After the final defeat at the battle of Waterloo in 1815, Napoleon was exiled to Saint Helena, a small island in the middle of the South Atlantic, where he died on May 5, 1821. Following Napoleon's instructions, his personal physician, Dr François Carlo Antommarchi, a pupil of the renowned anatomy professor Paolo Mascagni (1755 to 1815) at the University of Pisa, performed the autopsy one day after Napoleon's death. The autopsy was performed in the presence of several witnesses, including British medical doctors and Napoleon's companions in exile. The cause of death indicated in Antommarchi's report was an ulcerated “cancerous” lesion in the stomach.1
This conclusion was never seriously disputed until 1961, when a study showing an elevated arsenic concentration in one of Napoleon's hair samples suggested that he may have been poisoned. The study also found some support for this theory in the memoirs of Napoleon's servant in Saint Helena.2 In further studies, the Count of Montholon, one of Napoleon's companions in exile and an alleged British spy, was singled out as the most likely perpetrator of the poisoning. A wide array of possible motives had been put forward, including financial interests (Montholon was apparently generously considered in Napoleon's testament) and jealousy (there were rumors about a possible affair between Napoleon and Montholon's wife, Albine).3,4 Despite its undeniable appeal, this theory was strongly contradicted by many historical and scientific publications,1,5–27 resulting in a lingering debate on Napoleon's cause of death, in which the supporters of the poisoning hypothesis are often fiercely pitted against the backers of the gastric cancer theory.
We surmise that one of the main reasons for the ongoing debate has been the lack of a multidisciplinary study focusing on the different points of view covering the pertinent scientific fields, such as history, medicine (especially gastroenterology), pathology, forensic medicine, as well as toxicology and physics. In this critical review we attempt to fill this gap, by presenting a multidisciplinary approach in reaching an evidence-based consensus on Napoleon's cause of death.
THE GASTROENTEROLOGIST'S VIEWPOINT
In this section we attempt to correlate the evolution of Napoleon's digestive symptoms, as described by his two attending physicians in Saint Helena (Barry O'Meara and Antommarchi),1,28 with the anatomopathologic data in Antommarchi's autopsy report.
The first significant clinical signs were reported by O'Meara in October 1817: “pain on the side and in the shoulder associated with a considerable reduction in appetite.” Subsequent symptoms suggest a triad of recurrent pain, fever, and jaundice. In September 1819, Antommarchi noted “a distended gall bladder projecting into the right hypochondrium.” The characteristic triad and the cyclic course of the clinical signs are compatible with cholangitis, a likely complication of the microlithiasis detailed in Antommarchi's autopsy report.
Napoleon complained of chronic constipation that required regular use of purgatives and enemas. Episodes of diarrhea of various duration were also frequently observed. Although a diagnosis of chronic colitis would seem plausible in this clinical context, no lesions were noted in the colon at autopsy, suggesting that the alternating constipation and diarrhea could have resulted from different conditions, such as, for example, ischemic or microscopic colitis, dietary changes, or irritable bowel syndrome.
In September 1819 Antommarchi noted for the first time during a clinical examination a “hard epigastric region, extremely painful on palpation” that he attributed to isolated hypertrophy of the left lobe of the liver. Until that time there had been essentially no changes in the general clinical picture.
The most significant autopsy finding was a gastric tumor, described by Antommarchi as a “perforated obturated cancer of the lesser gastric curvature.” The growing gastric neoplasm with infiltration of the prepyloric region and resulting parietal thickening can account for the recurring epigastric pain, frequently accompanied by vomiting and weakness. The mass in the epigastric region noted in September 1819 could have been the gastric tumor. At the beginning of May 1821 Napoleon experienced a rapid worsening of epigastric pain, nausea, and vomiting. We suspect that this may be related to a perforation on the wall of the lesser curvature, noted at autopsy to have been adherent to “an indurated area in the left lobe of the liver.”
General Course of the Illness
The Emperor's clinical condition, already poor since at least 1817, took a turn for the worse in September 1820. His health was so deteriorated that in December he made the following statement about his legs: “there's nothing left, it's a skeleton,” and Antommarchi stated in the preamble to his autopsy report: “the Emperor had lost a considerable amount of weight since his arrival in Saint Helena (in 1815)—he did not have a quarter of the volume he had before.” Although this hyperbolic statement must not be interpreted literarily, it is consistent with our findings based on the measurements of Napoleons trousers, that during his time in exile he lost a considerable amount of weight.21–23
Since September the clinical course characterized by chronic anorexia and a severe persistent epigastric pain, frequently accompanied by vomiting or hiccups and followed by periods of extreme weakness. In April 1821, Napoleon repeatedly vomited his food, likely a manifestation of an outlet obstruction. On April 25 his vomit contained “stasis liquid” and coagulated blood. On May 3 at 11 PM, he passed copious “black tarry” stools. The following day Antommarchi noted an extreme distension of the stomach. Death occurred on May 5 at 5:49 PM with a clinical picture of cardiovascular collapse accompanied by a rapid loss of consciousness.
