We are fascinated by other people's problems; we are fascinated by celebrity - and when celebrities have problems, the effect is synergistic, rather than additive. This is not merely the province of tabloids and day-time television - serious scholars crave their fix of morbid gossip too. Historical diagnosis has a long and juicy history, and in “Post Mortem”, Mackowiak revisits some of the most controversial diagnostic conundra from ancient times to the more recent past. In many cases we have only documentary accounts or artistic representations, and the reports of the times may be coloured by hearsay, political spin or mistaken superstition. Be that as it may, we like to feel in touch with our forebears, and maybe there is no better way to do it than to pick over their symptoms, real or imagined. This volume arises from a selection of cases from a series of historical Clinicopathological Conferences (CPCs; analogous to the Grand Rounds or clinical meetings that we in the UK know and love) held by the author in Baltimore, where he is a distinguished professor of Medicine.
The first case on Mackowiak's cold analytic slab is Egypt's heretic sun king Akhenaten, who ruled in the glorious heyday of the New Kingdom in the 14th century BCE. Abandoning the ways of his forefathers, Akhenaten launched a radical programme in which he overturned the cults of the traditional Egyptian gods, and promoted the monotheistic worship of his one true god, represented by the solar disc, the Aten. Even the traditional representational art of Egypt was re-defined, and his depictions show him with elongated limbs, a pot belly, a serpentine neck, and other features previously unseen - and unthinkable - in the normally austere and idealised Egyptian artistic canon.
There has been a lively debate over whether these were depictions of Akhenaten in his true likeness, or an affected artistic style encapsulating new Atenist ideas of other-worldly royal divinity. Taking the former approach, many scholars have proposed diagnoses that might account for this etiolated phenotype. By far the most plausible proposition in my opinion is the connective tissue disorder Marfan syndrome, although Mackowiak ditches this on relatively flimsy grounds in favour of Klinefelter syndrome. Akhenaten and his wife, the legendary beauty Nefertiti, had at least six children who were represented in a similar style to Akhenaten himself, which would seem to exclude Klinefelter at a stroke, as Klinefelter syndrome causes infertility (and it is not even a particularly good match for the phenotype). Mackowiak largely glosses over this important objection, and sticks with what I feel is the wrong conclusion. However, whatever hypotheses we construct, without DNA confirmation we are not going to be able to resolve the issue. Akhenaten's mummy has never been firmly identified, so this may remain an open question, although recent work in Egypt suggests that the genetics of the New Kingdom rulers (including Akhenaten's probable son, Tutankhamun) might be a soluble problem after all. Watch this space.
Other cases from antiquity range from Herod the Great, whose gangrenous penis and worm-ridden demise were recounted with evident relish by the Jewish historian Josephus, to the emperor Claudius of Rome, who was plagued by movement and personality difficulties. We then advance a millennium or so, and run across Joan of Arc, Christopher Columbus and Florence Nightingale, among others. The cases are presented in a modified clinical format that is immediately familar, although such terminology as “the patient” (when referring to the case in question) feels a little contrived when we are discussing such matters from the dim and distant past. Each chapter ends with a very welcome set of references, which will undoubtedly prompt many readers to delve a little deeper.
This volume lends itself well to dipping, as each chapter is pretty much self-contained. It is a pleasant read, and stimulates and informs in equal measure. It is unfortunately let down a little by several typographical errors that seem to have crept in at the editorial stage. I am left thinking that “Differential Diagnosis” might have been a more appropriate title (with the format re-structured accordingly), and that a rather more argumentative discourse might have appealed more to a medical audience – generally a cantankerous bunch. Nevertheless, we get a strong feeling of “what might have been”, had things turned out differently for our patients, or had their ailments been diagnosed correctly at the time. Perhaps it is indeed best that we have them at the remove of several centuries - for one thing, it makes the relatives less likely to sue.