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Alexander the Great,Seafaring,
and the Spread of Leprosy
SAMUEL MARK
NCIENT ships are commonly described as conveyors
of merchandise,technology,and even ideas,but as
conveyors of disease they are seldom mentioned in
the literature.This is surprising because both passen-
gers and crew typically had to endure poor hygiene,
poor nutrition,and cramped quarters,especially on
long voyages.All of these factors provided an excellent environment
for the incubation and spread of disease.In contrast to ships,however,
armies are commonly assumed to be likely human vectors for the
spread of diseases,even if little or no evidence supports such an
assumption.One such assumption concerns the army of Alexander
the Great.
Alexander the Great (– bce) conquered much of the known
world of his time.He was a consummate general,tactician,and
statesman whose conquests led to the spread of Greek culture through-
out the eastern Mediterranean.Some paleopathologists,leprologists,
and historians have now bestowed another dubious honor on Alexan-
der.1They propose that members of his army may have contracted
. R.T.Steinbock,Paleopathological Diagnosis and Interpretation:Bone Diseases in Ancient
Human Populations (Springfield,Ill.: C.C.Thomas,),p. ; D.J.Ortner and W.G.J.
Putschar,Identification of Pathological Conditions in Human Skeletal Remains (Washington,D.C.:
Smithsonian Institution Press, ),p. ; C.Roberts and K.Manchester,The Archaeology
of Disease (Ithaca,N.Y.: Cornell University Press, ),p. ; W.H.Jopling and A.C.
I owe a debt of gratitude to Cassidy Yoder at Texas A&M University for her help and for
putting me in contact with Ulla Freund,who on very short notice found the illustrations
in the Anthropological Database,University of Southern Denmark,Odense,and sent them
to me.
2002 oxford university press
issn 0022-5045 volume 57 pages 285 to 311
[ ]
Journal of the History of Medicine :Vol. , July
leprosy during the Indian Campaign (– bce) and then spread
it to the Mediterranean region on their return.This opinion has been
repeated without critical analysis since Johs Andersen first proposed it
in . Furthermore,Andersen proposed that Pompey’s army
brought leprosy to Italy after his campaign against Mithridates of
Pontus in bce.2Yet the evidence does not support either assump-
tion.Instead,I propose that cargo ships carrying young slaves from
India to Egypt were probably the conveyors of this disease to the
Mediterranean world.
Andersen’s theory is based on his argument that the earliest written
description of leprosy in the Mediterranean region dates to around
bce and the earliest osteological evidence for leprosy to about
ce . Since publishing,however,the discovery of bones exhibiting
leprous lesions from Egypt has pushed back the date of the earliest
osteological evidence to about bce.3This does strengthen his
argument because it places the earliest evidence closer to Alexander’s
time.However,Andersen’s dating for the appearance of leprosy has
not been universally accepted.A few scholars still believe leprosy
appeared much earlier in this region,and the most ardent advocate
of this theory is Mirko Grmek;he argued that ancient Egyptian,
Mesopotamian,and Hebrew texts all describe leprosy.4So,my argu-
ment is two-pronged:leprosy did not appear in the Mediterranean
region before approximately bce or so,and it traveled there via
cargo ships,not via Alexander’s army.
McDougall,Handbook of Leprosy (London:Heinemann Medical Books, ),p.;J.M.
Grange,Mycobacteria and Human Disease (New York:Oxford University Press, ),p. ;
G.Kaplan and V.H.Freedman,“Leprosy:Immune Mechanisms in Disease,”inM.W.
Cunningham,G.L.Cross,and R.S.Fujinami,eds., Effects of Microbes on the Immune System
(Philadelphia:Lippincott Williams & Wilkins, ),pp. –, p. ; E.V.Hulse,“The
Nature of Biblical ‘Leprosy’ and the Use of Alternative Medical Terms in Moder n Translations
of the Bible,”Palest.Explor.Q., , ,–, p. ; S.G.Browne,“The History of
Leprosy,”inR.C.Hastings,ed., Leprosy (New York:Churchill Livingstone, ),pp.
–, p.;R.Jackson,Doctors and Diseases in the Roman Empire (Norman:University of
Oklahoma Press, ),p. .
. J.G.Andersen,“Studies in the Medical Diagnosis of Leprosy in Denmark,”Dan.Med.
Bull., , ,Suppl.,–, .
. T.Dzierzykray-Rogalski,“Paleopathology of the Ptolemaic Inhabitants of Dakleh Oasis
(Egypt),”J.Hum.Evol., , ,–.
. M.Grmek,Diseases in the Ancient Greek World (Baltimore,Md.: Johns Hopkins Univer-
sity Press, ),pp. –.
Mark :Seafaring and the Spread of Leprosy
the many manifestations of leprosy
To understand why such divergent interpretations have been pro-
posed,it is first necessary to understand the nature of leprosy.Leprosy,
or Hansen’s disease,is a slow,progressive,and chronic infectious
disease,which is produced by the bacillus Mycobacterium leprae.It can
bedifficult to diagnose in its early stages because it produces four
different forms:indeterminate,tuberculoid,borderline,and leproma-
tous leprosy.The difficulty is further compounded because these
different forms exhibit such a wide range of symptoms.Leprosy
typically begins as an indeterminate form that can spontaneously heal,
remain unchanged for long periods,or progress to a more severe
form.Indeterminate leprosy produces poorly defined patches or mac-
ules that are slightly hypopigmented in darker skin and have a slightly
reddish color in lighter skin.5
If the disease progresses,it may develop into the second form,
tuberculoid leprosy,which is associated with rapid and severe nerve
damage,resulting in a loss of sensation,local paralysis,loss of sweat
and sebaceous glands,and hair loss.Skin lesions are few;they are
macular,have sharp borders,and are hypopigmented.Typically,there
is also an enlargement of cutaneous nerves and peripheral nerve trunks
with localized infection that may ulcerate in the area of lesions.
However,nerve damage is often limited and infection usually heals
without treatment.6
The third form,borderline leprosy,is an unstable form that is
transitional between the tuberculoid and lepromatous forms,and it is
divided into three subgroups:borderline tuberculoid,mid-borderline,
and borderline lepromatous leprosy.Borderline tuberculoid leprosy
produces skin lesions similar to tuberculoid leprosy but the lesions
are more numerous and larger with less defined margins,and satellite
lesions may also form.In this subgroup,there is also a possibility of
rapid deterioration of nerve function leading to disability.The second
. L.K.Bhutani,I.Nath,N.K.Mehra,and N.H.Antia,“Leprosy,”The Lancet, ,
, –, pp. –; W.M.Meyers,“Leprosy,”inR.L.Guerrant,D.H.Walker,and
P.F.Weller,eds., Tropical Infectious Diseases:Principles,Pathogens,& Practice (Philadelphia:
Churchill Livingstone, ),pp. –, p. .
. D.Lockwood and K.McAdam,“Leprosy,”inS.L.Gorbach,J.G.Bartlett,N.R.
Blacklow,eds., Infectious Diseases,nd ed.(Philadelphia:W.B.Saunders Company, ),
pp. –, p. ; Meyers,“Leprosy,”p. .
Journal of the History of Medicine :Vol. , July
subgroup,mid-borderline leprosy,is the most unstable type,from
which patients can develop either tuberculoid or lepromatous leprosy.
