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Bedside Rounds is a medical podcast by Adam Rodman, MD, about fascinating stories in clinical medicine rooted in history. 91������ has teamed up with Adam to offer continuing medical education related to his podcasts, available exclusively to 91������ members by completing the CME/MOC quiz.

This is Adam Rodman, and I’m very excited to be here! Well, virtually at least. The title of this live podcast is “Fever on the Frontier”. Medical history is often presented as a top-to-bottom elite history. New ideas are generated by elite physicians in universities in major cities, and then over the years -- or decades, or centuries -- trickle down to ordinary health practitioners. This idea is pretty familiar to us in the 21st century. Just think of the phrase “ivory tower” and how it has shifted over the past few hundred years -- it’s from the Song of Songs, used as a symbol of purity for several millennia, but now is used derisively, meaning a rigid academic hierarchy largely out of touch with the experiences of the real world. I think it goes without saying that the reality of medical knowledge generation is much more complex than this. So when Rob invited me to give a live podcast for the South Dakota 91������ national meeting, I wanted to explore this idea -- knowledge generation, and multi-directional knowledge flows. So in this live podcast, I’m going to be talking about the intellectual understanding of fever in the early 19th century -- and because I wanted to do something relevant to the Dakotas, we’re going to talk specifically about the American frontier in the early 19th century. And if all this sounds a little ethereal, don’t worry -- because this story is a classic Holmesian whodunnit -- how in a simmering background of different ideas about the nature of fevers boiled over when a mysterious and deadly new disease called milk sickness started to wipe out settler communities throughout the frontier. And it’s a story worthy of a feature film: we’re going to talk about indiginous medicine and forced relocation, how milk sickness shaped the life of one of the most important US presidents, dueling ideas about the nature of disease imported from medical schools in Europe, and finally the Cassandra-like “Dr. Anna,” a pioneer medicine woman who figured out the cause and prevention of this dangerous disease but whose discoveries went unheeded for almost a century.

We are going to start by talking about American expansion West at the beginning of the 19th century, which decades later would be called Manifest Destiny or continentalism -- the idea that the United States was ordained by God to fill the entire Continent. The Louisiana purchase had basically doubled the size of the country in 1803. This absolutely massive amount of territory was essentially occupied by the same people who had lived there for thousands of years. Our best estimates suggest almost 600,000 indigineous people, down from as high as 10 million precontact. Despite becoming nominally part of the United States, widespread immigration didn’t start until after the War of 1812, and in particular after the Treaty of Ghent in 1815, which had two main effects -- the end of British fortifications in the area and an end to Indian hopes of establishing independent states in favor of an official policy of displacement by American settlers. After this, the slow trickle of settlers from the original 13th states turned into a torrent entering what was then called the “Middle West.” Now I’m speaking virtually in the Dakotas, and while most of these lands were part of the Louisiana purchase, they weren’t organized into the Dakota territory until right prior to the Civil War.

Very typical of these settler families was Anna Pierce. She was born in 1808 in Philadelphia, which was then one of the biggest cities in the United States, with over 40,000 people. When she was 16, like many Americans, her family moved into the frontier. They traveled westward, crossing the Ohio River at Ford’s Ferry, and settled on a homestead near what would later become the town of Rock Creek, in southeastern Illinois in 1824. Very quickly, Pierce became shocked at the poor health of the settlers. Disease was endemic and carried off large portions of the population. Physician visitors from the East and from Europe were shocked. David Thomas was a botanist from Philadelphia who traveled throughout the frontier to collect specimens. He reported that in the town of Vevay Indiana in the fall of 1820, one out of six people died from “bilious fevers.” The next year, in 1821, an eighth of the entire population of Indianapolis died of “intermittent fevers and agues.” Ague, by the way, was a common word meaning a high fever with rigors, and was often considered a disease in and of itself. The few people who were not affected had to care for the remainder of the sick. Fear of fever and death was universal among settlers. There was a saying that the pioneer had “a wholesome fear of two things: fevers and ague, and rattlesnakes.” A second saying suggested just how common this was:  “he ain’t sick, he’s only got the ager.”

