What Ails Castro?
Jan 31, 2007 Filed in: Medicine &
Science
Miami is set to party, the death watch latches onto
the latest details, and Cuban ministries insist Fidel
is just fine
Fidel Castro, borrowing a line from Mark Twain, would like you to know that reports of his demise are greatly exxagerated. Fidel Alejandro Castro Ruz, the 80-year-old dictator of the island nation of Cuba, transferred power to his younger brother on July 31st after “intestinal surgery” and has been recovering ever since. The city of Miami is planning a mega-party to celebrate his death, but many of Castro’s most bitter critics have been down this road too many times before and say they won’t believe it until they can spit on his corpse. It’s not surpsing that it is not known what his illness is, or that there are conflicting stories about it, given the web of secrecy, fabrications and double talk that has swarmed around Castro since the inception of the revolution that eventually toppled the Batista regime. But based on what little is known, using a little surgical detective work, we can get a pretty good idea of what happened.
The first report out of Cuba was a statement from the government that said Castro had undergone surgery for stress-related gastrointestinal bleeding. His condition was reported as serious, but his return was to be expected in a few weeks. According to the official statement, Castro said his intense schedule “promoted in me a sharp intestinal crisis with sustained bleeding that obligated me to undergo a complicated surgical procedure.” But during the next several days, when he didn’t appear in public, rumors began to swarm: Was it cancer? Was he dying? The Bush administration, always last to know what’s going on in the world, said it was caught off-guard by the reports of Castro’s illness and had no idea what his condition was.
As the speculation whirlwind reached tornado strength, the Cuban government released four photos of the recovering Castro, including one in which he is seated in a chair, holding up the August 12th edition of the state-run newspaper Granma and dressed in a red, white, and blue Addidas jumpsuit. The irony of the Communist leader dressed in a workout suit with the same color scheme as the American Flag and advertising a US corporation was lost on most Americans, as all attention focused on whether the photos were real or photoshopped. But Venezuelan President Hugo Chavez stopped over for a visit and had some photos taken with Castro, convincing the world that Castro was indeed alive, if not well. Additional state visits followed, with more pictures, an October video with Castro again reading from the current edition of the paper to prove it was not file footage, and lots of speculation.
The statements of any of the politicians who have visited or spoken with Castro can be discounted outright, as they are not physicians, and all have their own axe to grind. The first report of reasonable veracity on Castro’s condition came from Spanish surgeon Jose Luis Garcia Sobredo, the Chief of Surgery of Madrid’s Hospital Gregorio Maranon, who responded to a “humanitarian request” of the Cuban government. He confirmed that Castro did not have cancer and was recovering. Subsequent reports leaked out of Maranon gave further details: Castro was suffering from an infection of his large intestine and had undergone at least three failed operations to repair damage from complications of diverticulits. And here at last the story begins to make sense.
The diagnosis of diverticulitis is likely to be true, not only because of the reports, but also because they match his age, history, and survival this far into this illness. To start with, examine all the major candidates for bleeding intestinal illness: diverticulitis, vascular problems, cancer, pre-cancerous lesions, inflammatory bowel disease, hemorrhoids. Vascular problems, a large group of problems having in common compromised blood flow to the colon, can be excluded because they have very different presentation and course of action than has been seen with Castro, and are almost exclusively treated with medical treatment rather than surgical treatment. Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, are chronic diseases that present long before the ninth decade of life. Hemorrhoids and pre-cancerous lesions (polyps) are easily treated and would not require a 6-month recovery, even in someone Castro’s age. For colon cancer to have been the cause of his illness, given the known symptoms and lengthy recovery, it would have to have been at least Stage III colorectal cancer, but the treatment of Stage III and Stage IV colorectal cancer (meaning that it is a large tumor that had spread at least to the lymph nodes and possibly to surrounding organs) includes chemotherapy, and there has been no hint of Castro having undergone chemo. Also, chemotherapy or not, survivability of Stage III or IV is poor, which could explain his failing health, but does not match with the repeated surgeries. What remains from our differential diagnosis is diverticulitis.