It produces numerous lesions that vary in size,shape,and distribution
and have irregular borders.Lesions can also be macules,papules,
or plaques.The third subgroup,borderline lepromatous leprosy,is
characterized by small macules all over the body,which as the disease
progresses become infiltrated.Peripheral nerve involvement is also
widespread but is not as symmetric as in the lepromatous form.7
The fourth form,lepromatous leprosy,is the disfiguring form of
the disease that most people associate with leprosy.In its early stages,
however,it is typically insidious.Ill-defined hypopigmented papules
or macules can appear anywhere on the skin but usually do so in
cooler areas,such as the ears,center of the face,and extensor surfaces
of the thighs and forearms.It progresses slowly but relentlessly,pro-
ducing plaques,nodules,and infiltrations.As the skin becomes infil-
trated it thickens,and nerve damage leads to a loss of sensation.
This thickening in the face along with hypertrophied lips and nose,
pronounced wrinkles,and a yellow cast to the skin are all characteris-
tics of the leonine facies or “lion face” associated with lepers.Also
in the facial area,there is a loss of hair,especially the eyelashes and
the lateral third of the eyebrows;the eyes are attacked,sometimes
causing blindness;the ears may fall off; and the perforation of the
septa and destruction of the nasal bone,nasal spine,and even central
maxilla leads to the collapse of the bridge of the nose.This nasal
destruction and severe throat damage result in a hoarse whisper.In
the rest of the body,a loss of sensation usually appears first in the
hands and feet,which then become swollen and deformed.These
manifestations can then spread to the rest of the body (except the
axillae,groin,and scalp).Persistent injury,due to a loss of sensation,
along with the absorption of bone typically leads to a loss of fingers
and toes.8
The wide-ranging symptoms manifested by leprosy,especially in
its early stages,can make it difficult to distinguish from other condi-
tions.The ulceration of lesions on the face and limbs have been
mistaken for symptoms of leishmaniasis,and the secondary infections
seen in leprosy are similar to those exhibited by psoriasis,pellagra,
. Lockwood and McAdam,“Leprosy,”pp. –; Meyers,“Leprosy,”pp. –.
. Lockwood and McAdam,“Leprosy,”p. ; Meyers,“Leprosy,”p. ; Roberts and
Manchester,Archaeology,pp. –.
Mark :Seafaring and the Spread of Leprosy
eczema,and lupus erythematosis.9Finally,the swelling of the hands,
feet,and arms exhibited in the lepromatous form have been confused
with symptoms of elephantiasis,which causes swelling and skin thick-
ening of the legs,scrotum,labia,and arms.10
Although it may be difficult to diagnose the early stages of leprosy
with confidence,the symptoms exhibited in the advanced stages of
lepromatous leprosy are unique and easily recognizable.The macules,
the horrible disfigurement of the face,the loss of fingers and ears,
and a lack of swelling in the legs allowed classical physicians to easily
distinguish lepromatous leprosy from other conditions,especially ele-
phantiasis.Leprosy was called elephantiasis graecorum and elephantiasis
was elephantiasis arabum.Differential diagnosis is further simplified
because elephantiasis is a tropical disease caused by infection from
filarial worms.The habitat of these parasitic nematodes extends only
as far north as Egypt.11 Therefore,when ancient writers describe the
spread of elephantiasis or elephas to Greece,Italy,or other locations
in the Mediterranean region,they can only be describing leprosy.
The skeletal pathology of leprosy is also distinctive.In the maxillary
alveolar process there is resorption of the prosthion followed by a
bilaterally symmetrical resorption of the alveolae around the maxillary
incisors,usually resulting in the loss of all front teeth (Fig.).The
nasal bones are absorbed and the nasal aperture remodeled,and holes
may form in the palate (Fig.),creating a wide and empty depression
where the nose once existed.This horribly disfigured facial anatomy
is referred to as facies leprosa.12
Pathologies of the hands,feet,and leg bones are also marked.
Diaphyseal remodeling takes place in the proximal phalanges and in
the metacarpals and metatarsals;it is bilateral but rarely symmetrical.
In the hands,the terminal phalanges erode down to points as a result
of concentric resorption,which results in a tapered appearance to
the fingers.This tapered shape is commonly compared in appearance
. A.Carmichael,“Leprosy,”inK.Kiple,ed., The Cambridge World History of Human
Disease (New York:Cambridge University Press, ),pp. –, p. ; M.Allison,
“Leishmaniasis,”inK.Kiple,ed., The Cambridge World History of Human Disease (New York:
Cambridge University Press, ),pp. –.
. T.Savitt,“Filariasis,”inK.Kiple,ed., The Cambridge World History of Human Disease
(New York:Cambridge University Press, ),pp. –.
. Ibid., p. .
. A.Aufderheide and C.Rodrı
´guez-Martin,The Cambridge Encyclopedia of Human
Paleopathology (New York:Cambr idge University Press, ),p. .
Journal of the History of Medicine :Vol. , July
Fig..Human skull exhibiting alveolar bone resorption,the loss of all front
teeth,and the remodeling of the nasal aperture (from the Anthropological Data-
base,University of Southern Denmark,Odense,with permission).
to a “licked candy stick” (Fig.).It is a process that usually works
its way gradually from the finger tip in,so that eventually the bones
may completely resorb,leaving only stumps in place of fingers.In
addition,the joints of the hands and feet may show various degrees
of arthritis,subluxation,and dislocation.Similar deformities appear
in the feet.13
In the long bones,periostitis with subperiosteal new bone deposits
is common.Such periostitis has been reported in % of cases.Fur-
thermore,leprosy typically modifies the tibia and fibula,producing
pitting and irregularities in the surfaces due to infection of the perios-
teum.This results in fine,longitudinally striated subperiosteal bone
deposits.In addition,the tibia shows vascular grooves on the lateral
surface,but the fibula is rarely involved to the same degree.14
. Ibid., pp. –.
. Ibid., p. .
Mark :Seafaring and the Spread of Leprosy
Fig..Perforation of the palate caused by leprous lesions (from the Anthropo-
logical Database,University of Southern Denmark,Odense,with permission).
Of those suffering from leprosy,diagnostic skeletal pathologies
will develop in –% of the cases.A review of the medical and
osteological data suggests that leprosy in its later stages is not only a
horribly disfiguring disease with unique symptoms,but,in areas
where skeletal preservation is good,those suffering from leprosy will
leave easily identifiable skeletal evidence.
was leprosy present in the mediterranean world
before 400 bce?
There are many advantages to studying the spread of disease in the
Mediterranean,including good bone preservation and long,rich
medical and artistic traditions from which to draw.Medical evidence
for leprosy from ancient Mediterranean sites,however,does not exist
until relatively late,which is significant considering that an Egyptian
medical tradition can be traced at least as far back as the beginning
of the Old Kingdom (ca. bce).Imhotep was one of the earliest
and one of the most famous physicians.He was held in such high
Journal of the History of Medicine :Vol. , July
Fig..Concentric resorption of the phalanges resulting in a tapered appearance
(from the Anthropological Database,University of Southern Denmark,Odense,
with permission).
esteem that he was deified as a god of medicine;the Greeks also
identified him with their god of medicine,Asclepius,and called him
Imouthes.15 Besides Imhotep,the names of other physicians survive
from the Old Kingdom.Furthermore,the great reputation that Egyp-
tian medicine and physicians enjoyed throughout the ancient world
is reflected in a number of texts.Niqmad,the king of Ugarit,wrote
to the Pharaoh Akhenaten (ca. – bce) and requested a
physician because he lacked a capable one.During the reign of Ramses
II (ca. – bce),Hattusili,the Hittite king,requested a physi-
cian to treat his sister’s sterility.16 This high regard for Egyptian physi-
. I.Shaw and P.Nicholson,The Dictionary of Ancient Egypt (London:Harry N.Abrams,
Inc., Publishers, ),pp. –; J.H.Breasted,A History of Egypt from the Earliest Times
to the Persian Conquest (New York:Charles Scribner’s Sons, ),pp. –.
