Simon Bolivar's Medical Labyrinth: An Infectious Diseases ...

R E V I E W A R T I C L E

Simon Bolivar’s Medical Labyrinth: An InfectiousDiseases 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, and3Department 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 Prospere Reverend, the French physician

who cared for him during the terminal phase of his illness, have long been regarded as proof of the

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?’’

Simon Bolivar on his death bed to Dr. Reverend, 1830

(1).

Simon Bolivar (Figure 1), ‘‘the Liberator,’’ died in

1830 after a protracted illness. According to history

books, he died of tuberculosis (2). However, in 2008,

the controversial president of the Bolivarian Re-

public of Venezuela, Hugo Chavez, defied conven-

tional wisdom in announcing that General Bolivar,

his ‘‘spiritual father,’’ did not die of disease but was

assassinated by treacherous conspirators (3). Were it

not for Chavez and his verbal attacks on the United

States, few North Americans would take note of the

controversy, knowing almost nothing of Bolivar’s life

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

uncertainty regarding the etiology of General Boli-

var’s fatal illness is contrived, because of the com-

pelling evidence of ‘‘tuberculous consumption’’

found during post mortem examination by Dr.

Alexandre Prospere Reverend (Figure 2), the French

physician who cared for the general during his final

fortnight (1). What were the character and the

anatomy of Bolivar’s terminal illness? Was the illness

diagnosed correctly? If not, what was the correct

diagnosis?

Before Bolivar’s emergence as revolutionary leader,

apart from Brazil and the 3 Guyanas, the continent of

South America had been ruled by Spain for nearly 300

years (4). By 1825, Bolivar (with the help of Jose San

Martin, the national hero of Argentina) had wrested

from Spanish domination a new world empire that

was 5 times more vast than all of Europe (5). His

conquests, which began in 1811, involved 100 battles

and covered �80,000 miles of forced marches (6). In

1819, he liberated New Granada as victor in the battle

of Boyaca; in 1821, Venezuela (battle of Carabobo);

in 1822, Ecuador (battle of Pinchincha); in 1824,

Peru (battles of Junın and Ayacucho); and in 1825,

Received 7 July 2010; accepted 10 September 2010Presented in part: Historical Clinicopathological Conferences sponsored by the

Veterans Affairs Maryland Health Care System and the University of MarylandSchool of Medicine.Correspondence: Dr Philip A. Mackowiak, Medical Service-111, VA Medical

Center, 10 N Greene Street, Baltimore, MD ([email protected]).

Clinical Infectious Diseases 2011;52(1):78–85� The Author 2011. Published by Oxford University Press on behalf of theInfectious Diseases Society of America. All rights reserved. For Permissions, pleasee-mail: [email protected]/2011/521-0001$37.00DOI: 10.1093/cid/ciq071

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

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Bolivia (as victor in the battle of Tumusla, his last battle),

freeing the bulk of Spain’s American empire (4; p. 54–201).

Shortly after these campaigns ended, the general’s health

declined, and his former commanders began to desert him in

earnest.

Simon Jose Antonio de la Santısima Trinidad Bolıvar y Pal-

acios was born in Caracas on 24 July 1783. His parents were

Spanish-Americans of Basque descent (4). Both reputedly died

of tuberculosis (4); his father died at age 56 years, when Bolivar

was 2 years old, and his mother died at age 33 years, when he was

9 years of age. However, Bolivar’s father was a notorious

womanizer (4), and some have speculated that he died of par-

alytic syphilis and that congenital syphilis was responsible for the

death of a daughter (Bolivar’s sister) shortly after birth (7).

Bolivar had 3 siblings: an older brother and 2 older sisters. None

is known to have developed either syphilis or tuberculosis. His

sisters died of unknown cause at ages 65 and 68 years (7), and his

brother was lost at sea at age 30 years (4).

Bolivar married at age 18 years, and his young bride died of

malignant fever 8 months later (4). He never remarried

Figure 1. Simon Bolivar, Libertador de Colombia, by Jose Gil de Castro, Lima 1827. The John Carter Brown Library at Brown University.

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

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but had numerous subsequent affairs with mistresses and

prostitutes, none of which is known to have produced an

offspring (4).

