Lenin's Death Remains a Mystery for Doctors BALTIMORE - The patient founded a totalitarian state known for its "merciless terror," Dr. Victoria Giffi told a rapt audience of doctors and medical students on Friday afternoon. He died suddenly at 6:50 p.m. on Jan. 21, 1924, a few months before his 54th birthday. The cause of death: a massive stroke. The man's cerebral arteries, Dr. Giffi added, were "so calcified that when tapped with tweezers they sounded like stone." The occasion was a so-called clinicopathological conference, a mainstay of medical schools in which a mysterious medical case is presented to an audience of doctors and medical students. In the end, a pathologist solves the mystery with a diagnosis. But this was a conference with a twist. The patient was long dead - he was, in fact, Vladimir Ilyich Lenin. The questions posed to the conference speakers: Why did he have a fatal stroke at such a young age? Was there something more to his death than history has acknowledged? At the University of Maryland, an clinicopathological conference focused on historical figures has been an annual event for the past 19 years; attending doctors have reviewed the case records of Florence Nightingale, Alexander the Great, Mozart, Beethoven and Edgar Allan Poe. The pathologists" conclusion that Poe died of rabies even became a final question on the "Jeopardy!" game show. Dr. Philip A. Mackowiak, vice chairman of the university's school of medicine and organizer of these conferences, said he later did a much more comprehensive review of Poe's medical records and concluded that Poe's doctor had embellished Poe's medical history. "Poe was a hopeless alcoholic," Dr. Mackowiak said in a telephone interview. He almost certainly died of delirium tremens. On Friday, two experts were called upon to solve the mystery of Lenin's death: Dr. Harry Vinters, professor of neurology and neuropathology at the University of California, Los Angeles, and Lev Lurie, a Russian historian in St. Petersburg. Dr. Vinters began by telling the audience some details of Lenin's medical and family history. As a baby, Lenin had a head so large that he often fell over. He used to bang his head on the floor, making his mother worry that he might be mentally disabled. As an adult, Lenin suffered diseases that were common at the time: typhoid, toothaches, influenza and a painful skin infection called erysipelas. He was under intense stress, of course, which led to insomnia, migraines and abdominal pain. At 38, he was shot twice in an assassination attempt. One bullet lodged in his collarbone after puncturing his lung. Another got caught in the base of his neck. Both bullets remained in place for the rest of his life. Lenin's father died early, too, at 54. The cause of death was said to be cerebral hemorrhage, but Lenin's father had an illness at the time of his death that may have been typhoid fever. Most of Lenin's seven brothers and sisters died young, two in infancy. A brother was executed at age 21 for plotting to assassinate Emperor Alexander III, and another brother died of typhoid at 19. Of the three who survived past young adulthood, a sister died of a stroke at age 71, another sister died of a heart attack at 59, and a brother died at age 69 of "stenocardia," an archaic medical term whose meaning is no longer clear. In the two years before he died, Lenin had three debilitating strokes. Prominent European doctors were consulted and proposed a variety of diagnoses: nervous exhaustion, chronic lead intoxication from the two bullets lodged in his body, cerebral arteriosclerosis and "endarteritis luetica." Dr. Vinters speculates that the last term referred to meningovascular syphilis, inflammation of the walls of blood vessels mainly around the brain, resulting in a thickening of the interior of the vessel. But there was no evidence of this on autopsy, and Lenin's syphilis test was said to have been negative. He had been treated anyway with injections of a solution containing arsenic, the prevailing syphilis remedy. Then, in his last hours and days of his life, Lenin experienced severe seizures. An autopsy revealed a near total obstruction of the arteries leading to the brain, some of which were narrowed to tiny slits. But Lenin did not have some of the traditional risk factors for strokes. He did not have untreated high blood pressure - had that been his problem, the left side of his heart would have been enlarged. He did not smoke and would not tolerate smoking in his presence. He drank only occasionally and exercised regularly. He did not have symptoms of a brain infection, nor did he have a brain tumor. So what brought on the stroke that killed Lenin? The clues lie in Lenin's family history, Dr. Vinters said. The three siblings who survived beyond their 20s had evidence of cardiovascular disease, and Lenin's father died of a disease that was described as being very much like Lenin's. Dr. Vinters said Lenin might have inherited a tendency to develop extremely high cholesterol, causing the severe blockage of his blood vessels that led to his stroke. Compounding that was the stress Lenin experienced, which can precipitate a stroke in someone whose blood vessels are already blocked. But Lenin's seizures in the hours and days before he died are a puzzle and perhaps historically significant. Severe seizures, Dr. Vinters said in an interview before the conference, are "quite unusual in a stroke patient." But, he added, "almost any poison can cause seizures." Dr. Lurie concurred on Friday, telling the conference that poison was in his opinion the most likely immediate cause of Lenin's death. The most likely perpetrator? Stalin, who saw Lenin as his main obstacle to taking over the Soviet Union and wanted to get rid of him. Communist Russia in the early 1920s, Dr. Lurie told the conference, was a place of "Mafia-like intrigue." In 1921 Lenin started complaining that he was ill. From then until his death in 1924, Lenin "began to feel worse and worse," Dr. Lurie said. He complained that he couldn't sleep and that he had terrible headaches. He could not write, he did not want to work," Dr. Lurie said. He wrote to Alexei Maximovich Gorky, "I am so tired, I do not want to do anything at all." But he nonetheless was planning a political attack on Stalin, Dr. Lurie said. And Stalin, well aware of Lenin's intentions, sent a top-secret note to the Politburo in 1923 claiming that Lenin himself asked to be put out of his misery. The note said: "On Saturday, March 17th in the strictest secrecy Comrade Krupskaya told me of "Vladimir Ilyich's request to Stalin," namely that I, Stalin, should take the responsibility for finding and administering to Lenin a dose of potassium cyanide. I felt it impossible to refuse him, and declared: "I would like Vladimir Ilyich to be reassured and to believe that when it is necessary I will fulfill his demand without hesitation."" Stalin added that he just could not do it: "I do not have the strength to carry out Ilyich's request and I have to decline this mission, however humane and necessary it might be, and I therefore report this to the members of the Politburo." Dr. Lurie said Stalin might have poisoned Lenin despite this assurance, as Stalin was "absolutely ruthless." Dr. Vinters believes that sky-high cholesterol leading to a stroke was the main cause of Lenin's death. But he said there is one other puzzling aspect of the story. Although toxicology studies were done on others in Russia, there was an order that no toxicology be done on Lenin's tissues. So the mystery remains. But if Lenin had lived today, or if today's cholesterol-lowering drugs had been available 100 years ago, might he have been spared those strokes? "Yes," Dr. Vinters said. Lenin could have gone on for another 20 or 25 years, assuming he wasn't assassinated. History would have been totally different.