. P.Ghalioungui,The Physicians of Pharaonic Egypt (Mainz Am Rhein:Verlag Philipp
Von Zabern, ),pp. , , , .
Mark :Seafaring and the Spread of Leprosy
cians and medical tradition continued even in later times.According
to Herodotus (ca. – bce),Darius,the king of the Persian
Empire,employed the best physicians of Egypt.17
Fortunately,these ancient physicians have left behind medical texts
describing various illnesses and treatments.Furthermore,hundreds
of mummies and skeletal material have survived,which have proven
to be an invaluable source of information on the health of ancient
Egyptians.18 However,in spite of this large and varied amount of
written and archeological evidence,no sign of leprosy can be firmly
established in ancient Egypt.The only possible reference is from the
Papyrus Ebers,a medical treatise dating to the sixteenth century bce.
Bendix Ebbell,the translator,proposed that one entry in this text
described leprosy.Although Grmek states that this interpretation is
“ingenious and bold,” he does concede that it has never been ac-
cepted.19 In fact,it was strongly criticized and implicitly rejected.
The diagnosis simply did not fit the symptoms.According to Ebbell’s
translation,the text states that:
If thou examinest Chons’ big swelling on any limb of a man,and it is
horrible when it has produced many swellings,and there arises in him
something therein as if there were air therein,and it causes destruction of
the swelling,and it is proclaimed in thy presence (i.e.it is as if its appearance
calls out to thee):it is not like those swellings (previously mentioned),and
it is motley-coloured and it produces carvings (?),and all limbs on which
it is are heavy,then thou shalt say concerning it:it is Chons’ swelling.Thou
shalt not do anything to it.20
Andersen disagrees with Ebbell’s interpretation,pointing out that
these symptoms conform to those of gas gangrene.Gas gangrene is
caused by a type of bacterium that produces gas and poisonous toxins
as they invade human tissue.In affected areas,there is a sensation of
heaviness followed by severe pain,due to the accumulation of gas or
. Herodotus,Herodoti Historiae,Scriptorum classicorum bibliotheca Oxoniensis,C.
Hude,com., vols.(Oxford:Oxford University Press, ),I,book , sect. –
[.–].
. See,for example,R.David and E.Tapp,Evidence Embalmed:Modern Medicine and the
Mummies of Ancient Egypt (Manchester:Manchester University Press, ),pp.–; M.
Bucaille,Mummies of the Pharaohs:Modern Medical Investigations (New York:St.Martin’s
Press, );Roberts and Manchester,Archaeology,pp. , , –, , .
. Grmek,Diseases,p. .
. B.Ebbell,The Papyrus Ebers:The Greatest Egyptian Medical Document (Copenhagen:
Levin & Munksgaard, ),p. .
Journal of the History of Medicine :Vol. , July
fluid.In about % of cases,these tissues produce crackling sounds
as a result of gas bubbles forming under the skin,and in many cases
it is possible to feel these bubbles.The swollen skin may also be
blistered and red before progressing to a bronze,brown,or black
color.The diagnosis of gas gangrene matches the Egyptian text much
better than leprosy does.21 Other than citing Ebbell,Grmek admits
“Without this evidence,there is no substantial sign of leprosy in
Pharaonic Egypt (– B.C.).Paleopathical research makes its
endemic presence most unlikely.”22
Although Grmek concedes a lack of evidence in Egypt,he does
argue that leprosy was known in Mesopotamia as early as the second
millennium bce. Yet his evidence consists only of translations by
Assyriologists,who have consistently translated the Akkadian terms
sahars
˘ubbu,is
˘rubu,and garabu as leprosy or a disease like leprosy.All
we know of this condition is that it “covers the whole body” and
those who are afflicted with it are banished and chased from the city
and are forced to live “like wild-assess.”23 Grmek hedges that this
“disease is not necessarily leprosy in the modern sense;the evidence
that exists is inadequate for a diagnosis.” He goes on to argue,however,
that key evidence to support such a proposition can be found in a
Babylonian omen text (VAT ).He cites the translation by Kinnier
Wilson,who writes “If the skin of a man exhibits white patches
(pusu) or is dotted with nodules (nuqdu),such a man has been rejected
by mankind.” Wilson interprets this passage as a description of the
tuberculoid and lepromatous forms of leprosy,but he also allows
that since the ancient Mesopotamians did not have a well-developed
nosology,“other diseases could be included in the ‘leprosy’ of the
past,notably pellagra.”24 Wilson understates the level of development
of Mesopotamian medicine.Not only did they lack a well-developed
nosology,but their idea of medicine was so intricately intertwined
with magic that even the names of their diseases usually reflect the
deity or demon that was thought to cause a condition.25 Another
. Andersen,“Studies,”pp.–, . On gas gangrene,see D.Olendorf,C.Jer yan,
K.Boyden,eds., The Gale Encyclopedia of Medicine,vols.(Detroit:Gale Research, ),
III, –.
. Grmek,Diseases,p. .
. Ibid., p. .
. Ibid., pp. –.
. A.Oppenheim,Ancient Mesopotamia (Chicago:University of Chicago Press, ),
p. .
Mark :Seafaring and the Spread of Leprosy
problem with Wilson’s interpretation is that leprous lesions are not
white.
Although this interpretation has been consistently rejected by le-
prologists as being too vague,Grmek is undaunted.26 He feels that a
careful review of the information about leprosy among the Hebrews
supports his interpretation because both the “Babylonian evidence
and the Biblical prescriptions have a common origin and elucidate
each other.”27
Until the s,it was commonly accepted that the Hebrew word
tsara’ath in the Book of Leviticus meant leprosy,but upon critical
review it became clear that it did not.Tsara’ath exhibits a number
of symptoms,the most common of which are “white spots,” “white
swellings,” or “bright white spots.”28 It is also commonly translated
as “white as snow,” but E.V.Hulse has pointed out that this last
translation is in error and should be translated only “as snow.”29 This
translation reflects two qualities of snow,its whiteness and that it falls.
Hulse,therefore,proposes that two symptoms of tsara’ath are the
turning white and flaking offof skin.He goes on to point out that
neither is a symptom of leprosy.Furthermore,the other symptoms
described in Leviticus do fit a number of different ailments,including
psoriasis,seborrhoeic dermatitis,favus,patchy eczema,and pityriasis
rosea.30
While agreeing that none of these minor skin diseases mirror
leprosy,Grmek tries to save his argument by postulating that
the authors of Leviticus are concerned only with [leprosy’s] initial,indeter-
minate stage.So,it is understandable that certain important signs of leprosy
have escaped their attention.If such a practical definition of tsara’ath also
includes some harmless skin diseases,isn’t this because it seemed preferable
to err in overestimating its severity rather than risk the consequences of
dangerous diseases?31
The main flaw with this line of reasoning is that nearly all of the
symptoms listed in Leviticus appear to be those of harmless skin
. Browne,History,p..
