Cardiovascular Pathology 53 (2021) 107340
Contents lists available at ScienceDirect
Cardiovascular Pathology
journal homepage: www.elsevier.com/locate/carpath
The illness and death of King George VI of England: the pathologists’
reassessment ✩,✩✩
Rolf F. Barth, MD 1,a,∗, L. Maximillian Buja, MD 2,a
1
Department of Pathology, The Ohio State University, Columbus, Ohio 43210, USA
Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health and Science Center at Houston, Houston,
Texas 77030, USA
2
a r t i c l e
i n f o
Article history:
Received 11 March 2021
Revised 28 April 2021
Accepted 30 April 2021
Keywords:
illness and death of King George VI
coronary thrombosis vs lung cancer
pulmonary embolus vs hemothorax
a b s t r a c t
The illness and death of King George VI has received renewed attention based on the events portrayed in
the Netflix blockbuster series, The Crown. The King, a heavy smoker, underwent a left total pneumonectomy in September 1951 for what euphemistically was called "structural abnormalities" of his left lung,
but what in reality was a carcinoma. His physicians withheld this diagnosis from him, the public, and
the medical profession. The continuation of hemoptysis following surgery suggested that his cancer had
spread to his right lung. Although he made a slow and uneventful recovery from his surgery, King George
VI died suddenly and unexpectedly in his sleep on February 6, 1952, at the age of 56. Since the King had
a history of peripheral vascular disease, it was assumed that the cause of death was a "coronary thrombosis." In this report, we explore the cardiovascular and oncologic findings relating to his illness and
death and consider an alternative explanation for his demise, namely, that he may have died of complications from a carcinoma that had originated in his left lung and spread to his right lung, as evidenced
by continued hemoptysis. We suggest that this possibly could have led to his sudden death due to either
a pulmonary embolus or a massive intra-thoracic hemorrhage rather than a "coronary thrombosis."
© 2021 Published by Elsevier Inc.
1. Introduction
The first season of the Netflix blockbuster series, The Crown, begins with a dramatic portrayal in Episode 1 of the illness and, in
Episode 2, the subsequent death of King George VI leading to the
coronation of his daughter, Elizabeth, as Queen of the United Kingdom [1,2]. Albert Frederick Arthur George Windsor (called “Bertie”
within the royal family) reluctantly ruled England as George VI for
almost 16 years. This followed the abdication of his brother, Edward VIII in 1936 in order to marry the twice divorced American,
Wallis Simpson. Edward subsequently lived the rest of his life in
exile as the Duke of Windsor, and King George VI reigned until his
death on February 6, 1952 at the age of 56. The official statement
of King George VI’s death was as follows:
"The King was found dead in bed at Sandringham House in Norfolk, on the morning of February 6. He had died from a coronary thrombosis – a blocking of blood flow to the heart – as a
result of a blood clot in an artery – in his sleep. . . . The tea was
never drunk: a blood clot had stilled George VI’s valiant heart
as he slept [3]."
But was this really the cause of death of King George VI? Since
there was at that time a social stigma associated with the diagnosis of cancer, there was strong reason not to reveal that he had
undergone a total left pneumonectomy for lung cancer in September of the previous year. His medical history is complex and not
well documented and raises questions as to the nature of the acute
event leading to his death that we will address in the following report.
2. Clinical history
✩
This research received no specific grant support from funding agencies in the
public, commercial, or not-for-profit sectors.
✩✩
The authors declare that there is no conflict of interest.
∗
The corresponding author is: Rolf F. Barth, MD. The Ohio State University, Department of Pathology, 4132 Graves Hall, 333 W. 10th Avenue, Columbus, Ohio
43210 USA. Tel.: (614) 292-2177; fax: (614) 292-5844.
E-mail address: rolf.barth@osumc.edu (R.F. Barth).
a
Both authors have contributed equally to the writing of this report.
https://doi.org/10.1016/j.carpath.2021.107340
1054-8807/© 2021 Published by Elsevier Inc.
