabetes, peripheral vascular disease,
arthritis, or drug-induced hypothermia?
In the absence of
appropriate anamnestic, physical and laboratory findings these
diagnoses seem very unlikely.
THERAPY
The general principals of prehospital management are 1) prevent
further heat loss, 2) rewarm the body core temperature in advance
to shell, and 3) avoid precipitating ventricular fibrillation (6). For
hypothermic victims in the prehospital setting, cardiopulmonary
resuscitation, removing wet clothes, insulating the victim,
stabilization with warmed air/oxygen and intravenous fluids
constitute the initial treatment modalities (4,32-35). Individuals with
only mild symptoms of hypothermia may be rewarmed with external
active and passive rewarming techniques such as heating blankets,
hot wet towels, warmed water mattresses, warm packs, warm baths,
hot water bottles, and warm enemas (4,32,36).
Hospital
management should include, if necessary, central line replacement,
pleural lavage with warm saline, heated humified oxygen (33),
warmed peritoneal dialysis, and extracorporeal blood warming with
partial bypass (32,33). Post resuscitation complications should be
monitored; they include pneumonia, pulmonary edema, cardiac
arrhythmias, myoglobinuria, disseminated intravascular thrombosis,
and seizures (33).
Because it is more likely that the King suffered from mild
hypothermia, slow rewarming, such as covering him with clothes and
providing the shared body heat took place.
TO SUM UP: the sentence “Now King David was old and stricken
in years, and covered him with clothes, but he gained no warmth”
indicates hypothermia in the elderly. It is most likely that the King
suffered from subclinical mild hypothermia. Among the various
diseases that led to immobility and subsequent hypothermia the
most likely are senile osteoporosis, hyperparathyroidism, or
malignant disease. Among these diseases, malignancy is the most
acceptable. The presence of accidental hypothermia associated with
environmental factors is very unlikely. Viewed by a modern
physician, the story of King David unfolds as possibly the earliest
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description of patient affected by hypothermia, which features have
changed little through the ages.
References
1. Editorials. Hypothermia. Ann Intern Med. 1978;89:565-7.
2. Reuler JB. Hypothermia: pathophysiology, clinical settings, and management.
Ann Intern Med. 1978 89:519-27.
3. Davidson M, Grant E. Accidental hypothermia. A community hospital
perspective. Postgraduate Med. 1981;70: 42-9.
4. Besdine RW. Accidental hypothermia: the body’s energy crisis. Geriatrics.
1979;34:51-9.
5. Christensen C. Hypothermia. Physiology, clinical picture and treatment.
Ugerskr Laeger. 1990;152:2295-9.
rd
6. Long WB 3 , Edlich RF, Winters KL, Britt LD. Cold injuries. J Long Term Eff Med
Implants. 2005;15:67-78.
7. Exton-Smith AN. Accidental hypothermia. BMJ. 1973;4:727-9.
8. Petersdorf RG. Hypothermia. Editorials. Arch Intern Med. 1979;139:399.
9. Thompson MK. The care of the older patient in winter. Practitioner.
1979;223:787-91.
10. Navari RM, Sheehy TW. Hypothermia. In: Calkins E, Davis PJ, Ford AB (eds).
The Practice of Geriatrics. Philadelphia, PA: W.B. Saunders. 1986, pp. 291- 301.
11. Collins KJ, Exton-Smith AN, Dore K. Urban hypothermia: preferred
temperature and thermal perception in old age. BMJ. 1981;282:175-7.
12. MacMillan AL, Corbett JL, Johnson RH, et al. Temperature regulation in
survivors of accidental hypothermia of the elderly. Lancet. 1967;2:165-69.
13. Sallis R, Chassay CM. Recognizing and treating common cold-induced injury in
outdoor sports. Med Sci Sports Exerc. 1999;31:1367-73.
14. Lloyd L. Treatment of accidental hypothermia. BMJ. 1979;1:413.
15. Birrer R, Wilkerson LA. Sports injuries. Cold injuries. In: Rakel R (ed).
Textbook of Family Practice. 3rd ed. Philadelphia, PA: W.B. Saunders. 1984, pp. 68991.
16. Salvosa CB, Payne PR, Wheeler BF. Environmental conditions and body
temperatures of elderly women living alone or in local authority homes. BMJ.
1971;4:656-9.
17. Emslie-Smith D. Accidental hypothermia: A common condition with a
pathognomonic electrocardiogram. Lancet. 1958;2:492.
18. Duguid H, Simpson RG, Stowers JM. Accidental hypothermia. Lancet. 1961;
2:1214-9.
19. Society and Medical Officers of Health. A pilot survey into the occurrence of
hypothermia in elderly people living at home. Public Health. 1968;82:223.
20. Fox RH, Woodward PM, Exton-Smith AN, et al. Body temperature in the
elderly: A national study of physiological, social and environmental conditions. BMJ.
1973;1:200-3.
21. Jurkovitz GJ. Environmental cold-induced injury. Surg Clin North Am.
2007;87:247-67, viii.
22. Elbaz G, Etzion O, Delgado J, et al. Hypothermia in a desert climate: severity
score and mortality prediction. Am J Emerg Med. 2008;26:683-8.
23. Durakovid Z, Misigoj-Durakvid M, Corovid N, Cubrilo-Turek M. Urban
hypothermia and hyperglycemia in the elderly. Coll Antropol. 2000;24:405-9.
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24. Collins KJ. Effects of cold on old people. Brit J Hosp Med. 1987;38:506-14.
25. Medical News. Action needed to prevent deaths from hypothermia in the
elderly. JAMA. 1980;243:407-8.
26. Vaisburg S. Accidental hypothermia in the elderly. Editorials. JAMA.
1978;18:1888.
27. Aslam AF, Aslam AK, Vasavada BC, Khan IA. Hypothermia: evaluation,
electrocardiographic manifestations, and management. Am J Med. 2006;119: 297301.
28. Wong FW. J wave and hypothermia. Dynamics. 2005;16:17-8.
29. Southwick FS, Dalgish PH. Recovery after prolonged asystolic cardiac arrest
in profound hypothermia. JAMA. 1980;243:1250-3.
30. Ben-Noun L. What was the disease of the bones that affected King David? J
Gerontol Med Sci. 2002;57A:M152-4.
31. Ben-Noun L. Was the biblical King David affected by hypothermia? J Gerontol
A Biol Sci Med Sci. 2002;57(6): M364-7.
32. Part IV. Guidelines for cardiopulmonary resuscitation and emergency
cardiac care. Special resuscitation situations. JAMA. 1992;268:2242-9.
33. Weinberg AD. Hypothermia. Ann Emerg Med. 1993;22:370-7.
34. Arcangeli A, Cavaliere F, Pennisi MA, et al. Physiology and treatment of
accidental hypothermia. Receti Prog Med. 1990; 81:356-60.
35. Kjaergaard B, Rudolph SF, Lucas A, Holdgaard HO. Treatment of the
hypothermic patients. Ugeskr Laeger. 2008;170:2005-10.
36. Bristow G, Smith R, Lee J, et al. Resuscitation from cardiopulmonary arrest
during accidental hypothermia due to exhaustion and exposure. CMA. 1977;117:2479.
PRESSURE ULCERS
Older people have suffered from pressure ulcers since the dawn of
history. This research is unique in character, as it combines modern
medical knowledge with the presentation of a case taken from
ancient history. The main aim of this research was to analyze from a
modern perspective the biblical description of a geriatric case of
pressure ulcers. Biblical texts associated with the aged were
examined and a passage referring to an old person who suffered from
skin ulcers was studied. The passage “My necrotic ulcers stink”
indicates infected pressure ulcers, which have reached the third
degree. The risk factors for these ulcers include male gender, old age
- a 70 year old man in this case, osteoporosis, dehydration,
malnutrition and cachexia most probably due to malignancy,
depression, and various social problems.
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INTRODUCTION
Elderly patients have suffered from pressure ulcers for thousands
of years. This is indicated by the presence of pressure ulcers found
on Egyptian mummified bodies (1). Even today, pressure ulcers
remain a common problem in all health care settings.
Patients with pressure ulcers had significantly more pain,
immobility, lack of energy, more restrictions regarding their social
functioning, less vitality, and limitations with respect their emotional
roles. Other problem areas include restrictions in work capacity,
recreation, social interaction, psychological well-being, as well as
problems caused by treatment regiments, worries and frustrations
and a lack of self-esteem (2-4).
By studying the causes that led to the development of pressure
ulcers in a case taken from ancient history, modern physicians can
expand the horizons of their knowledge and thereby make their
approach more comprehensive. Who suffered from pressure ulcers
as described in the Bible? What were the most likely causes? This
research aims to answer these questions using a biblical description
of pressure ulcers.
SKIN ULCERS AS DESCRIBED IN THE BIBLE
King David, the second and greatest of Israel’s Kings who ruled
that country 3531 years ago, suffered from some type of skin disease.
The passage in Psalm 38:6 “My necrotic ulcers stink” tells us that the
King suffered from necrotic ulcers, which are compatible with
pressure ulcers.
DEFINITION
Pressure sores are complex wounds with clinical appearances
ranging from mild redness of the skin to severe necrosis (5-8). Some
patients develop pressure sores due to many intrinsic and extrinsic
factors (6,9-11), the extent of which may not be apparent on initial
assessment. Intrinsic factors include limited mobility, poor nutrition,
comorbidities, and aging skin while extrinsic factors include pressure,
friction, shear, and moisture (12).
There are many terms used to describe pressure ulcers: pressure
sores, decubitus ulcers, bedsores, pressure necrosis, and ischemic
ulcers (13). Of these terms, the most commonly used was once
“decubitus ulcer.” This term is related to the Latin word meaning “to
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lie down” (14) since it was thought that “decubitus ulcers” resulted
only from prolonged recumbency (15). However, it is now well
established that prolonged application of pressure in any position can
result in ulceration, so that “pressure ulcer” is now perceived as term
that is more correct.
DEVELOPMENT
Pressure ulcers are an area of localized damage to the skin and
underlying tissue induced by pressure, shear, friction or a
combination of these factors (12,16). The ulcers occur when soft
tissue is compressed between a bony prominence and an external
surface for a prolonged period of time (17). Pressure ulcers are
ischemic damage to soft tissues due to unrelieved pressure, usually
over a bony prominence (18). Persistent pressure on a bony site
obstructs healthy capillary flow, and therefore leads to tissue
necrosis (19).
Approximately 70% of pressure ulcers occur in patients over than
70 years of age (20). Of all pressure ulcers, 95% develop on the lower
body, with 65% in the pelvic area and 30% in the legs (21). The most
common sites involved are areas of skin overlying bony prominences
such as the sacrum, ischial tuberosities, greater trochanters, iliac
crest, lateral malleolus (ankle), calcaneous, occiput, chin, ear, elbow,
and scapula areas (15,22-24).
