The Case of the Middle-Aged General With a Fatal Postnuptial Hemorrhage

Albert B. Lowenfels, MD; Doris B. Lowenfels, MLS

Disclosures

April 20, 2006

Events Surrounding the Patient's Death

We will never be sure of the real diagnosis because the first account of Attila's death by the historian Priscus could be unreliable. At the time of Attila's death, Priscus (a secretary and employee of the East Roman Emperor Marcian) was in Egypt and simply gathered second- and third-hand information to weave his "authoritative" account, which has been the basis of all subsequent accounts.

There is some evidence that the original Priscus document may have included speculation about assassination, but the nosebleed story was accepted everywhere with relief because it would not require retaliation by Attila loyalists against other suspected Huns, or other tribes, or against Rome itself.[4]

Possible assassins included his new bride or a bribed and vengeful bodyguard.

The new bride Ildico was at Attila's side when he died and did not call for help. Almost nothing is known about her, but what little there is could give her a strong motive for revenge. She was a member of a tribe conquered by Attila, and he may have killed her close relatives. One 6th-century historian states: "Attila, king of the Huns and ravager of the provinces of Europe, was stabbed with a dagger one night by his wife.[4]"

A bribed or vengeful bodyguard could also have assassinated Attila. He had powerful enemies across the Roman Empire, including the Western Emperor Valentinian III; the Eastern Emperor Marcian; and Aetius, the commanding general of Roman forces. It was widely believed that Attila intended to resume his attacks either to the East or West when the season was propitious. Attila's top men all had diplomatic contact with Roman headquarters, which would have given ample opportunity for assassination arrangements.

Against the assassination theories is the reported lack of any external wounds. If Attila had been murdered, an external wound or some signs of violence should have been noted. Is it possible that he was poisoned? Very few poisons produce fatal gastrointestinal hemorrhage, but one exception is ricin, a powerful agent derived from the castor bean, which is almost as toxic as plutonium and botulism. A tiny amount can be lethal, making it a potential agent for terrorists. Ricin is the drug suspected to have been used to assassinate Georgi Markov, a Russian defector. However, ricin was unknown at the time of Attila's death.

The only general agreement among the various Roman and Christian historians (there were no Hun historians) seems to be that Attila died just after taking a new, young wife and just before further attacks on either the Eastern or Western Roman Empire. The actual circumstances of Attila's death and even the place at which he was buried are not known because those who buried him were then executed to protect the grave site from violation. There is even disagreement about the year of Attila's death, which most historians say was AD 454, but may have been AD 453.

A Brief History of the Huns

There were many famous barbarian chiefs during the huge migrations from as far as China's western borders to the shores of England, but only Attila the Hun inspired fear in everyone. Christian historians refer to Attila as the "Scourge of God." His treatment of conquered victims was ruthless; he lacked interest in anything but loot, slaves, and treasure, and his overwhelming force crushed all in his path.

Attila made decisions unilaterally, accepting advice from no one and relying solely on his instincts, invincibility, and an ancient sword of Mars, unearthed by a peasant, which Attila believed would make him ruler of the world.

He was able to hold his troops together as long as he was able to reward them with treasures. Providing rewards for his people and his troops was Attila's driving motivator and the reason why his victims feared him.

After Attilla looted several northern Italian cities, including Verona and Milan, it would have been expected in AD 452 that he would have gone on to invade Rome. A stone throne still visible on the island of Torcello, Italy, is believed to have been used by Attila, suggesting his presence there. Historians have attributed his failure to conquer Rome to bribes offered to him by Pope Leo, and to a plague sweeping Rome at the time, which was starting to spread to Attila's troops (see Figure). On the basis of recent evidence obtained by polymerase chain reaction analysis of children in Lugnano, a town near Rome, who died in AD 450, the plague appears to have been a virulent form of malaria.[9] Until the 20th century, malaria (from the Italian "mal aria" or bad air) was prevalent in the area surrounding Rome. Most likely, then, malaria was also threatening Attila's army -- an excellent reason why he decided to withdraw.

Figure.

Stone throne located on the island of Torcello, Italy. Known locally as "The throne of Attila." Photograph courtesy of Philip Greenspun.

After Attila died at the age of 47, his sons were unable to unite and keep the Hun confederacy together. Although the Huns left no cities, no monuments, and no civilization, their impact during their short history had been huge. Other barbarian tribes, forced to flee the depredations of the Huns, had begun their precipitous westward advances. All were glad to see the Huns disappear, and certainly both Roman Emperors must have rejoiced to hear of Attila's death. But once the Huns were gone, the other tribes turned their full attention to the richness of the West Roman Empire: The Ostrogoths invaded Italy; the Visigoths invaded Gaul; and the Vandals invaded North Africa until the inevitable dissolution of the Empire finally occurred in AD 476.[1]

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