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Herod the Great and Polyarteritis Nodosa—Reply

Herod the Great and Polyarteritis Nodosa—Reply In reply These letters propose interesting alternative diagnoses for Herod’s illness. Hepatic schistosomiasis occurs when the fluke’s eggs lodge in portal venules, causing granulomatous inflammation, fibrosis, and presinusoidal portal hypertension. The most evident clinical consequences are hepatosplenomegaly, sometimes visible as abdomen fullness, and gastrointestinal hemorrhage from varices.1 Josephus does not mention these features. Since significant cholestasis is absent, pruritus does not occur. Unless other diseases coexist, hepatocellular function remains fairly normal, and hepatic encephalopathy seldom develops. Schistosomiasis, therefore, could not readily explain itching or mental changes. The correspondents suggest that Herod had platypnea caused by intrapulmonary vascular dilatations associated with liver disease (hepatopulmonary syndrome). Josephus describes Herod’s breathing problem in The Jewish War (Book I: Paragraph 656)2 with the word “orthopnea” in Greek, which means he could breathe comfortably only when upright. The passage in Jewish Antiquities (Book 17: Paragraph 169)3 is more difficult and can be translated as “a sharp straining of his breath” or, possibly, “shortage of breath in the upright position,” which would contradict his other account (written communication and draft translations from Steve Mason, PhD, and Jan Willem van Henten, PhD, scholars in the ongoing Brill Josephus project, which provides English translations and commentary of Josephus’ writings; August 10–August 12, 2004). Josephus is often inconsistent. Even so, hepatopulmonary syndrome appears to be rare in schistosomiasis. “A vehement appetite to eating” depends on Latin translations of Jewish Antiquities. The original Greek reads “he had a terrible desire to take something from it/him, for he could find no relief.” Latin translators interpreted “taking” as “eating,” but the best sense may be, “a terrible desire to take away some of his body parts, for absolutely none did its duty” (written communication and draft translations from Steve Mason, PhD, and Jan Willem van Henten, PhD; August 10–August 12, 2004). In both sources, Josephus describes Herod’s genital condition with words best translated as “gangrene,” “putrefaction,” or “rottenness,” which indicate actual tissue destruction rather than just edematous, ulcerated skin. Since Josephus provides no chronology of Herod’s illness, the duration of his genital problem is unclear, and Fournier gangrene, which can last for several days to weeks, remains the best explanation. Moreover, the putrefied scrotal skin in untreated Fournier gangrene sometimes sloughed, providing natural drainage of the infection, and many patients in the preantibiotic era survived this grievous affliction.4 Josephus’ descriptions indicate severe cutaneous injury. Because the testicular blood supply differs from that to the scrotal and penile skin, substantial cutaneous damage does not accompany testicular infarction, invalidating polyarteritis nodosa as a single, unifying diagnosis and demonstrating, once again, that Occam’s razor is often disposable. Polyarteritis nodosa is, however, a plausible explanation, among many, of Herod’s apparent uremia, and it has the added bonus (to the diagnosis, not to the patient) of causing mesenteric ischemia, which could explain Herod’s abdominal pain. Chronic lead poisoning also plausibly explains uremia and abdominal pain, but Josephus mentions no features that would specifically suggest it, such as gout or motor neuropathy. From what is known, Herod’s palaces were not supplied with water through lead piping. The controversial thesis of widespread plumbism among Roman Empire aristocrats from ingesting lead-containing wines and sweeteners rests on speculation rather than scientific validation, and, moreover, lacks specific information about conditions in Judea.5 Unfortunately, studies of skeletal lead content are complicated by the difficulty in distinguishing endogenous sources from contamination by metal in the soil.6 Correspondence: Dr Hirschmann, Medical Service (111), VA Medical Center, 1660 S Columbian Way, Seattle, WA 98108 (Jan.Hirschmann@med.va.gov). References 1. Ross AGBartley PBSleigh AC et al. Schistosomiasis. N Engl J Med 2002;3461212- 1220PubMedGoogle ScholarCrossref 2. Josephus F The Jewish War. Williamson GAtrans-ed. London, England Penguin Books1981;115- 119 3. Josephus F Jewish Antiquities. Books XV-XVII. Marcus RWikgren Atrans-eds. Cambridge, Mass Harvard University Press1963;439- 461Google Scholar 4. Randall A Idiopathic gangrene of the scrotum. J Urol 1920;4219- 235Google Scholar 5. Nriagu JO Lead and Lead Poisoning in Antiquity. New York, NY John Wiley & Sons1983;147- 148399- 415 6. Rothschild BMCoppa APetrone PP “Like a virgin”: absence of rheumatoid arthritis and treponematosis, good sanitation and only rare gout in Italy prior to the 15th century. Reumatismo 2004;5661- 66PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Herod the Great and Polyarteritis Nodosa—Reply