We see that pressure ulcers are mostly located in the sacrum, and
in the legs.
EPIDEMIOLOGY
During each of the nine surveys conducted between 1989 and
2005, clinical teams in participating facilities predominantly in the US
(some facilities in Canada, Saudi Arabia, and Australia participated
after 2003) assessed admitted on assigned study dates. For this
study, trends using all records (n=447.930; average, 49.770) were
reviewed. The majority of facilities in each survey were in the US
(99%) overall. Nosocomial pressure ulcer prevalence rates ranged
from 9.2% and 5.6% in 1989 to 15.5% and 10% in 2003 and 2004,
respectively. The highest prevalence was documented in long-term
acute care (27.3% overall, and 8.5% nosocomial) (25).
In Maryland, 2015 residents aged 65 years and older admitted to
59 long-term-care facilities were studied. Of these residents, 208
(10.3%) had one or more pressure ulcers on admission to a long-
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term-care facility. The proportion of patients with 1 or more
pressure ulcers was 11.9% among those who were admitted from a
hospital and 4.7% among those not admitted from a hospital
(p<0.01). Admission from a hospital was significantly associated with
pressure ulcer prevalence on admission. A lower prevalence of
pressure ulcers on admission was significantly associated with being
white; a higher prevalence was associated with being chair bound or
bedridden, being underweight, and having fecal incontinence (26).
In Canada, the data included information from 18 acute care
facilities involving 4.831 patients, 23 non-acute care facilities with
3.390 patients, 19 mixed healthcare settings with 4.200 patients, and
five community care agencies that surveyed 1.681 patients, 19902003. Estimates of pressure ulcer prevalence were 25.1% for
patients in acute care settings, 29.9% for those in non-acute care
settings, 22.1% for patients in mixed health settings, and 15.1% for
those in community care. The overall estimate of the prevalence of
pressure ulcers in all healthcare institutions across Canada was 26.9%
(27).
In Europe, a convenience sample of university and general
hospital: of Belgium, Italy, Portugal, UK, and Sweden (5947 patients,
25 hospitals) participated in the study. The pressure ulcer prevalence
(grade 1-4) was 18.1% and if grade 1 ulcers were excluded, the
prevalence was 10.5%. The sacrum and heels were the most affected
locations (28).
In Germany, a total of 11.584 patients and residents in 66
institutions throughout Germany took part in the study. The
prevalence, including grade 1 pressure ulcers, was 11.7% (5.2%) for
the whole sample, while 24.5% (11.5%) for the group at risk. The size
of the group at risk in the nursing homes was 63.9% and less than
40% in the hospitals (29). In another report, the prevalence of
pressure ulcers ranged from 4% in Denmark to 49% in Germany,
while the incidence ranged from 38% to 124%, 2000-2005 (30).
In the Netherlands, the total prevalence of pressure ulcers
reached 28.7% in intensive care units (31); 10.1% (n=368) in the
university hospital; 13.7% (n=1541) in the home healthcare setting,
and 83.6% (n=122) in the nursing home. The most common lesions
were on the sacrum and below the knee (heel and malleolus) (32).
In Sweden, the prevalence of pressure ulcers was 23.9%
(university hospital), 23.2% (general hospital) and 20.0% (nursing
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home). Most (60%-66%) of the pressure ulcers in the hospital were
assessed as grade I (33).
We see a wide variation in the prevalence and incidence of
pressure ulcers in different countries.
HOSPITAL COST
Incident pressure ulcers were associated with significantly higher
mean unadjusted hospital costs ($7.288 vs. $13.924, p<0.0001) and
length of stay (30.4 vs. 12.8 days, p=0.0001). Compared with those
who did not develop pressure ulcers, patients who developed
pressure ulcers were more likely to develop nosocomial infections,
and other hospital complications. Length of state for those who
developed pressure ulcers remained significantly greater than for
those who did not develop pressure ulcers ($14.260 vs. $12.382,
p=0.03, and 16.9 vs. 12.9 days, p=0.02, respectively). Incident
pressure ulcers were associated with substantial and significant
increases in hospital costs and length of stay. Nosocomial infections
and other hospital complications were additional significant
independent predictors of health care utilization among patients at
risk for pressure ulcers (34).
THE CASE OF KING DAVID
King David developed pressure ulcers at the age of 70: “David was
thirty years when he began to reign, and he reigned forty years (II
Samuel 5:4). The King was not apparently hospitalized, nor was he
treated in any long-term treatment facility, but he remained in home
care. What was the grade of pressure ulcers? What were the areas
involved?
CLASSIFICATION
EUROPEAN PRESSURE ADVISORY PANEL
Grade 1: Non-blanchable erythema of intact skin. Discoloration of
the skin, warmth, edema, induration or hardness are used as
indicators, particularly in individuals with darker skin.
Grade 2: Partial thickness of skin loss, involving epidermis, dermis
or both. The ulcer is superficial and presents clinically as an abrasion
or blister.
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Grade 3: Loss of full skin thickness involving damage to or necrosis
of subcutaneous tissue that may extend down to, but not through
underlying fascia.
Grade 4: Extensive destruction, tissue necrosis, or damage to
muscle, bone, or supporting structures with or without full thickness
of skin loss (35).
MAKLEBUST & SIEGGREEN CLASSIFICATION SYSTEM
Grade 1: Non-blanchable erythema of intact skin.
Grade 2: Partial thickness of skin loss involving epidermis and/or
dermis. Presents as an abrasion, blister or shallow cavity.
Grade 3: Full thickness of skin loss involving damage or necrosis of
subcutaneous tissue extending to, but not through the muscle.
Clinical presentation is a deep crater with or without undermining
damage.
Grade 4: Full thickness of skin loss with extensive damage or
necrosis of muscle, bone or supporting structures.
Closed: A large bursa like cavity extending into fascia or bone.
Drainage is through a small sinus tract (8).
The Grade of Ulcers in King's Case
What grade did the pressure ulcers reach in the King’s case? The
words “My necrotic ulcers stink” indicate grade 3 or 4. Since there
are insufficient data concerning the extensive damage occurring in
the grade 4, it follows that his pressure ulcers reached grade 3.
RISK FACTORS FOR PRESSURE ULCERS
Extrinsic causes for pressure ulceration include pressure, shear,
friction and prolonged contact with moisture (36), especially from
urine and feces (37). Intrinsic factors include age > 65 years, male
gender, acute illness, recent weight loss (38), level of consciousness,
malnutrition and/or dehydration (36), limited mobility or immobility
associated with severe and multiple diseases (34), sensory
impairment, severe chronic or terminal illness such as metastatic
carcinoma (39), and vascular disease (13,36). Other medical
problems include spinal cord injury, hip fracture, dementia (37), such
as Alzheimer’s type, congestive heart failure, chronic obstructive
pulmonary disease, cerebral vascular accident, diabetes mellitus,
deep vein thrombosis, hip fracture, hip surgery, limb paralysis, lower
limb edema, osteoporosis, Parkinson’s disease, rheumatoid arthritis,
urinary tract infections (40,41), and emotional stress (39).
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Nursing home residents (n=4232) free of pressure ulcers on
admission to 78 nursing facilities, Hebrew Rehabilitation Center for
Aged, were studied. Significant factors associated with the formation
of pressure ulcers in high incident homes (21-month incidence =
19.3%) were ambulation difficulty (OR 3.3; 95% CI 2.0 - 5.3), fecal
incontinence (OR 2.5; 95% CI 1.6 - 40), diabetes mellitus (OR 1.7, 95%
CI 1.2-2.5), and feeding oneself difficulty (OR 2.2, 95% CI 1.5-3.3). In
the low incidence homes (21-month incidence = 6.5%) significant
factors associated with pressure ulcer incidence were ambulation
difficulty (OR 3.6, 95% CI 1.7-7.4), feeding oneself difficulty (OR = 3.5,
95% CI 2.0-6.3), and male gender (OR 1.9, 95% CI 1.2-3.6) (42).
According to this study, male gender, ambulation difficulty,
feeding oneself difficulty, fecal incontinence, and diabetes mellitus
were risk factors for pressure ulcers.
One of the variables is malnutrition. With age, there is a decrease
in food intake (13). Paradoxically, however, there is an increase in
body fat and obesity. This conundrum is explained by decreased
physical activity and the altered metabolism that accompanies aging.
Older persons fail to adequately regulate food intake and develop
physiologic anorexia of aging. Physiologic anorexia of aging puts
older persons at high risk for developing protein-energy malnutrition
when they have psychological or physical problems (43).
Malnutrition is associated with skin anergy and with immobility
because of mental apathy and muscle wasting (44).
Malnutrition is frequent in geriatric patients: it affects 30% to 60%
of elderly residents in institutions and 30% to 70% patients admitted
for short-term hospitalization. In elderly subjects, multiple and
interlinked factors may trigger or aggravate malnutrition; they may
be physical, psychological or social and may be worsened by drugs
and some diets (45). Malnutrition increases the risk of pressure ulcers
(46), leading to a delay in wound healing (44,47,48). In addition, a
low body mass index (BMI), low serum albumin, and weight loss are
associated with an increased risk of pressure ulcers (45).
Energy and nutrients such as proteins and vitamins B and C that
are often deficient in old age are needed to heal pressure ulcer (46).
Therefore, optimal nutrition is necessary to promote wound healing
(19).
What were the risk factors responsible for the development of
pressure ulcers in the case of King David, a particular geriatric patient
and the member of the highest socioeconomic stratum? Was David
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afflicted by physiological anorexia of aging that led to malnutrition?
As previously shown, a diagnosis of physiological anorexia of aging
seems very unlikely since an excessive loss of weight “…my bones
(the King’s) cleave to my skin” (Psalm 102:6) and “…my flesh failed of
fatness” (109:24), indicates severe malnutrition which led to cachexia
due to a serious or fatal disease (49). The King also suffered from
osteoporosis, which afflicted his bones. Among the various diseases
that may be associated with osteoporosis, the most likely here are
senile osteoporosis, hyperparathyroidism, or malignant disease with
the diagnosis of malignancy as the most acceptable (50). A
combination of cachexia and osteoporotic intractable bone pain
points towards a diagnosis of malignancy.
With regard to
malignancy, it seems that the King was affected either by multiple
myeloma, or by primary carcinoma of the kidney and/or carcinoma of
prostate with subsequent metastases to the bones. Thus, there are
two identifiable risk factors for pressure ulcers - malignancy and
malnutrition.
