Medical Mysteries eOmnibus

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MEDICAL MYSTERIES eOMNIBUS. Copyright © 2001 by Dr Jim Leavesley and Dr George Biro. All rights reserved under International and Pan-American Copyright Conventions. By payment of the required fees, you have been granted the nonexclusive, non-transferable right to access and read the text of this e-book on-screen. No part of this text may be reproduced, transmitted, down-loaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the express written permission of PerfectBound™. PerfectBound ™ and the PerfectBound™ logo are trademarks of HarperCollins Publishers, Inc. BONUS STORIES. Copyright © 2001 by Dr Jim Leavesley. Dr Jim Leavesley and Dr George Biro assert the moral right to be identified as the authors of this work. Adobe Acrobat E-Book Reader edition v 1. July 2001 ISBN 0–7322–7194–0 Print editions of What Killed Jane Austen?, How Isaac Newton Lost His Marbles and Flies in the Ointment first published in 1998, 1999 and 2001 by HarperCollins Publishers Pty Limited. 10 9 8 7 6 5 4 3 2 1

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CONTENTS WHAT KILLED JANE AUSTEN?

CHAPTER 1 KINGS AND QUEENS Mary I of England and Philip II of Spain (GB & JL) Marie Antoinette and Louis XVI of France — and sex (JL) Did a mutant enzyme make George III mad? (GB) Some royal operations (JL) Opening the tombs (JL)

CHAPTER 2 ECCENTRICS, REFORMERS AND PIONEERS The bizarre affair of James Barry (GB & JL) Francis Galton, the man who walked north, south, east and west (GB) Marie Stopes, champion of contraception (JL) Elizabeth Kenny, the bush nurse who took on the doctors (GB) Paul White, Jungle Doctor (GB) Bertram Wainer, abortion law reformer (GB)

CHAPTER 3 QUACKS, PSEUDOLOGISTS AND OTHER PHONEYS Quacks and charlatans (JL) Those who know water (GB & JL) Once despised and now revered (JL)

CHAPTER 4 FAMOUS PATIENTS The mystery of Napoleon’s final Waterloo (GB) What killed Jane Austen? (JL) A medical history of Oscar Wilde (JL) The death of V.I. Lenin (JL) Was Winston Churchill fit to rule? (GB) Josef Stalin and the doctors (JL) Did a stand-in take the rap for Rudolf Hess? (GB) Kafka, Orwell, Camus and Auden (JL)

CHAPTER 5 WARFARE AND MEDICINE Red jackets, tight trousers and cold steel: The medical aspects of the Battle of Waterloo (JL) Florence Nightingale: Nurses force their way into a man’s world (GB)

CHAPTER 6 DISCOVERIES AND DISEASES Early dentistry was a health hazard (GB) The mystery of Mawson’s Antarctic disease (GB) Kuru and the cannibals (JL) Swine Fever: The non-epidemic of 1976 (JL)

CHAPTER 7 DISASTERS Burke and Hare (JL) The blight of the Irish (GB) Typhoid Mary (JL) Painters dial R for death (GB) Wittenoom: The asbestos tragedy goes on and on (GB) Syphilis in Tuskegee, Alabama (GB)

CHAPTER 8 ADDICTIONS AND OBSESSIONS That drowsy numbness: Opium and the poets (JL) Sigmund Freud and cocaine (GB) Percy Grainger’s and William Gladstone’s curious obsession (JL)

CHAPTER 9 LONGEVITY The oldest of the old (JL) Alchemy, body-freezing or virgin’s blood? (GB)

FINAL WORD: CAN IMMUNISATION ALONE SAVE THIRD WORLD CHILDREN?

A

BIBLIOGRAPHY

HOW ISAAC NEWTON LOST HIS MARBLES THE

HISTORY OF MEDICINE IN A NUTSHELL

CHAPTER 1 MEDICINE AND THE ARTS Eunuchs, castrati and the like (JL) The emergence of the cripple (JL) Medicine and Charles Dickens (JL) The Divine Sarah (JL)

CHAPTER 2 MURDER, MYSTERY AND MAYHEM Fast food in Scotland (GB) Arsenic and adultery: The poisoned life of Florence Maybrick (GB) Death by umbrella (JL) Diet doctor’s dramatic death (GB)

CHAPTER 3 EPIDEMICS AND DISEASES Civilisation or syphilisation? (GB) Plague in Sydney (GB) Coolgardie’s fevers (JL) What is more lethal than swords and guns? (GB)

CHAPTER 4 FAMOUS PATIENTS What killed George Washington? (GB) Two pairs of historic legs (JL) How Isaac Newton lost his marbles (GB) The gross disabilities of Henri Toulouse-Lautrec and Alexander Pope (JL) Fanny Burney’s battle with breast cancer (GB) Two famous skins (JL) Vivien Leigh, phantom of delight (JL) Darwin sets the cat among the creationist pigeons (GB) Monkey business in the deep south (GB) How did President Jackson get lead poisoning? (GB)

CHAPTER 5 QUACKS AND QUIRKS James Graham, prince of quacks (GB) The rise and fall of a super quack (GB) Useless medicine and surgery (JL) How common is adultery? (GB) Lydia Pinkham’s vegetable compound: The cure for female complaints (GB) 150 centuries of left-handedness (JL)

The Stockholm syndrome: Why we love our captors (GB) Do you need your head read? (GB)

CHAPTER 6 TREATMENTS AND DISCOVERIES The discovery of insulin (GB) Malaria and quinine (GB) Curare: The anaesthetist’s arrow of desire (JL) Dying to conquer yellow fever (GB) Contraception becomes unstoppable (GB) Dutch doctor defuses deficiency disease (GB) Transfusions and blood grouping (JL) The monkey gland affair (GB)

CHAPTER 7 KINGS AND QUEENS The king who grew larger than life (GB) A salutary tale for complaining doctors (JL) Did medical mishap cause World War I? (GB) Euthanasia and the death of George V (JL) A smoker’s fate: The life and death of George VI (JL)

CHAPTER 8 DOCTORS AND MEDICAL SERVICES Medicine and cricket (JL) Surgeons of the First Fleet (GB) Getting off at Redfern (GB) James Parkinson and the shaking palsy (JL) The Great Windmill Street School of Anatomy (JL) ‘Don’t think, try’ (JL) Flying high (GB)

CHAPTER 9 WARS AND REVOLUTIONS The Aztecs, smallpox and genocide (JL) Dr Guillotin and his bright idea (JL) The execution of Edith Cavell (JL)

CHAPTER 10 DISASTERS Opium in white Australia (GB) Killer doctors (GB) Is your IQ a fraud? (GB)

A

FINAL WORD:

BIBLIOGRAPHY

THE

HEALTH OF

DON BRADMAN

FLIES

IN THE

OINTMENT

CHAPTER 1 PIONEERS Sir Norman Gregg and German measles (GB) William Harvey and the circulation of the blood (JL) Australian medical women trod a stony path (GB) Edward Jenner, Lady Mary Wortley Montagu and smallpox vaccination (JL) Aspirin: A headache to early chemists (GB) John Snow, cholera, and the Broad Street pump (JL)

CHAPTER 2 FRAUDS Doctor Summerlin and his mice (GB)

CHAPTER 3 VERSATILE DOCTORS Spies, lies and secrets (GB) Doctors and buccaneers (JL) Sun Yat-sen: Doctor to all his countrymen (GB) Dr Livingstone, I presume? (JL) Servetus should have stuck to doctoring (GB) Doctor Wakley juggled three careers (GB)

CHAPTER 4 MEDICINE AND THE ARTS Somerset Maugham’s dark secret (GB) Pepys and Gibbon: The urological vagaries of two famous patients (JL) What killed Mozart? (GB) Robert Louis Stevenson and his chest (JL) The macho life and death of Ernest Hemingway (GB) A very clubbable man: A medical history of Samuel Johnson (JL) A rake’s progress: A history of James Boswell and his social disease (JL)

CHAPTER 5 OPIUM Shameful start to British rule in Hong Kong (GB) Taking opium was like playing Russian roulette (GB)

CHAPTER 6 FAMOUS AND INFAMOUS PEOPLE Ataturk and the Anzacs (GB) King Edward VII: A royal bon vivant (JL) Elvis Presley: What killed the King? (GB) Was John Curtin a war casualty? (GB) What killed Franklin Roosevelt? (GB) Horatio Nelson: Hero and adulterer (GB) Rasputin: The man who would not die (GB) Pizarro: The misplaced conquistador (GB) President Grant: From West Point to the White House (GB)

CHAPTER 7 DEATH Deaths of the famous (GB) What really killed Socrates? (GB) The mysterious death of Edgar Allan Poe (JL)

CHAPTER 8 DISEASES Iodine: Protecting our children’s intelligence (GB) The genesis of Legionnaire’s Disease (JL) Tuberculosis came here with the convicts (GB) When is cot death a cover for murder? (GB)

CHAPTER 9 DISASTERS AND ECCENTRICS Suffer the children (GB) A patient’s revenge (GB) Voyage of the damned: The Second Fleet (GB) Mad King Ludwig II of Bavaria (JL) Sauerbruch: The rise and fall of a great surgeon (GB) Medical board crucified GP (GB) The freezing of Franklin (JL) Australia doctors’ battle with lead poisoning (GB) The murky history of tobacco (GB)

CHAPTER 10 QUIRKS AND ODDITIES It’s never too late to change (GB) Truth stranger than soap opera (GB)

A great way to keep your data safe (GB) Doctor Osler, the joker (GB)

CHAPTER 11 DISCOVERIES When less is more: The legacy of Samuel Hahnemann (GB) Medicinal plants: A key link with our past (GB) French freeze out foreign feminist physicist (GB)

CHAPTER 12 MAYHEM AND MURDER The blooding of genetic fingerprinting (GB) Medical patriot or agent of death? (GB) The rise and fall of Dr Roderigo Lopez (GB) Addicts make deadly doctors (GB)

CHAPTER 13 MIDWIVES, WOMEN AND BABIES A history of midwifery (JL) Doctors and midwives at each others’ throats (GB) Wet nurses (GB)

A

FINAL WORD:

LOUIS PASTEUR —

THE GREATEST (JL)

BIBLIOGRAPHY BONUS

STORIES

TB and some of its famous victims (JL) Abraham Lincoln: A case of Marfan’s Syndrome (JL) Howard Florey: One of Australia’s greatest (JL)

CREDITS ABOUT

THE AUTHORS

ABOUT

THE PUBLISHER

Chapter

KINGS

1

AND QUEENS

MARY I OF ENGLAND AND PHILIP II OF SPAIN Mary Tudor, Queen Mary I of England, or Bloody Mary, had staunch religious convictions which made her unpopular in various parts of the country. But what nobody knew at the time was that while on the one hand she displayed energetic piety, on the other hand she had an enervating and disheartening medical condition. If it had been treated successfully the course of English history would have been changed. Mind you, she would have had to wait for over 400 years to be properly investigated. Mary was born in 1516, the eldest child of Henry VIII by his first wife, Catherine of Aragon. Her father treated her very cruelly as a child, used her in a game of political cat and mouse, and often expressed the wish in her hearing that she were dead. Not surprisingly, her health was always indifferent — although details are sketchy, as the royal archives from Windsor only date from the reign of George III (1760). It is known, however, that she suffered from bouts of fever (perhaps malaria), anorexia

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and depression. Even at her coronation in 1553 it was said she had fallen prey to melancholy to the point of illness. At the time of her coronation she was unmarried. As queen, she became a glittering prize in the dynastic stakes of Europe. In the end her second cousin Philip, later Philip II of Spain, emerged as the frontrunner. Philip’s father — the Holy Roman Emperor Charles V and Charles I of Spain — negotiated the marriage (Philip’s second). True love had nothing to do with this match. Both Philip and Mary were devout Catholics and opponents of Protestant heresy, but above all, Charles needed English support against the French. To marry Philip, Mary defied the hostility of her people. Historian Hendrik Van Loon wrote: “Stout British hearts trembled at the prospect of the Spanish Inquisition establishing itself in their midst, and stout British fists were clenched in silent menace.” Charles set down reams of instructions; Philip must be devout, never trust anyone, never show his emotions. Above all, beware the perils of the bedroom: “When you are with your wife . . . be careful and do not overstrain yourself . . . because intercourse . . . often . . . prevents the siring of children and may even kill you.” At the age of 16 he had married the Princess of Portugal, who died only days after giving birth to Don Carlos. This first son of Philip was physically and mentally deficient; Don Carlos was to die in prison under mysterious circumstances. Mary and Philip were married in 1554, and the Venetian ambassador reported the bride to be of “low stature, had large white eyes, was very thin with a red and white complexion, had reddish hair, a low and wide nose, no eyebrows and were her age not on the decline, she might be called handsome” (which leaves us to wonder what he would call ugly). Philip was 12 years younger than Mary. Mary believed herself to be pregnant on two occasions. Four months after the nuptials her breasts swelled and discharged a fluid, and she had morning sickness. The following month she thought

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she felt movements. In April 1555 she withdrew from court in anticipation of a confinement on 9 May. The doctors assembled and a woman of similar age to Mary and who had recently been delivered of triplets was brought to see the queen by way of good luck. In a flush of premature enthusiasm Philip was misinformed by the Princess Dowager of Portugal that a son had been safely delivered on 7 May. At Hampton Court, scene of the lying-in, Dr Calagila thought delivery might happen any day. That was on 22 May, but he covered himself by adding it may be as long away as 6 June. On the strength of this, letters of announcement were prepared to send to Heads of State in Europe. The date was left blank. They are now in the Public Records Office, London, still waiting to be completed and posted; for nothing happened. On 26 June Philip was informed that the calculation could be out by two months. On 29 June movements were said to be confirmed and milk expressed. Still nothing. On 29 August Philip could wait no longer and left for Spain. He did not return until March 1557, some 18 months later. By this time Mary was 40 years old and her indifferent health was not improved by worrying about her barrenness. Philip stayed for four months then left England for good. In his report home, the Venetian ambassador wrote, among other snippets, that besides bouts of melancholy, Mary suffered from “menstrual retention and suffocation of the matrix to which for many years she has been often subject”. Significantly, he also added that she was so short-sighted that a book had to be held quite close to the face, and her voice was rough and loud like a man’s. In the autumn of 1557 Mary again thought she was pregnant. Alas, she waited in vain; she was not pregnant at all. So desperate was she for a child that there was a plot to pass off a substitute male baby as her own. Mary took her childlessness as divine vengeance for the heresies still being practised in England. So she executed eminent Protestant clerics like Thomas Cranmer, John Hooper, Nicholas Ridley and Hugh Latimer. During her brief reign, Mary had over

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300 of her own subjects burnt alive. She also pushed England into joining Spain against the French. When England lost Calais, Mary bore much of the blame. She remained well, until May 1558 when intermittent fever set in. No child was forthcoming, and by October she became febrile, confused and lost her vision. On 17 November 1558 Mary died — deserted by her husband and hated by her own people — aged 42 years and nine months. She was buried in Henry VII’s chapel, Westminster Abbey. Her half sister, Queen Elizabeth I, was later to be interred on top of her, and both are there still. What did she have? Certainly two phantom pregnancies, and with the discharge from the nipple, what sounds like so-called “prolactinaemia”. The hormone prolactin is produced in the pituitary gland, which is situated in the base of the brain. Normally prolactin is released into the bloodstream after childbirth and stimulates lactation while at the same time suppressing ovulation, thus stopping pregnancy occurring during breastfeeding. If there is a tumour (or prolactinoma) of the secreting cells, then an excess of the hormone is produced; this condition is called prolactinaemia, and is nothing to do with childbearing and can occur anytime, but the effect is as though the woman has just been delivered of a child, hence the breasts secrete and she is infertile. Apart from prolactinaemia, with her stressful, lonely and deprived childhood there must have been a psychological overlay. In 1994 a research team in Lisbon found that the unusual conditions of a prolactin-producing tumour and excessive secretion of the hormone prolactin for no known reason are more common in women reared without a father, or at least one who is violent and alcoholic. It is a strange connection, but Mary could fit it on the score of paternal deprivation. But from what has been positively observed, she had lack of menses, no eyebrows, a dry skin, a hoarse voice and everdiminishing vision. The conglomerate of signs and symptoms together with her mode of death would seem to indicate a pituitary

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disorder, probably a tumour (possibly a prolactinoma) in that small but important gland in the brain. The status of prolactin in the scheme of things medical and its place in a successful pregnancy was not elucidated until the 1970s, so Mary never stood a chance as far as a successful pregnancy was concerned. What we need is a peek at the skull, especially the bony cavity or fossa wherein lies the pituitary gland. If our theory is correct, this would still show the erosion of the bony walls from an expanding tumour, even though the pituitary itself has long since rotted away. The tomb was opened about 100 years ago, but the attendant Dean of Westminster was no pathologist, so the type of conclusion we are after did not emerge. The Queen is the custodian of the Abbey and decides such things as who opens tombs. Her permission to settle our idle curiosity is unlikely. We are left to speculate — if Mary had received successful treatment for her condition, perhaps she would have had an heir and Elizabeth I would not have ascended the English throne.What about Philip? “Workaholic” is what today’s critics would label him. Hendrik van Loon just calls him “obnoxious”. According to The Larousse Encyclopedia of Modern History, Philip was “Lacking tact and intuition, he ruled his empire through a vast intelligence network and was a slave to paper-work.” Still other critics considered him dull. But such dismissals do not do Philip justice; as historian J.H. Plumb writes: . . . a distorted picture of Philip has been created . . . Protestant historians . . . have portrayed him as a dedicated fanatic, sitting like a black spider in his bleak cell at the Escorial, working endlessly day and night to crush the Dutch, to reimpose Catholicism on England . . . For these ends he was prepared to imprison his own children, to assassinate opponents, and to rack and torture all who thwarted him.

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. . . but he was far more complex and much more human than the “ogre” of Protestant historians would allow us to believe.

Indeed Philip enjoyed fishing and hunting, and appreciated gardens, buildings, music, and birds and other animals. He had the largest private library in the Western world, and also collected coins, medals, musical instruments, jewellery and paintings. He also received respect and even love from many of his Spanish subjects. He was a devoutly religious man, leading a serious, purposeful life. As well as God, Philip had to contend with the figure of his father, forever watching over his shoulder. 1558, the year of Mary’s death, was a watershed for both Spain and England. Charles’s death from gout finally ended Philip’s apprenticeship. The same year, Elizabeth I succeeded her half-sister, Mary Tudor, as England’s ruler. The English alliance was as short-lived as the marriage of Philip and Mary. The rivalry of Catholic Spain under Philip II and Protestant England under Elizabeth I dominated European politics for the rest of the 16th century. Protestantism for Philip II meant rebellion and chaos, while Catholicism meant unity and devotion. Elizabeth always tried to avoid open conflict. According to the historian S.T. Bindoff, “She would cheerfully have fought Spain to the last drop of French blood.” The struggle ran for decades — a subtle, shifting game that Elizabeth played so well. At times Philip worked to overthrow Elizabeth. But he also negotiated to marry her, and she led him on. While he lived in hope, he appeased her. So when he was not plotting against her, Philip the Catholic monarch protected Elizabeth (an arch-heretic) from the Pope’s plan to depose her by force! But Elizabeth showed little gratitude. She kept supporting his

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rebellious Dutch Protestant subjects and encouraged Sir Francis Drake to plunder and destroy Spanish ships not only in the New World, but even in Spain itself. Finally, in 1587, Elizabeth reluctantly executed her cousin, the Catholic Mary, Queen of Scots, who had been plotting to kill Elizabeth and seize the throne. All this was too much for Philip. After 30 years of struggling with Elizabeth, he finally sent the “Invincible Armada” against England. Its failure was a bitter blow to him. According to J.H. Plumb: The problems that faced Philip were as great as his empire. He was constantly at war . . . The Turks were an unending menace . . . the Dutch and the English were officially or unofficially at war with him for decades . . . Philip could never be sure whether the English pirates might not appear — burning, ravishing and robbing . . .

