Microsoft Word - 01contentabs.doc

Syphilis in Jewish Sources: Medical

Halachic and Ethical Aspects

Abstract

Syphilis is a sexual disease which is rare today. This article discusses the historical and medical- halachic discussions of syphilis in Jewish medieval literature. For the first time in the history of Jewish law, sages in the 16th century discussed the implications of syphilis for the relationship between the syphilitic husband and his wife.

In the documented sources of this period syphilis was described as a skin illness that caused lesions covering the patient’s body. It was difficult for the ancient physicians to distinguish between syphilis and leprosy. Many sages claimed that the syphilitic patient must divorce his wife when he exudes a foul odor or his skin peels off. Others claimed that divorce should be forced on leprosy patients because the disease is incurable, in contrast to syphilis patients who can be cured.

It is reasonable to assume that many of the rabbinical discussions about syphilis were triggered by the outbreak of the syphilis epidemic in Europe in the late 15th and early 16th centuries.

This paper discusses syphilis in view of several halachic queries directed to Jewish sages who were active in Jewish Mediterranean communities in the 16^th-17^th centuries. This paper examines the historical, medical and ethnic-halachic background to their responses.

Syphilis - Medical Background

This dangerous disease, which is currently relatively rare, is caused by Treponema pallidum bacteria that are transmitted through sexual contact. In the first stage of the disease, an ulcerlike lesion develops at the site of the bacteria’s penetration into the body. The lesion is not painful but it is extremely contagious. Lymph nodes adjacent to the groin may also swell. Sometimes the lesion is not noticeable at all and it disappears spontaneously in the course of several weeks.

The second stage of the disease begins several weeks after the appearance of the lesion, and in approximately 75% of the cases, it is manifest as a non-itchy rash that covers the entire body, including palms of the hands and soles of the feet, and is sometimes accompanied by painless swelling of the lymph nodes and moist, lump-like growths surrounding the anus and/or the armpits.

This rash also disappears spontaneously within several weeks, when the disease enters its third stage, known as the latent stage, due to the absence of any symptoms. Today in almost all cases, the latent stage is the final stage of the disease, due to the use of antibiotics. In very rare cases of inadequate treatment, however, the disease progresses to a stage characterized by severe complications such as aortic insufficiency aortic aneurysm or neurological disorders. ^{^[6]}

Syphilis in the 16^th and 17^th Centuries:

Historical Background

An outbreak of syphilis occurred in Europe in the late 15^th century, around the time of the exile of the Jews from Spain (1492). Syphilis began to spread when the army of Charles the VIII of France invaded Italy, and first became known as the Napolitan disease. ^{^[7]}

According to one theory of the period, the disease was brought from America to Europe by Christopher Columbus’ sailors. Although syphilis apparently existed from time immemorial in the Old World, the bacteria underwent a worldwide mutation in the late 15^th century. ^{^[8]}

Medical texts from the Middle Ages, and as we see below, rabbinic sources as well, describe syphilis as a sexually transmitted disease that is similar to and sometimes indistinguishable from leprosy. Several sources discuss treatment of the disease using mercury, which in fact had no effect at all and even caused grave harm due to its toxicity.^{^[9]} Guaiacum officinalis, “the holy tree,” was used by native Americans to treat syphilis and was perceived as an effective cure, but had no medical value whatsoever. ^{^[10]} The first effective treatment of the disease was made possible only with the discovery of salvarsan by Paul Ehrlich in 1910. Before this discovery, many cases ended in complications.^{^[11]}

Syphilis in Questions and Responses of Rabbis in the 15^th-16^th century

Use of the Hebrew term “עגבת” for syphilis is relatively new.^{^[12]} In the Responsa literature, the disease is mentioned as “mal di Franca” (' מאל די פראנסה'), French pox, or in Hebrew, “חולי צרפתי”. This name was coined by the Italians who blamed the French for bringing the disease with them during the French conquest by Charles the VIII. The French believed that the Italians were the source of the disease and therefore called it “the Italian disease.” The Russians called it “the Polish disease,” and various countries similarly attributed syphilis to their adversaries. ^{^[13]}

The basis of the halachic discourse in each presentation of the disease was a discussion of the fundamental ethical issue - is the disease of one spouse sufficient grounds, being a grave and dangerous disease, to order a divorce. In the course of the halachic debate, additional related aspects of the issue were raised and became embedded in the responses, from which we learn of the disease and the attitude toward the disease at the time.