. Grmek,Diseases,pp. –.
. J.Moffatt,trans., The Old Testament,vols.(New York:George H.Doran Company,
)I, – [Leviticus XIII .–.].
. Ibid., pp.[Exodus .], [Numbers .], [II Kings .];Hulse,“Nature,”
p. .
. Hulse,“Nature,”pp. , –.
. Grmek,Diseases,p. .
Journal of the History of Medicine :Vol. , July
diseases.Although it is true that some symptoms of these diseases
have been confused with leprosy,Grmek fails to cite any symptoms
in Leviticus that are commonly confused with it.Furthermore,if the
purpose of this section of Leviticus was to list any possible symptoms
of leprosy in order to differentiate those suffering from this condition
from those suffering from other ailments,as Grmek suggests,then
conditions that are relatively easy to differentiate from leprosy should
not be included.Yet Leviticus states that “When a man or a woman
has a sore on the head or on the beard,[and] if it appears to go under
the skin,and if it has thin,yellow hairs,...it is ringworm,a
leprosy [tsara’ath] of the head or beard.”32 This description is consistent
with favus,which is a fungal infection that attacks hair and scalp and
that can spread,albeit rarely,to other parts of the body.33 It is also a
condition that is relatively easy to differentiate from leprosy.Therefore,
if the purpose of Leviticus was to protect against the spread of leprosy,
as Grmek contends,then this passage should not have been included.
Furthermore,if a person was suspected of suffering from tsara’ath,
he or she was typically quarantined for seven to fourteen days because
the diagnosis was sometimes confirmed by the rapid spread of the
condition;“on the seventh day ...,if the mark is unchanged in
colour and has not spread,then the priest must isolate him for seven
days more;on the seventh day ...if the eruption still spreads,the
priest must pronounce him unclean;it is a case of leprosy [tsara’ath].”34
This is a critical symptom because leprosy is a disease that typically
develops slowly over a long period,and any condition that spreads
as rapidly as described in Leviticus is unlikely to be leprosy.In effect,
these guidelines would be ineffective for limiting the spread of leprosy.
Grmek’s position is even more difficult to accept when we consider
that tsara’ath is a condition that also attacks clothing and buildings.35
These passages in Leviticus are not medical texts.Instead,they de-
scribe various types of ritual uncleanliness that afflict human skin,
cloth,leather,and the walls of dwellings.Because Grmek is aware
of the weakness of his arguments,he does try one last stratagem.
Grmek argues that “leprosy is the only chronic skin disease whose
. Moffatt,Old Testament,I, [Leviticus .–].
. Hulse,“Nature,”pp. , .
. Moffatt,Old Testament,I, – [Leviticus XIII,–].
. Ibid., pp. – [Leviticus .–].
Mark :Seafaring and the Spread of Leprosy
seriousness justifies the social remedies of the Biblical legislation.”36
In other words,leprosy would be the only condition justifying banish-
ment.This opinion is all that really connects the Hebrew texts with
the Mesopotamian ones.However,his argument lacks merit simply
because it is impossible to make such a value judgment about beliefs
and attitudes that existed more than years ago.For example,
according to Deuteronomy .–, if parents charge that their son
“is a stubborn and rebellious fellow who will not obey our orders;
he is a spendthrift and a drunkard,” and then “all his fellow citizens
shall stone him to death.”37 Similarly,if a husband were to discover
that his bride was not a virgin on their wedding night and no evidence
indicated she was a virgin before the wedding,Deuteronomy .–
states “she shall be taken to the door of her father’s house and stoned
to death.”38 Most people would agree that the seriousness of these
acts does not justify such social remedies,but neither does it justify
our assuming that we do not fully understand the behavior leading
to the remedy.
The only other texts written before Alexander’s time that may
shed light on this question make up the Hippocratic Corpus,which
is a collection of medical texts,most of which are believed to have
been written between and bce.39 Many scholars who translate
these works typically assume,with little critical evaluation,that leprosy
equates with the Greek word lepra.40 A review of the texts clearly
shows that this is not so.Instead,the Hippocratic descriptions of lepra
indicate that it refers to a scaling of the skin,possibly psoriasis or a
fungal infection,both of which are similar to the descriptions in
Leviticus.Even Grmek agrees that the descriptions of lepra “suggest
relatively benign skin ailments.”41 The reason for the confusion among
classical translators is due in part to a lack of medical training among
them and to the evolution of the classical word lepra into the modern
. Grmek,Diseases,p. .
. Moffatt,Old Testament,I, .
. Ibid., p. .
. M.C.Howatson,The Oxford Companion to Classical Literature (New York:Oxford
University Press, ),p. .
. See,for example,J.Chadwick and W.N.Mann,The Medical Works of Hippocrates
(New York:Penguin Books, ),p. [Aphorisms .];W.D.Smith,trans., Hippocrates,
vols.(Cambridge,Mass.: Harvard University Press, ),VII,[Epidemics ..].
. Grmek,Diseases,p. .
Journal of the History of Medicine :Vol. , July
word “leprosy.” Therefore,the skin condition ancient Greeks called
lepra was usually just assumed by scholars to be true leprosy without
evaluating the information in the texts.
Although Grmek agrees that lepra does not equate with leprosy,
he does believe leprosy is still mentioned in these texts.He cites
Galen,who proposed that the condition called “Phoenicians disease”
in the Hippocratic texts was leprosy.While Grmek does concede
that Galen is making a guess that cannot be proven,he still believes that
it is the most plausible explanation.42 A guess is the best description of
Galen’s interpretation,because the only mention in the Corpus of
this illness is that it is thought to be “one of the most deadly diseases.”43
Galen’s interpretation has not been accepted by scholars primarily
because no symptoms of the condition are listed.Furthermore,leprosy
is a slow,progressive,and chronic disease that most sufferers live with
for years,and there is no evidence to suggest otherwise for ancient
times.Leprosy simply does not fall within the definition of a deadly
disease,which is probably another reason so few scholars ever cite
this passage.As early as , the leprologist James Doull pointed
out that “Hippocrates makes no mention of the disease.”44
Finally,anyone who has read these works cannot help but notice
that these early Greek physicians had a keen interest in all types of
conditions,from common ailments like colds to more deadly illnesses
like tuberculosis,which is described in some detail.45 It therefore
seems inconceivable that these early physicians would ignore a disease
with such a wide range of distinctive symptoms.Even the ancients
found this odd.Rufus of Ephesus (early second century ce) points
out that “the ancients knew nothing of elephantiasis,and we must
wonder that men capable of contemplating everything in the tiniest
detail missed such a serious and common disease.”46 Furthermore,in
Plutarch’s Quaestiones conviviales,a question that is pondered is whether
it is possible for a new disease to appear suddenly.Although the
. Ibid., p. .
. P.Potter,trans., Hippocrates,vols,in Greek and English (Cambridge,Mass.: Harvard
University Press, ),VIII, [Prorrhetic II.] [passage trans.by author].
. J.Doull,“Salient Features in the Epidemiology of Leprosy,”inF.Moulton,ed.,
Tuberculosis and Leprosy:the Mycobacter ial Diseases (Lancaster,Penn.: The Science Press Printing
Company, ), –, p. .
. Aufderheide and Rodrı
´guez-Martin,Cambridge Encyclopedia,p. .
. Oribasius,Collectio medica,C.Bussemaker and C.Daremberg,eds.and trans., vols.