George VI was a moderate drinker, but a heavy smoker, having
begun as a teenager. Although it is impossible to determine precisely how heavy his cigarette smoking was, biographical descriptions [4,5] suggest that it is reasonable to estimate that his 40-year
history of smoking possibly 2 packs of cigarettes per day would
be equivalent conservatively to 80 pack-years. This would be an
R.F. Barth and L.M. Buja
Cardiovascular Pathology 53 (2021) 107340
extraordinarily high number for someone who was only 56 years
old at the time of his death. Furthermore, there was a strong family history of heavy cigarette smoking [4,5]. His father, George V,
also was a heavy cigarette smoker and developed chronic obstructive pulmonary disease that required intermittent oxygen and ultimately led to his death at age 71. His mother, also a smoker, died
at age 86 with a suspected lung tumor. His brother, the former
Edward VIII, also was a heavy smoker, developed laryngeal cancer, received cobalt radiotherapy, and ultimately succumbed to it
at age 77 in 1972. Finally, his daughter, Princess Margaret, also had
a heavy smoking history and underwent left partial pneumonectomy in January 1985 at the age of 55 for an unspecified lesion,
possibly a malignancy.
George VI’s medical history included an appendectomy at age
19 and a duodenal ulcer at 22, for which at that time he most
likely would have had a gastrojejunostomy [6]. In 1948, at the
age of 54, he gave up public appearances because of pain in his
right leg and foot. His doctors conclulded that the King suffered
from thromboangitis obliterans (Buerger’s disease) and that “all
his arteries were hardened beyond his years” [7]. "Hardening of
the arteries" is a lay term for arteriosclerosis, which is generally
used interchangeably with atherosclerosis. Because of the increasing severity of his symptoms, amputation was considered; however, fortunately a less drastic procedure was carried out. The King
underwent a right lumbar sympathectomy on March 12, 1949 in a
specially outfitted operating room in Buckingham Palace [4,5]. Unrelated to his physical health, he was noted to be shy and had a
severe stutter that he eventually overcame later in life [4,5].
In the summer of 1951, at age 56, George VI began to complain
of a severe cough with blood-tinged sputum (hemoptysis), and
generalized weakness extending over a 4-month period [4,5]. He
then developed a respiratory illness that began with fever, chills,
and a mild cough. An X-ray taken at that time revealed an area
of consolidation in his left lung, which euphemistically was called
"catarrhal inflammation." This was diagnosed as pneumonia, and
he was treated with a 1-week course of penicillin and bed rest.
However, his pulmonary symptoms persisted; and approximately 2
months after their onset, he had a chest X-ray that showed radiological signs in his left lung that were interpreted by Dr. Peter Kerley, a Westminster Hospital radiologist, to be characteristic of lung
cancer [8]. However, it is noteworthy that the word, cancer, never
was used in any bulletin before or after surgery [6]. Shortly thereafter, the King’s surgeon, Clement Price Thomas, who was one of
the leading lung cancer surgeons in Britain at that time, was consulted. A bronchoscopy was performed by his son Brian Thomas,
and a biopsy firmly established the diagnosis of lung cancer.
On September 23, 1951, one week after the bronchoscopy,
Thomas, assisted by two Surgical Residents, Charles Drew and Peter Jones, performed a left total pneumonectomy. Because the King
did not want to be hospitalized, the operation was performed at
Buckingham Palace in the Buhl room, which had been outfitted to
resemble Thomas’s operating theater in the Westminster Hospital
[9]. This event was depicted in Season 1, Episode 1, of The Crown.