Diverticulosis is a condition of the large bowel in which little outpouchings develop over the course of a lifetime. Think of a long skinny balloon, and along the balloon there are weak spots where the balloon pooches out. Changing –osis (presence of a condition) to –itis (presence of inflammation) means that an infection has set up shop in the outpouchings. This diagnosis agrees with his symptoms, his condition (as much as has been released by the Cuban government) and his history. Brazilian journalist Claudi Furiati, author of History Will Absolve Me, Castro’s authorized biography, reported that Castro suffered from diverticulitis 20 years ago. Again, this agrees with the course of the disease, which develops later in life and can recur at any time.
Diverticulitis can lead to abscess, rupture, inflammation of the abdominal cavity, and if untreated, death. The medical sources close to Dr. Sobredo said that a recurrence of the disease emerged last summer with large amounts of blood loss into the intestine. Why, then, three surgeries? The treatment of diverticulitis depends on its severity and location. It can be treated with antibiotics, CT-guided drainage, or surgery. If left untreated or improperly treated, it can spread to peritonitis (an infection of the lining of the abdomen) and ultimately sepsis and death.
This leaves us with a likely cause and timeline of Castro’s illness: He gets a bout of severe diverticulitis. The disease is more aggressive than the treatment, whatever medical or radiologic-guided treatment was attempted, and it progressed to the point of requiring surgery. A common story and still very treatable, but Castro is no typical patient. This is the same man who in October 2004 tripped and broke his left knee and right arm, but when he had to undergo surgery for his knee was reported to have refused tranquilizers and general anesthesia so that he would not have to hand over power. In all likelihood, he was not inclined to do everthing his doctors told him this time around either. When it came time for surgery, the usual procedure is to open the abdomen, clear out the pus, resect any dead or infected bowel, and if there is severe enough infection, perform a colostomy, with the possibility of being reconnected in 3 to 6 months. Did Castro consent to a colostomy? Probably not. More likely, he put extreme pressure on his doctors to restore normal continence. According to the reports from Madrid, at the initial surgery part of his colon and rectum were removed, and the proximal colon was connected to the distal rectum. But that kind of anastomosis will never heal in the face of ongoing infection, which would lead to the repeat surgeries, including further complications from the abdominal abscess.
There’s an old saying in surgery: Complications beget complications. Especially in the edlerly, you don’t want that first complication, because the treatment for each complication can lead to several more. To put it another way, kill one fly and two come to the funeral. So at this point in Castro’s belly there’s an incompletely treated abscess and a broken down anastomosis, which is spilling more stool into the abdomen, leading to more infection, more abscesses, and further complications. Again according to the Madrid sources one of these complications was an inflammation of the gallbladder and bile duct from the liver. The bile duct inflammation is a horrific complication and very difficult to treat. When the common bile duct, which drains bile from the liver into the intestines, breaks down, it’s game over. By the reports, stents were placed to keep the bile flowing, with poor results. And all of this infection would make for a non-healing incision and lots of drainage from the wound, which leads to fluid loss, nutrient problems, and lots of other problems, all of which also agrees with reports.
What next for Castro? First, he will never return to power. At his age, with this amount of complications, he will never fully recover. A study done several years ago on healthy medical students confined to bed for one week showed that it took months to return to their baseline weight, muscle mass, and conditioning. For 80-year-olds who are six months into a severe illness, there is only a downward spiral. How long will it take? That depends on his condition at the moment. Once a person with severe illness such as this gets to a point of disability where he cannot move his own body weight without assistance, survival is measured in days to weeks. As long as he is still able to move as he appears to be in the October video, he may have months to years. But, the complications leave him fragile and highly susceptible to a sudden event such as a heart attack, meaning he could go any day. And he has no realistic chance of being able to return to his former power, except in the most limited way.
Not that anything is likely to change that much in Cuba any time soon anyway, whether Castro survives or not. The 76-year-old Raul, who has been with his older brother since the beginning of the 26th of July Movement began and has been his close confidant, has shown no sign of changing Cuban policy and is unlikely to make radical changes any time soon. More likely, major change in Cuba is to have to wait until a new generation of politicians moves into power. For the moment, the death watch continues.