(Paris:A l’Imprimerie nationale, ),IV,[trans.by author].
Mark :Seafaring and the Spread of Leprosy
participants in the discussion find it difficult to accept that leprosy
could have just appeared so late,“they thought it would be no less
amazing if such striking symptoms had escaped notice for so long.”47
Even Grmek is impelled to address this issue by stating that it was
“scarcely known in Greece but apparently thought common among
the Phoenicians.” He goes on to say that “It was only an exotic
disease limited to eastern lands or sporadically arriving in Greece
from them.”48
For this to be a practical consideration,Greece would have to
have been relatively isolated from these eastern lands.However,the
evidence suggests otherwise.A permanent Greek trading colony was
established at the Phoenician site of Al Mina in Phoenicia as early
as bce.49 Even Homer (ca. bce) commonly mentions Phoe-
nicians in the Odyssey to the extent that Odysseus goes on a trading
voyage with a Phoenician,and he tells a sheep herder he was brought
back to Ithaca on a Phoenician ship.Furthermore,Homer points
out that even when Phoenicians are asked to make haste while trading,
they spend a full year in one foreign port before sailing on,and while
in port,they sell their wares door to door.50 So even as early as the
middle of the eighth century bce there was considerable interaction
among Greeks and Phoenicians.Finally,The Histories by Herodotus
is,to a large extent,a travel book describing in detail the various
peoples living in the lands to the East,and he never mentions leprosy
or any ailment that could be confused with it.In fact,all of the
textual and archaeological evidence seems to indicate that contact
was close between Greece and the East long before the Classical
period,and these contacts only continued to intensify as time passed.
Therefore,if leprosy was in fact Phoenicians disease and was a com-
mon ailment of Phoenicians,it should have spread to Greece long
before the writing of the Hippocratic Corpus.
Thucydides best illustrates how close these contacts were in the
. Plutarch,Plutarch’s Moralia,Loeb Classical Library,E.H.War mington,ed., E.L.
Minar,Jr., F.H.Sandbach,and W.C.Helmbold,trans., vols.(Cambridge,Mass.: Harvard
University Press, ),IX, [...B].
. Grmek,Diseases,p. , .
. J.Boardman,The Greeks Overseas (London:Thames and Hudson, ),p. .
. See Homer,Homeri Opera,Odysseae,Scriptorum classicorum bibliotheca Oxoniensis,
T.W.Allen,com., vols.(Oxford:Oxford University Press, ),IV,book , line
and book , lines – [Od. .; Od. .–];Odysseae,IV,book , lines
and lines – [Od. .; Od. .–].
Journal of the History of Medicine :Vol. , July
eastern Mediterranean by describing the spread of a contagious disease
that broke out in Athens in bce. He states that it was thought
to have begun “beyond Egypt in Ethiopia and then spread into Egypt
and Libya,and into most of the King’s land [Persian Empire].It then
suddenly struck Athens,first affecting the people of Piraeus.”51 Piraeus
was the port of Athens,and it is through this port that we would
expect diseases brought by ship to arrive.Therefore,considering that
the economies of the eastern Mediterranean were relatively tightly
integrated via sea trade and considering that much of ancient Greece’s
economy was based on sea trade,Grmek’s assertion that distance
would have protected Greece from leprosy is without foundation.
It should also be noted that by the first century ce Aretaeus of
Cappadocia had written a relatively detailed description of leprosy,
and from this time onward leprosy is typically described in medical
texts.52 However,from long before the time of the Hippocratic Corpus
to that of Aretaeus,there were no medical advances that would allow
for a more effective diagnosis of this disease.If it had gone virtually
unnoticed for centuries,what took place at this time that would
explain why leprosy suddenly became so easy to detect? Quite simply,
the evidence suggests that leprosy did not exist in the Mediterranean
region before the fourth century bce,and the four centuries from
when it was first described to the time of Aretaeus is consistent with
the time necessary for it to have spread,been observed,and described
in relative detail.
Besides medical evidence,scholars have also looked for evidence of
leprosy in artistic representations.Grmek reviews the various artifacts
cited as evidence for leprosy from sites across the eastern Mediterra-
nean,but he rejects all examples except for a clay anthropomorphic
jar from Bet She’an in Israel that dates to about bce. According
to Grmek,it “shows features resembling facies leontina and strongly
suggests a diagnosis of lepromatous leprosy.”53 However,his interpreta-
tion is unconvincing because he ignores earlier studies of this same
piece,all of which agree that this face does not represent an individual
with leprosy;instead,it is probably an Egyptian dwarf god,possibly
. Thucydides,Hitoriae,Scriptorum classicorum bibliotheca Oxoniensis,H.S.Jones and
J.E.Powell,eds.,vols.(Oxford:Oxford University Press, ),I,book , sect.[.]
[trans.by author].
. K.Hude,ed., Corpus Medicorum Graecorum II,nd ed.(Berlin: ),pp.– [.].
. Grmek,Diseases,p. .
Mark :Seafaring and the Spread of Leprosy
Bes or Ptah-Seker-Osiris.54 Grmek was undoubtedly aware of these
studies because he extensively cites an article by E.V.Hulse,who
discusses this piece in detail.55 In contrast,artistic portrayals of individ-
uals suffering from various diseases do exist;the earliest artistic repre-
sentation of an individual with tuberculosis dates to the predynastic
period of Egypt (before bce).56 Therefore,no known artistic
representations portraying leprosy exist.
Although Grmek fails to show that leprosy existed in the Mediterra-
nean region before the time of Alexander,his work has merit in that
he marshals every shred of evidence that he can find and presents it
in the most favorable light,but he is still unable to present a credible
argument for its appearance before the time of Alexander.The failure
of his argument therefore underscores the paucity of evidence for
leprosy in this region before the fourth century bce.
leprosy in ancient india
Andersen clearly presents stronger evidence that seems to suggest
Alexander was responsible for the spread of this disease from India.
The earliest evidence for leprosy comes from India and is found in
a medical text entitled The Sushruta Samhita,which dates to as early
as bce.57 In this work leprosy or kushtham has a number of
different forms.The most basic form,aruna-kushtha,is described as
being “slightly vermilion-coloured,thin and spreading in its nature.
A sort of pricking,piercing pain [is experienced in the affected
locality] which loses all sensibility to the touch.”58 This description
is consistent with a mild tuberculoid form.The most extreme form
exhibits a “contraction of the skin,local anesthesia,a copious flow
of perspiration,swelling,and piercing or cutting pain in the affected
part,together with a deformity of the limbs and hoarseness.” Other
symptoms include “breaking of the local skin ...falling offof fingers
. A.Rowe,The Four Canaanite Temples of Beth-Shan,Part I,The Temples and Cult Objects,
(Philadelphia:University of Pennsylvania Press, ),pp. , , pl.A:,;R.G.
Cochrane and T.F.Davey,Leprosy in Theory and Practice (Bristol:John Wright and Sons,
)p.;Browne,“History,”p.;Hulse,“Nature,”p. .
. Hulse,“Nature,”p. .
. Roberts and Manchester,Archaeology,pp. –.
. Andersen,“Studies”;Dharmendra,“Leprosy in Ancient Indian Medicine,”Int.J.
Lepr., , , –, p. .
. K.K.Bhishagratna,trans.and ed., The Sushruta Samhita,vols.(Varanasi,India:
Chowkhamba Sanskrit Series Office, ),II,–.
