Napoleon abdicating in Fontainebleau, by Paul Delaroche
1. Napoleon's death on the Island of St. Helena has been the subject of many medical debates. Elaborate theories about arsenic poisoning and potential foul play by his British captors have been around for centuries, though few fully consider the circumstances of his death. Let's walk through the available evidence and see if we can't put this matter to rest. During the first two years of his captivity his health was relatively stable, but in January 1819 he started complaining of severe epigastric pain radiating towards his right shoulder blade. The physician's log book reported emesis, diarrhea alternating with constipation, recurrent fevers, chills, and headaches. A note from December 1820 stated "The illness of the Emperor has definitively worsened. His pulse is weak, his gums, lips and nails are colorless." In the following months he began losing weight and experiencing such severe night sweats that he had to change his clothing several times each night.
In April 1821 there was noted hematemesis, melena, and tachycardia (112 bpm). The emperor died about a month later. According to the autopsy report filed by an esteemed Italian anatomist, his stomach was filled with dark "coffee ground" like material, and there was an ulcerated lesion with raised, hardened, and irregular borders extending from the cardia to the pyloric region. There were also hardened and enlarged lymph nodes around the stomach and mediastinum. In addition to all of this, he spent his life eating a large amount salt-preserved foods and smoked meats during military campaigns. There is even speculation that an episode of GI bleeding interrupted his command duties at the battle of Waterloo, and contributed to the infamous French defeat. Seems like a classic case, what did he die of? What are two other pathologies present in this description?
Some say this famous pose originated from Napoleon's chronic epigastric pain.
2. Theodor Billroth was one of the greatest surgeons of the 19th century, and is best known today for developing procedures that treat refractory peptic ulcer disease. However, he was also an avid violinist, and was a dear friend to the composer Johannes Brahms. Together they were at the center of the Viennese music scene. Brahms frequently used Billroth's opinion to influence his compositions, and Brahms helped Billroth with his research on cognition and musical perception, the first of its kind. Unfortunately, Billroth died in 1894, two years before Brahms developed an illness that he potentially could have helped with (as the father of modern abdominal surgery). Less than a year before Brahms' his death an observer wrote, "He looked terribly miserable. The thin white beard, the withered face, the yellow eyes, the flabby thin body, his clothes hanging like on a hanger." His doctor also noted "considerable swelling of the liver with complete obstruction of the biliary ducts," perhaps related to his lifelong alcohol consumption or heavy smoking. Before jumping to any conclusions, it is important to note that his health was very good up until his illness began at age 73, and his decline was very rapid. Of the several possible causes of his death, which is the most likely?
Theodor Billroth Operating, A.G. Seligmann
3. Hollywood icon Audrey Hepburn was born in Belgium in 1929 to semi-aristocratic parents, both of whom were members of the British Union of Fascists. Luckily her father, who was a real nazi sympathizer, left the family when Audrey was six years old, and didn't have any lasting impact on her sensibilities. Though what she experienced during the war in Holland impacted her for life, and by all accounts she conducted herself quite nobly. Despite suffering from malnutrition, anemia, respiratory problems and edema, she insisted on helping with the war effort. She gave secret dance recitals to collect money for the Dutch resistance, acted as one of their underground couriers, and baked cakes out of tulip bulbs during the Dutch famine of 1944. Later in her life she became heavily involved with UNICEF, and was very dedicate to fighting child hunger around the world.
Like many who survived the war, Audrey was left with lifelong psychiatric problems, and struggled with depression and an eating disorder throughout her career. She said the one thing that helped most was gardening, which she was very passionate about. In 1993 she made an emmy-winning program called "Gardens of the World," which aimed to transmit the serenity and catharsis she found in them. However, soon after she finished filming she began having sudden, terrible abdominal pain. She checked herself into Cedars Sinai in Los Angeles and the doctors performed laparoscopic surgery. Surgeons found a tumor of the appendix that had metastasized to the small intestine, and they removed a large portion of ilium. After that she received 5-Fluorouracil and leucovorin therapy, which was largely ineffective. She died several months later at the age of 63. What she had was an extremely rare cancer of the appendix called pseudomyxoma peritonei. Based on gut physiology, can you think of what made her tumor present with sharp pain so suddenly without preceding symptoms? The answer is not appendicitis.
Audrey Hepburn, 1929-1993
A clip from her excellent documentary on gardens: http://www.youtube.com/watch?v=t6ArElsvCUA
4. Dr. Frederick Treves was a British physician who had one of the most extraordinary careers in the history of medicine. He became famous for his relationship with Joseph Merrick, aka "The Elephant Man", which turned both of them into Victorian celebrities. He was also a renowned surgeon and was named honorary surgeon to the royal family. In 1902, Prince Albert of Wales (Soon to be King Edward the VII), who had waited 62 for his mother Queen Victoria to die, was finally going to assume the throne in a lavish coronation ceremony. Unfortunately, days before the event he fell ill with sharp lower right quadrant pain. Treves was called and explained that the king likely had an appendicitis, and would probably die if he did not operate. Appendectomies were not well received at the time, but Treves was adamant and finally convinced him. With the personal assistance of Lord Joseph Lister his operation was a success, the monarchy was saved, and from that point on surgery became the standard treatment for appendicitis. Dr. Treves retired having completed over 1000 appendectomies, and spent his final years traveling the world. He wound up in a Swiss nursing home, and in 1923 died from an abdominal infection. There was no autopsy, but it was noted that he suffered from peritonitis during his last few days. I searched and searched but there are no more details on this great doctor's illness. Had his pain started in the lower right it is likely he succumbed to an appendicitis of his own, but what would be the most likely diagnosis had it started on the left?
Dr. Frederick Treves, played by Sir Anthony Hopkins in The Elephant Man
A British newspaper clipping from 1902
5. There's not much history here, but I want to finish with another music clip. Pavarotti, despite his dalliances with the pop music world, was one of the most beloved singers of the 20th century. His powerful, golden voice was recognized the world over, and his death in 2007 sparked national mourning in his native Italy. A year earlier, he came to New York to have an tumor removed that appeared very suddenly and probably had something to do with his lifelong obesity. Despite complete resection and five rounds of chemotherapy, he was never able to recover. He will be missed.
Luciano Pavarotti, 1935-2007
My favorite aria, from Puccini's Tosca
1. Gastric adenocarcinoma, likely from an H. pylori infection. Cholecystitis (right shoulder blade pain), Iron deficiency anemia.
2. Pancreatic cancer (at the head of the pancreas)
3. Bowel obstruction. Ilius and intussesception often occur near the ileocecal valve and as a result of neoplasms in adults.
4. Diverticulitis
5. Pancreatic cancer
Finally, I would like to dispel a malicious rumor that our well-meaning but grossly misinformed lecturers propagated throughout the course. As brilliant as the ancient Greeks were, there is in fact no evidence that they knew about the regenerative capacities of the liver. Prometheus's liver did indeed grow back each day after being devoured by an eagle, but then, there are a whole host of other mythologies whose anatomic claims did not pan out with the coming of modern medicine. Manipulating history to reinforce our current beliefs is a slippery slope, and should not be indulged regardless of the stakes!
Tityus, by Titian. A lecturer used this painting to tell the story of Prometheus, unfortunately it portrays an entirely different legend concerning the god Tityus who had his liver eaten by two vultures. It's been a carnival of errors this year in terms of historical accuracy.
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