Margarita Nelipa
Introduction
For many decades western historians had to rely on each other to incorporate specific details about Emperor Alexander III into their own publications. Few availed themselves of the opportunity to travel to the Soviet Union to personally conduct their own research in the State Archives. For many the Russian language was a barrier to facilitate such an exercise, while no doubt for the majority, after a century there seemed to be no reason to examine in more detail how Alexander III died.
There is a paucity of English language publications describing this somewhat elusive Russian Emperor. Most entries appear as part of a series of Russian rulers that offer little depth to Alexander III as the man. Western historians tend to accept the various details about this Emperor as being credible. Unfortunately no one in the west bothered to question whether the allegations claimed about his personal habit of alcohol abuse were indeed factual. This one detail neatly provided a presumptive cause of death. However in reality that presumption failed to correctly reflect the medical records of the attending physicians and the pathology report. Agreeably the problem may be attributed to the fact that these records were in the Russian language. However with the collapse of the communist regime, engaging in archival research with the assistance of professional translation services is no longer the barrier it once was.
Recent archival research conducted by Russian historians has been published in Russia that completely contradicts previously held claims in the west. A few contradictions are mentioned in this discussion by way of example only. (1, 2, 3, 4) Many readers may have read that Alexander Alexandrovich allegedly had hidden a flask inside his boots, played with his children whilst sodden with alcohol, (5) and by nightfall was barely able to stand after further indulgence. Furthermore, to complete the scenario of a drunkard, allegations were created how he and his consort Mariya Fedorovna would argue, creating an atmosphere not unlike the local traktir (drinking establishments) around town.(6)
I am of Russian ethnicity with fluency in the language and have professional medical qualifications. Consequent to my personal interest in Russian Imperial history I was able to identify these newly published facts and now offer them here for the first time in the English language. The conclusions raised by the contemporary Russian historians contradict current western understanding about who Alexander III really was and what the probable cause of death actually was.
Time to Dispel the Myths
Alexander III (1845-1894) was often described as resembling a muzhik (common man) (7) because of his rugged portly appearance and immense proportions accompanied by manners more akin to the ordinary man than that of a man of royal birth. Perhaps it was these less than imperious traits that contributed to the derogatory myth that first appeared in Europe after his death. The first myth that was bandied around was that: Emperor Alexander III abused alcohol. Such an allegation was no doubt more convincing because Alexander Alexandrovich had suffered from renal failure during the latter years of his life. From a medical standpoint, renal disease can contribute to the cause of death of patients, but as we shall see in Alexander's case it was not the actual cause of his death. At no point during the Emperor's periodic medical examinations; especially during the latter years, was there a suggestion of underlying Liver Disease. This was the second myth. Such a diagnosis would have observable and would have been expected with persons who abused considerable volumes of alcohol for an extended period.
The negative scenario was strongly emphasized by the western historian Orlando Figes, who noted rather boldly stated that Alexander, had a "fatal addiction to liquor" and that his son Nikolai "grew up in the shadow of this boozy colossus". (8) With predictability, western writers have reiterated essentially the same details, although a few preferred to stress the point with more negativity whilst characterizing the autocratic rule of the emperor rather than the activity itself.
More recently, one author preferred to insert the following alleged witness account from a Danish Court representative to highlight that alcohol was practically consumed to the Emperor's last breath, and thereby creating the third myth: "Then without pain [Dr] Hirsch was presenting him with a glass of wine ¡ Sasha gave a sigh and his head dropped onto Dagmar's breast. Alexander was dead."(9) Evidence by actual witnesses who were present in the room at the time of death, describe a completely different impression. Only family, physicians and priests were permitted to be with the Emperor. Mariya Fedorovna ensured that Alexander was isolated from all visitors. (10) One can only wonder why the diary entries of Alexander's son Nikolai Alexandrovich (1868-1918) and daughter Ol'ga Alexandrovna (1882-1960) were not used to provide a more accurate account of the Emperor's final moments.
It would have been prudent to have researched Alexander III by sifting through readily available memoirs and to consult the medical records held in the Russian archives in Moscow. The reason that I am concerned by western portrayals of Alexander III is that it is disturbing that Russian history can be so readily created and then believed by the unsuspecting. I believe that it is important to understand this Russian Emperor and what he firmly believed in. His personal ethos was to act as Russia's protector from the influences of physical and moral harm. This was a role he sincerely believed was entrusted to him by the will of God and which he proudly affirmed through his Coronation Oath before the Church on behalf of the people in 1883. (11) It must be emphasized that Alexander above anything desired to elevate the status of the Imperial Court before the people of Russia and before the world. He believed the Court was too liberal under the reign of his father Alexander II (1818-1881). Under the umbrella of this strict self imposed condition, any suggestion of impropriety by Alexander III would be inconceivable. Broadly speaking, the suggestion of alcoholic abuse was at practical odds with Alexander's Imperial will. He ruled by way of example, placing himself at the apex of moral virtue in order to influence similar ideals first from within his family and secondly from the military and every citizen of Russia. (12)
Is there any credible evidence to dispel the claim of alcohol abuse?
As it turns out, there certainly is, and the reason behind the manufactured myths served its masters well until recently.
The contemporary Russian historian Alexander Bokhanov whilst researching his book on Alexander III found that the alleged source of the spurious claim was attributed to Petr Alexandrovich Cherevin (1837- 1896). One may ask who this man was. Peter Alexandrovich Cherevin was one of the emperor's General-Adjutanti and was commissioned to personally protect the Emperor in 1881. (13) Promoted to the level of General-Leitenant in 1886 he was appointed as one of the panel of investigators of the Borki imperial train derailment in October 1888 (14) that was conducted between January and May, 1889. In May 1894 he was promoted to act as the duty general within the imperial suite until his death. Clearly, sifting through these brief biographic details, any intimate contact with the Emperor would have extended for only a few months, until the Emperor's own premature death later that year. His biographic notes offer a fascinating insight into this individual, however there was one particular feature that distinguished this man. In the words of Count Witte, General Cherevin was an alcoholic, (15) addicted to vodka. He was tolerated by the Emperor despite this character flaw for two simple reasons: his faithful service and honesty. (16)
It has been alleged in the west that General Cherevin provided the secreted alcohol to the emperor and that these details were gleaned from his memoirs. However, Bokhanov affirmed that Cherevin never wrote his memoirs! It is tempting indeed to speculate that Cherevin may have served as the model to create this myth; however to investigate this mystery further, a connection to Cherevin needed to be established in the absence of those purported memoirs.