Journal of the History of Medicine :Vol. , July
...sinking of the nose and ears” and “redness of the eyes.”59 This is
the lepromatous form.The detail of description and categorization
of the disease into various forms suggests it was fairly common in
India and had been under observation for a considerable period before
this text was written.
The possibility that leprosy was widespread in India finds further
support in the Arthasastra by Kautilya.This work,which is dated
between and bce,is a manual on the art of government that
was intended as a guide for kings and for maintaining the earth.60
According to the text,“if unwilling,the man (husband) may not
approach a (wife) who is leprous or insane.A woman,however,shall
approach a (husband) even of this type,for bearing a son.”61 In regard
to inheritance,“An outcast,a son born to an outcast and an impotent
person are not entitled to a share,also an idiot,a lunatic,a blind and
a leprous person.” In regard to giving evidence,“The king,a Brahmin
learned in the Vedas,a village servant,a leper ...[shall not be cited
as witnesses] except in the case of their own groups.” This text also
covers fines for the vilification of a person in relation to a serious
malady such as “referring to leprosy,madness,impotence and so on,
when it is true,false and contains ironical praise.” Finally,knowledge
of leprosy had even been integrated into magical lore.To harm
someone,“Application all over the body of the bile and the liquid
of the egg of a parrot is a means of causing leprosy,” and for a cure
a “decoction of the pulp of priyala is a remedy for leprosy.”62 The
fact that social guidelines concerning lepers were so well developed
and codified and the evidence that lepers constituted a legally defined
group suggest that leprosy had been pervasive in India for a long
time.
The explicit descriptions of leprosy in India,dating to bce,
in conjunction with a lack of persuasive evidence for leprosy in
Egypt,Mesopotamia,and Persia before the time of Alexander,support
Andersen’s contention.The only new evidence that has come to
light since he published his work,as previously mentioned,has been
the discovery of osteological evidence of leprosy in Egypt,dating to
. Ibid., p. .
. R.N.Saletore,Encyclopedia of Indian Culture,vols.(Atlantic Highlands,New Jersey:
Humanities Press,Inc., ),I, –.
. R.P.Kangle,trans., The Kautiliya Artjasastra (Delhi:Motilal Banarsidass, ),p.
[..].
. Ibid., pp. [..], – [..–], [..], [..], [..].
Mark :Seafaring and the Spread of Leprosy
about bce. This pushes the osteological evidence to roughly a
century after Alexander’s time.To argue that earlier osteological
evidence has not survived is unconvincing when we consider that
such evidence for tuberculosis is found in Italy and Egypt from as
early as the fourth millennium bce.63 Therefore,Andersen is probably
correct that leprosy moved from India to the Mediterranean countries
about the time of Alexander.But I disagree about how it traveled.
did alexander’s army bring leprosy home from india?
It seems unlikely that leprosy traveled with Alexander’s troops.In the
first place,Alexander was not the first to invade India.The Persian
king Darius undertook a similar expedition in bce. Moreover,
Indian troops fought for Darius’s son,Xerxes,during the invasion of
Greece in bce and for Darius III against Alexander’s army in
bce.64 How then can we reconcile the possibility that Alexander’s
troops were infected during a campaign lasting less than two years
when Indian troops failed to spread this same disease while serving
in Persian armies from Mesopotamia to Greece for well over a century?
If an army was able to acquire and spread leprosy so easily,then
leprosy should have spread throughout the eastern Mediterranean far
earlier than suggested by the evidence.In fact,neither army was a
likely carrier because it is difficult for adults to contract this disease.
Leprosy is a chronic infectious disease,which is also highly infec-
tious.However,T-cell–mediated immunity protects more than
percent of a population from it.65 Therefore,only about percent
of an invading army would be susceptible to leprosy.Furthermore,
the susceptibility of soldiers to leprosy was even lower because adults
between the ages of twenty and forty appear to be comparatively
immune to leprosy.This is suggested by the rarity of infection among
adult volunteers and by an infection rate of only percent for spouses
of lepers,even after years of sexual relations.In contrast,percent
of children living in a family with an infected member develop the
disease as children or young adults.66 An army therefore appears to
be an unlikely vehicle for the spread of this disease.Although there
. Aufderheide and Rodrı
´guez-Martin,Cambridge Encyclopedia,p. .
. Herodotus,Herodoti Historiae,I,book , sect. ; II,book , sect. , ; Arrian,
Anabasis,Loeb Classical Library,G.P.Goold,ed., P.A.Brunt,trans., vols.(Cambridge,
Mass.: Harvard University Press ),I, [..–].
. Bhutani et al., “Leprosy,”pp. –.
. Jopling and McDougall,Handbook,p.;Grange,Mycobacteria,p. .
Journal of the History of Medicine :Vol. , July
were some children among the camp followers of Alexander’s army,
most were killed in a flash flood that washed over their camp,and
any survivors had to endure the subsequent trek through the desert
that killed so many of Alexander’s soldiers.67
Furthermore,people from the Mediterranean may have had an
additional immunity to leprosy due to the prevalence of tuberculosis
in this region.There appears to be some cross-immunity between
the two diseases with tuberculosis taking precedence,making it even
more difficult for leprosy to infect Mediterranean populations.68 The
evidence suggests that tuberculosis first appeared in the Mediterranean
region during the Neolithic period,and a description of this disease
in the Hippocratic Corpus indicates it was still common in Alexander’s
time.69
Finally,if Alexander’s army was responsible for the spread of leprosy,
we would expect Persian and Mesopotamian populations to be in-
fected first because these are the countries to which his army returned
after the Indian campaign.Shortly thereafter,troops returning to
Macedonia and Greece would have spread the disease to these popula-
tions.Leprosy should therefore have appeared in Persia,Mesopotamia,
Macedonia,and Greece at roughly the same time.
Yet the ancient texts suggest that leprosy originated in Egypt.
According to Rufus of Ephesus,it was “Straton,the disciple of
Erasistratus,who gave us the basic knowledge of this disease (elephan-
tiasis),which he called cacochymia.”70 Straton lived in Alexandria
around bce. Furthermore,the fact that he calls leprosy caco-
chymiaa general term for any illnessinstead of elephantiasis or
elephas suggests that a specific medical term for leprosy did not yet
exist and that it was previously unknown to these ancient physicians.
Rufus then goes on to describe some of the symptoms of elephantiasis,
which in the early stages was called “leontiasis because patients give
offa bad odor,their cheeks collapse,and their lips thicken.” In later
stages it was called elephantiasis,and the symptoms “consist of livid
and black raised areas,especially resembling bruises;some are located
on the face,others on the arms,and still others on the legs.It also
spread to the back,chest,and stomach.At first these raised areas
. Arrian Anabasis,II, , – [..–,..–].
. Jopling and McDougall,Handbook,p. ; Grange,Mycobacteria,p. .
. Aufderheide and Rodrı
´guez-Martin,Cambridge Encyclopedia,pp.–.
. Oribasius,Collectio medica,IV,[trans.by author].
Mark :Seafaring and the Spread of Leprosy
were not ulcerated,but later they ulcerate in the most hideous manner.
This ulceration was accompanied by the swelling of the lips,bya
decay so extensive that sometimes the ends of the fingers fall off, and
the ulcers never completely heal.”71 As previously mentioned,the
earliest osteological evidence for leprosy dates to about bce,
and these remains were recovered from the Dakleh Oasis in Egypt.
