The Last Illness and Death of Hawai‘i’s King Kalākaua: A New Historical/Clinical Perspective

Introduction

David La‘amea Kalākaua, the last king of the nation of Hawai‘i, reigned from 1874 to 1891.¹ Also known as the Renaissance King, his foreign policy was two-pronged: first, to maintain the independence of Hawai‘i as a nation, and second, to develop its economy, specifically through The Reciprocity Treaty with the United States. This treaty allowed Hawaiian sugar to be imported to the U.S. duty free.² The treaty was commercially successful but became controversial in Hawai‘i because of a fear that it would strengthen foreign control. Some even saw it as the first step in the annexation of the islands to the United States. Kalākaua set out on a secret mission to renegotiate the treaty that was due to expire. But he unexpectedly became ill and died at the Palace Hotel in San Francisco on January 20, 1891.³ The cause of death given was Bright’s⁴ disease, a chronic condition of the kidneys.⁵

Questions have been raised about Kalākaua’s death, including why he died so unexpectedly in a hotel far away from home, from a chronic illness it was known that he had. This study will reexamine that illness and his death.⁶

After searching and finding no further published investigation of the death, we chose to apply a method called the Historical Clinicopathological Conference.⁷ Its aim is to review the circumstances of Kalākaua’s last illness and death, and, using modern medical knowledge, to achieve a better understanding of it.

The Study

The traditional Clinicopathological Conference (CPC) is a regular hospital conference for the medical staff led by a senior staff physician, focused on the better understanding of a patient’s death. The format involves a presentation of the case by a staff physician, including the laboratory and other tests, followed by presentation of the autopsy findings by a pathologist. It concludes with an expert led discussion to arrive at consensus about the final cause of death.

The Historical CPC follows the same outline, but concerns some well-known historical figure (such as Wolfgang Amadeus Mozart or Edgar Allen Poe) whose cause of death was uncertain. It really represents a kind of medical detective work, using current medical knowledge to fit the various pieces together. One might think of it like trying to work with a jigsaw puzzle to form a picture, even though some pieces are missing. For example, with the Historical CPC there are usually no blood tests or x-rays nor autopsy findings to consider.

Our Kalākaua Historical CPC will follow the same standard format used in an actual hospital CPC: first, the deceased’s past personal and medical history; next, the course of his last illness; then, the cause of death as determined at the time. Second, we will review and update the cause of death, using current medical knowledge about his diagnosis and treatment. Third, we will consider some implications from the point of view of historical epidemiology, i.e., the prevalence and distribution of diseases at the time.⁸

First, however, we should consider the limitations to this study. Kalākaua’s personal medical history is incomplete. He had good medical care from doctors at Queen’s Hospital, but his name is not found in any of the patient archives. We found a detailed report by the attending physician who was at his bedside during his final illness, a senior U.S. Naval surgeon named George W. Woods. This report revealed data not previously published, including a partial autopsy.⁹

Historical Background

Hawai‘i is the most remote group of islands in the world.¹⁰ For centuries before Western contact, this isolation served as a mixed blessing for the ancient Hawaiians. On the one hand, it kept global diseases at bay, e.g., the black plague that so devastated Europe. On the other hand, it contributed to the evolution of a...