Physicians have long debated what caused King Herod’s death, but there is no doubt (or disagreement) that his demise was a horrid one. Many would say it was also well-deserved.
We know the king’s symptoms in some detail from the first-century Jewish historian Josephus. Josephus actually wrote two accounts, the first in his Jewish War—a narrative of the First Jewish Revolt against Rome, 66–70 C.E., written in the late 70s—and the second in his Jewish Antiquities—a much longer history of the Jewish people, written in the 90s. He wrote both works while he was in Rome. The second account of Herod’s final illness is more detailed than the first, but both are largely dependent on the firsthand account of Nicolaus of Damascus, who was Herod’s daily companion and thus an eyewitness to the king’s condition.1 Nicolaus was also in direct contact with the court physicians who treated Herod. Nicolaus wrote a 144-volume history of the world, but unfortunately almost all that remains of the Jewish section of this work is what was quoted or otherwise used by Josephus.
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Herod the Great became seriously ill when he was about 70 years old, in 4 B.C.; while ill he moved to his palace in Jericho. His final illness lasted only a few months. During that time he briefly rallied once, but then quickly succumbed (Antiquities 17.183). It began with a vague condition causing “uncontrolled anger” (Antiquities 17.148). Josephus tells us that Herod’s illness was considered to be “incurable” (Antiquities 17.150). Elsewhere, Josephus stresses Herod’s cruelty in his last days (Antiquities 17.164).
When Herod’s illness “increased greatly,” a fever fell upon him: “The fever he had was a mild one, which did not so much indicate the inflammation to those touching as contribute to the malignancy of the innards. Because of this he also had a terrible desire to scratch, for it was impossible not to seek relief” (Antiquities 17.168–169).2 This was only the beginning, however:
There was also an ulceration of the intestines with particularly terrible pains in the colon, and a transparent swelling of fluid around the feet. And similarly there was a malignancy in the abdominal area, as well as a putrefaction in the private member which was creating worms. His breathing had a high pitch [literally “upright tension”], and it was extremely loathsome because of the disagreeable exhalation and the frequency of gasping [literally “density of asthma”]. He also had spasms in every limb that took on unendurable force. (Antiquities 17.169)
At this point, his physicians decided to move him to the hot springs at Callirhoë beyond the Jordan River, 030near where it flows into the Dead Sea. Apparently, bathing in the springs did not improve his condition, so his physicians decided to bathe him in warm oil. This nearly killed him (Antiquities 17.172).
On Herod’s return to Jericho a melancholy seized him and made him enraged at everyone (Antiquities 17.173). As his pains continued to increase, he refused to take any food.
At one point he asked for an apple and a knife. Josephus explains that it was Herod’s custom to pare apples himself. But instead of peeling the apple, he attempted to use the knife to commit suicide, so great was his pain. He was prevented by his cousin Achiab whose cries soon brought help (Antiquities 17.183–184).
By this time, Herod was no longer able to stand (Antiquities 17.187; cf. 161). Five days later, he expired (Antiquities 17.191).
As noted in the citations, this account is taken from the Antiquities, which is generally considered more reliable than the War for the period before the outbreak of the Jewish revolt and the events leading up to it. With regard to Herod’s final illness, the War, although it misses some detail, does clarify a few points, such as Herod’s breathing condition. It seems that he could not breathe unless he was in an upright position (orthopnoia) and his breath was generally short and rapid (dyspnoia). Near the end he also developed a convulsive cough (vêx).
Josephus attributes Herod’s suffering to God’s judgment on his sins—a conclusion one might expect from Josephus, given his priestly background. Herod was born to a noble Idumean family that had converted to Judaism. His Helleno-Semitic cultural background provides the context for understanding much of his reign. A fortunate but also ingenious politician, Herod ruled Judea de jure from 40 B.C.E., by appointment of the Roman Senate, with the approval of Mark Antony and Octavian (later Augustus). He ruled de facto from 37 B.C.E., when he defeated Antigonus, the last Hasmonean king of Judea.3 Although Herod was hated by most Jews, the Greeks and the Romans found his charm (complemented by extravagant benefactions) irresistible. His passion for grandiose architecture was epitomized in the building of the “golden” Temple of Jerusalem, spectacularly destroyed by the Roman general Titus in 70 C.E.
Herod’s addiction to pleasure was manifest in the quality and size of his harem—with ten beautiful wives and numerous concubines and boy lovers. His dynasty flourished: We now know of 15 of his children, 20 grandchildren, 13 great-grandchildren, eight great-great-grandchildren and two great-great-great-grandchildren.