Syphilis in view of Rabbi Elihayu Mizrahi’s

Answer

The response of the Turkish sage, Rabbi Elihayu Mizrahi (Reem, רא"ם, Kustha 1450-1526) is one of the first and major sources that address the issue of syphilis. ^{^[14]} This disease was not discussed in either of the two basic halahkic books of the 16^thcentury: Shulchan Aruch by Rabbi Yosef Karo, or the commentary of the Polish sage, Rabbi Moshe Iserliss (Rema, ^{^[15]},(רמ"א which explains the significance of Reem’s response as the basic response in Jewish Law.

Following is the content of the query that was addressed to Rabbi Eliyahu Mizrahi:

“On your query in the matter of the wife whose husband contract at the disease known in our language as “mal di Francesca” in which the patient’s body breaks out in sores with secretions ( "בחולי הנקר'[א] בלשונ'[נו] מאל די פראנצה " שהוציא קצת אבעבועו'[ת] בגוף ויוצא מהם שחין) and the wife regrets the fact that she cannot suffer her husband and wishes to divorce him. Is this disease included in the"|W מוכה" law that is mentioned in the Mishna that compels the husband to divorce his wife? And is any person who has a skin disease with sores that “ooze pus” considered a "מוכה שחין"? Or is he compelled to divorce the wife only if specific, special sores appear^{^[16]}?

The exact date of the query is not known. It may be assumed that it was directed to Rabbi Mizrahi sometime between the late 15^th century and the early 16^th century, a timing that was related to the propagation of the major epidemic that erupted in Europe in the late 15^th century.

The query before us recounts the unfortunate story of a woman whose husband contracted syphilis. She complains that she cannot have intimate relations with him. The query contains the name and description of the disease; various parts of the husband’s body are covered with some type of blister ("אבעבועות"). Based on a description of the symptoms, it appears to have been secondary syphilis, in which a rash covers the body.^{^[17]}Although the symptoms should disappear by the third and latent stage of the disease, we can presume that the disease was known to worsen and develop complications without proper treatment which explains the reason for the woman’s appeal to the court.

From the formulation of the query, we infer that the woman did not refer her query directly to Rabbi Mizrahi’s court, but rather to another rabbi who presumably was also an important legalist but who was interested in a decision by a higher rabbinic authority, perhaps because it was a relatively new halachic issue.

The fundamental question posed to Rabbi Mizrahi was whether the law concerning syphilis was similar to the law concerning diseases and disorders mentioned in Sages’ literature, which compel the husband to divorce his wife, even against his will, due to the impossibility of maintaining proper marital relations with the husband. ^{^[18]}

The diseases and disorders mentioned in early Hebrew literature in this context are: "מוכה שחין" (stricken by boils)^{^[19]}, "בעל פוליפים" (an individual who suffers from halitosis or a bad smell from the nose), "מקמץ" (an individual who collects dog feces to prepare fertilizer etc.), "מצרף נחושת" (an individual who works in copper casting) and a "בורסקאי" (tanner).^{^[20]} All these individuals share the characteristic that they suffer from severe aesthetic defects (according to Rashi, they exude foul odors), and they are repulsive ("מאוס") to others in general and to their wives in particular.

The applicant focuses the query on the similarity between syphilis and boils ("שחין"). He questions whether boils mentioned above is a specific disease of the skin, apparently festering lesions (in his own words: "אבעבועות היוצא מהן שחין" - “blisters exuding boils”), or whether it is also a different serious skin disease such as syphilis.^{^[21]}

The term "מוכה שחין" (“stricken with boils”) mentioned in rabbinic literature is a general term for severe, pervasive gangrenous diseases that require amputation. ^{^[22]} Modern scholars have suggested to identify this ailment with various diseases including syphilis, leprosy, bubonic plague^{^[23]} or eczema - an inflammatory skin disease accompanied by redness, scales and tiny pustules and generally accompanied by itching. ^{^[24]}

Rabbi Eliyahu Mizrahi responds that the talmudic issue (Bavli, Ketubot 77a) defines two conditions for compelling a diseased husband to divorce his wife. The first is if sexual relations cause shedding of tissues from the diseased individuals’ body ("^{^[25]},("המקת בשר a symptom that is familiar in leprosy;^{^[26]} the second condition is if the husband exudes foul odors that the wife is unable to tolerate, similar to the other diseased individuals mentioned by the Sages. In the opposite case, when the wife is stricken with boils the situation should be treated similarly.