The threat of disease was omnipresent -- either killing off settlers or forcing them to flee back East. This is a quote from a pioneer describing his experience with the ague:

“You felt as though you had gone through some sort of collision, thrashing-machine or jarring-machine, and came out not killed, but next thing to it. You felt weak, as though you had run too far after something, and then didn't catch it. You felt languid, stupid and sore, and was down in the mouth and heel and partially raveled out. Your back was out of fix, your head ached and your appetite crazy. Your eyes had too much white in them, your ears, especially after taking quinine, had too much roar in them, and your whole body and soul were entirely woebegone, disconsolate, sad, poor, and good for nothing. You didn't think too much of yourself and didn't believe that other people did, either; and you didn't care. You didn't quite make up your mind to commit suicide, but sometimes wished some accident would happen to knock either the malady or yourself out of existence. You imagined that even the dogs looked at you with a kind of self- complacency. You thought the sun had a kind of sickly shine about it. About this time you came to the conclusion that you would not accept the whole state of Indiana as a gift; and if you had the strength and means, you picked up Hannah and the baby, and your traps, and went back 'yander' to 'Old Virginny,' the 'Jerseys,' Maryland or Pennsylvany.”

What was the cause of all these fevers, this “ague”? There was an extremely vigorous debate, which was informed by similar debates going on in academic circles in Europe, and to a lesser extent the new United States. The traditional Western understanding of disease was the four humors -- that is, that all health and disease came from balances and imbalances in these four constitutional fluids, blood, phlegm, black bile, yellow bile, as well as “pneuma” -- the air of life. The human organism was understood to exist in an equilibrium with nature -- with the food we ate, with the people we talked to, with the stars, planets, and constellations, with our emotional state, and with the weather. What caused disease then? Well, basically anything that would unbalance the humors. And treatment was by re-establishing this balance, which is where the traditional therapeutics of the Western armamentarium came in -- bleeding, purging, laxatives, blisters, intense dietary modification. Each of these would deplete or rebalance a specific or combination of humors. We’re usually taught that humoral medicine had pretty much died out by the beginning of the 19th century -- and that’s true in elite medical circles, like in Edinborough, where new ideas about discrete diseases defined by their symptoms had become popular, or in Vienna or Paris, where new ideas about “pathological anatomy” and diseases “living” in specific organs had come into vogue. But among regular people -- including doctors -- humoral ideas remained potent into the early 20th century. Our language is still peppered with this -- obviously we talk about people being sanguine, phlegmatic, or melancholic, but we also talk about having a “sense of humor” -- originally meaning well balanced, now meaning being merely funny. In fact, some of you have probably had older patients who talk about taking a “physic” -- a laxative -- for any sort of disease, which both in language and practice is an ancient humoral holdout that has almost completely died.

You would intuitively think that a humoral model of balance doesn’t make sense in the setting of epidemic disease. How could everyone be unbalanced at the same time in, say, a cholera epidemic? But of course there was an answer for that -- miasma. Miasma has been an explanatory model since antiquity to explain the fact that large numbers of people would become sick at a similar time, usually in a seasonal manner, or in the same place, such as swampy regions. Miasma held that toxic air -- smells, in particular -- were responsible for unbalancing the humors. And miasma indeed was an incredibly common explanation for the poor state of health of the settlers. The Portsmouth Scioto Telegraph of Ohio poetically described the poor climate: “The angel of disease and death, ascending from his oozy bed, along the marshy margin of the bottom grounds . . . floats in his aerial chariot, and in seasons favorable to his prowess, spreads mortal desolation as he flies”. This was clearly a common view among the pioneers themselves. As reported one pioneer in Michigan: “ as the land was plowed up the malarial gases set free, the country become very sickly…. Crops went back into the ground, animals suffered for food, and if the people had not been too sick to need much to eat they, too, must have gone hungry. The pale, sallow bloated faces of that period were the rule, there were no healthy faces except of persons just arrived.”