Although occasionally munificent, Herod was generally oppressive to his subjects and often ruthless, even by the standards of the savage world in which he lived. After his death, the Jewish deputies in Rome, perhaps slightly melodramatically, complained to the Emperor that “the miseries which Herod in the course of a few years had inflicted on the Jews surpassed all that their forefathers had suffered during all the time since they left Babylon to return to their country” (War 2.86).
Herod’s extermination of his many opponents (and supposed opponents), notably the Hasmoneans and their supporters, is clearly recorded. He executed his beloved wife Miriamme (the granddaughter of a Hasmonean ruler, Hyrcanus II, whom he had earlier also executed) because he suspected her of adultery. (“Mariamme’s hatred of [Herod],” Josephus tells us, “was as great as his love for her.”) He also executed three of his own sons, Alexander I, Aristobulus I and Antipater II. This gave rise to the celebrated phrase attributed to Augustus: Melius est Herodis porcum esse quam filium—“Better to be Herod’s pig [as a convert to Judaism, Herod would not eat pork] than his son.”4
Eusebius, the fourth-century Christian historian, concludes his description of Herod’s reign this way:
It is not now possible even to give a summary list of the ways by which [Herod] darkened what were 031reckoned the glories of his reign, by the successive misfortunes of his house, by the foul murder of wife and children and of the rest who were closest to him in family and in affection; for the shadows in their story, which Josephus narrated at length in the history of Herod, are darker than any in tragic drama.5
Among the “glories” of Herod’s reign was his ample modernization program. His Hellenized cultural background is reflected in his education (Greek philosophy, support of gymnasia and writing of memoirs), his prowess and love of theater and sport (construction of hippodromes, organization of festivals and patronage of the Olympic Games), his journeys to Greece and his benefactions there, his patronage of religious architecture and indeed in his interest in non-Jewish cults (Apollo, Hermes, the Dioscuri and Kore).
Even the names he chose for some of his children—Philip, Olympias, Alexander and Roxane—recall the royal family at Macedonia. So did the Greek names of most of his wives—Doris, Malthace, Cleopatra, Pallas, Phaedra and Elpis. No wonder Herod admitted feeling much “closer to the Greeks than to the Jews” (Antiquities 19.329).
Despite his achievements and the prosperity of his kingdom, it was, one must not forget, at a considerable cost to the majority of the Jewish society, which had to bear heavy taxations and religious indignities. Among other things, he erected a great golden eagle (the bird of Zeus and a Hellenistic and Roman symbol) over the Temple gate. When the people thought he was dying, a group of young men tore down the eagle and cut it to pieces.
Herod knew that he was hated by his Jewish subjects, despite his efforts to appease them. As he lay dying in Jericho, he called a group of Jewish leaders to his bedside. When they came, he had them imprisoned in the hippodrome. Fearing that he would not be truly lamented on his death, nor mourned appropriately for a king of his stature, he gave orders that when he died, his death should be kept a secret until the men in the hippodrome had first been murdered. His death would then be announced, assuring that the mourning at his funeral would be genuine. Fortunately, his orders were disobeyed and the men who were shut up in the hippodrome were released on Herod’s death.
Before undertaking a diagnosis of the cause of death, we need to look at Herod’s medical history. Herod’s physical condition in the early part of his life was reckoned to be excellent. He was said to have been foremost in hunting, and distinguished himself in horsemanship. As a fighter he was invincible, bending the bow and throwing the javelin with great precision. He fought in (and won) many wars (War 1.430). He survived numerous assassination attempts (Antiquities 14.462–463; 15.282–285; 17.55; War 1.340–341, 577) and plots to poison him (Antiquities 17.69; War 1.592). On one occasion the roof of a house collapsed on him (Antiquities 14.455; War 1.331). He was nearly shipwrecked at sea (Antiquities 14.377; War 1.280). In all these cases, through luck or otherwise, he escaped unscathed.
His first known illness occurred when he was about 30, in 42 B.C.E., before he became king. He was in Damascus at the time, Josephus tells us, and wanted to return to Jerusalem to help his elder brother Phasael quell a disturbance there, but was prevented from returning by an unexpected illness (nosos), of which no details are given (Antiquities 14.295; War 1.236).
A few years later, in his war against the Hasmonean ruler Antigonus and before his conquest of Jerusalem in 37 B.C.E., Herod was struck by a javelin in his pleura or side (War 1.332), around the area of the lapara or kidney (Antiquities 14.456). We are not told how serious the wound was, but since he continued fighting, it would not have been great.
