ABSTRACT

Gaius Julius Caesar Augustus Germanicus, better known as Caligula, (12 CE to 41 CE) was the third Roman emperor and ruled only four years. Throughout his life he experienced several traumatic events, and, in addition, historians mention some premorbid conditions that could cause him to become the monster that most historians know today. When Caligula was 25 years old, he suffered a near-fatal illness that turned his story around. One possible cause was lead poisoning due to the high consumption of wine, which contained lead, by Roman patricians. On the other hand, it is plausible that Caligula experienced epilepsy that began in childhood, later experienced status epilepticus in 37 CE, which triggered an epileptic psychosis with the consequent psychopathic and paranoid changes that led him to the madness noted by historians.

Keywords:
Lead Poisoning; Psychotic Disorders; Status Epilepticus

RESUMEN

Gaius Julius Caesar Augustus Germanicus, mejor conocido como Calígula, (12 C.E. - 41 C.E.), fue el tercer emperador romano y gobernó durante apenas cuatro años. A lo largo de su vida, experimentó diferentes eventos traumáticos y, adicionalmente, algunos historiadores mencionan condiciones premórbidas que pudieron causar que se convirtiera en el monstruo que los historiadores conocen hoy. Cuando Calígula tenía 25 años, sufrió una enfermedad casi fatal que le dio un giro considerable a su historia. Una posible causa es intoxicación por plomo, debido al excesivo consumo de vino, el cual contenía considerables niveles de este metal. Por otro lado, es posible que Calígula cursara con crisis epilépticas de inicio en la infancia. Posteriormente, en el año 37 C.E. experimentara un estado epiléptico, el cual desencadenaría una psicosis epiléptica, dejando secuelas que iban a desencadenar la locura de la que muchos historiadores hablan.

Palabras clave:
Intoxicación por Plomo; Trastornos Psicóticos; Estado Epiléptico

A BRIEF HISTORICAL OVERVIEW

Caligula was born in Anzio on August 31, 12 CE, and was the son of Agrippina and Germanicus. From an early age, he experienced several traumatic events that may have influenced his development in childhood and adulthood¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... . During his childhood, at the age of 18 months, he was left with his great-grandfather, Augustus, owing to his health conditions. Later, when he was 2, Caligula began to travel with his parents to military campaigns³3. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... . According to Suetonius, on one of his parents’ military campaigns, Caligula suffered from the falling sickness, the name for epilepsy¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... . At the age of 3, his mother made him a small uniform, due to the size of his boots, his father’s soldiers called him Caligula, the diminutive of caliga²2. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,44. Willcock D. Tony Robinson’s Romans: Caligula (Ancient Roman Documentary). 2003 [accessed on 2020 Apr 30]. Available at: Available at: https://www.youtube.com/watch?v=1Gpectv-3uc
https://www.youtube.com/watch?v=1Gpectv-... . When Caligula was 7 years old, his father was assassinated on a military excursion, and, after this incident, Caligula returned with his family and lived with his grandmother, Livia. Seven years later, Tiberius executed Agrippina and two of Caligula’s brothers, and exiled his sisters. Despite this, historians have noted that Caligula showed no feelings when his relatives died¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... .