Miasma was, of course, not the only explanatory model for these fevers. Diathesis had become an extremely popular argument. Diathesis means a hereditary disposition towards a disease. The term has strangely persisted in modern medicine only in the phrase “bleeding diathesis” -- which means presumed hereditary bleeding disorder. But research in the German states as well as England in the 19th century had shown that cases of phthisis -- tuberculosis, as the French were calling it by now -- clustered in family groups. And the same seemed to be true of many febrile diseases. Might there be some hereditary or constitutional cause to these diseases?

These arguments found fertile ground in the American frontier, especially as Prohibition movements started to grow.  James Hall, one of the first Eastern writers to survey the frontier, dismissed any complaints about the weather -- he found it quite lovely -- but blamed the constitution of the (often immigrant themselves) settlers -- “too much meat, not enough fresh vegetables, too much drinking.”

Daniel Drake of Indianapolis, the most important physician of the frontier in the 19th century, made this essential argument as well, arguing quite absurdly that the same factors that led to fevers also led to spontaneous combustion:

“The bodies of corpulent inebriates, when asleep, have, in several instances, taken fire, by the accidental contact of a burning coal or candle, and all the soft parts have been reduced to ashes, or driven off in clouds of thick smoke. To conceive of the possibility of this revolting catastrophe, we need only recollect the combustible nature of fat, and the still more inflammable quality of ardent spirits, which is composed of the very same materials; and which, being swallowed, daily, in excessive quantities, with reduction of food, may be presumed to alter, to a certain degree, the chemical composition of the body. Meanwhile its vital powers become greatly reduced, and thus render it an easier prey to fire or other external agents."

Of course, physicians had long noted that some diseases appeared to clearly be spread from person-to-person, the most famous example being syphilis. Contagion -- the idea that chemical or biological agents spread certain types of disease -- was still a pretty esoteric idea in the beginning of the 19th century in the American West, though it was being taken very seriously in Europe. Daniel Drake himself felt that cholera was likely spread by contagion -- from an “animalcule”, microorganisms that had been described by Leeuwenhoek a century before. Finally, there was the irritation or “unitary fever” view that had taken the American medical establishment by storm, especially Benjamin Rush. I don’t want to get too much into details, but this view held that every fever was a single disease caused by irritation, and the only therapy was to purge the irritation -- usually with copious amounts of bloodletting and calomel. 

So the intellectual milieu surrounding fevers was quite varied by the time Anna Pierce reached Illinois. In any event, she had a natural inclination towards healing, and in 1828 she returned to Philadelphia to pursue more medical education. Legends suggest a possibly more dramatic cause, including a drunken suitor and gunfire that caused the “Tomboy Pierce Gal” to disappear for a little while. In any event, once she was in Philadelphia she set about getting the most medical training open to her, taking courses in midwifery, nursing, and dentistry. In the early 19th century, Philadelphia, with the University of Pennsylvania, was the center of the American medical establishment. However, formal medical education was still completely closed off to women. Elizabeth Blackwell wouldn’t earn her degree until 1849, and co-education didn’t truly start until the 1870s. Medical education was rapidly expanding in the US -- in 1800, there were only four medical schools, U Penn, King’s College, Harvard, and Dartmouth, organized like English universities. Between 1810 and 1840, twenty-six more schools were started. In the early 19th century, the quality of these was incredibly, let’s just say, heterogenous. Generally, you’d be required to sit through a fixed number of lectures on anatomy, pathology, and the materia medica, or pharmacology. A second year of school could just be taking these lectures a second time. Procuring cadavers was difficult, and there was a thriving secondary market of “resurrectionists” who would raid graveyards. After finishing the classroom, newly minted medical doctors would often apprentice themselves to experienced physicians, sometimes serving as “house officers” in hospitals meant for the poor. But in reality, many just went off and started their own practice. All of this is to say, Pierce was probably as well-trained as any regular physician.