After he murdered his beloved Mariamme in 29/28 B.C.E., Herod became psychologically disturbed and suffered prolonged delusions (Antiquities 15.241–242; War 1.435–436). He was then about 45. In Antiquities (15.240–242), Josephus describes in some detail both his lament and his disturbed state:
His love for her was not passionless nor such as arises from familiarity, but in its very earliest beginnings had been a divine madness, and even with freedom of cohabitation it was not restrained from growing greater. But now more than ever he seemed to be a prey to it as if by a kind of divine punishment for the death of Mariamme. And he would frequently call out for her and frequently utter unseemly laments … And so he put aside the administration of the kingdom, and was so far overcome by his passion that he would actually order 034his servants to summon Mariamme as if she were still alive and able to heed them.
Soon thereafter a pestilential disease (loimôdês) hit Jerusalem, which drove Herod from the city (on the pretext of having to participate in a hunt). While Josephus does not say that the king himself became infected, we know Herod did fall ill while withdrawing to Samaria. There he developed an inflammation (phlogôsis) and what seems to have been a numbness (peisis) of the neck area (inion), besides temporarily losing his reason (dianoiasparallagê). His condition became so critical that his physicians “thought it best to give him whatever he might be moved to ask for, thus leaving to Fortune the faint hope of his recovery” (Antiquities 15.243–246).
At one point he also had a horrible hunting accident, falling from his horse and impaling himself on his own spears (Antiquities 16.315). Though unlikely, the impaling could have aggravated his previous wound in the kidney, had the injury been on the same side.
As time went on, the battles he had to fight both inside and outside his kingdom, the dissension and murders within his court, his sexual and drinking excesses, his tiresome journeys overseas—all caught up with Herod. He began looking old. He dyed his hair. He developed a suspicious mind and an uncontrollable anger that often led to cruelty. At the age of about 65, Herod became seriously ill again, under unknown circumstances, shortly before the death of his brother Pheroras in around 7 B.C. His final illness was not far off now.
For more than a century modern physicians have tried to diagnose the cause of Herod’s death. There are many difficulties: Are the descriptions in Josephus based on reliable eyewitness accounts devoid of much bias? If so, have they been accurately transmitted? Can we translate the ancient words into equivalent modern medical terms? Does more than one illness satisfy the same list of symptoms?
Classicists have argued that we cannot take Josephus’ description of Herod’s final illness at face value since the historian may have been biased against the king. Infection by “worms” is suspicious, for example, because it sounds like poetic justice: Worm-infestation was seen as a fitting end for detested rulers—a monstrous life calling for a miserable death. In hostile descriptions, Antiochus IV Epiphanes (d. 163 B.C.), Sulla (d. 78 B.C.), Agrippa I (d. 44 A.D.) and Galerius (d. 311 A.D.) were all described as dying “worm-eaten.”6 Could Herod’s ignominious condition have been wishful thinking and not historical reality?
The growth of larvae on the skin and in open wounds is a real medical phenomenon, and many historical figures—including unpopular ones—have actually suffered from it. Philip II, a detested king of Spain (d. 1598 A.D.) is one example.7 Each case must therefore be taken on individual merit. Even if we allow for unsympathetic 035bias in the adjectives used by Josephus (either his own, or derived from an ‘anti-Herodian’ source that contradicted Nicolaus), the individual symptoms—including worm-infestation—have been recognized by medical experts as being extremely realistic and accurate.8
Listed in the sidebar “Herod’s Symptoms and Diagnoses” are 16 symptoms that Josephus reports Herod as suffering from, as well as the 8 different diagnoses that have been proposed in modern times.
The first diagnosis was made in 1886 by Ernest Renan, a famous 19th century scholar, who gave poisoning as the cause of Herod’s final illness. Renan was no physician, however, and his diagnosis was not backed up by an argument. The next modern diagnosis to be offered was by Edward Merrins in 1904: cardio-renal failure, or failure of the heart and kidneys. That remains today the majority medical opinion. It is also the view of the medical expert I consulted, Walter Y. Loebl, Fellow of the Royal College of Physicians in London.
Dr. Loebl finds four of Herod’s symptoms particularly diagnostic. The intolerable itch can be attributed, he says, to kidney failure, which causes waste chemicals to accumulate in the blood. This would have been the end-stage of a number of processes, including “diminished oxygen to the kidneys due to arteriosclerosis [hardening of the arteries].”
Dr. Loebl interprets the transparent swelling around Herod’s feet as edema, a build-up of fluids that often occurs in older people, especially in their ankles and legs. Bedridden people can also get it in their lower back and genitalia, he says. The commonest causes are “heart failure, renal [kidney] failure and dilution of the blood in anemia.” Another type of edema—pulmonary edema, or edema of the lungs—may have contributed to his demise.
