Doctors, diagnoses and detective work

Forum: Professionals gather to discuss the deaths of historical figures -- and enhance their appreciation of the art of medicine.

January 26, 2002|By Jonathan Bor | Jonathan Bor,SUN STAFF

He ruled Judea with grandeur, building palaces, fortresses, aqueducts, entire new cities and the Mediterranean's best harbor. On the downside, he was a famous despot who killed his favorite wife, three of his children and assorted rivals.

These facts are known about Herod, the Roman Empire's client-king who ruled for 34 years until his death in 4 B.C. Historians are less sure about this: What caused his horrible, painful death?

Since June, Dr. Jan V. Hirschmann of the University of Washington in Seattle has been pondering the question, poring over an intriguing list of symptoms that included itching, fever, intestinal pain, swollen feet, depression, convulsions and gangrene in a most uncomfortable place.

Yesterday, he gave his answer to about 150 doctors, historians and students who gathered beneath the Roman-style dome of Davidge Hall on the campus of the University of Maryland School of Medicine.

Although Hodgkin's disease was a close contender, Hirschmann said he was reasonably sure -- if not certain -- that the culprit was kidney disease, or renal failure.

The occasion was the school's eighth annual clinicopathological conference, a forum in which a medical expert is asked to diagnose the illness that killed a famous historical figure. The event is sponsored by the medical school and the Veterans Affairs Maryland Health Care System.

In the past, guest lecturers have diagnosed the illnesses suffered by such figures as Edgar Allan Poe (rabies), Alexander the Great (typhoid fever), Pericles (typhus), Beethoven (syphilis) and Emperor Claudius (a mushroom toxin called muscarine).

Dr. Philip A. Mackowiak, the VA's medical director and conference coordinator, said the exercise gives students and doctors "a better appreciation for the art of medicine, as opposed to the science of medicine."

The conference also helps students consider how medicine is reflected in art, music and history, and that helps make them better doctors, he said.

Also, he said, it's fun.

To make his diagnosis, Hirschmann relied on an account written by Jewish historian Flavius Josephus about a century after the king's death.

"He had a fever, though not a raging fever, an intolerable itching of the whole skin, continuous pains in the intestines, tumors in the feet as in dropsy, inflammation of the abdomen and gangrene in the privy parts," Josephus wrote.

Trying one remedy after another, Herod allowed doctors to lower him into a bath of hot oil, "whereupon he fainted and turned up his eyes as though he were dead."

But he lived to suffer more, and tried at one point to end his life by stabbing himself with a paring knife. Restrained, he eventually died not by his own hand but from his affliction.

In a speech peppered with literary and historical references that spanned the ages, Hirschmann said the diagnosis required, in the words of 19th-century intellectual William James, "a peculiarly stubborn effort to think clearly."

He acknowledged that when he reviewed the symptoms, "it didn't add up right away."

Relying on a tried-and-true method, he selected a symptom -- in this case, itching -- that is caused by only a few systemic diseases. Then he reviewed the short list of illnesses to determine whether any was consistent with the rest of the patient's symptoms.

Hirschmann considered disorders of the thyroid, liver and blood, as well as Hodgkin's and chronic kidney disease. All are known to cause itching, but only kidney disease explained the remaining symptoms.

Except for one.

Hirschmann, who also is a staff physician at the VA Puget Sound Health Care System, was left with the perplexing question: How could kidney disease explain what might have been the king's most horrifying affliction, gangrene of the genitals?

The condition, also called Fournier's gangrene, is not a classic symptom of renal failure but could have been indirectly related, he said. Perhaps, he said, it was the result of a spreading intestinal infection. Or maybe he scratched himself so furiously that he introduced bacteria to his skin, causing a worsening and disastrous infection.

Later in the program, two professors held a mock dialogue intended to educate the audience about less clinical aspects of the Herod's life.

Ross Shepard Kraemer of Brown University played herself. Peter Richardson of the University of Toronto played King Herod, dressed for the occasion in a green robe trimmed in gold.

Touching on various topics, the king explained why he killed his wife ("I came to love her very deeply ... but she was willful and had a mind of her own") and denied that he ordered the Slaughter of Innocents, the biblical account of the killing of babies in Bethlehem.

"Utterly false," he said.

The king had one thing to say about his illness and the suffering it caused: "It was desperately uncomfortable."

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