Second Opinions

History winds up in the waiting room

By Cullen Murphy

If the story were presented as a formal medical case study, it might begin as follows:

S. is a thirty-five-year-old male of Middle Eastern ancestry with a long history of deceitfulness, physical violence, and other forms of unacceptable behavior. He is an only child; his mother had to be warned not to drink during pregnancy. The subject is known to be inordinately fastidious about his hair. His libido is powerful and indiscriminate. He is a nonsmoker. His life is believed to have culminated in a spectacular murder-suicide.

The case is that of Samson, son of Manoah, whose story is recounted in the biblical book of Judges, and it was cited not long ago in a letter to the editor of the Archives of General Psychiatry. The authors, led by Eric Lewin Altschuler, of the University of California at San Diego, suggest that Samson probably suffered from what would today be called antisocial-personality disorder, or ASPD. They note that psychiatry's official Diagnostic and Statistical Manual requires that three out of seven criteria be met in order to advance a diagnosis of ASPD, and that Samson's behavior met six of them. He was aggressive and impulsive. ("And he found a fresh jawbone of an ass, and put out his hand and seized it, and with it he slew a thousand men.") He was cruel to small animals. ("So Samson went and caught three hundred foxes, and took torches; and he turned them tail to tail, and put a torch between each pair of tails.") He lied and he stole. He preened and he gloated. He clearly manifested, according to the doctors, a "failure to conform to social norms with respect to lawful behavior."

If you're like me, you probably don't settle down with the latest issue of the Archives of General Psychiatry or The Annals of Thoracic Surgery or Genitourinary Medicine the instant it arrives. And yet anyone now catching up on medical literature from the past few years can't help being struck by the vast amount of attention devoted to intriguing cases from long ago. Large numbers of living Americans may have difficulty gaining access to decent health care, but if you happen to be a deceased historical personage, your chances of attracting first-rate medical attention are getting better all the time.

Physicians of yore did not always have a clear understanding of the ailments that afflicted their patients, but they left clues that have encouraged later speculation. Investigations by modern doctors have suggested that Catherine the Great suffered from syphilis, that Kant suffered from Alzheimer's, and that Brahms suffered from sleep apnea; that Van Gogh and Saint Teresa of Avila were afflicted with temporal-lobe epilepsy; that Chopin was felled by emphysema or cystic fibrosis; and that Mozart was done in by streptococcus, not by Salieri. An article in Clinical Toxicology argues that the Emperor Julian the Apostate and his successor, the Emperor Jovian, each experienced an episode of carbon-monoxide poisoning caused by the use of burning coals to heat a poorly ventilated room. (Julian recovered; Jovian, who had gone to bed in a drunken stupor, never woke up.) King Herod the Great underwent an unhappy demise. The chronicler Flavius Josephus, in The Jewish War, observed, "Distemper seized upon his whole body, and greatly disordered all his parts with various symptoms; for there was a gentle fever upon him, and an intolerable itching over all the surface of his body, and continual pains in his colon, and dropsical tumors about his feet." A closely reasoned analysis in the Journal of the Royal Society of Medicine provides a diagnosis: "end-stage type II diabetes mellitus."

The medical profession has long been home to a peculiar breed of hobbyist-detectives, most of whom work independently. They have started to find one another. For the past seven years the University of Maryland School of Medicine and the Baltimore VA Medical Center have hosted an annual "historical clinico-pathologic conference," the centerpiece of which is a case study of a medical mystery drawn from the history books. Each case study is handled by a designated investigator. "E.P. is a 40-year-old man who was brought to the emergency room in early October for evaluation of lethargy and confusion." Thus began the discussion, in 1995, of the case of Edgar Allan Poe. (The investigator that year, R. Michael Benitez, ventured the contrarian argument that Poe succumbed to rabies encephalitis, not to the effects of heavy drinking.) In 1996 the mystery case began like this:

A 32-year-old man presented with fever and pain in the right upper quadrant. The patient had been well until the day after a night of heavy alcohol consumption (12 pints of wine), when fatigue and generalized aches developed ... The patient was a native of northern Greece and was active in military service. He had traveled extensively through Asia Minor and the Middle East and to the Indian frontier. He had been married twice and was bisexual.