Although there appears to be no published operative report in the
medical literature, a detailed description of the anesthetic used
was written much later by an anesthesiologist, I. D. Conacher, who
was not a participant in the operation. This also included some information relating to the pneumonectomy [8] that was performed
for "structural abnormalities" involving his left lung. The left recurrent laryngeal nerve was "sacrificed" during the surgery, and
the King’s speech consequently was husky, slow, and muted during
his Christmas speech on December 25, 1951 [6]. Although it was
not specifically stated, most doctors assumed that the euphemistic
"structural changes", first announced on September 18, 1952, were
in fact lung cancer. Parenthetically, it should be noted that Thomas,
who was a heavy cigarette smoker himself, developed lung cancer
Fig. 1. Two photographs of King George VI (A and B) taken sometime during 1951
or January 1952. (A was obtained from Pinterest and there was no identified source
of B, but both of them were freely available on the Internet). Based on his appearance, Professor Harold Ellis stated “Every doctor and nurse in the country realized
he (George VI) had a malignant disease, he looked terrible [6].
in 1964 at age 70. He was successfully operated on by Mr. Charles
Drew, one of his assistants for the King’s pneumonectomy in 1964,
and died in 1973 at the age of 79 [6].
Despite a slow but uneventful recovery, the King slowly returned to his usual state of health and resumed his normal activities. However, a particularly ominous sign was the continued
hemoptysis, as depicted in The Crown (Season 1, Episode 2) [2] by a
bedside box of blood-tinged tissues, suggesting that his cancer had
spread to his right lung. On February 5, 1952, he went to Sandringham House in Norfolk to shoot hares and rabbits, and he was purportedly in "great form" [4]. However, as shown in Fig. 1, although
the official photograph showed him looking well, the "last" official
photograph suggested quite the contrary. This was in keeping with
the palace’s efforts not to reveal how sick the King really was. Later
in the evening, he retired to his bedroom, and he purportedly was
last seen alive at midnight by some gardeners who saw him at a
window [4]. At 7:30 on the morning of February 6, his valet, James
MacDonald, entered the bedroom with a cup of tea and found the
King dead in his bed. Dr James Ansell, "Surgeon Apothecary" to the
royal household at Sandringham was summoned, and he officially
pronounced the King’s death, attributing it to a "coronary thrombosis" [7]. However, considering how closely a guarded secret the
King’s diagnosis of lung cancer was, it was very likely that Ansell
was unaware of this. Although no official announcement was made
as to the cause of the King’s death, medical circles concluded that
it was a "coronary thrombosis." Therefore, it subsequently was reported in the popular press that a blood clot had caused his heart
to stop.
During a lecture on operations that made history, Professor
Harold Ellis, CBE, FRCS, provided a personal perspective on the illnesses and death of King George VI [6], although he himself was
not involved in the operation or subsequent care. Ellis stated that,
when photographs emerged of an ailing George VI in 1951, “Every
doctor and nurse in the country realized he had malignant disease, he looked terrible.” (as shown in Fig. 1) Ellis also said, “I
think George VI should be on every cigarette packet, because he
had severe vascular disease in his legs – 99% due to smoking. He
had carcinoma of the lung – 99% due to smoking. [And] he died of
coronary thrombosis – 90% due to smoking" [10].
Professor Ellis’s confident and quotable summary of King
George VI’s medical history not withstanding [6], we think his
unequivocal statement as to the cause of death should be reexamined from an evidence-based perspective. The diagnosis of
2
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Cardiovascular Pathology 53 (2021) 107340
lung cancer was suppressed because of a strong motivation by the
royal family and the government to avoid instability among the
British public [5], as well as the stigma associated with a diagnosis of cancer at the time. Based on the chest X-rays, the King most
likely had a squamous cell carcinoma of the lung, which is strongly
associated with a history of heavy cigarette smoking [11]. Since,
lung cancer can result in death by numerous and complex ways,
we discuss herein alternatives to the diagnosis of "coronary thrombosis" as an explanation for King George’s demise. We also discuss
the evolution of perceptions of the medical establishment and the
lay public regarding coronary artery disease, coronary thrombosis,
and lung cancer.