During his prime, Bolivar was slightly below medium

height (5#6’’), slim, and graceful. He ate frugally, avoided

alcohol and tobacco (4), and enjoyed excellent health

throughout most of his life, in spite of the privations and

stresses of commanding an army at war for 20 years in some of

South America’s most inhospitable terrain. Whereas his

complexion had been very white as a youth, by age 44 years, it

had become dark and rough. He required reading glasses by

his late 30s (4). An unsubstantiated report states that, ‘‘His

genital organs [were] small, the testes hard and the cords

short’’ [8].

Before his final illness, Bolivar had several other notable

episodes of illness. When he was aged 29 years, campaigning

in the Magdalena River basin (in north-central Colombia), he

had a febrile illness and furunculosis of unknown etiology

from which he recovered (9). During the ensuing decade, he

had repeated episodes of fever; during some of these episodes,

he at first ‘‘looked flushed and then pale and shivering with

cold.and then lost consciousness’’ (10). These episodes were

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

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

appearance was cadaveric, and his voice was barely audible (4).

Within a year, his associates marveled that, given his extreme

wasting, he was still alive (4).

According to Dr. Reverend (1), when first seen just 2 weeks

before he died, Bolivar was apathetic, emaciated, weak, and so

dyspneic that he was unable to walk. His countenance was

yellow. He was hoarse and coughed constantly, producing

copious green sputum. He also hiccoughed repeatedly. Of

interest, his sense of smell was unusually keen. Whether it had

always been so or had increased in acuity during his illness is

uncertain.

Over the ensuing 16 days, Bolivar coughed constantly and was

intermittently febrile, with a hot head and cold extremities. His

pulse was thready. Initially, he was brighter during the day than

at night, but he slept little and gradually drifted into delirium.

He also had episodes of indigestion and vomiting, sternal

pain, both right and left flank pain, a sore tongue (which was

dry, rough, and colored along its edges), and urinary

incontinence (1).

Throughout this phase of his illness, the general received

many drugs, potions, poultices, and maneuvers. These included

pectoral elixirs, narcotics, expectorants, quinine, turpentine

poultices, blistering plasters (derived from Cantharides beetles),

anodyne ointments, gum arabic, antispasmodics, cold com-

presses, leg rubs, purgatives, enemas, mustard plasters, linseed

water, and Gondret’s pomade (a concoction of beef marrow and

ammonia) (1).

Figure 2. Alexandre Reverend in 1874 (from Schael Martinez G. El�ltimo Medico de Simon Bolivar. Edicion del Concejo Municipal delDistrito Federal, Caracas: 1985, p. 39).


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When he was near death, Bolivar’s breathing was labored,

his visage a facies Hippocraticus, and the small amount of

urine that he produced was bloody. When he died in the early

morning of 17 December 1830, he weighed 27.7 kg. Reverend,

who had trained in anatomicopathological examination un-

der Laennec and Dupuytren, performed an autopsy later

that day (see Supplementary Appendix for the complete re-

port). He diagnosed ‘‘tuberculous consumption’’ on the basis

of the following findings (1):

‘‘[C]onvolutions of the cerebrum[were] covered by

a brownish material with the consistency and trans-

parency of gelatin.. both sides of the pleurae were

adherent as the result of semi-membranous material;

there was hardening of the superior two thirds of each

lung. The right, which was almost completely dis-

organised, looked like a fountain [sic] the colour of wine

dregs studded with tubercles of different sizes – not very

soft. The left lung although less disorganised showed the

same tuberculous affection. Dividing this with a scalpel I

found an irregular, angular, calcareous concretion about

the size of a hazelnut. On opening the rest of the lungs

with the instrument, I spilled some brown serous material

which as a result of the pressure was rather frothy. The

heart did not demonstrate anything particular although it

was bathed in a liquid of a light green colour which was

contained within the pericardium.. The liver [was] of

a considerable size and was a little excoriated on its convex

surface.. The mesenteric glands [were] obstructed.’’

How well do these facts support Reverend’s diagnosis of fatal

tuberculosis? On the positive side, the general died of an illness

with many of the cardinal features of galloping consumption

(fever, productive cough, and cachexia). Even more compelling

are the autopsy findings of tubercles and cavities in the lungs.

