2006

A Case of “Racial Characteristics”
This patient was one of the most admired Americans of his time. Born a slave, he was the successor of Frederick Douglass as leader and spokesman for black America in the aftermath of the Civil War. For over fifty years he relentlessly pursued the Puritan ethic of hard work, cleanliness and thrift. However, by his mid-fifties, he was wasted by a disease for which his physician claimed “racial characteristics” were, at least in part, responsible. Shortly before he died on November 15, 1915, at age 59, he was hospitalized in New York City. The following is a slightly abridged and annotated version of his hospital record:

November 1, 1915
COMPLAINT
Headache, sleeplessness, fatigue and dyspnoea on climbing stairs.
Palpitation, slight cough, occasional indigestion, loss of weight, loss of appetite, failing vision.

FAMILY HISTORY
Nothing known of father. Mother died 40 years ago, probably of dropsy. Patient has one older brother who is in only fair health. One sister died this year of apoplexy.

PAST HISTORY
About 20 years ago patient had a bad attack of malaria, lasting two or three weeks. He has always been troubled with dyspepsia.1 No sore throat or rheumatism. No other illnesses. Bowels are usually regular. Patient gets up two or three times at night to urinate for the past two or three years; voids large quantities of light colored urine. He drinks a great deal of water. Vision has been failing somewhat and varies from time to time. He takes about two tablespoonfuls of Scotch whiskey daily; no beer or wine, and never to excess. He smoked one or two cigars a day up to six months ago; since then, none. Patient denies all venereal infection.2

PRESENT ILLNESS:
Up to one year ago patient was quite well except for occasional headaches, which he called bilious headaches. He began to feel cold feet. In February, he was acutely ill with gastro-intestinal upset, and since that time he has noticed increasing ease of fatigue and dyspnoea on exertion. He has never had any oedema. Memory is good; no evidence of any mental symptoms.3

PHYSICAL EXAMINATION:
Patient is a middle-aged man.4
He lies in bed rather restless, moving constantly.
Head: Temporal arteries are dilated, tortuous and non-compressible.
Eyes: Pupils are equal and regular; react promptly to light. Movements normal. Eyeballs prominent. Ophthalmoscopic examination – Right Eye, red reflex normal. Margins of disc cannot be made out. Arteries narrow, veins dilated. There are a few flame-shaped hemorrhages. The retina is pale. Left Eye, red reflex normal. Disc slightly better outlines (sic) than in other eye, but temporal margin cannot be made out. There are several flame-shaped hemorrhages. Arteries very narrow.
Ears: Negative.
Nose: Negative
Mouth: Teeth are in fair condition,-numerous fillings.
Throat: Tonsils are not visible. No inflammation.
Neck: Thyroid not palpable. No glands palpable. Superficial veins dilated and pulsate.
Thorax: Symmetrical. Expansion limited on both sides.
Lungs: No dulness or change in vocal fremitus or voice sounds. There are a few fine râles over both bases at the end of deep inspiration.
Heart: No impulse is visible over the precordium. Area of cardiac dulness is [14.0 cm from the midline in the fifth interspace]. Apex is barely palpable in the fifth interspace 10.5 cm. from the mid-line. At the apex is a blunt first sound, followed by an accentuated and reduplicated second sound. At the left of the lower end of the sternum a low-pitched systolic murmur follows the first sound. At the base the sounds are the same as at the apex, but not so loud. The rate is rapid. The rhythm is perfectly regular.
Pulses: The two pulses are equal in volume and in time. Blood pressure is 225 systolic, 145 diastolic, right arm, patient lying down.
Abdomen: Not distended or tender. Liver palpable 5 cm. from the costal margin in the mid-clavicular line. Upper limit of dulness is in the fourth interspace. Spleen is not palpable.
External Genitalia: Negative.
Extremities; No epitrochlears. No oedema. No scars. Knee jerks present, not exaggerated. Radial arteries not easily compressible; palpable when compressed above, not beaded.