Apart from Spain itself, he ruled an empire of 50 million subjects. From Madrid, it took two weeks to send a letter to Milan or Brussels; two months to Mexico, and a year to the Philippines, which Spain was annexing. Philip distrusted people, and did not like to delegate. No wonder that he dealt with up to 400 documents a day. And his health? Philip’s pallor and fair hair had always made him look sickly. His diet was neither healthy nor varied. There were only two meals a day, both offering the same choice: soup, white bread, chicken, partridge, pigeon, venison or other game, beef and fish (on Fridays). Fruit and vegetables were not popular. For his constipation, Philip received turpentine, emetics and enemas. He reputedly had piles, asthma, gallstones and bouts of malaria (some have also said syphilis). The gouty arthritis that had killed his father Charles also ravaged Philip. By his mid-thirties, he had his first acute attack; within a decade, the gout had become chronic.

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As his health grew worse, so did his political fortunes. Marshall Dale believes that Philip saw his gout: . . . as God’s rebuke to a servant who was not properly diligent in the holy work of exterminating heretics and winning converts to the one true faith. His disease . . . largely explains the unspeakable cruelties inflicted by a man who was not basically inhumane upon the hapless victims of the Spanish Inquisition.

Some 35 years after his first attack of gout, Philip’s episodes gradually became more frequent and more severe. By his late sixties, one arm was nearly useless; one knee was rigid, and he could only just hobble around. But no one ever heard him complain. By the age of 70, he was nearly bedfast; he could neither dress nor toilet himself. His surgeons bled him over and over. To drain his swollen knee, they reportedly inserted threads which produced open, weeping sores. Infection wasted his frail body. Philip did not want to die in Madrid, but in the Escorial — the palace, church, monastery and school that he himself had built to honour God — about 40 kilometres away. To save him the agony of a jolting coach, litter-bearers carried him all the way. From his couch in the Escorial, Philip could draw comfort from the sight of the altar. Bedsores and ulcers now made it too painful to move him at all; the stench kept away most visitors. While the sun rose on 13 September 1598, Philip II, King of Spain for 42 years, clutched his father’s crucifix. As the children of his seminary began to sing Mass, he won final release from his sufferings. (GB & JL)

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MARIE ANTOINETTE AND LOUIS XVI OF FRANCE — AND SEX The year 1993 saw the 200th anniversary of the beheading of Louis XVI (21 January) and his Austrian wife, Marie Antoinette (16 October). To compile an essay on the medical history of beheading would be difficult, its swift finality leaves no room for conjecture, but aspects of the royal couple’s earlier life together do provide us with a few fascinating clinical morsels. In 1768 Marie Antoinette became betrothed to Louis, then Dauphin of France. She was 13 and he 14 years old. Marriage could not take place until after her first menstrual period, and as this did not manifest itself until February 1770, the ceremony was delayed until May that year. She was an attractive young woman, petite, blonde, and amiable. He was gawky, overweight, uncouth, painfully selfconscious, and described by the Austrian envoy as showing “only limited intelligence. Nature seems to have refused him everything”. His only accomplishments seem to have been an ability to hunt stag and to make locks in his private forge. Not a propitious beginning, but worse was to come. The nuptial bed was blessed by the Archbishop of Rheims; and King Louis XV, the groom’s grandfather, gave Louis his nightshirt. As the monarch was a well-known lecher whose string of conquests had included Madame Pompadour and Madame Du Barry, it may not have had much wear. The couple retired, and, half dreading, half curious at what was to come, Marie Antoinette waited. And waited. The bulky form beside her lay still, asleep. Night after night the same ritual was repeated. The chambermaids searched the dauphine’s bedclothes in vain for the telltale signs of loss of virginity, and the coy beginning soon became a matter of common gossip. Spies from the Viennese court reported back that Louis was “very much like a eunuch in his figure, and possibly a eunuch in

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fact”. The royal doctors were consulted and made reassuring noises, considering he was not yet mature and that in time, together with the right food and exercise, all would be well. To handle the royal genitals seems to have been outside the doctors’ brief, for they missed the vital clue — the unfortunate bridegroom’s phimosis. This is an inability to retract the foreskin or prepuce; during an erection, constriction of the penis by its nonretractable skin sheath causes excruciating pain. The remedy is a fairly simple operation. So, not having the gumption to seek help, the youth opted out of his marital duties altogether. Mind you, there no anaesthetic then, and the thought of knives flashing so close to the crown jewels would have caught the breath of even the most insensitive lad. So a stalemate was produced by name and by nature. To her credit, Marie Antoinette maintained her composure, at least outwardly. The two apparently discussed the problem, and surgery was agreed upon. But Louis decided to postpone things until his 16th birthday, 23 August 1770; and then, wham. Louis’ birthday came and went. The surgeon was not called and the shared virginity persisted. There was similar vacillation when he became king in 1774. As the surgeon spread out the instruments, the terrified patient fainted (surely that would have been just the moment to act!). After seven barren years, Marie Antoinette’s eccentric brother, Joseph, decided to journey from Vienna and sort them out. For the first time here was someone who did not mince matters. After a heart-to-heart he wrote to his brother that Louis was able “to have strong well conditioned erections”, but not complete the act. “He introduces the member, stays there without moving for perhaps two minutes, withdraws without ejaculating but still erect, and says good night.” Pain for Louis, disappointment for Marie Antoinette and frustration for both. The forthright Joseph went on in his blunt way: “This is incomprehensible because with all that he sometimes has nightly emissions, but once in place and going at it, never; he says plainly

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that he does it from a sense of duty but never from pleasure. They are two complete blunderers.” He wanted to whip Louis “so that he would ejaculate out of sheer rage like a donkey”. Joseph persuaded the dauphin to have the dreaded operation and advised his sister thereafter to entice her husband into bed in the afternoon when he still had energy; as later, after a meal, he would flag. Her brother then went off to reaffirm his faith in human nature by sampling the delights of the Parisian demimondes. Now, with the prodding of his brother-in-law, the deed was done, and when all was healed the seven-year-old marriage was finally consummated. At the end of August 1777 Antoinette wrote to her mother: “more than eight days since my marriage was perfectly consummated; the proof has been repeated and yesterday even more completely than the first time.” Smiles all round. Eventually, she went on to have four children, but only one survived to adulthood. But Marie Antoinette had other medical problems. When writing to her mother her whimsy was always to use the euphemism “General Krottendorf” when referring to her periods, and from her correspondence it is apparent that she had no menses for the first four months after arriving in France. With the upheaval and subsequent sexual stresses that is not perhaps surprising. But the reverse happened when Marie was incarcerated in her dank cell in the Conciergerie from 2 August 1793, when she suffered from menorrhagia, or excessively heavy periods. To add to her overall ignominy the queen, by now 37 years old and white haired, had to beg for linen rags from her attendant to help staunch the flow. The maid tore up her own chemises for the purpose. On the day of her execution the queen asked the guard if she could change her stained petticoat in private. He refused, so she took it off in front of him, rolled it up and stuffed it into a chink in the cell wall. The cell today is as she left it, chill and austere; I am

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not so sure about the undergarment. As she left to mount the tumbrel, the queen felt a need to go to the toilet. Her hands were unbound by Sanson, the executioner, and she relieved herself against the prison wall and before a clutch of bemused onlookers. Her humiliation was complete. It was sealed by her being trundled to the scaffold, where waited an inglorious end to a tragic and unfulfilled life. (JL)

DID

A MUTANT ENZYME MAKE GEORGE III MAD?

History has not dealt kindly with King George III. At school we learnt that his decision to transport convicts led to British colonisation of Australia, and that he lost the American colonies and then his wits. Historian John Clarke has called him “the only Hanoverian who could be called a genuinely decent and good man”. George was 22 when he succeeded to the English throne in 1760. Eighteen years later, soon after turning 50, he wrote to his prime minister, William Pitt, saying that on 11 June he had suffered “a pretty smart bilious attack” which forced him to bed. At the end of June, Sir George Baker, President of the Royal College of Physicians, advised rest at Kew. The king also had a spell drinking the waters at Cheltenham in Gloucestershire. But in July 1788, a month later, George suffered pain in the face and had persistent insomnia. In October, he had severe pain in his abdomen; Baker gave a purgative and opium, and reported that the king was in an uncharacteristic “agitation of spirits”. His condition worsened; more colic and constipation, muscular weakness, intractable, incessant talking, excitement, confusion, fits, failing eyesight and hearing. According to J.H. Plumb: He talked faster and faster and rarely slept.

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The Prince [of Wales, George’s son] was sent for and the King tried to throttle him. George III’s condition deteriorated rapidly and his death was expected. The Prince sat up waiting for it for two nights in succession, fully dressed . . . The King did not die, but they had to put him in a strait-jacket, and no one thought that he would rule again.

The king knew he was ill. Just like other patients of his day, he suffered not only the disease but also the cures: emetics, purges, bleeding, blistering, cupping and leeching. By November, George was reported to be “under an intire alienation of mind” and considered to be mad. The King’s disability became public knowledge. The Stock Exchange panicked. Parliament pressed the royal physicians for a diagnosis, but they could not agree. At last the Chancellor and royal family called in over their heads Francis Willis, who was both a clergyman and a keeper of a madhouse. Willis brought a strait-waistcoat, his son John and three keepers. They controlled the king by intimidation, coercion and restraint. If George refused food or even threw off his bedclothes, Willis clapped him in a “winding sheet”, or tied him to what George bitterly called “his coronation chair”. The Countess of Harcourt, Lady of the Bedchamber to the Queen, wrote: “The unhappy patient . . . was no longer treated as a human being . . . He was sometimes chained to a stake. He was frequently beaten and starved, and at best he was kept in subjection by menacing and violent language.” The Willises minimised his “excitement” by solitary confinement; not even his wife, Queen Charlotte, could visit without their approval. They treated George’s resistance to his treatments as part of his illness. In today’s terms, they simply blamed the victim. But we must not judge them by our own standards; their approach was typical of madhouse-keepers of their day. By January 1789, the need for a regency was obvious. But when the bill was with the House of Lords, the king started to improve.

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When George went bathing at Weymouth, an enthusiastic band followed him into the sea to play “God Save the King”. He remained well for the next 12 years, but had further brief attacks in 1801 and 1804. Yet, in his first 72 years of life, all George’s periods of mental incapacity hardly totalled six months when added together. But in 1810, George was reported to have suffered “a decided return of his former malady”, and never regained his health again. “His Majesty’s adherence to certain erroneous notions with some degree of consistence partakes of the true character of Insanity,” noted Dr William Heberden the younger. Parliament enacted the regency of the Prince of Wales (the future King George IV). Marshall Dale has a poignant description of George’s last years: “Stone blind and stone deaf and, except for rare lucid intervals, wholly out of his senses, the poor old King wandered from room to room of his palace . . . ” What caused the king’s recurrent episodes? Some historians said the stresses of monarchy overtaxed George’s modest abilities and caused his breakdowns. Some said he had manic-depressive psychosis (now also called bipolar mood disorder). But in the 1960s, two British psychiatrists, Ida Macalpine and Richard Hunter, claimed that George III had porphyria, a metabolic disease, in which patients show an excess of porphyrin in their blood and urine. Most forms of porphyria are inherited. The two psychiatrists supported this diagnosis by newly unearthed medical evidence of the king’s health, and an extensive review of George III’s ancestors and descendants. Macalpine and Hunter scanned 13 generations over 400 years for evidence of porphyria among the ancestors and descendants of George III, and found “the purple thread of porphyria running through the royal houses from the Tudors to the Hanoverians, and from the Hanoverians to the present day”. In all, Macalpine and Hunter diagnosed porphyria in 15 members of these three royal houses. These include Mary,

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Queen of Scots, her son James I of England (James VI of Scotland), Queen Anne, Caroline Matilda, Queen of Denmark (sister of George III), George III himself and four of his own 15 children (including the Prince of Wales, who became King George IV). On the Prussian side, there was Frederic the Great and his father Frederick William I. Coming to the 20th century, Macalpine and Hunter found four living descendants, analysis of whose urine and stools confirmed porphyria. Dr Lindsay Hurst has extended the Macalpine hypothesis. He believes that royal porphyria can be traced even further back, to Henry VI of England (1421–71) and Charles VI of France (1368–1422). But some experts reject Macalpine and Hunter’s diagnosis of porphyria altogether. In a letter to the British Medical Journal, Dr Geoffrey Dean wrote: “I shall end more firmly by promising to eat my hat . . . if the authors can produce convincing evidence that they are right.” We can never be sure. Whatever their cause, George III’s attacks did have one benefit; John Clarke has said: “The sympathy aroused by the royal malady opened people’s minds and eyes to the whole field of mental derangement and stirred the national conscience about the fate of the poor and mad.” (GB)

SOME

ROYAL OPERATIONS

One of the more memorable deathbed lines in history is when Caroline, the dying wife of George II, turned to him and gasped: “I want you to marry again,” to which he replied: “Never. I’ll never marry again. I’ll just take mistresses.” Despite his poorly timed insensitivity, he had the good grace to be weeping at the time. Caroline’s troubles started on 9 November 1736 with abdominal

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pain and vomiting. She was blistered, and given Sir Walter Raleigh’s Cordial and Duffy’s Elixir, popular patent medicines of the time. Enemas were returned without result. Indeed, everything that could be done for a queen was done. Short, that is, of actually examining her to try find out what was really wrong. If the attendant doctors could have brought themselves to do this basic medical manoeuvre, all would have been revealed. After three days of useless treatment, a surgeon was called and for the first time a hand was put on the abdomen. To his horror an enormous strangulated hernia was there for all to see and wonder at. The surgeon elected to incise the mass. A thin trickle of discoloured fluid escaped, but produced no relief. Two more days passed, the wound edges began to mortify and turn black, and the court despaired for the queen’s life. It was on this, the fifth day, that her husband uttered his immortal words. Two days later, the bowel burst, flooding the royal mattress with excrement. Caroline, 55 years old and mother of eight, bore the suffering with great fortitude and died on the tenth day. George was as good as his word. He never did remarry, though he lived for another 24 years. All told he reigned for 33 years, was the last British king to appear on a battlefield (Dettingen in 1743), and was the patron of George Frederick Handel, who composed a variety of well-known pieces in his honour. George II’s greatgrandson, George IV, is well known to medical history for harbouring an enormous infected sebaceous cyst on the back of his head. It first appeared in 1820 and when the festering wen became too noisome for decent society, the foremost surgeon of the day, Astley Cooper, was called. He took one look, refused to operate for fear of spreading the infection to the brain, and withdrew. It was one of the shortest consultations in regal history. The king took it in good part, but a year later Cooper was summoned again, this time to see his majesty in the Pavilion at Brighton. He arrived by coach from London in the middle of the

night to be told the monarch insisted that the offensive lesion be incised there and then. Treating a sebaceous cyst at 3 a.m. was not the eminent surgeon’s idea of a night out, and he bravely refused the royal command. The next day they returned together to more familiar ground in London. There Cooper dissected out one side, passed the scalpel to his assistant, who did the other, while the king sat quite still. Astley Cooper’s reward was a baronetcy (it is uncertain whether honours were heaped on the second surgeon, despite his doing half the job). In 1862 the 72 year old Leopold I of Belgium went to see his niece, Queen Victoria. While staying at Buckingham Palace he was seized with the torturing pain of bladder stone. The queen’s surgeon, Sir Benjamin Brodie (later to have a special type of abscess named after him) told the visitor to go home and send for Europe’s best lithotomist, or stone remover, Dr Jean Civiale of Paris. Civiale came with his patent lithotrite to crush the offending item. He had two goes, failed to grasp the illusive calculus, but did succeed in inducing bleeding, pain and fever. The well-favoured Dr Bernhard von Langenbeck was then summoned from Berlin. He applied the lithotrite four times. More haemorrhage and rigors, to say nothing of acute discomfort, but still no ping in the bucket. In desperation a plea went out to Henry Thompson, a young “stone crusher” who was making a name for himself in London. With the brashness of youth he had the offending calculus in his grasp first go. There was no bleeding or fever as the oxalic shards were “pissed away”, to use the contemporary vernacular. Lack of infection puzzled him, but in ignorance of the bacterial cause of infection in these pre-Lister days, the reason was almost certainly due to the fact that the instruments used were brand new. Indeed Thompson was later to recall taking them out of their original wrapping paper in the royal bedroom. The lithotrites of the other surgeons glistened with the scarcely rinsed-away urine of a hundred previous sufferers.

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Leopold gave the young man the right princely sum of £3,000. He was knighted by Victoria and became the toast of London. In 1872 Napoleon III was living in exile in Chislehurst, London. He knew he had a bladder stone and that year it flared up. The by now Sir Henry Thompson was summoned. He crushed the stone under anaesthetic, but only got half away. The remainder became jammed in the passage between the bladder and the outside. Another dash was undertaken. It was apparently successful, but urinary symptoms persisted. A third anaesthetic was deemed necessary, but just before the operation Napoleon collapsed and died. No huge hand-out or honours this time. A post mortem showed the kidneys to be bags of pus and in the bladder there was still a fragment of stone. To fail when treating royalty must cause the odd sleepless night as well as loss of face. Yet things are not as bad now as in the time of blind King John of Bohemia (1296–1346) who is said to have drowned all his surgeons in the Danube when they failed to restore his sight. But other days, other mores. As for Sir Henry Thompson, he became very wealthy, was one of the first doctors in London to own a motor car, and collected porcelain, wrote novels, exhibited his paintings at the Royal Academy and generally basked in the sunlight of success. (JL)

OPENING

THE TOMBS

Gazing on the dead long after their demise seems to hold a macabre fascination. Look at the hype which surrounded the discovery of the tomb of Tutankhamen; Beethoven’s body was dug up twice to try and help diagnose his deafness after his ossicles had been misplaced by the pathologist, who was, incredibly, called Wagner. Mainly out of curiosity, one set of graves which have been extensively ransacked down the years have been those of English

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monarchs. Let’s look at a few. William the Conqueror died in Rouen, France, in 1087, ten days after being thrown from his horse. He was buried at the abbey he founded in Caen, northern France, in a stone coffin so small the body had to be bent double. On instructions from the Pope, the tomb was opened in 1522 and the body said to be found in a reasonable state of preservation. It was reinterred. In 1562, the abbey was pillaged by Calvinists, and the bones scattered, with the exception of one femur. This relic was preserved and reburied in 1642 under a monument, which in turn was demolished during riots in 1793. Despite heavy fighting in the area of Caen during World War II, the femur’s resting place was undamaged. However, it was opened in 1987, and a thigh bone was indeed found. It was reinterred. William’s son, William Rufus, was shot by an arrow by person or persons unknown while hunting in the New Forest. Tradition has it that his body was trundled on a charcoal-burner’s cart to Winchester Cathedral for burial. The grave was opened in 1968, nearly 900 years on. Among the bones was an arrowhead. Richard I (Richard the Lionheart) spent most of his time fighting abroad. His body was buried in 1199 at the feet of his father, Henry II, in Fontevrault, France. His heart went to Rouen Cathedral. In 1838 a small silver box, believed to contain the heart, was discovered in Rouen. When the box was opened, the contents may indeed have once been a heart, but by now were found to be “reduced to the semblance of a reddish leaf”, according to Brewer. When Henry IV died in 1413 it was said his body and face were contracted by leprosy. But when viewed again in 1832, his face was in complete preservation and adorned by a full beard of deep russet colour. Henry’s face certainly was not leprous. Historians would love to get a look at Henry VIII to confirm or refute the syphilis legend. He lies in St George’s Chapel, Windsor, but nobody has had the nerve to ask Queen Elizabeth II for permission. Idle curiosity is not perhaps a good enough reason to go fossicking about among her ancestors. However, when Queen Victoria gave permission to survey the tombs in Westminster

