Jan. 28, 2002 BALTIMORE — Historians remember him as a brutal, unpredictable, paranoid and cruel leader. During his 36-year bloody reign as king of ancient Judea, Herod the Great ordered the executions of one wife and three sons, and, in a vain attempt to destroy the infant Jesus, directed the infamous Slaughter of the Innocents. It’s been more than 2,000 years since his death in 4 B.C., yet clinicians and scholars will unravel the mystery of what killed 69 year-old Herod the Great (or King Herod, as he is called in the Bible’s New Testament) during this year’s historical Clinical Pathologic Conference (CPC) sponsored by the Department of Veterans Affairs’ (VA) Maryland Health Care System and the University of Maryland School of Medicine in Baltimore.
"Herod the Great expired from chronic kidney disease probably complicated by Fournier’s gangrene," according to the medical investigative work of Jan Hirschmann, M.D., staff physician at the VA Puget Sound Health Care System and professor of medicine at the University of Washington’s School of Medicine.
"The texts that we depend on for a close description of Herod’s last days list several major features of the disease that caused his death—among them, intense itching, painful intestinal problems, breathlessness, convulsions in every limb, and gangrene of the genitalia," says Hirschmann.
Ordinarily, a CPC serves as a teaching forum where medical students can observe how an experienced clinician, working only with the case history of an unnamed patient, can accurately diagnose the probable cause of illness or death.
However, for Dr. Hirschmann, the challenge presented by the historical CPC will be two-fold. Working with a ‘blind’ case study, he will have to develop and present a credible diagnosis of the historical subject.
While past notions speculated that Herod the Great died from complications of gonorrhea, Dr. Hirschmann decided to dig deeper and focus on a single symptom of his final illness. He first determined what diseases could possibly cause it, then explored whether any of those diseases could explain the other symptoms.
"When I first looked at the general diseases that cause itching, it became clear that most of them couldn’t explain a majority of the features of Herod’s illness," says Dr. Hirschmann.
"At first, I considered Hodgkin’s disease and some diseases of the liver." Of the diseases that Dr. Hirschmann explored, the disorder that accounted for nearly all the features of Herod’s illness was chronic kidney disease. Still, one feature of Herod’s illness-- gangrene of the genitalia-- was not explained by that diagnosis.
"I finally concluded that the most likely explanation was that his chronic kidney disease was complicated by an unusual infection of the male genitalia called Fournier’s gangrene," explains Dr. Hirschmann.
Such detective work is part of the attraction of the conference, according to Philip A. Mackowiak, M.D., director of medical care at the VA Maryland Health Care System and professor and vice chair of medicine at the University of Maryland School of Medicine.
"We’ve been holding the historical CPC for eight years now," notes Dr. Mackowiak. "However, they’ve all been very different, so they remain exciting from one year to the next."
This annual conference, the only one of its kind in the world, is the brainchild of Dr. Mackowiak, who each year selects a new historical figure for study as well as a guest clinician and even noted historians who bring their own insights.
Since 1995, the historical CPC has examined the deaths of such notables as Edgar Allan Poe, Alexander the Great, Ludwig van Beethoven, General George A. Custer, Pericles, Wolfgang Amadeus Mozart and Claudius.
For Dr. Mackowiak, the conference serves a much greater purpose than that of a clinical exercise. "The historical CPC is cross-disciplinary. It links medicine to art, music, literature, and history in a special way that gives the liberal arts greater relevance to clinicians," he notes.
"In training physicians, we emphasize the science of medicine so much that we tend to ignore the relationship of medicine to society in general. This conference teaches our student and graduate doctors the importance of considering the art of medicine as well."
This year’s program will also feature a guest appearance by Herod the Great himself, as played in full costume by internationally known religion scholar Peter Richardson, Ph.D., professor emeritus at the University of Toronto’s Department for the Study of Religion. Richardson as King Herod will be interviewed onstage by another noted scholar, Ross Shepard Kraemer, Ph.D., professor of religious studies at Brown University.
"Herod is fascinating because of the complexity of his life and involvement with almost everyone who was anyone at that time—from Pompey and Julius Caesar through Augustus and Marcus Agrippa—all the great figures of late first century B.C. history," says Richardson.
"He was a very savvy politician and highly influential throughout the Eastern Mediterranean. Even after his death, his influence continued to be felt for hundreds of years."
Historians note that the volatile issues of the First Century B.C. Middle East can be connected with those of the 21st Century. "Herod’s world has a lot of relevance to our own," says Richardson. "He was 100 percent Arab by ethnicity and yet Jewish by religion. Many Jews of the time disliked Herod, because he was not Jewish by inheritance. From these early conflicts, you can draw clear comparisons to the conflicts in that part of the world today."
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