- 02:55 HPI
- 07:30 Past Medical History
- 14:23 Physician Exam findings
- 24:21 Historical Figure Revealed
- 26:28 Reflections on top 3 diagnosis
- The differential considerations in a middle-aged patient with progressive subacute-to-chronic cognitive and neuropsychiatric disturbances are numerous. Broad categories include:
- Neurodegenerative dementias: Alzheimer’s disease, Lewy body dementia, frontotemporal dementia, and others
- Congenital/hereditary conditions: Wilson’s disease and Huntington’s chorea
- Infections: Neurosyphilis, HIV-associated CNS disease, and prion diseases
- Vitamin deficiencies: Wernicke encephalopathy and vitamin B12 deficiency
- Substance-related encephalopathy and dementia, such as related to chronic alcoholism
- Rarely, chronic poisonings, such as with unrecognized lead or mercury exposure
- Rarely, indolent forms of autoimmune encephalitis and paraneoplastic syndromes, among others
- Chronic mercury poisoning in adults manifests as neuropsychiatric abnormalities — confusion, personality changes, emotional disturbances, and cognitive impairment — characteristically associated with tremor, neuropathy, diaphoresis, excessive salivation, and other signs/symptoms, which are collectively termed erethism.
- Exposure in the modern era can be occupational (artisanal and smelting professions), incidental (handling of broken fluorescent lightbulbs or mercury-containing medical equipment), or environmental (industrial runoff, such as in Minamata disease).
- Historically, the medicinal use of mercury, such as in the form of the purgative calomel, was a major cause of mercury poisoning into the early-20th century.
- A significant percentage of rabies infections in the United States are “cryptic”; i.e. no bite or definite animal exposure can be identified. Genetic analysis of viral strains suggests many of these cases are due to unrecognized bat bites.
- Problem representations are neither singular nor static. Clinicians must think about the patient’s clinical presentation through several provisional frameworks rather than just one.
John: Hey there Hoofbeats listeners, John Hwang, here with Cindy Fang. Hope that if you’re listening to this, in the midst of everything that’s been happening, it’s a good sign. Certainly feels good to be working on Hoofbeats again, though we are impossibly behind on episodes. But Cindy and I will keep trying to work on it.
Cindy: In the meantime, we have something a bit different for you today. One of our colleagues at NYU, Dr. David Kudlowitz, likes to put together “historical CPCs” — case discussions about famous people who had mysterious illnesses or deaths.
John: You may recall David as our discussant from a past episode, the “PEs three”, as it were. So it only seemed fair, when David offered to flip the tables and pitch a case challenge of his own, that we take him up on the offer.
Cindy: Though just to be clear, we’re not the discussants.
John: No, of course not. We commentate, everyone else performs — that’s the way things work on Hoofbeats.
Cindy: No, what happened is, John and I watched David challenge two senior faculty with a historical mystery case, presented in five “aliquots” of information.
John: And we’re happy to bring this challenge to you today. See if you can replicate the historical consensus on the case. And hope you enjoy listening in as much as we did.
Just a little warning: We recorded this as a real-time group interview, and as our discussants got excited talking about the case they started bumping into the microphones and thwacking fists on tables — so apologies in advance for the sound quality.
Kudlowitz: John and Cindy, thank you for having me. On our normal Hoofbeats episodes, we dissect the clinical reasoning of a complicated case with an expert discussant. Today we are going to slightly deviate from that blueprint. In this episode, we hope to analyze an expert discussant’s clinical reasoning of a historical figure’s medical dilemma. We hope to add teaching points about the patient and how medicine was practiced back in the olden days. Our expert clinical discussing is Dr. Verity Schaye. Dr. Schaye is an assistant professor of internal medicine at NYU. Dr. Schaye has a master’s of health professions education from Maastricht University. She’s also a Farber teaching scholar, the medical director of inpatient medicine units at Bellevue hospital, and a fellow of the Society to Improve Diagnosis in Medicine. In addition to all of that, she’s a mentor of mine and an authority on clinical reasoning. Dr. Verity Schaye, welcome to the program.
