The French Emperor Napoleon Bonaparte died at the age of 52 years due to multiple surgical problems with carcinoma stomach being the final nail on his coffin. His prolonged ill health later in life made him depressed and his attitude to the medical profession was irritable and sceptical and he was not fond of his personal physician Dr. Francesco Antommarchi. He developed trust on a British Army surgeon, Archibald Arnott and on 3 May 1821 Napoleon gave instructions that should he become insensible, no English physician but Arnott was to touch him. But the problem was that Dr. Arnott diagnosed Napoleon as a hypochondriac with a ‘not so serious mental illnesses‘. Even when in April 1821 he saw blood in Napoleon's vomit, he did not consider this a serious illness and gave him sedatives and enemas. The bottom-line is Napoleon, with his innumerable surgical problems needed good surgical care and management which eluded him and thereby hastened his death.

Napoleon Bonaparte may have lost the Battle of Waterloo on June 18^th, 1815 because he was suffering from an acute attack of painful thrombosed haemorrhoids that stopped him from riding his horse to the battlefield [¹]. Napoleon's doctors lost the leeches that they used to relieve his agony two days before the battle, and finally overdosed him with the painkiller laudanum. Napoleon was "acutely discomfited, a shadow of his usual self. He was distracted, failed to issue clear orders and delayed commencing hostilities until 11:20 a.m., more than five hours after originally intended”. The battle which he lost ultimately, is now known in the medical history book as ‘Piles of defeat’ and was remarked by Dr Maher A Abbas from Dubai’s Colorectal Clinic aptly as “What a shame, a painful set of thrombosed haemorrhoids settled the destiny of a great empire!” [²].

While in exile at St. Helena, Napoleon would frequently remark, “this is my weak spot, and it is by this that I shall die” referring to his bladder and strangury. After his death, Napoleon’s personal doctor Francesco Antommarchi noted his bladder to be “shrunken”, filled with stone debris, with thickened mucosa and erythematous patches upon post-mortem evaluation, which might be due to a urethral stricture and schistosomiasis. It is possible that Napoleon developed a urethral stricture from gonococcal urethritis from his first wife, Josephine. Furthermore, Napoleon may have contracted schistosomiasis while in Egypt which might explain his calculi in the urinary bladder. Napoleon was described to have had a severe episode of dysuria on the eve of the Battle of Borodino [³].

In September 1819, Antommarchi noted, “a distended gall bladder projecting into the right hypochondrium.” The characteristic triad and Napoleon was suffering from Charcot’s cholangitis triad of pain, fever and jaundice and the post-mortem report did show biliary microlithiasis. The “distended gall bladder” in the autopsy section contained “extremely thick and lumpy bile” which most likely corresponds to a microlithiasis [⁴].

Even though Napoleon was terrified of dying with the fatal disease from which his father suffered and died, he had a genetic autosomal dominant pattern of inheritance to stomach cancer. Napoleon, his father and grandfather, four sisters and a brother all died of stomach cancer. Bonaparte might well have had gastric infestation with Helicobacter Pylori, which could well have given rise to a predisposition to a chronic pre-pyloric gastric ulcer and later, the cancer. He vomited altered blood on April 25^th and black tarry stool on May 3^rd and died on May 5^th, 1821, at St Helena. The autopsy conducted by his personal physician, Dr François Carlo Antommarchi, revealed at least T3N1M0 (stage IIIA) gastric cancer. Napoleon's tumour extended from the cardia to the pylorus (>10 cm) without infiltration of adjacent structures, which provides strong evidence for at least stage T3. The N1 stage was determined by the presence of several enlarged and hardened peri gastric lymph nodes, and the M0 stage by the absence of distant metastasis [⁵]. The risk might have been further increased by his diet, which probably included salt-preserved foods, thoroughly roasted meats, and few fresh fruits and vegetables.

On December 17, 1793, during an assault in the Siege of Toulon, Napoleon was inflicted a pike wound on the inner side of left thigh, just above his knee by a British artilleryman and it was said that amputation had been considered. The wound became septic and intermittently discharged purulent material. Perhaps there were retained cloth or bone fragments. Years later, in front of his attendant physician Dr Antommarchi at St Helena , he was able to pull open the wound, which still discharged some thin serosanguinous material and might have been a chronic sinus. In 1798, during the Egyptian campaign, his horse kicked him in the right leg. This caused some bruising and a collection of old blood, which was drained by Surgeon Larrey. In April of 1809, a toe was damaged at the action of Eckmühl and the following day, at the Siege of Ratisbon, he received another injury, when a small canister or bullet struck his right (or probably his left) ankle behind the prominence of the malleolus. This caused some bruising. His Surgeon Alexandre Yvan, who advised that a chunk of leather should be cut out of his riding boot, to prevent painful chafing of the wound, dressed his wound [⁶].

In summary, as Napoleon had multiple surgical problems, he needed a modern-day team of doctors to treat him including a gastro surgeon, urologist, medical gastroenterologist colorectal surgeon, orthopaedician and a plastic surgeon. There was a complete lack of knowledge, no proper analysis and diagnosis of his condition was made, and his treatment was just symptomatic, overzealous and experimental as instituted by his personal doctors. Every day the doctors gave Napoleon an enema to relieve his symptoms of a stomach bloating and intestinal cramping. This, combined with regular doses of a chemical called antimony potassium tartrate for emesis would have left poor Napoleon perilously with electrolyte imbalance and hypokalaemia. Last but not the least, two days before his death, he was administered 600 mg dose of a purgative, mercuric chloride, which would have sent his potassium levels plummeting.

No wonder that one of the famous quotes of Napoleon Bonaparte is: “Doctors will have more lives to answer for in the next world than even we generals”.

CONFLICT OF INTERESTS

The authors have no conflict of interest to declare. The authors declared that this study has received no financial support.