Return to Home Page
Fidel Castro, borrowing a line from Mark Twain, would like you to know that reports of his demise are greatly exxagerated. Fidel Alejandro Castro Ruz, the 80-year-old dictator of the island nation of Cuba, transferred power to his younger brother on July 31st after “intestinal surgery” and has been recovering ever since. The city of Miami is planning a mega-party to celebrate his death, but many of Castro’s most bitter critics have been down this road too many times before and say they won’t believe it until they can spit on his corpse. It’s not surpsing that it is not known what his illness is, or that there are conflicting stories about it, given the web of secrecy, fabrications and double talk that has swarmed around Castro since the inception of the revolution that eventually toppled the Batista regime. But based on what little is known, using a little surgical detective work, we can get a pretty good idea of what happened.
The first report out of Cuba was a statement from the government that said Castro had undergone surgery for stress-related gastrointestinal bleeding. His condition was reported as serious, but his return was to be expected in a few weeks. According to the official statement, Castro said his intense schedule “promoted in me a sharp intestinal crisis with sustained bleeding that obligated me to undergo a complicated surgical procedure.” But during the next several days, when he didn’t appear in public, rumors began to swarm: Was it cancer? Was he dying? The Bush administration, always last to know what’s going on in the world, said it was caught off-guard by the reports of Castro’s illness and had no idea what his condition was.
As the speculation whirlwind reached tornado strength, the Cuban government released four photos of the recovering Castro, including one in which he is seated in a chair, holding up the August 12th edition of the state-run newspaper Granma and dressed in a red, white, and blue Addidas jumpsuit. The irony of the Communist leader dressed in a workout suit with the same color scheme as the American Flag and advertising a US corporation was lost on most Americans, as all attention focused on whether the photos were real or photoshopped. But Venezuelan President Hugo Chavez stopped over for a visit and had some photos taken with Castro, convincing the world that Castro was indeed alive, if not well. Additional state visits followed, with more pictures, an October video with Castro again reading from the current edition of the paper to prove it was not file footage, and lots of speculation.
The statements of any of the politicians who have visited or spoken with Castro can be discounted outright, as they are not physicians, and all have their own axe to grind. The first report of reasonable veracity on Castro’s condition came from Spanish surgeon Jose Luis Garcia Sobredo, the Chief of Surgery of Madrid’s Hospital Gregorio Maranon, who responded to a “humanitarian request” of the Cuban government. He confirmed that Castro did not have cancer and was recovering. Subsequent reports leaked out of Maranon gave further details: Castro was suffering from an infection of his large intestine and had undergone at least three failed operations to repair damage from complications of diverticulits. And here at last the story begins to make sense.
The diagnosis of diverticulitis is likely to be true, not only because of the reports, but also because they match his age, history, and survival this far into this illness. To start with, examine all the major candidates for bleeding intestinal illness: diverticulitis, vascular problems, cancer, pre-cancerous lesions, inflammatory bowel disease, hemorrhoids. Vascular problems, a large group of problems having in common compromised blood flow to the colon, can be excluded because they have very different presentation and course of action than has been seen with Castro, and are almost exclusively treated with medical treatment rather than surgical treatment. Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, are chronic diseases that present long before the ninth decade of life. Hemorrhoids and pre-cancerous lesions (polyps) are easily treated and would not require a 6-month recovery, even in someone Castro’s age. For colon cancer to have been the cause of his illness, given the known symptoms and lengthy recovery, it would have to have been at least Stage III colorectal cancer, but the treatment of Stage III and Stage IV colorectal cancer (meaning that it is a large tumor that had spread at least to the lymph nodes and possibly to surrounding organs) includes chemotherapy, and there has been no hint of Castro having undergone chemo. Also, chemotherapy or not, survivability of Stage III or IV is poor, which could explain his failing health, but does not match with the repeated surgeries. What remains from our differential diagnosis is diverticulitis.
