The patient was an ideological novelist of unrivaled genius, who produced some of the greatest works of Western literature. In a series of masterpieces, he perfected the art of integrating a personal perspective with the major sociopolitical and cultural issues of his day. Tragically, he bled to death on January 28, 1881, at the age of 59 years.

On Sunday, January 26 of his final year, the patient was dining with his immediate family and his sister Vera, who had come from Moscow for a visit. The meal began pleasantly, with jokes and reminiscences, but soon degenerated with talk of a contested inheritance. Vera, it turned out, had come as nuncio for the other sisters, to persuade their brother to give up his claim to the estate, which she attempted to do by denouncing him for his greed and cruelty. The argument ended with her bursting into tears, and he, mortified, fleeing to his study before the dinner was over. As he sat at his desk, his head in his hands, the patient suddenly realized that his hands were wet with blood that was trickling from his mouth. He was hemorrhaging.

A second more serious bleed occurred the next afternoon. The patient made light of it and tried to soothe his frightened children. A doctor arrived just in time to witness another flow of blood, which so weakened the patient he fainted. On recovering consciousness, he called for a priest, confessed and received Extreme Unction.

On Tuesday, the patient seemed better. A quiet night followed. However, on Wednesday evening, he had a hemorrhage so severe, he again lost consciousness, and this time did not awake.

The source of the patient’s bleed and its cause have never been determined. Of his three principal disorders, his “falling sickness,” pulmonary ailment and fatal hemorrhage, only his “falling sickness,” a bizarre form of epilepsy, has been subjected to critical analysis. Neither the seizure disorder nor the pulmonary ailment appears to have been related to the fatal hemorrhage. However, the patient’s complicated medical history contains other information of possible relevance to the etiology of his terminal bleed.

The patient’s father was a physician, who became addicted to alcohol. He is reported to have suffered from depression, rheumatism, hypochondria and “peculiar seizures” (possibly alcohol-induced). When the patient was eighteen years old, his father died, reportedly at the hands of his serfs, whom he had brutalized. When the patient was 16, tuberculosis claimed his mother.

The patient had five siblings, one of whom (a brother) became a hopeless drunkard, and a sister who was a sociopath. He also had an uncle who drank himself to death.

The patient was deeply religious. For him writing was not an escape, but a confession of sorts, through which he preached universal conciliation in the name of Christ. The themes of his short stories and novels drew heavily from his religious faith, but also from a host of intense experiences.

When in his 20s, the patient joined a secret society, known as the Petrashevsky Circle, which hoped to foment a revolution that would bring an end to the institution of serfdom in Russia. However, before the underground cabal could act, he and other members of the group were arrested, subjected to a mock execution, and sentenced to four years of hard labor in the Siberian village of Omsk. Although the patient later claimed that the work and exercise were healthful, life in the Omsk prison colony was harsh to the extreme. Prisoners were housed in a narrow, dark and dirty room with wood planks for beds covered with straw-filled sacks for mattresses and pillows of the same kind. The stench was awful, so much so that the patient took up smoking strong tobacco in an effort to mask the odor. The food consisted almost exclusively of bread and cabbage soup. In the winter, inmates froze, and in the summer they suffered under sweltering heat. Yet, except for loss of libido and the appearance of “scrofulous sores” on his face and in his mouth, the patient tolerated the experience surprisingly well.

After his release, the patient completed four years of compulsory military service, during which he married Marya Dimitrievna Isayeva before returning to Moscow. She died of tuberculosis seven years later.

He had affairs with at least two other women and one known trip to a brothel before marrying a second time to Anna Grigoryevna Snikina. She was a devoted spouse who cared for him and transcribed his manuscripts until his death. They had four children. The first, a daughter, died of pneumonia as an infant. Another child, Alexey, died of possible status epilepticus. The other two survived to adulthood with no recorded medical problems.

Poverty plagued the patient most of his adult life. Writing was his remedy. However, for nearly a decade, he pursued a mad dream of gambling as the solution to his financial woes. After years of catastrophic losses at the gaming table, the obsession finally released its hold as mysteriously as it had grasped him never to return.

The patient’s past medical history contains a welter of physical complaints of uncertain relation to his terminal hemorrhage. At age 16 years, he had a “stubborn affection of the throat,” which gave his voice “a curious throaty quality that never appeared quite normal.” When he was 25 years old, he again had “numerous spasms of the throat…[along with] irritation of the entire nervous system…causing the heart to become congested and inflamed…[and] barely checked by leeches and two blood lettings.” A medical evaluation was negative. The strange illness resolved on its own, and did not recur.

At age 28 years, the patient had intermittent attacks of vertigo of undetermined etiology and a bladder infection. He suffered with inflamed hemorrhoids at age 43 years, and several non-specific febrile illnesses in his late 40s. When his daughter was born in 1869, it appeared that at age 48 years, he was losing his memory. On registering the child’s birth, he amazed the clerk by being unable to remember the mother’s maiden name.

By age 53 years, the patient was having frequent colds and complaining of a persistent dry cough, shortness of breath, and intermittent wheezing. Given his long history of smoking cigarettes and evidence of hyper-expanded lungs on physical examination, emphysema was diagnosed and treatment initiated with compressed air. In July 1879, 18 months before his death, he complained: “My head is spinning and I see spots before my eyes.”

The patient was described as: “supersensitive, misanthropic…[given to] marked irritability, fits of anger, a large capacity for hatred, all earmarks for an aggressive-destructive disposition.” When a child, his parents nicknamed him the “hot head.” His work habits and lifestyle were equally consistent with those of a high-strung person. At least late in life: “For 10 or 12 hours he would sit hunched over his desk [drinking large quantities of strong tea], and at six o’clock in the morning, when the city was beginning to wake, he had not yet been to bed. When he did go to bed, his sleep was “wracked by terrifying dreams of fires, assassinations, and bloody battles.”

The patient’s “falling sickness” has been subjected to the most intense scrutiny of his many ailments and been the source of some of the most florid speculation as to its proper categorization. Yet, after over a century of investigation and debate, neither the time of onset of his seizure disorder, its cause, nor even its character is known for certain.

Most likely, his initial seizure occurred during his 20s, while he was imprisoned in Omsk. According to the physician who cared for him at the time, the patient’s first attack of “falling sickness” in 1850 had the following manifestations: an initial “outcry, loss of consciousness, convulsions of the extremities and face, foam at the mouth, stertorous breathing, a small, fast, abbreviated pulse. The attack lasted 15 minutes. Followed by general weakness on return of consciousness.” The attacks generally occurred at night, with some accompanied by instances of automation, as with one such attack when the patient awoke to discover that he had unconsciously rolled a number of cigarettes before falling to the floor and remaining unconscious for some 40 minutes. According to associates, though never confirmed by the patient, some attacks were preceded by momentary intense sensual feelings known as “ecstatic auras.”

The medical literature is replete with the names of particular types of epilepsy given to the patient’s disorder, none of which is accepted as conclusive. His daughter, Aimée, a notoriously unreliable biographer, believed that her father’s seizures were alcohol-induced, although there is no evidence that the patient drank alcohol to excess. Even Sigmund Freud weighed in on the controversy with the suggestion that the patient suffered with “hystero-epilepsy” that was a product of a love-hate relationship with his father.

Although the patient’s respiratory ailment and “falling sickness” have been given plausible diagnoses (i.e., emphysema and epilepsy), his fatal hemorrhage has not. Its source as well as its cause are riddles yet to be solved.