OMEGA, Vol.

60(2) 165-173, 2009-2010

THE FINAL DAYS OF EDGAR ALLAN POE: CLUES TO AN OLD MYSTERY USING 21ST CENTURY MEDICAL SCIENCE

ROGER A. FRANCIS, M.D., F.A.C.R. Nevada Regional Medical Center, Missouri

ABSTRACT

This study examines all documented information regarding the final days and death of Edgar Allan Poe (1809-1849), in an attempt to determine the most likely cause of death of the American poet, short story writer, and literary critic. Information was gathered from letters, newspaper accounts, and magazine articles written during the period after Poes death, and also from biographies and medical journal articles written up until the present. A chronology of Poes final days was constructed, and this was used to form a differential diagnosis of possible causes of death. Death theories over the last 160 years were analyzed using this information. This analysis, along with a review of Poes past medical history, would seem to support an alcohol-related cause of death.

INTRODUCTION When Edgar Allan Poe drew his last breath in the early morning hours of October 7, 1849, a mystery began which has caused endless debate among historians, literary scholars, dozens of biographers, medical doctors, amateur detectives, and thousands of Poe devotees all over the world. The world had lost one of its most famous and notorious literary figures at the age of 40. While popular opinion at the time indicated the death was probably due to alcohol
165 2009, Baywood Publishing Co., Inc. doi: 10.2190/OM.60.2.d http://baywood.com

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abuse, this was almost immediately disputed by a variety of writers on the subject including his attending physician while hospitalized prior to his death. Some alternative theories of Poes cause of death included trauma, murder, brain infections including tuberculosis, brain tumors, epilepsy, diabetes, rabies, and heart disease. These theories have been espoused in biographies, newspaper articles, medical journal articles, and various memoirs from immediately after his death until the present (Poe Society of Baltimore, 2009, http://www. eapoe.org/). The purpose of this review article is to look closely at the events leading up to Poes death, formulate a differential diagnosis based on the information available, then discuss some of the popular theories and how they stand up to the evidence in light of current medical knowledge. METHODOLOGY A thorough search of the literature relating to the death of Edgar Allan Poe was conducted primarily utilizing internet search engines, the extensive archives of the Edgar Allan Poe Society of Baltimore, and selected biographies of the poet, short story writer, and literary critic. Information gathered was closely reviewed to compile, to the extent possible, a chronology of Poes final days. This information was then used to construct a reasonable differential diagnosis of possible causes of death. Finally, each differential possibility was examined, in light of Poes medical history and the chronology of events as we know them. The above described technique has been used by physicians and medical investigators for several decades. Careful history taking and data gathering allow formation of a list of differential diagnoses or possibilities. That list is tested in light of known information, allowing for the list to be narrowed to a few reasonable possibilities. This type of protocol is basic to science, and can be used in any situation in which the cause of a phenomenon is not immediately clear, such as an unusual medical illness, an unsolved crime, or other mysterious events. Poe himself, through his detectives use of the technique of ratiocination knew how important this tool was. It is ironic that this method now allows us to help solve Poes greatest mystery, his final days and death. A CHRONOLOGY OF POES FINAL DAYS The following is a summary of what is generally known and accepted by scholars about the days and weeks leading up to Poes death. Early July until Late September 1849 Poe had traveled from his home in New York City to Richmond, Virginia. The purpose of the trip was primarily to raise money for a proposed literary magazine called The Stylus. To this end, he solicited donations or subscriptions

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toward the magazine. He also gave public lectures which were reportedly well attended and received by Richmond society. While in Richmond, he visited old friends as well as his sister, Rosalie, still living with foster parents. He reportedly visited and renewed a longstanding friendship with a childhood sweetheart, Elmira Royster Shelton, now a wealthy widow. There is speculation that he proposed marriage, but that she broke off the relationship because of a perception that his primary motivation was a need for money for his proposed magazine. Poe announced to friends in late September that he was returning to New York for a few weeks to finalize plans for his magazine, with a planned short trip to Philadelphia to edit a collection of poems, and then planned to return to Richmond and live there permanently (Weiss, 1878). Thursday, Sept. 27 Poe reportedly left Richmond by boat to travel to Baltimore, planning to continue on to Philadelphia and New York. He apparently left his trunk of clothing and personal effects behind at Swan Tavern in Richmond (Poe Society of Baltimore, 2009, http://www.eapoe.org/). Friday, Sept. 28 Poe arrived in Baltimore, although whereabouts and activities in Baltimore are unknown for several days. Some have speculated that Poe may have traveled to Philadelphia, then mistakenly back to Baltimore rather than New York as planned. He never kept his appointment in Philadelphia. Wednesday, October 3 A note from a printer, Jos. W. Walker, to Dr. J. E. Snodgrass, an acquaintance of Poe, describes having found Poe rather the worse for wear and in need of immediate assistance at Ryans 4th ward polls, a tavern. When Dr. Snodgrass arrived, he found Poe unconscious and in cheap, soiled clothing which were not customary for Poe. Also, no mention is made of any money being found with Poe, suggesting that he may have been mugged. Assuming Poe is intoxicated, Snodgrass made arrangements for Poe to sleep it off in a room upstairs at the tavern, but sent for Poes uncle, Henry Herring. Mr. Herring convinced Snodgrass that Poe should be taken to the local hospital instead. Poe, still unconscious, was carried to a waiting carriage and transported to the hospital in the early afternoon (Snodgrass, 1867). Poe was admitted to Washington College Hospital at 5 oclock in the afternoon, and was placed, still unconscious, in a private room in a section of the hospital customarily used for patients with alcohol problems. He is placed under the care of Dr. John J. Moran, resident physician.