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Abbey, the burial place of James I of England (James VI of Scotland) was rediscovered. He died in 1625 and nestles in with Henry VII, who died in 1509. Charles I was beheaded with a single stroke in 1649. His body was embalmed and placed on public display for a week. It was then taken to Windsor and placed next to Henry VIII (who had died in 1547) in a space which that king had left for his sixth wife, Catherine Parr. The snag was that she had remarried after Henry’s death and so was beyond the pale as far as sharing eternity with her former husband was concerned, and so she is buried elsewhere. Following his spectacular denouement, Charles lay undisturbed with Henry until 1813 when workmen preparing a tomb (seven years too early!) for George III accidentally broke into his grave. The Prince Regent was informed, and together with the royal physician, Sir Henry Halford, he rushed round to take a look. A decayed wooded coffin was found inside a lead one. A small opening was made and the shroud torn away. The skin was dark but the musculature of the face remained and the famous “Van Dyke” beard was intact. He was easily recognised from contemporary paintings. The head, of course, was loose and when held up to view it was seen that the hair on the neck had been cropped. The neatly severed fourth cervical vertebra was smooth, even and awesome. Charles was returned to his resting place, but when all had been resealed, the severed vertebra was found to have been left out. Halford kept it, had it mounted and used it as a saltcellar. It remained in the family until 1888 when it was returned to Queen Victoria. She had it put in a suitably engraved tiny casket and lowered through a small hole in the chapel floor onto the top of the coffin where it still is. Oliver Cromwell died of natural causes in 1658 (probably malaria, then endemic in England) and was buried in Westminster Abbey. At the Restoration in 1660, his body was dug up and hung at Tyburn, the execution ground near the present day Marble Arch. The next day his head was hacked off, the body buried at the foot

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of the gallows and his head taken to Westminster Hall, where it was displayed on a spike until 1684. It then blew down in a gale and was retrieved by a guard, who smuggled it home. Eventually sold by this man’s daughter, it passed through several hands until left in a Canon Wilkinson’s will to Sidney Sussex College, Cambridge. It was displayed from time to time and was last seen publicly in 1911 at the Royal Archaeological Institute. This irreverent gorping was then considered unseemly and after much debate it was buried by the college in 1960. To avoid student pranks this took place at a secret location. Between the years 1683 and 1710, Queen Anne had 17 pregnancies. All but one were stillborn — even the survivor, William, died in 1700 at the age of 12 — and child after child was lovingly enclosed in winding sheets and placed in the tomb of Mary Queen of Scots in Westminster Abbey. The tragic Queen Mary had been buried at Peterborough in 1587, but in 1612 was reinterred at Henry VII’s chapel at Westminster by her son, James I. Her fine sarcophagus became the repository of numerous fringe royals. When it was opened in 1867, besides Mary herself and that pitiful roll call of Anne’s offspring, there were found her own natural son, John Darnley; her grandson, Henry; her grand-daughter, Elizabeth of Bohemia; her great grandson, Prince Rupert; Lady Arabella Stuart; and sundry illegitimate children of the libertine James II of England (VII of Scotland). Is it in the interest of science or for mere curiosity that medical historians would so love to have one last peek in these tombs? As things are, the authorities think the latter. Pity! (JL)

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Chapter

2

ECCENTRICS, REFORMERS AND PIONEERS

THE

BIZARRE AFFAIR OF JAMES BARRY

“For a woman to succeed in a man’s world, she has to be twice as good as a man. Luckily, this is not too hard!” — Anonymous

About 1795, a daughter was born to the Barry family in London. For some reason, it was an aunt and uncle who raised her. The latter, a well-known painter, James Barry, believed in encouraging both males and females to achieve their potential. But this gem of an uncle died when the girl was only 11. She took her love of learning from him, and also his given name. At 15, “James” and the aunt moved to Edinburgh, where she passed herself off as a male to join the University Medical School. No way could she have done so as a female; that milestone was still over half a century away.

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Though fellow-students teased her about her slight build and hairless chin, she kept her secret safe. Her only close friend wanted to teach James to box, but she learnt the rapier instead. At 17, she completed a brilliant thesis on hernias. At the early age of 20, she gained her MD by defending this thesis against interrogation by the whole faculty, and by discussing two of Hippocrates’ Aphorisms. Much of this, of course, was in Latin! In 1813, she somehow avoided the usual physical examination, satisfied the Army Medical Board, and started on her lifetime career in military medicine. Soon she distinguished herself at the Battle of Waterloo. Next she coped well with a cholera epidemic at Cape Town. There she also saved a mother and child by performing a Caesarean delivery. Well before the time of antiseptics and anaesthetics, this was an exceptional outcome. Soon she rose to become private physician to the governor of Cape Town. Wearing high-heeled boots and satin waistcoats with padded shoulders, James won the favour of many ladies. Since she excelled at duels, the men didn’t dare rib her about her high voice or the little dog she always kept with her. By 1821, as colonial medical inspector, James was able to raise the level of medical care. For example, she decreed that only physicians or apothecaries should prescribe drugs, saying: “Pedlars and hawkers of drugs . . . do more real injury . . . than the most virulent diseases.” She also drafted the enlightened Rules for the General Treatment of Lepers and complained to the governor about floggings at the prison. Naturally such a stirrer made enemies. Headstrong and quarrelsome, James herself often went to prison for breaches of discipline, but never for long. In 1845, aged 50, she got the dreaded yellow fever. James forbade her colleagues from calling on her, and asked that if she did die, she should be buried fully dressed. But her assistant did visit while she was delirious and saw that James was no man. When James came to, she swore her assistant to secrecy.

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After a year’s sick leave she returned to duty. During the Crimean War, 400 of the 500 wounded in her hospital recovered; another exceptional result. At 62, as inspector general of all British Army Hospitals in Canada, she worked to improve the food, water and hygiene in her camps. When she died at 71, they found on the bedpost the sheet she had worn to flatten her breasts. Her unsuspecting valet had served her for 40 years. Had the army followed her request for instant burial in a sack, James would have taken her secret with her to the grave. But they called in a charwoman to lay out the body. She was furious: “What do you mean by calling me to lay out a general, and the corpse is a woman’s, and one who has borne a child?” The army authorities continued the deception; both her death certificate and her tombstone show her as a male. But there were many red faces at the War Office when her obituary appeared in the Manchester Guardian: Officers . . . may remember . . . Dr Barry . . . enjoy[ed] a reputation for considerable skill . . . in difficult operations. This gentleman had entered the army in 1813 . . . passed through the grades of assistant surgeon and surgeon in various regiments . . . Upon his death, [he] was discovered to be a woman.

Over 80 years later, the Journal of the Royal Army Medical Corps gave her a fitting epitaph: Whoever was “James Barry”, she has the distinction of being first — the first woman doctor of the British Isles. Secondly — one who has . . . served her country in all climates with distinction, and if she preferred to do so by the only way available in her lifetime, by assuming the trappings of the male sex, all the more credit to her courage and pertinacity.

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If James Barry was the first known female medical graduate in the English-speaking world, albeit a status gained and maintained in heavy and lifelong disguise, who were the true believers who slugged it out with the medical establishment to gain the first legitimate toehold for women in the medical profession? Elizabeth Blackwell, an American graduate of British birth, is regarded as being the very first. The Blackwells were a middle-class family from Bristol, England. Elizabeth’s father, Samuel, a sugar-factory owner, was a religious man and held unfashionable ideas on equality in education and independence for both sons and daughters. She herself was born in 1821, the third of what were to be eight surviving children. When Elizabeth was 11 years old, financial disaster overtook her father, and the family migrated to New York. Samuel died a bankrupt when Elizabeth was 17, whereupon she and her sisters opened a school and paid off the debts. Although there had never been a female medical graduate in America, she was determined to become a doctor, partly to fulfil her father’s ambition, partly to right the wrong a friend had suffered — the friend had died from a uterine disorder as she would not seek advice from a (male) doctor — and partly to satisfy an urge in her feisty nature to do the impossible. After 29 colleges had refused her application, Geneva College in New York State agreed to take her. The faculty had initially refused her application, but agreed to refer it to the student body, stipulating that any decision regarding admission must be unanimous. The students foresaw entertainment and notoriety, and voted “yes” — with one exception, and he was sat upon until he changed his mind. Miss Blackwell did the then usual two-year course, graduating as best student in 1849, and by so doing she seems to have set a pattern of excellence that women in medicine have found difficult to shake off since. Nonetheless, at her graduation ceremony she declined to walk in the academic procession “because it would not be ladylike”. Her success inspired the English humorous journal Punch to publish some congratulatory verses to “Doctrix Blackwell”.

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Although she was well received, almost feted, in New York, it was more as a freak than as a serious medical doctor, and openings did not present themselves. Elizabeth went to the more liberated Paris, but found that she could only get a job as a midwife. At work she contracted an inflammation of the eyes, which was diagnosed as gonococcal ophthalmia. In June 1850 the affected eye was excised, leaving shattered any thoughts of her being a surgeon. Dr Blackwell was welcomed in London, again perhaps more as a curiosity. At St Bartholomew’s Hospital she was able to work in every department except gynaecology! On her return to America she received social and professional antagonism, and was refused every post at every hospital to which she applied. She began to lecture on “The Laws of Life”, became known about town and steadily built up a large private practice, mainly of young and indigent women. Ultimately she opened a hospital staffed entirely by women. In 1869 she moved permanently to England, and in the teeth of great opposition helped found the London School of Medicine for Women (later the Royal Free). For a short time Elizabeth Blackwell was its professor of gynaecology. Dr Blackwell never married but did adopt a seven-year-old orphan, Kitty Barry (no relative to her enigmatic predecessor). Elizabeth Blackwell continued to write on medical issues throughout her life, eventually dying in Hastings in 1910 aged 89. Kitty died in 1936. The first female medical student in Australia was Dagmar Berne, who enrolled at Sydney University in 1885. There seems to have been no overt hostility from male staff or students and she completed the four-year course without incident. Then she blew her chance of becoming Australia’s first registered female doctor by electing to transfer to Great Britain to pass out as a Licentiate of the College of Physicians of Glasgow and Edinburgh and Licentiate of the Society of Apothecaries of London. Dr Berne returned to Sydney in 1895, practised briefly and died of

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tuberculosis in 1900 aged 34. Adelaide University enrolled Laura Fowler as its first woman medical student in 1886. She graduated in 1891, but did not register until March 1892, again thereby denying herself the unique honour of being number one on the register. Nonetheless, Dr Fowler had a long and eventful life, including missionary work in India and being held prisoner in Serbia in World War I. She died in 1958. At Melbourne University, no less than seven women enrolled as medical students in 1887. All eventually graduated, but the first two (in 1891) were Clara Stone and Margaret Whyte. They went on the register at once, thereby pipping Laura Fowler at the post and have their names writ large in the history of Australian medicine. Today in Australia there are more female than male medical graduates. (GB & JL)

F R A N C I S G A LT O N , THE MAN WHO WALKED NORTH, SOUTH, EAST AND WEST “He was a rough-cut genius, a pioneer who moved from one new field to the next, applying methods developed in one to problems in another, often without rigor, yet usually with striking effectiveness.” — Daniel J. Kevles

The Art of Travel (1855) by Sir Francis Galton was full of handy tips. If you were a long way from home and feeling under the weather, just drop a charge of gunpowder into warm soapy water and glug it down. Sore feet? Blisters? Just make a lather of soapsuds inside your socks, and break a raw egg into each boot to soften the leather. You want to keep your only set of clothes dry when it rains? Take them off and sit on them!

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Galton (1822–1911) was an English eccentric, explorer, geographer, author, inventor, meteorologist, anthropologist and statistician. Some have called him the father of modern psychology. Just before his fifth birthday, he boasted that he could read any English book, say all the Latin active verbs and recite 52 lines of Latin poetry. He must have been an insufferable brat. An expert later calculated Galton’s IQ at over 200 (but gave Galton’s first cousin Charles Darwin only 135 and Copernicus only 110!). He studied medicine at Birmingham University and King’s College, London. As a medical student, he proposed that there should be an “index of curative skill” to measure doctors’ merit and to regulate their fee. He did a statistical study of the efficacy of prayer. Findings: though churchgoers all over Britain prayed every Sunday for the lives of the royal family, the royals did not live longer than others. Galton dropped medicine when his father’s death gave him an independent income. In 1850 he set off to explore Syria, Egypt and the Sudan; then vast areas of South West Africa. Hearing that Hottentots were killing off missionaries, he demoralised their ferocious chief by wearing a pink hunting coat, riding into his doorway on a snorting ox and telling him to stop! Back in London after covering 2,700 kilometres in two years, Galton became a Fellow of the Royal Society. He was one of the first to discover that we each have a unique set of fingerprints that do not change with age. After Scotland Yard put Galton in charge of Criminal Investigation, his Fingerprints Branch successfully identified over 100 criminals in six months. Today we still use his system of arches, loops and whorls to classify prints. He devised a method to decimalise British currency; a method which resembled the one finally adopted in 1971. At home, he rigged up a signal that told everyone when the lavatory was engaged: “It saves a futile climb upstairs and the occupant is not subjected to the embarrassment of having the door

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rattled.” Galton often said: “Whenever you can, count.” He saw measurement as the basis of science. This passion for statistics enabled him to prepare weather charts more accurate than any before; he also discovered and named the anticyclone. Galton wanted to compare the number of beautiful girls in British cities. First he invented a pocket counter; then he toured the cities pressing the button every time he saw a beauty. London had the highest beauty quotient, while Aberdeen was lowest. But his life-interest was heredity. We can only speculate whether the infertility of his own marriage spurred this obsession. His genetic work on peas closely resembled that of Gregor Mendel, though he didn’t then know of Mendel. Galton was the first to separate the effects of nature and nurture by studying both identical and non-identical twins. In 1859, Charles Darwin’s The Origin of Species by Means of Natural Selection spurred Galton to look for ways to improve the human race. The idea was not new. Plato’s Republic idealised selective breeding. To prevent the human race from degenerating, Plato urged us to apply to humans the methods of breeders of dogs and birds. In Galton’s own work Hereditary Genius (1869), he concluded from a mountain of statistics that, given a fairly similar environment, most differences in ability are inherited: “nature prevails enormously over nurture when the differences of nurture do not exceed what is commonly . . . found among persons of the same rank of society and in the same country”. Moreover, Galton believed in one general ability, rather than in specific talents or aptitudes. When a historian argued that it was their specific specialised abilities that had made Caesar a great commander, Shakespeare a great poet and Newton a great scientist, Galton quoted Samuel Johnson: No, it is only that one man has more mind than another. He may direct it differently or prefer this study to that. Sir, the man

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who has vigour may walk to the North as well as to the South, to the East as well as to the West.

Galton argued for selective breeding between healthy people of ability. “It would be quite practical to produce a highly gifted race of men [obviously women didn’t get equal attention] by judicious marriages during several consecutive generations.” He urged the state to run competitive exams for hereditary merit, applaud the winners at a public ceremony, celebrate their weddings at Westminster Abbey, and give them grants to encourage their breeding! There was a downside as well. Galton advised “stern compulsion . . . to prevent the free propagation of the stock of those . . . seriously afflicted by lunacy, feeble-mindedness, habitual criminality and pauperism.” He coined the term eugenics (Greek for “good breeding”). In 1907, he founded the Eugenics Education Society, which influenced birth control, abortion reform, sex education, marriage guidance, family allowances and taxation. But Galton did not want revolutionary change. He would have approved of genetic counselling, but he would have been appalled to see eugenic ideas used to defend the Holocaust. Galton died in 1911, at the age of 88. His estate funded a Chair of Eugenics at University College, London. (GB)

MARIE STOPES, CHAMPION OF CONTRACEPTION Jeanie, Jeanie, full of hopes, Read a book by Marie Stopes. Now, to judge by her condition, She must have read the wrong edition. — Skipping chant, London 1924

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wedding present in 1947 was Married Love. It was a gift of the author, Marie Stopes, who in a covering letter said: “It seemed best to wait until you were married, and I now send it in the hope that you may be able to read it together.” It needs some gall to be so presumptuous, and Stopes had plenty of that. It was hardly surprising that, as with the copies sent years before to Queen Mary (mother of seven) and the by then 10 years widowed Queen Alexandra (five children), the gift elicited no response. Yet since its appearance in 1918 the book has sold well over a million copies and been translated into 13 languages. In 1935 American academics voted it 16th out of the 25 most influential books of the previous 50 years. It was just behind Marx’s Das Kapital and just ahead of Einstein’s Relativity. Dr Marie Stopes was a determined, single-minded, querulous and highly intelligent woman whose public behaviour became more eccentric as the years passed. She was born in Surrey in 1880. She studied botany at University College, London, graduating with first-class honours, and then went on to Munich where she obtained her doctorate. Her speciality was palaeobotany, and she was later to write the definitive work on the constitution of coal. She never had any formal medical training. As a young woman Marie had a number of suitors, but they were only entertained on a cerebral level; if passion did exist, it was confined to skittish and ebullient correspondence. She did chase one man to Japan, but it came to naught. On the rebound she married a pallid and sensitive fellow-botanist, Ruggles Gates. That was 1911. When they were divorced five years later she was still a virgin. But she had not completely wasted her time, for during the final arid couple of years she wrote what was to be her best-selling sexual treatise, Married Love. In the circumstances it would appear to have been something of a paradox, but maybe it helped set out her yearned-for ideal. The book was published in March 1918. Three months later she married Humphrey Vernon Roe and finally was able to test theory

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against reality. The wedding was solemnised by the Bishop of Birmingham, who, in a madcap moment of abstraction, had himself asked for her hand a short time before. The book was the first “sex manual” in the English language and its mere 116 pages meant that lusty teenagers could easily hold and read it under the bedclothes. Alternatively, it could be folded within the covers of the Anglican prayerbook. At one London club it was in such demand that members were allowed to read it for only an hour at a time. Today we wonder at its innocent, even puritanical, nature, but then it was dynamite. It spoke of “stirring a chaste partner to physical love”. It blamed a wife’s “coldness” on the husband’s “want of art”, and called for the “profound mutual rousing of passion”. It contained contraceptive advice and extolled the liberation of women from the yoke of childbearing and male insensitivity. Its hitherto unknown free-thinking ethos was heady stuff and ensured the book’s immediate success. It ran to six reprints in six months. Dr Stokes became a national figure with a vast correspondence, much of which revealed the depth of sexual misery and prejudice within the population. Clergymen featured large among the letter writers. An Essex vicar wrote about his frigid wife: “She is slow to rouse, once or twice a year . . . I am afraid I bore her . . . Single lust is a feeble squib; I want fireworks.” One from Gosport: “If I have touched my wife near the entrance she is much more ‘lively’ . . . I feel dreadful having written so frankly.” Another from Newark: “how best to arouse . . . my Wife always lies with her back to me, I make a ‘tender advance’ . . . and the end of the poetry is ‘I do not like your breath on my face’.” A comi-tragedy unfurled, which was sometimes leavened by missives from the likes of the ubiquitous “Disgusted”. One such with nine children angrily wrote: “If God sends the babies, he will also send their breeches.” Perhaps the most poignant was from a Yorkshireman who wrote about alternative methods of contraception. For him it amounted to “rubbing ‘stuff’ out of penis by hand of either self, wife or a middle