Abstract

In reply These letters propose interesting alternative diagnoses for Herod’s illness. Hepatic schistosomiasis occurs when the fluke’s eggs lodge in portal venules, causing granulomatous inflammation, fibrosis, and presinusoidal portal hypertension. The most evident clinical consequences are hepatosplenomegaly, sometimes visible as abdomen fullness, and gastrointestinal hemorrhage from varices.1 Josephus does not mention these features. Since significant cholestasis is absent,...
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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.164.22.2508-b
Publisher site
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Abstract

In reply These letters propose interesting alternative diagnoses for Herod’s illness. Hepatic schistosomiasis occurs when the fluke’s eggs lodge in portal venules, causing granulomatous inflammation, fibrosis, and presinusoidal portal hypertension. The most evident clinical consequences are hepatosplenomegaly, sometimes visible as abdomen fullness, and gastrointestinal hemorrhage from varices.1 Josephus does not mention these features. Since significant cholestasis is absent, pruritus does not occur. Unless other diseases coexist, hepatocellular function remains fairly normal, and hepatic encephalopathy seldom develops. Schistosomiasis, therefore, could not readily explain itching or mental changes. The correspondents suggest that Herod had platypnea caused by intrapulmonary vascular dilatations associated with liver disease (hepatopulmonary syndrome). Josephus describes Herod’s breathing problem in The Jewish War (Book I: Paragraph 656)2 with the word “orthopnea” in Greek, which means he could breathe comfortably only when upright. The passage in Jewish Antiquities (Book 17: Paragraph 169)3 is more difficult and can be translated as “a sharp straining of his breath” or, possibly, “shortage of breath in the upright position,” which would contradict his other account (written communication and draft translations from Steve Mason, PhD, and Jan Willem van Henten, PhD, scholars in the ongoing Brill Josephus project, which provides English translations and commentary of Josephus’ writings; August 10–August 12, 2004). Josephus is often inconsistent. Even so, hepatopulmonary syndrome appears to be rare in schistosomiasis. “A vehement appetite to eating” depends on Latin translations of Jewish Antiquities. The original Greek reads “he had a terrible desire to take something from it/him, for he could find no relief.” Latin translators interpreted “taking” as “eating,” but the best sense may be, “a terrible desire to take away some of his body parts, for absolutely none did its duty” (written communication and draft translations from Steve Mason, PhD, and Jan Willem van Henten, PhD; August 10–August 12, 2004). In both sources, Josephus describes Herod’s genital condition with words best translated as “gangrene,” “putrefaction,” or “rottenness,” which indicate actual tissue destruction rather than just edematous, ulcerated skin. Since Josephus provides no chronology of Herod’s illness, the duration of his genital problem is unclear, and Fournier gangrene, which can last for several days to weeks, remains the best explanation. Moreover, the putrefied scrotal skin in untreated Fournier gangrene sometimes sloughed, providing natural drainage of the infection, and many patients in the preantibiotic era survived this grievous affliction.4 Josephus’ descriptions indicate severe cutaneous injury. Because the testicular blood supply differs from that to the scrotal and penile skin, substantial cutaneous damage does not accompany testicular infarction, invalidating polyarteritis nodosa as a single, unifying diagnosis and demonstrating, once again, that Occam’s razor is often disposable. Polyarteritis nodosa is, however, a plausible explanation, among many, of Herod’s apparent uremia, and it has the added bonus (to the diagnosis, not to the patient) of causing mesenteric ischemia, which could explain Herod’s abdominal pain. Chronic lead poisoning also plausibly explains uremia and abdominal pain, but Josephus mentions no features that would specifically suggest it, such as gout or motor neuropathy. From what is known, Herod’s palaces were not supplied with water through lead piping. The controversial thesis of widespread plumbism among Roman Empire aristocrats from ingesting lead-containing wines and sweeteners rests on speculation rather than scientific validation, and, moreover, lacks specific information about conditions in Judea.5 Unfortunately, studies of skeletal lead content are complicated by the difficulty in distinguishing endogenous sources from contamination by metal in the soil.6 Correspondence: Dr Hirschmann, Medical Service (111), VA Medical Center, 1660 S Columbian Way, Seattle, WA 98108 (Jan.Hirschmann@med.va.gov). References 1. Ross AGBartley PBSleigh AC et al. Schistosomiasis. N Engl J Med 2002;3461212- 1220PubMedGoogle ScholarCrossref 2. Josephus F The Jewish War. Williamson GAtrans-ed. London, England Penguin Books1981;115- 119 3. Josephus F Jewish Antiquities. Books XV-XVII. Marcus RWikgren Atrans-eds. Cambridge, Mass Harvard University Press1963;439- 461Google Scholar 4. Randall A Idiopathic gangrene of the scrotum. J Urol 1920;4219- 235Google Scholar 5. Nriagu JO Lead and Lead Poisoning in Antiquity. New York, NY John Wiley & Sons1983;147- 148399- 415 6. Rothschild BMCoppa APetrone PP “Like a virgin”: absence of rheumatoid arthritis and treponematosis, good sanitation and only rare gout in Italy prior to the 15th century. Reumatismo 2004;5661- 66PubMedGoogle Scholar

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Dec 13, 2004

Keywords: polyarteritis nodosa

References