Thursday, September 21, 2017


Hutan Ashrafian, Francesco M. Galassi, Julius Caesar's Disease. Barnsley: Pen & Sword History, 2016. Pp. 192. ISBN 9781473870789. £19.99.

Reviewed by Patrick Cook, University of Cambridge (

Version at BMCR home site


Illness fascinates. As Susan Sontag pointed out, physical illnesses often become 'encumbered with the trappings of metaphor' about individuals and about society.1 There is an extra frisson when illness affects a person in a position of great power, as it suggests a vulnerability at odds with their social and political power. Roman sources were fascinated by the bodies of emperors and other members of the elite, including their susceptibility to disease. The existence of this book is proof of how enduring this fascination is.

The book's basic claim is that Julius Caesar most likely did not have epilepsy, but instead suffered from several small strokes. The authors previously made this argument in an article aimed at medical professionals.2 The conclusions of the original article received media attention.3 The present work is aimed at classicists, historians, and other readers who are not likely to be avid readers of neurological journals. The greater length of the book allows for a far more detailed argument, drawing on a far number of sources. These are analyzed with what the authors term a 'philologico-clinical approach'. One might wish for a more explicit definition of what is meant by this, but none is forthcoming. It has already been reviewed from a medical perspective with more expertise than I could manage, so this review will focus on the quality of the classical and historical scholarship and its relevance to those fields.4

The book's argument is made in five chapters. The first chapter begins by noting that, as Caesar was by all accounts cremated, bioarchaeologists will have no way of examining his body, as they have done with the remains from Vergina that are believed to be those of Philip II. In the absence of such remains, this study focuses on literary depictions of Caesar's disease. The first chapter goes on to discuss not only the major accounts of Caesar's disease in Suetonius and Plutarch, but also passing references in Cicero, Appian, and Dio. The authors rightly note that the accounts of Suetonius and Plutarch are contradictory and that much previous scholarship has mingled them together without always acknowledging this.

The second chapter, by far the longest in the book, examines various explanations for Caesar's symptoms, including early- onset epilepsy and late-onset epilepsy caused by a variety of factors, including alcoholism, head trauma, syphilis, or other infection. They also look at the possibility of several genetic conditions, including Hartnup disease. Both their discussions of late-onset epilepsy and of Hartnup disease lead to a discussion of Caesar's family, and particularly his imperial descendants. The authors note that none of the available evidence is sufficient to suggest that the Julio-Claudians suffered from a hereditary disease. This is surely correct as far as stating the limits of the evidence. I would argue, however, that the authors err in taking the absence of evidence for evidence of absence. They justify this approach by claiming that 'almost every single and minute detail of Caesar's life has been reported'. This is quite simply untrue. Furthermore, most of what has been reported is known only through sources writing a century or more after Caesar's death.

The third chapter presents alternative theories to epilepsy, focusing closely on the 1865 biography of Caesar written by Napoleon III. I must admit to being somewhat startled to see this book given such prominence, as it enjoyed a substantial but brief popularity at the time of its publication and is now remembered as a curiosity, if it is remembered at all. The authors do, however, make judicious use of it. They rightly note that Napoleon's diagnosis of 'nervous attacks' 'can mean almost anything and nothing at the same time'. From Napoleon III, they move on to Donnadieu's argument, made in 1937, that Caesar did not have epilepsy but was merely faking the symptoms. This eccentric theory is given more space than it really deserves, although it does allow the reader to appreciate Donnadieu's amusingly snide comment on Felix Jacoby's medical knowledge. Finally, they look at a theory proposed by Terence Cawthorne in 1957 that Caesar had Ménière's Disease. Again, they reject this diagnosis, rightly pointing out that Cawthorne seems to have accessed Plutarch through Shakespeare and other ancient sources not at all.

The fourth chapter presents their own conclusion, which as mentioned above, is that Caesar had a series of small strokes. They anticipate and address the complaint that cardiovascular disease is largely a problem arising from the diet and lifestyle typical in the modern Western world. They counter by pointing out that analysis of Egyptian mummies proves this untrue.

The fifth and final chapter examines why the epileptic diagnosis has proven so enduring. This is in some ways the most interesting question addressed by the book. Here, the authors widen their analysis to include the cultural role of illness. They rightly point out that epilepsy could be seen in the ancient world as either an indication of divine wrath or of divine favour, and could thus be exploited by both Caesar's admirers and his enemies.