Consequently, Rabbi Eliyahu Mizrahi argued that if an individual inflicted with syphilis exudes foul odors and his flesh sheds when he conducts conjugal relations, he must be compelled to divorce his wife even if she wishes to continue to live together. However, if his foul odor is not severe and his presence can be tolerated, and conjugal relations do not cause his flesh to “fall off,” he is not compelled to divorce her.

Syphilis in the Response of Rabbi Yosef Ben David Even Lev

Another case involving a woman’s demand for divorce due to her husband’s syphilis, is presented in a judgment rendered by the court of Rabbi Yosef Ben David Even Lev (מהר"י בן לב, Yugoslavia 1505-Kushta 1580) on 10 Tevet 1543, when he served as a rabbi and judge in the local rabbinical court of Saloniki for some time. This case concerns an appeal to the local rabbinical court by a woman named Duna Dola, through her lawyer, to compel her husband, Rabbi Baruch, to divorce her. Due to the significance of the details contained, the query is presented in entirety:

“We the undersigned court were requested by Duna Dola, wife of Rabbi Yosef Baruch, through her counsel, to investigate and examine the matter of the her husband’s aforementioned disease, because she wishes to separate from him, and the question is whether she is justified. At her request, we met with the physicians whose names appear below to examine the aforementioned individual to study his disease to examine his condition for us, according to their opinion. After several days they examined him and touched his body, and responded to us. Initially the supreme sage the physician Don Yitzhak came before us and said that he saw the aforementioned Yosef and investigated his disease and according to his opinion, he is a leper [...] Also appeared before us the specialist Rabbi Yitzhak Ben Alzo and that after examining and investigating the matter of the said Rabbi Yosef’s disease, he decided that he is afflicted with “bubas mal de francia” ["בובאש שקורין מאל די פראנסייא"] and this was his opinion and belief. Also appeared before us the specialist Rabbi Abraham Gaggi who said that for several days he has been treating Rabbi Yosef and has not seen any sign of leprosy other than “ulcera du narices” ["אולסירה די נאריזיש"= ulcers in the nasal cavity] that are caused by a head disease known as “catarrho” ['קאטארו'] and since when Rabbi Yosef was cured from one disease another disease appeared, he suspects that this is caused by “bubas disease” ['מחולי די בובאש'] and he believes that if he has a serious disease, it is “bubas” and no other [....] After the aforementioned investigation, we drafted and signed the statements of the aforementioned physicians to determine whether, based on the physicians’ opinions, if the law sides with the wife or the husband. This was in Saloniki on the 20^thday of Shvat, the year 1543. ^{^[27]}”

The following facts are implied in the above passage: in view of Mrs. Donna Luna’s complaint the court appointed three qualified physicians to diagnose her husband’s illness. After conducting a series of tests, the physicians presented their findings. The first physician, Don Yitzhak diagnosed Yosef as leprosy. The second physician Rabbi Yitzhak Ben Alzo suggested a completely different diagnosis. He claimed that the husband contracted syphilis (in his words, “bubas mal de francia”). The third physician, Avraham Gagi who apparently had treated the patient for some time prior to the appeal to the court, also suggested that the illness in question was syphilis. He found no indications of leprosy other than ulcers in the nasal cavity originating from headaches, that is, that radiated to the nasal area. He claimed that the husband, after having been cured of this illness contracted “mal du bubas” - syphilis. However there did not appear to be any connection between the two medical conditions.

The physicians’ dispute on whether the illness was leprosy or syphilis illustrates the difficulties physicians encountered in distinguishing between the diseases. We have already noted above that when the syphilis epidemic erupted in the late 15^th-early 16^th centuries, some viewed syphilis as a leprosylike skin disease. It is appropriate to emphasize here that although the physicians in this source, as in early sources in general, discussed “leprosy” it is impossible to ascertain which illness was actually indicated. They may have used this term to cover a broad range of illnesses^{^[28]} including itching psoriasis, fungal skin infections, ergotism (that inter alia, caused gangrene), and syphilis, whose clinical symptoms are also related to skin disorders. ^{^[29]}