The King also suffered from dehydration “…my tongue cleaveth to
my jaws…” (22:16), which is a risk factor for pressure ulcers. In
addition, King David was afflicted by mild hypothermia (51), although
it is very unlikely that this condition was related to the development
of pressure ulcers.
Psychosocial factors play an important role in the eating habits of
the elderly. Failure to eat among older people may be associated
with endogenous depression, bereavement, and dementia - mild
memory disturbances can cause older people to forget to eat (52). It
follows that depression and various social problems such as
loneliness, social isolation and neglect by others (53) can be
responsible for extreme loss of weight.
It can be concluded therefore that the risk factors for the
development of pressure ulcers in King David include: male gender,
old age – 70 years, osteoporosis, dehydration, and malnutrition most
probably due to malignancy, depression, and various social problems.
MALODOROUS WOUNDS
Infection may present as increased local pain, cellulitis, local
abscess, necrotizing fasciitis, osteomyelitis, bacteremia, or sepsis
(54). Factors that lead to odor formation include necrotic
tissue/slough, infection that multiplies and thrives in necrotic
tissue/slough, and exudates (55-57).
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King David
The smell of the exudates is embarrassing to the patient. If the
pressure ulcer is covered with black necrotic tissue, it is difficult to
establish depth of the tissue damage (58). Infections in non-healing
wounds contain a mixture of organisms, including gram-positive
cocci, gram-negative bacilli, and anaerobes.
The use of three separate 16S-based molecular amplifications
followed by pyrosequencing, shotgun Sanger sequencing, and
denaturing gradient gel electrophoresis were utilized to survey the
major populations of bacteria that occur in the pathogenic biofilms of
three types of chronic wound types: diabetic foot ulcer, venous leg
ulcers, and pressure ulcers. There were specific major populations of
bacteria that were evident in the biofilms of three types of chronic
wounds including Staphylococcus, Pseudomonas, Peptoniphilus,
Enterobacter, Stenotrophomonas; Finegoldia, and Serratia spp. Each
of the wound types reveals marked differences in bacterial
populations, such as pressure ulcers in which 62% of the populations
were identified as obligate anaerobes (59).
Bacteriological investigation of infected pressure ulcers in spinal
cord-injured patients, Microbiological and Orthopedics Department,
Abroise Paré University Hospital, Boulogne-Billancourt, France was
carried out. Tissue samples, sampled at the end of the surgical
intervention from unbridled and cleaned ulcers were analyzed. The
most frequently isolated species were enterobacteria, followed by
staphylococci and streptococci (60).
Thus, the words “My necrotic ulcers stink” indicate malodorous
infected non-healing pressure ulcers with necrotic tissue/slough.
Although data on bacteriological investigation are unavailable, it is
very likely that one or more of the pathogens described above were
responsible.
Malodor reduces appetite (61) at a time when good nutrition is
needed for healing and when quality of life is important (62) This
factor also contributed to David’s reduced or even absent appetite
and subsequent malnutrition.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of pressure ulcers includes ischemic
ulcers, neuropathic ulcers, vasculitides, skin cancers such as
squamous cell carcinoma, basal cell carcinoma or malignant
melanoma (63), radiation injury, rheumatoid arthritis, infectious
diseases that lead to tissue necrosis and ulceration by
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King David
microorganisms such as -haemolytic Streptococcus pyogenes,
necrobiosis lipoidica, pyoderma gangrenosum (63,64), venous leg
ulcers, diabetic foot ulcer, gangrenous wounds and fungating
malignant wounds (24,64). Although all these diagnoses are possible,
pressure ulcers provide the best overall explanation for David’s skin
ulcers.
TO SUM UP: evaluation of King David’s skin disease from a
contemporary perspective reflects the features of skin disease, which
have changed little through the ages. The words “My necrotic ulcers
stink” indicate infected pressure ulcers, which reached the third
degree. Risk factors for their development include male gender, old
age, osteoporosis, dehydration, cachexia and malnutrition most
probably due to malignancy, depression and various social problems.
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20. Norton D, McClaren R, Exton-Smith AN. An investigation of geriatric nursing
problems in hospital. Edinburgh: Churchill-Livingstone. 1975, pp. 193-236.
21. Odom RB, James WD, Berger TG. Mechanical injuries to the skin. Pressure
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the Skin. Clinical Dermatology. Philadelphia: W.B. Saunders. 2000, pp. 41-48.
22. Clarke M, Grace P. Understanding the underlying causes of the chronic leg
ulceration. J Wound Care. 2004;13: 215-8.
23. Djarmarajan TS, Ahmed S. The growing problem of pressure ulcers. Postgrad
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24. Allman R. Pressure ulcers among the elderly. New Engl J Med. 1989;320:8503.
25. Valginger C, Macfarlane GD, Meyer S. Results of nine international pressure
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27. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian
Healthcare settings. Ostomy Wound Management. 2004;50:22-4,26,28,30,32,34,368.
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pilot study. J Eval Clin Pract. 2007;13:227-35.
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30. Shanin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence and incidence in
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31. Bours GJ, De Laat E, Halfens RJ, Lubbers M. Prevalence, risk factors and
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33. Gunninberg L. Risk, prevalence and prevention of pressure ulcers in three
Swedish healthcare settings. J Wound Care. 2004;13:286-90.
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nutrition. Presse Med. 2008;37:1150-7.
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Gerontology Med Sci. 2004;59A(2):143-5.
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2002;11(16 Suppl):S33-4, S36,S40-1.
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infected pressure ulcers in spinal cord-injured patients and impact on antibiotic
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64. Moloney C. Understanding the underlying causes of chronic leg ulceration. J
Wound Care. 2004;13(6):213-7.
SEXUAL DYSFUNCTION
The elderly have suffered from sexual dysfunction (SD) since the
dawn of history. The main objective of this research was to evaluate
from a contemporary perspective the biblical description of a
geriatric patient who suffered from SD. This report analyzes the
sexual disorder that affected the biblical King David, the second and
greatest of Israel’s Kings, who ruled the country 3531 years ago. A
passage “And the maiden was very fair, and she cherished the king,
and ministered to him: but the king knew her not” indicates SD that
afflicted the biblical King David. Among various types of SD, erectile
dysfunction (ED) combined with low or absent libido was most likely
responsible. The numerous possible causes of King David’s SD
include malignancy such as multiple myeloma, or cancer of the
kidney and/or prostate, with metastases to the bones, major
depression and various social problems such as loneliness, lack of
close relationships with friends on whom the King could rely, feelings
of neglect, and loss of power and control over his people. The story
of King David unfolds as possibly the earliest description of an elderly
patient who suffered from SD.
INTRODUCTION
Sexuality is an important part of most men's quality of life (1), and
is an important component of emotional and physical intimacy that
men and women experience through their lives. About 60% of the
elderly population expresses their interest for maintaining sexual
activity (2). SD is one of the most common health problems affecting
men and is most common with increasing age. Who suffered from
SD in biblical times? How can this dysfunction be classified? What
factors were responsible? What were its characteristics? This
research evaluates a case of SD in a geriatric patient as described in
the Bible.
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THE BIBLICAL DESCRIPTION
King David, the second and greatest of Israel’s Kings who ruled the
country 3531 years ago, was about 70 years old at the end of his
reign. When the King reached old age, he suffered from SD: “Now
King David was old, advanced in years; and they covered him with
clothes, but he could not become warm” (Kings 1:1). David’s servants
decided to summon “ a young virgin; and let her lie in thy bosom,
that my lord the king may become warm” (I Kings 1:2). They “...found
Avishag the Shunammite, and brought her to the king. And the
maiden was very fair, and she cherished the king, and ministered to
him: but the king knew her not” (I Kings 1:3-4). These words indicate
that the old King was unable to have sexual relations with this pretty
young woman. We have here the case of an old man, from a high
socioeconomic stratum, who had loved many women during his long
life, had wives, concubines and many children, but in his old age was
afflicted by some type of SD.
In King David’s case the relevant information has been extracted
from the patient’s medical file, the biblical text, recorded more than
3000 years ago. In this case, the pertinent biblical passages studied
should be regarded as the patient’s interview.
CLASSIFICATION
Male SD can be classified as hypoactive desire - diminished or
absent libido, ejaculatory dysfunction - premature, difficulty in
achieving orgasm, including anorgasmia, anatomical abnormalities,
e.g., Peyronie’s disease, and ED (3).
PREVALENCE
ED is a common problem affecting sexual function in men. The
prevalence of sexual dysfunction increases with age; about 20-30% of
adult men have at least one manifested SD (2,4). SD is common
among individuals with chronic illnesses and is associated with
distress and reduced quality of life (5).
The inability to achieve or sustain an erection satisfactory for
intercourse in at least 75% of attempts is estimated to affect at least
10 million American men (6). Prevalence increases dramatically in
men over 50 years of age, with at least a quarter of older men being
affected (7). In men aged 40 to 70 years, 52% report some degree of
sexual dysfunction, 17.1% - mild, 25.3% - moderate, and 9.6%
complete (8).
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According to Willie (9), approximately one in 10 men over the age
of 40 is affected by this condition and the incidence is age related.
Fewer than 2% of men with erection problems report that their first
difficulty occurred before age 40 years, and in 4% it occurred
between ages 40 to 49 years. After the age of 50 years, the
percentage of men with ED increases sharply - from 26% between 50
to 59 years to 40% between 60 to 69 years (10).
It appears that ED afflicted the aged King, and since he was unable
to have sexual relations with a young, pretty woman – he “knew her
not” - his ED was severe, or complete.
ETIOLOGY
Normal erectile function requires the coordination of
psychological, hormonal, neurological, vascular and cavernosal
factors (11,12). Alteration in any of these factors, or their
combination, is sufficient to cause ED (13). Organic causes are the
main factor in 90% of cases in men over age 50, while in younger men
psychogenic causes are more common (14). ED often has multiple
causes (15,6,16). Diagnostic evaluation should include psychosexual,
endocrinological, neurological, vascular, traumatic, and iatrogenic
(drugs and surgery) factors (17).
ED is a sentinel marker for several reversible conditions including
peripheral and coronary vascular disease, hypertension, and diabetes
mellitus. Endothelial dysfunction is a common factor between the
disease states. Concurrent conditions such as depression, late-onset
hypogonadism, Peyronie's disease and lower urinary tract symptoms
may significantly worsen erectile function, other sexual and
relationship issues, and pen's dysmorphobia (9).
