Hemorrhage Part 2
Want to know what dictators’ autopsy was published on the front page of the newspaper, why he hated doctors and what that had to do with his death? What leeches were used for in 1950?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Today we’re going to shake things up a little. Your job today isn’t to save your patient, but to decide if this famous villain was poisoned or not! I hope this will be fun. This episode is part two, for more details on the poison, you may want to start with the last episode Hemorrhage.
Want to know what dictators’ autopsy was published on the front page of the newspaper, why he hated doctors and what that had to do with his death? What leeches were used for in 1950? Listen to find out!
Let’s go back in time to February 28, 1953 in Russia, outside of Moscow, the dacha of 74-year-old Joseph Stalin. Was his death due to a poison? Listen and tell me what you think!
That evening, as he often did, Stalin invited several people over for dinner and a movie. These men, his inner circle, and himself were called the 5. They were Nikita Khrushchev, head of the communist party in Moscow, Lavrentiy Beria, chief of the secret police, Georgy Malenkov, chairman of the Politburo, and Nikolai Bulganin, Minister of Defense. Exact details of the events vary between sources, but these are the general facts. The men left at 4 or 5 am on March 1. These hours were typical for Stalin who often went to bed late an didn’t wake up until 11am.
Stalin’s guards became concerned when he didn’t arise by the afternoon. However, they had strict instructions never to disturb him and were afraid to enter his room. At 6:30 pm a light came on inside, but nothing else. Finally, at 11 pm, either his housekeep or a guard summoned the courage to enter. Stalin was on the floor, unresponsive, soaked in urine. He made a few noises, perhaps attempting to speak, then fell completely unconscious. His watch, on the ground next to him, read 6:30 pm, suggesting he fell shortly after turning on the light. He was probably laying on the floor for 4.5 hours.
The guards lifted him onto a couch and called the head of the Ministry of State Security, predecessor to the KGB. This man wanted nothing to do with the situation and told them to call Beria and Malenkov instead. Beria and Malenkov arrived around 1 am, now February 2. After a long debate, they decided to Stalin’s room. Malenkov even took off his shoes to prevent them from squeaking.
Beria glanced at Stalin, said to the guards “What are you panicking for? The Boss is sound asleep. Let’s go, Malenkov!” attributing his symptoms to alcohol he drank the night before.
At 7:30am on March 2, Khruschev arrived, shocked and called for doctors. The doctors arrived about an hour later, now 9.5 hours after Stalin, the powerful dictator, was found unconscious. Reading this, my first thought was obviously Stalin was poisoned. He’s the powerful leader of a large country and no one calls a doctor until 9 hours after he’s found unconscious? But…in fact, there’s more to this, a lot more.
Let’s take a step back into the earlier years of Stalin’s life to shed light on other factors at play. He was born in Georgia, with the name Ioseb Jughashvili in 1878. He rose to power in the Soviet Union after Lenin’s death. Look at any list of the world’s worst dictators and Stalin is on all of them. He’s responsible for the Great Terror or the Great Purge, killing millions. By some accounts responsible for the deaths of 10-30 million people, including deaths in the Gulag, deportations, forced resettlement and starvation during famine.
It wasn’t just his subjects at risk; Stalin frequently purged his inner circle. Indeed, at the time of his death the 4 men at the dinner were far from immune. There’s evidence Stalin was suspicious of Beria, Khrushchev and Malenkov. Beria had fallen out of Stalin’s good graces, he was recently demoted, Khrushchev had been publicly rebuked and Malenkov’s increasing power was seen as a threat. It was said of Stalin no one ever knew if they’d return alive after a meeting with him.
Stalin not only distrusted doctor’s, he’d probably killed several of his own physicians. Being a doctor for the rich and powerful is difficult enough under the best of circumstances, being Stalin’s physician was a particularly perilous job. A neurologist who told his assistant Stalin was “paranoic” died of poisoning the next day.
In 1927, a neuropathologist and psychiatrist also diagnosed Stalin with paranoia and other neurological issues. He died during a medical conference supposedly from poisoned canned goods. Another physician who diagnosed Stalin, in a bold move, with megalomania and a persecution complex, was arrested shortly thereafter and executed by firing squad a few years later.