Bokhanov noted that the stories about flasks, the morning hangovers and so forth came from the imagination of a physicist by the name of Petr Nikolaeyevich Lebedev (1866-1912) who was a professor from Moscow University and founded the Moscow physics society. (17) There are no records of Lebedev ever having met the Emperor, but he did apparently associate with General Cherevin. Their mutual friendship, it was claimed, developed in Istanbul after the Emperor's death, when Cherevin allegedly came to visit his sister, Nataliya Shultz, who just happened to be the estranged wife of the good professor. The young Lebedev was preparing to defend his philosophy candidacy at the local university. As the story goes, during their heart to heart conversation in a local cafe, Cherevin "opened" Lebedev's eyes about the personal failures of Alexander III. Bokhanov stated that in reality Lebedev never wrote about these legendary revelations, nor was he able to disclose any other issues relating to the Emperor.
Delving into the mystery further it became obvious that Cherevin never traveled abroad in the later years of his life. He served the new Emperor and had never met Lebedev as was alleged. (18) In 1896 Cherevin died in Nikolai II's presence, during a personal visit to comfort the dying man. Nikolai II wrote about this sad event in his diary on 19th February. (19)
Lebedev lived in exile because he was an enemy of the Romanov dynasty and before his death in 1912, had apparently made a number of disclosures about the Tsarist regime. Bokhanov questioned why Lebedev would have waited so long after Cherevin's death to "reveal" these intimate details to the professional enemy of Imperial Russia, Vladimir L'vovich Burtsev (1862-1942). Burtsev eagerly published these imperial gems initially in 1912 in his own Parisian ¨¦migr¨¦ newspaper called Budushchee (The Future) (20) and then after the 1917 revolution the details were repeated in his political liberal-democrat journal quaintly called Golos Minuvshego (Past Voices):
"The Sovereign loved to drink. He was able to consume vast amounts without any symptoms, and also, (he) became unusually high spirited ¨C jolly and frolicked like a child" (21)
Burtsev was a revolutionary who sympathized with terrorism and used his energies to publish articles to expose Okhrana operations that were designed to incite his enemies. (22) Forced to defect to Paris taking his newspaper with him; he established himself as a critic of the Imperial regime, whilst identifying police agents as his main specialty to a captive European audience. (23) The Okhrana (24) was aware of his dealings in St. Petersburg, and placed him under surveillance noting all his contacts in Paris. Burtsev was involved with specializing in publishing falsified documents to discredit the previous Russian regime. (25) As was his talent; Burtsev's excerpt concerning Alexander III was not a direct account of any actual conversations. He wrote expos¨¦s himself for his personal benefit to supplement his meager pension. (26)
Why is it that no one stirred to disclaim the story that was first published in a socialist publication printed after the Soviet revolution? It seems extraordinary there was a failure to consult imperial Russian references, along with the brilliant 1895 English publication by Charles Lowe (27) (which remains the only comprehensive English language reference available). No one questioned the variations presented by the leftist source. No one questioned how plausible was such a source of information. Alarm bells should have been raised at the very least. Decades passed and still no one bothered to check the veracity of those allegations.
Thus, the spurious socialist inferences originally created to discredit the Romanov dynasty, in this case, Alexander III succeeded in establishing itself as a "historic fact".
Contemporary Russian historians state that there are no archival documents, critical notes or diary entries that attest to the Emperor's drunken episodes. Not one single piece of evidence was found. Furthermore not a single published memoir had ever suggested that there was such a problem with Alexander III's personal habit of consuming alcohol. In the absence of any such expressions - it is obvious that the allegation was indeed fabricated and everyone in the west accepted the stale bait.
What are the real facts?
The Emperor never drank vodka or liqueur or distilled products, but did enjoy kvass which was a traditional medieval fermented brew made from rye bread or grain which he served to guests as an "exotic drink". He was never drunk, and at formal functions drank a flute of champagne diluted with water. (28) Alexander was a very religious man who observed all Orthodox Lenten periods, which take up extensive periods of the Church Calendar. That fact alone would preclude any alleged alcoholism. It would be incomprehensible for any reasonable observer to contemplate that Alexander would compromise himself when he was trying to purify the Court from all its excesses. Furthermore taking the scenario one logical step further; an Emperor was on duty 24 hours of each day. To be found in an alcoholic stupor would be very compromising indeed. Such an indiscretion would have crossed the boundary of social decency and if such an event would have occurred even once, then his enemies would have relished the idea and published the "occurrence". All those who met him stated that he was a man of virtue and that he sincerely expected that the religious ideals he practiced were to be emulated by the citizens of Imperial Russia.
Count Sergei Iulevich Witte (1849-1915) whom Alexander III appointed to be Minister of Finance, described in his memoirs that in his personal estimation, Alexander III was a:
"Great and noble personality" those who did not know him painted him as limited, slow of mind. It is true he was below average in intelligence and education¡but he had a heart ¡ and the kind of mind that enables one to look ahead ¡ such a mind is more important than ¡intellect¡He respected every kopek that came from the Russian people. "He would not tolerate excessive luxury, in fact I noticed he lived modestly. .. He preferred the plainest of food. He said little but what he said he meant and never retreated from his word. When he died, all of Europe realized that with him there disappeared a man, who by his moral strength, had kept Europe calm and peaceful. He raised his country's prestige without having shed a drop of Russian blood." (29)
During the soviet era that lasted beyond seventy years, no experts inside the country were encouraged to re-assess the fallacious story that flourished abroad after the collapse of the Imperial Empire. Historians inside the Soviet Union remained mute while those in the west perhaps too readily preferred to accept the myths that flowed as a consequence of soviet disinformation. They preferred to tarnish Alexander III for their own self-serving interests. Thankfully contemporary Russian historians searched for the truth and found it.