Major causes of SD include vascular diseases such as
cardiovascular problems, particularly hypertension, peripheral
vascular diseases, atherosclerotic disease of the penile artery, and
the venous leakage from the corpora cavernosa; endocrine disorders
such as hyperprolactinemia, hypo/hyperthyroidism, diabetes
mellitus, hypogonadism that occurs with increasing age, and is
characterized by low levels of testosterone and luteinizing hormone;
neurological conditions such as epilepsy, lacunar infarcts and larger
strokes, spinal cord trauma, herniated lumbar disk injury, sensory
neuropathy, multiple sclerosis, Parkinson’s disease, and Alzheimer’s
disease; psychological factors - depression, stress, anxiety disorders,
or widower’s syndrome; social factors; other diseases - kidney
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King David
diseases,
obesity,
chronic
obstructive
lung
disease,
arthritis/degenerative joint disease, hyperlipidemia, cancer, the
sequelae of various operations such as prostatectomy, and various
ostomies; medications - thiazide diuretics, antihypertensive agents,
digoxin, gemfibrozil (Lopid), cimetidine, tranquilizers, antipsychotics,
anti-arrhythmics, statins, niacin, phenytoin; nutritional - zinc
deficiency; and life style such as cigarette smoking, alcohol abuse, or
lack of exercise (18,8,19-24).
Common disorders related to sexual dysfunction include:
individual general health status, cardiovascular diseases, diabetes,
genitourinary diseases, psychiatric/psychological disorders, other
chronic diseases, and socio-demographic conditions (2,4). Endothelial
dysfunction is a condition that present in many cases of ED and there
are common etiological pathways for other vascular diseases (4).
Most men experience an age-related testosterone decline, which
accounts for some decline in sexual interest and coital frequency
occurring even in healthy older men (25). Testosterone deficiency
may result in a reduction of trabecular smooth muscle content
concomitant with increased accumulation of extracellular matrix and
deposition of adipocytes in the subtunical region. All this can lead to
corporal veno-occlusive dysfunction (26). Androgens exert a direct
effect on penile tissue to maintain erectile function while androgendeficiency produces a metabolic and structural imbalance in the
corpus cavernosum, resulting in venous leakage and ED (27). In
humans, androgen-deficiency manifestations include: inadequate
development of the penis and loss of erectile function in prostate
cancer and benign prostatic hyperplasia in patients managed with
medical or surgical castration or antiandrogen therapy (28).
Aging in men is accompanied by a decrease in libido and sexual
activity. A significant proportion of men > 60 years have biochemical
hypogonadism. Hypoandrogenism, which is associated with other
conditions that negatively influence erectile activity, may be an
important cofactor in the induction of ED and in the response to
phosphodiesterase (PDE5) inhibitors in aging. Measuring plasma
testosterone levels in aged men with ED is essential and treating
them (with testosterone) barring clinical contraindications (29).
Hypogonadism should be considered a medical problem, termed
late onset hypogonadism (LOH) or testosterone deficiency syndrome
(TDS), only when symptoms are present. One of the most common
symptoms of LOH/TDS is SD. The prevalence of hypogonadism in
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King David
men with ED ranges from 1.7% to 35%. In ED patients, hypogonadism
is often associated with reduced sexual desire and nocturnal
erections, while association with sex-induced erection is less evident.
This is because testosterone regulates not only cyclic guanosine
monophoshate (cGMPP) formation, through nitric oxide synthase
(NOS)
stimulation,
but
also
its
catabolism,
through
phosphodiesterase-5 (PDE5) activity. The androgen-dependent PDE5
expression could explain the reduced effectiveness of PDE5 inhibitors
in the treatment of ED in hypogonadal patients. Recognizing
hypogonadism in patients with ED is essential in order to
appropriately treat the disease (30).
Hypogonadism may play a significant role in the pathophysiology
of ED. A threshold level of testosterone may be necessary for normal
erectile function. Testosterone replacement therapy is indicated in
hypogonadal patients and is beneficial in patients with ED and
hypogonadism (31). It is important to screen all men with ED for
hypogonadism, especially those with history of inadequate response
to prior PDE5 inhibitors. The combination of testosterone plus PDE5
inhibitors may be considered for the treatment of ED in men with low
to low-normal testosterone levels, who had inadequate response to
prior treatment with PDE5 inhibitors alone (32). The diagnosis of late
onset hypogonadism in men requires biochemical and clinical
evaluation (33).
A definite role of testosterone in ED has been controversial;
however, recent evidence is becoming available which substantiates
a key function for this hormone. Testosterone deficiency is
associated with a decline in erectile function and testosterone levels
are inversely correlated with increasing severity of ED. ED can be
caused by multifactorial pathologies. ED may be the first symptom of
cardiovascular disease. Testosterone increases the expression of
nitric oxide synthase and phosphodiesterase type 5, both principal
enzymes involved in the erectile process (34). The effects of
testosterone upon sexual function are dose-dependent up to a
threshold level that is consistent within an individual, but markedly
variable between individuals, ranging from 2 to 4.5 ng/ml (35).
Did King David suffer from testosterone deficiency and because of
this a decline in erectile function?
Low libido may be secondary to organic ED, or androgen
deficiency, and it may be due to systemic illness, depression or other
psychological problems. ED, androgen deficiency, and decreased
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King David
libido appear to be independently distributed, but overlap to some
extent (36). Since testosterone levels correlate with libido in both
sexes, therapy with testosterone may enhance libido (37). Since
“…the king knew her not” it is most likely that the King suffered from
low or absent libido relating to some organic disease and/or mental
disorder.
Premature ejaculation is generally acknowledged largely as a
psychogenic dysfunction, usually due to anxiety (38). This type of SD
can be excluded since the King had no sexual relations with the pretty
young woman at all.
Peyronie's disease consists of an acquired penile deformity,
caused by the formation of fibrous plaques within the tunica
albuginea (39), which alter penile anatomy (40). Peyronie's disease
results from a predisposing genetic susceptibility combined with an
inciting event such as micro trauma during intercourse. During the
initial acute phase (6-18 months), the condition may progress,
stabilized, or regress (41). Clinical presentations of this disease
include penile pain, angulation, penile deformities or shortening
during erection, painful erection, palpable plaque or induration
throughout the length of the penile shaft and ED (39,41).
The absence of specific clinical symptoms makes it unlikely that
the King suffered from this disease. There is no data arouse suspicion
that other penile disorders such as priapism, and other anatomical
defects were a cause of his SD (18).
Male ED, previously known as impotence, is defined as the
inability to achieve and maintain an erection sufficient to permit
satisfactory sexual intercourse and is one of the most common and
usually the most troubling forms of male SD (15,42).
ED is associated with treatable cardiovascular risk factors;
therefore, screening for ED and its cardiovascular risk factors is of
clinical importance. The Sexual Health Inventory for Men
questionnaire was handed out to military personnel aged 25-55 years
during routine examinations, Israel. Men (n=19.131), a mean age of
34.0 +/- 7.1 years, participated in routine physical examinations
during the years 2001-2005. One of every four men (25.2%) suffered
from ED, which was mild in 18.9%, mild to moderate in 4.4%,
moderate in 1.1%, and severe in 0.7%. Even though treatable
cardiovascular risk factors were quite prevalent in the study group
(45.2% of them suffered from dyslipidemia, 25.6% smoked, 4.2%
suffered from essential hypertension, and 1.6% from diabetes
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mellitus), ED was significantly associated with age and diabetes
mellitus alone (p<0.0001). There is a high prevalence of ED and
associated treatable cardiovascular risk factors in Israeli men aged
25-55, especially in those with diabetes (43).
The medical record of the King, that is the biblical text, gives no
details about the existence of cardiovascular risk factors such as
dyslipidemia, hypertension, diabetes, or smoking.
ERECTILE DYSFUNCTION IN KING DAVID
Can ED be related to the King's biological changes of aging? These
changes can be included among the factors relating to ED (23).
Although this possibility may exist, the presence of serious diseases
and social problems, as described below, rules out advanced age as
the cause of ED in this case.
Previous research indicates that the King suffered from mild
hypothermia (44). It seems very unlikely that this disease was
responsible for ED. King David also suffered from a disease of the
bones “My strength failed…and my bones are consumed” (Psalm
31:11) and “My bones wasted away through my anguished roaring all
day long” (32:3). The first passage indicates that the King’s bones
were used up, his strength was decreased, and he had become very
weak. In the second passage, the King’s bones had reached a stage
where they were extremely thin and weak, causing him severe pain.
A condition is compatible with osteoporosis, which affected his
bones. Among the various diseases that may be associated with
osteoporosis, the most likely in this case are senile osteoporosis,
hyperparathyroidism, or malignant disease. An extensive evaluation
of these conditions indicates that the diagnosis of malignancy is the
most acceptable (45).
The King also suffered from anorexia, fasting, extreme weight loss,
and subsequent cachexia. Among the numerous causes associated
with weight loss, we can consider malignancy, psychosocial problems
such as depression, loneliness, lack of close relationships and friends
on whom he could rely, loss of power and control over his people,
feelings of neglect and negative interpersonal relationships as playing
a part (46).
Malignancy is found to be related to the development of ED (23).
In this connection, it seems that the King was affected either by
multiple myeloma, or carcinoma of the kidney and/or prostate with
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subsequent metastases to the bones (46). It follows that one of these
malignant diseases was related to ED in the old King.
Common causes of psychogenic ED include performance anxiety,
or a strained relationship and lack of sexual arousal (47,48). King
David's rich sexual history and his high socioeconomic status make
these causes of ED unlikely. Males may also function poorly with
their regular partners while finding the excitement of a new
encounter sufficiently stimulating to allow adequate functioning (6).
This cause of ER can be excluded, since the King was unable to
perform sexual relations with his new sexual partner, a young, pretty
woman.
Depression, deep-seated social factors or relationship conflicts are
also identified as causes of ED (12,14,18,47-50). The risk of ED
associated with depression is particularly striking, with 90% of
severely depressed patients having moderate to complete ED (37). It
has been reported that King David suffered from major depression
(51). It can be concluded therefore that this mental disorder was also
partly responsible for his ED. Numerous social problems, as listed
above, also played a part in the development of ED as well.
Statistical analysis of data from the 2005-2006 National Social Life,
and Aging Project (NSHAP), a nationally representative U.S.
probability sample of 1.550 women and 1.455 men aged 57-85 at the
time of interview was carried out. Sexual problems among the
elderly were not an inevitable consequence of aging, but instead
responses to the presence of stressors in multiple domains. This
impact may partly be gender differentiated, with older women's
sexual health more sensitive to their physical health than for men.
The mechanism linking life stress with sexual problems is likely to be
poor mental health and relationship dissatisfaction. NSHAP results
demonstrate the consistent impact of poor mental health on
women's reports of sexual problems and the less consistent
association with men's problems. The results point to a need for
physicians who are treating older adults experiencing sexual
problems to take into account not simply their physical health, but
also their psychosocial health and satisfaction with their intimate
relationship (52).
