What disease could have caused the “Plague of the Philistines”?

The term “plague” is used in the Bible for highly contagious diseases that can spread quickly, reach epidemic proportions and be fatal. The Hebrew word for plague (dēver) comes from a root word meaning “to destroy” or exterminate, (2 Chronicles 22:10) and is translated in English literature to: pestilence, plague, murrain, cattle disease and cattle-plaque [1]. The law God gave the Israelites generally served to protect them from disease, both because of the high moral standards and the good hygiene regulations it contained. If they did not keep his laws and regulations, they would contract diseases, including plague and “all the plagues of Egypt”. Plague is often associated with God executing a judgment against the Israelites or their enemies. Numbers 14:12 says: “I will strike them down with a plague (pestilence; ESV) and destroy them”; Leviticus 26:25 says: “I will send a plague among you”.

In some cases, the Bible only says that the Israelites or other peoples were struck with plague without describing any symptoms. In those cases, we have nothing to base a more specific diagnosis on. In other cases, symptoms are described in which we can assess according to specific diseases. Leviticus 26:14-16 says: “But if you will not listen to me and carry out all these commands, and if you reject my decrees and abhor my laws and fail to carry out all my commands and so violate my covenant, then I will do this to you: I will bring you sudden terror, wasting diseases (tubercolosis; NV) and fever that will destroy your sight and sap your strength”.

Deuteronomy 28:21,22 says: “The Lord will plague you with diseases (pestilence; ESV) until he has destroyed you from the land you are entering to possess. The Lord will strike you with wasting disease (tubercolosis; NV), with fever and inflammation, with scorching heat and drought, with blight and mildew, which will plague you until you perish”.

Through the centuries and right up to our time, the Bible’s descriptions of plague and leprosy, among other, have been the subject of speculation regarding diagnoses. A well-known and much talked about and discussed story is the “plague of the Philistines” which is described in 1 Samuel, chapters 5 and 6, where God strikes the Philistines with plague.

The Philistines were an uncircumcised, polytheistic people who lived along the coastal strip of the Mediterranean from Gaza in the south to Joppa in the north. They probably came from Crete and lived in the area already in the time of the patriarch Abraham. They were enemies of the Israelites and they fought eachother in several battles. The account of “the plague of the Philistines” takes place in the Time of the Judges, i.e. around 1050 BC [2]. The Philistines invaded the lands of Israel and completely defeated them in two battles. After the first battle, the Ark of the Covenant, also known as the Ark of God, was brought to the camp of the Israelites. The Philistines crushed them in a battle in which 30,000 Israelites were killed, and the Philistines took the ark with them to their own land. It was placed in Ashdod in the house of the god Dagon. This led to the Ashdodites being troubled by hemorrhoids. They tried to move the ark to other Philistine cities, but with the same result. In Gath, the epidemic created panic. The inhabitants of Ekron said: “They have brought about the ark of the God of Israel to us, to slay us and our people” (1 Samuel 5:10-12). Further 1 Samuel 5:10-12 (KJV1900) says “For there was a deadly destruction throughout all the city; the hand of God was very heavy there. And the men that died not were smitten with the emerods (hemorrhoids; DARBY): and the cry of the city went up to heaven”.

Thus, this was an obviously contagious disease with a high mortality rate that frightened the Philistines. The only symptom specifically mentioned is emerods (hemorrhoids; DARBY). What we know today as hemorrhoids are varicose veins at the opening of the rectum, often with bleeding. In this painful disorder varicose veins have formed under the rectal mucosa, either within the sphincter (internal haemorrhoids) or outside this (external haemorrhoids), possibly in both places.

Hemorrhoids can be a painful and very uncomfortable condition, but it is not fatal, so what could it have been? The Hebrew word which is translated “hemorrhoids” (DARBY; Harkavy; NV; Le), “tumors” (AS; RS), “boils” (NO; EN; NB) and “plague boils” (AT), for example in 1 Samuels 5:6, is, ofalim, which denotes round swellings, hemorrhoids or tumors at the rectal opening. In the Masoretic text, the Hebrew word techoriḥm (tumours) is used in 1 Samuel 6:11,17 for the swellings that plagued the Philistines. In English, you find the expressions “emerods”, “buboes” and “boils”. In German translations one can find “heimliche Plage an heimlichen Orten” (Bible 1784), “Beulen”, “Ärse” (Luther translation from 1784) [3].

