1. One of the most prominent works in this field is Post, Jerrold M., When Illness Strikes The Leader (New Haven, 1993)Google Scholar. While the book is a fine introduction to the impact of clinical conditions on political leaders, its treatment of the subject lacks in both medico-biological depth and historical treatment that can only emerge from an in-depth study of sources, particularly medical documents. A more recent work, Crosby, Travis L., The Two Mr. Gladstones: A Study in Psychology and History (New Haven, 1997)Google Scholar, is representative of the “psychohistory” genre; a genre that has frequently been accused of reductionism and failing to take note of complexities in human behavior. The book attempts to place Gladstone`s dual character within a sophisticated psychological framework. Crosby, however, avoided a substantive investigation of some of Gladstone's potential organic pathologies that might have explained his labile behavior.

2. The Iranian tradition of hiding terminal diagnosis from patients is an example of the view that the patient must try to live life in dignity, unimpeded by illness, rather than be debilitated by the thoughts of his own mortality. (See Good, Byron J. “The heart of what's the matter: the semantics of illness in Iran,” Culture, Medicine and Psychiatry 1 [1977]: 25–58CrossRefGoogle ScholarPubMed; idem, “Medical Change and the Doctor-Patient Relationship in an Iranian Town” in Farmanfarmaian, Khodadad ed., The Social Sciences and Problems of Development [Princeton, 1976], 244–60Google Scholar; Good, Mary-Jo Delvecchio and Good, Byron J.. “Ritual, the State, and the Transformation of Emotional Discourse in Iranian Society,” Culture, Medicine, and Psychiatry 12 (1988): 43–63CrossRefGoogle Scholar.)

3. Abbas Amanat's substantive study of Nasir al-Din Shah examines some of the Freudian complexities that led Nasir al-Din to form paternal attachments to his Premier Mirza Taqi Khan Amir Kabir. (See Amanat, Abbas, Pivot of the Universe [Berkeley, 1997]Google Scholar.

4. For some idea of the role of foreign physicians in the Qajar court, see: Amir Arsalan Afkhami, “Epidemics and the Emergence of an International Sanitary Policy in Iran,” Comparative Studies of South Asia, Africa and the Middle East, 19, 122–136; idem, “Compromised Constitutions: The Iranian Experience with the 1918 Influenza Pandemic,” Bulletin of the History of Medicine 77 (2003): 367–92CrossRefGoogle Scholar; and idem, “Joseph Desirée Tholozan,” Encyclopedia Iranica (forthcoming).

5. The shah's cancer was diagnosed in 1973 and hidden from the public in subsequent years. The battery of chemotherapeutic agents used to treat Muhammad Reza Shah included steroids (used to treat his bouts of hepatitis) that could produce unwanted manic and depressive side effects. See Shawcross, William, The Shah's Last Ride: The Fate of an Ally (New York, 1988), 244Google Scholar. For more on the shah's medical condition see Breo, Dennis L., Extraordinary Care: (Chicago, 1986), 72–92Google Scholar. The shah's physicians, Dr. Benjamin H. Kean, Dr. Morton L. Coleman, and Dr. George Flandrin have written extensively on the shah's illness.

6. Psychiatric diagnosis is an imperfect science, even when the patient is evaluated in a clinical setting. Diagnosing historical figures presents its own obvious set of challenges. However, Muhammad Musaddiq's condition appears consistent with an anxiety disorder, particularly his habit of refusing to travel without a nurse and his perpetual concern with his health (and constant fear of political persecution-a fear that eventually came true). It is not unusual for anxiety disorders to be concomitantly accompanied by depression. The close connections between anxiety and depression is believed to be mediated by an “adrenal axis overload” which sensitizes individuals to “collapse” when the anxiety phase has resolved itself. Moreover, it is common for anxious and depressed individuals to have irregular stomach secretions. In addition there is a strong genetic component to both anxiety disorders and manic-depression. It should not be surprising, therefore, that Muhammad Musaddiq's youngest child, Khadija, had been a patient in various Swiss psychiatric hospitals since the age of twenty (1942). Katouzian, Homa ed., Mosaddiq's Memoirs (London, 1988), 3, 144Google Scholar.

