The Case of the Internationally Acclaimed One-Legged Actress

Albert B. Lowenfels, MD

Disclosures

June 01, 2007

Introduction

The patient was a 71-year-old actress with swollen, tender right knee.

When the patient was in her early 70s, her right knee became progressively painful and swollen. Motion of the knee was restricted and weight bearing was extremely painful. In an attempt to alleviate the pain, her physician applied a cast to immobilize the right leg. However, over the next several months, despite the cast, the pain became unbearable. When the cast was finally removed, her physicians were dismayed to find widespread sepsis. In desperation, they performed a mid-thigh amputation of the right leg.

Following the above-knee amputation, she had no further bouts of infection in the right leg and no additional pain or swelling in any of her joints. After the wound healed, she tried many prosthetic appliances, which proved unsatisfactory. Nevertheless, within several months she resumed her stage career, restricting her performances to roles that could be played while seated.

The patient lived for 8 years after the amputation. At age 73, she had a prolonged recovery after undergoing surgery for 'kidney disease,' and eventually died from uremia at age 79.

The patient was an illegitimate child, and parental illnesses are unknown. One sister with whom the patient had close contact died of tuberculosis at age 15. The patient was described as being frail, had an occasional hacking cough, and occasional bouts of hemoptysis. As a teenager, she had attacks of 'pleurisy.' Her medical history also included a childhood burn.

The patient had experienced a number of knee injuries over a period of many years, beginning at age 4 when her knee was injured after she fell from a window. In her early 40s while on an acting tour, an abscess on her knee required drainage. A few years later she sustained repetitive injuries to her knees while playing the role of Joan of Arc, which required that she fall to her knees during each performance. On another occasion, after a fall on board a ship, her knee became swollen and remained painful over many years.

Who was the patient

  1. Clara Bow

  2. Josephine Baker

  3. Sarah Bernhardt

  4. Jenny Lind

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What is the most likely diagnosis?

  1. Osteosarcoma of the right knee

  2. Systemic lupus erythematosus

  3. Gout

  4. Extrapulmonary tuberculosis

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Tuberculosis (TB) is an ancient disease, which was widespread during early civilized times.[3,4] DNA studies of bone and soft tissue material from Egyptian mummies revealed solid evidence for TB dating back to 2000 BC. At the end of the 19th century, TB was still a common infectious disease and during Sarah Bernhardt's lifetime, TB remained a dreaded killer: in the latter half of the 19th century, TB was responsible for 1 in 7 deaths.

Robert Koch's (1843-1910) discovery of Mycobacterium tuberculosis, the organism, for which he received the Nobel Prize in 1908, formed the foundation for subsequent progress in developing treatments for TB. In 1932, Selman Waksman showed that when Mycobacterium tuberculosis was added to certain types of soil, the bacteria died, which led to his discovery of streptomycin -- the first specific agent for treating TB, for which he won the 1952 Nobel Prize in medicine

In addition to development of effective drugs, housing conditions and sanitation improved during the 20th century, so that TB became less common in Western countries. However the 'white death' never disappeared, and, since the onset of the AIDS epidemic, it is once again a serious public health problem.

Today, after the death of her sister from suspected TB, Bernhardt would be screened for TB and, if the test result was positive, she would receive antibiotic therapy, making the development of tuberculous arthritis of the knee unlikely. If TB of the knee did develop, early multidrug therapy for a year or more should lead to healing. Surgical treatment, if drug therapy fails to solve the problem, might include synovectomy or arthrodesis.[5] Knee replacement has also been performed for TB of the knee if the infection has been quiescent for many years.[6]

Another major difference between past and current treatment of monoarticular arthritis is the application of a cast, which, conceivably, was one of the factors leading to eventual amputation. Pressure necrosis may have eroded the underlying skin and subcutaneous tissues, leading to sepsis of the extremity. Today, if a patient has monoarticular arthritis, joint aspiration along with imaging procedures would lead to a correct diagnosis and appropriate therapy. Even in the absence of a TB test, a radiograph taken of Bernhardt's knee would likely have exhibited findings consistent with TB, as shown in Figure 2. In any event, it is extremely unlikely that any patient with monoarticular arthritis of the knee would undergo an above-knee amputation unless the cause was an aggressive tumor.

Rehabilitation. It is difficult to compare Bernhardt's outcome with modern experience because most patients undergoing amputation now have underlying vascular disease and/or diabetes. There is no evidence that Bernhardt had either of these diseases. Bernhardt was unable to ambulate with her prosthetic leg even though she continued to lead an active life after her amputation, including resuming her career as a much admired actress. Even today, with modern prostheses available, most patients older than 70 years of age are unable to walk after a lower limb amputation.[7,8,9]

Sarah Bernhardt was born in Paris in the middle of the 19th century. She was the illegitimate daughter of Judith Van Hard, a Dutch Jewess and prostitute. Her father may have been Edouard Bernard, a notary in Havre, who eventually settled 100,000 francs on Sarah as a dowry when she came of age.

She began acting in her teens and because of the intensity of her personality and her melodious voice, she quickly became the leading actress of the 19th century. Sarah became known for the special passion and spirit with which she portrayed hundreds of different roles and, although she was emaciated and handicapped in later life, could seem to drop years off her actual age as soon as she began to use her voice and weave the spell that made her the most famous actress of her age.

Known as 'The Divine Sarah' she acted in theaters throughout the world including 9 tours within the United States. Endowed with a vibrant personality, she had numerous acquaintances (and lovers) who greatly admired her gifts not only as an actress, but also as a sculptor and a painter. She was also one of the first theatrical stars to make the transition to movies. Supposedly she has been a role model for more recent actresses including Marilyn Monroe and Sandra Bernard (whose name, obviously, is very similar to that of the 19th-century actress).

On one of her early transatlantic voyages, Sarah Bernhardt encountered Mary Todd Lincoln and saved the President's widow from a potentially fatal fall down a flight of stairs. It is ironic that the wife of a President assassinated by an actor may have been saved by an actress.

The impresario P. T. Barnum offered a large sum of money to exhibit Bernhardt's amputated leg as an attraction at his circus, but Bernhardt refused to give permission. The current location of the famous limb is unknown.

After her amputation, and near the end of her career, Bernhardt gave a special performance for Queen Mary. When the Queen saw how emaciated the actress looked, she suggested that Sarah take more rest. Sarah said, "I shall die on the stage; 'tis my battlefield." Indeed one of her famous sayings was: "It is in spending oneself that one becomes rich." This philosophy compelled her to continue acting even after the loss of her right leg. Although severely handicapped, Bernhardt continued to act until the very end of her life.

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