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aged widowed cook in absence of wife”. The mind boggles. The medical profession was divided. Apart from obstetrics, sexual physiology was not taught at medical school; indeed there was precious little to teach. Knowledge of hormones was in its infancy, and all, including Stopes, thought the ‘safe’ period was in the middle of the month — we now know that this is, in fact, the most fertile period. To the profession’s amused contempt Stopes opened a birth-control clinic in 1921, mainly fitting cervical caps. It made a slow start but enough to outrage the Catholic Church, which intensified the scorn and vilification it had heaped upon her for the previous three years. Though she had been denounced as immoral, Stopes held her hand. Then Dr Sutherland, a staunch Catholic, wrote that she was conducting “a monstrous campaign of harmful methods” (cervical cap), and “a class conspiracy against the poor”. Although Sutherland’s words were mild when compared with the usual abuse, she snapped and sued for libel. Sutherland won, but obtained a derisory £200 damages. Stopes appealed and the judgment was reversed. The Catholic Church was not to be denied, however, and appealed to the House of Lords inviting monetary contributions from “right minded people”. Three of the five Law Lords were over 80 years of age, and Stopes lost 4–1. Sales of Married Love reached the half million mark. Over the next 20 years Dr Stopes undertook numerous other legal battles with varying success. She also wrote two more big sellers, Wise Parenthood and Radiant Motherhood (both before her only child was born), but Married Love stands supreme. She and her second husband became estranged after 10 troubled years of marriage. She treated her son, Harry, in a bizarre way, not allowing him to read until he was 10, forcing him to have only carrots in the morning, and dressing him in knitted frocks so as not to interfere with the growth of his genitals. In the end mother and son fell out and she cut him out of her will. Although she was certain she would live to be 120, Marie Stopes died in 1958, aged 78. While regarded by many as paranoid and/or

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a deluded megalomaniac, it was the very nature of her overdrawn personality and unappeasable pugnacity which allowed the emotive subject of sex to be thrust into the full sunshine for the first time. It remains there today. (JL)

E L I Z A B E T H K E N N Y, THE BUSH NURSE WHO TOOK ON THE DOCTORS “I was supposed to get married . . . to justify my existence” — Elizabeth Kenny “How can we explain this woman who was called both a fraud and a medical genius, a cheap quack and an unhappy martyr, a raging old tiger and a merciful angel?” — Victor Cohn

Elizabeth Kenny was born in Warialda, New South Wales, in 1880. After several moves, the family settled on the Darling Downs in Queensland. She planned to work as a missionary in India, but at 33, she became a volunteer nurse in a local maternity hospital. Next she was an unpaid visiting bush nurse in Queensland, by necessity often acting also as doctor and midwife. In 1911, when Kenny was 31, she saw a feverish girl aged two, who was paralysed in one arm and both legs. By telegraph, Kenny consulted her friend Dr Aeneas McDonnell, who could only advise: “Infantile paralysis (polio). No known treatment. Do the best you can . . . ” Kenny tried poultices without result, so she applied bits of blanket soaked in hot water. Soon she started moving the paralysed limbs and also encouraged the girl herself to try to move them. Moving limbs affected by polio was medical heresy, but Kenny did the same with five other children. Dr McDonnell was surprised to

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hear that all did well. In 1915, she enlisted in the Australian Imperial Forces. From Nurse, she rose to Staff-Nurse, and later to Sister. While serving in France, she herself was wounded, and won a British War Medal. After the war, Kenny returned to bush nursing. According to the accepted teaching of the day, since polio weakened affected muscles, these weak muscles needed splinting. Without splinting, people believed, the unaffected strong muscles would pull the weak ones out of place. Doctors “knew” all this. With her usual total confidence, Elizabeth Kenny disagreed: “No, I see only tight, shortened muscles in spasm — your splints and casts are illogical; throw them out.” She invented and patented a stretcher that enabled people in shock to receive treatment while being transported. In the polio epidemic of 1933, she used her royalties to open a free clinic in a Townsville backyard. There she treated patients disabled by polio. She replaced the conventional splints, braces and callipers with salt baths, foments, and exercises. The following year the Queensland government appointed staff to work with Kenny to research unfantile paralysis. The “Kenny Clinic” was the first nursing research clinic in Australia. Her results impressed a few doctors, but most opposed her vigorously; one of the latter wrote: “This quack must be exposed.” But Kenny clinics opened in Townsville, Cairns, Rockhampton, Toowoomba, Newcastle, Sydney and Melbourne. One headline acclaimed her as “A new Australian Florence Nightingale”. Her public support grew and grew, and not only in Australia. Grateful parents of children she had helped paid her fare to England, where she cared for inpatients at Queen Mary’s Hospital in Surrey. In 1935, the Queensland Government appointed a Royal Commission of doctors to review the treatment of polio. After three years, they reported: “The abandonment of immobilisation is a grievous error.” However, the report was never requested nor

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presented to Parliament. The government nevertheless gave her a ward at the Brisbane Hospital. Here she could treat early cases of polio, who might respond better than older cases. Kenny’s few medical friends convinced the government to pay her fare to the United States. Many American doctors rejected her explanations, with some accusing her of using hypnosis. But she did gain the use of beds at the Minneapolis General Hospital, and the support of three orthopaedic doctors. One of these, Dr John Pohl, wrote: Before she came . . . you would have seen little kids lying stiff and rigid, crying with pain . . . We’d take children to the operating room straighten them out under anaesthetic, and put them in plaster casts. When they woke up, they screamed. The next day they still cried from the pain. That was the accepted and universal treatment . . . She said, “That’s all wrong.”

In 1941, the American Medical Association endorsed the Kenny treatment that the Queensland Royal Commission had rubbished five years earlier. Doctors and physiotherapists from Greece, Russia, Turkey, Belgium, Germany, Sweden and China flocked to learn her methods at the Sister Kenny Institute in Minneapolis. The New York Sun named her the world’s “Outstanding Woman of the Year”. In 1950, America awarded her Free Passage across its borders; an honour Elizabeth Kenny shared with French General La Fayette. Many grateful people remembered that for over 20 years, she never took a penny for her work. But Elizabeth Kenny herself and her teachings remained controversial. Her dogmatic belief in her own God-given gifts actually hindered her cause. She was merciless with anyone who dared to doubt her. Had she been gentler, could she have been more

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effective? Or would the critics have just ground her down? She published two textbooks on her treatment of polio, as well as an autobiography and was awarded three honorary doctorates from leading American universities for her contribution to polio research. In 1951 she retired to Toowoomba, where she died a year later. The Sydney Morning Herald mourned “the loss of one of our great ones”. The influential British Medical Journal said: The influence of Sister Kenny on the treatment of infantile paralysis has been exceedingly beneficial . . . in an empirical way she hit on much that was good in the treatment of poliomyelitis, and . . . wakened orthopaedic surgeons and physiotherapists the world over.

Sadly Elizabeth Kenny herself did not live to see this blessing by the medical establishment. The world has gradually accepted modifications of her teaching on the treatment of polio. (GB)

PAUL WHITE, JUNGLE DOCTOR Dr Paul White, the Jungle Doctor from Australia, earned renown for his work in the 1930s in Tanganyika, East Africa. There, despite his lifelong asthma, he was far more than a medical missionary: he was a surgeon, anaesthetist, pathologist, pharmacist, handyman and building supervisor. Dr White learnt his first lessons in hygiene and public health as a small boy in Bowral: Before dawn, each Friday, a shadowy figure would come to our outhouse and play his key part in our pan-andfly hygiene system. He was also our mayor, carrying off all his ceremonial duties spruce and shining in his robes of office.

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At a Christmas party, one of my mother’s staidest friends asked me for a poem. I recited one our mayor had left us: “Although the police keep order There’s no more useful man Than the bloke who comes at sunrise And juggles with the pan.” To my amazement, they stopped me.

In 1921, his widowed mother and young Paul moved to Sydney. At Sydney Grammar School, he became a runner, cricketer and active Christian. He started his medical course in 1929, at the height of the Depression. Paul gained a University Blue in 1931 and 1932. In my third year, I ran in the Intervarsity athletics. A Melbourne runner, Wellesley Hannah, beat me over the mile. Then I found that he was also a committed Christian. This friendship was to change both our lives. As medical students, we followed the desperate search for weapons against the great killers like pneumonia and meningitis. I felt especially bitter about meningitis which had killed my father. By the time I graduated in 1935, I’d decided to work as a medical missionary in East Africa. First I spent one year at Royal North Shore Hospital, where our training included infectious diseases and obstetrics. For anaesthetics, we used the old ether with a rag and bottle. As interns we earned eleven [shillings] and threepence a week and had every third weekend off. In my spare time, I practised tracheotomy [emergency opening of the windpipe to bypass blockage] on an old piece of garden hose. Soon after, I had to do the real thing on a small boy who had severe diphtheria and couldn’t breathe.

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He met many challenges during his preparations: Most of our equipment was borrowed: if we couldn’t get it, we had to make it; if we couldn’t make it, we had to go without. Mosquito nets were crucial, since mosquitoes transmit malaria, yellow fever, dengue and elephantiasis.

Among the things he learned: keeping a corrugated-iron roof cool, making a surgical retractor from two bent spoons, driving through mud or sand, and plugging a hole in a radiator or petrol tank. In 1937 Dr White, with his wife Mary and son David, sailed to Dar-es-Salaam, the capital of Tanganyika (now Tanzania). Then to Dodoma and Mvumi. Sechela the head nurse welcomed us with her story of a cobra emerging from its hole to watch her delivering twins. Over 100 people came for my first outpatient session; some walked 50 kilometres. Relatives led the elderly who were blinded by cataracts. We had so few medicine bottles that people brought their own. Those with malaria shivered in the scorching sun. Our only antimalarial was quinine, which we bought from the Tanganyika Post Office for two shillings per 100 tablets. Our operating room of granite, cement and corrugated iron cost 120 pounds. A burly African pedalling a jacked-up bike which charged a battery, gave most of our light. We built our anaesthetic machine from a pickle bottle, a car footpump, a football bladder, the Y-piece from a stethoscope, an eye-dropper glass and rubber tubing. It worked really well.

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I removed many cataracts; trachoma I treated with surgery and zinc sulphate drops that cost threepence. Twelve times a day, our two water carriers made their round trip of over three kilometres. Each carried 36 litres in petrol cans. Twice a week, the mailbag came, along the paths where lions and rhinoceros prowled. The dry season lasted eight months and ended in October with torrential rain. Within minutes, a parched riverbed became a torrent. Within two days, grass would grow. We built water tanks to see us through the next dry, only to see them cracked by an earthquake. In one hour, we helplessly watched three months’ water disappear. Once sulphonamide drugs were discovered, we could fight the next epidemic of meningitis. Our second child Rosemary was born in 1939. After my wife’s illness forced us to return home, Wellesley Hannah came to Tanganyika to take over from me. He stayed 20 years.

Dr White’s Jungle Doctor books numbered 54 and have appeared in over 100 languages. In 1977, he published an autobiography titled Alias Jungle Doctor. Later he was awarded the Order of Australia Medal (OAM) for services to religious welfare. Dr White died in 1992, at the age of 82. (GB)

BERTRAM WAINER,

ABORTION LAW REFORMER

“I did not set out to be a reformer; I . . . became involved with a law which was inflicting human suffering” — Bertram Wainer

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Melbourne, 1968. She was 21, and had already had a baby at 15.

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Now she was pregnant again. Terrified of telling her father, she took an overdose and landed in a psychiatric hospital. Then she threatened Dr Bertram Wainer that she would kill herself if he didn’t terminate her pregnancy. Not only did he do the abortion, but he told the Press, the Homicide Squad, the Chief Secretary and the Attorney-General. Dr Wainer was relying on a 1969 judgment of Mr Justice Menhennitt: “A lawful abortion is one believed by the doctor to be necessary to preserve the woman from serious danger to her life or her mental health.” Dr Wainer’s challenge did not provoke any legal response, but it marked his entry into the campaign that Australian women were fighting for the right to legal abortions done openly by capable doctors. In the 1960s there were about 70,000 women having abortions in Australia each year; many abortions were performed by unqualified abortionists. Dr Wainer fought against strict abortion laws and their narrow interpretation. He fought also against the police corruption that he felt was a consequence of those laws. By proving the extent of police corruption feeding on undercover and backyard abortionists, he forced society to face both issues. His efforts helped to clean up the Victorian police force and to bring about a more liberal interpretation of abortion laws. (Nowadays, in most states of Australia, a woman can get an abortion on demand, in the early stages of her pregnancy, if her physical or mental health is in danger.) Wainer’s outspoken views brought him abuse, vilification, threats and even attempts on his life. The Australian Medical Association found him guilty of unprofessional conduct. Rumours said he was mad and had a criminal background. Criminals shot at him and tried to run him over. For years he lived in fear of his life. What made a man fight at such personal cost for the right of Australian women to have safe and legal abortions?

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His background gives us some clue. His father died soon after Bertram Wainer was born in Edinburgh in 1928. His stepfather was an illiterate alcoholic. Bertram’s mother’s sweet shop failed during the Depression, forcing the family to live in the slums of Glasgow. World War II added more traumas. During the Blitz, young Bert and his mother were caught in an air raid away from home: . . . bombs (were) exploding around us, ack-ack screaming . . . fires devouring houses, incendiary bombs blazing . . . then the relief of reaching an air-raid shelter. We were told: “You can’t come in here, this is a private air-raid shelter . . . We have carpets and heaters and food. We can’t let just anyone in.” The door slammed . . .

Bert Wainer never forgot this experience. He left school at 13 to help his mother, and was still underage when he entered the army, where he served for the rest of the war. In 1949, the family migrated on free passages to Australia. Supporting himself with a remarkable range of jobs, he somehow managed not only to matriculate but also to study medicine at Melbourne University. By the mid–1960s, he was a lieutenant-colonel in charge of a large military hospital. After leaving the army in protest against the Vietnam war, Dr Wainer became a GP in St Kilda. In 1969, he went to the Press with evidence of backyard abortionists paying senior police large bribes for protection. In June of the same year, radio station 2GB invited him to Sydney to debate abortion law reform. Before he left Melbourne, Dr Wainer told reporters that he planned to put before the New South Wales Chief Commissioner of Police (Norman Allan) evidence on abortion and police corruption in that state. The threatening phone calls increased: “If Wainer goes to Sydney, he will never come back alive.” The evening before the trip, a man offered to sell him protection in the shape of a shortened shotgun.

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Dr Wainer and two trusted friends booked a flight on TAA, but actually took a tiny charter plane from Moorabbin airport. It might have been safer, but the unpressurised Piper Aztec took about three hours each way. From Mascot airport, they took a convoy of cabs to the back entrance of 2GB. Sydney police didn’t know that Dr Wainer had arrived until they heard him on air. Then they rang and invited him to police HQ, but he made them come to 2GB. Mr Allan did not come himself, but sent Superintendent Donald Fergusson and Detective-Constable Roger Rogerson. According to Dr Wainer’s account, he went to hand Fergusson a sealed envelope with his information. The latter asked who his two friends were. When he heard they were journalists, Fergusson said it would be unethical to accept the information in their presence. Dr Wainer replied: “The only possible reason . . . is that you will be forced to act upon it. [If] I want to report a crime or a murder in Sydney, [do] I have to crawl into a wardrobe with a policeman and whisper it in his ear?” The tension rose, Fergusson refused to budge, and the futile meeting ended. Leaving 2GB, the visitors didn’t risk ringing for cabs, but picked two at random. At the airport, Dr Wainer waited in the pilots’ room. Then, steeling himself for the impact of a bullet, he forced himself to walk, not run, to the plane. Despite the dangers, he did return to Sydney. In March 1970, Dr Wainer appeared on the current affairs television program Four Corners. In May, on another television program, prominent journalist Michael Willesee asked Chief Commissioner Allan if he believed there were abortionists operating in Sydney. When he said “no” Willesee offered him Dr Wainer’s list. When Mr Allan would not accept that, Willesee showed him films: first of an abortionist’s surgery, reportedly within one block of police headquarters, then interviews with patients who had had abortions there. Instead of receiving Dr Wainer’s information in front of two

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journalists, Mr Allan had to do so in front of two million viewers. New South Wales police then raided many abortionists, forcing Sydney women to turn to backyarders. As a result, more and more women came to public hospitals with severe infections from their abortions. Police raided the Heatherbrae Clinic in the Sydney suburb of Bondi and charged the two owners and three doctors on 10 counts of unlawfully using an instrument to procure a miscarriage. If found guilty, they could face 10 years in gaol. But the implication was that in some cases, procuring a miscarriage could be lawful. In 1972, Mr Justice Aaron Levine in the Darlinghurst Court House, ruled that, for a guilty verdict, the Crown had to prove that a doctor did not reasonably believe the operation to be necessary for the woman’s physical and mental health: “The termination of pregnancy by competent use of instruments in the hands of medical practitioners is not an offence in this state.” This ruling reinforced the Menhennitt ruling of 1969 and drastically redefined key sections of the Crimes Act. In 1986, in response to the liberalisation of abortion laws and their interpretation, Wainer said with surprise: “Do you know what I am now? I’m almost respectable!” He died of heart disease in January 1987. Friends organised what amounted to a state funeral; an opera singer sang A Scottish Soldier. His close friend Evan Whitton called him “the most extraordinary man I ever met”. In the eulogy, it was said: Dr Wainer’s legacy to the people of Victoria from his great eight-year campaign was . . . a relatively uncorrupt [police] force, and the consequent failure of organised crime to get more than a toehold in this state. One’s only regret must be that Dr Wainer did not happen to live in Sydney.

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(GB)

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Chapter

3

QUACKS, PSEUDOLOGISTS AND OTHER PHONEYS

QUACKS

AND CHARLATANS

Generally speaking, the free interchange of ideas, the publication of new discoveries, the ready application of medical knowledge in sophisticated surroundings, and a commitment to aid the patient by sharing expertise, is the way in which modern medical practitioners go about their business. Although you may occasionally feel that medical personnel are not always so virtuous, and can sometimes even be grasping, it is salutary to remember that in the past ethical standards have often been considerably lower. In fact, today’s most rapacious practitioner has much to learn from some of his or her predecessors. So let us go back a couple of hundred years to look at some real phonies. A charlatan is one who pretends to skills he or she does not possess, and the term is usually applied to the vendors of quack remedies who cover their ignorance in a

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spate of hifalutin and meaningless words. These people played on the gullibility and touching faith of the population, and for them 18th-century Europe was their high noon. Their advertising used jargon, classical or oriental names, intimation of royal patronage, claims of infallibility and ‘secret formulations’. To compound the hard sell, there were usually unsubtle hints about the worthlessness of the opposition who, as one contemporary writer had it, commonly used his skill “to influence the minds of the vulgar, or help especially those lately sporting in the garden of Venus and now tasting the bitter grapes”. A good pictorial representation of such a person can be seen in William Hogarth’s crowded drawing “Southwark Fair”. He stands there, in laced hat and embroidered waistcoat, expanding on his cryptic skill. A written description comes from Samuel Curwen, who in 1781 travelled through London’s Moorfields district (now the site of one of the most famous eye hospitals in the world) and came across such a character. He described the scene: A stage doctor on an elevated scaffold covered with a ragged blanket discoursing to the more dirty-faced ragged mob; demonstrating to their satisfaction no doubt, the superior excellence of his nostrums to those of the dispensary, and the more safe and secure state of patients under his management than hospitals and common receptacles of sick and wounded poor.

So the characteristics which seemed to set the quack apart from the journeyman apothecary of that era were secrecy, advertising, including dubious testimonials, the popular image of a care-lined pedagogue in declamatory pose gazing meaningfully at a retort of urine, and, above all, the skilful use of crowd psychology. The purveyors of these impenetrable skills ranged from the simple market-day pedlar with his handbills and treatments for ruptures, VD and the like, to such as Dr Clark, “sworn physician

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and oculist”, as he wrote, “to Charles II, James II and Queen Anne”. He advertised in top magazines offering his secret of “the lamp of light”, promising success where others had failed through the use of his infallible cure for the King’s Evil (tuberculosis), cancers, and the stone (in the bladder) without recourse to cutting. No disease too trivial, no duke too poxy. A less up-market practitioner was a Dr Cerf, “lately arrived from France” who claimed to be: Well known for curing all kinds of disorders, both internal and external; likewise the SECRET DISEASE . . . Trusses to be disposed of for all kinds of ruptures. Any person that cannot attend personally, by sending their morning urine, may be faithfully informed of their complaint, and receive such medicines as are proper for their disorder, on the most reasonable terms . . . [There is] A back door with latch, by which persons may let themselves into the surgery. The doctor may be spoken with in all languages.