So: what brought an end to Alexander the Great? In the view of the investigator, it was "Salmonella typhi enteritis, complicated by bowel perforation and ascending paralysis."

One sub-branch of historical clinico-pathology involves looking for evidence of illness in works of art. A recent letter to the editor of the Journal of the Royal Society of Medicine points out the "attenuation of the outer third of the eyebrows" in contemporary portraits of Henry VIII and wonders whether the English King might have suffered from myxedema, a thyroid condition whose complications may include impotence and mental deterioration. A haunting item in The New England Journal of Medicine last fall drew attention to the misshapen marble breast on the allegorical female figure Night, by Michelangelo, in the Medici Chapel in Florence. The authors, an oncologist and an art historian, speculated that the woman used as a model was suffering from advanced breast cancer.

Literature, too, has come under newly intensive medical scrutiny. I remember once, years ago, attending a lecture at a gathering of Sherlockian scholars in Washington, D.C., at which a distinguished local pathologist went on for an hour about the possible ailments afflicting young Jack Ferguson in "The Adventure of the Sussex Vampire." (Conan Doyle, writing in the voice of Dr. Watson, had provided some clues. For instance: "The boy went off with a curious, shambling gait which told my surgical eyes that he was suffering from a weak spine.") An article in The Lancet in 1998 called attention to a case of "Alice in Wonderland syndrome," involving a patient's distorted perception of the size of personal body parts. Could the fantastical experience of Lewis Carroll's Alice be attributable to "ischaemia of distal parts of both anterior cerebral arteries"? Shakespeare's All's Well That Ends Well is the subject of a remarkable recent article by Bard C. Cosman, in the journal Diseases of the Colon & Rectum, which persuasively pinpoints the location of the French King's fistula, the cure for which is an important element of the plot.

"Disease has to be counted as one of the wild cards of history," the historian Robert Cowley writes, "an unforeseen factor that can, in a matter of days or weeks, undo the deterministic sure thing or humble the conquering momentum." Historians have long indulged a taste for counterfactual history—for asking "What if ... ?" questions, many of which hinge on medical issues. What if earlier intervention had arrested the throat cancer of Germany's Frederick III—thereby delaying Wilhelm's accession to the throne? What if Sennacherib's army had escaped the plague—and gone on to grind Jerusalem into dust?

The same sort of question could profitably be applied to literature. The medical investigation of pathology in fiction as yet lags far behind its counterpart in history, so "What if ... ?" has not been as frequently asked. But given the role of illness and death in literature, the field is potentially enormous. To be sure, many of world literature's most famous plots would not survive an encounter with antibiotics and the rest of the modern pharmacopoeia, but the stories would be free to evolve in happier directions. What if Oliver Twist's mother had survived childbirth? What if Beth, in Little Women, had enjoyed access to penicillin? What if Raskolnikov and Ophelia had known about Prozac? What if streptomycin had obviated the need for that tuberculosis sanatorium in The Magic Mountain?

Even the characters in a work as innocent as Winnie-the-Pooh may be long overdue for their checkups. Last December, Sarah E. Shea, a pediatrician, and several colleagues published an article in the Canadian Medical Association Journal titled "Pathology in the Hundred Acre Wood: A Neurodevelopmental Perspective on A. A. Milne." The authors contend that Pooh shows signs of "comorbid cognitive impairment" and attention-deficit hyperactivity disorder. Eeyore is given a diagnosis of "chronic dysthymia." Piglet "suffers from a Generalized Anxiety Disorder." Tigger exhibits "a recurrent pattern of risk-taking behaviours." The article recommends a variety of interventions, from methylphenidate (Pooh) to fluoxetine (Eeyore) to paroxetine (Piglet) to clonidine (Tigger).

Medical science can do nothing now for Catherine the Great or Mozart. But literary characters are, in a sense, immortal. And for them, help may be on the way.

This article available online at:

http://www.theatlantic.com/magazine/archive/2001/06/second-opinions/302241/