Similar to Rabbi Eliyahu Mizrahi’s decision Mahari’s Even Lev court deliberated on the question of whether only individuals “stricken with boils” were obligated to divorce their wives, or whether individuals with syphilis were also obligated to do so. On one hand, Mahari claimed that the very fact that the Rambam limited the identification of “מוכה שחין” exclusively to lepers ^{^[30]}indicates that he believed that divorce should be compelled specifically in leprosy, whose symptoms are well known. In contrast, with respect to other skin diseases, in the absence of a clear diagnosis or identification of the type of boil, the judges cannot resolutely determine when to compel a husband to divorce his wife when and when not to do so. On the other hand, Rabbi Eliyahu Mizrahi already determined (above) that a person who is afflicted with syphilis and suffers from halitosis and his organs slough off during conjugal relations, is also obligated to divorce his wife.

Thus, it was clear to Rabbi Even Lev that leprosy requires a man to divorce his wife. In the case before us, however, the physicians did not agree on whether Rabbi Yosef, Dona Luna’s husband, was a leper or syphilitic and therefore the duty to divorce her was in doubt. In view of this, he proposed:

“From now on I will say, according to my humble opinion and knowledge: all the physicians of this city should assemble. If the majority decides that this man is a leper, they will force him to divorce his wife against his will. If they agree that he has the French pox or another disease of the “bubas” type [ "חולי הצרפתי או בחולי אחר ממיני הבובאש"], even if a minority of the physicians are hesitant in determining whether an individual afflicted with French pox has these signs, in any case, since the situation is not clear and several physicians believe that it is not the French pox, I cannot be lenient and compel the man to divorce his wife other than in the case of leprosy and according to the opinions of specialists. And may God save us from our errors...²⁶”

In other words, the physicians did to obtain a clearer diagnosis of Rabbi

Yosef’s disease, a larger forum of qualified physicians must be convened. If the physicians conclude that the man is a leper - he will be compelled to divorce his wife.

This case may possibly involve a different disease that is accompanied by swelling (bubas).²⁷However, if the physicians diagnose the disease as syphilis, he will not be forced to divorce his wife even if the disease also involves sloughed off skin and foul odors.

Syphilis in Rabbi Yosef Tirani’s Response

Syphilis was also discussed in another query that was presented to Rabbi Yosef Tirani, one of Zfat’s most important sages (Maharit, מהרי"ט, Zfat 1568-Kushta 1639).²⁸ His discussion focused on the conditions in which a wife of a leper could demand a divorce, but he also addressed syphilis in this discussion.

One of the major points in Tirani’s discussion was whether there were two necessary conditions for divorce (foul odor and gangrenous body) or whether one was sufficient to compel divorce. He claimed that individuals afflicted with boils suffer from both afflictions, and that is also the identifying mark of the disease. In the case of a leper, his wife can clearly demand a divorce, and from the perspective of the halacha, physicians are capable of diagnosing this disease to determine the divorce because it is a well known disease with familiar symptoms. However, it is doubtful, as the sages before him doubted, whether a female leper can also demand the same treatment:

"Indeed it is the French pox [ חולי הצרפתי''] [...] because several abscesses were discovered on the patient’s body and they secrete discharge, but it remains doubtful whether the disease is classified under “afflicted with boils” ["מוכי שחין"], because this disease is curable. Just as we see in reality that physicians who treat these patients succeed in curing them completely. However, some cases are difficult to cure and the affliction remains for a long time, while others are cured easily. Therefore, the Rabbi [Rabbi Eliyahu Mizrahi] determined that even though the patient was not a leper, it is possible that he is included under “afflicted with boils”, who should be compelled to divorce their wives".²⁹

The Maharit offers an additional argument to distinguish between syphilis and leprosy. Leprosy has no effective cure, while syphilis can be cured and there are known cases of people who were cured. Therefore this is not a hopeless case that requires divorce. The source of Maharit’s distinction between the diseases is not clear. To the best of our knowledge, the early sages had no effective cure for syphilis either.

Although the Maharit was no physician, he specified the medical reasons for gangrene that developed in individuals afflicted with various skin diseases during conjugal relations, such as were known to medical sciences in his time. The affliction of the skin is related to prolific conjugal relations. The disease itself incites the patient’s passion for sex (?) and therefore such activity

should be restricted. According to the medical perspective in his time, which does not meet the test of current medical knowledge, the skin lesions stem from a blood-related defect in the liver and the secretion of toxic substances to the skin.³⁰Conjugal relations debilitate the body’s ability to separate between positive substances that should remain in the body, and noxious substances which should be eliminated from the body. The body is affected by noxious substances and responds by sloughing off tissue.