We see that ED afflicts old men who suffer from various
psychosocial problems. Thus, an evaluation of each particular patient,
including organic problems and psychosocial extensive evaluation is
recommended.
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TO SUM UP: ED and reduced or absent libido in King David were
due to a combination of causes, but the most likely is malignancy
which includes either multiple myeloma, or cancer of the kidney
and/or prostate with metastases to the bones, together with major
depression and various deep-seated social problems.
References
1. Swendsen KO, Schultz A. Sexual dysfunction in men. Tidsskr Nor Largeforen.
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4. Lewis RW, Fugl-Meyer KS, Bosch R, et al. Epidemiology/risk factors for sexual
dysfunction. J Sex Med. 2004;1:35-9.
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role of flexibility in coping. J Sex Marit Ther. 2006;32:235-53.
6. Morley JE. Impotence. Am J Med. 1986;80(5):897-905.
7. Slag ME, Morley JE, Elson MK, et al. Impotence in medical clinic outpatients.
JAMA. 1983; 249:1736-40.
8. Feldman HA, Goldstein I, Hatzichriston DG, et al. Impotence and its medical
and psychological correlates: results of the Massachusetts male ageing study. J Urol.
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9. Wylie K. Erectile dysfunction. Adv Psychosom Med. 2008;29:33-49.
10. Bacon CG, Mittelman MA, Kawachi I, et al. Sexual function in men older than
50 years of age: results from the health professionals follow-up. Ann Intern Med.
2003;139:161-8.
11. Wagner G, Saenz De Tejada S. Update on erectile dysfunction. BMJ.
1998;316: 678-82.
12. Lue TF. Erectile dysfunction. New Engl J Med. 2000; 342:1802-13.
13. Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl J Med.
1989;321:1648-9.
14. Morley JE. Management of impotence. Diagnostic considerations and
therapeutic options. Postgrad Med. 1993;93:65-72.
15. NIH Consensus Development Panel on Impotence. NIH consensus
conference: impotence. JAMA. 1993;270:83-90.
16. Morley JE. Impotence in older men. Hosp Pract. 1988;23:139-42, 145-6.
17. Kirby RS. Impotence: diagnosis and management of male erectile
dysfunction. BMJ. 1994;308:957-60.
18. Wagner G, Mulhan J. Pathophysiology and diagnosis of male erectile
dysfunction. BJU Int. 1991;88(Suppl)3:3-10.
19. Morley JE, Kaiser FE. Sexual function with advancing age. Geriatr Med.
1989;73:1483-95.
20. Korenman SG, Morley JE, Mooradian AD, et al. Secondary hypogonadism in
older men: its relation to impotence. J Clin Endocrinol Metab. 1990;71:963-9.
21. Nephra A, Moreland RB. Neurologic erectile dysfunction. Urol Clin North Am.
2001;28:289-305.
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22. Sullivan, ME, Keoghane SR, Miller MAW. Vascular risk factors and erectile
dysfunction. BJU Int. 2001;87:838-45.
23. Phanjoo AL. Sexual dysfunction in old age. Adv Psychiat Treat. 2000;6:270-7.
24. Parmet S, Lynm C, Glass RM. Male sexual dysfunction. JAMA. 2004;291:307
25. Martin CE. Factors affecting sexual functioning in 60-79 year old married
males. Arch Sex Behav. 1981;10:399-420.
26. Pan LJ, Xia XY, Huang YF. Androgen deficiency and erectile dysfunction.
Zhonghua Nan Ke Xue. 2006;12:1030-4.
27. Traish A, Kim N. The physiological role of androgens in penile erection:
regulation of corpus cavernosum structure and function. J Sex Med. 2005;2:759-70.
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29. Caretta N, Ferlin A, Palego PF, Foresta C. Erectile dysfunction in aging men:
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30. Morellli A, Corona G, Filippi S, et al. Which patients with sexual dysfunction
are suitable for testosterone replacement therapy? J Endocrinol Invest. 2007;30:8808.
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treatment of erectile dysfunction. Int J Clin Pract. 2006;60:1087-92.
32. Shabsigh R. Testosterone therapy in erectile dysfunction and hypogonadism.
J Sex Med. 2005;2:786-92.
33. Stanworth RD, Jones TH. Testosterone for the aging male; current evidence
and recommended practice. Clin Interv Aging. 2008;3:25-44.
34. Blute M, Hakimian P, Kashanian J, et al. Erectile dysfunction and testosterone
deficiency. Front Horm Res. 2009;37:108-22.
35. Buvat J, Bou Jaoudé G. Significance of hypogonadism in erectile dysfunction.
Words J Urol. 2006;24;657-67.
36. Fine SR. Erectile dysfunction and comorbid diseases, androgen deficiency,
and diminished libido. JAOA. 2004;104(1Suppl 1):S9-15.
37. Morley J. Endocrine factors in geriatric sexuality. Clin Geriatr Med.
1991;7:85-93.
38. Gottfried LA, Richie JP. Sexual problems. Premature ejaculation. In: Branch
WT (ed). Office Practice of Medicine. Philadelphia, Toronto: W.B. Saunders. 1987,
pp.1407-14.
39. Briganti A, Salonia A, Deho F, et al. Peyronie’s disease: a review. Curr Opin
Urol. 2003;13:417-22.
40. Hellstrom WJ. History, epidemiology, and clinical presentation of Peyronie's
disease. Int J Impot Res. 2003; Suppl 5:S91-2.
41. Hellstrom WJ. Medical management of Peyronie's disease. J Androl.
2009;30:397-405.
42. Korenman SG. Advances in the understanding and management of erectile
dysfunction. J Clin Endocrinol Metab. 1995;60:1985-8.
43. Heruti RJ, Steivil A, Shochat T, et al. Screening for erectile dysfunction and
associated cardiovascular risk factors in Israeli men. Isr Med Assoc J. 2008;10;686-90.
44. Ben-Noun L. Was the biblical King David affected by hypothermia? J Gerontol
Med Sci. 2002;57A:M364-7.
45. Ben-Noun L. What was the disease of the bones that affected King David? J
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46. Ben-Noun L. The disease that caused weight loss in King David the Great. J
Gerontol A Biol Sci Med Sci. 2004;59A: M143-5.
47. Araujo AB, Durante R, Feldman HA, et al. The relationship between
depressive symptoms and male erectile dysfunction: Cross-sectional results from the
Massachutes Male Male aging Study. Psychosomat Med. 1998;60:458-65.
48. Shabsigh R, Klein LT, Seidman S, et al. Increased incidence of depressive
symptoms in men with erectile dysfunction. Urology. 1998;52:848-52.
49. Johnson LE, Morley JE. Impotence in the elderly. AFP. 1988;38:225-40.
50. Makhlouf A, Kparker A, Niederberger CS. Depression and erectile
dysfunction. Urol Clin North Am. 2007;34:565-74, vii.
51. Ben-Noun L. Mental disorder that afflicted King David the Great. His
Psychiatry. 2004;15:467-76.
52. Laumann EO, Waite LJ. Sexual dysfunction among older adults: prevalence
and risk factors from a nationally representative U.S. probability sample of men and
women 57-85 years of age. J Sex Med. 2008;5:2300-11.
MENTAL DISORDER
This research uses the tools of modern medical science to
examine ancient descriptions of the symptoms suffered by King
David. Biblical texts were examined, with a close study of verses
relating to the mental disorder that afflicted King David, the second
and greatest King of Israel, who ruled Israel more than 3531 years
ago. Evaluation of the passages referring to King David indicates that
he was afflicted by some mental disorder. Among the many
disorders that could have affected the King, major depression,
dysthymia, and minor depression seems the most likely. Of these
diagnoses, major depression seems the most acceptable.
INTRODUCTION
Patients have suffered from mental disorders since the dawn of
history. There is an indication of this in the book of Deuteronomy,
which talks of God’s punishment for those who violate divine
commands: “The Lord shall smite thee with madness, and blindness,
and astonishment of heart” (Deuteronomy 28: 28). Thus, we learn
that even in those ancient times there was a negative attitude
towards some mental illnesses.
Contemporary interpretation of the currently available literature
on mental disorders is important since it may give us a better
understanding of the roots of modern psychiatry. By studying the
mental disorder of a patient from ancient history, modern physicians
can expand their knowledge and thus improve their professional
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skills. Building a bridge to the remote past can be a way of better
coping with today’s psychiatric patient.
The purpose of this article is to determine whether the second
and greatest King of Israel, King David, was affected by some mental
disorder. The study focuses on biblical passages associated with the
King’s mental state, and evaluates his mental status using
contemporary diagnostic criteria. Viewed by a modern physician, the
story of King David unfolds as possibly the earliest description of
mental illness. This case highlights the challenges encountered in the
diagnostic experience.
HISTORICAL BACKGROUND
King David, who ruled Israel over 3531 years ago, was “...the son
of Ephrathite of Beth-lehem-judah, whose name was Jesse; and he
had eight sons” (I Samuel 17:12). David was the youngest and
tended his father’s sheep. He was a ruddy and handsome young man
(17:42), and even in his youth was already very strong, showing his
skills by killing a lion and a bear. Subsequently, David killed Goliath, a
terrifying giant from the area of Gat, and also defeated the
Philistines. Participating in numerous wars, he built a great empire
located between Mesopotamia and Anatolia in the north and Egypt
in the south. King David was an enigmatic warrior, whose name
evokes a mystical power almost like that of a deity (1). Even today,
after thousands of years, King David continues to live in the heart of
the Israeli people. One very popular song proclaims that “David, the
King of Israel, lives, lives and exists.” We can assume that medical
information relating to this great leader is important to many people.
In his old age King David began to suffer from a number of
physical ailments (2,3). Was he also afflicted by some mental
disorder? This article aims to answer this question by studying all
biblical passages relating to the King’s mental state.
The passages “....My soul in distress...” (Psalm 31:8), “...having
agony in my heart daily” (13:3), “My soul is alarmed..” (6:4), “...Heal
my soul ; because I sinned..” (41:5), “The troubles of my heart are
widened;. bring thou me out of my distress” (25:17) indicate that the
King had some mental problem. What was the mental disorder that
afflicted King David in his old age? Are mental disorders prevalent in
contemporary days?