Schaye: That’s a tough act to follow. [laughter]
Kudlowitz: In addition to our expert clinical discussant, we also have an expert historical discussant. I’m really excited to welcome Dr. David Oshinsky. Dr. Oshinsky is director of the division of medical humanities .He’s also a professor in the Department of History at NYU. Dr. Oshinsky obtained his PhD from Brandeis. He won the Pulitzer prize in History for his 2005 book, Polio: An American Story. His most recent book, Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital, was published in 2016. We are really excited to have him on the show to give us historical tidbits throughout the case presentation.
Oshinsky: Happy to be here. Thanks for inviting me.
Kudlowitz: Great, so let’s get started with the case.
A 40 year-old man arrived at the Washington College Hospital in Baltimore on Wednesday, October 3rd, 1849. He was delirious and could not provide a thorough history. He was found disoriented outside of Ryan’s fourth ward polls in the heart of Baltimore and brought to the hospital by his friend, Dr. Snodgrass. He wore “a stained faded old bombazine coat, pantaloons of a similar character, a pair of worn-out shoes run down at the heels, heels, and an old straw hat. The clothes had a telltale shabby appearance.” Six days prior to his admission to the hospital, the patient had a considerable fever. Despite feeling ill, the patient left his home in Richmond, Virginia, to visit and pick up his mother-in-law in New York, to bring her back for his wedding. He never made it to New York; instead, per his doctor in Baltimore, the patient was “seized by two roughs, dragged into one of the many sinks of iniquity or gambling halls which line the Baltimore wharf, drugged, robbed, and stripped of every vestige of clothing he had on before, in effect, having been left to die.”
So Dr. Schaye, any further thoughts after that bundle of information?
Schaye: What I’m hearing so far is: A male on the younger side. Certainly some exposures, in terms of different places he’s been and potential risk factors. We’re hearing the primary symptoms of delirium and fever, and so of course infections come into mind, and then the different areas that he’s traveled in the week or so before this illness has transpired.
Some historical questions are, I don’t know what a “Ryan’s Fourth Ward polls” are and what that exposure is. And also the description of his clothing, is that related to the work he does and other exposure history? So those are some historical questions I will have for Dr. Oshinsky, that will frame the subject’s exposure and risk, particularly if this ends up being an infection or another cause of his symptoms. The other thing too is, this whole “seized by two roughs”, it sounds like he’s being beaten up in alleyways, was he having any odd behavior that led to that? Or was it just this was a dangerous time, dangerous area and he just got mugged? I don’t know if there was any specific significance of this date, or we’re just orienting ourselves specifically in history of consider other epidemics that were going on in that period of time, which is knowledge I do not have at the tip of my head; that would be other historical information I would ask to Dr. Oshinsky. Those are some of the initial thoughts that are running through my head with this initial information.
Kudlowitz: Dr. Oshinsky, what do you think?
Oshinsky: Thank you for setting that up so well. “Ryan’s Fourth Ward polls” means the following. The Founders had never intended to have a secret ballot; secret ballots only come in in the United States in the 1880s. The belief was that you would literally line up at a polling place, you would give your vote verbally or say it to someone who would write it down. What would happen is — certainly in the bigger cities where there are a lot of immigrants, Baltimore being one, Boston, Philadelphia, New York City — you had a process known as cooping. And what cooping was that gangs of toughs working for various candidates would actually kidnap people, they would get them incredibly drunk, they would beat them. And then on polling day, these people would be brought to the polls and sort of supervised by these toughs to give their vote to a certain candidate. And what would happen is that they would often go to multiple polling places, and the way they would do that would be by changing their clothing. So when you look at the clothing here, which is kind of crazy looking clothing, it is very, very possible that the subject, having been beaten, either drugged or really putting an alcoholic stupor, was forced to change clothes many times. And when finally he had voted numerous times, he was simply left on the street in front of those polls.