Summary and Discussion

For the first time in the history of Jewish law sages in the 15^th and 16^th centuries addressed the halachic attitude towards the continuance of marriage between syphilitic individuals and their wives, on the backdrop of the severity of the disease which, like other skin diseases, had an adverse affect on couples’ lives.

The sources of that period describe syphilis as a skin disease accompanied by sores covering the body. As we have seen, physicians of the period found it difficult to make a medical distinction between syphilis and leprosy. This difficulty was also expressed by sages of the 16^th century who found it difficult to determine whether syphilis was included under the definition of one who is “stricken with boils” (מוכי שחין"". according to the Rambam: leprosy) mentioned in early Hebrew literature, which requires a divorce.[31]

Several sages argued that the syphilitic individual, like the leper is required to divorce his wife when he exudes a foul odor or when his skin sloughs off. However according to a different approach, divorce was compelled only in the cases of leprosy, whose diagnosis was well-known. Some argued that there was a substantive difference between these two diseases: leprosy was incurable and therefore divorce should be compelled, while syphilis could be cured and therefore the couple’s problematic relationship was merely temporary.

It was the nature of the rabbinic sources to discuss a specific halachic issue in a focused manner, frequently understating or obliterating geographical, historic or other background factors. Although the sources before us do not mention, or even hint, about a connection to any specific syphilis epidemic, it is presumable that the foundation for some of the discussions noted above resulted from the syphilis epidemic that spread throughout Europe in the late 15^th and early 16^thcentury. The fact that several discussions on this new issue emerged within a relatively short span may attest to the circumstantial connection.

A very small number of queries appear on this issue. This may be related to two reasons:

A. The geographic location of the origins of the responses was far removed from the sites of the epidemics and the number of cases of infection could be presumed to be smaller.

B. More significantly, the traditional Jewish population had few ties of marriage or sexual liaisons with the non-Jewish population; as a result syphilis could be expected to occur less frequently. The Jews’ strict sexual morals of were documented in various historic sources, including by A. Russell, a naturalist who lived in Aleppo in the mid-18^th century and reported the rarity of syphilis in the Jewish community there, in contrast to the prevalence of the disease among Muslims and Christians. ^{^[32]}^{^[33]}

Assuming that the cases before us illustrated the dissemination of the syphilis epidemic in Europe, the sites at which the issue was discussed in the Responsa literature may serve as historic indicators of the course of the epidemic from Europe to the Mediterranean - Turkey, Greece and the Land of Israel.

Syphilis is a sexually transmitted disease. In the rabbinic discussions noted above, the rabbis made no reference to the cause of the disease, that is, the concern that one of the marriage partners had extra-marital sexual relations. This may stem from their lack of knowledge regarding the manner of transmission of the disease, or their desire to discuss the disease per se rather than be diverted into secondary issues. Another possibility is that the sages assumed that members of the traditional community as a rule avoided sexual relations with the surrounding non-Jewish population.

An exception to the lack of reference to the source of the disease was Rabbi Tuvia Katz of Mitz (17^th century). In his medical volume, “Tuvia’s Practice", first published in Venice in 1707, Tuvia Katz devotes a chapter to the “French pox its symptoms, causes and cures.” He argues that this disease began to spread after Columbus’ conquests, and is a direct result of God’s punishment for prostitution:

“French pox ["חולי הצרפתים"] is new in these countries although it is an old disease in India or the New Land [=America], because in 1493, the great traveler Christopher Columbus returned to his country from the New Land. He and his crew began to have sex with the women of Italy, and God was angry with them and therefore brought this severe disease upon them. And the French army was then fighting along the border of Naples and they also contracted the disease, and therefore it is called the French pox [ "מאל ³².[פראנציז"י"

Rabbi Tuvia emphasizes the connection between the disease and improper sexual conduct. He also describes the sites of affliction on the body, alluding to the sinner’s punishment “measure for measure”:

“and his poison [of the infected man] is the poison of the actual epidemic, because the poison infects a person who sleeps with an impure woman [...] the poison spreads through his reproductive organs and causes a stench. It begins from the site of the sin, where the semen seeped, and blisters develop on the man’s penis and the woman’s vagina.”^{^[34]}