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PSYCHIATRIC EPIDEMIOLOGY
US population estimates, based on combined site data, indicate
that 15.4% of the population 18 years of age and over fulfilled criteria
for at least one alcohol, drug abuse, or other mental disorder during
the period one month before interview. Men had higher rates of
substance abuse and antisocial personality, whereas women had
higher rates of affective, anxiety, and somatization disorders (1988
data). (4). In addition, men have a significantly higher rate of
cognitive impairment than women did after controlling for the effects
of age, race or ethnicity, marital status and socioeconomic status (5).
In Great Britain, data were from the Psychiatric Morbidity Survey
(2000), covering a sample of 8.500 responders aged 16-74 years.
Prevalence rates for having any common mental disorder in men
aged 65-69 years (5%; 95% CI 2.7-7.3) were dramatically lower than
in the age group 60-64 years (14.5%; 95% CI 10.6-18.5). Prevalence
rates in women peaked at age 50 and declined thereafter; but no
large changes in the prevalence were evident around age 60 or 65
years. In men, leaving work early (aged 50-64 years), the prevalence
of common mental disorders remains high until the conventional
retirement age (6).
In France, 36.000 people aged 18 years and older were
interviewed using the Mini International Neuropsychiatric Interview.
Anxiety disorders were most common (17% in men and 26% in
women), while prevalence estimates for mood disorders were 10% in
men and 14% in women. Prevalence of troubles was consistently
higher among those in the lowest occupational categories. Among
those reporting mental disorders, in about 50% their work was
affected (7).
In Austrian tertiary care hospital, two 1-year surveys over two
years (2003-2005) were compared. In Survey A, the most common
psychiatric diagnoses were adjustment disorders (21.4%), depressive
disorders (18.5%), and delirium (18.1%). The most prevalent
diagnoses in Survey B were adjustment disorders (24.5%), delirium
(18.8%), and depressive disorders (14.3%) (8).
The prevalence of mental disorders in inpatients in general
hospitals, Germany and Austria, ranges from 41.3% to 46.5%. The
most prevalent groups of psychiatric disorders among general
hospital inpatients are organic mental illness, depressive disorders,
and alcohol dependence or abuse. The prevalence rates of organic
brain syndromes, adjustment disorders with depressed mood, and
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alcohol dependence in general hospital inpatients are above of the
general population (9).
In Australia, according to the National Mental Health and Wellbeing Survey, of 1792 elderly responders, 13% reported symptoms
consistent with a mental disorder in the past 1 month, and 16%
reported symptoms consistent with a mental disorder in the past 12
months. Women experienced higher rates of affective disorders and
generalized anxiety disorder (GAD) and had lower rates of substance
abuse compared with men. After excluding cognitive disorder,
increasing age was associated with less likelihood of having
symptoms of any mental disorder. Older age and never having been
married were associated with less likelihood of having symptoms of
an affective disorder (10).
In Chile, of the 2.659 interviewed 352 were over age 64. Elderly
adults had lower prevalence rates of lifetime mental disorders than
the younger population, 20% in comparison with 34%. Dysthymia,
agoraphobia, simple phobia, and alcohol dependence disorders were
less common among elderly subjects. Those over the age of 64 in
comparison with those over the age of 74 had higher prevalence
rates of mental disorders. One third of elderly responders with major
depression had a late onset disorder (11).
Adults (n=1394) systematically sampled from Al Ain community,
the United Arab Emirates, were assessed with a modified version of
the Composite International Diagnostic Interview as well as with
other psychiatric instrument, Self-Reporting Questionnaire, and the
Structured Clinical interview for DSM-IV Axis 1 disorders screening
module. Overall prevalence of ICD-10 psychiatric disorder was 8.2%
(95% CI 6.7-9.7); while the 1-week prevalence rate of mental distress
was 15.6% (95% CI 11.8-19.5) and the life prevalence rate of mental
distress was 18.9% (95% CI 11.5-25.9). Mood disorders and anxiety
(neurotic) disorders were more common in women while alcohol and
substance use disorders were exclusively confined to men. Female
sex, young age, quality of marital relationship, life events over past
year, chronic life difficulties, physical illness, family history of
psychiatric disorders and past history of psychiatric treatment were
associated with ICD-10 psychiatric disorder. Multivariate analysis
revealed that age, sex, exposure to chronic difficulties and past
history of psychiatric treatment were the most significant predictors
of ICD-10 psychiatric disorders, while exposure to chronic difficulties,
past history of psychiatric treatment and educational attainment
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were the significant predictors of lifetime ever and current mental
distress (12).
A 2-phase total population survey of 1544 adults in an urban and
rural area of Timor Leste was carried out. Phase 2 yielded a DSM-IV
point prevalence estimate of 5.1% (including psychosis, 1.35%; and
PTSD, 1.47%). Psychotic disorders were most disabling, primarily
attributed to supernatural causes and treated mainly by traditional
healers. Those with depression and PTSD experienced substantial
disability but had received little treatment. They attributed their
mental problems to social and traumatic causes (13).
Mental disorders are prevalent in the contemporary general
population and their pattern varies in different countries.
DEPRESSION
Depression is associated with high morbidity, and (with the
exception of serious heart disease) causes greater impairment to
physical and social functioning, more pain (apart from arthritis) (14),
high medical utilization and more functional impairment than most
chronic medical illnesses (15). This mental disorder occurs in 2%-4%
of persons in the community, 5%-10% of primary care patients, and
in 10%-14% of medical inpatients (15).
In the Unites States and worldwide, depression is the most
common mental disorder among older adults. This descriptive,
correlational study of 314 older adults with chronic conditions
examined three measures to assess depressive symptoms: the center
for Epidemiological Studies Depression Scale (CES-D), the short form
of the Center for Epidemiological Studies Depression Scale (CES-D10), and an Emotional Symptom Checklist (ESC). About 12% of the
older adults exceeded the CES-D criteria for severe depressive
symptoms, with the greatest percentage among those aged 75 to 84.
The most frequently reported negative emotions were sadness (by
women and elders through age 84) and loneliness (by men and elders
aged 85 and over) (16).
Although effective treatments exit, individuals with depressive
and anxiety disorders can remain ill for years. In the United States, in
a community-based cohort study (n=1.642), the estimated national
prevalence of a persistent depressive or anxiety disorder was 4.7%. In
this subgroup, 87% had a chronic comorbid condition. Between
baseline and follow-up, the percentage using appropriate medication
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increased (21% to 29%), but there was insignificant change in the use
of appropriate counseling (19% to 23%) (17).
In a community-based study, Amsterdam, The Netherlands, the
prevalence of depressive symptomatology and risk indicators were
assessed in 2850 participants aged 75 years or more. The prevalence
of depressive symptoms was 31.1% (18).
In Finland, a random sample of non-institutionalized Finnish
individuals aged 15-75 years (n=5993) was interviewed in 1996. The
population prevalence of major depressive episode was 9.3% [95% CI
8.5-10.1], and the age-adjusted prevalences for females and males
were 10.9% [95% CI 9.7-12.0] and 7.2 [95% CI 6.2-8.2], respectively
(19).
One hundred and six patients in Indian Health Service primary
care clinic were enlisted for participation in this study. Participants
completed the Inventory for Diagnosing Depression. Twenty two
(20.7%) responded with answers scoring positively for a depressive
syndrome. Nine of these 22 (8.9% of the 106 participants) met
Inventory for Diagnosing Depression criteria for a major depressive
syndrome (20).
Depression is a common psychiatric problem of the elderly.
Geriatric depression is often difficult to recognize as patients tend to
present with somatic complaints, anxiety, or loss of concentration
and memory problems (21,22) rather than depressed mood. When
strict DSM-III criteria were applied, approximately 3% of the elderly
living in the community were found to be suffering from major
depression (23,24) and 15%-20% exhibit clinically significant
depressive syndromes (25,26).
Depression is a prevalent mental disorder worldwide, and its
prevalence varies in different countries.
CRITERIA FOR MAJOR DEPRESSION
The well-known criteria of DSM-IV are presented here as a means
for evaluating biblical verses relating to mental distress in King David.
Major depressive syndrome is characterized either by a severely
depressed mood [1] or by loss of interest or pleasure in nearly all
activities [2], with the change in previous level of functioning lasting
for at least two weeks. At least four additional symptoms are
required for a definite diagnosis of the disorder, including changes in
appetite or weight [3], insomnia or hypersomnia [4], psychomotor
agitation or retardation [5], fatigue or loss of energy [6], feelings of
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worthlessness or excessive or inappropriate guilt [7], diminished
ability to think or concentrate or indecisiveness [8], and recurrent
unfocused thoughts of death or suicide, or suicide attempt (27,28).
The words “...a broken and depressed heart..”.(Psalm 51:19) and
the verse “I am feeble and depressed: I have groaned by reason of the
suffering of my heart” (38:9) indicate a depressed mood (criterion 1).
The verse “My knees are weak through fasting; and my flesh failed
of fatness” (109:24) describes a significant loss of weight. This loss
may indicate criterion 3.
The verse “..All the night make I my bed to swim; I water my couch
with my tears” (6:7) points to insomnia during which the King wept so
much that his bed was wet with tears (Criterion 4).
The passages “Fearfulness and trembling are come upon me...”
(55:6), “My heart is shivering within me ..” (55:5) and “..Like a deaf
man I would not hear and like a mute I would not speak..” (38:14)
indicate psychomotor agitation or retardation that are compatible
with criterion 5.
The verse ”My strength failed because of mine iniquity...” (31:11)
indicates fatigue or loss of energy (criterion 6).
The subsequent passages “But I am a worm, and no man; a
disgrace of men, and despised of the people” (22:7) and “I am
forgotten as a dead man out of mine mind: I am like a lost tool”
(31:13) express feelings of worthlessness (criterion 7).
Fear of death and recurrent thoughts of death (criterion 9) are
found in numerous passages: ”...has brought me into the dust of the
earth to death” (22:16), “... the terrible fears of death had fallen
upon me” (55:5), “The sorrows of death compassed me...” (18:5) and
“...The mines of death preceded me..” (18: 6).
This study found seven criteria for major depression in King David.
Criterion 3 can be related either to depression or to physical illness
such as bone diseases, with the diagnosis of malignancy as the most
probable (1). Since cancer may have a link to depression, this
criterion is removed. Criterion 6 can also be attributed to physical
illness, for example anemia. If criteria 3 and 6 are dropped, there are
still sufficient criteria (five) for a diagnosis of major depression.
SUBSTANCE-INDUCED MOOD DISORDER
Did King David suffer from a substance-induced mood disorder,
characterized by prominent and persistent mood disturbances
associated with the direct physiological consequences of drug abuse,
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or the use of medication such as glucocorticoids, anabolic steroids,
reserpine in high-dose, and cocaine or amphetamine withdrawal, or
toxic exposure (27,29-32). In the absence of appropriate anamnestic
data, the diagnosis of substance-induced mood disorder seems very
unlikely.