Sudden death is generally defined as a natural, unexpected fatal event occurring within 6 hours of onset of a pathophysiological
derangement; the episode may or may not elicit symptoms from
the victim and may or may not be witnessed. Cardiovascular sudden death is by far the most frequent type (over 90%), followed by
deaths induced by cerebral causes or respiratory causes. Cardiovascular causes of sudden death are numerous and include obstructive coronary atherosclerosis which is the most frequent and often is associated with plaque disruption and thrombosis, followed
by cardiomyopathies, and a variety of other conditions. Most cases
have arrhythmic cardiac arrest as the pathophysiological mechanism (over 90% of cases) and a minority are due to mechanical
cardiac arrest caused by conditions such as aortic rupture and pulmonary thromboembolism [24,25].
Did King George VI have a sudden arrhythmic death due to
a coronary thrombosis in the setting of clinically silent coronary
atherosclerosis? This question brings up the issue of the speculative and often inaccurate statements regarding the cause of death
and information entered on death certificates in the absence of
an autopsy. In 1971, Walford published a study of the accuracy of
death certification in 142 patients who died suddenly and were
designated as dying of coronary thrombosis [23]. Eleven physicians
were asked to make an estimate of how accurate they thought
each death certificate was. They were asked to assign each patient
to one of three groups: Group 1, 100% accurate; Group 2, probably fairly accurate; and Group 3, a “toss-up,” no good evidence
one way or another. The physicians assigned their cases as follows:
Group 1 - 60 cases (42%), Group 2 -40 cases (28%) and Group 3
-42 cases (30%). Of the 60 Group 1 cases, 46 were proven by autopsy or documented history of previous angina pectoris or coronary thrombosis. The 40 Group 2 cases had significant past histories of angina pectoris, coronary thrombosis or other cardiovascular conditions. The certification of death due to coronary thrombosis in the 42 Group 3 cases was by definition little more than
guesswork.
We posit that King George VI was in the Group 3 category of
certification of death due to coronary thrombosis by guesswork,
perhaps based on the history of significant peripheral vascular
disease, but not conclusively shown to be of atherosclerotic etiology. Walford points out that, given the prevalence of coronary
artery disease, the guesswork is bound to be right in many cases
[23]. In fact, we could find no record of a formal medical certification of King George VI’s cause of death other than the statement attributed to Dr. James Ansell, Surgeon Apothecary to the
royal household that the King had died of a "coronary thrombosis." Speculation by medical specialists in press reports apparently
led to general acceptance of coronary thrombosis as the cause of
the King’s death (UPI website 2/6/52). Nevertheless, Walford correctly states that without postmortem confirmation, a considerable
although unquantifiable error is introduced in death certification
records [23].
4. King George VI’s cardiovascular disease
At issue are the extent, severity, and nature of King George
VI’s vascular disease. As previously described, he was a heavy
smoker. In 1949, 2 years before developing lung cancer, he developed another smoking-related malady, namely, arterial insufficiency of his right lower extremity, as manifested by claudication
[12]. To alleviate these symptoms, a lumbar sympathectomy was
performed [6]. This procedure frequently was used at the time to
improve arterial circulation to the lower limbs [13]. Peripheral vascular disease of the lower extremities is most often due to arteriosclerosis. However, it also can result from a variety of nonatherosclerotic conditions [14] and is frequently complicated by
thrombosis of the iliofemoral arteries [15,16]. Major risk factors are
cigarette smoking and diabetes mellitus. In the case of George VI,
he had been diagnosed with Buerger’s disease in 1949 [17]. This is
a non-necrotizing vasculitis with luminal inflammatory thrombosis involving medium and small arteries, veins and nerves [14,18].
