Medical mystery: What killed Joseph Stalin?

Joseph Stalin (1878-1953), who would become one of history's most feared dictators, could not have strayed further from the career his mother envisioned for him. The former Josef Vissarionovich Djugashvili changed his last name to a Russian term for "Man of Steel" when he left his priesthood studies at a Georgian Orthodox seminary. Now an atheist, he joined the original Bolshevik revolutionaries of 1917 and became a member of the Communist Politburo under Vladimir Lenin.

Stalin rose to general secretary of the Central Committee of the Communist Party of the Soviet Union in 1922.  After Lenin's death in 1924, Stalin maneuvered his way to the top of the political heap, directing his nation through numerous purges, World War II, and the beginnings of the Cold War. His policies were so brutal, it has been estimated that he was responsible for the deaths of about 20 million people.

In the early 1950s, Stalin experienced increasing fatigue, dizzy spells and high blood pressure. His doctor, Vladimir Vinogradov, noticed Stalin's health was markedly deteriorating by early  1952 and suggested that his patient slow down.

True to form, Stalin -- who also was growing increasingly paranoid -- flew into a furious rage and ordered the doctor's arrest, along with that of other medical men whose advice he did not want to hear.  The government-run newspaper published  tirades against "murderers in white gowns," provoking widespread rumors about a medical conspiracy.

Publications said Tass, the Soviet news agency, announced that it had uncovered a terrorist group of doctors whose purported goal was to shorten the lives of active Soviet statesmen by "sabotage in the course of medical treatment.'' Pravda published a letter signed by Soviet leaders containing inciting condemnations of the spurious plot. Nine doctors, six of them Jews, were arrested and sent to prison.

Despite these efforts, Stalin's health did not appear to improve.

On Feb. 28, 1953, a visibly tired Stalin left the Kremlin for his dacha, or second home, outside Moscow. Stalin had met with Levrentyi Beria, minister of internal affairs, and future premiers Georgy Malenkov, Nikolai Bulganin, and Nikita Khrushchev, who later wrote of Stalin's mounting paranoia and his ministers' fear of crossing him. Stalin questioned Beria about the  "Doctors' Plot" and was assured that the culprits would be exposed and dealt with.

After his customary night of heavy drinking, Stalin was found lying on his bedroom floor  barely conscious, paralyzed, covered with urine, making only incoherent noises. The frightened guards called Stalin's doctors the next day. At 7 a.m. on March 2, 1953, doctors found Stalin on his back on a sofa with urine soaked pajamas. His eyes were closed and his head was turned to the left. His face was red, a hallmark of excess blood flow or hyperemia, and his blood pressure was 190/110.

What had felled the Man of Steel?

The doctors — understandably nervous about treating Stalin — diagnosed  a cerebral hemorrhage (massive stroke) caused by hypertension. Unexplained were simultaneous stomach and heart hemorrhage. Stalin was treated in his dacha by applying multiple leeches. By March 3, 1953, Stalin's condition had worsened. Doctors noted that his heart sounded weaker and his liver was enlarged. The next day, his skin was blue (signifying cyanosis), and he stopped breathing several times.

On the evening of  March 5, Stalin was soaked with perspiration, his pulse was weaker, and his cyanosis had intensified. Doctors administered carbogen -- a mixture of carbon dioxide and oxygen gas -- in an effort to improve his respiration. At 9:40 p.m. artificial ventilation was applied. Stalin's daughter, Svetlana, was at her father's bedside when he raised his left hand, pointing upward. He was declared dead at 9:50 p.m.

An autopsy by the Soviet Ministry of Health reported the 74-year-old died of "hypertensive cerebral hemorrhagic stroke plus multiple lacunar infarcts (blockages of small arteries in the brain) secondary to uncontrolled hypertension." Also noted were cardiac hemorrhage, gastrointestinal hemorrhage, and adrenal hemorrhage. The autopsy results were known to the Politburo but were not  released publicly until 2011.

What remains shrouded in mystery, however, is whether Stalin died of natural causes because of his numerous health problems, or whether his end was helped along by poisoning.

The American historian Jonathan Brent and Russia's Vladimir Naumov, executive secretary of the Presidential Commission for the Rehabilitation of Repressed Persons, suggested that Beria, with Khrushchev's complicity, slipped warfarin into Stalin's wine. Beria, Khrushchev, Malenkov, and Bulganin were briefly investigated at the time of Stalin's death, but the inquiry was quickly dismissed.

Two months after Stalin's death, Beria supposedly boasted of killing Stalin. ''I did him in! I saved all of you,'' he was quoted as telling Vyacheslav M. Molotov, a Politburo member, in Khrushchev's 1970 memoirs. Beria was later arrested, interrogated, and executed for treason.

Warfarin is used medically to prevent clotting and thrombotic heart attacks and strokes. Used properly, it is a lifesaver. In excess, it can lead to hemorrhagic stroke (cerebral hemorrhage), which is what also makes it an effective rat poison.

Allan B. Schwartz, M.D., is a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine.