“A Bright But Unsteady Light”

Edgar Allan Poe died 165 years ago today in the early morning of 7 October 1849. Only a few details of the illness that extinguished his “bright but unsteady light” are known because his physician, Dr. John Joseph Moran, used the illness to promote his own celebrity and in the process denied posterity an accurate clinical description. One of his later accounts, one summarized by Charles Scarlett, Jr. in the Maryland Historical Magazine (1978; 73: 360-75) came to my attention shortly after returning to Baltimore after 14 years at the Dallas VA Hospital in 1988. I was so taken by Moran’s fascinating and detailed description of Poe’s final days, I decided to use it as the subject of a clinical conference that has long been my favorite – the Clinical Pathologic Case Conference (CPC) Conference. This would prove to be the first of an ongoing series of historical CPCs devoted to the likes of Alexander, Columbus, Mozart and Lenin, stretching over two decades and spawning too-numerous-to-count articles in the international press, scores of manuscripts published in medical journals, and two books.

The clinicopathological conference is a standard medical conference designed to teach physicians and physicians-in-training basic medical concepts and clinical problem-solving techniques. It is a case-based exercise, in which the featured speaker and the audience struggle together to diagnose a particularly challenging illness of some patient using only the information included in a clinical summary prepared especially for the conference. That clinical summary, distributed well in advance of the conference, typically contains all of the medical information pertaining to the case in question, except for the definitive, diagnostic test result. That result, known only to the conference organizers, is revealed at the very end of the conference as a validation or repudiation of the presenter’s conclusions. To my knowledge, our “Poe Historical CPC” was the first to use an historical, rather than a current, patient as the subject of the conference.

In 1995, during this first Historical CPC at the University of Maryland, Dr. R. Michael Benitez concluded that Poe died of rabies resulting from an unrecorded and most likely unrecognized animal exposure prior to his hospitalization in Baltimore. His diagnosis became a media sensation covered in venues as diverse as Science magazine and the answer to the final Jeopardy question of the TV show of the same name. Benitez based his diagnosis on evidence of autonomic instability (dilating and contracting pupils and an irregular pulse which alternated between rapid and slow), fluctuating delirium, and hydrophobia (suggested by Poe’s adamant refusal of alcohol and difficulty swallowing water) included in Moran’s later descriptions of the terminal illness.

Rabies, in fact, has much in common with Moran’s later description of Poe’s final illness. It is a viral encephalitis (i.e., an infection of the brain) marked by acute onset of confusion, hallucinations, combativeness, muscle spasms and seizures, all of which tend to wax and wane during the course of the illness. Autonomic instability marked by alternating tachycardia (racing pulse) and bradycardia (slow pulse), profuse sweating, lacrymation, and salivation are also characteristic. The infection is virtually always fatal, with a median survival time after the onset of symptoms of four days. Poe died four days after being admitted to the hospital.

Moran gave no such indication of autonomic instability or hydrophobia in the letter he wrote to Mrs. Clemm a month after her son-in-law’s death. Only decades later, most likely relying on memory alone, does he mention a “very low pulse” and that his famous patient’s “pulse which had been as low as fifty was rising rapidly, though still feeble and variable.”

Many diagnoses have since been offered to explain Poe’s death. The earliest and most persistent has been that of alcohol-induced delirium tremens. Moran’s later case summary, one almost certainly written to satisfy his public’s appetite for ever more moving and ironic details of his patient’s final hours, has generated several more. These include homicide, carbon monoxide poisoning, suicide, syphilis, and mercury intoxication, reflecting more an unwillingness on the part of the proposers to accept an ordinary disease as the cause of Poe’s death than any convincing clinical evidence of such disorders.

Given numerous well-documented instances of Poe’s refractory alcohol abuse and its adverse effects on his physical and mental health prior to his departure from Richmond in late September of 1849, and the nature of the illness described by Moran in his letter of 15 November 1849 to Poe’s mother-in-law, one need look no further than delirium tremens as an explanation for his death. Whether his last bout with alcohol was the result of “cooping,” his own inability to control the craving that had for so many years driven him to drink, or a second (successful) attempt at suicide will never be known. However, if one ignores Moran’s later expanded description of Poe’s final illness, which deviates so spectacularly from his initial description in his letter to Maria Clemm a month after his patient’s death, neither rabies, homicide, mercury intoxication, nor, for that matter, any of the myriad other explanations proposed in the century and a half since Poe’s death, offers a better fit than delirium tremens.

Headline image credit: A photograph (taken by C.T. Tatman in 1904) of a daguerreotype (taken by Edwin H. Manchester in 1848) of Edgar Allan Poe. Public domain via Wikimedia Commons.