7. McGhee, George, Envoy to the Middle World (New York, 1983), 393Google Scholar and Farmanfarmaian, Manucher and Farmanfarmaian, Roxane, Blood and Oil (New York, 1997), 269Google Scholar.

8. McGhee, Envoy, 388; Roosevelt, Kermit, Countercoup (New York, 1979), 8Google Scholar. Roosevelt quotes John Foster Dulles as referring to Musaddiq as a madman.

9. Musaddiq, a nephew of Muzaffar al-Din Shah, carried the quintessential Qajar hypochondria and fear of disease. While some of his illnesses did have very real sources, his over dramatizations possibly stemmed from the childhood experience of losing a father to the 1892 cholera epidemic.

10. Hemophilia, a disorder characterized by the inability to properly form blood clots, is a sexlinked recessive disease, which is passed from the mother (generally an asymptomatic carrier) to the son. The Romanovs and much of Europe's royalty owe the durability of their hemophilia gene to intermarriage. It became known as the “royal disease” because it spread to the royal families of Europe through Victoria's descendants.. In this case, the marriage of Nicholas II to Princess Alix of Hesse (Czarina Alexandra Feodorovna), a granddaughter of Queen Victoria, brought hemophilia into the family. Their son, Czarevich Alexis (1904–18), was afflicted with the disease.

11. One of the most eminent books on the history of gout is Porter, Roy and Rousseau, George, Gout: The Patrician Malady (New Haven, 1998)Google Scholar. Sadly, it is also one of Roy Porter's last books before this historian of medicine's untimely passing this past year.

12. Elgood, Cyril, A Medical History Of Persia and the Eastern Caliphate From the Earliest Times Until the Year A.D. 1932 (Cambridge, 1951), 49Google Scholar.

13. A survey of the correspondence between Muhammad Shah, a nineteenth-century Qajar monarch, and his premier, Mirza Aghasi, splendidly illustrates this attribute, to the point that even the political dialogue between these men reveals an almost obsessive concern with sickness (nākhūshī)) and the menace of new diseases. (See the Qasim Ghani Collection of Qajar Documents, Manuscripts and Archives, Sterling Memorial Library, Yale University.)

14. Elgood, A Medical History, 498.

15. In his memoirs of Nasir al-Din Shah, Qahraman Mirza ᶜAyn al-Saltana recounts “In his sixty-seven years the shah has only been ill for four whole days. The main illness of the shah has only been the occasional cold, rhinitis, and hemorrhoidal bleeding.” (See Qahraman Mirza Salur ᶜAyn al-Saltana, Ruznāmah-i Khāṭirāt-i ᶜAyn al-Salṭana (Tehran, 1374), 1: 945.

16. Browne, Edward G., The Persian Revolution 1905–1909 (Cambridge, 1910), 98Google Scholar.

17. Both Muhammad Shah and Muzaffar al-Din delayed their entry into Tehran and ascension to the throne to coincide with an astrologically auspicious moment. The religious influence on Muzaffar al-Din Shah was another parallel between the Qajars and the Romanovs. Rasputin, the mystical Orthodox preist, held Czarina Alexandra “under a spell” through his ability to stop Czarevich Alexis’ hemophilia-related bleeding. See: Mostoᶜ, Abdollah, The Administrative and Social History of the Qajar Period, trans. Glenn, Nayer Mostoᶜ (Costa Mesa: Mazda Publishers, 1997), 2: 349Google Scholar.

18. Mirza ᶜAli Khan Amin al--Dawla, Safarnāmah, ed., Hafez Farmayan (Tehran, 1341/1962), 250 and Mostofi, Administrative and Social History, 2: 373Google Scholar.