The book is well presented and attractive. The prose is unusually lively. Medical terminology is usually glossed for a lay audience, and there are numerous literary allusions. This is undeniably more fun to read than the typical clinical language of medical journals, but it does introduce problems when it degenerates into a boy's-own bombasticism. If Caesar's soldiers were indeed 'almost invincible' in the Civil War (as claimed on the first page), then it seems curious that they were defeated at Bagradas and Dyrrachium and nearly routed at Ruspina. Furthermore, the excitable prose does not actually make the book a particularly easy read, as it cannot compensate for a repetitive and circuitous argument.

There are other, more serious, problems. The first relates to the use of ancient sources. There is occasionally an attempt at something approaching Quellenkritik, as for instance when the authors point out that Plutarch's knowledge of Latin may have been limited. More frequently, however, the authors operate under the assumption that their ancient sources were proto-Rankeans aspiring to write history 'as it actually happened' and, furthermore, largely successful in this endeavour. In particular, the accounts of Plutarch and Suetonius are treated as if they were clinical case studies, with little acknowledgement that they might be works of a very different genre. In fairness, Suetonius in particular has often been portrayed, even by academic classicists, as a compiler of unadorned factual minutiae. This view has now rightly fallen from favour. Had the authors engaged with Tamsyn Barton's work on the 'invention of Nero' in Suetonius, they might have been led to question whether Julius Caesar and his symptoms were equally the product of a rhetorical tradition quite different from that of modern Western medicine.5 This is unfortunately indicative of a general lack of engagement with recent classical scholarship.

The need for this level of rhetorical awareness is particularly acute with epilepsy, which is described in radically different terms in different cultures. It is no coincidence that one of the books most frequently assigned to teach cultural competency to medical students is about epilepsy.6

Reviewers writing for this journal are given a list of instructions that prohibits 'attacks for not being the book you would have written'. I have endeavoured to keep to these terms. I am reminded, however, of Keith Hopkins' review of Fergus Millar's The Emperor in the Roman World (a classic case of a reviewer doing what we are instructed not to do).7 Setting the scene for many of his objections, Hopkins uses as an epigraph a quotation (actually somewhat paraphrased) from the social anthropologist Rodney Needham: 'Problems do not present themselves, they must be conceived'.8 Conceiving the right problems and asking the right questions is a central role of the historian's job. The decision to frame the book's question in terms of whether or not Julius Caesar had epilepsy is limiting. Only in the last chapter are the wider social, cultural, and political implications given serious weight. Given that the authors made their purely medical diagnosis in a one-page article, a book nearly 150 times longer should have provided an opportunity to expand on its wider significance. Unfortunately, the opportunity has been left largely unseized. The last chapter provides a tantalizing taste of what might have been.

It must now be clear that I have serious problems with this book's methodology. Despite its flaws, it can be useful to classicists. It is most successful when it problematizes, rather than when it proposes solutions. It will not stop the parade of diagnoses de jour. Since publication of the original article, there has already been a new suggestion of coeliac disease9. This book presents a useful critique of any tendency to assert Caesar's epilepsy as a straightforward historical fact. Anyone reading this book will realize that things are not so simple. That, in the end, is a more valuable conclusion than any specific diagnosis.


1.   S. Sontag, Illness as Metaphor and Aids and its Metaphors. London: Penguin, 2002. Quotation from pg. 5.
2.   F.M. Galassi and H. Ahrafian, 'Has the diagnosis of a stroke been overlooked in the symptoms of Julius Caesar?', Neurological Sciences, Volume 36, Issue 8 (August 2015), pp 1521–1522.
3.   I. Sample, 'Julius Caesar may have suffered mini-strokes, say doctors', The Guardian, The Guardian 14 April 2015.
4.   It was reviewed by M. Traversari in Neurological Sciences, Volume 38, Issue 1 (January 2017), pp 209–210
5.   T.S. Barton. 'The Inventio of Nero: Suetonius' in J. Elsner and J. Matthews (eds.), Reflections of Nero: Culture, History, and Representation. Chapel Hill: The University of North Carolina Press, 1994, pp. 48–63.
6.   A. Fadiman. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus and Giroux, 1997.
7.   K. Hopkins, 'Rules of Evidence', rev. of F.G.B. Millar, The Emperor in the Roman World. Reviewed in The Journal of Roman Studies, Vol. 68 (1978). pp. 178–86.
8.   The original quotation is from R. Needham, Introduction to idem (ed.) Rethinking Kinship and Marriage. London: Tavistock Publications, 1971, p. xvi.
9.   F. Imparato, Letter to the Editor: 'Celiac Disease Could Have Been the Cause of Caesar's Epilepsy', Journal of Clinical Gastroenterology, Vol. 50, Issue 9 (October 2016), p. 797.

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