Formally trained physicians were generally regarded with skepticism among frontier communities which largely relied on manual labor, though by the 1830s these views were changing. It was fairly standard for a doctor to be a jack of all trades -- like Pierce delivering babies, pulling teeth, doing minor surgeries, and treating illnesses. Her lack of a medical degree didn’t stop her from gaining respect -- she was called “Dr Anna” by her patients, which is what I’m going to call her for the remainder of the episode. The implements of the physician were generally lacking -- in Vienna and Paris in the 1830s, stethoscopes, thermometers, plexometers, and a panoply of surgical implements were commonplace, but by Dr. Anna’s time all of this was incredibly rare. A frontier doctor spent most of her time on the road, and fees were often IOUs. I have no idea what Dr. Anna would have charged, but as an example, in Springfield, IL, physicians agreed to this payscale:

“Daytime visit in town, $1; up to four miles, $2; each additional mile, 50 cents; prices double for night visits; verbal advice, $1; each dose of medicine, 50 cents; vaccination, $1; natural parturition, $5 to $10; fractures, $5 102 to $10; amputation of leg or arm, $25 to $100; lithotomy, $100 to $200”

Dr. Anna, as the only physician in southeastern Illinois, had a thriving practice -- in fact, colorful legends were still being told about her in the 1930s, when they were finally written down. There’s no evidence that her practice strayed from the traditional practice of a country physician until the 1830s, when a new mysterious disease hit town after town in southeastern Illinois -- milk sickness.

The fevers that Dr. Anna and the people of the frontier had seen were terrible no doubt -- but they were diseases well-known to medicine. Milk sickness appeared to be something completely new. It arose seemingly out of nowhere, devastating livestock, killing entire families, and causing whole settlements to become abandoned. I am going to guess most of you have never heard of this disease -- but on the frontier, it caused massive amounts of death. In an analysis of Dubois County, in Indiana, half of the recorded deaths in the early 19th century were from milk sickness. Similar studies from areas where it was endemic show similar mortality rates.

The first case shows up in the medical literature in 1809, describing a syndrome of weakness, myalgias, vomiting, foul breath, and then coma and death that appeared to affect both livestock and humans alike. The locals called it “the trembles”. There wasn’t yet a clear association with drinking milk. We can suspect, however, that the name milk sickness is a bit older than this -- there’s a mountain in my home state of North Carolina named “milk sick mountain,” though the details of that are also lost in legend. The next year, this small report was reprinted and expounded on by Dr. Drake -- who remained skeptical but wanted “physicians to determine how far it deserves the appellation of a new disease.” By 1811, milk sickness was front page news -- the Cincinnati Liberty Hall described the disease as “sick stomach,” clearly linking it to consumption of milk, in particular from cows raised on uncultivated pastures. This was reprinted several places, including in the Medical Repository of New York -- the nation’s first, and at the time most important, medical journal. Despite a pretty comprehensive description, including an association with milk products, especially from cows outside of pastures, printed as front page news and in the nation’s largest medical journal, milk sickness continued to be mysterious for decades.

Settlers were left to learn about the disease through their own experience and suffering. Like these early descriptions, they quickly realized that early signs of the disease could be seen in grazing animals or their suckling offspring developing “the trembles,” with human disease soon following by drinking milk or eating dairy products from affected animals. Settler experience with milk sickness likely changed American history. In the Summer of 1816, Thomas and Nancy Hawks Lincoln settled near Pigeon Creek in Indiana, eventually building a log cabin. In the summer of 1818, milk sickness struck this new community -- first a cluster of neighbors died, then Nancy’s aunt and uncle, and finally Nancy Lincoln herself, leaving behind her husband and children, including 10 year-old Abraham. Like many pioneer communities afflicted by milk sickness, the Lincolns left and moved to Illinois.