The Agony of Imminent Death
The Emperor suffered from one form of Glomerulonephritis. What many authors have failed to appreciate is that the condition Glomerulonephritis contributed to his death. Few historians may be aware that this condition is symptomatic of a multiplicity of underlying pathologies, including hypertension, infection, and malignancy to highlight a few causes that can contribute to renal failure.
To attribute alcohol as the direct cause of his death is erroneous and only perpetuates the socialist myth-maker's claim of 1912. Those myths certainly led to a neat cause of death, but in the absence of reviewing an autopsy report or any clinical records it is unwise to leap to such unsafe conclusions.
Let us go back and review the available information and piece together some of the available documented evidence.
Alexander III was born on 26 April, 1845. His birth was attended by the Lieb-akusher (Obstretician-in-ordinary) Vasilii Bogdanovich Shol'tz (1798-1860). His childhood proved to be a healthy one requiring no specific medical intervention. Whilst at the age of 27, in 1872; he suffered a severe bout of typhus, which is spread by flea and lice infected rodents, and associated with a high mortality rate during the epidemic that was ravaging St. Petersburg at the time. (30) The disease can progressively affect both the circulatory and neurological systems. (31) The event coincided with significant hair loss. (32)
A significant event in the emperor's life occurred on 17 October 1888 near the Borki railway station. The imperial train was de-railed due to high speed. (33) Alexander sustained a massive impact trauma to his back but was apparently not affected in any other way. Following the catastrophic event, Alexander's demeanor not surprisingly had changed. He was often tearful and became nervous. (34)
Almost one year after the Borki train disaster, in a letter to Konstantin Petrovich Pobedonostsev (1827-1907), his friend and advisor, in November 1889, Alexander wrote:
"[Am] still feeling dreadful; 4 nights [I] have not slept and have not lain down from the pain in my back. Today, finally, slept from foolish weakness." (35)
This might have been the first documented symptoms expressed by the Emperor. Professor-physician Vil'gel'm Fedorovich Grube (1827-1898), was the director of the Kharkov Clinical University, (36) and was the first clinician to observe the Emperor after the accident. He observed that Alexander sustained a blunt trauma to the kidney region. Pain in the region of the emperor's waist was observed and found to be associated with obvious weakness. (37) The trauma was caused by a non-penetrating external force. The only initial sign of injury would be bruising to the area of impact. However hematuria (blood in the urine), which is the cardinal sign of kidney damage, may be either visible to the naked eye or assessed only on microscopic examination of the urine.
It seems that Alexander was relatively stable at the time, and no further medical attention was necessary. Other signs can progress and include lumbar and abdominal pain, sometimes with rigidity of the abdominal wall and local tenderness. (Refer to the letter above to Pobedonostsev). Conservative treatment would have necessitated bed rest until the urine was clear. Complications when left untreated are formation of an abscess; hematoma formation and hemorrhaging etc whereby any laceration to the kidney can bleed extensively into the space outside. The worst case scenario is that the injury may lead to hypertension that will contribute to renal insufficiency. (38)
Professor Grube (and this author agrees with his learned medical opinion), contended that this was the starting point of the Emperor's medical problems.
On a trip to Denmark in August 1893, the Emperor experienced epistaxis (blood loss from his nose) which was so severe that he experienced visible signs of weakness. (39) It was spontaneous and normally would be considered worthy of medical attention in our times, especially when hypertension may be the underlying cause. (40) Unfortunately this pathological phenomenon could not be measured during Alexander's lifetime (not until 1896) (41). Repeated small bleeds over a period of time can lead to anemia with its consequent problems if left unattended.
In a letter written by Pobedonostsev to the Grand Duke Sergei Alexandrovich (1857-1905) residing in Moscow, dated 16 January 1894:
"His Majesty from Christmas has not felt well, [is] overcome, and only three days ago [he] was persuaded to go to bed." (42)
The consequence of this letter caused Professor Grigorii Antonovich Zaharin (1829-1895), a notable Russian therapist, (43) to be summoned from Moscow University, in January 1894 to attend the Emperor. In the capacity of a consultant only, he diagnosed that the Emperor was suffering influenza, which is a highly contagious respiratory infection that will cause extreme fatigue. According to Lowe, it was the second bout of this disease. (44) Nothing medically could be done except to prescribe sleep and rest. (45) After two weeks recuperation, the Emperor began to resume his formal duties, and against medical advice to continue resting. (46) Symptoms of influenza may persist for three or more weeks.
Today, clinicians are aware that the burden of influenza virus may cause acute glomerulonephritis which left untreated can progress to end stage kidney disease in weeks or months. (47) By contrast, those who have underlying chronic kidney disease and are infected with the influenza virus are at a higher risk of severe complications due to the viral overload. (48)
According to a letter written by Professor Zaharin to the Moscow Gazette, (49) there was no evidence of chronic kidney disease at that time.
"The attack of influenza undoubtedly weakened the Emperor, but his health was already far from good. He had been severely weakened by an extraordinary bleeding from the nose, after which all the autumn he suffered from fever and bronchitis. I was first called in January, and the daily chemical and microscopic examinations ¡showed no signs of nephritis. The action of the heart was normal."
Charles Lowe expressed the following illuminating insight in 1895:
"When the Emperor himself began to feel the presence of the shadow of the hand of Death we shall probably never know. But it is probable that the course of his fatal malady began towards the end of 1889, when he fell victim to the influenza; and on the other hand, the door of the disease was probably opened by the terrible shock to his nervous system which he experienced at the railway accident in Borki." (50)
With the ever present memory of his father's assignation in 1881, the fear of a terrorist lurking to end his own life would never have been far away. Traumatic shock may occur as a result of a crushing abdominal injury. It is a critical state brought on by inadequate peripheral blood flow through the body, causing a drop in blood pressure (hypotension) and depletion of oxygen to body organs. It can compromise kidney function by restricting the removal of waste products causing acute kidney failure. (51) Over a period of years, with additional medical crises, without treatment, the acute phase will become chronic. This process will take years to progress.
