|Year : 2019 | Volume
| Issue : 3 | Page : 178-180
Did job in the bible have flatbush diabetes mellitus?
Sanjay Kalra1, Andrew Uloko2, Jubbin Jagan Jacob3
1 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
2 Department of Medicine, Endocrine, Diabetes and Metabolic Unit, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
3 Department of Medicine, Endocrine and Diabetes Unit, Christian Medical College and Hospital, Ludhiana, Punjab, India
|Date of Submission||03-Nov-2018|
|Date of Decision||06-Nov-2018|
|Date of Acceptance||16-Dec-2018|
|Date of Web Publication||13-Aug-2019|
Jubbin Jagan Jacob
Department of Medicine, Endocrine and Diabetes Unit, Christian Medical College and Hospital, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
The Book of Job, a poetic book in the Old Testament narrates the story of Job, the “richest man in the East.” Job was afflicted by a severe illness, which tested his coping abilities and his resolve. Job's illness, and the way he coped with it has many lessons for health-care providers. In this brief communication, we hypothesize that Job suffered from diabetes, with various acute and vascular complications. We further suggest that he had type 1.5 diabetes or flat bush diabetes which is a subtype of type 2 diabetes with an explosive presentation like type 1 diabetes initially followed by sustained course like regular type 2 diabetes mellitus. This explanation accounts for the severity of his symptoms, as well as his eventual recovery. Job's words retain their relevance for modern readers: We take this opportunity to remind ourselves of the importance of patient-centered care.
Keywords: Bible, biblical endocrinology, diabetes, flatbush diabetes, latent autoimmune diabetes of the adult, medical history, painful sensory neuropathy, religion, type 1.5 diabetes
|How to cite this article:|
Kalra S, Uloko A, Jacob JJ. Did job in the bible have flatbush diabetes mellitus?. CHRISMED J Health Res 2019;6:178-80
| Introduction|| |
Job is an important character in the Old Testament. Afflicted with a severe painful disease, he exhibits various positive and negative coping mechanisms, before getting cured/relieved of his symptoms. Job syndrome is a synonym for the autosomal dominant hyper-immunoglobulin E syndrome. This rare polysystemic condition is characterized by frequent infections, skeletal abnormalities, and coronary artery disease. Pellagra, scabies, variola, eosinophilic syndrome, pemphigus foliaceus, elephantiasis or filariasis ,,,, are some other suggestions that have been made for the malady which Job was afflicted with. A well-documented and researched article proposes chronic renal failure as the etiology of Job's disease but does not discuss the possible causes of a “reversible” chronic renal failure. A careful reading of the Book of Job, however, reveals that his symptoms and signs are more concordant with a much commoner endocrine ailment: Diabetes. In this brief communication, we hypothesize that Job had diabetes. We further suggest that he had type 1.5 diabetes, which is also known as Flatbush or ketosis-prone diabetes.
| Predisposing Factors|| |
“He also had a large number of servants and was the richest man in the East” (Job 1.3).
“Job's sons used to take it in turns to give a feast ……….” (Job 1.4).
Sedentary lifestyle, excessive calorie intake, and overweight are predisposing factors for the development of type 2 diabetes. Job was a rich person with lots of servants. Accustomed to frequent feasting, he probably would have led a sedentary life. On top of such a background, he suffered sudden grief, due to the death of all his children and loss of his crops and animals.
We do not have a description of Job's phenotype before the onset of disease. However, a verse in the later part of the Book of Job (“my skin hangs loose on my bones”) (Job 19.20) suggests that he must have been well-built to begin with.
“…. Made sores break out all over Job's body “(Job 2.7).
“…To scrape his sores “(Job 2.8).
“…Because they saw how much he was suffering” (Job 2.13).
“My body is full of worms; it is covered with scabs; pus runs out of my sores.” (Job 7.5).
“My skin has turned dark; I am burning with fever” (Job 30.30).