GENERAL MEDICAL CONDITION
A variety of other general medical conditions, apart from
depression, may cause mood symptoms, including neurological
ailments such as Parkinson’s disease, Huntington’s disease,
dementia, stroke, metabolic conditions such as vitamin B12
deficiency,
endocrine
disorders
such
as
hyperand
hypoparathyroidism, hyper- and hypoadrenocorticism, cardiovascular
disease, arthritis, autoimmune diseases such as systemic lupus
erythematosus, viral or other infections such as hepatitis,
mononucleosis, human immunodeficiency virus, carcinoma of the
pancreas, and sensory loss (27,30,33). Did the King suffer from any of
these medical conditions? Although it has been previously shown
that King David suffered from mild hypothermia (2), it seems unlikely
that this disorder was the cause of his depression. In the absence of
appropriate anamnestic, physical, and laboratory findings, other
diagnoses seem equally unlikely.
DYSTHYMIC DISORDER
This disorder refers to a chronic mild depressive syndrome, with
insidious onset often commencing in childhood or adolescence,
characterized by less acute, less severe, and less disabling depressive
symptoms, symptomatically subsyndromal and psychologically
intractable to change, which are present for at least 2 years and may
last for many years (27,34-37). Dysthymic disorder is a chronic
condition with a protracted course and a high risk of relapse. Almost
all patients with dysthymic disorder eventually develop
superimposed major depressive disorder. Although patients with
dysthymic disorder show mild to moderate symptoms, from a
longitudinal perspective, the condition is severe (38,39).
Did King David suffer from this syndrome? The following verses
indicate severe mental distress and significant suffering: “...a broken
and depressed heart (51:19); I am feeble and depressed: I have
groaned by reason of the suffering of my heart (38:9); All the night
make I my bed to swim; I water my couch with my tears (6:7);
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...having agony in my heart daily (13:3); .. I am a worm, and no man;
a disgrace of men, and despised of the people (22:7); I am forgotten
as a dead man out of mine mind: and I am like a lost tool” (31:13).
For this reason, the diagnosis of dysthymia seems very unlikely.
MINOR DEPRESSION
Did King David suffer from minor depression? Subsyndromal
subthreshold (minor) depression is common and associated with
symptoms of impairments of clinical importance (40).
This
depression is a condition in which a person has depressive symptoms
but does not meet the criteria for a depressive disorder.
Subthreshold depression has serious consequences for the quality of
life, but not as serious as in the case of a depressive disorder.
Subthreshold depression has considerable economic consequences
for the individual concerned, although again less severe than if the
individual had a major depressive disorder (41).
DSM-IV criteria for this disorder include two to four depressive
symptoms, such as depressed mood or anhedonia, causing significant
impairment in social, occupational or other important areas of
functioning for at least 2 weeks (27,42). Minor depression, an
unofficial diagnosis that has been designated for further research
study, is defined as a mental disorder with an insufficient number of
symptoms for a diagnosis of major depression (27,42,43).
Subsyndromal symptoms in bipolar disorder are strongly
associated with both social and occupational functioning (44,45), but
not as serious as in the case of a depressive disorder. Subjects with
subthreshold depression have an increased risk of developing a major
depression (41).
Was King David afflicted by minor depression? Since this study
found sufficient diagnostic criteria for major depression, the
diagnosis of minor depression is disregarded in King David’s case.
STRATEGIES FOR DIAGNOSIS DEPRESSION
There are a number of strategies for diagnosing depression. In
DSM-III-R and DSM-IV, the approach of counting symptoms toward
depression is “etiological”. According to this strategy, symptoms are
counted towards the diagnosis of depression only if the clinician
decides that a particular symptom is not due to “..a physical
condition” (DSM-III-R) or “.. a general medical condition “ (27,46).
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The reliability of this method is poor given the lack of a standard for
the decision (47).
In King David’s case all the relevant information was extracted
from the patient’s medical file (the biblical text), recorded more than
3531 years ago. Since the clinical diagnosis of depression is usually
based on an interview with the patient (30), the pertinent biblical
passages should be regarded as interviews. According to the
“etiological” strategy, King David was afflicted by major depression.
The “inclusive” approach counts all depressive symptoms towards
the diagnosis of depression, regardless of whether the clinician
judges that any symptom is due to medical or psychological causes
(42). This approach is highly sensitive and reliable, since the only
decision needed is whether the relevant symptom is present or not
(46). When the two approaches are compared, the etiological
approach is found to be less reliable than the inclusive approach (42).
The “inclusive” strategy, however, has been criticized as having poor
specificity and for inflating rates of depression (46), since all relevant
symptoms, regardless of cause, are taken into account in the
diagnosis of depressed mood. If this approach is adopted, King David
was certainly afflicted by major depression.
A third strategy, called the “substitutive” approach, eliminates
symptoms that are most likely to be confused with medical illness,
such as loss of energy, weight loss, psychomotor changes and
impaired concentration (48).
In place of these symptoms,
consideration is more likely to be given to symptoms that are
cognitive or affective in their origin, such as irritability, tearfulness,
feelings of being punished, or social withdrawal (48,49). Irritability
may be identified in the passage “...Why hast thou forgotten me?
why go I mourning because of the pressure of the enemy? (42:10).
Tearfulness is shown by ” I water my couch with my tears”(6:7).
Feelings of being punished can be seen in the passage “...neither is
there any rest in my bones because of my sin” (38:4). Social
withdrawal is indicated by the passage “But I am a worm, and no
man; a disgrace of men, and despised of the people.” (22:7). Thus,
the substitutive approach also indicates that King David suffered
from depression.
An additional simple method for diagnosing depression is a case
finding instrument. A single question “Have you felt depressed or
sad much of the time in the past year?” is asked to elicit a yes or no
response (50). The simple question strategy was compared with a
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20-item Questionnaire from the Center for Epidemiological Studies of
Depression that focuses on depressive symptoms within the last
week (51). The simple question strategy was found to have similar
performance characteristics to the longer questionnaire and is more
feasible because of its brevity (52). If the simple question had been
posed to the King, the answer would have been “...a broken and
depressed heart..” (51:19) and “I am feeble and depressed ” (38:9).
Such answers are a convincing indicator of depression. Although no
time spans are given for the duration of the depression, it is most
likely that the King had suffered from the depression for a long time.
In summary, according to four different diagnostic strategies, King
David was afflicted by depression, most likely a major depressive
episode, causing clinically significant mental distress.
MECHANISMS OF DEPRESSION DEVELOPMENT
Stressful and adverse life events are a potent factor in predicting
major depression (53-56).
Certain cognitive personality
characteristics also indicate susceptibility to depression (57). Beck’s
cognitive theory of depression proposes that the cognitive
personality characteristics of sociotropy and autonomy act as
“vulnerability markers for depression by sensitizing individuals to
certain types of negative life experiences” (57). Interactions between
sociotropy (or interpersonal dependency), characterized by a strong
need for close relationships and concern over disapproval (58) and
negative interpersonal events, such as the death of a loved one, have
been reported to predict depression (59). In addition, the major
factors associated with major depressive episode include urban
residency, smoking, alcohol intoxication, chronic medical conditions
for both sexes, and being single and obese only for males (19).
As mentioned previously, depressive symptoms are highly
prevalent in the elderly population and increase with age. This
increase seems to be attributable to age-related changes in risk
factors rather than to ageing itself (18).
Patients with depression often go under diagnosed or are
misdiagnosed. The evidence suggests a multifactorial etiology for this
problem. Many patients with depression selectively focus on the
somatic components of their depressive syndrome and minimize or
even deny affective and cognitive symptoms. Depression and medical
disorders also often occur concomitantly with depression causing
amplification of somatic complains (60).
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Evolved mechanisms, and underpinning attachments and social
rank behavior are the basis for some forms of major depression,
especially those associated with chronic stress. Some of depression
core symptoms, such as behavioral withdrawal, low self-esteem and
anhedonia, may have evolved in order to regulate behavior and
mood and convey sensitivity to threats and safety. Focusing on the
evolved mental mechanisms for attachment and social rank helps to
make sense of depression's common early vulnerability factors (e.g.,
loss of close relationships, being defeated and/or trapped in low
socially rewarding or hostile environments), and the psychological
preoccupations of depressed people (e.g., sense of unloveliness, self
as inferior and a failure) (61).
The extent to which loneliness is a unique risk factor for
depressive symptoms was determined in two population-based
studies of middle-aged to older adults, and the possible causal
influences between loneliness and depressive symptoms were
examined longitudinally in the second study. In study 1, a nationally
representative sample of persons aged 54 and older completed a
telephone interview as part of a study of health and aging. Higher
levels of loneliness were associated with more depressive symptoms,
net of the effects of age, gender, ethnicity, education, income marital
status, social support, and perceived stress. In study 2, detailed
measures of loneliness, social support, perceived stress, hostility, and
demographic characteristics were collected over a 3-year period from
a population-based sample of adults' ages 50-67 years from Cook
County, Illinois.
Loneliness was again associated with more
depressive symptoms, net of the effect of age, gender, ethnicity,
education, income, marital status, social support, and perceived
stress. Latent variable growth models revealed reciprocal influences
over time between loneliness and depressive symptomatology.
These data suggest that loneliness and depressive symptomatology
can act in a synergistic effect to diminish well-being in middle-aged
and older adults (62).
A study investigated relationships between loneliness, health, and
depression in 216 older men (>65 years). A diagnosis of illness or
disability was unrelated to depression, however, self-reported health
was associated with depression, with those reporting poorer heath
experiencing greater depression. Social support variables were
unrelated to depression. The most significant relationship to
depression was that of loneliness. Although depression is often a
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response to declining health and functional impairment in the older
adult, the present finding suggest that social isolation may influence
the experience of depression. Age-related losses such as loss of
professional identity, physical mobility and the inevitable loss of
family and friends can affect a person's ability to maintain
relationships and independence, which in turn may lead to a higher
incidence of depressive symptoms (63).
Within a prospective population-based study of 85-year-olds, the
15-item Geriatric Depression Scale and the Loneliness Scale were
annually applied to 476 participants with a Mini-Mental State
Examination score of 18 points or more, the Section of Gerontology
and Geriatrics, The Netherlands. Depression was present in 23% and
was associated with marital status, institutionalization, and perceived
loneliness. When depression and perceived loneliness were assessed
during follow-up, neither depression nor perceived loneliness had a
significant effect on mortality. However, those who suffered from
both depression and feelings of loneliness had a 2.1 times higher
mortality risk (64).