By the 1830s, when milk sickness arrived in southeastern Illinois for Dr. Anna, the disease was no longer considered uncommon on the frontier -- but its cause remained equally mysterious. I should add that on the east coast, the disease was completely ignored, or even thought to be superstition. Only one medical textbook from the first half of the nineteenth century mentioned it. In any event, such a deadly disease needed some sort of treatment. The states of Kentucky and Illinois actually offered a reward to anyone who could prove a cause of the disease. In Dr. Anna’s time, there were three major theories on what caused the disease -- miasma, a metallic poison, or a vegetable poison. By the late 19th century, a fourth cause would be posited as well -- infectious microorganisms.

Let’s start with the arguments for miasma, mostly made by Dr. William Lea, a Tennessee physician in 1821. He noted that the areas afflicted by milk sickness appeared in the valleys west of the Appalachian range. In Tennessee, for example, the valley serves as a strict demarcation between areas where milk sickness was common and where it was unheard of. This flatter land had dramatically different vegetation and climate -- in particular ponds with stagnant water. It was this stagnant water and climate, which were “impregnated with noxious effluvia” and which caused other miasmas like yellow fever, which best explained the presence of milk sickness. In defense of his arguments, he pointed out the seasonal component to the disease -- the late summer especially, when water was at its most stagnant. It was unheard of in the winter. These were initially popular arguments -- Drake himself initially thought that “marshy exhalations” were a possible cause.

But ultimately his arguments were rejected -- though not because of skepticism about miasma. Drake himself would point out that milk sickness wasn’t even truly a fever, despite the common appellation. The areas that were affected were also very small -- only 40-50 acres at a time, and tended to be areas that did not have ponds and swamps. Forested hills and valleys were where the disease seemed to strike most frequently. And finally, by this period, the association with the consumption of tainted milk and cheese had clearly been made, which was not at all consistent with miasma.

This made the poisoning argument much stronger. One popular theory, driven by Seaton, suggested that poisoning with arsenic, or another similar heavy metal, was to blame. This was based mostly on the symptoms, especially after consumption of food. But all of the mineral arguments had the same fundamental problem -- if the disease came from a mineral in the soil, why did it have such a clear seasonal association? The trembles in animals and milk sickness in humans should be present whenever cows were producing milk. And why would the disease just immediately disappear from an area after killing dozens?

Which brings us to the vegetable poison hypothesis and Dr. Anna.

In 1834, milk sickness came to southeastern Illinois. As the only medical practitioner around, Dr. Anna spent her days treating the ill -- but found that none of her traditional therapeutics -- presumably bloodletting, calomel, and herbs that served as both laxatives and purgatives -- worked. The disease struck very close to home -- both her mother and sister-in-law were killed by the disease, and her father was sickened close to death. Just like the Lincolns, and the settler I quoted early on, this experience convinced the Pierce family to return to Philadelphia; Dr. Anna, however, wanted to stay with her community. She had married Jefferson Hobbs and settled into a small homestead where she continued her medical duties. Her journal documents her increasing obsession with milk sickness. I should note that there is absolutely no evidence that Dr. Anna received any medical journals, or had any communication with the formal medical establishment -- which in any event was hundreds of miles away. In her personal journals, however, you can see that she approached this medical problem with a scientific eye. She noted that over three years the disease had been completely seasonal -- starting in June and ending after the first frost. Cows were certainly the most affected -- but milk cows less so. This seemed to confirm the association with milk consumption. Thus her first intervention: “I am now convinced that the poison which kills the calves and people saves the cows by being daily discharged through the milk glands. So I am writing a few letters this morning and telling everyone I can to abstain wholly from milk and butter from June till after the killing frosts.”