Dermatological manifestations are a common complication of uncontrolled diabetes, especially in the settings of poor hygiene and in hot climates. Job's symptoms correspond to those of impetigo, or multiple carbuncles and furuncles. The darkening of the skin is characteristic of diabetic dermopathy [Figure 1]; pruritus and fever are frequently reported in severe skin infections. The description of poor hygiene, as listed below, adds credibility to our opinion.
“Then Job stood up and tore his clothes in grief. He shaved his head and threw himself face down on the ground.” (Job 1.20).
“Job went and sat by the rubbish heap and took a piece of broken pottery to scrape his sores” (Job 2.8).
“Won't you look away long enough for me to swallow my spittle?” (Job 17.19).
“I crumbled like rotten wood, like a moth eaten coat” (Job 13.25).
“My arms and legs are as thin as shadows.” (Job 17.7).
“My skin hangs loose on my bones.” (Job 19.20).
Job's case is a perfect demonstration of the classic symptoms of diabetes: weight loss and dry mouth. Job does not complain of increased hunger or increased micturition. However, this anomaly can easily be explained. Ketosis suppresses hunger, and dehydration endured while sitting under the hot sun of Uz (where Job lived) may lead to oliguria.
“But who can eat tasteless, unsalted food? What flavor is there in the white of an egg? I have no appetite for food like that, and everything I eat makes me sick” (Job 6.6).
“I have no strength left to save myself ….” (Job 6.13).
“You terrify me with dreams, you send me visions and nightmares.” (Job 7.14).
“The end of my life is near, I can hardly breathe.” (Job 17.1).
“My wife can't stand the smell of my breath.” (Job 19.17).
The aforementioned verse suggests a strong possibility of ketosis. Type 1.5 diabetes is characterized by ketoacidosis. In Job's case, multiple factors may have led to the ketonemia: Diabetes per se, starvation, and superadded infection.
“Instead of eating, I mourn, and I can never stop groaning.” (Job 3.24).
“I have no peace, no rest, and my troubles never end” (Job 3.26).
“When I lie down to sleep, the hours drag; I toss all night and long for dawn.” (Job 7.4).
“I lie down and try to rest; I look for relief from my pain.” (Job 7.13).
“At night my bones all ache; the pain that gnaws me never stops.” (Job 30.17).
Job describes the classic symptoms of painful sensory neuropathy, which worsens at rest or night. Restless legs syndrome and osteomalacia are other endocrine differentials that come to mind. A verse that suggests the possibility of osteomalacia is:
“God seizes me by my collar, and twists my clothes out of shape.” (Job 30.18).
“… My eyes are swollen and circled with shadows.” (Job 16.16).
“My grief has made me almost blind.” (Job 17.17).
The presence of microvascular and macrovascular complications at diagnosis is well documented. Nonretinal ocular complications of diabetes are also known. It is possible that Job may have had a refractory error related to changes in the refractive power of the lens because of hyperglycemia or an ocular infection.
“I wish I had died” (Job 3.11).
“I mourn and wear clothes made of sackcloth, and I sit here in the dust defeated.” (Job 16.15).
“My eyes pour out tears to God.” (Job 16.20).
“I am overcome with terror; my dignity is gone like a puff of wind, and my prosperity like a cloud” (Job 30.15).
Diabetes is frequently associated with psychological and psychiatric illness. Job's case is a perfect exemplar of the same. There seems to be a bidirectional link in his case: grief leading to dermatological infection (which is the presenting symptom of diabetes), that accentuated his poor metabolic health, which in turn disturbed Job's coping skills and precipitated depression. The depression is compounded by the economic and personal catastrophe that Job faced.
| A Happy Ending and Remission|| |
“The Lord answered Job's prayers.” (Job 42.9).
“The Lord made him prosperous again and gave him twice as much as he had had before.” (Job 42.10).