Schaye: My only other question: You mentioned both drugs and alcoholic stupor. When you say “drug”, given his delirium, fever, obviously could be both intoxication and withdrawal symptoms… Were there specific agents that were typically used to drug these people?
Oshinsky: No, I would say there were not specific agents, but morphine was around and was used quite liberally at this time. As far as hallucinogens, there were a few… but it would seem to me that in this particular case, really we’re talking about alcohol.
Kudlowitz: Great. So with that, let’s move to our second aliquot.
So the patient’s past medical history was notable for recurrent bouts of significant alcohol use. To discuss that a little bit more: The patient was once arrested, as he describes: “For more than ten days, I was totally deranged, although I was not drinking one drop. […] All was hallucination arising from an attack.” After the death of his first wife and some intense drinking, the patient collapsed. Dr. Valentine Mott diagnosed “brain fever” brought on by extreme suffering of the mind and body. Diagnoses of nervous depression and mania of persecution were in his theoretical chart. He also had one suicide attempt by ingesting laudanum.
Cholera in 1849 in Philadelphia is something that he had, which was earlier in the year of his presentation, while he was in jail. He wrote to a loved one about this experience: “I have been so ill, have had the cholera or spasms quite as bad, and can now hardly hold the pen.” He was treated extensively with calomel, which is a purgative derived from mercury. He claimed to have significant side effects from this medicine.
His family history is notable for a mother who died of tuberculosis; and a father, brother and paternal cousin who died of alcoholism. Social history is notable for being a sergeant major in the United States Army. He was court-martialed and forced to leave West Point. The charges against him were gross neglect of duty and disobedience of orders.
So Dr. Schaye, any further thoughts after that bundle of information?
Schaye: Certainly. What I’m thinking a lot about now is: What is the time course of this illness? Certainly with the first part of the history, it’s seeming more like an acute or subacute delirium and fever. With this additional history, how does this fit in? Is this an acute exacerbation of more of a chronic disease process? Certainly, alcohol is at play here, and it sounds like by first description this gentleman maybe just had DTs. But some of these other things of having some psychiatric symptoms, and the mania… and his being (I’m not sure when this happened and how long ago) the discharge from the army, the gross neglect of duty and disobedience of orders — brings to mind some cognitive dysfunction and neuropsychiatric symptoms that make me question the chronicity of this illness. Certainly syphilis was pretty predominant at this time period, and without a treatment. Whenever I think of — whether this was in the 1840s or now — a young patient and neuropsychiatric symptoms, I feel like Wilson’s is always one of those can’t-miss diagnoses that comes to mind. Certainly this all could be related to his alcohol. He obviously has a very strong alcohol history, and now maybe his acute presentation is related to maybe acute withdrawal syndrome, and he’s got maybe some Wernicke’s, Korsakoff’s, or just some cognitive dysfunction from his chronic alcohol use. Those are some of the things that are coming to mind.
Kudlowitz: Dr. Oshinsky, I’m really curious to hear your thoughts about cholera, and everything that was going on with that in the 1840s and 50s — but also Valentine Mott.
Oshinsky: Valentine Mott was seen as the father of vascular surgery. He was the person, if you had to have an amputation at the hip, this was the guy you wanted. What is interesting about Valentine Mott is that he was extraordinarily wealthy, lived at One Gramercy Park in Manhattan, which is still one of the great townhouses you will ever see in this particular area. And what Mott did, like many physicians at this time, is he had a rich clientele, and then he believed it was his Christian duty to treat others. And this person was clearly an “other” at this time, which means that this person was in New York City for a considerable amount of time. And so in other words, it’s sort of Baltimore, Philadelphia, New York. You can see the pattern, it’s like an Eastern city pattern with this particular person.