Pathogenesis likely involves an immune-mediated reaction to components of cigarette smoke [17]. It typically presents in young men
in their 40s or younger who are heavy smokers, but onset can also
occur in older individuals. Buerger’s disease usually begins with
lower extremity ischemia due to involvement of the distal small
arteries and veins [17]. As the disease progresses, it may involve
more proximal arteries, including the iliac artery [18]; but, coronary artery involvement is rare [17].
Statements made by King George’s physicians have led us to
believe that he suffered from both Buerger’s disease and arteriosclerosis [6]. He undoubtedly had an increased risk for coronary artery disease based on his history of heavy smoking. Yet,
if the King did have coronary artery disease, he was clinically
asymptomatic, since, to the best of our knowledge, angina pectoris
never was reported as a symptom that he had experienced [4].
Whether the King had more than minimal coronary atherosclerosis
is a key issue, since thrombosis of a major coronary artery, which
was declared to be his immediate cause of death, only occurs as
a complication of coronary atherosclerosis involving arteries with
atherosclerotic plaques.
There is a long and convoluted history of evolving interpretations of the relationships among coronary atherosclerosis, coronary
thrombosis, acute myocardial infarction and sudden death [19-22].
Up until the first part of the twentieth century, sudden coronary
occlusion always was considered to produce sudden cardiac arrest.
There also was confusion between myocarditis and myocardial infarction. Coronary thrombosis was considered a secondary event
following decreased blood flow to the inflamed, necrotic myocardial region [23]. In 1912, a breakthrough came when James Herrick
proposed that coronary thrombosis did not always cause sudden
death but could cause death of heart muscle in patients with an
acute myocardial infarction [19]. Subsequently, coronary thrombosis became established as a major cause of both sudden cardiac
death and acute myocardial infarction.
5. King George VI’s lung cancer
King George VI, a heavy cigarette smoker with a possible 80pack year history of cigarette smoking, developed a mass in his left
lung that was identified by X-ray and chest tomography as cancer
and which was easily reached by bronchoscopy and then biopsied.
These features point to a centrally located bronchial tumor, most
likely a squamous cell carcinoma [11,26]. His slow recovery and
sudden death 4.5 months after his pneumonectomy raises the possibility that, although complete resection of the primary tumor was
achieved, it already had spread to the right lung.
Briefly summarized, Clement Price Thomas, the King’s surgeon,
was one of the leading British chest surgeons specializing in cancer of the lung [27]. Between 1935 and 1958, he performed a to3
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Cardiovascular Pathology 53 (2021) 107340
tal of 826 operations for lung cancer, of which only 163 were resectable. The early death rate, defined as death in the hospital following surgery, was 21%; and the five-year survival rate for patients with resectable tumors, which would have included those
who had lobectomies or pneumonectomies, was 11.6%. As stated by
Thomas, the criterion for a standard lobectomy was that the tumor
should be confined to the excised lobe. The very fact that a pneumonectomy was performed on the King would clearly indicate that
the tumor had spread to other lobes of his left lung. We can only
speculate that George VI’s tumor also had spread to his right lung,
as suggested by the continuation of hemoptysis, as depicted in The
Crown (Season, 1, Episode 2) [2].
Death from lung cancer can result from many complications, including: pneumonia secondary to bronchial obstruction; fatal hemorrhage from invasion and disruption of blood vessels; a hypercoagulable state leading to fatal pulmonary thromboembolism; pulmonary and/or hepatic failure due to large tumor burden; and
severe cachexia due to extensive metastatic disease [28]. Nichols
et al. characterized the immediate and contributing causes of death
for 100 patients with lung cancer [28]. The immediate cause of
death was attributed to major tumor burden in 30 decedents, infection in 20, complications of metastatic disease in 18, pulmonary
hemorrhage in 12, pulmonary embolism in 12, and diffuse alveolar
damage in 7 decedents. The most likely causes of sudden death are
either a large pulmonary thromboembolism leading to cardiogenic
shock or erosion into a major blood vessel with massive bleeding into the chest cavity leading to hypovolemic shock. We suggest
that either of these two causes could explain George VI’s sudden
death. Although the King was shown lying peacefully dead in his
bed in The Crown, there is no hard evidence to support that this
indeed was the case.
