Diagnosing the past

The bare bones of diagnosis

Sometimes pathogens can be identified in past populations through the analysis of skeletal remains. Debates around the causes of the Black Death, which reduced the population of Europe by at least a third in the mid-14th century, went back and forth between academics from all backgrounds up until the end of the 20th century.

Some argued for the bacterium Yersinia pestis – bubonic plague – others for something else. But with DNA evidence from plague pits and collaboration between scientists and historians, we now know that a primitive strain of Yersinia pestis was in fact the culprit – or at least, one of the culprits.

In the majority of cases, however, we can’t use bones to give us answers, because most diseases don’t affect skeletal remains.

King Alfred’s complaint

I don’t want to make this purely about monarchs and other famous figures, but unfortunately those are the individuals whose lives we know the most about, so they are prime targets for retrospective diagnosis.

Let’s begin, then, with a well-known figure from Anglo-Saxon England: Alfred the Great, King of Wessex (871–99). In 1991, nurse Gillian Craig published an article giving Alfred a definitive diagnosis of Crohn’s disease, a modern autoimmune condition that causes the intestines to inflame. The most common symptoms include pain, bloating, diarrhoea, anal fistulas  and lethargy. Occasionally, people with Crohn’s experience constipation.

We don’t have Alfred’s bodily remains, and even if we did, his skeleton would tell us nothing about any soft-tissue problem. Craig’s claim is based purely on written sources. Asser’s ‘Life of Alfred’ was written by a man who was intimately acquainted with Alfred. Asser tells us that after Alfred’s marriage to Ealhswith in 868, he:

So Asser reveals that Alfred suffered pain (although not where he had this pain), and that some people thought it was caused by a fever and others by piles (ficus in Latin).

The saintliness of suffering

The other piece of evidence for Alfred’s ‘condition’ is Bald’s ‘Leechbook’, a medical compendium assembled in Alfred’s reign. The ‘Leechbook’ states that Elias, Patriarch of Jerusalem, sent Alfred some remedies for constipation, diarrhoea and pain in the spleen. Diarrhoea and constipation are such universally common conditions that it isn’t particularly surprising that he would be sent remedies for them.

This, then, is the sum total of the evidence that we have for Alfred’s illness. Bald’s evidence is brief, and we must keep in mind that Asser’s ‘Life’ is written in a hagiographical form – that is, a text designed to emphasise the sanctity of the subject. One of the things these sorts of texts do is stress extreme suffering as a marker of saintly worth. So, despite the fact that Asser knew Alfred personally, he might well have exaggerated just how awful Alfred felt.

Fungus or witchcraft?

Retrospectively diagnosing modern medical conditions in past populations is also a way to try and understand mindsets that are alien to us. To steer away from the royals, let’s take a diagnosis that’s been applied to a group of people. Ergotism is a condition caused by the long-term ingestion of a fungus called ergot that grows on grains of rye. Ergot contains a toxin with properties similar to those of LSD, and therefore causes mental symptoms such as psychosis and mania, as well as gastric upset and convulsions.

In the 1970s, Linnda Caporael, a behavioural psychologist, was studying the Salem witch trials of 1692. Witchcraft was blamed when several children in Salem became very unwell. Reported symptoms included abnormal speech, strange postures and gestures, and convulsions. Based on an examination of these symptoms, the weather conditions that year, which allowed the fungus to grow, and Salem’s physical environment (which was also favourable to ergot), Caporael published an article in 1976 suggesting that ergotism was the cause of the sickness.

It is undoubtedly a good thing to want to exonerate women falsely accused of a crime they almost certainly did not commit nearly 400 years ago. And Caporael does acknowledge the problem with alien mindsets:

Suggesting a modern medical condition as a cause flattens out a fascinating snapshot of life in early America. It’s much more interesting, in my opinion, to examine the cultural and social context in which these accusations arose to get a fuller picture.

Groin strain and gonorrhoea

Another problem in diagnosing the past is one of terminology. Let’s take ‘gonorrhoea’, a common diagnosis in early modern records. An interesting example is that of Robert Higgens, who consulted the astrologer and medical practitioner Richard Napier in January 1604. Higgens sprained his groin by leaping over a hedge, and this caused ‘gonorrhoea’.

Of course, today the word ‘gonorrhoea’ refers to a specific sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae. But in the 17th century gonorrhoea – from the Greek gonos (semen) and rhoia (flux) – meant a discharge from the genitals. According to the physician Pieter van Foreest (1521–97), gonorrhoea had three causes: sexual transmission, trauma to the genital area, and celibacy (thanks to Boyd Brogan for sharing his translation of van Foreest's work). So based on this definition, Napier’s diagnosis makes perfect sense.

Historians trying to trace a history of Neisseria gonorrhoeae through written documents are likely to be misled, especially since one cause of this condition in the early modern period was celibacy – the very opposite of how the gonorrhoea we know today is spread.

The madness of King George?

A final important issue with retrospective diagnosis is that it can be used as a political tool, as in the example of George III (1738–1820). Alan Bennett’s play ‘The Madness of George III’ and the film adaptation ‘The Madness of King George’ suggest that George was not ‘mad’, but was suffering from a condition called porphyria, a neurological disorder of which periods of confusion are one symptom.

The diagnostic team behind this claim were a mother-son psychiatric duo, Richard Hunter and Ida Macalpine, whose book ‘King George and the Mad-Business’ (1969) was hugely popular. The authors combed the voluminous records produced by George’s physicians during his several periods of incapacity, and picked the symptoms that suited their conclusion.

Even from a modern perspective, this diagnosis does not stand up, as pointed out in several articles by Timothy Peters (a physician who, unfortunately, goes on to give us his own questionable retrospective diagnosis that George’s problem was bipolar disorder). Acute porphyrias usually have a genetic basis, so we would expect to hear reports of similar symptoms in both George’s ancestors and descendants. But such evidence does not exist.

So why was the diagnosis of porphyria so readily accepted? Simply put, the idea that the royal family might be ‘tainted’ with mental illness was not savoury, and the porphyria diagnosis was a way to show that George’s problem had a physical, ‘unpreventable’ cause.

The sad truth is we will probably never shake the porphyria myth. Whatever afflicted George, he was severely impaired over long periods. Working out ‘exactly what was wrong’ says nothing about his life – or his suffering.

Stories about symptoms and society

Retrospective diagnosis is by no means a done debate among historians of medicine – many colleagues who I respect a great deal will disagree with my position. I may even change my mind in future.

But for now, I don’t see it as my job to impose modern categories of thinking onto past cultures. My role is to discover how medical practitioners and patients in the past thought about their illnesses – how they diagnosed sickness, what their treatments were, and how they described their diseases – in order to better understand the worlds they inhabited.