As for diseases at this time… David, you asked about cholera. Cholera is a relatively recent disease. And New York City has a number of major cholera outbreaks — one in 1831, one in 1849 — that kill thousands and thousands of people. Many of the wealthy who can get out actually flee the country. One of the consequences of cholera at this time, because we know it generally comes from bad water, contaminated water, is that the entire New York City water system coming from the Croton reservoir down to Manhattan really begins as a result of cholera, which is extraordinary. New York City had just had shallow wells and when you talk about Canal street, Canal street was a street where waste flowed from that canal into both the Hudson and the East Rivers.
The one other thing I would say about cholera is, we know today that if we have a cholera patient, we rehydrate, perhaps use antibiotics. And if that happens and we get it in time, it’s not a big deal. Cholera was a very fatal disease at that time. You could be fine in the morning, and dead by evening. And one of the problems was that the physicians who dealt with cholera did exactly what you wouldn’t want them to do, meaning that bleeding and purging was what mainly was done to patients, to put the four humors into balance. So what you would have with someone like this patient was when that patient had cholera, rather than knowing about issues of rehydration, he was purged. And calomel was one of the leading purging agents of this time. So we talk about that, you are talking about agony for the patients who are being dealt by physicians and who have cholera. And Bellevue Hospital was one of the centers.
Kudlowitz: And when we’re talking about calomel, we’re really talking about mercury. So potentially long-term effects of mercury include neuropathy, tachycardia, salivation, hypertension, psychiatric symptoms as well.
Oshinsky: David, I just want to quote, here is the average calendar day for a physician in New York City in the late 18th century. “Patient one: bleeding, bleeding twice. Patient two: a visit and calomel. Patient three: sewing up boys’ lip with sundry dressings and cure of it. Patient four: rising in the night of visit and a dose of calomel. Patient five: mercurous wash and calomel. Patient six: purge for child bleeding and puke. Patient seven: drawing a tooth. Patient eight: draining a tooth.” So calomel is literally in five of these eight.
Kudlowitz: Yeah, it sounds, it sounds like any ED physician’s regular day [laughter]. I also learned a lot. I want to live at One Gramercy Park, and I’d never want to go to Canal street. That’s what I’m learning so far.
The case continues. So the patient was admitted to the hospital. He refused liquids. An account of his hospitalization written 30 years after the fact states that when the patient was given water, he had difficulty swallowing it. He appeared ravenous and delirious. His skin was pale and his body was drenched with perspiration. Per his doctor’s notes, he did not smell of alcohol. He had dilating and contracting pupils with a pulse that alternated between rapid and slow.
Schaye: So now we’re actually getting some concrete physical exam findings. Some of the biggest features here is, either he has hydrophobia or actual dysphasia, or both. And then also hearing some autonomic dysfunction, of this perspiration, his pupils dilating and contracting, and his alternating pulses, all sort of bring to mind that there’s some autonomic dysfunction here. And so kind of just piecing together what we’ve heard so far, and just really then taking a step back and rethinking about the differential. So again, I guess in our day and age a younger man (at that time, maybe a 40-year-old was an older man), a 40-year-old male, who has significant alcohol history and certainly a suggestive history of potentially some neuropsychiatric symptoms, coming in with acute onset, or acute-to-subacute, delirium and fever, with various different sort of exposures, recent history of cholera, and calomel treatment. And again, I’m still struggling a little bit with the time course of this illness. I think the way to frame the problem is to have one differential for if this was truly just a one week acute syndrome, versus this is all part of one more chronic disease process, and a progression, or deterioration, or acute exacerbation of his chronic disease process. And I think you just have to approach it both ways.
Certainly if this is more acute and all that past history is true, true, and unrelated, when you hear hydrophobia and dysphasia and automatic dysfunction, from fast thinking, rabies comes to mind. And certainly you can, I’m sure it was in areas where he could have been exposed. I mean, we’re not hearing about a bite, but you know, again, we obviously I’m sure don’t have the most complete and thorough skin exam and physical history that we’re going to get. And so that’s like the fast thinking in terms of whether there’s acute illness.