It is possible that the King might have had a paraneoplastic
syndrome, which could have resulted in a hypercoagulopathy that
could have led to a massive pulmonary thrombus, resulting in sudden death [29,30]. Alternatively, presuming that his cancer had
spread to his right lung, it is possible that it could have eroded
the wall of a major vessel and produced a massive hemorrhage
into his right hemithorax, a contained space that could have hidden any external evidence of bleeding. The only possible way that
blood could have escaped from the chest cavity would be if the
tumor simultaneously had eroded the wall of both a major blood
vessel and an adjacent bronchus. Only an autopsy would have provided a definitive answer confirming or refuting these alternative
hypotheses [31].
Following the prevailing custom at the time [32,33], King
George VI’s physicians chose to withhold the diagnosis of lung cancer from the King and the general public, opting instead to say that
his operation was necessary to remove certain "structural abnormalities" involving his left lung. Undoubtedly the fear of an adverse reaction and the possible stigma among the populace if such
a diagnosis was rendered for the head of state of Great Britain
weighed heavily on the approach used by the King’s physicians.
Also, this lack of candor was the norm at the time. In the 1950s,
the general attitude among physicians in Western countries did not
favor fully discussing with patients either the diagnosis or prognosis associated with their cancer [32,33]. The attitude among the
public regarding wanting to know was not particularly different up
until later.
The change in attitude in the West in the 1970s was due to
multiple factors. Major epidemiological studies, such as the one led
by the British Doctors Study, were performed and reported in the
medical literature. These definitively established the causal role of
cigarette smoking as a major risk factor for a number of diseases,
including lung cancer, chronic obstructive pulmonary disease, and
cardiovascular disease [33,34]. This was a period of social upheaval
when movements for human rights were in the fore. Patients be-
gan to demand that they be fully informed about their diagnosis, prognosis, and treatment options. In parallel with this development, physicians recognized the need for greater communication as an effective means of increasing patients’ understanding of
their disease and compliance with their physician’s recommendations [34]. This new attitude of openness among physicians was
documented in a 1987 international survey of physicians’ attitudes
and practice in regard to revealing the diagnosis of cancer [33].
Needless to say the outcome of King George VI’s illness and cause
of death may well have been different had he been diagnosed in
the 2020s.
6. Conclusions
Our interest in medical history is based on our belief that
knowledge of major events and people that influenced the evolution of medical science and practice enriches and enhances the
contemporary practice of medicine. This extends to the role of
the autopsy in medicine[31,35]. Another interest is the elucidation of new information and insights into the deaths of historically
noteworthy individuals [36,37]. It is in this vein that we have reexplored the death of King George VI, and we would like to suggest
that he may have died as a result of a fatal complication of his lung
cancer rather than the speculative diagnosis of a "coronary thrombosis." The final take home message is that if an autopsy had been
performed, we would have had a definitive answer to this question!
Acknowledgments
We could like to thank Mr. Pankaj Chandak, Transplant Surgery
(Adult and Pediatric), Guys and Great Ormond Street Hospitals, London, England; Dr. Nahush Mokadam, Division of Cardiac
Surgery, and Dr. Sergey Brodsky, Department of Pathology, The
Ohio State University, Columbus, Ohio; and Dr. Christofer Barth,
Director, Cardiac Surgery Intensive Care Unit, St. Luke’s Hospital/Aurora Health Care, Milwaukee, Wisconsin for their insightful
comments relating to the sudden death of King George VI. Finally,
we would like to thank Mr. Shawn Scully for his assistance in retrieving unretouched photographs of the King and Mr. David Carpenter for assistance with the preparation of this manuscript and
for his remarkable good looks, genial attitude, and natty fashion
sense.
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