On 28 February, Alexander III turned 49, which would prove to be his last birthday celebration.
Count Sergei Yul'evich Witte (1849-1915) in his memoirs noted that at Easter (no date provided), but we can assume that it was somewhere between March to April:
"The Emperor always appeared anemic, but by this time it was evident that he was quite ill." (52)
On 2 June 1894, a new complication developed that necessitated another visit by Professor Zaharin from Moscow as well as the summoning the German clinician Dr Ernst Leiden (1832-1910) from Berlin, to the Gatchinskii Dvoretz (Gatchina Palace). They advised that the Emperor seek a warmer climate because of his kidney disease. However Alexander declined to leave Russia. (53, 54)
Many eyewitnesses noted that he was not well months after that initial influenza infection. Charles Lowe in his 1895 English appraisal of Alexander III noted the following:
"For some considerable time prior to the Emperor being stuck down, it was noticed that a curious kind of stagnation had overtaken the course of Russian affairs ¡ that ship no longer appeared to indicate the grasp of a firm and energetic hand " (55)
We should remember that the emperor had received a blunt trauma to the kidneys, and that he was in experiencing pain in that region one year after the event. It would not be inconceivable that the viral infection caused his already compromised kidneys to deteriorate further. His imperial duties and overall distrust of medical attention (56) also precluded him from recovering properly after the first event ¨C the Borki train accident. Alexander preferred natural remedies, but rest was not among the choices he permitted himself. The same pattern in not adhering to medical advice after his influenza attack continued ¨C avoidance of complete rest. Overwork, lack of sleep (57) and including the Emperor's habit of going outside in all weather: the extreme cold winter or the damp of late summer and also the intense cold of his bedroom (58) was less than ideal. These deficiencies in his recovery process, all the doctors agreed, exacerbated his medical status to the point of no return.
Glomerulonephritis in its chronic phase may be asymptomatic. Fatigue, nausea and muscle pain are observable symptoms of this kidney condition. Excessive urination is another symptom, but in the absence of documentation to confirm this symptom, it would be unsafe to presume that Alexander experienced this problem. Although Alexander confided about his back pain one year after Borki to his advisor, he never complained about delicate matters such as his discomfort to his wife Mariya Fedorovna. She like many who knew him, began to notice changes in her husband, but all her concerns were always received with the same non committal reply. (59)
A clinical exam conducted in July by Leib-Hirug Gustav Ivanovich Hirsch (1828-1907) revealed the presence of albumen. (60) This result forwarded onto Professor Zaharin prompted a more complete evaluation of their patient. By this time Alexander had lost considerable weight.
The next medical crisis appeared on 7 August 1894, (61) at Krasnoe Selo, whilst on maneuvers. Following a horse ride over 12 versts, he fainted and was moved immediately to the infirmary at 5 pm. To the attending physicians and his family, he appeared most unwell. He was barely able to move his legs, his eyes were lackluster and his eyelids were drooping. The Tsesarevich Nikolai Alexandrovich announced to the attending that the Emperor's kidneys were not functioning properly.
By 9 August, 1894, the Emperor's health deteriorated further. He experienced sharp pains in the region of his waistline. (62) Professor Zaharin was summoned back to Gatchina accompanied by Professor Nikolai Fedorovich Golubov (1856-1916?). Professor Golubov was the Director of the Therapist faculty at Moscow University. (63) At this examination the microscopic evaluation confirmed the presence of albumen and clumps of red blood cells (casts) in the urine. Uremia ¨C excess urea in the blood was also identified. This confirmed the diagnosis of nephritis. Dr Leiden agreed with the diagnosis. Furthermore, the clinicians detected a cardiac insufficiency ¨C abnormal heart rhythm and enlargement of the left ventricle. He was experiencing somnolence, nausea and had a bad taste in his mouth. (64, 65) All these details were printed in the St. Petersburg newspaper Niva # 46.
With the associated muscular pains, and cardiac involvement the condition had progressed to the chronic form. The Emperor's condition was now terminal.
Nephritis is an inflammation at any site of the kidney tissue, (66) where there is infection in either the filtration tubules ¨C the glomeruli leading to Glomerulonephritis; or within the surrounding interstitial tissue, and can include renal blood vessels. It could also affect all sections of the kidney at the same time. The kidneys are unable to concentrate urine or excrete metabolic waste products from the body. The result is that urine production diminishes and there is a toxic overload in the blood. When damage is severe, inflammatory cells and the injured glomerular cells accumulate, compressing the capillaries within the glomerulus and interference with filtration is its consequence. Nephritis can be a symptom diagnosed as a complication of Glomerulonephritis.
The current optimal treatment of dialysis and transplantation was not an option in Alexander's era. The prognosis depends on the cause, the person's age, and any other diseases the person might have.
With trepidation, knowing that the Emperor appreciated only the truth, a report was presented to the Emperor by both Zaharin and Hirsch. The patient was informed of the bad news ¨C that his prognosis was very poor, and that his condition was terminal. It was patently obvious to all that the giant Bogatyr - a Russian folklore warrior of heroic proportions; a name given to him by his beloved grandfather Emperor Nikolai I (1796-1855), was now a shadow of his former self.