“Job lived-long enough to see his grandchildren and great grandchildren. And then he died at a very great age” (Job 42.16-17).
Type 1.5 diabetes mellitus has a clinical course, which mimics that of both type 1 and type 2 diabetes mellitus. The initial stormy picture accompanied by ketosis is usually precipitated by infection. This is followed by a prolonged phase in which glucose control is easily achieved with oral glucose lowering drugs or even in some cases lifestyle changes. The temporal profile of illness that the Book of Job relates is not uncommon in modern diabetes care. Patients on occasion present with significant “symptomatic” diabetes, accompanied by severe hyperglycemia and at times by ketonuria. The correction of lifestyle, along with supportive care, some of these patients are able to achieve remission of diabetes.
Job may have had impaired glucose tolerance, to begin with. Extreme grief and skin infection brought about by tearing of his clothes and smearing ashes on his body may have coincided or even precipitated the onset of type 1.5 diabetes, which deteriorated rapidly. The Biblical description of painful sensory neuropathy, with nocturnal worsening of symptoms, is classic of diabetic neuropathy. Pointers towards other microvascular dysfunction, in the form of ocular and renal symptoms, exist in the Book of Job. An endocrine Sherlock Holmes may also consider Addison's disease, due to tuberculosis, fungal infection, or autoimmune causes, as a strong differential. However spontaneous recovery from these diseases and remission is difficult to comprehend.
Syphilis could be a differential diagnosis, too, but Job was “a good man, careful not to do anything evil” (Job 1.2) and syphilis is usually accompanied by sensory painless neuropathy. Once Job learnt how to cope with his disease, through mindfulness meditation and calorie restriction, his symptoms abated. He was then able to return to a normal and productive life.
| Lessons for the Reader|| |
Diabetes has become endemic to modern society, and the health-care profession needs every help possible to tackle this condition. The Book of Job, from the Old Testament of the Holy Bible, offers such assistance.
The description of symptoms shared by Job should stimulate medical students to learn the possible differential diagnosis, and explore atypical forms of disease and presentation. The beautiful poetry that expands on various coping mechanisms exhibited by Job, and those suggested by his friends, should be understood in the context of modern life.
Healthy coping styles help in coping with illness as well and facilitate recovery from disease. Through this hypothesis, we hope to stimulate further interest and discussion in the diagnosis and management of diabetes. We welcome comments and ideas regarding other possibilities that Job may have had.
| The Patient's Viewpoint|| |
Job's words continue to echo today in our clinics and hospitals. We conclude with these verses of his, which, to us, epitomize the definition of patient-centered care.
“Listen to what I am saying; that is all the comfort I ask from you.” (Job 21.1-2).
“Give me a chance to speak and then, when I am through, sneer if you like” (Job 21.3).
“All scriptures passages are taken from the Good News Bible published by The Bible Societies/Collins@ American Bible Society.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The Bible Societies/Collins. The Book of Job: Good News Bible. The Bible Societies/Collins; 2008. p. 485-520.
Grimbacher B, Holland SM, Puck JM. Hyper-IgE syndromes. Immunol Rev 2005;203:244-50.
Brim CJ. Job' illness: Pellagra. Arch Dermatol Syphilol 1942;45:371-6.
Rosner F. Julius Preuss' Biblical and Talmudic Medicine. New York: Hebrew Publishing Company; 1983. p. 339-41.
Davis SD, Schaller J, Wedgwood RJ. Job's syndrome. Recurrent, “cold”, staphylococcal abscesses. Lancet 1966;1:1013-5.
Hartley JE. The Book of Job. Grand Rapids: Eerdmans; 1988. p. 82.
Adeyemo T. Africa Bible Commentary. Nairobi: Zondervan; 2006. p. 573.
Resende LA, Kirchner DR, Ruiz e Resende LS. Solving the conundrum of job: A probable biblical description of chronic renal failure with neurological symptoms. Arq Neuropsiquiatr 2009;67:544-7.