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Thursday, October 4 Poe regained consciousness at about 3 a.m. Dr. Moran attempted to question Poe, but the patient appears incoherent and disoriented. He stated that he had left a wife behind in Richmond, but doesnt know what happened to his trunk of clothing. Poe exhibits tremors, sweating, delirium, and hallucinations (talking to walls) (Letter from Dr. Moran to Poes mother in law, Maria Clemm, 1849). In an article published several years later, Dr. Moran also described a twitching of the eyelids, and some shaking of the limbs (Moran, 1875). Friday and Saturday, Oct. 5 and 6 Poe continued in a state of delirium, cannot be calmed by anything done by his caregivers. On Saturday night Poe for several hours reportedly called out the name of someone, possibly Reynold, although no one by that name can be traced to the hospital or to Poe (Moran, 1849). Sunday , October 7 At 3 a.m., he seemed to calm down and rest briefly. Then, quietly turning his head, he said Lord help my poor soul, and expired (Moran, 1849). There is no record of a death certificate or any postmortem examination. DIFFERENTIAL DIAGNOSIS Based on the information from the above chronology of Poes final days, the scenario is that of 1. a state of consciousness of unknown duration; followed by 2. 72 hours of semiconsciousness with delirium, tremors, sweating, hallucinations, possible seizure activity and decreased cognitive ability; followed by death. Reasonable differential possibilities for this scenario would include the following conditions: 1. drug or alcohol intoxication followed by withdrawal symptoms; 2. trauma to the brain; 3. intracranial infections including viral encephalitis (including rabies), meningitis (including tuberculous infection), and rare conditions including brain abscess; 4. brain tumors; 5. seizure disorders (epilepsy); 6. stroke or transient ischemic attack; 7. metabolic conditions such as diabetes with coma; and/or 8. other diseases (heart disease, syphilis, etc.).

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CASE ANALYSIS Based on what we have learned about Poes past medical history from the literature review, and based on the final chronology of events discussed above, the following observations can be made regarding the list of differential diagnoses. Trauma to the Brain Several kinds of traumatic brain injury can result in unconsciousness, later followed by varying degrees of consciousness. These include cerebral concussion as well as some kinds of intracranial hematoma (Price & Wilson, 2008). However, there was no evidence given for trauma, such as bruising, abrasions, or lacerations. Also, those who observed Poe during his final days gave no history to indicate any kind of injury. Intracranial Infections Inflammation or infection of the brain often produces unconsciousness, which can resolve if the infection is treated or improves without treatment (Minegar & Alexander, 2005). Since his wife Virginia reportedly died of tuberculosis (called consumption in those days), it has been speculated that Poe also may have been infected. However, it is known that Poe frequently visited medical doctors throughout his life, and there is no evidence that he was ever diagnosed with tuberculosis or any other serious infection. Also, one of the signs of intracranial infection is fever, and there was no mention of fever during his final hospitalization (Moran, 1849). One 1996 journal article even speculated that Poe may have died of rabies, a viral infection spread to humans by a bite from an infected animal. This was based on a quotation from Dr. Moran describing Poes difficulty in swallowing water in the days following regaining consciousness in the hospital. However, the natural progression of the disease includes hydrophobia (fear of water) followed by coma and death, not coma followed by swallowing difficulty (Benitez, 1996). Brain Tumors There has been speculation that Poe may have suffered from a brain tumor, resulting in some of the symptoms of his final days. Brain tumors most commonly result, depending on the location, in headaches, visual problems, seizures, and focal neurologic signs including weakness or paralysis of the neurologic distribution affected. A tumor would be unlikely to result in unconsciousness, followed by delirium and hallucinations, followed by death. Also, nothing written by anyone would indicate a focal neurologic deficit.