To counteract all rumors flying around the nation about Alexander's health, a public statement was issued. It failed however to present the gravity of Alexander's real situation. It was a trip that necessitated that the Tsesarevich abandon his journey to Darmstadt to visit his future bride by the awaiting special train. (67)
"Since the severe attack of influenza, from which the Tsar recovered in January last, his Majesty's health has not been fully restored, This summer, the disease of the kidneys, nephritis, supervened, and this renders it necessary for his majesty during the cold season to stay in a warm climate ¡ Acting upon the advice of Professors Zaharin and Leiden, the Tsar will make a temporary stay in Livadia."(68)
This was the sunny retreat situated in the Crimea on the Black sea thousands of miles from the capital, where Alexander III was sent to die. Finally adhering to medical advice the Emperor departed from Gatchina for the final time, traveling to his favorite hunting ground, the Belovezh Forest. The Tsesarevich wrote the following in his diary:
"Poor Papa is very upset, now he has fallen in the hands of the doctors, which on its own is not pleasant. Now he is happy, that [he] is traveling to Belovezh." (69)
Everyone hoped that the warmer climate and cleaner air would assist in a better outcome. However this was not to be. Sadly he was unable to participate in his favorite sport. (69) The weather proved too wet and damp, that only contributed to Alexander's personal misery. According to a diary entry written by Grand Duke Konstantin Konstantinovich, the Emperor refused to see the accompanying medical staff on a daily basis, and he refused to maintain his strict dietary regime and his sleep was deficient. (71)
From here he wrote a letter dated 8 September to his eldest daughter, Kseniya Alexandrovna (1875-1960) from Spala, located near Warsaw:
" From the moment, when we arrived here, [I] feel a little better and more cheerful, but sleep ¨C there [is] none, and this torments and tires me terribly, to despair. In Belovezh I did not (feel like) hunting, and there were days , that [I] did not go outside of the house, am very weak today, and walking was difficult for me. Unfortunately I did not lunch or breakfast with all the others, just myself, since I have been placed on a strict diet, and no meat, even fish is not offered, and to add to this I have a dreadful taste, everything I eat or drink tastes disgusting. Unable to write more today; because this is tiring me. Your elderly and so far unfit Papa"(72)
This letter is not just intriguing by its content but it is Alexander's final written correspondence with anyone. Alexander had only 42 days to live.
The physicians quite correctly restricted his diet and reduced his protein intake of meat and fish, to minimize the protein overload on his deteriorating kidneys, and to stabilize hypertension.
On 15 September, the Tsetsarevich wrote in his diary:
" Mama informed Papa about the arrival of Leiden and asked him to permit an examination ¡ that Papa at first did not agree to, until finally persuaded by Vladimir. Leiden found he had inflamed kidneys, in the same condition, which Zaharin observed, but not only that [he] had a nervous disorder." (73)
Finally reaching Yalta, in the Crimea by train, he settled in Livadia on 21 September. He arrived obviously ill in an open carriage dressed as a General. The commander of the 16th Regiment, Pulkovnik (Colonel) Pavel Pavlovich noticed the Emperor was very pale, somewhat jaundiced with cyanosed lips. Against Mariya Fedorovna's wishes, he firmly insisted he must carry out his duty to his regiment. With immense willpower, pacing very slowly ¨C barely able to walk - he inspected the awaiting Strelki (regular troops). Thanking the men, it was to be his swan song with his beloved regiment. (74)
Alexander's condition did not improve. His pulse was elevated to 100 (normal is 72 beats/minute). His legs were severely swollen (edema), caused by the accumulation of fluid in the extremities of the body. He was unable to lie down or sleep and felt a tightening in his chest. By now walking any distance proved difficult. Grand Duchess Ol'ga Alexandrovna recalled in her memoirs that:
"Everyday movement was agony. He could not even lie in bed. He felt more comfortable when they wheeled his chair. The doctors could do nothing except to vary his diet day to day. Always suspicious of drugs he refused to have his pain relieved in any way."(75)
The last time Alexander ventured outside was on 2 October, when he rode in a carriage. After this adventure, he remained in the same room on the second floor. The weight loss was immense ¨C gone were the broad shoulders and his large head appeared to sit on his sinewy neck with some difficulty. (76) It was obvious to all that the Emperor's days were numbered. On this day, Dr Leiden and the Protopresbyter Father Ioann Yanishev (1826-1910) the family's spiritual confessor (77) arrived, followed by three more physicians, Grube, Popov, and Zaharin on 3 October. (78) All of Russia's finest specialists were summoned with urgency to Livadia by Mariya Fedorovna to attend the Emperor as best they could. (79) The members of the imperial family were also asked to attend, as was Father Ioann Kronshtadskii, who it was believed possessed divine powers and thus enjoyed the highest authority among the Russian Orthodox to the point that he was considered a living saint". (80)
Twice daily, from 5 October, official bulletins were issued to the nation informing the people of the Emperor's deteriorating health:
"The kidney disease has not improved, but his strength has diminished."(81)
Isolated from visitors except his family and physicians, some of whom came from abroad, to maintain privacy, the dying Emperor was able to sit in his wicker chair and stare at the sea with his wife constantly by his side. (82) Nikolai noted in his diary on 7 and 8 October that his father gained an appetite by nightfall, and was able to read dokladi (reports) and newspapers. (83) Sadly any quality sleep had eluded him. The physicians observed that his tiredness had increased, and that the peripheral edema had increased slightly while the activity of the heart remained stable. (84) At the microscopic level there was a progressive increase in albumen in his urine, this is indicative of renal failure.
On Sunday 9 October, Nikolai Alexandrovich wrote that his father experienced a number of episodes of epistaxis (bleeding from the nose).
By this time his skin became extremely itchy, and against the wishes of the Tsaritsa he sought the assistance of his son, Mikhail, to apply a coarse brush to his feet. (85) This is a classic symptom accompanied with an unpleasant sensation in the oral cavity. These symptoms are often observed in patients with end-stage renal failure. He received daily massages, but soon even these delicate manipulations proved ineffective. Lieb-medik Professor Nikolai Alexandrovich Vel'yaminov (1855-1920) ascertained that aside from nephritis, the emperor was experiencing cardiac failure, which was evidenced by sharp chest pains and breathlessness.
