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According to history books, tuberculosis was responsible for the death of Simon Bolivar at the age of 47
years in 1830. The results of an autopsy performed by Alexandre Prospère Révérend, the French physician
who cared for him during the terminal phase of his illness, have long been regarded as proof of the
‘‘How will I get out of this labyrinth?’’ or legacy and much less of the mysterious illness that
caused his death at age 47 years. Moreover, many
persons in South America would argue that the
Simon Bolivar on his death bed to Dr. Révérend, 1830
uncertainty regarding the etiology of General Boli-
(1).
var’s fatal illness is contrived, because of the com-
Simon Bolivar (Figure 1), ‘‘the Liberator,’’ died in
pelling evidence of ‘‘tuberculous consumption’’
1830 after a protracted illness. According to history
found during post mortem examination by Dr.
books, he died of tuberculosis (2). However, in 2008,
Alexandre Prospère Révérend (Figure 2), the French
the controversial president of the Bolivarian Re-
physician who cared for the general during his final
public of Venezuela, Hugo Chávez, defied conven-
fortnight (1). What were the character and the
tional wisdom in announcing that General Bolivar,
anatomy of Bolivar’s terminal illness? Was the illness
his ‘‘spiritual father,’’ did not die of disease but was
diagnosed correctly? If not, what was the correct
assassinated by treacherous conspirators (3). Were it
diagnosis?
not for Chávez and his verbal attacks on the United
Before Bolivar’s emergence as revolutionary leader,
States, few North Americans would take note of the
apart from Brazil and the 3 Guyanas, the continent of
controversy, knowing almost nothing of Bolivar’s life
South America had been ruled by Spain for nearly 300
years (4). By 1825, Bolivar (with the help of José San
Received 7 July 2010; accepted 10 September 2010
Martin, the national hero of Argentina) had wrested
Presented in part: Historical Clinicopathological Conferences sponsored by the from Spanish domination a new world empire that
Veterans Affairs Maryland Health Care System and the University of Maryland
School of Medicine.
was 5 times more vast than all of Europe (5). His
Correspondence: Dr Philip A. Mackowiak, Medical Service-111, VA Medical conquests, which began in 1811, involved 100 battles
Center, 10 N Greene Street, Baltimore, MD (philip.mackowiak@med.va.gov).
and covered 80,000 miles of forced marches (6). In
Clinical Infectious Diseases 2011;52(1):78–85
Ó The Author 2011. Published by Oxford University Press on behalf of the
1819, he liberated New Granada as victor in the battle
Infectious Diseases Society of America. All rights reserved. For Permissions, please of Boyacá; in 1821, Venezuela (battle of Carabobo);
e-mail: journals.permissions@oup.com.
1058-4838/2011/521-0001$37.00
in 1822, Ecuador (battle of Pinchincha); in 1824,
DOI: 10.1093/cid/ciq071 Peru (battles of Junı́n and Ayacucho); and in 1825,
Bolivia (as victor in the battle of Tumusla, his last battle), 9 years of age. However, Bolivar’s father was a notorious
freeing the bulk of Spain’s American empire (4; p. 54–201). womanizer (4), and some have speculated that he died of par-
Shortly after these campaigns ended, the general’s health alytic syphilis and that congenital syphilis was responsible for the
declined, and his former commanders began to desert him in death of a daughter (Bolivar’s sister) shortly after birth (7).
earnest. Bolivar had 3 siblings: an older brother and 2 older sisters. None
Simón José Antonio de la Santı́sima Trinidad Bolı́var y Pal- is known to have developed either syphilis or tuberculosis. His
acios was born in Caracas on 24 July 1783. His parents were sisters died of unknown cause at ages 65 and 68 years (7), and his
Spanish-Americans of Basque descent (4). Both reputedly died brother was lost at sea at age 30 years (4).
of tuberculosis (4); his father died at age 56 years, when Bolivar Bolivar married at age 18 years, and his young bride died of
was 2 years old, and his mother died at age 33 years, when he was malignant fever 8 months later (4). He never remarried
When he was near death, Bolivar’s breathing was labored, contained within the pericardium.. The liver [was] of
his visage a facies Hippocraticus, and the small amount of a considerable size and was a little excoriated on its convex
urine that he produced was bloody. When he died in the early surface.. The mesenteric glands [were] obstructed.’’
morning of 17 December 1830, he weighed 27.7 kg. Révérend,
who had trained in anatomicopathological examination un- How well do these facts support Révérend’s diagnosis of fatal
der Laennec and Dupuytren, performed an autopsy later tuberculosis? On the positive side, the general died of an illness
with many of the cardinal features of galloping consumption
that day (see Supplementary Appendix for the complete re-
(fever, productive cough, and cachexia). Even more compelling
port). He diagnosed ‘‘tuberculous consumption’’ on the basis
are the autopsy findings of tubercles and cavities in the lungs.
of the following findings (1):
Nevertheless, if Bolivar had died of far-advanced cavitary tu-
‘‘[C]onvolutions of the cerebrum[were] covered by berculosis, possibly with laryngeal involvement (as indicated by
a brownish material with the consistency and trans- his terminal hoarseness), he would have been extraordinarily
parency of gelatin.. both sides of the pleurae were contagious. If so, how did Révérend, who lived to the age of
adherent as the result of semi-membranous material; 85 years, escape infection (14)? Furthermore, Manuela Sáenz, the
there was hardening of the superior two thirds of each general’s long-time mistress, apparently died at age 60 years of
lung. The right, which was almost completely dis- diphtheria, not tuberculosis (15). His nephew Fernando, who
organised, looked like a fountain [sic] the colour of wine was his uncle’s private secretary and confidant throughout his
dregs studded with tubercles of different sizes – not very terminal illness, lived to age 88 years (16). Why were episodes of
soft. The left lung although less disorganised showed the hemoptysis not prominent? If Bolivar was infected by his parents
same tuberculous affection. Dividing this with a scalpel I as a child, as many believe, how did his 2 sisters and brother
found an irregular, angular, calcareous concretion about escape a similar fate? Perhaps most important, the chronic
the size of a hazelnut. On opening the rest of the lungs cavitary form of pulmonary tuberculosis and the disseminated
with the instrument, I spilled some brown serous material form rarely coexist. If this is true, as reflected in numerous case
which as a result of the pressure was rather frothy. The series of the latter (17–19), how does one explain the presence of
heart did not demonstrate anything particular although it pulmonary cavities and evidence of simultaneous invasion of the
was bathed in a liquid of a light green colour which was brain, liver, and mesenteric glands on post mortem examination?
If Bolivar’s fatal illness was not tuberculosis, what was introduction in the 1770s of Fowler’s solution, a potassium
it? Of the myriad possibilities (Table 1), which might be arsenate–containing medicinal used to treat malaria, syphilis,
explored in tests performed on specimens recently removed and many other less-severe ailments. As noted above, Bolivar’s
from the general’s casket in the national pantheon in Ca- recurrent attacks of biliary fever (probably malaria) were treated
racas (20–22), 2 are of particular interest: arsenicosis and with an arsenic-based medicine, although the particular one
paracoccidioidomycosis. given to him is unknown. He likely received additional arsenic in
Bolivar’s headaches, weakness, apathy, gastrointestinal com- the food and water that he consumed while campaigning in the
plaints, coarse dark skin, and cachexia are consistent with, al- Andes, where high levels of the element have been detected in
though not diagnostic of, arsenicosis (23). Arsenic-based soil and in the tissue samples from pre-Colombian mummies
remedies were popular during Bolivar’s time, after the (24, 25).