[6] See T. Smith, Handbook of Family Health, Am Oved, Tel Aviv, 1988, pp. 612-613 (hereinafter, Smith Handbook) [Hebrew]. For the background of the disease and its characteristics in Israel, with an emphasis on the last twenty years, see A. Hodek, “Trends of Morbidity of Syphilis in the State of Israel,” Family Physician, 12 (1984), pp. 336-338 [Hebrew]

[7] Extensive research on the historical background to syphilis is available. Several of the prominent studies are; H. W. Haggard Devils, Drugs and Doctors, The History of the Science of Healing from Medicine-Man to Doctor, New-York 1929, pp. 243-270 [hereinafter, Haggard History]; C. Quetel, The History of Syphilis The Johns Hopkins University Press, Baltimore 1992; M. S. Amsteys, “The Political history of Syphilis and its Application to the AIDS Epidemic”, Womens Health Issues, 4 (1) (1994), pp. 9-16;Y. Or, Syphilis vs AIDS - Historical and Social Aspects, Korot 11(1995), pp. 73-87 [Hebrew]; R. Marguta, History of Medicine Hed Arzi, Jerusalem 2001, pp. 80-81 [Hebrew. hereinafter Marguta History].

[8] The problematics regarding the origin of syphilis in Europe have been discussed extensively in M. D. Grmek, Diseases in the Ancient Greek World, (trans. M. Muellner & L. Muellner), Baltimore 1989 pp. 51-131. See also Haggard History, pp. 245-246. On early findings of the disease in Israel, see G. Zeas, "Diseases and Cures in Ancient Israel in view of Paleo-Pathological Research" Kadmoniyot, 133 (1997), pp. 54-59 [Hebrew]. Note that some scholars believe that leprosy mentioned in the bible and rabbinic literature is syphilis. On this suggestion and other suggested skin disorders including scabies, fungal infections, and leprosy, see Katzenelson, The Talmud and Medical Wisdom, p. 304 ff., and p. 371 ff. [Hebrew]; Julius Preuss, Biblisch Talmudische Medizin Berlin 1911 (=J. Preuss, Biblical and Talmudic Medicine, (trans. F. Rosner), Northvale, New Jersey and London 1994, pp. 323 ff. [hereinafter, Preuss Biblical Talmudic Medicine]; A. Steinberg Halachic Medical Encyclopedia, Jerusalem 1996, pp. 175-180 [Hebrew. hereinafter, Steinberg Encyclopedia]. On skin disorders in biblical and rabbinic literature, see Z. Muntner, “Terms of Skin Disorders in Ancient Hebrew Literature”, Harefua, 15 (1938), 1-2 pp. 1-16 [Hebrew. hereinafter, Muntner Terminology].

[9] Mercury treatments for syphilis was first used by Swiss physician Paracelsus (1493-1541) although the origin of this treatment is not clear. See R. Kalder, Medicine and Man - The History of Medicine from its Beginning to Our Times, Jerusalem 1969, pp. 27-28 [Hebrew]. Mercury treatments are mentioned, for example, in the 16^th century, in a medical essay by Daoud al-Antaki, Tathkarat al- Antaki, Cairo 1928, 1, p. 169. See also M. Plessner, “On the Medical and Magical Encyclopedia of Daoud al-Antaki and on Several of its Origins,” Eretz Yisrael, 7 (1964), p. 139 [Hebrew].

[10] Marguta History, pp. 80-81. On the medicinal uses of guaiacum see A. Penelope, Medicinal Herbs, Am Oved, Tel Aviv 1997, p. 180 [Hebrew].

[11] On this discovery and modern treatment of syphilis, see D. Erlik,
Medical Breakthroughs, Jerusalem, 1990, pp. 114-116 [Hebrew].

[12] The term "syphilis" is taken from a poem written in Latin by the Italian Girolamo Fracastoro. The protagonist, Syphilis, contracted the disease as a punishment for insulting Apollo. See Haggard History, p. 252.

[13] Haggard History, pp. 250-251; R. H. Major, Classic Descriptions of Disease, Charles C. Thomas, Springfield 1959, pp. 15-16.