Stalin reportedly had a fear of physicians. Was this due to his well-documented paranoia? Or was it a legitimate fear? During Stalin’s regimen, psychiatry was weaponized, with dissenters and dissidents falsely diagnosed with mental illness and locked up in so called psychiatric hospitals, really prisons. An addition Stalin succeeded Lenin, as I mentioned earlier. How? After Lenin suffered several stokes becoming incapacitated, Stalin used the opportunity to take over, seizing power. He was likely concerned someone might do the same to him.
Stalin didn’t like exercise, including walking, smoked and ate a heavy diet. So it’s no surprise he had cardiovascular disease. Apparently he drank alcohol only in moderation, though it's unclear what that might have meant by Russian standards in the 1950s. He probably had a heart attack in Oct 1945, at the end of WWII, as well as several small strokes.
He hadn't seen a doctor for at least a year prior to his death. Some say his primary medical advisor at this time was a bodyguard who’d worked as a veterinarian. Stalin treated his hypertension by drinking iodine in water. In fact, at the time he fell ill, Stalin’s own doctors were being tortured in prison. Yes, you heard that correctly. It’s known as the Doctor’s Plot, more on this in a few minutes.
Let’s talk about what the doctors, when they finally arrived at Stalin’s dacha on the morning of March 2, found. Stalin was unresponsive with a blood pressure of 190/110. His right arm and leg were paralyzed. He had + right sided Babinski sign. If you stoke the sole of a person’s foot, normally their toes curl down. A positive Babinski sign, also called an upward Babinski, is when the toe goes up instead.
Question # 1. These symptoms are most consistent with?
A. Intracranial hemorrhage or bleeding in the brain
B. A stroke
C. Myocardial infarction or heart attack
D. Gastrointestinal bleeding
The answer is B. A stroke and the physicians diagnosed him specifically with a middle cerebral artery stoke.
They ordered the application of leeches behind his ears; a cold compress on his head; an enema of milk of magnesia, and the removal of his false teeth. Let me remind you this was 1953. Question # 2. Leeches help with strokes.
A. True
B. False
Answer: B, False leeches haven’t been proven to help strokes in humans, but partial credit for both answers. Hirudin is an anticoagulant derived from leeches and a few rodent studies suggest it’s helpful in reducing ischemia. Improving a few rat cells in a Petrie dish, however, is a far cry from proving the application of leeches behind someone’s ears is treating a stroke.
I was surprised to find leech therapy is still popular in Russia today. It sends a shiver of horror down my spine. I guess what a Russian friend’s mom once said is true, Americans are too weak for strong medicine. In my case, definitely guilty as charged.
Back to Stalin and the doctors. None of the treatments worked. Stalin’s condition worsened, he developed Cheyne-Stokes respiration, a patten of alternating slow and fast breaths signifying severe brain pathology. His blood pressure rose as high as 210/120. He was also treated with magnesium to lower his blood pressure and camphor, strophantin, which is like digoxin, caffeine, and glucose.
Descriptions of these events always mention the shaking hands of the doctors examining Stalin. They could barely examine him. The dentist was so tremulous he dropped Stalin’s dentures on the floor. They were terrified. Why? This brings us back to the doctor’s plot.
In 1952, his cardiologist recommended Stalin resign for health reasons. Shortly thereafter the doctor was arrested. A few months later, the newspaper Pravda announced 9 “murder-doctors” were arrested to stop an alleged terrorist plot to kill high ranking Soviet leaders. These weren’t local practitioners, but prominent physicians including the Kremlin’s medical director. Of note, all were Jewish. This led to mass paranoia across Russia with hospitalized patients refusing care and mother’s refusing to give their children medicine out of fear it was poisoned.
At the time of Stalin’s illness, as I said earlier, his personal physicians were literally being tortured. Several reports note interrogators stopping torture to instead ask medical questions. One doctor was asked what Cheyne-Stokes respirations were. Another was asked for recommendations for physicians to treat Stalin. He gave several names, but none were available, as all of them were also in prison.
Why did Stalin arrest the doctors and induce paranoia about medicine in general? As with much of what happens in Russia, it’s not entirely clear, but at the time 5 huge prisons were under construction in Siberia. It’s believed he was planning to start another purge, a mass genocide against Jews, using the false allegations to incite fear and hatred.
