Abstract
Reassessment of the illnesses of famous historical figures has sometimes led to revised diagnosis and provided insights into former areas of medical practice. However, such reassessments may be difficult as the historical person cannot amplify his medical history, medical records may be incomplete, the physical findings may be inadequate and key laboratory diagnostic tests may have not been performed.
Despite these hindrances, some reviews have led to more precise diagnostic probabilities. But which cases should be analysed? Some indication may be given when clinical data may have previously been interpreted erroneously, details of an illness may be in an obscure source that awaits discovery, new information may have emerged recently, knowledge of candidate diseases may have been insufficient at the time, key diagnostic studies may have been unavailable, new medical discoveries may lead to a diagnostic re-evaluation and emotional investment in a diagnosis may have discouraged analysis.
Archival materials include medical records, pictures, writings and correspondence from the subject, physicians, family, friends and colleagues. The search may take one to medical libraries, historical collections, newspapers and other pertinent sources.
Much may be gained from examining the remains of famous individuals. Analysis of human and microbial genes in preserved tissues may provide evidence for a genetic or infectious disease. Heavy metal toxins found in hair, bones or other preserved tissues 1 can be informative. Skeletal remains and remnants of other organs can be imaged for evidence of disease including congenital deformity and trauma, or infectious disease such as tertiary syphilis or tuberculosis. Imaging methods augmented by computer analysis can also aid in reconstructing facial and other body configurations that might help in diagnosis.2,3 In addition, the family history and genetic analysis of descendents may be helpful. Investigators should also understand that medical archaeology poses certain important ethical questions. When should disinterment be permitted? What investigational purposes are ethically acceptable? Who should give permission?
The time in which we live dictates our understanding of disease processes and the available diagnostic tools. Before and during the first half of the 19th century, the diagnosis of most disease was limited to historical, physical and gross anatomical findings. From the mid-19th century to the early part of the 20th century, the diagnosis of most infectious diseases was limited to bacterial stains and cultures and to histopathology. By the mid-20th century the diagnostic armamentarium included radiology, cytology, chemical and serological tests, and bacterial stains and cultures. During the last half of the 20th and in the early 21st century, many diagnostic methods were discovered including advanced microscopy, more sensitive imaging methods, immunological techniques, specialized biochemical tests and molecular genetic analyses.
It is easy to second-guess physicians who practised before modern times; physicians are limited by the knowledge and tools of their times. Surely, future physicians and historians will shake their heads at the depths of our ignorance. Thus, when medical diagnoses in past eras are found to be questionable, it is wise to admit that we would have most likely come to the same conclusions if we had lived then. Moreover, some diseases remain unfathomable. For example, the cause of Wolfgang Amadeus Mozart's death at the age of 35 years in 1791 remains obscure. Suggested causes include arsenic poisoning, 4 trichinosis, 4 a beta-haemolytic streptococcal infection, 5 bacterial endocarditis, 6 Henoch-Schönlein purpura,4,7 rheumatic fever, 8 renal failure 9 and the obscure disease ‘hitziges Frieselfieber’ (military fever).4,8,10 One of these diagnoses may be correct but the paucity of data and conflicting observations render the problem unsolvable for now. Thus, retrospective analyses are limited by the amount of relevant clinical data and by the meaning of certain medical terms used centuries ago. Even when an alternative diagnosis is reasonable, the conclusion should be stated as a probability and not as certainty unless the new evidence really is conclusive.
What is to be gained from a retrospective evaluation of an illness of a famous individual? History will not change but insights may be gained into the medical knowledge and practices of that time and how medicine and society interacted. An understanding may be obtained as to how afflicted individuals contended with particular diseases at given times in history. Finally, such cases may demonstrate the importance of clinical skills and analytical thinking in medical diagnosis.