After a few days of nausea he vomited on 16 October in the presence of his attending physicians. (86)
On the following day 17 October during the evening at 8 pm the usual coughing had brought up blood with his sputum. He had chronic nasopharyngeal catarrh, which is an inflammation of the mucous membranes in the nose accompanied by mucus secretions and indicative of a cold either caused by a virus or bacterium. (87) According to the health bulletin published on the following day, the emperor had severe hemoptysis, which is the expectoration of blood from the respiratory tract through the oral cavity. (88) This symptom is indicative of serious lung disease. The emperor's health proved so critical that the Tsesarevich claimed that they were all awoken during the night and instructed to go to the second floor. (89)
It is of some interest that on this day the family solemnized the 6th anniversary of the Borki train derailment. As was customary, they all took the holy sacraments after the Panihida (Orthodox rites for the dead), (90) to remember the ones who did not survive.
By the 18th October all of Russia awaited the inevitable. His health on this day deteriorated considerably. All Alexander could do was sit in his favorite armchair. He had refused pain relief because of he was always suspicious of all medication. With an immense show of dignity, disliking theatrics, he never complained of his discomfort and suppressed any groans from the pains (91) coursing his tired body. Breathing was difficult (hypoxia), with overwhelming tiredness. The physicians at 10 a.m. determined that the Emperor now had multi system dysfunctional syndrome (previously referred to as multiple organ failure) (92) ¨C where two or more solid organs are no longer functioning correctly. There was also evidence of an infarct in the left lung. (93) Organ failure is a common consequence of infection and shock (low blood pressure or hypotension, leading to a reduction in the flow of blood). The condition is also associated with a deficient immunologic and endocrine function. Simply stated all his inter-dependent organs were physiologically shutting down. This clinical condition leads to the death of the patient with hours or days.
Public press releases were issued three times each day from this day with the consensus of Professors Zaharin, Popov and Leiden, and Lieb-mediki Girsh and Vel'yaminov. (94) The Tsesarevich noted that it was a "difficult gruesome day" and he called for God's mercy in his diary, such was the intense grief for his father's continuing suffering. (95)
The evening Bulletin, issued at 10 p.m. announced that the emperor was now experiencing chills; (96) which is a secondary symptom associated with fever and occurs in an attempt to produce heat in order to raise the body temperature. His temperature was slightly elevated to 37.8C and the pulse was weak but elevated to 90 beats/minute.
After a sleepless night on 20 October the Emperor knew that his time was almost up. At 10 a.m. all the family gathered around, to whom with complete lucidity, seated in the armchair the Emperor spoke a few kind words, kissed all who were present; not forgetting to congratulate Grand Duchess Elizaveta Fedorovna's on the occasion of her thirtieth birthday with his last breaths. (97)
The following Bulletin was released at 11 a.m.:
Livadia. 20 October, 11h morning.
"(The) activity of the heart continues to diminish. Shortness of breath is increasing. Fully conscious." (98)
In the presence of Father Ioann Kronshtadskii, Alexander took communion at 11.30 a.m. Before the kneeling family Alexander enunciated his final prayer, while Mariya Fedorovna knelt before her husband by the corner of the armchair, encircled her hands around his head pressing him to her. Quietly he whispered to his wife:
"(I) feel my end" (99)
At 2.30 p.m. he received the final sacraments, then his breathing became labored, distant and then moments later it ceased forever. Until the very end he was completely lucid. At 3.00 p.m. Professor Leiden declared the absence of a pulse and the Bogatyr's final battle was over. (100)
What was the Cause of Death?
On 22 October, at 7 p.m. an autopsy was conducted and the Report is provided below for the first time in English in Table 1.
Table 1
1894 Autopsy Report on Alexander III
1. Significant interstitial edema in the extremities.
2. Blotchy redness on the left shinbone (between the ankle and knee).
3. In the left pleural cavity, 200 cc of "buttermilk" fluid, with red tinge.
4. The right pleural cavity contained 50 cc the same type of fluid.
5. The right lung had ancient fibrosis (scar tissue) in the upper right quadrant.
6. Pulmonary edema in right lung.
7. In the left lung edema in the top half of the lung and a hemorrhagic infarct in the lower half field. This lower field is filled with blood and contains little air.
8. The hemorrhagic infarct is located at the upper edge of the lower field of the left lung and on dissection is triangular shape 1.5 cm long x 1.0 cm diameter.
9. The pericardium was filled with 30 cc "buttermilk" fluid.
10. Heart was significantly enlarged (Cardiomegaly), 17 cm long x 18 cm diameters, extensive accumulation of fatty deposits (Lipomatosis cordis); the heart contracted poorly.
11. The left side of the heart was enlarged, and the wall of the left ventricle was thickened (2.5 cm).
12. The muscle of the left ventricle was pale, dry and yellow in color (degenerative infiltration of myocardial adipose tissue).
13. The right ventricle wall was reduced (6 mm) and is also yellowish in color. Pericardium was normal.
14. In the stomach there was approximately 200 cc "buttermilk" fluid. The stomach and intestines were filled with gas.
15. The liver was slightly enlarged, and highly vascularized.
16. The kidneys had the following dimensions: the left kidney 16 cm long x 7 cm wide x 4 cm thickThe right kidney: 15 cm long x 6.5 cm wide x 4 cm thick. The kidney capsule was usual thickness and separates easily. The outer surface of the kidneys had a micro-granular pattern, dark red in color; kidney density is insignificant. The cortex is reduced (from 6 to 7 mm) and yellowish, the medulla is dark red in color (Interstitial nephritis and granular atrophy of the cortex). Also in the left kidney there was a 3 mm diameter cyst. Summary of AutopsyWe believe that his Majesty Emperor Alexander Alexandrovich passed away from paralysis of the heart in the presence of degenerative cardiac muscular hypertrophy and interstitial nephritis (granular atrophy of the kidneys). Professors Ivan Fedorovich Klein (Moscow University pathologist), Dmitrii Nikolayevich Zernov (Moscow University anatomist), Mitrophan Alekseyevich Popov (Kharkov University anatomist), and the dissectors Nikolai Vladimirovich Altuhov (Moscow University) and Aleksei Konstantinovich Belousov (Kharkov University). (101)
Professors Zaharin, Popov and Leiden, and Lieb-mediki Hirsch and Vel'yaminov published the following official cause of death 28 October (102) in Niva, 1894, # 45.
