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REVIEW ARTICLE

Simon Bolivar’s Medical Labyrinth: An Infectious


Diseases Conundrum
Paul G. Auwaerter,1 John Dove,4 and Philip A. Mackowiak2,3
1Department of Medicine, Johns Hopkins University School of Medicine, 2Medical Care Clinical Center, VA Maryland Health Care System, and
3Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and 4School of Literatures, Language and Cultures,
University of Edinburgh, Edinburgh, United Kingdom

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

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diagnosis. On careful reanalysis of Bolivar’s medical history and post mortem examination, we reach
a different conclusion. On the basis of several critical clinical, epidemiological, and pathological features
of his fatal disorder, we conclude that either paracoccidioidomycosis or bacterial bronchiectasis
complicating chronic arsenic intoxication was more likely responsible for his death than was tuberculous
‘‘consumption.’’

‘‘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,

78 d CID 2011:52 (1 January) d Auwaerter et al.


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Figure 1. Simón Bolívar, Libertador de Colombia, by José Gil de Castro, Lima 1827. The John Carter Brown Library at Brown University.

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

Bolivar’s Medical Labyrinth d CID 2011:52 (1 January) d 79


treated, in some instances, with quinine and, in others, with
arsenic. On one occasion, the latter treatment is reported to
have induced a severe attack of dysentery (11). Although
Bolivar also experienced recurrent colic, rheumatism, and
chronic hemorrhoids (4), he was reasonably fit until age 40
years, when he developed a high fever and collapsed, possibly
as a result of heat stroke (4). For 7 days, Bolivar was near
death in a small village north of Lima, and for 2 months, he
was so weak and emaciated that he was hardly recognizable.
Nevertheless, within 4 months, he had recovered sufficiently
to lead his army to Pasco (in central Peru; elevation, 4262
meters) over some of the most mountainous land in the
world, in what was described later as ‘‘a mightier feat than
Hannibal’s passage of the Alps’’ (12).
Exactly when the general’s final illness began is uncertain.
Although some believe that the first symptoms of the pulmonary
disorder of which he died began at age 35 years (9), others
claim that, besides the aforementioned episodes of illness, he

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was physically fit until age 45 years, when his health began
decline (4).
According to the patient’s letters, of which a great many have
been preserved (13), shortly before he turned 46 years of age,
Bolivar was tormented by persistent headaches and bilious at-
tacks that left him weak and exhausted. Within 6 months, his
Figure 2. Alexandre Révérend in 1874 (from Schael Martinez G. El
appearance was cadaveric, and his voice was barely audible (4).
ltimo Médico de Simón Bolívar. Edicion del Concejo Municipal del
Distrito Federal, Caracas: 1985, p. 39). Within a year, his associates marveled that, given his extreme
wasting, he was still alive (4).
According to Dr. Révérend (1), when first seen just 2 weeks
before he died, Bolivar was apathetic, emaciated, weak, and so
but had numerous subsequent affairs with mistresses and dyspneic that he was unable to walk. His countenance was
prostitutes, none of which is known to have produced an yellow. He was hoarse and coughed constantly, producing
offspring (4). copious green sputum. He also hiccoughed repeatedly. Of
During his prime, Bolivar was slightly below medium interest, his sense of smell was unusually keen. Whether it had
height (5#6’’), slim, and graceful. He ate frugally, avoided always been so or had increased in acuity during his illness is
alcohol and tobacco (4), and enjoyed excellent health uncertain.
throughout most of his life, in spite of the privations and Over the ensuing 16 days, Bolivar coughed constantly and was
stresses of commanding an army at war for 20 years in some of intermittently febrile, with a hot head and cold extremities. His
South America’s most inhospitable terrain. Whereas his pulse was thready. Initially, he was brighter during the day than
complexion had been very white as a youth, by age 44 years, it at night, but he slept little and gradually drifted into delirium.
had become dark and rough. He required reading glasses by He also had episodes of indigestion and vomiting, sternal
his late 30s (4). An unsubstantiated report states that, ‘‘His pain, both right and left flank pain, a sore tongue (which was
genital organs [were] small, the testes hard and the cords dry, rough, and colored along its edges), and urinary
short’’ [8]. incontinence (1).
Before his final illness, Bolivar had several other notable Throughout this phase of his illness, the general received
episodes of illness. When he was aged 29 years, campaigning many drugs, potions, poultices, and maneuvers. These included
in the Magdalena River basin (in north-central Colombia), he pectoral elixirs, narcotics, expectorants, quinine, turpentine
had a febrile illness and furunculosis of unknown etiology poultices, blistering plasters (derived from Cantharides beetles),
from which he recovered (9). During the ensuing decade, he anodyne ointments, gum arabic, antispasmodics, cold com-
had repeated episodes of fever; during some of these episodes, presses, leg rubs, purgatives, enemas, mustard plasters, linseed
he at first ‘‘looked flushed and then pale and shivering with water, and Gondret’s pomade (a concoction of beef marrow and
cold.and then lost consciousness’’ (10). These episodes were ammonia) (1).

