Dead Men Talking

Did Julius Caesar stage his own death? Was King Tut murdered? And what killed Alexander the Great? A forensic psychiatrist joins hot debates over cold cases.

Harvard Medical Alumni Bulletin, Spring 2005

by Harold J. Bursztajn

Julius Caesar, the Haruspices warned, would ignore their gut instincts at his own peril. One morning in early March 44 B.C., these specialists in the Etruscan art of divination carefully peered at sacrificial animal entrails. The signs were troubling. But Caesar would not be deterred from his plan to attend the Senate.

It was not the only dark omen the fabled Roman dictator received—and ignored—in the days preceding his murder. A soothsayer had famously warned him that a grave danger would befall him no later than the Ides of March. Caesar's wife was so disturbed by her dream of their house collapsing that she begged him not to leave that fateful day. And as Caesar made his way to the Senate, someone who had learned of the conspiracy pressed a warning note into the doomed man's hand.

While many historians agree on the chain of events surrounding Caesar's assassination—one of the most meticulously documented murders in history—an intriguing question remains: why did this man succumb in the manner he did? Did Julius Caesar—a genius, a shrewd general who never lost a battle, and perhaps history's most brilliant military tactician—really walk blindly into a trap? He had access to high levels of intelligence; he even died with the warning note clutched in his hand. Why did he dismiss his bodyguards shortly before his murder? How could such a wily, well-informed power broker and long-term political survivor come to be killed in front of hundreds of witnesses at a Senate gathering?

When Atlantic Productions, a British-based, award-winning television production company, asked me to participate in its investigation into this puzzle for the Discovery Channel, I couldn't resist. To cover as many angles as possible in its planned documentary—"Who Killed Julius Caesar?"—the company had assembled a team of researchers that included an internationally distinguished forensic criminal investigator and several talented classical historians. This would not be my first foray into the realm of psychohistorical inquiry. I had already served as a forensic psychiatric analyst on another Discovery Channel program, "The Assassination of King Tut."

In the Caesar analysis, I would be applying many of the same tools and principles 1 had employed on the Tut project. Psychoanalytically informed decision analysis modifies the assumption of traditional decision analysis—that under conditions of uncertainty, humans make choices based on rational self-interest—with the psychoanalytic perspective that "rational" and "irrational" in a given context may not be obvious, commonsensical, or universal. I was intrigued by the chance to apply this type of analysis to the seeming paradox of Caesar's murder.

Body of Evidence

Although the crime took place more than 2,000 years ago in a setting that now bears little resemblance to the imposing complex it once was—today the locals use the ruins of Pompey's portico as a cat sanctuary—substantial and detailed clues remain. The conspirators had not intended to leave such a trail; their original plan, historical sources recount, had been to dump Caesar's lifeless body in the nearby Tiber. The reasons behind the timing and motive of their change of heart remain murky, but all accounts agree that Caesar's corpse lay sprawled on the spot where the dictator had been cut down for some time before slaves finally transported it to Caesar's household.

Antistius, a doctor who may have been Caesar's personal physician, was summoned to conduct a postmortem examination. According to his autopsy report—perhaps history's first recorded application of medical knowledge to a homicide investigation—only one of Caesar's 23 stab wounds had proved fatal. Although it is impossible to verify Antistius's conclusions—the frenzied crowd at Caesar's public funeral improvised a pyre and cremated the body—his inquiry marked the beginning of the pathologist's role as expert witness to murder.

Given our inability to reexamine the physical evidence, it made sense to extend our investigation in a different forensic direction, one geared toward psychiatric analysis. The Italian detective on the case, Luciano Garofano, was anxious to reassess questions about Caesar's physical and mental conditions in the period leading up to the assassination. Specifically, Garofano sought to understand why Caesar had acted so strangely in the weeks before his death.

We contemplated in particular one instance of Caesar's odd behavior that took place not long before his murder. By 44 B.C. resentment of Caesar was already festering among Rome's powerful old aristocratic elite. He had been named dictator for life, and some citizens referred to him as their king, although Caesar had ostentatiously refused to accept a crown, despite adopting many regal trappings. In January of that year, Caesar's likeness began appearing on Roman coins. This unprecedented, shocking use of the image of a living person fueled suspicions that Caesar, despite his protestations, was planning to overthrow the republic and declare his reign royal. Rumors swirled that an illegitimate Egyptian son—by Caesar's lover Cleopatra—would succeed Caesar, a prospect that left Rome's aristocracy aghast. When a group of senators went to Caesar—according to some accounts, to placate his ambitions by offering him deification—rather than rising to honor the senators upon their arrival, he remained seated, a grievous insult that may have sealed his fate.