Nevertheless, if Bolivar had died of far-advanced cavitary tu-

berculosis, possibly with laryngeal involvement (as indicated by

his terminal hoarseness), he would have been extraordinarily

contagious. If so, how did Reverend, who lived to the age of

85 years, escape infection (14)? Furthermore, Manuela Saenz, the

general’s long-time mistress, apparently died at age 60 years of

diphtheria, not tuberculosis (15). His nephew Fernando, who

was his uncle’s private secretary and confidant throughout his

terminal illness, lived to age 88 years (16). Why were episodes of

hemoptysis not prominent? If Bolivar was infected by his parents

as a child, as many believe, how did his 2 sisters and brother

escape a similar fate? Perhaps most important, the chronic

cavitary form of pulmonary tuberculosis and the disseminated

form rarely coexist. If this is true, as reflected in numerous case

series of the latter (17–19), how does one explain the presence of

pulmonary cavities and evidence of simultaneous invasion of the

brain, liver, and mesenteric glands on post mortem examination?

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

Wilson disease genetic copper overload Tissue copper analysis

Diabetes mellitus insulin deficiency None

Adrenal insufficiency steroid hormone deficiency None

Abbreviation: PCR, polymerase chain reaction.


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If Bolivar’s fatal illness was not tuberculosis, what was

it? Of the myriad possibilities (Table 1), which might be

explored in tests performed on specimens recently removed

from the general’s casket in the national pantheon in Ca-

racas (20–22), 2 are of particular interest: arsenicosis and

paracoccidioidomycosis.

Bolivar’s headaches, weakness, apathy, gastrointestinal com-

plaints, coarse dark skin, and cachexia are consistent with, al-

though not diagnostic of, arsenicosis (23). Arsenic-based

remedies were popular during Bolivar’s time, after the

introduction in the 1770s of Fowler’s solution, a potassium

arsenate–containing medicinal used to treat malaria, syphilis,

and many other less-severe ailments. As noted above, Bolivar’s

recurrent attacks of biliary fever (probably malaria) were treated

with an arsenic-based medicine, although the particular one

given to him is unknown. He likely received additional arsenic in

the food and water that he consumed while campaigning in the

Andes, where high levels of the element have been detected in

soil and in the tissue samples from pre-Colombian mummies

(24, 25).

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


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Bolivar’s complexion, as noted above, changed from

white as a youth to dark and rough 3 years before he died.

The transformation might simply have been the result of

years of exposure to the harsh elements during his campaigns.

However, it is also possible that it was an additional mani-

festation of arsenicosis, because diffuse melanosis, papules,

and keratoses are among the earliest signs of such in-

toxication (26). Of interest, facial flushing, which Bolivar

manifested during episodes of biliary fever, is a reaction to

arsenic tonics, which practitioners during Bolivar’s time re-

garded as desirable (27). Peripheral neuropathy is another

complication of arsenicosis, but Bolivar apparently did not

develop this.

Arsenic intoxication also might have contributed to the

general’s pulmonary difficulties, the onset of which co-

incided with and were likely precipitated by an assassination

attempt in 1828 (4). Bolivar was in Lima at the time. To

escape his attackers, he spent 3 h shivering under a bridge in

the murky water of the San Agustin River. Shortly thereafter,

his respiratory difficulties flared. The clinical and patho-

logical characteristics of his pulmonary disorder are typical

of a refractory bacterial pneumonia that degenerated into

nontubercular bronchiectasis—a process that evolves over

months to years and manifests as productive cough, fatigue,

dyspnea, and weight loss. Moreover, it is a disorder easily

confused with tuberculosis (28, 29). If Bolivar’s green peri-

cardial fluid indicated a purulent pericarditis, it would likely

have been caused by bacteria spreading from pre-existing

bronchiectasis—a dreaded complication of such infections

before the advent of antibiotics (30).

Chronic arsenic exposure, for reasons not entirely clear,

predisposes one to both bronchiectasis and cancer (31, 32).

The latter complication might explain Bolivar’s

hoarseness (due to paralysis of the left recurrent laryngeal

nerve) and, if metastatic, also his yellow countenance, his

enlarged liver, and his obstructed mesenteric glands. His

terminal hematuria might have also been precipitated by

metastatic cancer. However, more likely, the hematuria re-

sulted from a low-grade coagulopathy caused by the ca-

thardin-based blistering plasters administered by Dr.

Reverend (33).