At the age of 20, Tiberius brought him to Capri to live with him and his nephew Gemellus and declared them co-heirs¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... . By March of 37 CE, Tiberius died, and Caligula was chosen as emperor of Rome. During the first months, Romans loved Caligula because of his exceptional work on the government¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... . In October of the same year, when he was 25 years, Caligula experienced a severe illness. Some historians argued that Caligula had a history of seizures and mental illness, some other sources have also suggested that he suffered from a “disorder of intellect” and experienced anxiety and insomnia. However, regardless of the nature of the disease, most historians have concluded that Caligula’s illness affected his mental health and caused the personality changes that he experienced after his recovery¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... ^,55. Maeztu M. Rome revealed - Madness of Caligula 7/8. 2013 [accessed on 2020 Apr 30]. Available at: Available at: https://www.dailymotion.com/video/xwobz3
https://www.dailymotion.com/video/xwobz3... ^,66. Baratta A, Halleguen O. Quelle pathologie psychiatrique pour l’empereur romain Caligula? Inf Psychiatr. 2009 Jan;85(1):83-92. https://doi.org/10.1684/ipe.2009.0433
https://doi.org/https://doi.org/10.1684/... ^,77. Benediktson DT. Caligula’s Madness: Madness or Interictal Temporal Lobe Epilepsy? Class World. 1989 May-Jun;82(5):370-5. https://doi.org/10.2307/4350416
https://doi.org/https://doi.org/10.2307/... ^,88. Camargo CHF, Teive HAG. Searching for neurological diseases in the Julio-Claudian dynasty of the Roman Empire. Arq Neuropsiquiatr. 2018 Jan;76(1):53-7. https://doi.org/10.1590/0004-282x20170174
https://doi.org/https://doi.org/10.1590/... ^,99. Katz RS. The Illness of Caligula. Class World. 1972 Mar;65(7):223-5. https://doi.org/10.2307/4347670
https://doi.org/https://doi.org/10.2307/... ^,1010. Mackie A, Townshend A, Waldron HA. Lead concentrations in bones from Roman York. J Archaeol Sci. 1975 Sep 1;2(3):235-7. https://doi.org/10.1016/0305-4403(75)90062-x
https://doi.org/https://doi.org/10.1016/... . After his near-fatal illness, he became an alcoholic, believed he was a deity, and, moreover, he became paranoid about the risk of assassination, which led him to sentence Gemellus and Macro to death¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... ^,55. Maeztu M. Rome revealed - Madness of Caligula 7/8. 2013 [accessed on 2020 Apr 30]. Available at: Available at: https://www.dailymotion.com/video/xwobz3
https://www.dailymotion.com/video/xwobz3... ^,66. Baratta A, Halleguen O. Quelle pathologie psychiatrique pour l’empereur romain Caligula? Inf Psychiatr. 2009 Jan;85(1):83-92. https://doi.org/10.1684/ipe.2009.0433
https://doi.org/https://doi.org/10.1684/... ^,77. Benediktson DT. Caligula’s Madness: Madness or Interictal Temporal Lobe Epilepsy? Class World. 1989 May-Jun;82(5):370-5. https://doi.org/10.2307/4350416
https://doi.org/https://doi.org/10.2307/... ^,88. Camargo CHF, Teive HAG. Searching for neurological diseases in the Julio-Claudian dynasty of the Roman Empire. Arq Neuropsiquiatr. 2018 Jan;76(1):53-7. https://doi.org/10.1590/0004-282x20170174
https://doi.org/https://doi.org/10.1590/... ^,99. Katz RS. The Illness of Caligula. Class World. 1972 Mar;65(7):223-5. https://doi.org/10.2307/4347670
https://doi.org/https://doi.org/10.2307/... ^,1010. Mackie A, Townshend A, Waldron HA. Lead concentrations in bones from Roman York. J Archaeol Sci. 1975 Sep 1;2(3):235-7. https://doi.org/10.1016/0305-4403(75)90062-x
https://doi.org/https://doi.org/10.1016/... ^,1111. Demetrioff J. Mad, deranged, insane: a case study of madness as a diagnosis in antiquity. Crossings. 2018 Jun;(2):205-22.. Finally, after all the eccentric behavior Caligula displayed in his short period of government, he was assassinated in 41 CE at the age of 28 years¹1. Reese MR. The Madness of Caligula: Rome’s Cruelest Emperor? Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-famous-people/madness-caligula-rome-s-cruelest-emperor-002132
https://www.ancient-origins.net/history-... ^,22. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... .

FROM WHICH NEUROLOGICAL AND PSYCHIATRIC ILLNESSES DID CALIGULA SUFFER?

Historians have proposed several possible conditions and illnesses that Caligula may have had during his life. These conditions are summarized in Table 1.

One of the most common suggestions for Caligula’s illness is encephalitis. In modern times, even with adequate treatment, encephalitis has a high mortality rate that varies between 8.8 and 12.8% depending on its etiology¹²12. Mingren W. Savoring the Danger: Romans Loved Toxic “Sugar of Lead” Wine. Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-ancient-traditions/savoring-danger-sugar-lead-was-used-flavor-roman-food-and-wine-toxic-021771
https://www.ancient-origins.net/history-... ^,1313. Lessler MA. Lead and lead poisoning from antiquity to modern times. 1988 Jun [accessed on 2020 Apr 30]. Available at: Available at: https://kb.osu.edu/handle/1811/23252
https://kb.osu.edu/handle/1811/23252... . Additionally, the disease can lead to serious neurological sequelae¹³13. Lessler MA. Lead and lead poisoning from antiquity to modern times. 1988 Jun [accessed on 2020 Apr 30]. Available at: Available at: https://kb.osu.edu/handle/1811/23252
https://kb.osu.edu/handle/1811/23252... . For that reason, the probability that Caligula had encephalitis is low. Because of the previously mentioned, this review will focus on lead poisoning and epilepsy.