Her next observation was even more essential. While other animals, such as pigs, would get the trembles, horses, sheeps, and goats very rarely, if at all, got it. What was the difference between these animals? They were very picky eaters, and would travel further afield for good food. Cows, on the other hand, would eat whatever was around. The cause, therefore, must be something that a cow would eat, but that a horse, sheep, and goat would not. On an early fall day in 1834, Dr. Anna set out on an experiment that would give her her answer. She packed a small lunch, her rifle and her dogs for protection, as well as her herb basket, and followed her cattle into the woods. Everytime they ate an herb, she would collect it in her basket, intending to test them all later. She had collected a number of herbs and roots when she ran into an older Shawnee woman, whom she called in her journal “Aunt Shawnee.” I mentioned earlier about the hundreds of thousands of indigenous people who had long lived in the lands now considered the American frontier. One of these groups was the Shawnee, who had lived in what was now Ohio, based around the village of Wapakoneta. In 1831, the US government forced the Shawnee to sign a removal treaty, and they were force-marched to a reservation in Kansas, and later to Indian territory, now Oklahoma.

This woman, fleeing forced removal, was a traditional healer, a medicine woman like Dr. Anna. Dr. Anna gave her her lunch, and then brought her back to their homestead to recover. “Aunt Shawnee” proved to be incredibly helpful. She already was aware of the cause of the “trembles” and looked through Dr. Anna’s collected herbs and quickly showed her the causative agent -- a plant called white snakeroot. This herb was used as a traditional medication for treating snakebites, and Aunt Shawnee quickly identified a large stand of it on the north ridge of their homestead. Dr. Anna used this stand of snakeroot to perform a number of experiments with their own livestock -- and in every case feeding them snakeroot caused the trembles. After this, she launched an eradication program in southeastern Illinois -- educating men and boys about the plant, and ordering them to uproot and burn it. The eradication program went on for three full years, and the disease was successfully eliminated from the area. Dr. Anna even grew a patch of white snakeroot in her garden so that anyone visiting could identify it and eliminate it in their own homesteads.

A few years later, a farmer named John Rowe repeated Dr. Anna’s experiment, feeding white snakeroot to his cows and was again able to show that the herb caused the trembles, and by extension milk sickness. His results were written up in multiple newspapers, as well as a medical journal. So that was it, right? The cause of this disease was settled, with a workable solution. Of course not. Dr. Anna and John Rowe’s findings were explicitly rejected by the scion of frontier medicine himself, Drake, who by this time was a believer in the vegetable poison hypothesis, but had decided that poison ivy was the culprit. I should note that Dr. Drake, based in Indianapolis, had never seen a case himself, though did travel to meet Rowe and observe his experiment.

So the cause of milk sickness went completely unheeded by the medical community, though the disease started to become far less common over the middle of the nineteenth century, probably because of two main reasons -- the first that as the Middle West developed more, cultivated pastures became more common, and the second, as settlements grew into towns, milk was often mixed at dairies, diluting out any poisons.

Milk sickness would have one final nosologic moment in the sun, even as it killed far less frequently -- and that’s germ theory. As a quick refresher, Robert Koch had identified the anthrax bacillus in 1876, and within a few short decades microorganisms had been found to be the cause of a panoply of diseases: tuberculosis and cholera, both discovered by Koch and his team, but also pneumonia, erysipelas, plague, and a whole host of animal diseases. Koch had advanced his four postulates -- essentially that an organism must only be found in the diseased, able to be cultured independently, able to cause the disease in a healthy individual, and then be cultured again. They weren’t accurate even in Koch’s day, and he knew it. But they set off an optimistic scientific adventure that EVERY disease could be defined in terms of infectious microorganisms. And milk sickness was no different. The most famous example was in 1909, where Jordan and Harris isolated an organism they called “bacillus lactimorbi” from a cow with the trembles. They inoculated six dogs with a culture of this organism -- two showed symptoms consistent with the trembles, and one died. In retrospect, they made the animals septic with an unrelated bacillus species, and the tests were far from conclusive.