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Seizure Disorder (Epilepsy) Seizure disorders usually result in abnormal body movements which may be localized or generalized. After a major seizure, there is often a period of decreased responsiveness, which usually resolves. A sustained period of seizure activity (status epilepticus) can result in coma (Bauer, 2006). However, this would seem unlikely in Poes case, since possible seizure activity described was transient, and followed unconsciousness, not preceding it (Moran, 1875). Diabetic Coma Type 2 diabetes can result in coma for a variety of reasons, especially due to a scenario of abnormally high blood sugar resulting in dehydration, or of abnormally low blood sugar (hypoglycemia). In either case, consciousness returns when the underlying metabolic abnormality is corrected (Seiber, 2008). Diabetes resulting in coma would be unlikely to result in the sequence of events before Poes death. Also, as previously mentioned, Poe often consulted physicians for various complaints, but was never diagnosed as diabetic. Stroke or Transient Ischemic Attack Interruption of blood flow to parts of the brain usually results in motor symptoms such as focal or unilateral weakness or paralysis. A massive stroke resulting in a large area of cerebral edema can also cause varying degrees of loss of consciousness. However, this would be accompanied by focal weakness or paralysis, a scenario not reported in Poes final days. A temporary interruption of blood supply to a part of the brain (transient ischemic attack) would be unlikely to result in unconsciousness, followed by delirium and other reported symptoms. Other Medical Illnesses Some have postulated that Poe may have had heart disease. Although loss of consciousness could result from low blood pressure, cardiac arrhythmia, heart failure, or heart attack, there is no indication of heart disease in any of Poes writings or history. Other diseases including syphilis have been questioned by some writers. Late syphilis can result in diffuse cognitive impairment and dementia. This is unlikely given the sudden onset of unconsciousness in Poes final days. Drug or Alcohol Intoxication Followed by Withdrawal Symptoms At the time of Poes death, the prevailing view was that he died from the effects of alcohol (Poe Society of Baltimore, 2009, http://www.eapoe.org/). There was even speculation that he was addicted to opium, and that this contributed to his

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demise. Some of Poes stories talked about opium use, and Poe himself once described taking an overdose of laudanum (Poe Society, 2009). However, those who knew him and the physicians who examined him over the years agreed that there was no evidence of abuse of opium or narcotics. What most have agreed is that alcohol was his drug of choice. The following is a brief review of Poes drinking history. Poes natural father and his brother, Henry, were both reputed to be alcoholics (Poe Society, 2009). This is consistent with current understanding of alcoholism as a genetically predisposed disease. Poes earliest reported use of alcohol was during his time as a student at the University of Virginia. Later, as a cadet at West Point, there were also reports of excessive drinking. Poe was dismissed from his first job as an editor and critic for the Southern Literary Messenger due to habitual absence from work due to drinking binges (Poe Letters, 2009, http://www.eapoe.org/). A clear picture begins to emerge of Poes drinking habits. Rather than daily drinking as in some alcoholics, Poe was a binge drinker. He would drink continuously for a few days, then abstain from alcohol for periods up to several months or even years, according to his own admission (Poe Letters, 2009, http://www.eapoe.org/). His alcoholism contributed to his lack of steady employment, as well as difficulty in interpersonal relationships. It is reported that his drinking became decidedly worse during the period of 1842 through 1847, during his wifes illness and death from consumption. Despite international fame beginning in the mid 1840s, Poe and his family lived constantly in poverty. He was widely portrayed in the popular media as being a brilliant writer and poet, but a hopeless drunkard (Poe Society of Baltimore, 2009, http://www.eapoe.org/; Poe Letters, http://www.eapoe.org/). In the last 2 years of his life, Poe was a selfproclaimed promoter of the temperance movement in America. However, friends report that drinking binges continued through his final visit to Richmond in the summer of 1849 (Weiss, 1878). The understanding of alcoholism as a disease has increased dramatically in the last 10 years due to advances in neurosciences, including increased knowledge of the brain due to modern imaging modalities including magnetic resonance imaging and positron emission tomography (Oscar-Berman, 2006). We are also gaining a greater understanding of alcohol withdrawal and its complications. Symptoms can occur as early as 6 hours after drinking cessation, and include tremors, anxiety, insomnia, nausea, and restlessness. Approximately 10% of patients may have more severe withdrawal symptoms, including fever, rapid breathing, sweating, and seizures. Delirium tremens is characterized by mental confusion, hallucinations, and disorientation. Mortality rate for untreated D.T.s is 5% to 25%. The Wernicke-Korsakoff syndrome is actually due to thiamine deficiency, but most commonly occurs in alcoholics in the developed world. The syndrome consists of cognitive impairment, delirium, gait disturbance, and eye muscle paralysis. Untreated, it can progress to coma and death (Trevisan, 1998). Another neurologic complication of chronic alcoholism is central pontine

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myelinolysis. This is a demyelinating condition affecting the brainstem, resulting from rapid correction of a low serum sodium level. This can cause sudden paralysis, swallowing difficulty, speech difficulty, double vision, and coma. This condition was virtually unknown until the widespread use of magnetic resonance imaging in the last 20 years (Rizek, Campeau, & Miller, 2004,). These conditions illustrate the seriousness of alcohol addiction and withdrawal, how it can lead to death if not properly treated.