He sounds quite talented. Dr Benjamin Thornbill of “the orthodox city of Wells” (and few more orthodox than Wells, that’s for sure) cured the lame, blind, deaf, and diseased, with dismissive ease. No possible pathological condition was regarded to be beyond his expertise. Lengthy lists of treatable syndromes probably came about as a result of the welshing nature of the quacks’ trade, in that they lacked those personal ties of reputation which the proper practitioner enjoyed within a neighbourhood. Mind you, proper practitioners were not above a bit of advertising to help retain an irresolute clientele. Besides stability, the local practitioners had two advantages over the itinerant quack: access to hospitals and the treatment of the poor and indigent for free. The fly-by-night needed to concentrate on cures which were quick, could be confirmed at once by sight and background conversation, and conditions which did not recur

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before he or she had passed on to new pastures. The bizarre constituents of the nostrums added to their mystical quality, in itself part of the therapy. For instance, a concoction of snails mashed with bay leaves and mallows was advanced as a cure for the ague (malaria, then endemic in England) and a mixture of woodlice ground up with sugar and nutmeg was recommended for cancer. The juice of wild cucumber aided dropsy, and dung tea, stewed owls and crushed worms were given for a variety of complaints. A Joanna Stevens was so jealous of her secret “universal cure” it took an Act of Parliament and £5000 from the Treasury to winkle it out of her. It turned out to be a mishmash of powdered snails, Alicante and other soap, calcined eggshells, wild-carrot seeds and honey. Among other cures were Dr Belloste’s pills for rheumatism advertised at a guinea a box and Parke’s pills for the stone at 2s 6d a pill. Such a price would guarantee success: having been foolish enough to pay that, you would hardly admit to the cure’s failure. Also sold, with equally spurious reputations, were Velno’s vegetable syrup for venereal disease, Daffy’s Elixir, Godfrey’s Cordial, Scott’s pills and Indian root. Godfrey’s Cordial was given to quieten fractious children, and very popular at London’s Foundling Hospital. The snag was it contained laudanum (an opiate) and spirits, and its use resulted in numerous fatalities; a classic case of the treatment being infinitely worse than the complaint. A favourite remedy of the time, and one which the writer Horace Walpole said would be the one thing he would rescue if his house was burning down, was Dr James’s Antimonial Fever Powders. These were a combination of antimony oxide and phosphate of lead, a ferocious combination with a distinctly lethal potential. Nonetheless, the actor David Garrick gave a glowing testimonial recounting how the powders had cured his mother of severe hip pain. This Dr Robert James was a qualified physician and had been at

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school with Samuel Johnson in Lichfield (Garrick’s home town, too). He took to the bottle later in life, and it was said that he had been drunk every day for 20 years. He was damned by Johnson as a rascal after his improbable explanation for taking a whore about with him in his coach. James’s reason for such a coach companion was that “he always took a swelling in his stones” if he abstained too long from sexual intercourse. Despite his dubious lifestyle, he wrote a three-volume medical dictionary and was the inventor of perhaps the most popular patent medicine of his era. His pills were among many others which were used futilely to treat the mentally troubled George III. Few were better at marketing themselves than another topdrawer charlatan, Chevalier Taylor. He claimed to be the “sole master of nostrums and specifics in Nature, and the only oculist for the teeth in the universe”. You can bet he was. Doubtless he only dealt with the eyeteeth his clients would have given for a cure. As a result of his unabashed advertising, Taylor became one of the most widely known men in 18th-century England, even though Dr Samuel Johnson said of him, “He is the most ignorant man I have ever met” — no doubt to be noticed at all by the old curmudgeon was a kind of reward in itself and grist to the publicity mill. Despite Johnson’s riposte, or maybe because of it, he was appointed oculist to George II, George Friederic Handel and the eminent historian Edward Gibbon. Chevalier Taylor had his comeuppance in the end, for he himself became blind — but not before he had published a three-volume autobiography. A contemporary of Chevalier was Joshua Ward, popularly known as Spot Ward on account of a birthmark on his face. He had started life as a footman, but obviously had his eye on higher things. Such was his influence in the court of George II that he was accorded official thanks by the House of Commons for his attention on the king, and granted the singular honour of being allowed to drive his carriage through St James’s Park. His famous Antimony Pill pepped up the likes of King George, Lord Chesterfield and Alexander Pope. Chesterfield was high on the

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social register, so that when he wrote Ward a fulsome testimonial, the quack was assured of a continuing and respected place in society. Mind you, the fact that Chesterfield was a vegetarian may have modified the action of the quite dangerous contents of the pill. Ward’s Antimony Pills were in the same chancy category as Bateman’s Pectoral Drops and Hill’s Medicine for Mad-Dog’s Bites — truly “kill or cure” medicines. One of the more interesting of these fashionable oddballs was Mrs Mapp, or Crazy Sal as she was known to her admiring and considerable clientele. She held court both at Epsom, outside the city of London, and in the Grecian Coffee House in Devereux Court, just off the Strand and a favourite resort of Oliver Goldsmith. She was a bonesetter, as had been her father before her, and enjoyed in her time such a towering reputation that the town of Epsom actually paid her a hundred guineas a year to live there in order to attract people of quality to the borough. She was there in the 1730s, before the advent of what was to become the town’s even bigger attraction, the Derby. This was first run in 1780. She ran foul of the medical establishment, especially Percival Pott, of Pott’s fracture fame and eminent surgeon at St Bartholomew’s Hospital, no less. He was stung to write of her: . . . the lowest labourer and the most exalted not only did not hesitate to believe implicitly the most extravagant assertions of an ignorant, illiberal, female savage, but even solicited her company, or at least seemed to enjoy her society.

It sounds as though he was feeling the competition. Sal, cross-eyed and waving what looks like a humerus bone, together with Taylor and Ward, birthmark and all, can be seen making up the ghoulish back row in Hogarth’s cartoon “The Honourable Company of Undertakers”. In fairness, it should be pointed out that the majority of figures portrayed in the drawing, though pillars of the contemporary medical establishment, are

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made to look no less loathsome by the artist. Perhaps the most remarkable practitioner of this tumultuous era, certainly the most celebrated, was a man who ran a glittering establishment in London. He didn’t have to trail round the royal court or country fairs soliciting custom — clients came to him, and gladly. His name was James Graham. In 1780 Graham established the so-called Temple of Love in fashionable Pall Mall. He allowed his fertile imagination to run riot in decorating this up-market bordello, a place which was allegedly dedicated to breathing life into the flagging libidos of aristocrats and the well-heeled, so that, he claimed, “sexual intercourse became an urgent need rather than a passing fancy”. Or, to quote his handbill, which he had distributed by servants in splendid livery and gold-laced cocked hats, those visiting his establishment would “find the whole art of enjoying health and vigour of body and mind”. Inside the Temple of Love, the customer found a conceit of ceiling mirrors, glass dragons breathing bogus fire, and suggestive drawings depicting the sexual athleticism to which his clientele aspired. To heighten the drama, scattered in the foyer as practical proof of the place’s therapeutic worth, were discarded crutches, ear trumpets, eye glasses and wheelchairs. A popular feature of the establishment was the obvious presence of gossamer-clad nymphettes among the potted palms. Included among these lovelies is said to have been Emma Lyon, the future Lady Hamilton, posing as a Goddess of Health. But its main claim to fame was the huge “Celestial Bed”, where was guaranteed a rip-roaring night of lusty satisfaction to the impotent and certain pregnancy to the infertile. Indeed, “perfect” children were promised “as even the barren must conceive when so powerfully agitated in the delights of love”. Inscribed on the carved headboard was the legend: “It is a sad thing if a rich man has no heir to his property.” You might think Graham could have done better than that, but perhaps if you were paying a hundred 18th-century pounds for a night of bliss (which

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you were), mottos chiselled on the woodwork would be about the last thing on your mind. The bed itself is said to have cost £60,000 and had a mirror-lined dome above, coloured sheets and a mattress “filled with the strongest, most springy hair, produced at vast expense from the tails of English stallions”. Despite all the hype, it came to pass, as day follows night, that Graham died in poverty in a lunatic asylum. Why did people visit such charlatans? Well, they were not all clearly defined as such. There was no doubt about the difference between the itinerant pedlar in the marketplace and the MD of Oxford. But until the Apothecaries Act of 1815 and the Medical Registration Act of 1858, the term “qualified medical practitioner” had no precise meaning or limits, and differences between quack and doctor were fuzzy. So the reasons for their popularity are complex. For the poor, the fairground quack was available and cheap. But the wealthy and educated also flocked in droves to their favourite pseudologist. Did they have a positive faith in the seemingly magical procedures? Possibly, but it is more likely that they attended after regular medical men had failed with their admittedly pretty thin therapeutic armoury. They marketed themselves well, and the medicines they dispensed — which often contained brandy and opium — were very patient-acceptable. If none of the proffered concoctions, unadulterated or sinister, is going to do any good, then you might as well take the one which makes you at peace with the world. On the other hand, quacks would have poisoned quite a few with the large doses of antinomy and heavy metals which were commonly used. Down the years those who function outside the main stream of medicine have had a popular appeal when orthodoxy seems to have faltered. According to where you stand, they have been described as effective and efficient, or vulgar and dangerous, or natural and harmless. Doctors complain that the mistakes of quacks are not given the same full glare of publicity from which they themselves suffer in similar circumstances. True enough, many quacks have

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proved to be grasping opportunists, but many have not; the same can be said of “regular” doctors, for the division between the two is not always easily defined. (JL)

THOSE

WHO KNOW WATER

Throughout time, people have used urine in various ingenious ways. They have studied it to diagnose illness, applied it as a salve and drunk it as a tonic. In ancient Babylon, India and Egypt, healers assessed their patients by looking at their urine. So did the Sumerians, who called their doctors “those who know water”. In 1090, the Jerusalem Code decreed that any physician who didn’t examine a patient’s urine should be publicly whipped. At the medieval medical school of Salerno in Italy, uroscopy (inspecting and testing urine) went to astonishing lengths, including the degree of urine’s concentration, its colour and smell, whether it was transparent or cloudy, and so on. The urine flask or matula became the badge of physicians. In fact, paintings of Cosmas and Damian, the patron saints of physicians, often show them with a matula. Some famous physicians depended on uroscopy so much that they treated patients without seeing them. Charlatans naturally followed suit. Calling themselves water-casters, water-diviners, urinarians or even doctors of urine, they flourished in most of Europe. Critics called them piss-prophets. Many charlatans had an assistant chat up patients in the waiting-room. Behind a thin wall with a peep-hole the pissprophet himself would listen. Then he would leave the house quietly by the back and come bustling in the front door. Now he could simply glance at a specimen and tell patients that their husband had back pains, or that their mistress was pregnant. Other assistants marked the flasks with codes for their master to read.

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Some patients had tricks of their own. In the 10th century, Duke Henry of Bavaria sent urine from a pregnant woman to a Swiss uroscopist for testing, saying it was his own. But there were no flies on this piss-prophet (also monk and physician), for Notken tested it and declared: “God is about to produce a miracle, for within 30 days, our Duke will be suckling a child born of his own belly.” In London, the College of Physicians condemned those practising uroscopy without seeing the patient; a 16th-century statute also forbade the practice. But all to little effect. One sceptic is on record as having sent a specimen of his gelding’s urine which he purported was that of his wife. Unfortunately for the cynic, part of the quack’s stock in trade was to keep himself informed on the ills of the district, and thus appear to have second sight at the psychological moment. So, having waxed eloquent about the lady’s known gynaecological maladies, the quack concluded by saying: “I grant that I may do your gelding good, if not your wife”. A well-known uroscopist, or piss-prophet, of the 18th century, at the high-water mark, so to speak, of such folderols, was Dr Theodor von Myersbach. He took up the art in the improbable circumstance of having been adjudged too short to be a rider in an equestrian circus. A doctorate of medicine was purchased at Erfurt in Germany and he was in business. Myersbach moved from place to place on the Continent, usually at night to be just one step ahead of the law, eventually to fetch up in London. There he rapidly acquired an up-market following, with such classy people as David Garrick and the Duke and Duchess of Richmond in his thrall. His consulting rooms were in Berwick Street, Soho, and he charged half a guinea for a consultation. It must have been regarded as money well spent, for he is said to have seen up to 200 people a day. (They are the kind of numbers which can support a very large overdraft.) However, his carping detractors put this figure down to the fact that he had only charmed, rather than cured,

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hypochondriacal High Society ladies such as “Lady Hysteric”, “Lady Credulous” and the “Hon Miss Pregnant”. No doubt you can put up with a lot of hypochondria for 100 guineas a day. He diagnosed by gazing at the subject’s urine or allowing his hands to hover over the patient’s body, crying: “It’s here, it’s here,” when the vibes were right. Outstretched hands just about cover an average-sized abdomen, and if you move quickly enough you have a fair chance of being right, and in truth, “it would be there”. Location of the trouble was followed by suitably vague diagnoses such as “disorder of the womb” or “slime in the blood”. Suspicion was aroused concerning the effectiveness of his “green drops”, “silver pills” and the like when a proper doctor, John Coakley Lettsom, detected poisoning in some of his own patients who had sneaked off to be treated by Myersbach. Analysis of the quack’s prescriptions showed lead acetate in many, and in doses which would calm the colic all right, but only just before it killed the patient. Other medications were found to be water in which toast had been steeped — at least they would do no harm. When Myersbach was presented with another sample of urine (actually port wine), he attributed the colour to a severely diseased uterus. The next specimen, cow’s urine, showed “too great a pleasure in women”. Lettsom wrote pamphlets about what he described as “this outbreak of urinomania”, and sent letters to the Press to expose the charlatan. The public took sides, and a wearisome and vituperative slanging match unfolded. Myersbach upped sticks and returned to Germany, but he came back to London the following year and quickly regained his former popularity. Indeed, it was because of such charlatans that uroscopy — which had been a respectable diagnostic procedure since ancient times — fell into disrepute, to be revived in the 20th century.

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Over the centuries, many people have applied urine as a salve and even drunk it as a tonic.

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Ancient Egyptian physicians treated sore eyes with the urine of a faithful wife. Chinese warriors would pause during battle to urinate on the wounds of their comrades to help them heal. In ancient times, the fly agaric mushroom (Amanita muscaria) was a popular hallucinogenic in Europe and Asia. Its active compound, muscarine, is passed unchanged in the urine. So poor people wanting to be “as drunk and jovial as their betters” drank the urine of the rich. The famous physician and anatomist Thomas Willis (1622–75) described the urine in diabetes as being “wonderfully sweet as if it were imbued with Honey or Sugar”. Of course, he was tasting for the presence of diabetes, rather than advocating drinking it. However, a standard 17th-century authority recommended several glasses of urine each morning for gout, bowel obstruction and hysterical vapours. People drank urine for “Epilepsies, Vertigoes, Apoplexies, Convulsions, Lythargies, Migraine, Palsie, Lameness, and Numbness”. Those with toothache rubbed it into their gums. It was also rubbed onto chilblains and chapped hands. Women drank it to restore their periods. Russians used to sell urine to the French, who used it to make hormonal soaps and face-creams. A French dentist made a fortune selling urine as a mouthwash. Better still, he proclaimed, people rubbing it their body could lose lots of weight! One Yorkshireman not only drank urine to cure his cancer, but also used it as an aftershave! Early in the 20th century, a Mr J.W. Armstrong wrote a bestseller, The Water of Life. He assured his readers that drinking urine could cure cancer, leukaemia, syphilis, nephritis, heart failure, malaria, swollen testicles, bedwetting, and even the common cold. Clearly Mr Armstrong looked on the bright side of life. He found the taste of morning urine “merely somewhat bitter and salty; not nearly as objectionable as, say, Epsom salts”. (GB & JL)

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ONCE

DESPISED AND NOW REVERED

It would only be fair to mention a couple of practitioners who were regarded as quacks at the time, but who are now held in some esteem, if not reverence. The Chamberlen family fell into this category. At the end of the 16th century Peter Chamberlen and his brother, also called Peter, invented the obstetrical forceps. The way in which the handles locked was kept a secret in the family for over 100 years. Because they would not share the mystery, and as one of the hallmarks of quackery is keeping knowledge to oneself, they were branded charlatans by their contempories. Eventually the secret was sold and the locking device was seen to be effective. Their invention came to be generally accepted by the medical profession and is used to this day. The second family whose members were looked upon with some suspicion in their time was the Thomas family. In 1740 two small boys were washed ashore on the coast of Anglesey in North Wales. They were, it was said, the only survivors of a shipwreck. Both were adopted by a Mr Thomas. The elder boy, whom Mr Thomas named Evan, showed a singular aptitude for treating injured animals. That skill, plus the improbable story of his arrival, was enough to make the medical establishment purse their lips and wrinkle their noses in bristling disapproval. However, it was this very same magical and mysterious aura which made the villagers take him to their collective bosom. To cut a long story short, this healing gift, used in both animals and humans, was passed down through the generations. The grandson, also called Evan, spread his wings and settled in Liverpool to become the “bonesetter of Crosshall Street” (later used as the name of a play about the family and presented in the 1950s). Naturally he incurred the wrath of the local doctors, and three times in the 1840s Thomas was charged with neglecting a patient. On each occasion he was acquitted, the last time being carried from the court on the shoulders of a rapturous crowd, given a hero’s

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dinner and presented with a testimonial. He was regarded as the saviour of the local dock workers, for they knew that if they landed in hospital with a broken limb they stood a good chance of it being amputated. If they went to Thomas, however, he would manipulate rather than amputate. His ability to set bones with consummate skill gained him considerable kudos among the less well-to-do. Evan Thomas recognised, however, that the medical establishment was powerful, so he arranged that his three sons had a formal medical training. The eldest, Hugh Owen Thomas, was to emerge as the greatest of all the Thomases. Hugh worked first with his father in the city of Liverpool and then as an osteopath in the dock area of the port. As time went on he became outspoken and a mite too forthright for the medical establishment. Although he obtained remarkable results in straightening and lengthening limbs, the medical establishment was very suspicious of the young upstart, for did he not fulfil one of the main criteria of a charlatan in that he was denigrating of others, especially doctors? What the surgeons either did not realise, or, more likely, chose to ignore, was that he was one of their own, having qualified at University College Hospital, London, in 1857. He never had access to any hospital beds, yet managed to leave the profession two legacies, one of which is used to this day — the famous Thomas Splint for fractured legs. The other is the rather gruesome Thomas Wrench for straightening bones, and long since abandoned. Hugh Owen Thomas died childless in 1891 aged 57, and although his funeral was attended by thousands, many in tears, it was not until years later that he was eventually recognised as the father of orthopaedic surgery, and one who had metamorphosed the treatment of diseases of the joints. Who can tell which of the eccentrics of today may not become pillars of the establishment tomorrow? (JL)

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Chapter

FAMOUS

THE

4

PATIENTS

MYSTERY OF NAPOLEON’S FINAL WATERLOO

The historian Hendrik van Loon described Napoleon Bonaparte as having an ego “so great that he needed an entire planet . . . for his ambitions”. But when he died in 1821, he was in exile on the British colony of St Helena, a small island 200 kilometres west of Africa. What killed him? Napoleon’s list of ailments reads like a hypochondriac’s wish-list: epilepsy, migraine, relapsing fever (probably malaria), probable bladder stones, skin problems, stomach ulcer, underactive thyroid gland, pneumonia, insomnia, piles and attempted suicide! Some biographies also list chest and thigh wounds, though Dr Richard Gordon says Napoleon’s only campaign wound was when his horse kicked him in the foot. The French still argue that Napoleon’s agonising piles were the sole reason for the delay that cost him victory at Waterloo in 1815. His opponent, the Duke of Wellington admitted: “It was the most desperate business I ever was in . . . and never was so near being beat.”

