Cao Cao, “a capable minister in peaceful times and a hero in troubled times,” died of what disease?

The Yangtze River flows eastward, and the waves wash away everything. Among the heroes of the Three Kingdoms, Cao Cao is the most outstanding. He had a broad mind of "looking at the vast sea from the east of Jieshi", and a poetic sentiment of "drinking and singing, how long is life", but he died of illness in Luoyang at the age of 66. What disease did this great hero die of?

Let’s unravel the mystery and take a closer look!

Evidence 1

Cao Cao suffered from headaches and was suspicious by nature. Whenever he lost a battle, he would become emotionally unstable, which would lead to headaches.

Evidence 2

Hua Tuo initially used acupuncture to relieve his condition, but it only treated the symptoms and not the root cause. He finally recommended a craniotomy as a treatment plan, but was killed by Cao Cao.

Evidence 3

His descendants Cao Pi and Cao Rui also died suddenly of brain diseases.

infer

The Records of the Three Kingdoms records that Cao Cao suffered from headaches every time he had them, and his heart became confused and dizzy, and his descendants also died of this disease. It is speculated that the most likely cause of Cao Cao's death was hypertensive cerebral hemorrhage (HICH).

What is the probability that Cao Cao suffered from high blood pressure?

HICH is caused by long-term hypertension, which leads to pathological changes in the walls of small arteries in the brain, such as degeneration, ischemia, necrosis, and microaneurysm formation. When blood pressure rises sharply, these small blood vessels rupture and bleed, resulting in cerebral parenchymal hemorrhage.

As a northern man, Cao Cao basically could not escape the high-salt eating habit; as a famous general on the battlefield, he must have eaten meat and drank wine with big mouthfuls of wine. Due to poor eating habits and irregular lifestyle, Cao Cao was likely to suffer from high blood pressure.

In addition, Cao Cao was suspicious by nature, and his mood swings were greater than those of ordinary people. In addition, the frequent wars made it difficult to predict the outcome, so drastic mood changes were inevitable. Judging from the fact that his descendants died suddenly of brain diseases, the possibility of hereditary disease cannot be ruled out.

To sum up, it is highly likely that Cao Cao suffered from high blood pressure and failed to keep it under control for a long time.

Is the craniotomy recommended by the legendary doctor Hua Tuo reliable?

In modern medicine, the diagnosis of HICH requires the exclusion of diseases such as arteriovenous malformations, cavernous hemangiomas, arteriovenous fistulas, moyamoya disease, and amyloidosis, and the diagnosis can only be made in combination with the patient's history of hypertension. Therefore, vascular imaging examinations are necessary.

The neurological damage caused by HICH is mainly related to the compression of the hematoma. Surgical treatment of HICH can directly remove the hematoma and relieve the compression symptoms. On the other hand, after removing the hematoma, it can minimize the generation of metabolic products and reduce secondary brain damage. Therefore, craniotomy is also a common method for modern treatment of HICH. It can be seen that the craniotomy recommended by Hua Tuo is probably the only way to turn the tide.

However, if we travel back to the Three Kingdoms era, these modern scientific and technological means would definitely not exist. There had been no rigorous examination and diagnosis, and no successful precedents to learn from. It is no wonder that Cao Cao did not believe in Hua Tuo, the great doctor, not to mention that he was a suspicious person by nature!

How can we avoid repeating Cao Cao’s mistakes?

Prevention is better than cure, strictly controlling blood pressure is the most important!!!

Hypertension is a controllable and preventable disease. Stable control of blood pressure levels can significantly reduce stroke events.

According to the grading standards of the "2020 International Society of Hypertension Global Hypertension Practice Guidelines", if diagnosed with stage 1 hypertension (140-159 mmHg/90-99 mmHg), a healthy lifestyle and good emotional control can help keep blood pressure within the target range.

If you have grade 2 hypertension (≥160mmHg/≥100mmHg), you should seek medical attention promptly and take medication on time as directed by the doctor. When a single drug fails to achieve control, a combination of drugs is required.

It is particularly important to emphasize that clinicians will develop individualized medication plans based on the patient's actual situation - professional matters should of course be left to professionals!

For example, patients whose main symptoms are water and sodium retention are suitable for combined medication including renin-angiotensin system (RAAS) inhibitors (such as prils and sartans) and diuretics; patients with arteriosclerosis and/or vasoconstriction can be treated with a combination of RAAS inhibitors and calcium channel blockers (diazepines) or thiazide diuretics.

There are many speculations about the cause of Cao Cao's death. This article does not intend to argue which possibility is the most likely. It only reminds all hypertensive patients to strictly control blood pressure, monitor and check regularly, take medicine on time, and maintain the following good living habits:

1. Keep a stable mood, avoid getting excited, reduce mental stress, and get adequate rest.

2. Avoid high-salt, high-protein diets that increase blood pressure.

3. Exercise appropriately every day and avoid strenuous exercise.

4. Quit smoking and drinking, drink less coffee, strong tea, and thick broth, and reduce the intake of spicy and stimulating foods.

5. Lose weight, control your weight, and keep your BMI between 18.5 and 23.9.

6. It is also important to maintain sleep at night and reduce the accumulation of stool!

Author: Chen Lumei and Yu Nianxi, Chief Pharmacists of Shanghai Changzheng Hospital

Review expert: Wu Rong, deputy chief pharmacist of Shanghai Changzheng Hospital

Liu Guiyang, Chief Pharmacist of the Pharmacy and Pharmacology Department of the Fourth Medical Center of the PLA General Hospital