Plutarch claimed that Caesar refused to stand for fear of having an epileptic seizure, while another ancient historian, Dio, suggested that Caesar may have stayed in his seat to prevent an attack of diarrhea. Considering other details in descriptions of his behavior, the question as to whether temporal lobe epilepsy influenced Caesar's choices seemed well worth exploring. Symptoms of temporal lobe epilepsy, which become more common as the seizures progress and become more generalized, include increased dissociation and incontinence of bladder and bowel.

As 1 reviewed all the evidence, including Caesar's medical history, a suspicion began to form. Might Caesar, driven by narcissistic concern for his own image and dignity, have engineered his own death? Might a man who had risen to become the most powerful ruler in his world have found it deeply humiliating to lose control of both his sense of continuity in space and time and his body in public? It is reasonable to infer that Caesar would have found it far more painful to be perceived as pitiable and incontinent than haughty and rude. The life choices he faced might have struck him as especially stark: old age and increasing fits, temporal lobe-influenced loss of memory, and even public diarrhea—or a dramatic exit worthy of the most powerful dictator the world had ever known.

Suicide by Cop?

I next raised the question of whether Caesar's pubic murder was not simply a narcissist's suicide, but also a consciously chosen strategic act designed to ensure his succession. One classical historian on our team has argued that Caesar effectively handed the conspirators a deadline when he announced his impending departure for war with Parthia. Garofano noted that Caesar secretly changed his will to name his successor six months before his death—and he left every citizen enough money to live on for three months, guaranteeing a groundswell of mourning and adulation. It does not seem farfetched to interpret these events not as the acts of a man blinded to his vulnerability by his own arrogance, but as the careful orchestrations of someone who, in writing about his life, clearly craved historical immortality.

It is one hypothesis but no more than that; I used forensic neuropsychiatry and psychoanalytically informed decision analysis as ways to open other paths of inquiry, rather than to come to a definitive conclusion. As a working psychoanalyst, I exercise curiosity in the most private of settings about an analysand's received truths and accepted "absolute" wisdom, to help free the analysand to ask previously unthinkable questions. As a forensic psychiatrist, I work on interdisciplinary teams to explore potential translations between the clinical world of meaning and the legal world of objectivity, to understand the choices people make when faced with ambiguity or adversity.

While the circumstances of Caesar's death must remain shrouded in speculation, the aftermath clearly dovetailed with his enormous ambitions. Within a few years, every one of the conspirators would be dead, some by their own hands. The Roman Republic, which the killers had ostensibly hoped to preserve, effectively ended with Caesar's murder. Power passed quickly from the dead dictator to his handpicked successor. Caesar's grand-nephew Octavius was only 19 at the time of his uncle's assassination, but as the chief heir to Caesar's tremendous fortune and powerful family name, he commanded the loyalty of the Roman middle and lower classes outraged by the murder of their champion. He would become Rome's first emperor, known as Caesar Augustus.

Two years later, his dead uncle would be formally deified as "the Divine Julius," and Caesar Augustus would take the title of "Son of God." Every Roman emperor who followed Augustus also adopted Caesar as part of his name until the reign of Hadrian, who designated Caesar as the title of the heir apparent; the imperial use of Caesar would reverberate many centuries after Julius Caesar's death with the German Kaiser and the Russian czar, cementing a legacy of immortality that perhaps even Caesar himself couldn't have imagined. But, then again, Caesar had always gotten everything he wanted in life. Why not also in death? ■

Pyramid Scheme

Of all history's medical mystery Controversies, none has raged more fiercely than the question of whether King Tutankhamun's death resulted from natural causes or foul play Did the 1 8-year-old boy-king fall victim, as one scholar has proposed, to an infected insect bite? To tuberculosis? To an accidental fall from a chariot? To poison? Or to an assassin's blow to the back of his skull? These are just a few of the many theories that have been hove advanced over the years.

This spring, the media widely reported that the mystery had finally been solved; King Tut, a team of Egyptian scientists who conducted the first-ever CT scans on his mummy concluded, hoc not been murdered but had likely died of gangrene that set in following a leg fracture. Yet, while the media presented the team's findings as definitive, not all scholars are convinced.

In my role as a forensic psychiatric analyst on the Discovery Channel documentary, "The Assassination of King Tut," I considered a number of people in Tut's inner circle who might have had the motive, means, and opportunity to engineer the young king's demise. The two principal suspects. Ay, Tut's prime minister who succeeded Tut as king and appears to have forced Tut's widow into marriage, and Horemhab, Tut's military commander, who in turn succeeded Ay to the throne, were the de facto rulers of Egypt from the time Tut was crowned at the age of nine.