Furthermore,according to Plutarch,“both elephantiasis and hydro-
phobia first made their appearance [in Greece] in the time of Asclepi-
ades.” Asclepiades of Bithynia was a physician who lived around
bce.72 Yet even by the time of Celsus,who lived during the reign
of Tiberius (ce –),“elephantiasis whilst almost unknown in Italy,
is of very frequent occurrence in certain regions.”73 Finally,according
to Pliny (ce –),“elephantiasis did not occur in Italy before the
time of Pompeius Magnus” (– bce),and it “is native to Egypt.”74
The first quotation by Pliny appears to be the only evidence to support
Andersen’s supposition that Pompey’s army brought leprosy to Italy
after his campaign against Mithridates of Pontus in bce. However,
there is nothing in the text to suggest Pompey was in any way
responsible.Instead,it seems likely that Pliny,who was a military
man,was dating the appearance of this disease by alluding to an
important historical event.
The ancient sources indicate that Egypt was thought to be the
original source of leprosy and suggest that it spread very slowly
throughout the Mediterranean.Approximately two centuries passed
before it spread from Egypt to Greece and another forty or fifty years
before it reached Italy,but even by the time of Tiberius it was still
rare.In contrast,no evidence exists to suggest leprosy had infected
the populations of either Persia or Mesopotamia.The only evidence
we do have is the possible mention of leprosy in passages of the
Vendidad and other Avestan books (Persian texts, – bce),but
its identification is uncertain because the disease is never described.75
. Ibid., IV,– [trans.by author].
. Plutarch,Plutarch’s Moralia,IX, .
. Celsus,De medicina,Loeb Classical Library,T.E.Page,E.Capps,L.A.Post,W.H.
D.Rouse,and E.H.Warmington,eds., W.G.Spencer,tran., vols.(Cambridge,Mass.:
Harvard University Press, ),I, – [..–].
. Pliny,Natural History,Loeb Classical Library,G.P.Goold,ed,. W.H.S.Jones,trans.,
vols.(Cambridge,Mass.: Harvard University Press, ),VII, – [..–].
. P.Prioreschi,A History of Medicine:Primitive and Ancient Medicine,vols.(Lampeter,
Dyfed,Wales:The Edwin Mellen Press Ltd., ),I, .
Journal of the History of Medicine :Vol. , July
Leprosy did not travel to the Mediterranean via Alexander’s army:The
mechanism for transmission was too weak,and the first appearance of
the disease in Egypt points to another source.
leprosy traveled to ancient egypt
in cargo ships from india
If Alexander and his men were not responsible for the spread of
leprosy,then the most likely culprits were the seafarers who were
taking advantage of the burgeoning trade that resulted from the
formation of the Ptolemaic and Selucid empires.Many cities grew
wealthy during the Hellenistic period.They include Seleucia-on-
the-Tigris,Antioch,Rhodes,Ephesus,Alexandria,Corinth,and De-
los,most of which were connected by sea.76 It was also at this time that
we see direct evidence for trade between India and Egypt.Ptolemy
Philadelphus (– bce) imported women,spices,zebus (Indian
cows),and dogs,while Ptolemy Philopater (ca. – bce) im-
ported marble for columns.77 Trade between Egypt and India was
carried out by Arabian seafarers who would offload Indian cargoes
and pick up Egyptian cargoes at the port of Aden,which is located
on the southwestern corner of Arabia.Cargoes would then be sent
by caravan to northern Arabia and trans-shipped to Egypt or would
be carried directly to Egypt by sea.78 Ptolemy Philadelphus may have
founded the two port cities of Myos Hormos and Berenice on the
Red Sea coast to take advantage of this expanding trade.79 Women,
cattle,and marble were cargoes most efficiently shipped by sea.Marble
for columns would be too heavy and bulky to move by land,while
large numbers of humans and animals would be difficult to feed and
water on a long trek through the deserts of Arabia.What is most
important is that at about the same time Straton describes the earliest
case of leprosy in the Mediterranean region,slaves were being im-
ported into Egypt from India.
Young women were probably in the greatest demand,possibly
followed by children of both sexes.A child in India could be sold
. W.W.Ta r n ,Hellenistic Civilization (New York:New American Library, ),p. .
. Athenaeus,Deipnosophistae,Bibliotheca scriptorum Graecorum et Romanorum Teu-
bneriana,vols.(Stuttgart:B.G.Teubner, ),I, –, p. .
. G.F.Hourani,Arab Seafaring (Princeton,N.J.: Princeton University Press, ),p.
.
. Pliny,Natural History,II, – [.];Strabo Strabonis Geographica,A.Meineke,
ed.,vols.(Graz,Austria:Akademische Druck-u.Verlagsanstalt, ),III, [.].
Mark :Seafaring and the Spread of Leprosy
for export as early as the age of eight,and females attained marriage-
able age at twelve.80 Both groups are highly susceptible to leprosy,
and they were effective carriers of the disease to others.Furthermore,
the conditions aboard ship during a long voyage from India to Egypt
would be ideal for its spread.Leprosy bacilli appear to spread princi-
pally by discharge from the nose,but it may also be possible to inhale
the bacilli.Nasal secretions remain viable for up to a week and in
humid environments like the hold of a ship for up to ten days.81 In
addition,the close confines of a ship,the tendency to huddle together
at night to stay warm,and the sharing of communal meals would all
facilitate the spread of this disease.
The possibility of ships being efficient incubators is reflected in
the variation of incidence for leprosy.One of the odd characteristics
of leprosy is its increased prevalence near seacoasts and on islands,
which led medieval and early-modern theorists to propose that a diet
consisting of fish was a cause of leprosy.82 Therefore,a connection
between seafaring and the spread of leprosy does appear to exist.
Furthermore,if a person wanted protection,a stone engraved with
the design of a ship was worn on the ring finger of the left hand.83
Another important factor allowing the spread of leprosy is its
incubation period,which can last from six months to ten years,with
an average period of three to five years before symptoms appear.Even
the early stages of the lepromatous form are insidious,which made
it difficult to distinguish this form from other nonspecific skin erup-
tions.84 This allowed leprosy to spread more easily.Therefore,an
individual could contract the disease,be shipped to Egypt,and be
part of a household for several years before symptoms started to
appear.Furthermore,because a person’s reaction to leprosy and the
incubation period can vary considerably,it was possible that an in-
fected individual could manifest symptoms before the original carrier
did.Under these conditions,it would be difficult to determine the
source of leprosy.
Unfortunately,we do not have any exact numbers for the importa-
tion of Indian slaves to Egypt,but this trade does have a long history.
. See Kangle,The Kautiliya,pp. [..], [..].
. Grange,Mycobacteria,p. .
. Carmichael,“Leprosy,”p. .
. M.W.Dols,“Leprosy in Medieval Arabic Medicine,”J.Hist.Med.All.Sci., ,
, –, p. .
. Grange,Mycobacteria,pp. , –.
Journal of the History of Medicine :Vol. , July
One of the earliest Egyptian records describes the importation of a
slave from Punt or present-day Somalia by one of the sons of King
Khufu (ca. bce).85 These slaves worked in the fields,in food
production,the military,and as domestic servants.86 During the Ptol-
emaic period,when Egypt was being ruled by the Ptolemies who
were of Greek extraction,the view of slavery changed.Slaves were
used primarily in household service,and since concubinage was com-
mon,female slaves were prized.87 Slaves in these positions would have
close contact with their master’s family,making it relatively easy to
infect a large number of people.Furthermore,in Greek Ptolemaic
society,ownership of slaves was not based on class but on one’s
financial status.Therefore,such slaves would have been owned by
the king at one end of the social spectrum as well as by any commoner
who could afford one.