So back to the reluctance by Stalin’s inner circle to call a doctor. Maybe a guilty party did want to cover up poisoning. But it’s just as likely they were afraid to anger him by calling in a doctor to treat a paranoid, hater of doctors.
Health and illnesses of political leaders is always fraught with secrecy and coverups. As I'm sure you know, the health of Russian leaders is considered a state secret. There’s conjecture as to whether or not Vladimir Putin might've undergone cancer treatment. And it’s not just Russia, in the United States there is ongoing speculation about Joe Biden's mental health while he was in office.
In 1953, there was an interesting mix of secrecy and details surrounding Stalin’s illness. It was kept secret until a public announcement on March 3, but afterward surprisingly detailed bulletins followed. According to recently declassified CIA documents, the government wanted to avoid any suggestion Stalin was under the care of physicians involved in the supposedly murderous Doctor’s Plot.
If doctors had been called sooner, would Stalin have survived? Well, it's doubtful given what they did when they did arrive. But in truth at that time, there was little that could be done for a stroke other than give aspirin. And knowing subsequent events, aspirin might have made it worse.
Stalin’s condition deteriorated on March 5th, he vomited blood several times, developing a low heart rate and blood pressure. Reportedly he opened his eyes, gave a “terrible glance, insane or perhaps angry and full of the fear of death” raised his hand in a strange gesture as if “bringing down a curse… the gesture was incomprehensible and full of menace,” Then he died.
The official cause of death was hemorrhagic stroke due to hypertension. Stalin’s autopsy results were summarized on the front page of Pravda. There’s a great photo of it on Wikipedia if you’re interested. The autopsy noted the following: a large hemorrhage in the subcortical areas of the left cerebral hemisphere, hypertrophy of the left ventricle of the heart, numerous hemorrhages in the myocardium, stomach, and intestines, and atherosclerotic changes in the blood vessels. Apparently, notation of these GI hemorrhages was missing or buried in the report to the Central Committee, coming to light much later when the autopsy itself was declassified.
Ok, these are the general facts of the circumstances surrounding Stalin’s death.
So, now we come to the toxicology part of this story. Several historians suggested Stalin didn’t die of natural causes, but poisoning. Poisoning rivals and enemies was, and still is, as any listener of this podcast knows, a well-documented method of murder in Russia. It’s clear members of his inner circle were at risk of a purge, and perhaps resorted to a means to a quick end.
Time to pick your poison. Question #3. What poison might have killed Stalin?
A. Snake venom
B. Superwarfarin rat poison
C. Warfarin
D. Aspirin overdose
Answer: C. warfarin. Acute aspirin toxicity results in death from acidosis and altered mental status rather than bleeding, superwafarins weren’t invented and he wasn’t bitten by a snake. Snake venom is inactivated in the stomach, so you can’t kill someone that way.
It’s been postulated by historians and physicians that Stalin was poisoned with warfarin, leading to his death. Arguing for this, the vomiting up blood just before his death and the hemorrhages noted on autopsy. Brain hemorrhage, as well as throughout his GI tract.
Was it warfarin? Let’s look more closely at some of the details.
First, can we believe the autopsy? Who knows. Stalin’s brain was removed for study, but is missing or no longer exists, so the gross pathology can’t be corroborated. Without any other sources, we have to take the autopsy results at face value.
Second, what do you believe about the delay with the doctors? A cover-up? Or fear of retribution from a paranoid man who concocted the doctors plot who was currently—literally—torturing his physicians. Quick aside, the doctors arrest by Stalin in the Doctor’s Plot were released and exonerated a few weeks after his death.
Did Beria really believe Stalin was asleep on the couch? Especially when others said the dictator looked horrible and reeked of urine? There are a lot of conflicting details. Guards said variably Stalin was drunk the night before his death, others said he drank little. They said they were never allowed to enter his room, others said the order not to enter was new the night of his death.
The government itself had reason for a cover up. First, the inner circle and certainly heirs-apparent to leadership were in significant danger of a purge. Second, Stalin was extremely popular, having led the Russians to victory over the Nazis in WWII. He was only the second leader of the communist Soviet Union following the Bolshevik revolution. Any suggestion of an untimely death might’ve resulted in civil unrest. In fact, so many people turned out for his funeral that 100s were crushed and trampled to death.