In terms of more chronic disease processes, these neurologic symptoms we’re hearing from the physical exam aren’t really fitting neurosyphilis. Certainly some of the other things with autonomic dysfunction and now whether he’s got like dysphasia, other progressive neurodegenerative diseases certainly come to mind. We don’t have a full neurological exam and it’s not really fitting per se something like Parkinson’s or Lewy body dementia or things in that domain. But you know, I think, certainly have to be on the broader differential. I think something like Wilson’s disease certainly is still on the differential for me and we, we haven’t heard of, you know, we don’t really have a sense of what his hepatic function is or any signs or symptoms of liver disease, but we’re also not getting that data.
Kudlowitz: I think it’s really amazing when you don’t have all of the information that you need in order to make the correct diagnosis or even come up with a cohesive differential, you separate your differentials into different categories into what if one situation were true, if this were a chronic disease versus what if it was, what if a different situation were true and it was acute. And I really thought the way that you did that was really awesome.
Schaye: That it did not exist in 1849? [laughter] Well, it existed…
Kudlowitz: …It did exist, we may not have known what it was.
Dr. Oshinsky, any comments from this, this physical exam?
Oshinsky: Yeah, just a couple. If you look at the records public hospitals and were also called dispensaries in this era, a dispensary would be a place where if you didn’t have a very serious injury but you were ill, uh, in some way, generally your employer would pay for you to go to a dispensary. But when you look at the records of these places, what you generally see are people come in for accidents, they come in for delirium tremens, and they also come in most of all for respiratory distress. And that is the one thing I found lacking in the diagnosis. It was so common at this particular time, and yet there seems to be no hint in any of the medical diagnoses of this time that involved that. And it went along with alcoholism, it went along with virtually everything. And that I think is to me one of the more surprising things, what is lacking in the diagnosis.
Kudlowitz: Great. So let’s move on to our next aliquot. So on hospital day one, the patient was tremulous. He was constantly talking, and had “vacant conversations with spectral and imaginary objects on the wall”. On hospital day two, he was visibly agitated. He was described as “talking like a man insane, perfectly self-possessed in all other aspects, his brain and tongue were evidently beyond his control.” It is reported that the patient poetically said, “Lord, help my soul before he expired.” The official cause of his death was “congestion of the brain”. Being a well known literary figure, he had previously written about dying. He once described the afterlife as “where the good and the bad and the worst and the best have gone to their eternal rest.” One should note, he was well-known for his macabre literary style. The next aliquot will reveal the answer.
So, Dr. Schaye, give us some more of your thoughts.
Schaye: I keep on going back to the initial thought process that maybe this is — I mean, granted, maybe he’s got some chronic manifestations stations of his alcohol use — but that this is all related to an acute withdrawal syndrome and delirium tremens. You know, sometimes once the first thing comes to mind, you’re trying to convince yourself, “Okay, it’s something else”, and slowing down and doing a check on that fast thinking. But certainly things fit with that diagnosis: I mean, we’re hearing evidence of hallucinations, tremulousness, agitation… So I’m wanting to pause and take a step back. The rapid progression of this makes me think that maybe some of the historical things are part of the chronic disease process, and now this is something maybe more acute just because of his rapid decline and progression. This was really happening — his decompensation — over two days, and his delirium started, I think it was a week ago. I mean, granted, we never got exactly when his last drink was, but I’m assuming it fits in the time course of things.
I have to say, I would have to refresh my memory on mercury poisoning. That’s certainly not something I think of all the time.