Again,there are no exact numbers for the size of the slave popula-
tion during this period.However,commercial relations continued
to grow,until by the first half of the first century ce,India was one
of Rome’s largest trading partners,with Egyptian traders living in
India and Indian traders in Egypt.Moreover,Augustus received many
embassies from India,and at about this same time,Indians were a
common sight in Alexandria,allowing leprosy to be spread by visitors
and businessmen.88
Even if the numbers of slaves were modest,it would not take a
large number of them to spread this disease given their intimate place
in the household.Furthermore,it is possible that imported Indian
slaves may have had a higher rate of leprosy than the general Indian
population.As previously mentioned,the various forms of leprosy
were well understood in India by bce,and laws were instituted
to protect slave owners.These laws included fines for selling slaves
. Breasted,Ancient Records,I, .
. J.P.Rodr iguez,The Historical Encyclopedia of World Slavery vols.(Santa Barbara,
California:ABC-CLIO, ),I, –.
. W.L.Westermann,Upon Slavery in Ptolemaic Egypt (New York:Columbia University
Press, ),p. .
. H.Bell,“Egypt Under the Early Principate,”inS.Cook,F.Adcock,M.Charlesworth,
eds., The Cambridge Ancient History X,The Augustan Empire
b.c.–a.d.
.(Cambridge:
Cambridge University Press, ),pp. –, ; F.Oertel,“The Economic Life of
the Empire,”inS.Cook,F.Adcock,M.Charlesworth,and N.Baynes,eds., The Cambridge
Ancient History XII,The Imperial Crisis and Recovery
ce
–.(Cambridge:Cambridge
University Press, ),pp. –, .
Mark :Seafaring and the Spread of Leprosy
with preexisting conditions.89 Therefore,if a slave was exhibiting
early symptoms of leprosy,a way to recoup an investment would be
to export an infected individual to a foreign land where the disease
was unknown.Leprosy was also typically thought to be a hereditary
disease before modern times,possibly because it is common for
children living in a family with an infected member to develop it.
Under these circumstances,a slave owner may have sold the children
of a leprous slave even though they did not exhibit any symptoms.
Although there is no direct evidence that this practice did take place,
the fact that laws were instituted in India to protect slave buyers from
unscrupulous sellers suggests such practices were not uncommon.
Furthermore,we see similar parallels in other places and other times.
Maliki law,one of the four Sunni schools of law,guarantees a slave
buyer a period of three days to return a slave if he detects any faults.
In the case of leprosy,this guarantee is extended to a year.Even with
guarantees in place,a buyer was still forced to be vigilant because
leprous sores were sometimes concealed.90 Therefore,it is well within
the realm of possibility that Indian slave owners were knowingly
shipping out leprous slaves.
Finally,if we accept the premise that leprosy originated in the East
and came to Egypt via seaborne trade,it may allow us to understand
how leprosy spread to sub-Saharan Africa.The origin of leprosy is
sometimes attributed to Africa,possibly as early as Pleistocene times.
From there,it is thought to have spread to other lands.91 The problem
with this theory is a lack of any osteological or textual evidence to
suggest when leprosy first appeared Africa.Furthermore,if leprosy
did originate in Africa,especially at such an early time,we would
expect to see it appear relatively quickly in Egypt and then throughout
the Mediterranean region instead of first appearing in India.Direct
sea trade between Egypt and sub-Saharan Africa begins at the begin-
ning of the third millennium bce. As previously mentioned,the first
description of a slave being imported to Egypt from East Africa dates
to about bce. Such voyages from Egypt were undoubtedly
. Kangle,The Kautiliya,p. [..].
. M.Dols,“Diseases of the Islamic World,”inK.F.Kiple,ed,The Cambridge World
History of Human Disease (New York:Cambridge University Press, ),pp. –,
–.
. Aufderheide and Rodrı
´guez-Martin,Cambridge Encyclopedia,p. , .
Journal of the History of Medicine :Vol. , July
arduous but probably fairly common,especially considering how
often they are mentioned throughout the history of ancient Egypt.92
Furthermore,in a Theban tomb dating to about bce,there is
a scene recording the voyage of a vessel from Punt carrying cargo to
Egypt,suggesting direct trading voyages were initiated from both
locations.93 Moreover,Egypt is an integral part of Africa.If leprosy
was endemic to Africa as early as the Pleistocene,as has been proposed,
then it should have appeared very early in Egypt and northern Africa.
However,as the earliest evidence for leprosy comes from the East,
it seems likely that it spread to sub-Saharan Africa in the same way
that it spread to Egypt,via sea trade.After offloading cargo at the
Port of Aden for transit to Egypt,ships would then continue trading
down the coast of Africa possibly as far south as what is today central
Tanzania.From here they would catch the eastern winds to sail
home.94 Therefore,leprosy probably spread at about the same time
and in the same way to East Africa as it did to Egypt.Although we
lack evidence for this scenario,it seems a more likely one than having
it originating in Africa,spreading to India,back to Egypt,and then
to the eastern Mediterranean region.
Invading armies undoubtedly spread diseases far and wide during
ancient times.Ye t ,we should not be complacent and automatically
accept such a notion for every disease before evaluating the evidence.
Alexander’s troops were unlikely to have contracted leprosy because
of age and a cross-immunity with tuberculosis.Furthermore,Indian
troops served in Persian armies for more than a century and still
failed to spread leprosy to the West.It is therefore improbable that
Alexander’s men would do so after less than two years in India.In
contrast,leprosy appeared in Egypt at a time when slaves were being
carried on small ships from India to Egypt,and it spreads most
easily among children and young adults,a group not represented in
Alexander’s army but common among slaves.Furthermore,its spread
among slaves would be facilitated by a long confinement in the damp
hold of a small ship.Once arriving in Egypt,slaves could easily infect
the children and young adults in the households they served.The
. Breasted,Ancient Records,I, , , , , , , ; II, –, , ,
; III, , , ; IV, .
. T.Sa
¨ve-So
¨derbergh,The Navy of the Eighteenth Egyptian Dynasty (Leipzig:Otto Harras-
sowitz, ),p. .
. L.Casson,The Periplus Maris Erythraei (Princeton,N.J.: Princeton University Press,
),pp.–.
Mark :Seafaring and the Spread of Leprosy
spread of leprosy in Egypt would be facilitated by a difficulty of
differentiating it from other diseases and by its long incubation period.
If Alexander’s men had brought it back from India,we would expect
to see leprosy appear in Persia,Mesopotamia,Egypt,and Greece at
about the same time as his troops returned home,but ancient texts
state that leprosy was native to Egypt and from there it slowly spread
north and west.The description of the pattern in which leprosy
appears and slowly spreads throughout the eastern Mediterranean,in
conjunction with its slow appearance in the medical texts is consistent
for leprosy suddenly appearing and spreading from Egypt in the fourth
century bce. Finally,higher rates of leprosy have been associated
with coastal sites and islands.In fact,all of the evidence suggests that
the most likely scenario for the spread of this condition was that it
was brought to Egypt on countless small ships and,in this same
manner,slowly spread throughout the Mediterranean region.