CASE SUMMARY AND CONCLUSIONS We have reviewed the events which have been documented in the days leading up to the death of Edgar Allan Poe. Based on this information, we have compiled a reasonable differential diagnosis of possible causes of Poes death. We have examined each of these possible causes in light of what is known about Poes medical history. To review, Poe was found unconscious and taken to a hospital. He regained some level of consciousness the next morning, but exhibited cognitive impairment, delirium, sweating, possible seizure activity, and apparent hallucinations. These persisted until he suddenly died 4 days after admission. There were no signs of trauma, but circumstances suggest that he may have been robbed of clothing and belongings. He had a long history of binge drinking, but his whereabouts and activities for several days before he was found unconscious are unknown. Based on the above analysis, the most likely explanation for Poes death is the effects of alcohol intoxication followed by withdrawal syndrome, delirium tremens, and possibly a neurologic complication such as central pontine myelinolysis. This would indicate that Poe had been binge drinking for the days before being found unconscious at the tavern in Baltimore. Despite the care available in a hospital in 1849, he became semiconscious the next morning, but developed withdrawal symptoms including delirium tremens and probably Wernicke-Korsakoff syndrome. Without adequate fluid and nutritional support, he progressed to coma and death. The terminal event may have been central pontine myelinolysis. As discussed above, other enumerated possible causes of death are not entirely consistent with the known sequence of events and Poes past history.

REFERENCES
Archives of Edgar Allan Poe Society of Baltimore, http://www.eapoe.org/. These contain an extensive compilation of Poes writings, biographical information, Poes letters, and a vast amount of information which has been written about Poe. Bauer, G., Bauer, R., Pfausler, B., & Trinka, E. (2006). Non-convulsive status epilepticus and coma. Epileptilogia, 14, 195-206.

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Benitez, M. R. (1996, September). Death of Poe due to rabies? Maryland Medical Journal, 91-94. Fleming, J. & Suresh, B. (2008).Central Pontine Myelinolysis. New England Journal of Medicine, 359(23), e29. Minegar, A., & Alexander, J. (2005). Inflammatory diseases of the nervous system: Pathogenesis, immunology and medical management. Germany: Humana Press. Moran, J. J. (1875, October 28). Official memoranda of the death of Edgar Allan Poe, New York Herald, p. 4, col. 1-3. Moran, J. J. (1941). Letter to Maria Clemm, Nov. 15, 1849, quoted in Quinn, A. & Hart, R., Edgar Allan Poe; Letters and Documents. Oscar-Berman, M., & Marinkovic, K. (2003). Alcoholism and the brain: An overview. Publication of National Institute on Alcohol Abuse and Alcoholism, 27(2), 125-133. Poe Letters. (2009). E. A. Poe Society of Baltimore, archives available on line at: http://www.eapoe.org/ Poe, drugs and alcohol. E. A. Poe Society of Baltimore, available online at: http://www.eapoe.org/ (updated September, 2009). Price, D., & Wilson, S. (2008). Epidural hematoma. Emergency Medicine, available online at: http://emedicine.medscape.com/ (posted January 2008). Ruzek, K. A., Campeau, N. G., & Miller, G. M. (2004). Early diagnosis of central pontine myelinolysis with diffusion weighted imaging. American Journal of Neuroradiology, 25(2), 210-213. Seiber, J. (2008). Diabetic coma in type 2 diabetes. Cleveland Clinic Web M.D, available online at: http://diabetes.webmd.com/hyperglycemic-hyperosmolar-nonketonic-syndrom/ (posted September, 2008). Snodgrass, J. A., (1867, May). The facts of Poes death and burial, Beadles Monthly, pp. 283-287. Trevisan, L. A., Boutros, N., Petrakis, I., & Krystal, J. (1998). Complications of alcohol withdrawal. Alcohol Health and Research World, 22(1), 61-66. Weiss, S. A, (1878, March). The last days of Edgar Allan Poe, Scribners Magazine, pp. 707-716.

Direct reprint requests to: Roger Alan Francis, M.D., F.A.C.R. Nevada Regional Medical Center 800 S. Ash St. Nevada, MO 64772 e-mail: rogerrad@embarqmail.com

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