The related putrefaction in Herod’s private member, Dr. Loebl sees as “myiasis.” He explains that “the moist skin with edema and the hot climate would have attracted flies who laid eggs, developing larvae looking like worms—[like] maggots used by fishermen!”
Dr. Loebl regards Herod’s inability to breathe unless in an upright position (orthopnoia) as “the most reliable part of the description.” As used in clinical medicine, “orthopnea is a typical sign in heart failure, renal failure or anemia.”
His conclusion is that, most likely, “Herod died of age-related failure of his heart and kidneys with terminal edema of the lungs.” 9
Another theory that has recently gained fresh support from the medical profession is that Herod suffered (and died) from diabetes mellitus. This is open to criticism, because it is partly based on the mistaken assumption that Herod had an increased appetite. This assumption arises from a corrupted word in Josephus’ text in Antiquities, which says that Herod had an insatiable need to “receive” (dexasthai) something, which translators have assumed to be food, as opposed to a need to “scratch” (odaxasthai). My version, based on this emendation, clearly agrees with the “itch” (knêsmos) given in the corresponding passage in War. Hunger is not actually mentioned in the account: When Herod asks for an apple, his aim is only to get hold of the paring knife to kill himself. Dr. Loebl says that in diabetes, “when there is lack of insulin, the most obvious complaints are an increased thirst, the production of much more urine and weight loss—progressing to confusion and coma.” These symptoms are absent in Herod’s case.10
Whatever the medical reality behind Herod’s demise, it is clear that he suffered much pain that was not alleviated by his transfer to the hot springs at Callirhoë, and indeed that led him to attempt suicide. It is also apparent that his mind had severely deteriorated, leading to his command that on his death the community leaders imprisoned in the hippodrome should be killed, a command fortunately disobeyed.
Some surprising new evidence regarding Herod’s mental state has recently been discovered in the lava desert of northeastern Jordan—a 2,000-year-old graffito written in Safaitic (an early Arabic script) by a local nomad, referring to “the year Herod died mad”!11 This may reflect only the personal opinion of one individual, but it is the only surviving contemporaneous testimony, aside from Josephus. It converges well with what we would otherwise conclude: Herod, reviled king of Israel, was horribly troubled in both body and mind when he finally met his end.12
Physicians have long debated what caused King Herod’s death, but there is no doubt (or disagreement) that his demise was a horrid one. Many would say it was also well-deserved. We know the king’s symptoms in some detail from the first-century Jewish historian Josephus. Josephus actually wrote two accounts, the first in his Jewish War—a narrative of the First Jewish Revolt against Rome, 66–70 C.E., written in the late 70s—and the second in his Jewish Antiquities—a much longer history of the Jewish people, written in the 90s. He wrote both works while he was in Rome. The second […]
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I offer my translation (more literal than convenient) as an improvement upon that of Ralph Marcus in the Loeb Classical Library’s volume 8 of Josephus. While there are a few problems with the Greek text of Antiquities, only one is worth mentioning here. I translate the word odaxasthai as “to scratch.” This word is a modern but necessary emendation—the manuscripts erroneously give dexasthai, that is “to receive”—because in the parallel account of War the word is knêsmos, meaning “itch.” The problem is an old one. Already the Latin translator of Josephus, unable to emend the text, accepted the reading dexasthai and went on to render the sentence with food (cibus) in mind. But this is not right. Diagnoses based on the interpretation that Herod had a terrible desire “to receive” food or drink, are therefore invalid.
3.
On Herod and his background, and for elaboration of any detail not referenced below, see my The Herodian Dynasty: Origins, Role in Society and Eclipse (Sheffield: Sheffield Academic Press, 1998).
4.
The attribution to Augustus is noted by the 5th-century writer Macrobius, in his Saturnalia 2.4.11.
5.
Eusebius, Ecclesiastical History 1.8.4.
6.
See T. Africa, “Worms and the Death of Kings: A Cautionary Note on Disease and History,” Classical Antiquity 1 (1982), pp. 1–17.
7.
See C. Petrie, Philip II of Spain (London: Eyre & Spottiswoode, 1964), p. 309; G. Parker, Philip II (Boston: Little Brown, 1978), pp. 197–198.
8.
