Editorial Comment:  Tinker, tailor, soldier, spy.  Doctor, detective, toxicologist, felon?

In Philip A. Mackowiak, MD’s Post Mortem (2007), the author draws partly from Robert Graves’s I, Claudius in describing a Roman emperor who suffered throughout life with a plethora of illnesses.  However sympathetically represented as he was by Derek Jacobi (in the 1976 BBC adaptation of the novel), alcoholism appears to be easily counted among them.  Discussing the onslaught of infirmities from childhood on, he writes, “…he was a veritable battleground of diseases, ‘who seemed to survive only because the competing disorders could not agree as to which should have the honor of carrying him off.’”

It’s a reminder that alcohol addiction, like syphilis, is in some ways the “great imitator.”  In considering the confluence of illnesses that can be aggravated or caused by alcohol use, we identify just one role required of an addiction physician - sorting out the many health impacts of which substance use is capable.  This is the detective, the differential diagnostician.  There are several such roles. Claudius conveniently provides an opportunity to look at another, toxicology.  For, when his end comes, the Emperor’s immediate cause of death is less the cumulative subtraction from his vitality associated with alcohol, than the efforts of his wife and his minions to poison him.  If the blame is most directly placed upon amanita phalloides, of which an extract was likely added to his final meal, it is a reminder that we include “toxicologist” (and MRO) among our professional sub-titles.

Unfortunately for Claudius, whose judgment was dissolved in alcohol at the time of the poisoning, his trust in others was misplaced, and he could rely upon none of the usual supporters whom our patients might seek.  Erosion of relationships was likely as much a hallmark of alcoholism in his time as in ours.  His wife, his friends, his son, all seem to have colluded to rid themselves of this exasperating drunk.  And worst for us, for our professional reputation, was the collaboration of his physician, Xenophon, in the final poisoning.  Mind you, this was fully four centuries after Hippocrates and this admonition: “…neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.”

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Two weeks before Christmas.  Please look out for one another.

- Editor-in-Chief: William Haning, MD, DFAPA, DFASAM