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Not only did the British win the battle, Napoleon threw himself at their mercy. But what to do with him? Napoleon himself hoped to settle near London. Metternich suggested exile in the north of Scotland. The Times wanted to hang him. Hanging might have been kinder than exile on the “living tomb” of St Helena, where Napoleon lived out his remaining six years. Napoleon had 12 servants, three French officers and 3,000 British guards! He kept up a flood of petty rows with Sir Hudson Lowe, who arrived as governor of the island in 1816. Napoleon was convinced that Lowe meant to kill him. Napoleon became ill in 1817, with vomiting and diarrhoea. Dr Barry O’Meara, a naval surgeon, diagnosed tropical hepatitis (amoebic infection of the liver), which was common on the island. He wanted Napoleon moved, so in 1818 the authorities sacked him. The next doctor, John Stokoe, agreed with O’Meara, so they court-martialled him. Then, by request of Napoleon’s mother came a fellow Corsican, Dr Francesco Antommarchi. But the prisoner didn’t do well. He still had vomiting and diarrhoea, and he was very ill for six weeks with a cough and with pain in his abdomen and shoulder. He was given calomel (chloride of mercury), but without benefit. He was dizzy, so the doctor bled him. By early 1821, he could no longer take solids. Still Dr Antommarchi called it hepatitis. While he was still alive, no one seemed to consider that Napoleon might have cancer, though his father had died of stomach cancer. In March 1821, the vomiting was worse; by April it was black, suggesting internal bleeding. As he got worse they gave him more calomel. Finally, on 5 May 1821, Napoleon died. He was 51 years old. Six British doctors helped Dr Antommarchi with the autopsy. Since they could not agree, they wrote four separate reports. At first Dr Antommarchi reported cancer, but later he said hepatitis had

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killed Napoleon and blamed the British for exposing him to the dangerous climate of St Helena. One of the British doctors also reported an enlarged liver consistent with hepatitis, but the governor pressured him into removing this from his report. So did the former emperor die a natural death? He himself wrote in his will: “I die before my time, murdered by the English . . . ” Over a century later, in the 1960s, there came to light several samples of hair said to belong to Napoleon. One sample reportedly showed that he had taken at least 40 doses of arsenic in his last few months of life. In 1982, other researchers found that the emerald greens in 19th-century wallpaper contained a copper–arsenic pigment which a fungus could convert into arsenic vapour. They found a scrap of Napoleon’s wallpaper which contained enough arsenic to make him ill, but not to kill him. Some Frenchmen believe that he died of arsenic given over a long time, followed by cyanide. Others believe the confessions of Count de Montholon, aide-de-camp to Napoleon, who allegedly laced Napoleon’s wine with daily doses of arsenic. Why? Because he believed that his wife was Napoleon’s mistress. So what or who killed Napoleon? Cancer? Hepatitis? The English? The wallpaper? Or the jealous husband? (GB)

WHAT

KILLED

JANE AUSTEN?

Like its houses and its chairs and its coffee pots, social intercourse in 18th-century England has managed to convey to us a society which was at once both sensible and elegant. It seemed to manifest good manners, piety, and cultivated discernment — at least it did if you were of “the gentry”, which was the case with one of the greatest writers in the English language. Indeed, the lifestyle of the era provided the ideal ambience in which the genius of Jane Austen could flourish.

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She was born in 1775, the daughter of a clergyman, and the seventh of eight children in a closely knit family. She lead a life of middle-class gentility and ease spent entirely in the quiet of rural southern England. Austen’s characters and their backgrounds were drawn from her own circle, and they never strayed from the world in which she moved. Furthermore, she was much too well-bred to let her own name grace the title page of her novels, and all her books were styled as being written “By a Lady”, as indeed they were. And yet her towering reputation is based on only six works of fiction published over a seven-year period. The first, Sense and Sensibility, appeared in 1811; the last, Northanger Abbey and Persuasion, were published posthumously in 1817 (dated 1818). They have never been out of print and have flourished even more since the mid 1980s. Jane Austen was of a caring disposition and was the wit of the family. She never married, and it appears the creative impulse, then customarily fulfilled by the task of being wife and mother, was in her fulfilled through her art. She said her books were her children. The author took considerable pains to conceal from friends and visitors the nature of her life’s work and wrote on small pieces of paper, the more easily to slip under a blotter or into a drawer if chanced upon. She led a sheltered life at home, interspersed with occasional visits to Bath to take the waters, or to London, or to the not too distant houses of her elder brothers. It all sounds like a rural idyll, and so it was, until June 1816 when, at the age of 40, she had an attack of nausea and vomiting and low backache. It could have been something or nothing, but, in the light of subsequent events, was probably significant. In July she was depressed and felt weak. This was put down to her dissatisfaction with the book Persuasion, which she had just completed. It may well have been, but two months later it was noted she tired more easily than had usually been the case, had uncharacteristic mood swings and further back pains. However, everything subsided and life progressed in its customary leisurely way.

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In December she declined an invitation to dinner using as an excuse that “the walk is beyond my strength (though I am otherwise very well)”. The following month she wrote to a friend that she was stronger but felt “bile” was at the bottom of her general malaise. This may indicate a recurrence of her gastric upsets of nausea and vomiting. All pretty vague so far, but then in March 1817 Jane wrote a letter to her favourite niece, Fanny, and in it gave the clue which could lead us to the likely diagnosis. She wrote: “I certainly have not been well for many weeks . . . I have a good deal of fever at times, but am considerably better now and recovering my looks a little, which have been . . . black and white and every wrong colour . . . Sickness is a dangerous indulgence at my time of life.” Over the next two months she wrote to a friend recounting details of recurrent vomiting attacks, concluding: “my chief sufferings were from feverish nights, weakness and languor”. We know the slightly built Austen was bright-eyed and had an olive complexion, certainly not “black and white and every wrong colour”. But a visitor in May later wrote that the author was looking very pale and spoke in a weak, low voice. The family became concerned and moved her to Winchester to be nearer expert medical help. It was to be of no avail. Over a six-week period she became progressively weaker and had a number of fainting fits, until on 18 July 1817, after several hours of unconsciousness, Jane Austen died in the arms of her only sister, Cassandra. So what did she have? The story is one of unimpaired intellect but increasing languor, intermittent backache, fainting attacks, gastrointestinal disturbances, and fever, especially at night. Added to all that, and crucially, is a darkening of the face. The delicacy of the era regrettably precludes us from knowing about skin changes elsewhere, especially the vagina or in the mouth, or where pressure was applied to the skin (at the waist, for instance). A number of conditions come to mind, but probably only one fits the whole scenario.

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The lassitude could have been due to a rare neuromuscular condition, myasthenia gravis, but there seems to have been no speech or swallowing problems. Maybe the heart could be implicated in the form of bacterial endocarditis, an infection on the valves of the heart, but fainting crises are not known with this. Perhaps cancer of the stomach with resulting anaemia from the slight but persistent blood loss characteristic of the condition. Yet the digestive problems did not seem either very great or progressive. Skin discolouration occurs in a number of general diseases: the rare so-called “bronzed diabetes” or haemochromatosis, but the other symptoms do not fit; chronic inorganic arsenic poisoning with its raindrop pigmentation and abdominal symptoms, or indeed poisoning from any of the heavy metals, lead especially, and which could be ingested from medication or water pipes. But the other history is inappropriate, and no other family members were affected. Pellagra, an ailment caused by a deficiency of the vitamin niacin, could be a long shot with its diarrhoea, dermatitis and dementia; but her diet was good and she was certainly not demented. No! None of these seem right. From the records and the fact she was a country person with ready access to probably tubercularcontaminated milk, the most likely diagnosis is Addison’s Disease due to tuberculosis of the hormone-producing adrenal gland. Thomas Addison only graduated two years before the death of Miss Austen, and it was not until 1848 that he first described the disease which bears his name. Its best known feature is the skin discolouration, which Addison described as “smoky or various tints of deep amber or chestnut brown”. With the medical knowledge of his era, Addison was unaware that the blood pressure is lowered in this malady, for he had no means of measuring it. Until the mid 20th century tuberculosis was the prime cause of Addison’s Disease. Now it is likely to be due to an auto-immune reaction, as was the case in that other famous sufferer, John F. Kennedy.

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Only one aspect does not completely fit. It is said that tubercular patients are commonly more sexually charged than the general run of the population, possibly due to the persistent lowgrade fever. No hint of sexual impropriety in Miss Austen has come down to us. Due to an overall lack of surviving correspondence, Jane Austen’s biographers have an incomplete picture of what her dayto-day life was really like, either in sickness or in health. But we all know from her books that she was a consummate writer whose genius was tempered with gentle humour and a subtle insight into the moral nature of humankind. It is better we remember her thus, rather than someone suffering from an uncommon and debilitating medical disorder. (JL)

A

MEDICAL HISTORY OF OSCAR WILDE

Oscar Wilde was born in 1854, the second of three children of Sir William and Lady Jane Wilde of Dublin. Sir William was an ophthalmic surgeon, editor of the Dublin Journal of Medical Science, a writer on Irish superstitions and defendant in an alleged rapeunder-anaesthetic case. He lost, but only a farthing in damages was awarded against him. Lady Wilde was a noted poet, and wrote a book on ancient cures and charms of Ireland. So Oscar was well-connected, medically. The first serious illness of the author was in 1877 while he was at Oxford. He contracted what he called “a positive sin”, a Victorian euphemism for syphilis. Due to the coy attitudes of the era, apart from that comment, diagnosis is based on circumstantial evidence only. For instance, we know he was given mercury, the contemporary treatment for luetic (syphilitic) disease, and statements by close friends at his death and a doctor’s certificate at that time seem to indicate the pathology. Furthermore, he broke off a promising liaison with a young lady

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following advice that he should not marry until two years after the primary episode. There seems to have been no obvious signs of infection (such as skin lesions) during his life, and the diagnosis remains conjectural. The only obvious effect of the mercury was that it turned his slightly protrusive teeth black, and thereafter he usually covered his mouth while talking. If the diagnosis of syphilis was genuine, there was certainly no long-term effect on his mental capacity. He took the university by storm, turning Victorian Oxford into Periclean Athens with his repartee and well-honed English. He was awarded a rare double first in Greats (Roman and Greek history, literature and philosophy) at his graduation from Magdalen College, he won the prestigious Newdigate Prize for poetry, and all his life was renowned for the brilliance of his wit. In the early 1880s Wilde easily established himself in the social and artistic circles of London by his flamboyant presence. The publication of his poems in 1881 was followed by a lecture tour of America. He hardly endeared himself when on arrival in New York he announced: “I have nothing to declare but my genius.” But America left one legacy: he contracted malaria, which he described as an “aesthetic disease”. He must have had repeated bouts, as quinine was found in his effects when he was arrested 13 years later. Wilde married Constance Lloyd in 1884, and by 1886 they had two children, Cyril and Vyvyan. That year he met Robert Ross, “with the face of Puck”, and they became lovers. He had no intention of giving up his wife, but had to find an excuse to live apart sexually. It is conjectured by his well-regarded biographer, Richard Ellmann, that he told her about the syphilis and that celibacy was necessary. In any event, she suspected nothing, and sexual intercourse ceased. In 1891 he formed an intimate friendship with Lord Alfred Douglas. This infuriated Douglas’s father, the Marquess of Queensberry, who left an open card at the Albemarle Club, which said: “To Oscar Wilde posing as a Somdomite”(sic).

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In February 1895 Wilde sued the Marquess of Queensberry for libel, failed, and in April was arraigned for sodomy. He was tried twice, the first trial being aborted by a hung jury, despite the joyous evidence of blackmailing boys. At the second trial in May he was found guilty and given two years’ hard labour; a crushing blow for such a sensitive man. At Pentonville Prison he was declared medically fit, so spent six hours a day on the demoralising treadmill, where he peddled mindlessly for 20 minutes then rested for five minutes, slept on bare boards and for the first three months had no communication with anyone on the outside. The result was that he lost weight, became withdrawn and depressed, and suffered from insomnia. After some weeks, diarrhoea set in. As the prison lavatories could only be used during the hour of exercise, a tin bowl in his cell was his toilet. He was later to write that warders vomited at the indescribable sight that greeted them in the morning. The prisoner fainted in chapel, and in the fall injured his ear so badly he spent two months in the infirmary. He was troubled by pain in the ear for the rest of his life. Wilde was transferred to Reading Gaol. When discharged in May 1897 he was bankrupt, a social pariah and a broken man. He went to live in France. There a persisted rash developed, possibly a vitamin deficiency — though he put it down to eating mussels — and he went to Rome to be blessed by the Pope. It did not help therapeutically, but of the event Wilde wrote mockingly to a friend: “My walking stick shows signs of budding!” Wilde deteriorated physically, and by September 1900 he had become bedridden. The skin rash was florid and his ear so painful that, according to a surviving bill, his doctor visited 68 times between September and December. On 10 October, in his beggarly room, his ear was operated on, either to puncture the eardrum to let accumulated fluid escape or for removal of polyps. It was during one of the daily post-operative dressings he made his famous remark: “I am dying beyond my

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means . . . My wallpaper and I are fighting a duel to the death. One or other of us has to go.” On 29 October the ear developed an abscess. It was then his doctor lent credence to the syphilis story, by recording it as: “a tertiary symptom of the infection he contracted when twenty”. Morphine and chloral hydrate had no effect on the pain. On 27 November he became delirious and meningitis manifested itself. Neither ice packs to the head nor mustard plaster to the feet had any effect, and on 30 November 1900 Oscar Wilde died. It is incredible to think it is only 100 years or so since a blinkered morality could cause such mental and physical suffering in trying to sanitise the actions and works of this towering genius. (JL)

THE

DEATH OF

V. I . L E N I N

Among the side issues of the upheavals in Russia in the fairly recent past was the macabre rumour that the body of Vladimir Il’yich Ulyanov, better known as Lenin, was removed from its splendid glass-enclosed sarcophagus in the Kremlin wall and deposited elsewhere. Before he disappears completely from our consciousness, as well as our vision, let’s just take a look at the drawn-out death and ghoulish preservation of the old revolutionary. Ulyanov was born in 1870, the third of six children, one of whom, his eldest brother, was hanged for conspiracy in 1887. He adopted the pseudonym Lenin in 1901 during his clandestine party work after exile in Siberia. One grandfather was a physician and the other a serf, and he himself was regarded as a very bright student of Greek and Latin. But the fire he felt in his belly could not be fuelled by the classics, only by revolution, so he turned to politics. His subsequent public life is well recorded; what we want to know are the medical aspects. During the greater part of his life he was physically strong. This robust nature held him in good stead in August 1918 when, after

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an assassin fired two bullets into him, he made a speedy recovery, even though both missiles remained in the body. But early in 1922 at the young age of 52 Lenin became seriously ill with headaches, and in April his doctors thought it prudent to remove some of the ironmongery. He recovered, but in May had a stroke which left him partially paralysed and unable to speak. By dint of will power and a sterling constitution, the following month he recovered enough to throw himself into the formation of the nascent USSR. In December he had another stoke with paralysis, and then on 10 March 1923 yet another cerebral haemorrhage which deprived him of his speech. It never returned, and he was in this hapless and, for him, surely most frustrating state until he died in the city of Gorki on 21 January 1924. It was then there occurred an exacting postmortem examination which in the end became a pathological tour de force, followed by preservation. The autopsy was done by one man, Professor A.I. Abrikosov, but he had no less than eight top-flight pathologists and clinicians standing by, ready to purse their lips and suck their teeth at the slightest hint of hesitancy. Not only that, the Minister of Health himself was present, presumably to make sure the rites were enacted in an ideologically sound way. As reported in Izvestiya of 25 January 1924, it took three hours 10 minutes to complete. Externally, two old bullet scars were apparent, one in the left arm and the other over the right clavicle where the missile had been removed. The remaining bullet was found in the muscle covering the shoulder joint. The surface of the left hemisphere of the brain was depressed, and when cut open found to be extensively collapsed. Beneath the collapsed area were areas of yellow softening involving both white and grey matter, and cavities containing cloudy fluid. There were marked arteriosclerotic changes in the main arteries at the base of the brain. These arteries were considerably narrowed, as were their tributaries and the carotid arteries (the principal arteries on each side of the neck). In fact the left internal carotid was completely blocked. There was fresh blood in the mid brain. F

A M O U S

P A T I E N T S

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There were a few adhesions in the lungs and a healed scar in the left apex (the upper extremity of the lung, behind the first rib). The coronary arteries were narrowed, and fatty deposits were present in the aorta. The cause of death was put as due to haemorrhage over the corpora quadrigemina area of the brain, and it was stressed that the postmortem showed that most of the very severe brain damage must have been present for some time before death (a point perhaps lost on later generations). It was decided to have the body lie in state. To this end it was soaked in the usual solution of formalin, glycerin, potassium iodide, alcohol and zinc chloride to preserve it for a matter of weeks only. In six weeks some 100,000 people filed past, and there were many requests from outlying areas to hang on until they got there. Signs of deterioration with autolysis (cell and tissue degeneration) and skin desiccation began to set in, yet still the faithful filed reverentially past. It then dawned upon officials that the population of the USSR being what it was, this could go on until something pretty unpleasant was the only thing left. So they decided to embalm the body properly and display it in a specially built mausoleum in Red Square. It was then that the embalmers received what they surely would consider the call of a lifetime, and the anatomy professor at Kharkov University was given the awesome task. Bit by bit every part of the body, including bones, was hydrated, depigmented with acids, peroxides and aldehydes, and then embalmed. Work proceeded day and night for four months, and the body was finally inspected by the appropriate committee on 26 July. It was declared to be sweet and, well, lifelike. The Soviet Government wisely decided to publish the autopsy data at the time; political mileage might otherwise have been made out of it. One bit was missing, however — the brain. It was hoped that its study by the renowned German neuropathologist Oskar Vogt would throw light on the alleged genius of its owner. In return for the honour, the Germans undertook to train Soviet scientists in

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their methods. A special institute was later built in Moscow, from which the Russians operated. For three years the brain was scrutinised and picked over, until at last Vogt concluded that the pyramidal cells in Layer III of many cerebral areas were unduly numerous and large. At the time this was thought to have a mental association and was in tune with Lenin’s intellect. More work was deemed necessary to compare the brain with those of other deceased intellectual giants, of which it seems they had 13 in stock. In addition, specimens from different ethnic groups were called for, as well as from some animals and children. A special questionnaire on Lenin’s personality was devised, which was to be filled in by those who had known him. And then, nothing; no articles, no huzzas, no Red Stars. The project was quietly, and probably mercifully, dropped. (After World War II the laboratory was found to be in ruins and containers with specimen brains and slides scattered over the floor. Nowhere was there any trace of Lenin’s name.) Vogt’s study did not throw much more light on the alleged genius of the subject. There is no doubt about Vogt’s diagnosis, but his ideas about the size of cells being of significance or that racial peculiarities affect intelligence were a bit outdated even then. At least the team of embalmers did a good job. The old chief only needed to be dusted every now and again to maintain his pristine appearance which he held for over 67 years. Where is Lenin’s body now? Apparently it is still in the mausoleum in its original spot. The mausoleum was closed after the uprising of 1993 and the body disappeared from view for some time, but the building has been reopened on a very restricted timetable while the authorities ponder the sensitive issue of the final resting place of the old leader. The Moscow Brain Institute, the child of the project, still stands as one of the leading neurological centres of the world. Perhaps they should bury Vladimir Il’yich Ulyanov there. (JL)

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WAS WINSTON CHURCHILL FIT TO RULE? “It was [Churchill’s] exhaustion of mind and body that accounts for much that is otherwise inexplicable in the last year of the war — for instance the deterioration in his relations with Roosevelt” — Lord Moran