That said, in my opinion, the evidence against poisoning is stronger. First, the published descriptions are classic, extremely classic, medical school textbook classic, for an MCA stroke. We see these symptoms everyday in the ED. There’s often some confusion about ischemic and hemorrhagic strokes. When we say stroke, we typically mean ischemia, due to blocked blood vessels, in Stalin’s case the middle cerebral artery. It’s not uncommon, however for ischemic strokes to convert to hemorrhagic ones. Meaning the area of the stroke, a few days later might start bleeding. Given Stalin’s high blood pressure, this is actually a very likely scenario.
Particular note is made by supporters of the poisoning theory of the other hemorrhages, especially those in his GI tract. I actually wasn’t surprised at all when I read this. GI bleeding is a well-known complication in the ICU, due to stress ulcers. Any sick patient can develop gastric hemorrhage, so much so that prophylaxis with medicines like acid blockers is administered to critically ill patients. And in fact, intracranial disease is itself associated with development of gastric ulcers and bleeding.
An additional issue is the timing. Warfarin simply doesn’t work that quickly. It would take at least 2 days, if not longer to cause bleeding. Even if Stalin was poisoned, it wasn’t at the dinner party. From my perspective he suffered the consequences of advancing age, stress, poor diet and exercise, as well as lack of treatment for chronic diseases like hypertension.
However, it’s a topic of considerable interest and ongoing debate. In 2003, the Library of Congress assembled a round table discussion on whether or not the Cold War could have been averted after Stalin’s death. The conversation turned to the topic of his death. Interestingly, one of the participants was Sergei Khrushchev, the son of Nikita Khrushchev. Question # 4. Sergei said he believed Stalin was poisoned.
A. True
B. False
Answer is B. False Sergei Khrushchev stated emphatically that he did not think Stalin had been poisoned, noting Stalin didn't eat any food unless his closest advisors including his own father Nikita and Malenkov tried the food first. That’s how paranoid Stalin was about not just poisoning, but poisoning by those in line for succession.
It’s not just debated in the West, but in Russia too. According to news reports in 2024, the communist party asked the FSB, the current name of the secret police, to investigate whether western intelligence services were involved in Stalin's death. It doesn’t seem very likely, given Stalin’s paranoia and the close proximity of his inner circle.
Beria’s name always comes up as the most likely suspect. It’s known he poisoned rivals and said at the time of Stalin’s death he whispered, “I took him out.” A doctor in the group who performed the autopsy supposedly detected signs of poisoning. One month later, the doctor was dead. I’m really glad I never had to practice medicine in the old Soviet Union.
Others note Beria laid off all of Stalin's bodyguards the day after his death, sending them away from Moscow. Two apparently committed suicide by shooting themselves. Beria gave a strange order to remove all furniture and dishes from Stalin’s dacha. Very suspicious, but on the other hand, Beria’s wife noted that his position was even more precarious after Stalin’s death then before. In June 1953, Malenkov and Khrushchev conspired to have Beria arrested. He was shot in December. Khrushchev of course became the next leader of the Soviet Union. He banished Malenkov to Kazakhstan after a failed who died of natural causes at 86.
Before this podcast, I assumed Stalin’s memory, like Hitler’s was banished as a terrible dictator to the annals of history. I was shocked to find he retains popularity with many in Russia. There are reports Putin has a picture of Stalin in his office. And just last month, a statue of Stalin was unveiled in Moscow honoring his construction of the Metro.
The cause of Stalin’s death is fascinating discussion and I’d love to spend days debating it. In the end, the truth is left to “history with its flickering lamp” as Winston Churchill said. What do you think? Was the death of one of histories most infamous villains it the sequelae of hypertension or a sinister plot?
One of the most famous photos of Stalin is at the Yalta conference in 1945, sitting with Winston Churchill and Franklin Roosevelt. Interestingly, all three suffered from hypertension and atherosclerosis. Last question in today’s podcast. Churchill and Roosevelt died of what disease?
A. Myocardial infarction (heart attack)
B. Intracranial hemorrhage
C. Stroke
D. Gout
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.