[14] According to Rabbi Yosef Miterani (Israel, 16^th century), syphilis was discussed by Rabenu Asher (Rosh (רא"ש). Spain and Ashkenaz, 13^th century):

"The Lord brought to my hands the Book of Responses of the Rosh in handwriting, and it contains several responses that were not printed, and I found there a discussion of a man who contracted the French disease ("בחולי הצרפתי"), and the question arose whether this disease is included in the law concerning “מוכה שחין” who must divorce his wife.” (Responsa Maharit, Tel Aviv, 1949 (facsimile Lemberg 1861), Section 2, Even Haezer, 14). However, it is extremely doubtful whether this is an authentic reply or a later response that was appended to the Book of Questions and Responses that Rabenu Asher wrote.

[15] The opinions of the halachic judgments concerning diseases which require the husband to divorce his wife were summarized in Shulchan Aruch, Even Haezer, siman 154. In this chapter, Rabbi Yosef Karo, concentrated a variety of medical problems that raise concerns regarding the future of the marital relationship, such as improper behavior of the wife or husband, such as insanity of the husband or wife, fertility issues, disability, etc. The discussion of syphilis was raised by interpreters of the Shulchan Aruch several hundred years later. See for example, Baher Hetev, Even Haezer, 154, 3.

[16] Responsa, Mayim Amukim, Jerusalem 1970 (facsimile, Berlin 1778)

1, 19

[17] See ibid, Medical Background.

[18] According to Jewish halahka, divorce could be performed only by the husband.

[19] An example of the problematic of marriage with a "מוכה שחין" is found in a halachic essay by Rabbi Shmuel di Modina: “Reueven contracted a serious extended disease and became bedridden and had no sons. Relatives of his wife Dina feared that he might die and his wife would be required to marry his brother Shimon, who was “stricken with boils” ("מוכה שחין") with an incurable disease ill" (Responsa Marshadam, New-York 1949 (facsimile, Lemberg 1862) Even Haezer, 183).

[20] In Mishna Ketubot 7, 10 and in the corresponding Talmudic tractate 77a. Parenthetically we note that questions of a similar type evidently appeared in other rabbinic texts. For example, for Radbaz, another 16^th century Sage of Zfat, it was sufficient to know whether a husband who defecates or urinates in his bed is considered a foul man ('אדם מאוס') from whom a wife has a right to demand divorce: “You asked my opinion about a woman who claims that her husband defecates in his bed and is unaware of this. This occurred several times due to "חולי קרירות" (a cold?) and the question is whether he should be forced to divorce his wife and grant her Ketuba similar to the other individuals mentioned in the Mishna.” (Responsa Radbaz, Jerusalem 1972 (Warsaw 1882 facsimile), Section 4, Mark 260, 1031.

[21] In fact, in ancient sources, the term "שחין" (“boil”) is a term for a variety of skin disorders. Rabbinic sources distinguished between three types of boils: dry inside and outside: moist inside and outside; dry inside and moist outside (Bechorot, 41a). See for example Tosefta Ketubot (R.S. Lieberman edition), 7, 11: "Raban Shimon ben Gamliel said, we met on old man, one of the “stricken with boils” ("ממוכי שחין") adjacent to Zippori and he told me that there are twenty [four] types of boils, and the most harmful to women are "בעלי ראתן" only"). Compare to Bavli Ketuvut 77b. The Sages also noted the names of several types of boils such as ""גרב חכוך" "ילפת"" (Bavli Bechorot 41a). Z. Muntner notes that the meaning of the word "שחן" is hot or burning, and refers to a variety of inflammatory skin diseases. On the likely nature of the types of boils, see Muntner Terminology, p. 2 cf.; Steinberg Encyclopedia, 5, pp. 180-181.

[22] Keritut 83, 48.

[23] Summary see Steinberg Encyclopedia, ibid p. 180.

[24] Summary see Smith Handbook, pp.253 - 254.

[25] And in his words: “Diseases such as the French pox ("מאל די פראנסיש "), if the physicians affirm that intercourse has an adverse affect on the patient’s body and pieces of his flesh and skin fall off"( שתשמיש ממיקתו ומופל בשרו חתיכות חתיכות"). Responsa Mahari Ben Lev, Jerusalem 1949, Section 1, 30). Compare to Responsa Mayim Amukim, Jerusalem 1970 (facsimile, Berlin 1778), 1, 19: “when intercourse adversely affects the flesh and pieces of it are cut. The disease melts the skin like bees’ wax near a fire”.