"Chronic Interstitial Nephritis subsequent to cardiovascular disease, hemorrhagic infarct in the left lung, following inflammation."
The autopsy report confirmed the ongoing clinical history. Nothing else remarkable was found. The most significant findings were renal disease that contributed to an enlarged heart. However more relevant to this appraisal there was nothing unusual found in the liver. The autopsy report did not identify the presence of any form of liver disease. This clear finding it must be agreed is at all odds to the allegations that the Emperor abused alcohol. Any consideration that the Emperor suffered underlying liver disease (Alcoholic Cirrhosis) must be excluded.
In the absence of medical intervention Chronic Interstitial Glomerulonephritis (CIG) is the final inflammatory response of the kidney by a variety of insults. There is slow progressive destruction of the interstitial spaces outside the glomeruli filtration system, but can include the glomeruli of the kidney. The progressive loss of kidney function leads to end stage kidney disease, cardiac disease and death as the final outcome. By far the most common form of CIG inflammation is due to an immunologic response, such as a previous viral infection (influenza).
A Contemporary Evaluation of the Cause of Death
Recently Dr Vladimir Vasil'yevich Vetz, with forty years of service at the A. A. Vishnevskii Central Military Clinical Hospital located in Moscow, familiarized himself with the Autopsy Report and he has offered the most recent evaluation. (103) [Table 2]
Table 2
Contemporary Evaluation of the Original Autopsy Report of 1894
1. Hypertonia associated with primary hypertrophy of the left ventricle of the heart.
2. Arteriolonephrosclerosis (indicated by the fine granular surface of the kidney).
3. Chronic cardiac decompensation,
4. Chronic venous infiltration in the liver.
5. Bilateral Pneumothorax.
6. Choric Thrombophlebitis in the left leg.
7. Thromboembolism in the pulmonary artery.
8. Pulmonary infarct in the lower left lung. (pneumonia)
9. Pulmonary edema.Associated condition: Meta-tubercular fibrosis at the apex of the right lung and left kidneyCause of Death: Progressive cardiac de-compensation and pulmonary infarction
There was no new pathology described for the liver.
This new evaluation of the autopsy report does not in any way detract from the original findings. It merely places the original observations into a modern context. Hypotonia was not known until it was first described by G. F. Lang in Soviet Russia in 1922. (104) It is a condition marked by an abnormal increase in muscle (or arterial) tension limiting muscle tone. (105) It is caused by injury to motor pathways in the central nervous system.
An infarct is an area of tissue in an organ such as the lung in this case, that undergoes necrosis following the cessation of blood supply. It may be due to an occlusion of the vein supplying the lung. Pulmonary infarction is due to an embolism. (106) Evidence of this event was described by the original Russian pathologist and confirmed by the recent evaluation. It was described as a hemorrhagic infarct because of its red color caused by the seepage of red blood cells into the necrotic area. The embolism originated from the Emperor's left leg. Thrombophlebitis (107) is a condition in which a blood clot causes the inflammation of the vein in an extremity such as the leg. The dislodged clot (thrombus) would have then traveled to the lung causing a blockage. Clinically this is described as a pulmonary embolism. [Refer to Table 3.] That embolism was observed on autopsy. The presence of marked red skin which extended between the ankle and medial lower leg provided pathological evidence of Thrombophlebitis. It is a typical sign of chronic venous stasis. It is a common manifestation in immobilized patients and those with congestive heart failure.
Most patients will have cardiac arrhythmia (irregular heart beat) which can precipitate a cardiac arrest.
Table 3
Pathological Relationship between Thrombophlebitis and Infarction
Thrombophlebitis - Clot in leg - thrombus travels to lung - Blockage of pulmonary artery - pulmonary embolism - Cessation of blood flow - Pulmonary infarction
Returning back to the definition used by Dr Vetz, Cardiac Decompensation it simply refers to heart failure. It occurs when the heart fails causing insufficient blood to reach to the organs of the body, starving them of oxygen. Heart failure is often referred to as congestive heart failure. The pressures of the chambers filling the heart become elevated causing high lung pressures and shortness of breath.
Glomerulonephritis was certainly present, but that condition was not what the caused the death of the Emperor.
Dr Vetz identified that the kidney disease was an associative condition that would have contributed to the final outcome: congestive heart failure
Conclusion
In the west many rumors have persisted in literature about Alexander's alleged alcoholic abuse. As a result of the new evidence extracted from Russian Archival sources that were published in two recent books focusing on the life of Alexander III that information has been presented here for the first time in the English language.
It is my personal desire that the myths surrounding Alexander III must be dispelled forever in view of the information presented here. Taking note of the medical and historic details alluded to here for the first time in English and in this more complete format; it would be worthy that western historians shall from now on provide more respect to a Russian patriot who was Emperor of Imperial Russia for thirteen years (1881-1894).
I have offered information that completely contradicts accepted western beliefs that Emperor Alexander III abused alcohol. All the medical evidence that I have presented offers proof that Alexander Alexandrovich died from a completely different cause than has been believed. Both the original and subsequent modern evaluation clearly indicates that the Emperor died from heart failure.
The Emperor was a man of contradictions who came to power because of a terrorist persecution against his father, Alexander II. Alexander III was a pious, honest man lauded for his peacekeeping abilities to protect Russian borders from military intervention. To discredit him by believing in the spurious soviet disinformation is wrong and unjust. It is time to re-appraise this largely unknown figure in Russian history and permit him rest in peace. Indeed, it is appropriate to initiate this renewal during this auspicious year when Alexander III will be finally united with his wife the Dowager Empress Mariya Fedorovna in death at the St. Peter and Paul Cathedral in September 2006.