As the country  was being destroyed by rats at the same time (1 Samuel 6:5), some Bible commentators believe that the Philistines were affected by the bubonic plague [4], an infectious disease with a high mortality and with symptoms such as fever, chills, exhaustion and painful enlargement of the lymph nodes. The infection is mainly transmitted by fleas that have bitten dead or dying rats or other rodents that have the disease. Plague can also be transmitted from body lice and fleas directly to people, possibly via clothing, carpets etc. which is infested with fleas and body lice [5]. From the boils, the bacteria will often spread further with the blood and cause pneumonia, blood poisoning (sepsis) and sometimes meningitis.

Pneumonic plague can be caused by droplet transmission from patients with plague infection in the lungs. The disease manifests itself as pneumonia with violent edema formation (fluid leakage) in the lungs, and has a fatal outcome within two to three days due to respiratory failure.

The bacterium that causes bubonic plague is Yersinia pestis. It was discovered in 1894 by Alexandre Yersin [6]. He detected the microbe in dead rats. Some of the rats had boils. He also showed that sick animals that were put together with healthy animals, infected the healthy ones so that all became sick and died. It was shown that the bacterium affected laboratory animals such as rats, mice and guinea pigs. That it also infected humans was not recognized until 1899.

Gold castings of both tumors and rats are mentioned in 1 Samuel 6:4, where it is said that the Philistine priests and deviners said: “the same plague has struck both you and your rulers”. Over the years, writers have had different opinions as to whether the Philistines believed that there was a connection between the tumors and the rats. The Marigold Bible [7] from 1630 had, among others, a copper engraving that illustrated the Philistine plague and it also showed mice/rats.

The same is the case with a painting by Nicolas Poussin from about 1630 [8]. However, it is uncertain whether the artists believed that there was any connection between the plague and the rats. Several authors and commentators have suggested that it is unlikely [9,10,11], while Sticker G. [12] argued that they did.

Many Bible commentators believe that the Hebrew word, akhbar, which has been rendered by various Bible translators as “mouse”, “rat”, “spring mouse” and “jumping rodent”, is perhaps a general term that refers to both rats, mice, spring mice and similar rodents. However, Koehler and Baumgartner’s Hebrew and Aramaic dictionary says that the word means “spring mouse” [13]. Spring mouse can cause great damage to cornfields and other crops.

Previously, it was assumed that humans were infected exclusively via rodents. In recent times, however, it has been established that body lice and fleas can infect humans directly and be a reservoir for the bacteria [5,14]. It can therefore be argued that the rats and the plague that befell the Philistines were not necessarily connected.

Some authors have different views regarding the likely diagnosis, and one of them [15] argues that the plague of Philistines was an epidemic of tularemia (rabbit fever) [16,17]. It is caused by the bacterium Francisella tularensis. It was known in the Middle East and Egypt in ancient times, and written accounts from ancient Egypt (Hearst Papyrus and London Medical Papyrus) tell of an epidemic that could possibly have been tularemia around 1715 BC. It was described as “Asian disease”. Both papyri believed that the disease originated in the Near East and that it came to Egypt via contaminated ships. The Bible’s description of both the fifth and sixth plagues can be interpreted as a new epidemic [15]. The same author, Trevisanto, argues that Canaan was a reservoir for the disease and that the outbreak among the Philistines was a good indication of that.

There are different variants of rabbit fever/tularemia. In Norway and Europe, there is a mild variant, but other subtypes can have a significant mortality rate. It is transmitted from animals to humans, in Norway most often by dead mice or leeches infecting wells, streams and other water sources. The disease usually starts acutely with fever, chills, headache and fatigue. The symptoms vary with the mode of infection:

• Skin infection often causes sores and rashes on the hands. The wound may appear without prior injury, has a rampart-shaped border, does not heal and is painful. Lymph nodes draining from the wound are often swollen and tender. Fever, headache and vomiting are common.
• Contagion through food and water causes painful, sore throat/pharynx/tonsils with local lymph node swelling.
• Inhalation can cause symptoms of pneumonia.
• In some cases, a typhoid form of rabbit fever occurs where fever and poor physical functioning are the main symptoms, eventually possibly diarrhea and abdominal pain.

Mortality among sick animals can be high, up to 80-90%.