Nov. 2, 1915 (Dr. Cohn)
Two weeks ago patient had palpitation. He gets tired more quickly now, especially if he is excited. He does not do a day’s work now, formerly worked from nine to five and in the evening. He has never had any pain in the chest or cough. He has headache in the frontal region for one or two days out of every eight or nine. He thinks that last night’s headache came on because he ate too much. He rarely vomits, but often induces vomiting and says it relieves his headache. Mentally, he thinks he is slower than he was and requires more concentration. If he is to make speeches5, he finds it is necessary to master all the details first; he is now unwilling to trust himself to impromptu speeches. Blood pressure – 220 systolic, 150 diastolic. At the base of the sternum a systolic murmur is not always present; it is in quality, like the shuffle (sic) of the pericardium, but is of course, only single. It is post-systolic and ends in the second sound. At the base the second sound is accentuated in the second left interspace. The right radial pulse is larger than the left; it is thick. No plaques are felt. The upstroke of the pulse is slow, only fairly sustained. There are a few râles at the left base. Liver is not felt. There is no oedema.
Examination of eyes (Dr. Schirmer). Great many yellowish spots (fatty degeneration) around posterior pole of the eye. The ordinary regular arrangement around the fovea is missing. The number and size of retinal hemorrhages is scarce in comparison with the yellow spots.
Diagnosis: Papillo-retinitis albuminuris , with relatively few and small hemorrhages.

Laboratory Studies:
Wassermann reported negative (Dr. Jagle).

Notes
1 – The patient had chronic indigestion, particularly when traveling, which he treated with Bell’s Papayan tablets, a protein-splitting enzyme from unripe papayas. In 1911, he spent several days receiving unspecified treatments at John H. Kellogg’s Sanitarium in Battle Creek, Michigan. In 1914 he was persuaded to drink radium water as a possible cure for his digestive distress.
2 – Additional Past History: In 1911, the patient was beaten while visiting the tenderloin section of New York City. He received two large gashes in his head and a torn ear but recovered without apparent sequellae.
3 – Social History: The patient was married three times. His first wife died of injuries caused by a fall from a wagon; his second wife died of unknown cause. His third wife was alive and well at the time of his hospitalization. He had three children – a daughter who lived until her 90s, a son who died in his late 50s of unknown cause (he had a history of “thumping in his head and dizziness when concentrating”), and another son who developed blindness in one eye and reduced vision in the other. The latter son died in his early 50s of unknown cause.
The patient was a graduate of the Hampton Institute and throughout his life worked as a salt processor, houseboy, janitor, coal miner, waiter, teacher, college president, author, political boss and presidential advisor.
4 – The patient was African-American, variously described as having “medium brown skin of a mulatto, luminous gray eyes, short, wiry and powerful,” with “a rather Irish face” and the “odd look of an Italian”.
5 – In his prime, the patient was a renown orator with the “power to sway crowds and move men to his purposes,” one who seemingly never tired. He could speak, and frequently did, several times a day to packed houses.

 

2006 Guest Participants

Jackson T. Wright Jr., MD, PhD, FACP, is professor of medicine and program director of the general clinical research center at Case Western Reserve University. He is also director of the clinical hypertension program at Case/University Hospitals of Cleveland. Dr. Wright received both his MD and PhD (in pharmacology) from the University of Pittsburgh. An experienced clinical investigator, he has published extensively and served on several national and international advisory panels. Among them are the National High Blood Education Program Coordinating Committee and the treatment section of Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNC 7. His research experience includes leadership roles in nearly all the major clinical outcome trials conducted in Black populations over the past two decades.

W. Fitzhugh Brundage, PhD, is the William B. Umstead Professor of History at the University of North Carolina in Chapel Hill. His general research interests are American history—post Civil War —with particular focus on the American South. Prof. Brundage’s first book, Lynching in the New South, received the Merle Curti Award from the Organization of American Historians for the best book in American Social History in 1994. His most recent work, The Southern Past: A Clash of Race and Memory, was released in 2005. Prof. Brundage served as editor for Booker T. Washington and Black Progress: A Centenary of Up From Slavery (Gainesville: University Press of Florida, 2003). He received a BA degree from the University of Chicago in 1981 and MA and PhD degrees from Harvard University in 1984 and 1988, respectively.

 

 Final diagnosis