Plausibility of the Gastric Cancer Diagnosis
As noted above, between 1817 and 1820, Napoleon presented a diverse array of clinical symptoms related to various benign digestive and extradigestive pathologies. Retrospectively, a diagnosis of cancer became obvious only toward the end of 1820, when the first alarming symptoms appeared, soon followed by a further deterioration of his health. The functional signs of the preterminal phase, characterized by intractable vomiting and hematemesis, are explained by tumor infiltration into the prepyloric region (noted at autopsy) with resulting outlet obstruction. The perforation of the tumor, which was probably necrotic and eroded for some time, eventually led to the severe hemorrhage accompanied by rapid loss of consciousness, can be seen as the proximal cause of death. In summary, the course of Napoleon's illness is compatible with a diagnosis of gastric cancer and with the anatomic lesions described at autopsy. Survival of approximately 1 year after the onset of the first clinical signs is also in agreement with this diagnosis.
THE PATHOLOGIST'S VIEWPOINT
Antommarchi performed the postmortem examination on May 6, 1821, one day after Napoleon's death. This section concerns itself with the interpretation of his autopsy report, excepted below in its English translation.1 “The convex exterior surface of the left lung adhering in several places to the adjoining costal pleura. About 3 ounces of lymphatic liquid in the sac of the left costal pleura. The lungs in normal condition. The heart in good condition enveloped in its pericardium and covered with a small amount of fat. The stomach, intestines, liver, spleen, and the greater omentum in their natural positions. The superior convex surface of the left lobe of the liver adhering to the adjoining part of the concave surface of the diaphragm. The posterior concave surface of the said lobe strongly adhering to the anterior surface and to the lesser curvature of the stomach as well as to the lesser omentum. After I had, both with the scalpel and with my finger, carefully parted the said adhesion, I observed a hole of about 3 “lignes” in diameter situated in the anterior surface of the stomach near its right extremity. After I had opened the stomach behind the greater curvature I observed it was partially filled with a blackish liquid substance of pungent and disagreeable odor. Having removed the said liquid I observed a very extensive cancerous ulcer occupying, especially, the upper part of the intestinal surface of the stomach and extending from the cardiac orifice to about an inch from the pylorus. On the edge of this ulcer toward the pylorus I recognized the above-mentioned hole produced by ulcerous corrosion of the coat of the stomach. The ulcerated surface of the stomach was considerably swollen and indurate. Between the ulcer and the pylorus and near the ulcer I observed distension and a scirrhous hardness of a breadth of several lines which is formed a circular mass at the right extremity of the stomach. The liver was congested and of more than normal size. All the intestines were in good condition but filled with air.”
In the absence of a microscopic examination, a pathologist reading Napoleon's autopsy report is confronted with 4 main questions: (1) Was Napoleon's gastric lesion benign or malignant? (2) If malignant, do the morphologic aspects suggest an early or an advanced gastric cancer? (3) If malignant, what risk factors for gastric cancer did Napoleon have? (4) Was Napoleon really too obese (as it has been suggested)3 for having died of gastric cancer?
Was the Gastric Lesion Benign or Malignant?
The diagnosis of Napoleon's gastric lesion is primarily based on the characteristic morphologic appearance of gastric tumors. Borrmann's classification of gastric cancer subdivides tumors into 4 types: polypoid, fungating, ulcerated, and infiltrative.29 Benign gastric ulcers are usually small, well-circumscribed, punched-out lesions with a clean base and smooth, edematous margins, whereas ulcerated carcinomas have irregular borders, which are firm, fixed, and often raised; the malignant ulcer crater is typically filled with necrotic and hemorrhagic material. Careful inspection usually allows the pathologist to distinguish a malignant from a benign lesion.29
By comparing Antommarchi's description of an “ulcerated gastric lesion with hardened, irregular borders covering the stomach from the cardia to the pyloric region” to the macroscopic pictures of 50 histologically proven benign ulcers and 50 gastric adenocarcinomas (including all Bormann's 4 subtypes) obtained from the pathology archives at the University of Basel, Switzerland, we concluded that Napoleon's lesion was most likely a Bormann's type III (ulcerated) gastric cancer.22
An alternate explanation for the findings in Napoleon's stomach would be tertiary syphilis, which may lead to a linitis plastica aspect often associated with ulcers and bleeding. Nevertheless, according to the original autopsy report, Napoleon's gastric lesions were more suggestive of an ulcerated tumor (Borrmann III) than of diffuse infiltrating process (Borrmann IV, or linitis plastica).