As Tut matured into manhood, he would likely have posed a threat to their behind-the-scenes power. To be a compliant child in need of the protection of a powerful regent might mean something very different than to be an adolescent king eager to take the reins of power from that regent. People will resort to far riskier acts, including murder, to avoid the loss of power than they might simply to gain power. When the question is asked, "Who had the most to lose from Tut continuing to be alive?" only one suspect leaps out as prime: Ay, whose influence could only diminish as the king came into his own.

Although the Egyptian investigators insist that the physical evidence points away from conspiracy, others are not so sure. Experts continue to disagree about the origin and significance of bone fragments found loose in Tut's skull. Some suspect they resulted from the embalming process itself or from early rough handling of Tut's mummy by archaeologists. To others, they signal evidence of lethal—perhaps deliberate—head trauma. Tut might have been particularly vulnerable to a fall—or a push; some experts have interpreted the x-rays of his mummy as revealing signs of Klippel-Feil syndrome, a musculoskeletal malformation that can make it impossible for those born with the condition to turn their heads without moving the entire torso. Even if Tut suffered from a medical condition that increased his risk of accidental death, that doesn't necessarily mean that his death was an accident.

It is possible that the mystery will never be solved to everyone's satisfaction; the politics of contemporary Egyptology are every bit as complex as the politics of power were during Tut's reign, with many staking out absolutist claims about what remains a case open for analysis. ■

Alexander the Great

Alexander the Great was one of the most powerful military conquerors who ever lived, a daredevil who insisted on personally leading the charge into battle. He founded numerous cities and colonies, was crowned pharaoh of Egypt and king of Persia, and survived war-related injuries and illnesses ranging from hypothermia, to arrow strikes, to a splintered rib and torn lung. Is it possible that this man, one of history's fiercest warriors, succumbed to a broken heart?

Whispers of regicide swirled when 32-year-old Alexander met his sudden, mysterious end. Ancient chroniclers agree that, following one of his customary bouts of heavy drinking with friends, Alexander came down with a burning fever. His condition deteriorated steadily for nearly two weeks before he died. Scholars have proposed a number of natural causes, including malaria, tuberculosis, influenza, alcoholic liver disease, schistosomiasis, leptospirosis, and even West Nile virus. One infectious-disease expert theorized, in a 1998 New England Journal of Medicine article, that Alexander fell victim to untreated typhoid fever, perhaps complicated by ascending paralysis and bowel perforation. Ascending paralysis, which mimics rigor mortis, could explain the odd legend, the author claims, that Alexander's body didn't decay for days after his death.

But others have argued that the recorded symptomatology and time course of Alexander's final illness are inconsistent with each of the various proposed diagnoses. Could something more sinister have cut down this battle-hardened young man in his prime? Some have eyed with suspicion the wine Alexander imbibed so heavily, suggesting that it may have contained poison. Certainly, jealousy, ambition, or revenge could have motivated one or more of Alexander's many enemies—OS they inspired the murders of Alexander's father, mother, half-siblings, wife, heir, and illegitimate son.

Another theory holds that white hellebore, a plant widely used in ancient Macedonia as a purgative, might have been to blame. Alexander may have made regular use of it, and even a small overdose of hellebore could have proved lethal. Whether hellebore felled Alexander by means of a murderous conspiracy or accidental overdose, or some infectious disease defeated Alexander's immune system, the king's vulnerability may ultimately have been more psychological than physical. As a forensic psychiatric consultant to a third Discovery Channel investigation, I considered that, at the time of his death, Alexander was in despair, figuratively if not literally brokenhearted. Hephaistion—Alexander's second in command, best friend, and lover—had died months earlier, perhaps of typhoid fever, or perhaps of poisoning by those resentful of the power he wielded as Alexander's favorite.

Whatever the cause of Hephaistion's death, Alexander is reported to have gone mad with grief, shaving his head and the manes of the army horses, and, legend says, executing the attending doctor, who had failed to save his lover's life. A huge funeral memorial to honor Hephaistion—who, Alexander stipulated, was to be worshiped as a divine hero—was still under construction when Alexander himself died.

Alexander's frenzy may well have led him to self-medicate with alcohol and to take more risks than usual. Did his excessive drinking and staggering grief signal weakness to enemies who decided to take him out? In his zeal to plunge himself quickly back into the distraction of battle, did he unwittingly swallow too much of the purgative that had helped him return to fighting trim in the past? Or did his grief and depression fatally compromise his ability to resist infectious disease? Whatever the immediate cause of death, I think it likely that the loss of Hephaistion, coupled with Alexander's inability to complete the grieving process, marked the beginning of Alexander's spiraling vulnerability to sickness, overindulgence, self-destructive behavior—and perhaps even wicked plots. ■

Harold J. Bursztajn 76 has served as co-director of the Harvard Medical School Program in Psychiatry and the Law at the Massachusetts Mental Health Center since 1982. He also maintains a private practice in Cambridge, Massachusetts.