Paracoccidioidomycosis, although not a perfect fit, is in cer-

tain respects an even better explanation for the clinical, epide-

miological, and pathological facts concerning Bolivar’s case. In

fact, it might account for nearly all the features of his terminal

illness—the fever, the weight loss, the apathy, the hoarseness, the

productive cough, the flank pain, the skin changes, the thready

pulse, the heightened sense of smell, the hematuria, the absence

of secondary cases, and the presence of both cavitary pulmonary

disease and disseminated granulomatosis in the same patient

(34–41).

Paracoccidioidomycosis (also known as ‘‘South American

blastomycosis’’) is one of the most common deep-seated

mycoses of tropical Latin America. Although Brazil has the

highest incidence, the infection is endemic throughout much

of the region in which Bolivar campaigned. Unlike tuber-

culosis, with which it is often confused, para-

coccidioidomycosis is not transmitted from person to

person. Therefore, whereas Bolivar would likely have

transmitted his infection to intimate contacts if he had had

fulminate tuberculosis, he would not have done so if he had

died of paracoccidioidosis. Soil is believed to be the mi-

crobe’s natural habitat; its portal of entry is the lungs. The

disease has a long latent period, rarely manifesting clinically

before the age of 30 years. Men are affected 15-times more

often than are women (41).

In advanced cases of paracoccidioidomycosis, unlike those

of tuberculosis, progressive cavitary lung lesions regularly

coexist with disseminated foci of infection in sites, such as

the tongue, liver, mesenteric lymph nodes, and adrenal

glands (41). Productive cough is common, hemoptysis less

so. Fever and weight loss occur in more than half the cases,

hoarseness (due to laryngeal involvement) in a fifth, and

hepatomegaly in 18%. In the rare instances in which calcified

pulmonary nodules have been encountered, they have been

attributed to coinfection with either tuberculosis or histo-

plasmosis (35), which occurs in 15% of cases (41). Myo-

carditis has also been observed in paracoccidioidomycosis,

although infrequently. Invasion of the adrenal glands is

common in this disease, occurring in as many as 85% of

symptomatic adults (41). Seven percent of cases exhibit ev-

idence of Addisonian crisis, such as profound weakness, cold

extremities, and the thready pulse exhibited by Bolivar. In

the general’s case, destruction of the adrenal glands was in-

dicated further by his dark, coarse skin and, perhaps also, by

his heightened sense of smell, a little-known feature of ad-

renal insufficiency (42).

Shortly before midnight on 16 July 2010, Venezuelan

President Hugo Chavez and a team of soldiers, forensic

specialists, and presidential aides entered the National

Pantheon in Caracas (Figure 3), unscrewed the lid of the

Liberator’s casket, and removed several fragments of bone

and some teeth (20–22). These have been sent to a newly

inaugurated state forensic laboratory for analysis (20). An

attempt will first be made to verify the remains as those of

‘‘El Libertador’’ by comparing DNA retrieved from the

specimens with that extracted from the bones of Bolivar’s

sisters Juana and Maria Antonia (43). Other tests to be

performed have not yet been revealed to the public but

presumably will include assays for arsenic, Mycobacterium

tuberculosis and Paracoccidioidomyces braziliensis. If and

when these analyses have been completed, the challenge will


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be one of interpreting the results. Almost certainly disputes

will arise not just about their meaning but also about their

validity. For these reasons, Bolivar’s second post-mortem

examination is not likely to close the book on the etiology of

his fatal disorder. In all likelihood, the information con-

tained in the clinical summary provided above and Rever-

end’s autopsy report will remain the principal evidence on

which the solution to General Bolivar’s medical conundrum

will have to be based.

Supplementary Material

Supplementary materials are available at Clinical Infectious

Diseases online (http://www.oxfordjournals.org/our_journals/

cid/).

Supplementary materials consist of data provided by the

author that are published to benefit the reader. The posted

materials are not copyedited. The contents of all supple-

mentary data are the sole responsibility of the authors.

Questions or messages regarding errors should be addressed

to the author.

Acknowledgments

We thank Frank M. Calia, MD, for editorial advice; Steven D. Munger,

PhD, for calling our attention to the information in [42]; and Adriana

Naim and Richard J. Behles, for assisting in the literature review.

Financial support. none reported.

Potential conflicts of interest. All authors: no conflicts.

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http://www.washingtonpost.com/wp-dyn/content/article/2010/08/30/AR2010083004125.html

http://www.washingtonpost.com/wp-dyn/content/article/2010/08/30/AR2010083004125.html

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Simon Bolivar's Medical Labyrinth: An Infectious Diseases ...

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