Can we understand what drove a man as great as Winston Churchill (1874–1965)? Was it his parents’ constant rejection of young Winston that made him strive so hard? At 18, he wrote to his mother: “I can never do anything right. I suppose I shall go on being treated as ‘that boy’ until I am 50 years old.” Or was it his belief that, like his father, he would die at the age of 46? What better goad to overachieve? These were not his only burdens. Churchill was also unlucky in his choice of ancestors: five of the previous seven Dukes of Marlborough had had severe recurrent depression. Churchill himself called his recurrent moods of depression “black dog”. In 1915, at the time of Churchill’s Dardanelles fiasco, his close friend, Lord Beaverbrook, wrote: “What a creature of strange moods he is — always at the top of the wheel of confidence or at the bottom of an intense depression.” All this is very strong evidence that Churchill had what psychiatrists now call bipolar mood disorder (formerly known as manicdepressive disorder). Even as a young man, Churchill was a health faddist, selfmedicator and lover of quack remedies. He used inhalations before speaking in public, and travelled with cylinders of oxygen. When Britain declared war on Germany in September 1939, Churchill emerged from 10 years of political exile to become First Lord of the Admiralty. In May 1940, after Germany invaded France, Belgium and Holland, Churchill succeeded Chamberlain as Prime Minister. He looked like Britain’s only hope. Hitler had made (temporary) peace

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with Stalin and now controlled Europe; the United States still remained neutral. But Churchill was now 65, and there were many concerns about his health. So in November 1940, Sir Charles Wilson (later Lord Moran) became Churchill’s personal doctor. This doctor–patient relationship continued, though not smoothly, until Churchill’s death 25 years later. In December 1941, at the White House, Churchill got chest pain. He said it was muscular but he was frightened; Moran thought it came from the heart. Luckily, it did not recur. From early 1943, Churchill had several attacks of pneumonia. After meeting Roosevelt and Stalin at the Teheran Conference, he had pneumonia with heart problems. Alanbrooke, Chief of the Imperial General Staff, complained in March 1944: “He seems quite incapable of concentrating for a few minutes on end, and keeps wandering continuously.” At the Potsdam Conference, Churchill was too tired to read his briefing papers, and had to be carried in a chair. The Labour landslide of July 1945 unexpectedly dumped the Conservatives. Churchill was depressed for months, but unfortunately stayed on as Leader of the Opposition. A month later, after a long game of gin rummy, he had weakness of the right hand, but he recovered. Lord Beaverbrook made officials announce that it was “a chill”. A Cabinet Office Under-Secretary, Sir George Mallaby, described Churchill at this time as rambling and lacking comprehension. In October 1951 he narrowly won an election, and returned to Downing Street; he was now 76. Moran wrote: “The old capacity for work had gone, and with it much of his self-confidence . . . Everything had become an effort.” For his fatigue, Churchill vainly consulted the osteopath Stephen Ward (who later led to the fall of a Conservative Government). In early 1952, Churchill had a more serious stroke affecting his speech. By now, he insisted on even the most complex issues being

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condensed into one paragraph before he would consider them. Moreover, the Prime Minister often could not even follow a discussion. Moran wrote: “. . . he was not doing his work. He did not want to be bothered by anything; he was living in the past . . . ” But not once did Moran encourage Churchill to resign. Just the opposite: Winston . . . once asked me whether he ought to have retired earlier . . . I was, I think, alone in urging him to hang on, though I knew that he was hardly up to his job for at least a year before he resigned office. His family and friends pressed him to retire; they feared that he might do something which would injure his reputation. I held that this was none of my business. I knew that he would feel that life was over when he resigned . . . It was my job as his doctor to postpone that day as long as I could.

In 1953, after an official dinner, Churchill had another stroke. This one affected his left side: he could neither speak nor leave the table. Again, officials hushed it up. The neurologist Sir Russell Brain doubted whether Churchill would live another year, and agreed with Moran’s view that immediate retirement might hasten death. A cardiologist was emphatic that Churchill could not act as Prime Minister. But somehow, the wilful, wily old man defied such opinions, and carried on the pretence: instead of dealing with matters of state, Churchill read novels and played cards. He himself once conceded that a prime minister could get to be past it, and should be removed, as Adam Sykes and Ian Sproat record in The Wit of Sir Winston: “The office of Prime Minister is unique. If he trips he must be sustained; if he makes mistakes, they must be covered; if he sleeps he must not be wantonly disturbed; if he is no good he must be pole-axed.”

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But there was no one strong enough to pole-axe Churchill. In late 1954, he had to apologise after misleading the Commons (and jeopardising the government’s foreign policy) about a telegram he claimed to have sent to Field-Marshal Montgomery during the war. There was no such telegram; by now even the Conservatives had had enough. But it was April 1955 before the Prime Minister finally stepped down. By then, he was spending most of his days in bed; his last years must have distressed those who had known him in better days. In January 1965, aged 90, Churchill died. Details of Churchill’s poor health did not reach the public until 1966, when Moran published his book Winston Churchill: The Struggle For Survival. Uproar! Churchill’s family and many colleagues were indignant that Moran had revealed personal medical details. But there is another issue, more important than that of confidentiality. Despite repeated evidence of Churchill’s serious ill-health during the war, he did not resign as prime minister until 10 years after the war ended. As Churchill’s personal doctor, should not Moran have balanced his duty to his patient against the interests of his country? Could he have induced Churchill to step down earlier? Could anyone else have done so? If we make pilots and bus drivers pass medical examinations, why don’t we do the same for politicians? (GB)

JOSEF STALIN

AND THE DOCTORS

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Josef Vissarionovich Djugashvili was born in Georgia, Russia, in 1879. If he had retained that name he may well have lived and died a peasant. But he didn’t, for in 1912, when he was invited by Lenin to join the Central Committee of the Bolshevik Party, he changed it to the Russian for “man of steel” — Josef Stalin. It suited him well.

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Stalin was born into abject poverty, the son of a drunken, abusive father. As a child he endured a severe attack of smallpox which left his face permanently scarred. It was so disfigured that when he came to power, thousands of photographs had to be doctored to disguise the lesions. At the age of 10 his left arm was injured, possibly as a result of being thrashed by his father. Osteomyelitis (inflammation of the bone) followed, and poor treatment led to a “Volkmann’s contracture” where the hand would not open fully and muscle control was lost. There also a permanent shortening of his left arm by about 7.5 centimetres. He often wore a glove, allegedly for rheumatism, but probably to conceal the defect in his hand. At times he also wore a brace on the arm, as can be seen in some unguarded photographed moments. Despite these defects, Stalin was physically very strong as illustrated by the story that late in life he swung the beefy Marshall Tito off his feet in a bear hug. But his violent upbringing had its effect, for as the years rolled by Stalin grew mentally unstable and more and more paranoid. He had thousands shot on the suspicion of plotting against him; his motorcade comprised five identical cars which changed position continually to confuse would-be assassins. In his apartment there were four rooms fitted out as bedrooms; not before retiring did he choose the one in which to sleep. After World War II Stalin chose (or was forced) into partial retirement due to his high blood pressure, whereupon he became even more suspicious, calculating and irritable. Locks and bolts increased in number, and he had members of the Politburo eat with him every night so he knew where they were. All his food had to be tasted — and often had to be doubly tested — by his cronies. By 1952 he was dosing himself with a variety of pills and iodine drops for unspecified symptoms. Though he had a physician, Stalin considered it far too dangerous to let him near. And then out of the blue on 13 January 1953 the newspaper

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Pravda proclaimed that Stalin had uncovered a sinister medical conspiracy. It seems the dictator had received a letter from a Dr Lydia Timashuk in which she claimed Comrade Andrei Zhdanov and other Soviet luminaries had been poisoned by his (Stalin’s) doctors. Zhdanov had been the party chief in Leningrad and freely canvassed as Stalin’s successor. But Georgy Malenkov, a prominent Communist Party official, also coveted the top post. In 1946 he had lost his job in the Party Secretariat following criticism by Zhdanov of his management of the dismantling of German industrial equipment and its transportation to the Soviet Union. So Zhdanov’s death in 1948 was suspiciously providential as far as Malenkov was concerned. And indeed after Stalin’s death he did become prime minister for a couple of years. Following his old philosophy that “if a report is 10 per cent true we should regard the entire report as fact”, Stalin believed Timashuk’s letter. Zhdanov had, of course, been treated by trusted Kremlin doctors who were well-known and respected in the medical as well as the political world. The hint was enough. Nine were arrested and jailed for what came to be known as the “Doctors’ Plot”. Among those arrested was Stalin’s personal physician of 20 years, Dr V.N. Vinogradov. He was arrested, beaten, manacled and committed to a dungeon on the suspicion of being a British spy. Significantly, six of the nine arrested had Jewish surnames. It was said that five had worked for American intelligence through a Jewish organisation, and three were British agents. All were distinguished, but anti-Semitism was in the air. More letters poured in purporting medical involvement in intrigue, and Stalin allowed the Press campaign to gain momentum. Members of the Presidium felt there was a lack of substance in the accusations, but never discussed it openly, because, as Khrushchev was to write later: “once Stalin had made up his mind and started to deal with a problem, there wasn’t anything to do”. The interrogations began. Stalin was in a rage and, according to

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Khrushchev, berated the Minister of State Security to “throw the doctors in chains, beat them to a pulp and grind them into powder”. All the doctors confessed. On 20 January 1953 Dr Timashuk was awarded the Order of Lenin. On 1 March Stalin had a stroke. At first his fearful servants were loath to disturb the apparently sleeping chief. When they realised what had happened, all hell broke loose and his room was packed with a host of doctors, politicians and security men. However, there was no public announcement of any illness until three days later, on 4 March. Then Radio Moscow gave the news that Comrade Stalin had lost consciousness, was unable to speak and his right leg and arm were paralysed. Nine doctors were in attendance; a group of men who no doubt harboured very mixed feelings. The communique added that the leader’s treatment was under the constant surveillance of the Central Committee of the Communist Party and the Soviet Government. His chances of recovery were slim anyway, but such guidance would have snuffed out any hope. Over the next few hours a wealth of medical detail was given to show that everything possible was being done: oxygen, camphor, caffeine, strophanthin and penicillin. Leeches were applied to his head. An artificial respirator was trundled in but, as nobody could work it, it lay idle as the patient slowly choked to death. He died on 5 March 1953, aged 73. A fully reported postmortem absolved the attendant medical staff from blame. Nevertheless, of the nine doctors who signed the report, one died suddenly six weeks later and two others were removed from their posts and disappeared at about the same time. The Doctors’ Plot was Stalin’s last purge. As no more doctors were arrested after 24 February, it has been postulated that from that date he himself was no longer directing affairs. It has been claimed the stroke was on that day and there was a power vacuum until 5 March.

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It has been mooted that Stalin was murdered by poison and a battery of terrorised doctors went along with the lie. To support this it is pointed out that after the first bulletin the communiques became more woolly. For instance, it was said that the albumin and red blood-cell ratio in the urine was normal, but for either matter to be there at all is abnormal. We shall never know if he was poisoned. We do know that Dr Timashuk’s award was revoked on 4 April, a month after Stalin’s death and the day the seven remaining doctors were ultimately released. Two had been tortured to death. (JL)

DID

A STAND-IN TAKE THE RAP FOR RUDOLF HESS?

“. . . on May 10, 1941 . . . the real Hess took off from Augsburg; a different man and a different plane reached Scotland. So much is certain. But the plot which achieved the substitution is still largely mysterious . . . ” — Dr Hugh Thomas

History tells us that Rudolf Hess became Hitler’s deputy in Nazi Germany. On 10 May 1941, during World War II, Hess flew solo to Scotland — without Hitler’s knowledge — apparently to offer Britain a peace proposal. While a prisoner of the British, he showed signs of mental instability. After the war, the international court at Nuremberg sentenced him to life imprisonment. In August 1987, at the age of 93, he hanged himself in Berlin’s Spandau gaol. But Welsh surgeon Dr Hugh Thomas agrees with Henry Ford who said “history is bunk”. He argues that in 1941 it was “an impostor who was thrust upon, or infiltrated by the British”. The real Rudolf Hess was shot down somewhere over the North Sea, perhaps on the orders of his rival, Heinrich Himmler. Moreover,

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the impostor did not hang himself in Spandau, but was murdered. The following account is based on Dr Thomas’s research. A German pilot did land in Scotland on the night of 10 May 1941. He claimed to be Rudolf Hess, in search of peace. Though thinner than Hess, this man did resemble him. But it is hard to accept the “confused and pathetic character” who landed in Scotland as Hitler’s successor and designate, after Goëring. The pilot asked for talks with senior British officials, but knew little of international politics, or even of his own “peace proposals”. Prime Minister Winston Churchill did not announce the pilot’s arrival, forbad any photos and kept him away from anyone who had known the real Hess. Both Hitler and Goebbels announced that Hess was mentally unstable. Indeed, throughout his confinement over the remaining 46 years of his life, the prisoner’s behaviour was puzzling and difficult. At times, he pleaded loss of memory; for the first 28 years, he refused visits from his wife or any other relative. At the Nuremberg trials of 1945–46, the court sentenced 12 war criminals to death. Though the prisoner didn’t seriously defend himself, he received only a life sentence. By October 1972, when Dr Thomas joined the British Military Hospital in Berlin, the man known as “Hess” was the only prisoner in Spandau. Dr Thomas unearthed Rudolf Hess’s old World War I records. In 1917, he had a gunshot wound which injured his lung, kept him in hospital for four months, made him breathless and ended his active service. But a medical report at Nuremberg in 1945 showed that the prisoner had no gunshot wounds. During the time he had been a prisoner in Britain, Hess’s British doctors had not believed his frequent complaints of stomach pains, but in Spandau, much later, he almost died of a perforated duodenal ulcer. In 1973, the prisoner had stomach X-rays. When Hess was dressing again, Dr Thomas was close by, looking for a gunshot wound on his bare torso. But there was none. Nor did his chest

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X-rays show any lung damage. One day in Spandau an officer called out for Hess. The prisoner answered: “Sir, there is no such person as Hess here. But if you are looking for Convict Number 125, then I’m your man.” In late July 1987, messages reached the Foreign Office in London that a Soviet warder had reported the prisoner’s “loose talk”. Moreover, Soviet secretary Mikhail Gorbachev was pressing for his release, which the British privately opposed. The four powers controlling Spandau (USSR, Britain, France and USA) were to meet and decide this in late August 1987. On 17 August the prisoner — by now very old and frail and in poor health — was resting in a garden shed after a walk. The American warder guarding him was called away to the phone in the main block. The warder returned to find the prisoner’s head propped against a folding chair. His face was purple, and round his neck was a length of flex. The warders could not revive him. The British insisted that only their own military police should investigate the death and that only one of their own army pathologists (rather than an international panel) should do the autopsy. They also vetoed photos, fingerprinting and genetic testing of the body. From this autopsy, Professor J.M. Cameron of the University of London concluded that death was not due to natural causes, but to asphyxia, compression of the neck and suspension. Moreover, contrary to Rudolf Hess’s 1917 records, the prisoner had never been shot. Though Cameron’s report did not even suggest suicide, the British media release stated that Rudolf Hess had hung himself. In outrage, the Hess family insisted on a second autopsy. Still no gunshot wound, but this second report stated that the prisoner had received a savage blow to the back of his head. Finally, 26 German pathologists took nearly one year to compose a third autopsy report, which supported probable strangulation. Scotland Yard spent six months investigating the death, but British authorities suppressed its report.

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Dr Thomas concludes that the prisoner was far too frail and stiff to have possibly hung himself. Instead he was struck on the head and then strangled. Furthermore, Thomas says, British authorities have continued this deception (“one of the most shameful crimes in history”) ever since. There is independent support for his views. Seventy-six members of the Royal College of Surgeons of Edinburgh unanimously agreed that the prisoner who died in Spandau in 1987 could not have been the real Rudolf Hess. (GB)

KAFKA, ORWELL, CAMUS AND AUDEN For many people “the classics” are books they feel they ought to read, but somehow never do. This is especially true of the modern classics by, among others, Kafka, Orwell, Camus and Auden. Often these books are so tortuous that after the first few pages a reader feels he or she has the drift and puts them away for another occasion. For some, remembered books are the ones they have never read. The authors are well-known enough, however, and a number of these moderns have had interesting medical histories. Take Franz Kafka (1883–1924), for instance. Besides being the stimulus for a new word in the language — “kafkaesque”, meaning “man’s bewilderment in a nightmarish world” — medically he had two claims to fame. A thin, stooped, introspective man, at the age of 34 Kafka concluded that his then persistent cough was psychosomatic in origin, being initiated and stimulated, he felt, for the sole purpose of putting to an end his insoluble internal struggles. Being the reflective, introspective person he was, Kafka seems to have thought it necessary to have an explanation for every bodily function. In fact the cause was much more mundane — he had

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tuberculosis and was to spend half of his remaining six years in sanatoriums. However, it was not so much the symptoms produced by the bacillus at its common location, the lung, which are of interest, but the symptoms produced from another, fairly uncommon, area for which he is best remembered medically. The germ affected the writer’s larynx, and eventually left him speechless, parched and gaunt, a victim, he claimed, of a conspiracy of his own body. Kafka’s second connection with medicine was to do with his work. He lived in Prague and worked at his day job at the Worker’s Accident Insurance Institute, where his task was to assess the degree of disability caused by workplace injuries. He was there at a time when workers’ compensation was an emerging feature of industrial life, and quickly recognised that it did not always pay to get well quickly; a clean bill of health often meant being sent away empty handed. Limbs became a commodity to be haggled over, and at night Kafka returned home to write about those more seedy aspects of human nature he had seen during the day. Kafka always felt that he should have won the Nobel Prize for Literature. When it became obvious that was not going to happen, in a fit of gallows humour he exclaimed: “At least I think I deserve the Nobel Prize for sputum.” He was 40 when he died in 1924. Had he not succumbed then, a second fatal trap may have been sprung 20 years on, for his three sisters were gassed in a German concentration camp. Another well-regarded modern writer was George Orwell (1903–50). He was born in Bengal, where his father was a minor civil-service official, and he grew up in an atmosphere of impoverished snobbery. Nonetheless, he was bright enough to win a scholarship to Eton. Orwell was also to die of tuberculosis in a sanatorium. Furthermore, like Kafka, he had a laryngeal condition which affected his speech. It was not a chronic infection, however, but the result of a wound to the throat sustained during the Spanish Civil War. Thereafter he spoke in an odd, strained manner.

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The Algerian writer Albert Camus (1913–60), who did manage to win the Nobel Prize for Literature, contracted tuberculosis at the age of 17. As a youth he rather fancied himself as a soccer player, but the disease cut short his promising sporting career. He had several flare-ups of the disease, but, as he lived on into the era of antibiotics, he survived with the aid of their use. In the end it did him little good for he died aged 46, not of a diseased chest, but of an automobile accident. But of this small group of modern writers it is the poet, and one of the angry young men of literature of the 1930s, W.H. Auden (1907–73), who perhaps has the most interesting medical history. He was born in York, where his father was a general practitioner (well-off enough to employ a coachman, two maids and a cook — those were the days). The year after Auden was born the family moved to Birmingham, where his father had been appointed to a post at the university’s medical school. Auden felt destined to be a poet from the age of 15, and his undergraduate days at Christ Church, Oxford, cemented his early aspirations. Photographs taken in his youth show his rather florid face, thick lips and large hands and feet. Apparently he was clumsy in his movements, rather grubby in his personal habits and lived in an apartment which was to be avoided by the fastidious. He was described by Alan Bennett as: “scattering his ash as liberally as he did his aperçus. If one wanted to entertain Auden, the first requirement was a good carpet sweeper”. He was a professed homosexual and his long-time lover was Chester Kallman, an undistinguished young poet who apparently, as Bennett succinctly has it, “went down on posterity but not to it”. With Auden’s heavy features and thick digits, at first glance he had the appearance of an acromegalic. Acromegaly is an uncommon malady caused by a pituitary disorder. Often the first signs of the disease are when the sufferer notices that his hats have become too small and dentures ill fitting.