80 d CID 2011:52 (1 January) d Auwaerter et al.


Table 1. Diagnostic Considerations and Tests Worth Performing on Bolivar's Remains

Condition Cause Test


Infections
Tuberculosis Mycobacterium tuberculosis PCR amplification and/or electron microscropy
Paracoccidioidomycosis Paracoccidioides brasiliensis ‘‘
Histoplasmosis Histoplasma capsulatum ‘‘
Meloidosis Burkholderia pseudomallei ‘‘
Syphilis Treponema pallidum ‘‘
Bronchiectasis Haemophilus spp. ‘‘
Pathogens Streptococcus pneumoniae ‘‘
Staphylococcus aureus ‘‘
Klebsiella spp. ‘‘
Pseudomonas aeruginosa ‘‘
Toxins
Arsenicosis Arsenic Inductively-coupled plasma mass spectrometry
Cantharidin intoxication Extract from Lytta vesicatoria Gas chromatography mass spectrometry
Genetic or acquired
Hemochromatosis genetic iron overload PCR mutational analysis, tissue iron analysis

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Wilson disease genetic copper overload Tissue copper analysis
Diabetes mellitus insulin deficiency None
Adrenal insufficiency steroid hormone deficiency None
Abbreviation: PCR, polymerase chain reaction.

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?

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Figure 3. The National Pantheon in Caracas, Venezuela (Photograph taken by the author, John Dove, July 2010).

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).

82 d CID 2011:52 (1 January) d Auwaerter et al.


Bolivar’s complexion, as noted above, changed from Paracoccidioidomycosis (also known as ‘‘South American
white as a youth to dark and rough 3 years before he died. blastomycosis’’) is one of the most common deep-seated
The transformation might simply have been the result of mycoses of tropical Latin America. Although Brazil has the
years of exposure to the harsh elements during his campaigns. highest incidence, the infection is endemic throughout much
However, it is also possible that it was an additional mani- of the region in which Bolivar campaigned. Unlike tuber-
festation of arsenicosis, because diffuse melanosis, papules, culosis, with which it is often confused, para-
and keratoses are among the earliest signs of such in- coccidioidomycosis is not transmitted from person to
toxication (26). Of interest, facial flushing, which Bolivar person. Therefore, whereas Bolivar would likely have
manifested during episodes of biliary fever, is a reaction to transmitted his infection to intimate contacts if he had had
arsenic tonics, which practitioners during Bolivar’s time re- fulminate tuberculosis, he would not have done so if he had
garded as desirable (27). Peripheral neuropathy is another died of paracoccidioidosis. Soil is believed to be the mi-
complication of arsenicosis, but Bolivar apparently did not crobe’s natural habitat; its portal of entry is the lungs. The
develop this. disease has a long latent period, rarely manifesting clinically
Arsenic intoxication also might have contributed to the before the age of 30 years. Men are affected 15-times more
general’s pulmonary difficulties, the onset of which co- often than are women (41).
incided with and were likely precipitated by an assassination In advanced cases of paracoccidioidomycosis, unlike those
attempt in 1828 (4). Bolivar was in Lima at the time. To of tuberculosis, progressive cavitary lung lesions regularly
escape his attackers, he spent 3 h shivering under a bridge in coexist with disseminated foci of infection in sites, such as