If Malignant, Does the Morphologic Aspect Correspond to an Early or an Advanced Gastric Cancer?
In an attempt to determine the Tumor Node Metastasis stage Napoleon's cancer by using a control group of 135 patients with gastric cancer, we demonstrated a significant association between tumor size (greatest diameter), and T stage (depth of invasion) and N stage (N0 vs. >N0) (Fig. 1).22 Napoleon's tumor, which measured more than 10 cm and was described as extending from the cardia to the pylorus, was, therefore, likely to be stage T4. Although no infiltration of adjacent organs was specifically mentioned in the autopsy report, the description that the “posterior concave surface of the (left) lobe (of the liver) strongly adhere(d) to the anterior surface and to the lesser curvature of the stomach as well as to the lesser omentum”1 suggests the possibility of a tumor extension into the liver parenchyma. In our series tumor size was also associated with the N stage.
The lymph node status of Napoleon's gastric cancer is consistent with at least N1. As no distant metastases were described in the autopsy report, a conservative estimate would stage Napoleon's gastric cancer as T3 N1 M0 (stage IIIA). Today, the prognosis for treated stage IIIA gastric is dismal, with less than 50% survival at 1 year and <20% survival at 5 years.30–32
If Malignant, What Risk Factors for Gastric Cancer Did Napoleon Have?
The main risk factors for gastric cancer are male sex, chronic gastritis caused by Helicobacter pylori infection, and genetic susceptibility.33,34 Bile reflux, diet (high in salt, smoked meat and fish, and low in fresh fruit and vegetables), smoking, and alcohol are more likely to increase the risk in H. pylori-infected patients.35,36 In a recent study, we proposed H. pylori infection as an important risk factor for Napoleon's gastric cancer. In support of this hypothesis is the presence of an apparently non-neoplastic penetrating prepyloric ulcer in Napoleon's stomach, which is suggestive of a history of chronic H. pylori gastritis. It is well established that a personal history of gastric ulcers confers an increased risk for subsequently developing gastric cancer.37 The occurrence of gastric cancer started to be first noticed among hospitalized patients during the second half of the 18th century, and hospitalization secondary to gastric cancer rose throughout the 19th century.38 The analysis of historic death certificates from many European countries, including France and Italy, also reveals quite clearly how mortality from gastric cancer increased among consecutive generations born during the period between second half of the 18th and the first half of the 19th century.39 Familiar predisposition may also have played a role in increasing Napoleon's risk for cancer,22 although the evidence is somewhat limited. The autopsy report of Napoleon's father, Charles Bonaparte, who died at the age of 39 years, described a “tumor of semicartilaginous consistency, which was of the shape and size of a large potato or a large elongated pear” in the distal part of the stomach.40 The differential diagnosis might include a gastric carcinoma (type I, polypoid), but a gastrointestinal stromal tumor or a lymphoma cannot be excluded. Autopsies on other members of the Bonaparte family were not performed, the cause of their death is only suspected and based on the recorded clinical symptoms or medical reports.22,40 Therefore, there is essentially no evidence to confirm a hereditary gastric cancer syndrome in Napoleon's family.
In addition to H. pylori infection, the diet of military campaigns, rich in salt-preserved foods, thoroughly roasted meats, and few fresh fruits and vegetables, is likely to have played a synergistic role in the pathogenesis of Napoleon's gastric cancer.
Was Napoleon Really too Obese for the Diagnosis of “Gastric Cancer”?
Napoleon's apparent obesity at the time of his death has been used as a strong argument against gastric cancer as his cause of death.3 However, a systematic analysis of Napoleon's weight changes over the course of his life, noticeable from the contemporary iconography, does not support this argument. In 2005 we performed a study to test the hypothesis that Napoleon's weight at death could be compatible with a diagnosis of terminal gastric cancer by estimating the changes of his weight during the last 20 years of his life.20 Our weight modeling was based on the examination and measurement of different pairs of trousers worn by Napoleon between 1800 and 1821 (Fig. 2). Our analysis, based on control data from a cohort of 121 male European patients suggested a weight increase from 67 to 90 kg between 1800 and 1820 and a subsequent weight loss of 11 kg (to 79 kg) during the last year of his life. We confirmed this estimated weight by a second approach based on the subcutaneous fat measurement performed at autopsy (1.5 inches) and using a control group of 270 men (Fig. 3). In conclusion, we suggest that Napoleon's loss of more than 10 kg over the course of 1 year is highly consistent with the course of gastric cancer. An example of the trousers we were allowed to measure is depicted in Figure 3.