Kudlowitz: Why not? [laughter]
Schaye: I see it all the time! Um, but that’s how we constantly learn. Right. Like that is certainly a knowledge gap of mine. I don’t have a very solid illness script for mercury poisoning. And I just don’t have enough knowledge right now without that disease entity to solidly say it is or is not. Just thinking about a broader differential of, you know, clearly this seems like, you know, delirium and hallucinations and you think that is the core problem with some of his potential autonomic dysfunction, which would fit delirium tremens, but I think I ought to take a step back and kind of look again at my diagnostic schema for delirium and sort of broaden out to make sure I’m not missing anything here. We talked about toxidromes, infections, neurodegenerative diseases, we talked about electrolyte deficiencies related to cholera… Thiamine deficiency, like Wernicke’s? This isn’t really fitting the sort of the classic presentation of Wernicke’s. I mean, granted, we’re not getting a full, I don’t know what his gait is or his ocular exam is — though granted, you do not have to have the classic triad there — but that is certainly something that would be on the differential. We haven’t heard that he’s having active diarrheal symptoms. But that certainly would also be something that’s still on the differential in terms of metabolic causes. Other things we haven’t mentioned. A metabolic cause like thyroid dysfunction? But again, I can’t really fit all these symptoms into thyroid disease. …I’m gonna pause there.
Kudlowitz: I think it’s appropriate that one of the things you said was, we haven’t concentrated a lot on infections, but at the time it would have been difficult to recognize a lot of the infections that we know of now.
Dr. Oshinsky, before I give away who this is and talk about what we think the diagnosis may have been, any further thoughts?
Oshinsky: I will let you give the reveal the name.I think I figured it out from your description as a writer and his words. What I will say is that you have a person with a long history of alcoholism, he was probably badly beaten before he died, he was left in harsh weather, basically alone, with no attempt to take care of him… And the one thing you also have to understand is that in this era, he was not considered a young man. I mean the lifespan in this time was quite a bit shorter. So when you hit his age, you were already entering the danger zone, particularly someone with a history that we have defined here today.
Kudlowitz: Dr. Schaye, any thoughts as to who this person may be?
Schaye: I have to say, I do not know — in terms of historically — I have no idea who this person is.
Kudlowitz: So our patient is the infamous Edgar Allen Poe. And while we may not know exactly what he died from, and we’re going to talk a little bit about it, the differential diagnosis includes delirium tremens, rabies, and mercury poisoning being some of the top diagnoses. So I guess the way I want to continue our discussion is first talk a little bit about Edgar Allen Poe, and then to move on and maybe we could all almost hypothesize what we think Edgar Allen Poe may have died from. Because I think it is definitely up for debate. So Dr. Oshinsky, you’ve been eager to talk about it, right?
Oshinsky: Well, one of the things I did want to talk about is that, when you look at his life, one of the things I’ve found in my own research was that when Edgar Allen Poe lived in New York City, he was a regular visitor to these dispensaries. In other words, this was not someone who, in a relatively short period of time, had serious medical issues. And a lot of the medical issues he had at these dispensaries were respiratory issues, which were very, very common at this time. When I look and you put together calomel, the mercury poisoning, the possibility of cholera, the extremely hard drinking, the fact that he was terrorized in the last days of his life and literally left for dead… We’re never going to get the perfect diagnosis here, but there really is a life curve to the medical experiences of this particular individual that I think are very common to the era in which he lived.
Kudlowitz: And I think that that leads us right into an opportunity to talk about what we think the diagnosis for Edgar Allen Poe could have been. I think one of the things I do when I’m with my residents and we’re talking about a complicated case that we don’t know the diagnosis for, we, I asked them to give one thing for and one thing against. So I’m going to open it up to the rest of our group, as far as what they think may be going on here. You can’t be wrong, which is great, because we don’t know the actual answer… [laughter]
Alright, John, give us some thoughts.