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the murky water of the San Agustin River. Shortly thereafter, the tongue, liver, mesenteric lymph nodes, and adrenal
his respiratory difficulties flared. The clinical and patho- glands (41). Productive cough is common, hemoptysis less
logical characteristics of his pulmonary disorder are typical so. Fever and weight loss occur in more than half the cases,
of a refractory bacterial pneumonia that degenerated into hoarseness (due to laryngeal involvement) in a fifth, and
nontubercular bronchiectasis—a process that evolves over hepatomegaly in 18%. In the rare instances in which calcified
months to years and manifests as productive cough, fatigue, pulmonary nodules have been encountered, they have been
dyspnea, and weight loss. Moreover, it is a disorder easily attributed to coinfection with either tuberculosis or histo-
confused with tuberculosis (28, 29). If Bolivar’s green peri- plasmosis (35), which occurs in 15% of cases (41). Myo-
cardial fluid indicated a purulent pericarditis, it would likely carditis has also been observed in paracoccidioidomycosis,
have been caused by bacteria spreading from pre-existing although infrequently. Invasion of the adrenal glands is
bronchiectasis—a dreaded complication of such infections common in this disease, occurring in as many as 85% of
before the advent of antibiotics (30). symptomatic adults (41). Seven percent of cases exhibit ev-
Chronic arsenic exposure, for reasons not entirely clear, idence of Addisonian crisis, such as profound weakness, cold
predisposes one to both bronchiectasis and cancer (31, 32). extremities, and the thready pulse exhibited by Bolivar. In
The latter complication might explain Bolivar’s the general’s case, destruction of the adrenal glands was in-
hoarseness (due to paralysis of the left recurrent laryngeal dicated further by his dark, coarse skin and, perhaps also, by
nerve) and, if metastatic, also his yellow countenance, his his heightened sense of smell, a little-known feature of ad-
enlarged liver, and his obstructed mesenteric glands. His renal insufficiency (42).
terminal hematuria might have also been precipitated by Shortly before midnight on 16 July 2010, Venezuelan
metastatic cancer. However, more likely, the hematuria re- President Hugo Chavez and a team of soldiers, forensic
sulted from a low-grade coagulopathy caused by the ca- specialists, and presidential aides entered the National
thardin-based blistering plasters administered by Dr. Pantheon in Caracas (Figure 3), unscrewed the lid of the
Révérend (33). Liberator’s casket, and removed several fragments of bone
Paracoccidioidomycosis, although not a perfect fit, is in cer- and some teeth (20–22). These have been sent to a newly
tain respects an even better explanation for the clinical, epide- inaugurated state forensic laboratory for analysis (20). An
miological, and pathological facts concerning Bolivar’s case. In attempt will first be made to verify the remains as those of
fact, it might account for nearly all the features of his terminal ‘‘El Libertador’’ by comparing DNA retrieved from the
illness—the fever, the weight loss, the apathy, the hoarseness, the specimens with that extracted from the bones of Bolivar’s
productive cough, the flank pain, the skin changes, the thready sisters Juana and Maria Antonia (43). Other tests to be
pulse, the heightened sense of smell, the hematuria, the absence performed have not yet been revealed to the public but
of secondary cases, and the presence of both cavitary pulmonary presumably will include assays for arsenic, Mycobacterium
disease and disseminated granulomatosis in the same patient tuberculosis and Paracoccidioidomyces braziliensis. If and
(34–41). when these analyses have been completed, the challenge will

Bolivar’s Medical Labyrinth d CID 2011:52 (1 January) d 83


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