TOXICOLOGY AND NUCLEAR PHYSICS: NEW APPROACHES TO THE DETECTION OF ARSENIC
Arsenic poisoning can take two forms. If the dose is large, acute symptoms ensue with severe vomiting and diarrhea often rapidly followed by death. With smaller doses over a prolonged period, chronic poisoning may be seen. Signs of chronic poisoning include “rain drop pigmentation” of the skin (likened to rain-drops on a dusty road) more pronounced in the moist areas, and arsenic corns and hyperkeratosis of the palms of the hands and soles of the feet, which may progress to skin cancer (Fig. 4). Napoleon had none of these features: the autopsy report indicated that “the skin was particularly white and delicate as were the hands and arms.”1 Other manifestations of chronic arsenic poisoning include neuropathy, often severe paresthesia, and reduced sensory and motor functions, particularly in the lower extremities. None of these signs or symptoms were reported to affect Napoleon at any time, either during his stay at Saint Helena or earlier. Weight loss is also a common effect of chronic arsenic poisoning, but Napoleon gained substantial weight during his first 5 years on the island (when he was purportedly being poisoned with arsenic). The rapid weight loss that occurred in his last year was very likely caused by his growing gastric carcinoma.
Thus, Napoleon's clinical course and physical findings are difficult to reconcile with a diagnosis of arsenic poisoning.
Another major problem with the arsenic poisoning theory is that it relies entirely on the finding of elevated hair concentration in a sample of Napoleon's hair. Many problems exist in the interpretation of hair arsenic concentrations. First, an elevated hair arsenic concentration supports the diagnosis of poisoning only if external contamination can be excluded, and this is often not possible. Second, the correlation between severity of poisoning and hair concentration is poor at best, as variations in concentration between hairs from the same subject and even in different segments of the same hair can be very large. To minimize these problems in clinical practice we usually analyze a minimum of 1 g of hair taken from several sites on the head. Because of the scarcity of samples, Napoleon's measurements were all made from single hairs; this can explain the wide range of reported concentrations from samples of equal provenance collected on the same day.1
Arsenic compounds were widely used in the 19th century, and Napoleon had plenty of exposure to them. Longwood, the Emperor's home in Saint Helena was heavily infested with rats, and arsenic trioxide was widely used as rat poison. The walls of Longwood were decorated with green wallpaper based on arsenic pigment (known as Scheele's and Paris green), and these pigments were also used for dying textiles, and Napoleon reportedly had a preference for green clothes. Finally, most cosmetics and hair powders at that time contained arsenic, and Napoleon made abundant use of hair powder. Thus, the potential for contamination of the Emperor's hair was very high.
Although before 1950 arsenic was also a common component of tonics (eg, Fowler's Solution), there is no evidence that the Emperor, who reportedly was reluctant to take any medicines, made any use of these substances. Arsenic can also be naturally present in water supplies. However, we have analyzed the water source used by Napoleon on Saint Helena (the “Geranium spring”), kindly provided by Monsieur M. Dancoise-Martineu, Honorary Consul of France in Saint Helene, and found it to have an arsenic content from 0.8 to 2 ppb, with an average of 1.28±0.4, about 10-fold lower than the presently accepted limit of 10 ppb.1
New measurements on the presence of arsenic in Napoleon's hair have been made possible by the advanced instrumentation developed in the underground “Laboratori Nazionali del Gran Sasso” of the Italian Institute of Nuclear Physics, where background cosmic rays are shielded by a large layer of overhanging rock. Examples of experiments conducted in these laboratories include the detection of very rare events, such as interactions by solar neutrinos, the yet mysterious “dark matter” (particles that could account for a large fraction of the mass of the Universe), or very rare nuclear decays.46,47 These rare events can be mimicked by environmental radiation or by radioactive nuclei present in the detector itself. A powerful technique to detect these “disturbing” atoms is neutron activation analysis (NAA) whose principle is shown in Figure 4. A thermal neutron is captured by a nucleus from the searched element with the consequent emission of a prompt x-ray and the production of a radioactive isotope that is then detected by x-ray spectroscopy.48
We have used this technique in our searches for uranium and thorium contamination in Roman lead and in copper, reaching a sensitivity of ∼10−12 g/g,49 almost 2 orders of magnitude greater than with standard neutron activation analysis. These results encouraged us to perform accurate measurement of arsenic contamination in large certified hair samples from Napoleon Bonaparte and his relatives, which were kindly provided by some of the most important Napoleonic Museums in Europe. In addition to Napoleon' hairs from his infancy in Corsica and Elba (Napoleonic Museum, Rome) and from Saint Helena (Malmaison Museum, Paris), we have measured hairs from Napoleon's son (Napoleon II and King of Rome), cut and brought to Parma by his mother during the years 1812, 1816, 1821, and 1826 (Glauco Lombardi Museum, Parma), and of Empress Josephine (Malmaison). All neutron activations were carried out with thermal neutrons at the Nuclear reactor Triga Mark II of the Laboratorio di Energia Nucleare Applicata of the Pavia University. The γ-ray spectroscopy was performed with hyper pure intrinsic HpGe detectors both in the Radiochemical Laboratory of the Department of General Chemistry at the same University, as well as in the Radioactivity Laboratory of the Italian Institute of Nuclear Physics section and Physics Department of Milano-Bicocca, where also the delicate measurements of hair mass have been carried out.