Their youngest daughter Grand Duchess Ol'ga Alexandrovna summed up the myths surrounding her father best:
"How much unkind and unjust nonsense has been written about him! ¡ My father was everything to me" (108)
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5. Wortman, R., p 278
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7. Perry, J. op cit., p 44
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17. Barkovets, O. op cit., p 256
18. Bokhanov, A., op cit., p 323
19. Diary of Emperor Nikolai II 1896 In: http://www.wave.net.ru/~monarchist/library/docs/1896.htm
20. Lauchlan, I. Russian Hide-and-Seek The Tsarist Secret Police in St. Petersburg, 1906-1914 FLS, Helsinki, p 315
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23. Ibid., pp 94-5
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25. Bokhanov, A., op cit., p 324
26. Ruud, C. op cit., p 169
27. Lowe, C. Alexander III of Russia (1895) Macmillan and Co. New York
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29. Harclave, S., op cit., pp 170-173
30. George, A. St. Petersburg (2003) Taylor Trade Publishing, New York, p 338
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33. Rysskoe Natstionali'noe Stroitel'stvo In: http://dinastya.narod.ru/page_4.htm
34. Nahapetov, B. op cit., p 104
35. Ibid., p 104 [Translation by Margarita Nelipa]
36. Professor Grube, V. In: http://www.distedu.ru/mirror/_rus/www.hi-edu.ru/Brok/01040360.htm
37. Nahapetov, B. op cit., p 104
38. Taber's Cyclopedic Medical Dictionary op cit., p 804
39. Poslednie Dni Aleksandra III In: http://dinastya.narod.ru/page_6.htm
40. Corrigan, R. Epistaxis and Hypertension In: Postgraduate Medical J. 1977 May;53 (619):260-1.
41 1856-1957 In: http://www.who.int/cardiovascular_diseases/en/cvd_atlas_27_MILS_1856_1967.pdf
42. Nahapetov, B., op cit., p 104 [Translation by Margarita Nelipa]
43. Zaharin, G. A. In: http://www.distedu.ru/mirror/_rus/www.hi-edu.ru/Brok/01080179.htm
44. Lowe, C, op cit., p 276
45. Taber's Cyclopedic Medical Dictionary op cit., p 846
46. Nahapetov, B. op cit., p 104
47. Glomerulonephritis Causes In: http://www.fpnotebook.com/REN43.htm
48. WHO Influenza Overview Fact Sheet In: http://www.who.int/mediacentre/factsheets/2003/fs211/en/
49. Lowe, C. op cit., p 276
50. Ibid., p 275
51. Taber Cyclopedic Dictionary op cit., p 1556
52. Harcave, S., op cit., p 205
53. Nahapetov, B. op cit., p 105
54. Lowe, C. op cit., p 277
55. Ibid., p 275
56. Bokhanov, A. op cit., p 325
57. Barkovets, O. op cit., p 223
58. Lowe, C. op cit., p 278
59. Bokhanov, A. Serdechnie Taini (2004) ACT Press Kniga, p 145
60. Barkovets, O. op cit., p 223
61. Nahapetov, B. op cit., p 106
62. Ibid., pp 106-107
63. Barkovets, O. op cit., p 251
64. Ibid., p 223
65. Lowe, C. op cit., p 277
66. Taber's Cyclopedic Medical Dictionary op cit., p 1107
67. Lowe, C. op cit., p 283
68. Ibid., p 281
69. Bokhanov, A. Serdechnie Taini p 146 [Translated by Margarita Nelipa]
70. Bokhanov, A., op cit., p 455
71. Barkovets, O. op cit., p 223
72. Bokhanov, A. Serdechnie Taini pp 146-147 [Translation by Margarita Nelipa]
73. Dnevnik Imperatora Nikolaya II (1991) Polystar, Moscow p 77 [Translation by Margarita Nelipa]
74. Poslednie Dni Aleksandra III In: http://dinastya.narod.ru/page_6.htm
75. Vorres, I. The Last Grand Duchess (2001) Key Porter Books, Toronto, p 51
76. Bokhanov, A. Serdechnie Taini op cit., p 148
77. Bokhanov, A. Imperator Aleksandr III i Imperatritsa Mariya Fedorovna Perepiski (2001) Russkoe Slovo, Moscow, p 172
78. Dnevnik Imperatora Nikolaya II op cit., p 81
79. Bokhanov, A. Serdechnie Taini op cit., p 148
80. Lowe, C. op cit., p 284
81. Barkovets, O., op cit., p 225 [Translation by Margarita Nelipa]
82. Barkovets, O. op cit., p 224
83. Dnevnik Imperatora Nikolaya II op cit., pp 82-83
84. Nahapetov, B. op cit., p 109
85. Bokhanov, A., op cit., p 457
86. Dnevnik Imperatora Nikolaya II op cit., p 85
87. Nahapetov, B., op cit., p 109
88. Taber's Cyclopedic Medical Dictionary op cit., p 749
89. Dnevnik Imperatora Nikolaya II op cit., p 86
90. Ibid., p 86
91. Vorres, I., p 51
92. Marshall, J. Multiple organ dysfunction syndrome In: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=surg.chapter.5364
93. Nahapetov, B. op cit., p109
94. Barkovets, O. op cit., p 224
95. Dnevnik Imperatora Nikolaya II op cit., p 86
96. Nahapetov, B. op cit., p 109
97. Poslednie Dni Aleksandra III In: http://dinastya.narod.ru/page_6.htm
98. Barkovets, O. op cit., p 225 [Translation by Margarita Nelipa]
99. Ibid., p 225 [Translation by Margarita Nelipa]
100. Bokhanov, A. Serdechnie Taini op cit., p 151
101. Nahapetov, B. op cit., pp 100-112 [Translation by Margarita Nelipa]
102. Barkovets, O. op cit., p 225 [Translation by Margarita Nelipa]
103. Nahapetov, B. op cit., p 113-114
104. Ibid., p 115
105. Taber's Cyclopedic Medical Dictionary op cit., p 804
106. Nahapetov, B., pp 839-40
107. Ibid., p 1730
108. Vorres, I., The Last Grand Duchess (2001) Key Porter Books, Toronto, pp 54-55
Copyright: Margarita Nelipa, 2006
Not to be used without the author's permission