Historic Puzzler II

An Historic Puzzler—The Answer at Last

The winners of March’s “Flashback” contest

By Jamie Newman, MD, FACP

In the March issue (“Flashback,” p. 9) I presented an historic puzzler. A patient presented in 1752 with abdominal pain and weakness of one-month duration. He had recently been treated for gonorrhea.

We received many good guesses. Many respondents suspected a complication of therapy for gonorrhea—especially from mercury. Arsenic was also considered a possibility. Other thoughts included syphilis, Guillain-Barré, smallpox, hypomagnesemia, and porphyria.

Mercury poisoning was a popular choice. “It has been said that it was not until sometime in the 20th century that a patient was more likely to be helped than harmed by a visit to the doctor,” notes Beach Conger, MD, chief of hospital medicine at Temple University Hospital, Philadelphia. “Given our proclivity in earlier times to prescribe—for the eradication of some unwanted pestilence—medications that were often more toxic to the host than they were to the invader, it is not all surprising that a man would become deathly ill shortly after getting treatment for gonorrhea.”

John Ross MD, Tufts University School of Medicine, Boston, also thought the case was mercury poisoning. He mentioned Shakespeare’s mercury toxicity (Ross JJ. Shakespeare’s chancre: did the bard have syphilis? Clin Infec Dis. 2005 Feb 1;40(1):399-404). As the saying goes, “A night with Venus, a lifetime with Mercury.” Mercury poisoning can present with a variety of neurologic complaints. Hat felters used mercury in the felting process, thus the term “mad hatter.” Abdominal pain is generally not the major complaint, though it can be present with mercury poisoning. Nephrotic syndrome is common, but our patient did not have edema.

Arsenic poisoning was posited as the cause of death for Napoleon, George III of Britain, and Van Gogh. Symptoms of arsenic poisoning may include nausea, vomiting, diarrhea (which may be bloody), and abdominal pain. A garlicky breath odor may be detectable. Delayed cardiomyopathy, acute tubular necrosis, and hemolysis may develop. In chronic arsenic poisoning, the onset of symptoms comes at two to eight weeks. Typical findings include skin and nail changes, such as hyperkeratosis, hyperpigmentation, exfoliative dermatitis, and Mees lines (transverse white striae of fingernail beds that become evident after two to three weeks of exposure), and sensory and motor polyneuritis manifesting as numbness and tingling in a “stocking-glove” distribution.

This would be a distinct possibility for our patient; however, although he did have several symptoms suggestive of this diagnosis, he did not have diarrhea. He also was not noted to have skin or nail findings, and had motor weakness without sensory changes.

The Winners

Three respondents recognized the diagnosis. One of these was a professional historian, but he missed the gonorrhea connection (plus he’s not a hospitalist!).

The most succinct and correct response goes to Ron Greeno, MD, chief medical officer, Cogent Healthcare, Irvine, Calif. “It sounds like our gentleman may be presenting with ‘lead colic’ and neuropathy associated with lead poisoning,” he says. “In his day the heavy metals including lead and mercury were used as treatment for gonorrhea. It appears that in his case, the treatment may have been worse than the disease.”

The most academic answer goes to Colin Kroen, MD, at the Cleveland Clinic, Ohio, “I believe this patient had lead poisoning. The typical ‘lead colic’ and the peripheral neuropathy are direct giveaways. His symptoms of fatigue and his weak pulse are likely due to anemia. The green tongue is an interesting finding, different than bluish pigment found at the teeth-gum line. In the American colonies, the ‘West-Indian dry gripes’ was from rum fermented in stills with lead-lined condensers.

“Thomas Cadwalader wrote ‘Essay on the West India Dry-Gripes,’ published by Ben Franklin. Franklin later wrote of certain occupations where lead exposure produced the same syndrome,” continues Dr. Kroen. “Unfortunately the chelating therapies that we now use were not employed in these times and such interesting attempts at cure as lead-containing medicines, purgatives, emetics, and laxatives [were used instead]. I suspect this patient is a description from his ‘A treatise on the colica Pictonum; or the dry belly-ache.’”

Eighteenth-century physician Dr. Theodore Tronchin (and Voltaire’s doctor) made the diagnosis of lead poisoning. This was, as Dr. Kroen noted correctly, from a 1757 treatise mentioned in the preceding paragraph. The patient in question had been treated with Sugar of Lead twice daily for two weeks for the treatment of his gonorrhea. This patient has classic lead toxicity with neurologic and abdominal symptoms. Dr. Tronchin, in the same article, described an outbreak in Amsterdam from lead-lined gutters. Fallen leaves turned acidic and extracted the lead, which collected in barrels that was used as drinking water.

Flash Forward

In our modern age of generally safe drugs, we no longer need to worry about unexpected medication side effects. Perhaps there is still a place for therapeutic nihilism.

Drs. Greeno and Kroen will both receive SHM and Wiley gifts for their answers.