Measurement results on hairs from presently living subjects were compared with those of the Emperor, the Empress, and his son. As controls, we used hairs from 10 normal living subjects. Hairs from Napoleon's son showed large arsenic levels, whereas Empress Josephine' were lower, yet considerably greater than control subjects. The samples of Napoleon's hair taken when he was a child and when he was on Elba isle have average arsenic contents of 7.3±0.5 and 4.0±0.3 ppm, respectively. The arsenic concentration in the hairs of the Emperor taken the day of his death and the following one were similar, with average values of 15.9±0.7 and 12.4±1.2 ppm, respectively. To further test the murder hypothesis, the longest hair (“hair number 2”) was cut into 6 pieces to investigate a possible temporal variation of the arsenic contamination with time, as hairs grow at a rate of about 1 cm per month. This measurement was considerably difficult because of the low mass of the fragments and the consequent limited statistics. Results, depicted in Table 1, show no evidence of a sudden increase of the arsenic contents, as one would expect if expected a lethal dose had been administered during the Emperor's last 6 months of life.
THE FORENSIC PATHOLOGIST'S VIEW
An autopsy allows the assessment of the morphologic alterations that have occurred before death, but because it is not always possible to establish the sequence of events, the determination of the cause of death is often incomplete. Integrating the concepts of atrium mortis (“entrance gate of death”) and manner of death may be helpful in establishing the cause of death.50 For example, a hemorrhage can be caused by a ruptured vessel in a patient with cardiovascular disease, but can also be due to a firearm wound. In both cases the cause of death is hemorrhage, but the manner of death is quite different.
Napoleon's atrium mortis was an upper gastrointestinal bleeding associated with an advanced gastric cancer. This is supported by the well-documented unrelentingly progressive course of his illness, characterized by of epigastric pain, weight loss, weakness, and eventually melena and hematemesis. It must be noted that in some circumstances results from hair mineral testing can be difficult to interpret51 and correlation with other clinicopatholgical findings is crucial. History, physicals signs, and repeated arsenic content measurements provide evidence against the hypothesis of poisoning. Therefore, gastric cancer can be established as Napoleon's cause of the death.
CONCLUSIONS AND HISTORICAL IMPLICATIONS
In this brief exposé we have summarized the viewpoints of clinicians, clinical epidemiologists, pathologists, toxicologists, nuclear physicists, and forensic pathologists. After weighing the available evidence, we conclude that Napoleon Bonaparte died of natural cause. Some of his supporters were planning to spirit him away from his South Atlantic exile and reestablish his empire in France or to make him the King of Louisiana. Even if any of these improbable plans had succeeded, the course of history would have remained largely unchanged. Before long the once powerful Emperor would succumb not to battle wounds inflicted by gallant rivals or to the toxic schemes of vile adversaries, but to gastric cancer, an enemy that still remains unconquered two centuries later.
The authors thank the following people who provided generous help and advice: (1) the director and personnel of Laboratorio di Energia Nucleare Applicata for the continuous and efficient help in the neutron irradiation; (2) the Napoleonic Museum of Rome and the Glauco Lombardi di Parma of Parma; (3) doctors Giulia Gorgoni, M. E. Tittoni, and Francesca Sandrini; (4) Mr Michel Dancoisne-Martineau, the Honorary Consul of France in Saint Helena; and (5) Dr Bernard Chevallier director of the Museum of Malmaison, who provided us with samples of hairs cut from Napoleon body after his death and also illustrated for us, with great historical competence, the last months of the Emperor's exile.
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