The dispute regarding Napoleon's cause of death continues after 180 years because the practice of medicine was not scientific at that time.
When we analyze the doctors who treated Napoleon at different times before his death we should judge them fairly according to the standards of knowledge at that time. Nevertheless, the same treatment and medical care applied in the 21st century would cause a scandalous malpractice case against the doctors who might even stand accused of murder. It is my opinion that even for the year 1821, the doctors caring for Napoleon's last illnesses were guilty of poor judgement, lack of medical knowledge of that time and negligence.
One issue is the doctors' inability to diagnose pulmonary tuberculosis (TB). TB was a common, well-known, well-described disease enabling doctors to diagnose it. The French doctor, René Laënnec (1781-1826) ingeniously hypothesized that “puzzling varieties of lung lesions as diverse as tubercles, miliari lesions, caseous nodules and pleural effusions could represent different expressions of the same disease which he called tuberculosis on the basis of the similarity with potato tubercles.” By 1800 TB was proclaimed the most common disease and in 1815 Thomas Young (1773-1829) surmised that TB brought a premature death to one in four in the general population. Autopsies conducted in the chief Paris hospitals recorded TB as the cause of death in some 40% of cases. A physician from Provence, France, who practiced in Paris, Dr. Gaspar Laurent (1774-1816) gave pathological findings for TB in “Recherches sur La Phtisie Pulmonaire” published in 1810.
After the dismissal of the two British doctors, Barry O'Meara and John Stokoe, Dr. Francesco Antommarchi, a Corsican, was selected in 1819 by Napoleon's uncle, Cardinal Fesch, to be Napoleon's doctor. This was a poor choice since he was a young man of 30 who lacked professional experience and proved to be presumptuous, careless and frivolous. Not related but important is the fact that Dr. Antommarchi plagiarized a number of anatomical designed plates of Paolo Mascagni (1752-1815) in a work purporting to be his own. For this he faced court proceedings. He was an anatomist (a specialist in anatomy) and a pathologist (a specialist in the nature and causes of disease) and, no doubt lacked clinical experience. Napoleon himself must have sensed this since he refused to be treated by Dr. Antommarchi toward the end and called him “a blockhead, an ignoramus, a fop, a sneak.” No wonder because Dr. Antommarchi gave Napoleon a double dose of tartaric emetic (a very strong purge) after which the Emperor rolled on the floor in pain. He refused to take any medication prescribed by Dr. Antommarchi after this incident. Although Dr. Antommarchi remained as one of Napoleon's physicians, Dr. Arnott, a British physician of the 20th regiment, was called to attend to Napoleon. As he too was ignorant, Dr. Arnott diagnosed Napoleon as a hypochondriac with a mental illness being “more mental than physical and not serious.” All this just to ingratiate himself with the British governor Sir Hudson Lowe. Even when in April 1821 he saw blood in Napoleon's vomit, he did not consider this to be a serious illness.
Dr. Antommarchi’s Autopsy Report
The sac formed by the costal pleura (a membrane which lines the internal surface of the thorax or chest, and covers its viscera of the left side) contained a glass of fluid of a citrine color. A slight coat of coagulable lymph covered part of the surfaces of the costal and pulmonary pleura corresponding to the same side.
The left lung was slightly compressed by the effusion and adhered by numerous threads to the posterior and lateral parts of the chest, and to the pericardium (A membranous bag that surrounds the heart.) I carefully dissected it, and found the superior lobe covered with tuberculae (small tumors) and some small tuberculous excavations.
A slight coat of coagulable lymph covered part of the surfaces of the costal and pulmonary pleura corresponding to that side.
The sac of the costal pleura on the right side contained about two glasses of fluid of a citrine color.
The right lung was slightly compressed by effusion,… Many of the ganglions (knot or protuberance) of the bronchiae and of the mediastinum (a membrane occupying the middle of the thorax or chest and dividing its cavity into two parts) were rather enlarged, almost degenerated and in a state of suppuration.
Astonishingly, the five British doctors who signed the official autopsy report state “the lungs were quite sound…about three ounces of reddish fluid were contained in the left cavity (of the pulmonary pleura) and nearly eight ounces in the right.” Dr. Antommarchi refused to sign this one-page report.
It is difficult to understand how Dr. Antommarchi who having been Napoleon's last physician could not relate the clinical signs of TB he had observed for nearly two years with his autopsy report in which he describes TB but does not diagnose it.