By the early 20th century, human disease was a passing thought -- the trembles was a disease of cattle. Finally, in 1928 a scientist at the US Department of Agriculture finally settled the debate, isolating a toxic from white snakeroot that he called “tremetol” -- named after the tremors the disease caused. Fifty-five years after her death, Dr. Anna had been proven right.

Why did it take so long for the medical community to definitively establish the cause of milk sickness? Why was Dr. Anna’s work not heeded? Well, in retrospect, there were some pretty practical reasons. We know now that tremetol exists in different concentrations in different strains of snakeroot, so it’s likely that when Dr. Anna’s experiment was repeated, it may not have worked. For example, one of the reasons Drake so dismissed Rowe was that other farmers reported that their cattle ate from different stands of snakeroot without developing the trembles.  Similarly, almost by definition, milk sickness would only strike isolated communities. Large population centers pooled their milk, diluting out any toxin, so that elite physicians -- even those living on the frontier like Drake -- had effectively never seen a case.

There was also considerable bias against irregular physicians, let alone women and indigineous healers. Even when they were respected in their own communities, the medical world at large would not take the word of an irregular medicine woman helped by an indigineous healer. No amount of practical experience could shake the hierarchy of the ivory towers -- and I know I’ve been picking on Drake a lot, but at least he accepted that the disease existed. Back in Philadelphia and Boston, the zeitgeist was that milk sickness was just mis-identification of other types of fevers by ignorant country doctors.

Finally, and generally what I get excited about, there were epistemological reasons that it took so long to identify. The search for a cause of milk sickness was clouded by pre-existing intellectual ideas about the cause of disease -- the first, that it must be caused by miasma, and later that it had to be an infectious organism. Even as all the evidence pointed to a poisonous source, medical elites -- the type of people who write textbooks -- tried to fit the disease into a model they understood. And while to us, Dr. Anna’s approach appears to be scientific -- based on empirical observations and experimentation -- this approach to medical therapeutics took a considerable amount of time to catch on in the United States, note until the middle of the 19th century, decades after they had started in Europe.

So what happened to the protagonist and antagonist of our story? The rest of Dr. Anna’s life were not necessarily happy -- her husband died of pneumonia the next year, and she later remarried an abusive bandit. I have no idea how much truth there is in these stories -- unlike the milk sickness stories, they’re based off of oral legends and not documentary evidence -- but stories tell that she jumped off a cliff over the Ohio River to escape him, and was later essential in stopping his band of river pirates. And as for milk sickness, by the last 19th century, it had effectively disappeared with the closing of the frontier, though it lived on in medical texts for years since Osler included it in his textbook, mostly as a historical note, because there’s basically no chance he had ever seen a case. It wasn’t even included in the ICD, the International Classification of Diseases. There have been clusters of cases in the 20th century -- the most recent I could find was from the 1960s entitled “Tremetol Poisoning -- Not quite extinct”. We know now that tremetol poisoning causes a severe ketoacidosis; in fact, oral and rectal bicarbonate had been used successfully in the late 19th and early 20th centuries. And in fact, in that case, the two infant children showed a dramatic ketoacidosis which was treated with intravenous bicarbonate; both made full recoveries. It’s almost a given that cases still exist and just go unidentified. These almost did too, but after the fact the attending physician remembered a case long ago: “It is certain that the possibility of tremetol poisoning would not have occurred to me had I not remembered one previous, similar case seen in 1946. This patient was an older child, from across the Mississippi River in Illinois, drinking raw milk from a poisoned cow. Snakeroot poisoning developed in the typical manner.”

So that is it for my story! I hope this has been a fascinating look at a case report in epistemology and nosology, and how the identification of a new disease can stress our explanatory models -- even when the answer is right in front of our noses.

None of those named above have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  March 31, 2022

Expiration Date: March 31, 2025

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