Diverticulosis is a condition of the large bowel in which little outpouchings develop over the course of a lifetime. Think of a long skinny balloon, and along the balloon there are weak spots where the balloon pooches out. Changing –osis (presence of a condition) to –itis (presence of inflammation) means that an infection has set up shop in the outpouchings. This diagnosis agrees with his symptoms, his condition (as much as has been released by the Cuban government) and his history. Brazilian journalist Claudi Furiati, author of History Will Absolve Me, Castro’s authorized biography, reported that Castro suffered from diverticulitis 20 years ago. Again, this agrees with the course of the disease, which develops later in life and can recur at any time.
Diverticulitis can lead to abscess, rupture, inflammation of the abdominal cavity, and if untreated, death. The medical sources close to Dr. Sobredo said that a recurrence of the disease emerged last summer with large amounts of blood loss into the intestine. Why, then, three surgeries? The treatment of diverticulitis depends on its severity and location. It can be treated with antibiotics, CT-guided drainage, or surgery. If left untreated or improperly treated, it can spread to peritonitis (an infection of the lining of the abdomen) and ultimately sepsis and death.
This leaves us with a likely cause and timeline of Castro’s illness: He gets a bout of severe diverticulitis. The disease is more aggressive than the treatment, whatever medical or radiologic-guided treatment was attempted, and it progressed to the point of requiring surgery. A common story and still very treatable, but Castro is no typical patient. This is the same man who in October 2004 tripped and broke his left knee and right arm, but when he had to undergo surgery for his knee was reported to have refused tranquilizers and general anesthesia so that he would not have to hand over power. In all likelihood, he was not inclined to do everthing his doctors told him this time around either. When it came time for surgery, the usual procedure is to open the abdomen, clear out the pus, resect any dead or infected bowel, and if there is severe enough infection, perform a colostomy, with the possibility of being reconnected in 3 to 6 months. Did Castro consent to a colostomy? Probably not. More likely, he put extreme pressure on his doctors to restore normal continence. According to the reports from Madrid, at the initial surgery part of his colon and rectum were removed, and the proximal colon was connected to the distal rectum. But that kind of anastomosis will never heal in the face of ongoing infection, which would lead to the repeat surgeries, including further complications from the abdominal abscess.
There’s an old saying in surgery: Complications beget complications. Especially in the edlerly, you don’t want that first complication, because the treatment for each complication can lead to several more. To put it another way, kill one fly and two come to the funeral. So at this point in Castro’s belly there’s an incompletely treated abscess and a broken down anastomosis, which is spilling more stool into the abdomen, leading to more infection, more abscesses, and further complications. Again according to the Madrid sources one of these complications was an inflammation of the gallbladder and bile duct from the liver. The bile duct inflammation is a horrific complication and very difficult to treat. When the common bile duct, which drains bile from the liver into the intestines, breaks down, it’s game over. By the reports, stents were placed to keep the bile flowing, with poor results. And all of this infection would make for a non-healing incision and lots of drainage from the wound, which leads to fluid loss, nutrient problems, and lots of other problems, all of which also agrees with reports.
What next for Castro? First, he will never return to power. At his age, with this amount of complications, he will never fully recover. A study done several years ago on healthy medical students confined to bed for one week showed that it took months to return to their baseline weight, muscle mass, and conditioning. For 80-year-olds who are six months into a severe illness, there is only a downward spiral. How long will it take? That depends on his condition at the moment. Once a person with severe illness such as this gets to a point of disability where he cannot move his own body weight without assistance, survival is measured in days to weeks. As long as he is still able to move as he appears to be in the October video, he may have months to years. But, the complications leave him fragile and highly susceptible to a sudden event such as a heart attack, meaning he could go any day. And he has no realistic chance of being able to return to his former power, except in the most limited way.
Not that anything is likely to change that much in Cuba any time soon anyway, whether Castro survives or not. The 76-year-old Raul, who has been with his older brother since the beginning of the 26th of July Movement began and has been his close confidant, has shown no sign of changing Cuban policy and is unlikely to make radical changes any time soon. More likely, major change in Cuba is to have to wait until a new generation of politicians moves into power. For the moment, the death watch continues.
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