[26] Leprosy is an infectious bacterial disease that deforms the physical appearance and leads to disability. Its symptoms include: thickened and discolored dermis, lumps under the skin as a result of thickening surrounding affected nerves, loss of sensation in the organs controlled by affected nerves, especially hands and feet. As a result, patients feel no pain when their limbs are injured. See Smith, Handbook, p. 565.

[27] Responsa Mahari Ben Lev, Jerusalem 1949, Section 1, 30 .

[28] Julius Preuss, one of the most important scholars of ancient Hebrew medicine, has already written that the term leprosy caused much confusion. See Preuss, Biblical Talmudic Medicine, p. 323.

[29] On leprosy in biblical or Sages literature, see for example Y. Tess “Leprosy,” Biblical Encyclopedia, VI, Jerusalem, 1981, pp. 774-778; Preuss, p. 323 cf. On biblical leprosy as a disease through which God punishers sinners, see M. Bar Ilan, “On Sacred Diseases,” Korot, 15 (2001-2), pp. 27-36 [Hebrew. hereinafter, Bar Ilan Sacred Diseases]; S. G. Browne, Leprosy in the Bible, London 1974; R.R Willcox, "Venereal Disease in the Bible", British Journal of Venereal Disease, 25 (1949), pp. 28-33; E. V. Hulse, "The Nature of Biblical Leprosy and the use of Alternative medical Terms in Modern Translation of the Bible", PEQ, 107 (1975), pp. 87-105. On leprosy in rabbinic literature see Y.L. Katzenelson, The Talmud and the Wisdom of Medicine, Berlin 1928, pp. 304-340 and p. 271 cf. [Hebrew]; Steinberg, A. Medical Halackic Encyclopedia, Jerusalem, 1996, V, pp. 175-180 [Hebrew]; M. Michael, “The syndrome of leprosy of human skin according to the Mishna,” Korot, 6 (1972), pp. 77-84 ["]; and recently, Z. Amar, “What are boils in the words of the sages,” Asia, 75-76 (2005), pp. 65-69 [Hebrew]. On leprosy and the attitude toward leprosy in the classical world, see M. Grmek, Diseases in the Ancient Greek World, Baltimore-London, 1989, pp. 152-176.

[30] As we can understand, the group of judges adhered to Rambam’s identification, that “stricken with boils” in the Mishna is a leper. See: Interpretation of Rambam’s Mishna, Ketubot 8, 7. It is justified to suggest that the Rambam (1138-1204) who was a famous physician, adhered specifically to this identification because according to the Talmud, an individual “stricken with boils” could lose parts of his body while performing the sexual act (apparently because this involved friction of the affected parts of the body), a symptom that is well known in leprosy. On the symptoms of leprosy see above footnote 21. On the identification of leprosy in the bible and rabbinic literature, see Steinberg Encyclopedia, ibid footnote 3; Hebrew Encyclopedia (Y. Leibovitz, editor), Jerusalem 1971 "Leprosy", pp. 887-889.

[31] 30. Tuvia Katz, a 17th century Jewish physician presents a similar reason: “On the causes of the French Disease ["חולי הצרפתים"], there are many opinions [...] The members of the Galen group [based on statements by Galen, one of the most important physicians of the Classical period, 130-200 CE] say that the disease is caused from the stench of blood and the nutritional power of the liver, and some say that it is caused by some infection in the blood.” (Maase Tuviya, Venice 1707, 107b).

[32] A. Russel, The Natural History of Aleppo, Vol. II, London, 1794, p. 84. Also see Burstein-Makovtzky, "The Jewish Woman in Aleppo in the Ottoman Period", in T. Cohen and S. Regev (eds.), Women in the Orient, Women from the Orient, Ramat Gan 1995, p. 59 [Hebrew]. There is much more available historical data on the prevalence of syphilis in the region of Syria and Israel in subsequent centuries. For example, we can learn of the prevalence of the disease in the 19^th century from the descriptions of the traveler Titus Tobler, who notes that despite the relatively moral lifestyle in Israel compared to Europe, the disease was prevalent, probably due to a lack of proper treatment. See T. Tobler, Nazareth in Palastina Berlin, 1868, pp. 266-280 and compare to N. Shur, Book of Travelers to Israel in the 19^th Century, Jerusalem 1988, p. 68.

[33] Maaseh Tuvia, Bayit Hadash, Section 3, Chapter 11, 107a-109a

[34] Maaseh Tuvia, ibid.

[35] See ibid, historical background to the disease.