Another proof of the lack of good judgement is the dispute the doctors had during and after Napoleon's autopsy related to the size and disease of the liver. Dr. Short, one of the seven British doctors present at the autopsy as observers, was the principal medical officer who had to affix the first signature to a report destined to become historical. He declared the liver to be enlarged; but the three delegates representing Governor Sir Hudson Lowe, Adjutant General Sir Thomas Reade, Major Harrison and the orderly officer Crokot, were greatly annoyed at this opinion and insisted upon further examination. After a very long discussion, Dr. Antommarchi cut the liver open to show signs of disease. Under further pressure the British doctors, now including Dr. Short, signed a report concluding that the liver was of normal size. “No unhealthy appearance presented itself in the liver.” In contrast Dr. Antommarchi in his autopsy report describes the liver as “very large and distended with blood and affected by chronic hepatitis.” It is hard to understand such discrepancies without blaming all the doctors present at the autopsy for not measuring and weighing the liver. They certainly had a measuring tape because the autopsy report indicates the size in inches of the body from five locations and also the circumference of the head.
Written at different times, neither the British autopsy report nor Dr. Antommarchi's autopsy report contain a final diagnosis or conclusions tied in with the cause of death which has left and continues to leave room for different interpretations. Dr. Antommarchi in his autopsy report finds abnormalities of the stomach, such as “obstruction, apparently of a scirrhous nature (at that time scirrhous meant cancer),… a cancerous ulcer,… lymphatic glands tumefied and scirrhous, some even in a state of suppuration (oozing).” “The stomach was perforated through and through in the center…the aperture closed by the adhesion of the liver. The stomach was filled with a considerable quantity of substances of a color resembling the sediment of coffee which exhaled an infectious odor.” (This is processed blood from a severe irritation with hemorrhage caused by an enormous dose of Calomel, a laxative used at that time.) It did not require medical knowledge, just common sense, not to give a sick patient, who had vomited repeatedly and had loose bowel movements, an increase in the accepted dose of one grain of Calomel, to a dose ten times that amount. Napoleon's valet, Louis Marchand, knew better when he refused to give the Calomel to him but Dr. Arnott won and a moribund Napoleon got his last dose of gross medical error. Every historian writes that this enormous dose of Calomel was given by the British Dr. Arnott unintentionally. Or was it?
As there is not enough evidence I cannot get into the controversy of the improbable cause of death due to chronic arsenic poisoning or mercury cyanide developing. I believe that on a debilitated body diseased with tuberculosis, chronic hepatitis and cancerous ulcer of the stomach with perforation (fatal diseases), the profuse bleeding caused by an excessive dose of Calomel hastened Napoleon's death.
How difficult it must have been for the doctors to care for Napoleon is reflected in the attitude of the Governor at St. Helena, Sir Hudson Lowe, who would not accept the diagnosis of hepatitis on his “clean island.” Dr. Barry O'Meara, a British Royal Navy surgeon, was dismissed for diagnosing and treating Napoleon for hepatitis. Dr. O'Meara, a spy for the British government and later declared by Sir Hudson Lowe to be a double spy, was court martialed and dismissed from the navy for implying that Sir Hudson Lowe had government orders to speed up Napoleon's death. Dr. Stokoe, a British naval surgeon, met with the same fate after he diagnosed Napoleon with hepatitis.
Today we can conclude that Napoleon had bad medical care, even for the medical knowledge available at that time, administered by a group of doctors selected for political reasons and terrorized by the British Governor of St. Helena.
Bibliography
1) Antommarchi, Francesco, The Last Days of Napoleon Forming a Sequel to the Journals of Dr. O'Meara and Count Las Cases, (London: H. Colburn, 1826)
2) Fremeaux, Paul, The Drama of St. Helena, (New York: Appelton, 1910)
3) Fremeaux, Paul, With Napoleon at St. Helena – Being the Memoirs of Dr. John Stokoe, Naval Surgeon, (London: Lane, 1902)
4) Forsyth, William, History of the Captivity of Napoleon at St. Helena, includes letters, journals of Lieut. Gen. Sir Hudson Lowe (New York: Harper, 1853)
5) Anderson's Pathology edited by Ivan Damjanon, MD, PhD, James Linder, MD (Mosby 10th Edition)
6) Garrison, Fielding H. (AB, MD), An Introduction to the History of Medicine, 1913
7) Martineau, Gilbert, Napoleon's St. Helena, (New York: Rand McNally & Co., 1968).