19. Amin al-Dawla, Safarnāmah, 250. While European physicians were partial to Hakim al-Mulk's skills, he had studied for more than nine years in France and it is doubtful that with the constellation of physicians around Muzaffar al-Din, Amin al-Dawla's libel would have been taken seriously. In fact, Amin al-Dawla's ad-hominem attack against Ibrahim Khan Hakim al-Mulk should be viewed in the context of the infighting at Muzaffar al-Din Shah's court, which pitted the “Turkic” faction (those who had arrived from the Turkic-speaking city of Tabriz with Muzaffar al-Din, and included Hakim al-Mulk and Sultan ᶜAli Khan Vazir Afkham) against the “Fars” faction, established politicians like Amin al-Dawla) who felt a sense of lost entitlement with the rising star of these newcomers. For more on the infighting amongst Muzaffar al-Din's courtiers see: Mostofi, Administrative and Social History, 2: 373Google Scholar.

20. “Le Shah de Perse á Contrexville,” Le Petit Journal, July 1, 1900.

21. Browne, The Persian Revolution, 98.

22. Seyed Taghi Barakchian, “An Annotated Translation of Nazim Al-Islam Kirmani's Tarikh-i Bidari-i Irani” [History of Iranian Awakening],” Ph.D. thesis, State University of New York at Binghamton, 1984, 3: 183.

23. Martin, Vanessa, Islam and Modernism: The Iranian Revolution of 1906 (Syracuse, 1989), 42–51Google Scholar is a good example of the predominantly Marxist or economic-determinist approach which attributes this movement principally to Iran's poor fiscal condition and the special merchant-clerical alliances. While this interpretation is probably correct, the importance of high-powered individuals and their health and state of mind should also be recognized as playing a pivotal role, especially in autocratic societies such as Iran.

24. Barakchian, “An Annotated Translation,” 3: 187.

25. Ibid., 3: 165.

26. The role and influence of physicians, both European and Iranian, at the Qajar court was extensive. The most prominent European physician was Joseph Desirée Tholozan, Nasir al-Din Shah's French ḥakīm-bāshī. However, Muzaffar al-Din's particularly debilitated condition contributed to the rising political star of Iranian physicians like Hakim al-Mulk. (See Amir Arsalan Afkhami, “Disease & Environment in Iran: The Case of Cholera in the 19th Century” in Jeff Albert, Magnus Bernhardsson, Roger Kenna, eds., Transformations of Middle Eastern Natural Environments: Legacies and Lessons (New Haven, 1998) [http://www.yale.edu/forestry/bulletin/103pdfs/103Afkhami.pdf] and Amir Arsalan Afkhami, “Compromised Constitutions: The Iranian Experience with the 1918–1919 Influenza Pandemic,” Bulletin of the History of Medicine [2003].)

27. Archives des Ministres des Affaires Éttrangeres (AMAE), Correspondance Politique et Commerciale (Nouvelle Serie) 1897–1918 (CP), Perse, Francais au Service de Perse: médecins dossier personelles 1896–1905 Volume 57, Dossier 6A. Dépeche (direction politique n. 72) Le Ministre de France á Tehran á Son Excellence Le Ministre Des Affaires Étrangeres á Paris. Téhéran, 30th October, 1906.

28 AMAE, Correspondance Politique et Commerciale (Nouvelle Serie) 1897-1918 (CP), Perse, Francais au Service de Perse: médecins dossier personelles 1896-1905 Volume #57, Dossier 6A. Dépeche (direction politique n. 60) Le Ministre de France á Tehran á Son Excellence Le Ministre Des Affaires Étrangeres á Paris. Téhéran, 16th August 1906.

29. AMAE, Correspondance Politique et Commerciale (Nouvelle Serie) 1897-1918 (CP), Perse, Francais au Service de Perse: médecins dossier personelles 1896–1905 Volume 57, Dossier 6A. Dépeche (direction politique n. 762) Le Médecin 1re Classe Schneider á Monsieur Le Ministre Des Affaires Étrangeres á Paris. Téhéran, 15th July, 1906.