The impact of recent life events in the provoking of depressive
episodes is well established, but their weight in the course of
depression has not been frequently studied. Firstly, life events
occurring before the beginning of the episode are predicative neither
of the response to treatment, nor of the long-term evolution of
major depressive episodes. Reactional depression is more sensitive
to placebo than non-reactional depression, and, minor reactional
depression could have a better spontaneous course. Secondly,
stressful life events and long-lasting difficulties are contemporary
with the episode and are some of the most important clues for
durability, and sometimes chronicity, of depressive symptoms. Some
of those events are independent (not controlled by the subject), but
some are dependent, produced by the subject and his depressive
state. On the other hand, certain types of life events (like
"neutralizing events" or "fresh start events") and the stress reduction
of long-lasting difficulties seem to favor remission of minor
depression. Thirdly, weight of life events in relapse and recurrence of
depression is significant, but seems to be less important than the
release of first depressive episodes. The interaction between life
events and the genesis of depression can be observed from
sociological, psychological or biological point of view (65).
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The mechanisms of the development of depression in King David’s
case are demonstrated by the passages “Be not far from me; for
trouble is near; for there is no help “ (Psalm 6:12), “I am helpless”
(25:16) and “I am wretched..” (6:3). Here we learn about the King’s
loneliness, need for close relationships and lack of friends on whom
he can rely. Additional passages: “But I am a worm, and no man; a
disgrace of men, and despised of the people” (22:7) and “I am
forgotten as a dead man out of mine mind. I am like a lost tool”
(31:13) show loss of power and control over his people, feelings of
neglect and negative interpersonal relationships. Thus, persistent
negative stress and negative interpersonal experiences played a role
in the development of his major depression. Furthermore, the King
was aware of his iniquity, wickedness and sin “...my strength failed
because of mine iniquity” (31:11) and “Save me from all my sins...”
(39:9). All these causes acted together in the development of the
King’s mental disorder.
OUTCOME
Information on the naturalistic outcome of major depressive
disorder is important in developing rational clinical practices. The
Vantaa Depression Study is a prospective, naturalistic cohort study of
269 secondary-level care psychiatric outpatients and inpatients
diagnosed with a new episode of DSM-IV major depressive disorder.
The median length of time that patients met full criteria for a major
depressive episode was 1.5 (95% CI 1.3 - 1.7) months, and the
median time to full remission was 8.1 (95% CI 5.2 - 11.0) months after
entry. During the follow-up, 38% had a recurrence. Although
numerous factors predict outcome of major depressive disorder to
some extent, severity of depression and current comorbidity were
the two most important predictors of longer episode duration and
recurrence. The course of major depressive disorder in modern
psychiatric settings remains unfavorable. Any estimates of duration
of depressive episodes and rates of recurrence are likely to be
dependent on the severity of depression and level of comorbidity. At
least among a population of mostly outpatients with major
depressive disorder in medium-term follow-up, severity of
depression and comorbidity appears to be more useful predictors of
recurrence than does the number of prior episodes (66).
In Dublin, Ireland, 100 consecutive depressed inpatients were
followed prospectively over 18 months. The cumulative
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probabilities of remission onset by 3 and 18 months were 0.67 (95%
CI 0.57-0.77) and 0.82 (95% CI 0.74-0.90). The cumulative
probability of relapse was 0.25 (95% CI 0.15-0.35); 53% of those
relapsing did so in the first 2 months. Younger age at onset, longer
illness length, higher depression and anxiety ratings, predicted
delayed remission onset (67).
Inpatients and outpatients (n=150) 60 years and older with major
depression were enrolled in a naturalistic treatment study and
followed up for 10 years; 34.8% of the patients had comorbid major
depression and dysthymia at baseline enrollment. Compared with
those with major depression alone, they had longer time to both
partial (median number of days = 175 vs. 106) and full remission
(median number of days = 433 vs. 244) from major depression. The
effect of having comorbid dysthymia was not consistent over time,
with patients with both disorders having higher predicted scores
after initial response.
Older patients with comorbid major
depression and dysthymia have a less favorable trajectory of
recovery compared with those with depression alone (68).
What was the outcome of major depressive disorder in King
David's case? Did the King recover?
IMPACT ON QUALITY OF LIFE AND FUNCTIONAL
STATUS
Screening surveys of depressive symptoms were conducted
among primary care patients at six sites in different countries.
Subjects aged 18 to 75 were recruited from participating primary
care facilities in Beer Sheva (Israel), Porto Alegre (Brazil), Melbourne
(Australia), Barcelona (Spain), St Petersburg (Russian Federation) and
Seattle (USA). Depressive symptoms were measured by CES-D. A
total of 18.489 patients were screened, of whom 37% overall (range
24%-55%) scored > or = 16 on the CES-D and 28% (range 17%-42%)
scored > or = 20. Overall, 13% reported current treatment for
depression (range 4%-23%). Patients with higher depressive
symptoms scores had worse health, functional status, QOL, and
greater use of health services across all sites. Among those with a
CES-D score > or = 16, subjects reporting treatment for depression
were more likely than those reporting no treatment to be satisfied
with their health (except St Petersburg), and have higher depressive
scores. Higher depressive symptom scores in primary care patients
were consistently associated with poorer health, functional status
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and QOL, and increased health care use, but not with demographic
variables (69)
n association between major and subsyndromal depression on
quality of life (QOL) and attitudes toward aging was examined in a
large international sample. A cross-sectional study assessed 4.315
responders in 20 countries from five continents. The study used the
World Health Organization Quality of Life (WHOQOL) Assessment for
Older Adults, known as the WHOQOL-OLD; the brief version of the
WHOQOL instrument, known as WHOQOL-BREF; and the Attitudes to
Ageing Questionnaire. Even relatively minor levels of depression
were associated with a significant decrease in all quality of life (QOL)
domains and with a pattern of a negative attitudes toward aging
(overall WHOQOL-OLD R(2) change = 0.421). QOL and attitudes
toward aging scores were lower as depression intensity is increased,
even in subsyndromal levels (overall WHOQOL-OLD mean scores of
97.7 vs. 86.4, p<0.001). This phenomenon happened not only for
clinically depressed individuals but also for subsyndromic individuals
(70).
Depressed patients are assiduous users of primary care services,
although their depression is very often misdiagnosed. The objective
this study was to evaluate the association between depressive
symptoms and social functioning in individuals (n=2.201) at primary
care services, Porto Alegre, Brazil. The intensity of depressive
symptoms (measured by CES-D) was 20.2 for women and 16.2 for
men. Depressive symptoms have a strong association with poor
social functioning and quality of life and a high utilization of health
resources in primary care patients (71).
An additional cross-sectional study was carried out in a primary
care clinic also in a Brazil. The cases were divided into three groups
according to the severity of depressive symptoms: 1) subjects with
major depressive disorder; 2) subjects with subsyndromal
depression; 3) subjects without depressive symptoms - controls. The
sample consisted of 438 primary care users (35.2% of them had
subsyndromal depression). The subjects with major depression
presented the worst impairment of quality of life, which was
measured by the WHOQOL- BREF and the QLDS. The patients with
subsyndrome depression have a smaller impact on their quality of life
and the subjects without depression presented an even lower
impact. The hierarchical linear regression involving demographic
variables and the severity of depressive symptoms showed that the
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severity of depression was the variable with higher correlation with
quality of life dimensions, presenting increased variation in the
domains (from 9% to 24%) (72).
Predictors of depression severity and functional impairment at 10year outcome include older age, less education, concurrent anxiety
disorder, greater familial loading for chronic depression, a history of a
poorer maternal relationship in childhood, and a history of childhood
sexual abuse (73).
These studies show that both major depression and subsyndromal
depression cause severe impairment of the quality of life. We can
conclude that the quality of life, as well as functional status and
health were impaired significantly in the King's case, who was
afflicted by major depression.
Was social functioning impaired in King David's case? The
passages: “But I am a worm, and no man; a disgrace of men, and
despised of the people” (32:7) and “I am forgotten as a dead man out
of mine mind. I am like a lost tool” (31:13) also indicate a severe
impairment of social functioning due to loss of power and control
over his people.
GENERALIZED ANXIETY DISORDER
GAD is characterized by at least 6 months of excessive
uncontrollable worry accompanied by symptoms of motor tension
and vigilance and scanning. As with other anxiety disorders, GAD is
less prevalent in older adults than younger adults. GAD has a high
level of comorbidity with other psychiatric disorders and this has a
bearing on estimates of its prevalence. GAD that is comorbid with
another psychiatric disorder has a period prevalence of
approximately 4% in community-dwelling older adults. On the other
hand, "pure" GAD is less common, with a period prevalence of
approximately 1% (74).
Did King David suffer from GAD? Some passages such as ”...having
agony in my heart daily.” (13:3), “My soul is alarmed..” (6:4), “The
troubles of my heart are widened; ..bring thou me out of my distress”
(25:17) “...My soul in distress..”(31:8) and “Be not far from me; for
trouble is near; for there is no help “ (6:12) indicate restlessness, and
“..All the night make I my bed to swim; I water my couch with my
tears” (6:7) show sleep disturbances, while ”My strength failed
because of mine iniquity...” (31:11) and “...My heart failed me”
(40:13) indicate fatigue or loss of energy. The last two passages can
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also be attributed to physical illness. Thus, although some symptoms
may be attributed to GAD, in general there are insufficient criteria for
a diagnosis of this mental disorder.
Similarly, there are insufficient data to suspect other types of
anxiety disorder such as social phobia, obsessive-compulsive
disorder, separation anxiety disorder, anorexia nervosa, somatization
disorder or hypochondriasis. For panic attack, only three criteria
were found (diagnosis requires 4): trembling: “Fearfulness and
trembling are come upon me...”, palpitations: “My heart is shivering
within me ..”, and fear of death: “... the terrible fears of death had
fallen upon me.” In the absence of other symptoms, such as
sweating, shortness of breath, chest pain, feeling of choking,
derealization, fear of losing control, paresthesia, chills or hot flashes
(27), the diagnosis of panic attack seems unlikely.
TO SUM UP: King David’s mental status taken as a whole indicates
that he was afflicted by some kind of a mental condition. Among the
many disorders, which could have affected the King, major
depressive episode, minor depression, or dysthymic disorder are the
most likely. Of these diagnoses, major depression disorder provides
the best explanation (75). An examination of the biblical King David’s
mental illness from a contemporary perspective shows that features
of mental illness have changed little through the ages. Although new
diagnostic and treatment strategies have been developed over time,
both ancient and modern psychiatric patients deserve similar
diagnostic investigation and subsequent treatment. We need to
increase our knowledge of ancient history and learn from the
psychiatric cases we find there, in order to improve our treatment of
contemporary patients.
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