John: I don’t know.. I think an exercise like this is always a mirror. You look into the case and you see what you want to see. I like infections. I would argue that they were very common that era. The description of hydrophobia and the autonomic instability that seems to be indicated by the chaotic pulse — I read the case and I wanted it to be rabies, I very much wanted it to be rabies. I would say that there are some findings in the case that are characteristic of that diagnosis. I think the major problem, or one of the major problems with that diagnosis, is that for any infection you’ve got to consider the host, the environment, and the pathogen, and there doesn’t seem to be anything special about this person as far as I know, or what you described and what he was doing that would bring him to contact with that particular agent. I mean, I could contrive something of course. He was left for dead and then a dog came over and bit him. [laughter] But that seems forced. And if there’s one thing that I’ve learned from Cindy, it’s that experts think a lot about who the patient is; they don’t try to focus on the disease and make things fit. That’s a recipe for disaster — particularly in cases like this, where descriptions of the disease may be, I think, inaccurate or imprecise or maybe even influenced by the thoughts of a prejudiced provider.
Kudlowitz: And that lets me talk a little bit more about rabies for a second, which I think is a really interesting diagnosis here. Most of the time when patients have rabies, there’s no identifiable bite, there’s no identifiable cause to it. Most of the time throughout the world it’s caused by dogs, a dog bite. And the historical perspective here is that the vaccine was actually developed by Louis Pasteur about 25 years after this. But still rabies is a big problem throughout the world; about 40 to 70,000 people die of rabies each year.
Dr. Schaye, you’ve given us a great differential diagnosis and your thought process… Is there a diagnosis that you want to land on here, for Edgar Allen Poe?
Schaye: Yeah, I mean, as I was mentioning before, I feel like my knowledge gaps for mercury poisoning limit me from committing to that diagnosis, and so my next steps there would be to read more about mercury poisoning; it’s hard to commit to that one, versus the other diagnoses of rabies and delirium tremens, which I have illness scripts for, and so I’m more able to say what’s going for or not. Absolutely I agree with John and his comments, and certainly when I heard the initial part of the physical exam, it was like, “This is rabies, this is rabies, this is rabies.” [laughter] Some of the progression of the symptoms afterwards, maybe not, and so that’s what made me lean more towards delirium tremens, between those two diagnoses, over rabies, for those reasons.
John:The way that you wrote the case makes it very clear that this case predates modern understanding of medicine. Which I think makes you wonder. We talk on our show about how hypotheses drive data collection. So on the one hand I’m thinking, wow, “Why can’t my residents write descriptive descriptions of patients like this?” I want my patients to be described in those terms. [laughter] Don’t tell me the lungs are clear to auscultation bilaterally, tell me that the patient “cannot control his tongue or mind”! But then at the same time, one wonders what value this information actually has, when it comes from somebody who doesn’t understand how disease actually works, and who doesn’t know all the diseases that rightly belong on the differential. Is what you’re doing here actually a CPC, or is it more akin to what you do as a teaching attending? Attempting to gather information of dubious reliability and precision and turn it into something useful? It really struck me that a lot of what you’re doing actually is struggling to define, to constrain the problem representation.
Schaye: And I think that’s an excellent point, right? In terms of sources of diagnostic errors, certainly data gathering itself is a… if you have the data that you’re working with, you can only generate what you can from it. Certain data that you would expect to have taking care of a patient now is not here, which creates a challenge, for sure.
Kudlowitz: Absolutely. We’re using a lot of data here to discuss Edgar Allen Poe, but we always have to question whether that data is actually accurate within itself. I was wondering, Dr. Oshinsky, if you could comment on that.
Oshinsky: Well, when you look at the diagnoses of patients in hospitals or in dispensaries at this time, they do tend to be often very, very general. And they’ll just have large categories, like influenza, and they will just put enormous numbers of people into that category. If it’s simply a fever, sometimes coughing, particularly if you’re an alcoholic, coughing is so common that might not even arise in the diagnosis. So it is very possible in my mind, someone who had severe health problems, went through a traumatic experience, was left out on the street. I mean, you can talk about anything, you know. Could it be cholera, could it be alcoholism, could it be people who just saw something like influenza as so absolutely common, and that he may have had two or three of the symptoms by not the major symptoms, that that is what they’re going to say. It was, and it’s very likely that it was; there were enormous influenza epidemics up and down the East Coast at this particular time. And someone in his weakened condition, I think, would be a very strong candidate for that.
