The 8th Historical Clinicopathological Conference


Presentation of Case

A 69 year-old man presented with chronic low-grade fever, edema, abdominal pain, insatiable hunger pangs, shortness and foulness of breath, pruritus, inability to stand, convulsions, and, according to one source, “gangrene of his privy parts, engendering worms.” His illness had begun some weeks to months earlier, and had caused steady deterioration of both his physical and mental condition. The patient became convinced that his illness was terminal and began exhibiting signs of depression. About a week before dying, he attempted suicide with a paring knife but was restrained. Prior to the suicide attempt, he had sought treatment for his illness from medical experts. They prescribed total immersion in a bath of hot mineral oil. The treatment was not beneficial, and actually scalded the patient’s eyes causing temporary blindness.

For most of his life, the patient had enjoyed remarkably good physical health. He was a skillful soldier and a politician with a reputation as an accomplished builder and philanthropist, both in his own kingdom and abroad. His only recorded prior disability was a war injury to his side from which he recovered quickly. There is no mention of any previous illnesses. In fact, his biographer states that as a young man he was an outstanding archer, javelin thrower, and hunter. He survived several military campaigns, most of which were successful, and he showed considerable ability as a military commander.

He had ten wives and fourteen children, including nine sons. He also had at least two brothers and a sister. His sister served as de facto “first lady” of the kingdom. One of his brothers died a violent death at the hands of foreigners; the other two siblings died of natural causes after long lives. Otherwise, nothing more is known of their medical histories. The cause of death of the patient’s mother is unknown. The patient’s father was a politician who was poisoned by political enemies.

Whereas the patient’s physical health had been excellent until his terminal illness, his mental health left something to be desired. He was suspicious, distrustful, paranoid and mean-spirited to the point of cruelty. These qualities seemed to increase as he grew older. During his thirty-four years as king, he had one of his wives and three of his sons executed, and he ordered the deaths of numerous political opponents including several religious leaders. During the final weeks of his life, when he knew his condition was terminal, he ordered dozens of the leading men in his kingdom brought to his city and imprisoned. He then instructed his sister to have all of the hostages executed upon his death, in order to ensure “mourning throughout the land” when he died. Five days before he died, he ordered the crown prince executed for “disloyalty.”

The patient’s biographer gives the following two descriptions of the final days of his terminal illness:

” From this time onwards, [his] malady began to spread to his whole body and his sufferings took a variety of forms. 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 of the privy parts, engendering worms, in addition to asthma, with great difficulty in breathing, and convulsions in all his limbs. His condition led diviners to pronounce his maladies a judgment on him for his treatment of the professors. Yet, struggling as he was with such numerous sufferings, he clung to life, hoped for recovery, and devised one remedy after another. Thus he crossed the [river] to take the warm baths at Callirrhoe, the waters of which descend into the Lake Asphaltitis and from their sweetness are also used for drink. There the physicians deciding to raise the temperature of his whole body with hot oil, he was lowered into a bath full of that liquid, whereupon he fainted and turned up his eyes as though he were dead. His attendants raising an uproar, their cries brought him to himself, but, now despairing of recovery, he gave orders to distribute 50 [coins] per head to the soldiers and considerable sums to his friends.”

“But [his] illness became more and more acute, for God was inflicting just punishment upon him for his lawless deeds. The fever that he had was a light one and did not so much indicate symptoms of inflammation to the touch as it produced internal damage. He also had a terrible desire to scratch himself because of this, for it was impossible not to seek relief. There was also an ulceration of the bowels and intestinal pains that were particularly terrible, and a moist, transparent suppuration of the feet. And he suffered similarly from an abdominal ailment, as well as from a gangrene of his privy parts that produced worms. His breathing was marked by extreme tension, and was very unpleasant because of the disagreeable exhalation of his breath and his constant gasping. He also had convulsions in every limb that took on unendurable severity. Accordingly it was said by the men of God and by those whose special wisdom led them to proclaim their opinions on such matters that all this was the penalty that God was exacting of the king for his great impiety. But though he was suffering greater misery than could well be endured, he still had hopes of recovering, and so he summoned his physicians and made up his mind to use whatever remedies they might suggest. He therefore crossed the river and took baths in the warm springs at Callirrhoe, the waters of which beside all their other virtues are also good to drink. Now these waters run into Lake Asphaltophoros, as it is called. And when his physicians decided to warm his body there and had seated him in a tub of (warm) oil, he looked to them as though he had passed away. But he was brought round by the cries of lamentation uttered by his servants, and since he had not the slightest hope of being restored to health, he gave orders to distribute 5-[coins] apiece to all his soldiers. He also gave considerable sums to their officers and to his friends.”