The attempt by D.J. Ladouceur (“The Death of Herod the Great,” Classical Philology 76 [1981], pp. 25–34) to show that Herod’s final illness is based solely on Thucydides’ account of the Athenian plague (History of the Peloponnesian War 2.49–50) is not convincing, and it still tampers with the Greek text. G. Mader (Josephus and the Politics of Historiography [Leiden: Brill, 2000], p. 56) supports Ladouceur but offers no evidence. We must recognize that the Greek literary assistants employed by Josephus in the War did not rely heavily on Thucydides (unlike Antiquities)—see H. St. J. Thackeray, Josephus the Man and the Historian (repr. New York: Ktav, 1967), pp. 104–106; T. Rajak, Josephus the Historian and his Society (London: Duckworth, 1983), pp. 233–236; S. Schwartz, Josephus and Judaean Politics (Leiden: Brill, 1990), pp. 24, 38.
9.
Walter Loebl has been invited to contribute a full diagnosis in a Herodian volume I am editing—one of two volumes of papers read in the international conference The World of the Herods and the Nabataeans (held at the British Museum in April 2001). I am grateful for the permission to use his statements here.
10.
Insulin is produced in the pancreas, so not surprisingly cancer of the pancreas has also been suggested. But Dr. Loebl observes that “in cancer of the pancreas the pain is in the back and not the abdomen.”
11.
The graffito was discovered in the late 1980s by G.M.H. King, and will be published in her forthcoming collection of more than 2,000 Safaitic inscriptions. It was mentioned briefly by M.C.A. Macdonald, “Herodian Echoes in the Syrian Desert,” in S. Bourke and J.-P. Descoeudres (eds.), Trade, Contact and the Movement of Peoples in the Eastern Mediterranean: Studies in Honour of J.B. Hennessy (Sydney: Meditarch, 1995), p. 286. I thank both for sending me information at an early stage.
12.
Poisoning: E. Renan, Les Apôtres (Paris: M. Lévy, 1886), p. 65; J. Preuss, Biblisch-Talmudische Medizin (Berlin: Karger, 1911), pp. 190–195. Cardio-renal failure: E.M. Merrins, “The Deaths of Antiochus IV, Herod the Great, and Herod Agrippa I,” Bibliotheca Sacra 61 (1904), pp. 558–560; E.W.G. Masterman, Hygiene and Disease in Palestine in Modern and in Biblical Times (London: Palestine Exploration Fund, 1920), p. 55; N. Manson and V. Kalbian, published in S. Perowne, ed., The Life and Times of Herod the Great (London: Hodder and Stoughton, 1956), pp. 185–186; A.T. Sandison, “The Last Illness of Herod the Great, King of Judaea,” Medical History 11 (1967), pp. 381–388; G.M. Burden, “Examination of Literary Evidence Points to Heart Failure as the Cause of Herod’s Death,” The Celator 6:1 (January, 1992), p. 34; S.S. Kottek, Medicine and Hygiene in the Works of Flavius Josephus (Leiden: Brill, 1994), pp. 186–190. Liver cirrhosis: M. Neuburger, Die Medizin in Flavius Josephus (Bad Reichenhall: Bachkunst, 1919), p. 58; J.O. Leibowitz, published in A.T. Sandison, “The Last Illness of Herod the Great, King of Judaea,” Medical History 11 (1967), p. 385; and in A. Schalit, Kônig Herodes: Der Mann und sein Werk (Berlin: de Gruyter, 1969), pp. 639–640. Sexually transmitted disease: R. Eisler Iêsous Vasileus ou Vasileusas, vol. 1, (Heidelberg: C. Winter, 1929), p. 156. Cancer of the bowels: A.H.M. Jones, The Herods of Judaea (Oxford: Clarendon Press, 1938), p. 47. Diabetes mellitus: S. Muntner, “Qôrôth,” Vierteljahresschrift für die Geschichte der Medizin und der Naturwissenschaften 1 (1953), pp. 134–142.; J. McSherry, “Worms, Diabetes and King Herod the Great,” Journal of Medical Biography 5 (1997), pp. 167–169; W.R. Litchfield, “The Bittersweet Demise of Herod the Great,” Journal of the Royal Society of Medicine 91 (1998), pp. 283–284. Cancer of the pancreas: J. Meyshan “The Disease of Herod the Great, King of Judaea,” Harefuah: Journal of the Medical Association of Israel 53 (1957), pp. 154–156 (in Hebrew with summaries in English and French); I. Buhacû, “Über die Erkrankung und den Tod des Herodes,” Deutsche Medizinische Wochenschrift 88 (1963), pp. 287–288. Amoebic dysentery: A. Patrick, published in A.T. Sandison, “The Last Illness of Herod the Great, King of Judaea,” Medical History 11 (1967), pp. 385–386.