Kudlowitz: And when I think of the diagnosis for this case, for me, his history and his symptoms and just the frequency of seeing alcohol use and delirium tremens for me, that was the diagnosis that stuck out the most. But again, questioning the historiography of this, I know that the day after he was buried, there was an obituary written about him by one of his rivals that really panned him for all of his drinking and his lack of temperance. And I always wonder if that was used against him in reflection of that, and if thinking that, maybe a lot was made of his alcohol use after the fact instead of it actually being a real thing. I guess there’s just no way to know.
Oshinsky: It’s possible. There’s just no way to know.
John: Has anyone made an attempt to actually figure out the cause? Like exhumed him from… Who decides when these historical CPC are worth…? No one’s tried. Is there a consensus?
Kudlowitz: I don’t think so.
Oshinsky: Have you or have you seen the death certificate?
Kudlowitz: So there is no death certificate. Someone has looked for it and it has been unable to find it. It was assumed destroyed at some point.
John: When you say brain congestion, presumably that a pathologist did an autopsy? Do we at least know that, that there was cerebral edema?
Kudlowitz: I think that that was just a word that they use.
Schaye: That’s how I interpreted that too. Like, “he was delirious.”
Kudlowitz: Valentine Mott said that about him previously, that he had brain congestion and that was his issue. So then later when they said he died of brain congestion. That was just a word that they use to do that, you know? Yeah.
Well, I want to thank Dr. Schaye and Dr. Oshinsky for participating in this “Historical Hoofbeats.” Thanks to Cindy and John for allowing for an exciting experiment and reviewing a historical case.
And finally, what better way to end a podcast about the eerie death of Edgar Allen Poe than with a poem?
Here’s a story, somewhat eerie, of a long forgotten theory
Of the death of the poet who was known for tales of gore.
He left for Richmond, strong and strapping, for the girl he was entrapping.
With the ring she’d be unwrapping, slapping on forevermore.
“Will you marry me?”, he uttered, yapping his words of amour.
She agreed to, “yes,” she swore.
What came next, well, it’s uncertain, for on that train he did divert in-
stead of back home to New York, he wound up in Baltimore
They say he went there for a meeting, but his time there it was fleeting
For soon he was found bleating, outside a bar down on the floor
Clearly he needed treating, his mental state was quite unsure
Folks thought, he’s drunk and nothing more
But one man who then did pass, wrote a doctor named Snodgrass
Telling of Poe’s state, a sight too sorry to ignore.
His faculties waxed and waned, and his swallowing seemed pained
His odd clothes could not be explained; an unkempt, vestless shirt he wore.
And the doctors ascertained that Poe’s delusions would endure.
And for the end, Poe did implore.
John: …That’s the best H&P that I’ve ever heard. “Time spent with patient: 30 minutes.”
Kudlowitz: I’m going to have to re-record that… get the flow… [laughter]
John: The more I think about it, the more I suspect David’s real agenda was to recite poetry on air.
In any case, that should about do it for us today. Once again, thank you to our discussants Verity Schaye and David Oshinsky, and to David Kudlowitz for conceiving of and developing this episode of Hoofbeats. Special thanks to all those who gave input on this episode, specifically Clem Lee, Alexis Vein, Irene Swanenberg, Ryan Chippendale, Aaron Troy and Lauren Kuwik, along with audio editor Solon Kelleher, and to our CoreIM colleagues Amy Ou, Shreya Trivedi, Harit Shah, and Marty Fried.
Cindy: And an honorable mention, as always, to Dr. Steven Liu.
John: Opinions expressed in this podcast are our own, and do not represent the opinions of other affiliated institutions, nor should they be construed as medical advice.
Cindy: Thank you for joining us. With CoreIM, I’m Cindy Fang, still a NYU hospitalist.
John: And I’m John Hwang, of NYU and Bellevue. See you next time.
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Tags: case based learning, Clinical reasoning