Both bubonic plague and tularemia/rabbit fever can be compatible with the Bible’s account of the Philistine plague. Both diseases can have a high mortality rate. Tularemia presupposes that the rodents are disease carriers. As for bubonic plague, it can be, but it is not a requisite. The Bible does not expressly say that there was such a connection. Nor does it say anything that the rodents were sick or that they died in greater numbers, only that there were many of them. If one assumes that there is no connection between the rodents and the disease, it cannot have been tularemia. It may have been bubonic plague with infection directly from ectoparasites (body lice and fleas in clothes, carpets, etc.).

As we can see from Leviticus 26:14-16,25 and Deuteronomy 28:21,22, wasting disease, or tuberculosis was a known illness. However, it does not act as an acute epidemic with high mortality, but is the chronic killer that claims many lives over decades. Dysentery (shigellosis) has been mentioned as a possible cause of the Philistine plague without us having specific symptoms that could indicate it. A number of infectious diseases caused by parasites, bacteria and viruses can affect the skin (rash, sores and boils) and cause epidemics with high mortality.

So what struck the Philistines, was it plague, tularemia or something else? What we can say for sure is that it was an infectious disease with the occurrence of boils, especially in/around the pelvic region and with a high mortality rate. We have no way of determining the infectious agent (parasite, bacteria, virus).

The Philistines were required to pay a guilt offering to the Israelites (1 Samuel 6:4). One of these was 5 gold models of hemorrhoids/tumors. If we assume that this reflects that the boils largely originated in the groin/genital/perianal area, this would fit better with bubonic plague. The infection often enters through bites (e.g. from fleas) on the legs, and boils and swollen lymph glands with the formation of boils typically occur in the groin area. And although both diseases have variants with high morbidity and mortality, this is probably more often the case with bubonic plague than with rabbit fever.

[1] Bible Lexicons; Old Testament Hebrew Lexical Dictionary. Available from: https://www.studylight.org/lexicons/hebrew/1698.html
[2] T.H. R. A history of Israel. Oxford: Clarendon Press; 1932.
[3] Die Bibel, oder die ganze Heilige Schrift des alten und neuen Testaments, nach der deutschen Übersetzung D. Martin Luthers. 86. Auflage ed. Halle, Tyskland: Cansteinische Bibel-Anstalt; 1784.
[4] Bjørn M. Pest 2019; Myrvang, Bjørn: pest i Store medisinske leksikon på snl.no. Hentet 14. oktober 2020 fra https://sml.snl.no/pest.
[5] Katharine R. Dean FK, Lars Walløe, Ole Christian Lingjerde, Barbara Bramanti, Nils Chr. Stenseth, Boris V. Schmid. Human ectoparasites and the spread of plague in Europe during the Second Pandemic. PNAS. 2018;115(6):1304-9.
[6] A Y. La peste bubonique a` Hong Kong. Ann Inst Pasteur. 1894;8:662-7.
[7] Merian M. Merian Bible. Strasburg: Lazarus Zetzners Erben; 1630.
[8] R A. Was wussten unsere Vorfahren von der Empfänglichkeit der Ratten und Mäuse für die Beulenpest des Menschen? Eine Studie zur Seuchengeschichte. Z Hyg Infectionskrankh. 1901;36:89-119.
[9] Koehler W KM. Plague and rats, the “Plague of the Philisines”, and: what did our ancestors know about the role of rats in plagiue. Int J MedMicrobiol. 2003;293:333-40.
[10] Mollaret H.H BJ. Alexandre Yersin ou le vainqueur de la peste. Paris: Fayard; 1895.
[11] S W. Geisseln der Menschheit. Kulturgeschichte der Seuchen. Düsseldorf, Zürich: Artemis & Winkler; 1997.
[12] G S. Abhandlungen aus der Seuchengeschichte. Giessen: A. Töpelmann; 1900.
[13] Koehler B, Stamm. Hebräisches und Aramäisches Lexikon zum Alten Testament, Studien Edition (2 Vol. Set; Bd. 1: Alef-Ajin, Bd. 2: Pe-Taw)2004.
[14] Anne Karin Hufthammer LW. Rats cannot have been intermediate hosts for Yersinia pestis during medieval plague epidemics in Northern Europe. J Archeol Science. 2012;40:1752-9.
[15] S.I T. The biblical plague of the philistines now has a name, tularemi. Medical Hypotheses. 2007;69:1144-6.
[16] Folkehelseinstituttet. Harepest (tularemi)2019. Available from: https://www.helsenorge.no/sykdom/infeksjon-og-betennelse/harepest-tularemi/#symptombilde.
[17] Tularemi2017. Available from: https://no.wikipedia.org/wiki/Tularemi.