LEAD POISONING

Lead poisoning is known as “saturnism” or “plumbism”, and its clinical manifestations include cognitive disorders, fatigue, irritability, anxiety, vomiting, and anorexia. Its name is attributed to the god Saturn who shared some of these characteristics, particularly a melancholic temperament and sullen behavior¹²12. Mingren W. Savoring the Danger: Romans Loved Toxic “Sugar of Lead” Wine. Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-ancient-traditions/savoring-danger-sugar-lead-was-used-flavor-roman-food-and-wine-toxic-021771
https://www.ancient-origins.net/history-... .

In ancient Greece and Rome, a syrup named “sapa” was added to wine during its preparation to improve its taste. Sapa was prepared in lead vessels in which acidified wine was boiled, which promotes the synthesis of lead acetate¹³13. Lessler MA. Lead and lead poisoning from antiquity to modern times. 1988 Jun [accessed on 2020 Apr 30]. Available at: Available at: https://kb.osu.edu/handle/1811/23252
https://kb.osu.edu/handle/1811/23252... . Several historians, including Pliny the Elder, Cato the Elder, and Columella, mention this “lead sugar” in their writings¹²12. Mingren W. Savoring the Danger: Romans Loved Toxic “Sugar of Lead” Wine. Ancient Origins; 2019 [accessed on 2020 Apr 30]. Available at: Available at: https://www.ancient-origins.net/history-ancient-traditions/savoring-danger-sugar-lead-was-used-flavor-roman-food-and-wine-toxic-021771
https://www.ancient-origins.net/history-... .

Gilfillam mentions that wine was ingested almost exclusively by aristocrats and the emperor. Furthermore, he attributes the problematic behavior of some Roman emperors to lead poisoning. This can be supported by Mackie et al., who analyzed human bones from ancient Rome and found that the bones of aristocrats contained higher levels of lead than those of slaves¹⁰10. Mackie A, Townshend A, Waldron HA. Lead concentrations in bones from Roman York. J Archaeol Sci. 1975 Sep 1;2(3):235-7. https://doi.org/10.1016/0305-4403(75)90062-x
https://doi.org/https://doi.org/10.1016/... . Many people have therefore considered this as one of the factors that led to the fall of the Roman Empire¹⁴14. Gilfillan SC. Lead poisoning and the fall of rome. J Occup Med. 1965 Feb;7:53-60. https://doi.org/10.1016/B978-0-12-815339-0.00014-7
https://doi.org/https://doi.org/10.1016/... . However, Gilfillan's work has been criticized by many disciplines, who point out that some other factors contributed to the fall of Rome¹³13. Lessler MA. Lead and lead poisoning from antiquity to modern times. 1988 Jun [accessed on 2020 Apr 30]. Available at: Available at: https://kb.osu.edu/handle/1811/23252
https://kb.osu.edu/handle/1811/23252... .

EPILEPSY

Most historians agree that epilepsy is the most likely candidate for Caligula’s illness. There are several details in Caligula’s biography that support this argument. It has been suggested that members of the Julius family suffered from epilepsy²2. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,88. Camargo CHF, Teive HAG. Searching for neurological diseases in the Julio-Claudian dynasty of the Roman Empire. Arq Neuropsiquiatr. 2018 Jan;76(1):53-7. https://doi.org/10.1590/0004-282x20170174
https://doi.org/https://doi.org/10.1590/... . Additionally, several historians point out that, during his childhood, Caligula had episodes of sudden falls in which he lost consciousness and had difficulty remaining upright³3. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... ^,77. Benediktson DT. Caligula’s Madness: Madness or Interictal Temporal Lobe Epilepsy? Class World. 1989 May-Jun;82(5):370-5. https://doi.org/10.2307/4350416
https://doi.org/https://doi.org/10.2307/... ^,1111. Demetrioff J. Mad, deranged, insane: a case study of madness as a diagnosis in antiquity. Crossings. 2018 Jun;(2):205-22.. Analyzed from a modern perspective, these episodes may indicate atonic seizures.

