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Thursday, Jan. 24, 2002

NATURAL SELECTIONS

What was eating away at Judea's King Herod?


Herod the Great, King of Judea, died more than 2,000 years ago, in 4 B.C. He is remembered, among other things, for ordering the Massacre of the Innocents, the systematic execution of baby boys in Bethlehem. It was an attempt, if we are to believe biblical records, to kill the newborn Jesus.

The bloody example set by Herod in Judea in the first century B.C., marked by the paranoid, brutal and unpredictable nature of his 36-year rule, continues in the Middle East of the 21st century. Yet this week, Herod is not the subject of a historical discussion, but a medical one: at the Clinical Pathology Conference held at Baltimore's University of Maryland School of Medicine.

Jan Hirschmann, professor of medicine at the University of Washington's School of Medicine, will reveal on Friday how the 69-year old Herod died. Like the power struggles in the Middle East in Herod's time, the disease that claimed him is still around. And like the struggles, it is getting worse.

"Herod the Great expired from chronic kidney disease, probably complicated by Fournier's gangrene," said Hirschmann before the conference, whose historical diagnosis goes against the previously accepted theory that Herod died from complications of gonorrhea.

"The texts that we depend on for a close description of Herod's last days," added Hirschmann, "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."

Some of these symptoms are consistent with the advanced stages of gonorrhea infection. The fact that Herod had 10 wives -- not to mention his infamous lust for his stepdaughter, Salome -- was probably enough to convince historians that Herod, when not committing bloody atrocities, enjoyed female company, and thereby contracted the sexually transmitted disease. But Hirschmann wasn't convinced by the gonorrhea explanation and decided to dig deeper. He focused on a single symptom of Herod's illness: itching. In the sleuthing tradition of Sherlock Holmes, Hirschmann first identified all possible causes of the itching, then eliminated those that could not also account for the other known 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," he said. The medic-turned-detective considered Hodgkin's disease and some diseases of the liver, and found that the disorder that accounted for nearly all of Herod's symptoms was chronic kidney disease. But that didn't explain one particularly gruesome feature -- gangrene of the genitalia.

"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," explained Hirschmann.

The detective work is a major attraction at the conference, according to organizer Philip Mackowiak, vice chair of medicine at the University of Maryland. Each year Mackowiak selects a different historical figure to investigate. Previous subjects include Mozart, Claudius and General Custer.

"In training physicians, we emphasize the science of medicine so much that we tend to ignore the relationship of medicine to society in general," said Mackowiak. "This conference teaches our student and graduate doctors the importance of considering the art of medicine as well."

Peter Richardson, professor emeritus at the University of Toronto's department for the study of religion, agrees. As a Herod expert, Richardson is also taking part in the conference.

"Herod is fascinating because of the complexity of his life and involvement with almost everyone who was around at that time, from Pompey and Julius Caesar through Augustus and Marcus Agrippa," he said. "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."

Herod the Great was ethnically Arab, but Jewish by religion, a combination that is even more mind-boggling today than it must have been 2,000 years ago.

"Even after his death, his influence continued to be felt for hundreds of years," said Richardson.

And in a way, his influence is still felt now. As the subject of this year's conference, Herod's death highlights the horrors of Fournier's gangrene, a disease that is as distressing in its physical effects as Herod's political acts were in theirs. It is an aggressive, necrotizing (flesh-eating) microbial infection of the male genitalia. The blood supply to the genitals is restricted, and gangrene develops. As the infection progresses, the surrounding tissue swells and rots, and fever, chills and malaise set in. The condition is potentially fatal. Upon diagnosis, immediate surgery is required.

The most likely causes of Fournier's gangrene today are diabetes mellitus, alcoholism, intravenous drug use and immunosuppression. The last reason explains why this rare disease is starting to show up more and more in medical journals. Immunosuppression is, of course, the hallmark of AIDS.

In Africa, some 6,000 people die of AIDS every day. In Zambia, one of the worse-affected countries, one study found 10 cases of Fournier's gangrene in a 14-month period. In the pre-HIV era, there was one case a year.

Hirschmann's investigation will have value over and above its cross-disciplinary benefits if it succeeds in increasing awareness of the terrible disease that killed Herod.

E-mail Rowan Hooper at rowan@japantimes.co.jp


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