30. AMAE, Correspondance Politique et Commerciale (Nouvelle Serie) 1897–1918 (CP), Perse, Francais au Service de Perse: médecins dossier personelles 1896-1905 Volume 57, Dossier 6A. Dépeche (direction politique n. 72) Le Ministre de France á Tehran á Son Excellence Le Ministre Des Affaires Étrangeres á Paris. Téhéran, 30th October, 1906.

31. Other causes of hyperuricaemia include high intake of foods containing purine (an amino acid), which is abundant in certain meats, seafood, dried peas, and beans. Because of the foods in which purine is found, this disease has been frequently associated with a “rich” diet common to the more aristocratic strata of society. Other causes of hyperuricaemia include obesity, high alcohol intake, certain analgesic and blood-pressure medications, as well as longstanding kidney disease which can lead to an accumulation of uric acid in the system.

32. Goldman, Lee et. al., Cecil Textbook of Medicine Twenty-first Ed. (Philadelphia, 2000), 599Google Scholar.

33. Named after the nineteenth century English physician, Richard Bright, Bright's is an obsolete eponym for a disease of the kidneys (acute or chronic). It generally refers to nonsuppurative inflammatory or degenerative kidney diseases characterized by proteinuria and hematuria and sometimes by oedema, hypertension, and nitrogen retention. For Dr. Schneider's diagnosis of Bright's disease in Muzaffar al-Din see AMAE, Correspondance Politique et Commerciale (Nouvelle Serie) 1897–1918 (CP), Perse, Francais au Service de Perse: médecins dossier personelles 1896–1905 Volume 57, Dossier 6A. Dépeche (direction politique n. 762) Le Médecin 1re Classe Schneider á Monsieur Le Ministre Des Affaires Étrangeres á Paris. Téhéran, 15th July, 1906.

34. The most common regulatory defect in causing kidney failure is the body's inability to get rid of sodium. In the case of the shah, sodium retention also led to increased fluid retention, overloading his heart and leading to cardiac output malfunction.

35. In its worst state, this condition could progress to stupor or coma.

36. Cardiac disease is a major risk factor for stroke, ranking third after age and hypertension. See: Pullicino, M., et. al. “Stroke in patients with heart failure and reduced left ventricular ejection fraction,” Neurology 54 (2000): 288–94CrossRefGoogle ScholarPubMed.

37 A positive Babinski sign is characterized by an upturned big toe and the fanning of the other toes. A positive Babinski sign is always abnormal in adults (though present in children) and it usually indicates a lesion in the upper nervous system. In this case a combination of a Babinski sign together with hyperreflexia (also abnormal) and the paresis and hemiplegia all point to a lacunar stroke. Lacunar strokes are small subcortical infarctions of the deep penetrating arteries.

38. “The Sick Man of Persia: The Shah's Serious Illness,” The Illustrated London News, December 29th 1906, 984.

39. While in modern times nephropathy cased by analgesic agents (phenacetin and aspirin) are important cause of chronic interstitial nephropathy and by extension chronic renal failure. However, historically and in Muzaffar al-Din Shah's case metabolic causes caused by his grout induced hyperuricemia and uric acid stones were probably the responsible agents.

40. Hyperuricemia, or the supersaturation of plasma and extracellular fluids with uric acid, is the hallmark of gout. Under the right conditions, excess uric acid can become crystallized and bring about some of the more dramatic clinical aspects of the disease such as acute gouty arthritis and renal acid (kidney) stones (calculi).

41. Rales are often described as a wet crackling sound whereas crepitus is a dryer crinkly, crackling, or grating sound of the lungs. These nuances can be appreciated by auscultation.

42. A complete hemiplegia is total paralysis of the arm, leg, and trunk on the same side of the body.

43. Paresis is a term describing weakness.