Furthermore, Benediktson citing Suetonius reports that Caligula sometimes became febrile, which is a symptom concomitant with the onset of temporal epilepsy⁷7. Benediktson DT. Caligula’s Madness: Madness or Interictal Temporal Lobe Epilepsy? Class World. 1989 May-Jun;82(5):370-5. https://doi.org/10.2307/4350416
https://doi.org/https://doi.org/10.2307/... . However, Demetrioff points out that these episodes were not frequent during Caligula’s adolescence. This may not necessarily be evidence against the epilepsy theory, because people with epilepsy can lead a normal life during interictal periods¹¹11. Demetrioff J. Mad, deranged, insane: a case study of madness as a diagnosis in antiquity. Crossings. 2018 Jun;(2):205-22..

Regarding Caligula’s background, it is possible that he experienced status epilepticus in 37 CE, which left him with emotional, behavioral, and cognitive sequelae. After this episode, he showed constant mood swings with irascibility or unmotivated laughter, lack of impulse control, perverse behaviors, hypersexuality, and sadism, and was terrified by thunder and loud noises²2. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,66. Baratta A, Halleguen O. Quelle pathologie psychiatrique pour l’empereur romain Caligula? Inf Psychiatr. 2009 Jan;85(1):83-92. https://doi.org/10.1684/ipe.2009.0433
https://doi.org/https://doi.org/10.1684/... . Caligula also suffered from severe insomnia and could not sleep more than three hours per night. Furthermore, he experienced delusions of grandeur, paranoid episodes, and strange behaviors, such as when he ordered his troops to collect seashells from the shore²2. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... .

All these symptoms fit what in modern epileptology is known as epileptic psychosis. This condition has a prevalence of 5.6 to 5.9% and can occur with any type of epilepsy. However, its prevalence increases to 9.3% in people with temporal lobe epilepsy¹⁵15. Agrawal N, Mula M. Treatment of psychoses in patients with epilepsy: an update. Ther Adv Psychopharmacol. 2019 Jul;9:2045125319862968. https://doi.org/10.1177/2045125319862968
https://doi.org/https://doi.org/10.1177/... ^,1616. Hilger E, Zimprich F, Pataraia E, Aull-Watschinger S, Jung R, Baumgartner C, et al. Psychoses in epilepsy: A comparison of postictal and interictal psychoses. Epilepsy Behav. 2016 Jul;60:58-62. https://doi.org/10.1016/j.yebeh.2016.04.005
https://doi.org/https://doi.org/10.1016/... . One of the first onset symptoms is insomnia, something frequently mentioned in accounts of Caligula²2. Sandison AT. The madness of the emperor Caligula. Med Hist. 1958 Jul;2(3):202-9. https://doi.org/10.1017/s0025727300023759
https://doi.org/https://doi.org/10.1017/... ^,33. Sidwell B. Gaius Caligula’s mental illness. Class World. 2010 Winter;103(2):183-206. https://doi.org/10.1353/clw.0.0165
https://doi.org/https://doi.org/10.1353/... ^,99. Katz RS. The Illness of Caligula. Class World. 1972 Mar;65(7):223-5. https://doi.org/10.2307/4347670
https://doi.org/https://doi.org/10.2307/... ^,1111. Demetrioff J. Mad, deranged, insane: a case study of madness as a diagnosis in antiquity. Crossings. 2018 Jun;(2):205-22.^,1717. de Almeida CAV, Lins OG, Lins SG, Laurentino S, Valença MM. Sleep disorders in temporal lobe epilepsy. Arq Neuro-Psiquiatr. 2003 Dec;61(4):979-87. https://doi.org/10.1590/s0004-282x2003000600017
https://doi.org/https://doi.org/10.1590/... . Epileptic psychosis can also be characterized by symptoms of depression, delusions, manic psychosis, strange thoughts, and behavior¹⁷17. de Almeida CAV, Lins OG, Lins SG, Laurentino S, Valença MM. Sleep disorders in temporal lobe epilepsy. Arq Neuro-Psiquiatr. 2003 Dec;61(4):979-87. https://doi.org/10.1590/s0004-282x2003000600017
https://doi.org/https://doi.org/10.1590/... ^,1818. McIntosh WC, Das JM. Temporal Seizure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020 [accessed on 2020 Apr 30]. Available at: Available at: http://www.ncbi.nlm.nih.gov/books/NBK549852/
http://www.ncbi.nlm.nih.gov/books/NBK549... .

It is plausible that Caligula experienced epilepsy that began in childhood, possibly with febrile seizures and later dialeptic or cognitive seizures. Caligula later experienced status epilepticus in 37 CE, which triggered an epileptic psychosis with the consequent psychopathic and paranoid changes. This clinical condition may have been affected by excessive alcohol intake and lead poisoning.

ACKNOWLEDGMENTS

We thank Diane Williams, PhD, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

References

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