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In Auden’s case, it was not until later in life, when he developed his famous creased, gouged and rumpled face, that the true diagnosis became apparent. He suffered not from acromegaly but from the rare Touraine–Solente–Golé syndrome, also known as pachydermoperiostosis. It is a very rare syndrome, but oddly enough it seems Racine, a towering French poet and dramatist of the 17th century, was similarly affected. The condition apparently mainly attacks males and is an inherited developmental defect. It is characterised by clubbing of the fingers and toes, coarsening of the features, a rather lugubrious expression, oiliness of the skin and marked furrowing of the scalp. (The features can indeed be confused with acromegaly, however in that condition the facial skeleton, the jaw and skull as a whole are enlarged.) There is no therapy. It is not fatal, and progresses for five to 10 years before becoming stable. The ailment had no effect on Auden’s capacity for work, and he lived to the age of 66, dying in Vienna in 1973. His face, while not his fortune, was a constant source of wonderment to the public. After painting Auden’s portrait, the renowned artist David Hockney surely had the final say when he remarked: “I kept thinking, if his face looks like this, what must his balls look like?” (JL)

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Chapter

WARFARE

5

AND

MEDICINE

RED

JACKETS, TIGHT TROUSERS AND COLD STEEL: THE MEDICAL ASPECTS OF THE BATTLE OF WATERLOO There was a sound of revelry by night, And Belgium’s capital had gather’d then Her Beauty and her Chivalry, and bright The lamps shone o’er fair women and brave men — Lord Byron, Childe Harold’s Pilgrimage

Thus wrote Byron on the Duchess of Richmond’s ball held on 15 June 1815, a function graced by the Duke of Wellington himself, no less, as well as “a thousand hearts beating happily when Youth and Pleasure met to chase the glowing hours with flying feet”, to quote the poet. It was then, just when “joy was unconfined” that “was heard the cannon’s opening roar” of the Battle of Waterloo. It all happened a long time ago, when medical care of the casualties of war was quite different from that practised today. Sterility, antibiotics, anaesthetics and

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rapid evacuation are the norm for the 20th century. But what was it like then? On 1 March 1815 Napoleon had landed near Antibes in the South of France, having escaped from Elba four days earlier. Thus began the drama of the Hundred Days which reached its climax in Belgium, in the countryside just outside Brussels, near the hamlet of Waterloo. During those three months the former Emperor had managed to gather around him 115,000 of France’s finest troops, and on the very day of the Duchess’s ball he quietly slipped over the river Sambre in the north east of that country, and, although he did not know it at the time, into military folklore. His plan was to drive a wedge between the 102,000 Anglo–Dutch–Belgium troops under Wellington and the 140,000 approaching Prussians under Marshal Blücher. Initially there was success and the Prussians were driven back to within 40 kilometres of Brussels. Over the next three days several bloody battles were fought, culminating in the final showdown at Waterloo on 18 June. Many valorous stories are told of the brief campaign, but when the cannon fire had stopped and the smoke cleared, the chilling and sombre fact remained that all told there had been 102,000 fatal casualties including 47,000 at Waterloo itself. These latter were about equally divided between the two forces. And Ardennes waves above them her green leaves, Dewy with nature’s tear-drops as they pass, Grieving, if aught inanimate e’er grieves, Over the unreturning brave — alas!

The question is: if Byron could thus verbalise the country’s collective sorrow over the dead, how did the army deal with the daunting problem on the spot of those only marginally better off, the wounded? In a word: ingloriously. In deed and in fact, they had met their Waterloo. The British Army medical department of the era fell into two categories, those who staffed hospitals, a phalanx of top medical

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brass — led in this instance by Dr John Grant, who was headquartered in Brussels — and those attached to regiments, who were, indeed, at the cutting edge, in more ways than one. For the Waterloo offensive there were 52 staff surgeons who were distributed among general hospitals at Ostend, Ghent and Bruges as well as Brussels. In the field the theory was that each battalion of 600 men was allocated one regimental surgeon and two assistant surgeons. In fact, of the 40 battalions, only 22 had this complement. All told there were 36 regimental medical officers and 69 assistant surgeons in the action of June 1815. A veritable thin red line, with sleeves up and eyes down as the foot sloggers went pouring forth “with impetuous speed, and swiftly forming in the ranks of war”, to quote Byron again. Assistant surgeons were unqualified apprentices and usually inexperienced in battle conditions. The medical field station, such as it was, was often within cannon-shot range of the battle itself and established in a farmhouse or barn. It was expected to move with the action, leaving the more seriously wounded in the care of the local inhabitants. As the war had already ravished their land, a wounded pillager in their midst must have raised mixed feelings in the unwilling hosts. In the Waterloo campaign, however, most Belgians were generous, caring and unstinting in their efforts to aid the injured, after all they were actually on the side of the allies. Nonetheless, some went onto the field of battle when the combatants had departed and stripped the bodies of any marketable bric-a-brac. Moreover, to further that grisly end, they were not above dispatching a few of the badly wounded. Between the front and the base hospital there were no intermediate units, but to overcome this deficiency, the authorities supplied each battalion of 600 with one sprung cart, some blankets and 12 stretchers. Brussels is about 19 kilometres from Waterloo, and in the end it proved to be a long and halting walk for many. No operating instruments were provided, as each surgeon was required to bring along his own boxed set. These included items

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such as bullet forceps to grope for missiles, a punch to knock out teeth, a pair of strong nippers for trimming the ends of protruding bones and a probang. This later was a flexible strip of whalebone for rummaging about down the throat to clear the passages. (Since this surgically gung-ho era, of course, such boxed sets of surgeons instruments have become collectors’ items; so much so, in fact, that many extra assortments were manufactured to satisfy the ghoulish curiosity and morbid interest of the amateur collector. One seen now in mint condition probably never saw the inside of a field operating theatre or drew blood in the line of duty.) The overwhelming size of their task at Waterloo concentrated the minds of the surgeons wonderfully, and the whiff of cordite and press of numbers rapidly overcame any hesitancy due to lack of formal qualifications or dexterity. For his pains, a Regimental Medical Officer was paid 10 shillings a day and in seniority ranked below the youngest ensign in the regiment. Apart from three defended farms, the battle itself was fought over open country with little cover. This facilitated artillery fire and mass deployment of troops. As a consequence there were three modes of injury. First, heavy macerating wounds from 6, 9 or 12 pound round shot. The allies had smaller cannon, but the French had the more deadly 12-pounder. The cannon fire was liable to produce violent effects up to about 1,000 metres, and a well-directed shot was capable of killing a dozen or more men in line. A ricochet could be just as lethal. Fortunately, the formalities that June day had been preceded by heavy rain, and the wet ground reduced the chance of ricochet. Second, injuries from low-velocity lead musket fire. This was effective up to about 30 to 40 metres and the shot frequently fragmented on contact with bone. Over 250 metres it was little more than a nuisance, so muskets could only effectively be used at close quarters, which added a psychological dimension. Multiple shot exploding out of canisters was particularly effective against massed infantry.

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And, if that was not enough, the third possible tribulation was of a cutting, chopping or piercing variety of injury from swords, lances or bayonets. This was very much the era of dash and elan, and the later recounting of tales of hand-to-hand fighting, especially if having taken place in scarlet jackets and tight trousers, was the stuff for romantic interludes in front parlours for years to come — if you lived, that is. You may recall Byron on “Brunswick’s fated chieftain” who: . . . roused the vengeance blood alone could quell; He rush’d into the field, and, foremost fighting fell.

He was one of those felled on a tiny four-kilometre front. The Battle of Waterloo itself was the third and final encounter in the three days of the brief campaign, the exhausting culmination of a quite bloody frenzy. It lasted just the one day, getting off to a late start at 11 a.m., when the muskets had dried out, and ending at sunset with the final defeat of the Old Imperial Guard. In that time the combatants managed to inflict 47,000 casualties on each other. If wounded, but you survived, what would be your likely injury? On the head and neck, chopping injuries were common, compound skull fractures frequent and death the rule. True, portions of the impacted bone were removed and skin flaps replaced, but the ensuing meningitis or cerebral abscesses with fits heralded the inevitable. There was the odd exception, of course, and he dined out on the story for years. Penetration of the chest wall by ball or bayonet resulted in contaminated sucking wounds and drains had to be inserted. Your chances were pretty thin. It was thought at the time that if the man survived a glancing blow, any later onset of breathlessness was due to electricity from the passing ball. In fact, it was almost certainly due to bleeding within the lung.

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Abdominal wounds were also usually fatal. If the bowel was divided it was sutured to the abdominal wall in the vain hope of preventing contamination of the peritoneal cavity. A musket ball could lodge in the bowel and at least one soldier is recorded as having passed the shot by way of the rectum at a later date. It is to be hoped that the po-faced warrior kept it. That leaves us with the limbs, and here, you will be glad to know, there was a glimmer of hope. Many tales are told of the survivors of chopping injuries and of those with limbs torn off. One sergeant rode upright the 19 kilometres to Brussels after his left arm had been torn off at the shoulder. He lived for another 43 years. One famous limb injury occurred during the heat of battle. Cavalry leader Henry Paget (then Lord Uxbridge, and later to become the Marquess of Angelsey) was at the receiving end of a famous interchange while riding with the Duke of Wellington. It seems a cannon ball whistled just over the Iron Duke’s horse and struck the knee of the disconcerted Paget riding by his side. Paget is reported to have suddenly looked down and said: “I have lost my leg, by God.” To which Wellington replied: “By God, have you?” He then turned and got on with running the battle. The shattered leg was later removed under fire to complaints from Paget that the knife was blunt. But then he added that he had had a pretty good run and this would give the younger men a chance. (He was actually referring to the boudoir, not to the regiment.) Despite all his vicissitudes, Paget lived until the age of 86, and the wooden leg which saw him through all those years remains with the family to be still touched and marvelled over. Surgical thinking at the time was that the surest way to save the life of a person with a compound fracture was to amputate, and the sooner the better. If left, sepsis, gangrene and tetanus could prove fatal. Incredibly, approximately 500 amputations were carried out during the period of the battle, and about

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12 per cent of those with a limb injury had the limb removed. No doubt many amputations were unnecessary, but hesitancy had no place with bullets flying about, so the motto was: “when in doubt, amputate”. Mortality following immediate amputation was about 30 per cent, but if amputation was left until later at a base hospital, the deaths amounted to about 45 per cent due to fever and gangrene. So there was probably something in the clinical catch phrase, but either way you were pretty well on a hiding to nothing. The actual operation was done by a kind of guillotine method and the skin edges brought together by sutures or tape. Speed of operation was the hallmark of the skilled practitioner and the drama took anything from a few minutes to quarter of an hour. As there were no anaesthetics available it must have been the longest few minutes in the man’s life. But in truth, it was not quite so bad as you would think, for the shattering nature of the injury had an important surgical consequence, which was not lost on the surgeons, even if the sufferer had his reservations. The blow numbed the limb and relaxed the muscles for a few centimetres above and below the injury, and as the blood pressure was low from shock, so bleeding was reduced. Another advantage of early operation, but not realised at the time, was that a dirty wound was converted into a relatively clean one which would travel and heal better. Further, it did not need dressing for several days and if the victim fell into the hands of itinerant sawbones keen to make a quick financial killing (if not one of any other sort), at least the operation had already been done by a skilled person. So carrying out surgery on the field of conflict could be defended. Amputees were agreed that the most painful part was the skin incision and the clamping of the arteries together with their accompanying nerves. It was described as a powerful burning sensation. What they did not know was that it was better to be one of the early cases, while the knives were comparatively clean if not actually sterile.

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Lord Fitzroy Somerset had the presence of mind to call for his arm to be brought back after amputation as he had forgotten to take off his signet ring. Another story for the boudoir. He later became Lord Raglan and lent his name to a type of sleeve which has no shoulder seams, the sleeve extending up to the neck, perhaps done to accommodate his injury. He lived for another 40 years. Musket balls were probed for and removed and skin wounds brought together with either tape or sutures of waxed linen or twisted gut. The overall mortality of these procedures was about nine per cent. Wounded men sometimes lay for days on the field of battle and occasionally for weeks in adjacent barns. For some survivors such a delay may have saved their limb, as there was some medical reticence about vigorously treating malodorous lesions. For those who were picked up, the roads were choked with wounded making their way to Brussels, where six hospitals catered for about 2,500 wounded. The overflow of a similar number went on to Antwerp and beyond. With the breaking of the news in England, many civilian surgeons journeyed to Belgium to help not only with the wounds but the gangrene, dysentery, and fulminating infections which were the inevitable consequence of most of the injuries. However, not all things medical at Waterloo were of a traumatic nature. In his pursuit of Blücher, Napoleon uncharacteristically hesitated at what proved to be a crucial moment in the proceedings. He returned to his quarters and became preoccupied not with deep strategy, but with a pressing need to ease an acute attack of prolapsed piles. Having been in the saddle all day, doubtless he found this less than amusing. Indeed, the fact did not come to light until 50 or so years later when his servant, previously sworn to secrecy, told all. Ultimately, of course, his mundane lesion proved to have a more far-reaching importance than all the desperate surgical heroics being carried out at the same time all round Waterloo.

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It is also said that the Little Corporal had a fit the night before the encounter, and his doctor left him to sleep in. He had had one previously, while locked in the arms of his mistress during a particularly strenuous sexual joust. On that occasion, the lady fled in hysterics when she feared her gyrations and excesses had killed the chief. As it has been speculated that Napoleon died of cancer of the stomach six years later, his night before the battle may also have been disturbed by the odd twinge of indigestion too. It is not recorded. The man who let Napoleon sleep in was his chief medical officer, Baron Dominique-Jean Larrey, and as he was the dominant medical figure in the otherwise oppressive military bravura of Waterloo. We ought to digress slightly and take a closer look at this remarkable man and his background. Since the invention of the cannon and other gunpowder-propelled firearms in the 14th century, battles had become bigger and casualties numbered thousands rather than hundreds, or even tens. With few exceptions, notably Ancient Rome, medical officers were not found in the army before the 18th century. Some went as servants to the nobility, but the rank and file looked after themselves, were tended by local inhabitants or treated by itinerant charlatans or camp followers. Logistically the wounded posed no real problem; they either tagged along with the baggage wagons as best they could, or were abandoned. Ambroise Pare in 1537 witnessed an old soldier calmly cut the throats of three men who were badly wounded; the old soldier then turned to Pare and said he hoped the same would happen to him if he were similarly wounded. Queen Isabella of Spain (1451–1504) had provided bedded wagons to transport the wounded after the battle had passed. The Duke of Wellington during the Peninsular War of 1804–14 thought bedded wagons a confounded nuisance and would allow nothing to interfere with the movements of his army. At that time

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French regulations stated that so-called ambulances should wait three miles to the rear. These were huge cumbersome vehicles known as fourgons and needing up to 40 horses to pull them. With the usual mud and road confusion, it could take 24 to 36 hours to reach the collection point to where the wounded had been manhandled, by which time those in need were either dead or in extremis. Many were left on the field to be swooped on by camp followers, stripped, robbed and mutilated; friend or foe it made no difference. Someone was needed with medical skill and a will to stand up to military authority and get some order into caring for the wounded. Dominique-Jean Larrey was that man. He was born in 1766 and joined the army as a medical officer in 1792. Besides his drive and enthusiasm, he had another crucial asset — he was a superb surgeon, a skill soon recognised by the highest authority. Larrey insisted on attending to the surgical needs of soldiers regardless of rank or nationality. For the era he displayed a quite unique humanity towards his fellow man. At the beginning of his career he joined the army on the Rhine and chaffed at the rear. He thought he could get the wounded onto panniers slung on horses, but it proved to be impractical. The following year he sought out the commander, General Custine, and pointed out that while the infantry had the support of very mobile artillery, the same was not true for the wounded. He sought permission to construct a vehicle on similar lines to the gun carriages, and which he christened “flying ambulances”. Custine was a 50-year-old aristocrat; Larrey was a 26-year-old provincial doctor. Normally Larrey would have been sent packing with a flea in his ear for such a hare-brained scheme, but by significant chance the Terror was in full cry, and it struck the officer it would never do for the National Convention to learn that one of its generals had turned down a plan to help its citizens. So, amazingly, young Larrey got the nod.

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The ambulance, Larrey insisted, had to be a carriage, well sprung and light. He got his wish, and each division was equipped with 12 carriages, eight with two wheels for use in flat country, the others with four wheels for mountainous terrain. The smaller carriage resembled an elongated cube with two small side windows and doors at each end. The floor was able to be slid out over four central rollers and was provided with a horsehair mattress and bolster. The side panels were padded for about 25 centimetres above the floor and four metal handles were set into the floor so they could be pulled out and used as stretchers. At 110 centimetres wide, it could take two patients at full length. It was drawn by two horses, one ridden. The four-wheeled variety was longer and wider, though externally it looked similar. The floor was fixed, but the left side opened for almost its whole length by means of two sliding doors, so the wounded could be laid inside. It could accommodate four if they bent their legs slightly. A wheelbarrow was slung underneath to act as the forerunner of a trolley. The whole was drawn by four horses, two ridden. Thus Larrey devised one of the greatest advances in emergency military medicine, initiating the principle of rapid evacuation of casualties which is still a cardinal rule today. It was a masterstroke. Meanwhile, back at Waterloo, Larrey was actually in the French line during the final denouement and was observed at work by the commander of the enemy forces, the Duke of Wellington. When told who it was, Wellington remarked: “Tell them not to fire on him. Give the brave fellow time to pick up his wounded.” Then, wheeling his famous horse, Copenhagen, the commander-inchief raised his hat in a distant greeting to the Frenchman, telling his aide: “I salute this honour and loyalty you see yonder.” Then it was on with the slaughter. The Waterloo campaign was a close-run military victory for the British and their allies, even the Iron Duke himself admitted as much. Drawn and haggard, Wellington rode through the field

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of battle the day after. It was littered with the dead, and he silently wept. The earth is cover’d thick with other clay, Which her own clay shall cover, heap’d and pent, Rider and horse, — friend, foe, — in one red burial blent!

It proved to be the bloodiest battle of Wellington’s long career. During the action Wellington lost 29 per cent of his army, and out of his 63 commanders, 11 were killed and 24 wounded. But, as Dr Haddy James, assistant surgeon to the Life Guards, had it: . . . was the real valour displayed more in the face of the enemy or by those who watched the long torture of bullet probing or saw the agony of an amputation, however swiftly performed, knowing that their turn was to come? Those who regained their native shores deserved the prayers and the ovation of the population.

As for Larrey, he became a confidant of Napoleon, was created a Baron and maintained a surgical dexterity until his old age. In his prime, his time for removing a leg — without anaesthetic, of course — was two minutes. At that speed, the fingers of any slow moving assistant would have been in danger, too. He died in 1842, aged 76. (JL)

FLORENCE NIGHTINGALE: NURSES

FORCE THEIR WAY INTO A MAN’S WORLD

“My God! What is to become of me? I see nothing desirable but death” — Florence Nightingale

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It was 1850 in Victorian England. The despairing young woman had money, position, beauty, brains and education, yet she wanted more. Florence Nightingale’s mission was to serve God by serving others. During her lifetime she was to fight and win a “continual battle against officialdom, medical jealousy, incompetence and inertia”, in the words of her biographer Elspeth Huxley. Before the nursing revolution that owed so much to her, nurses were drudges, famous for drinking and immorality. Doctors despised them, while some took advantage of them. Overcoming family opposition, she prepared herself by visiting the best nursing schools and hospitals in Britain and Europe. In 1854, when she was about to take charge of nursing at King’s College Hospital in London, the Crimean War broke out. The British reached the Black Sea, but since there were too few transports to take them to the Crimean Peninsula, they had to leave their medical supplies behind. They could boost their spirits on the long crossing by looking out at the bloated bodies of their comrades — victims of cholera — bobbing in the water. Many died before ever seeing battle; the victory at Alma brought more casualties. Care of the sick and wounded was hopeless. British war correspondent W.H. Russell’s reports in The Times shocked Britain. The ambulance men were retired veterans, themselves more likely to need nursing than to help others. Both medicine and warfare were still very much male domains. The military had quashed an earlier move to send female nurses, but by now Florence Nightingale’s friends included the Secretary of State for War. At his invitation, she left England with 38 women “ranging from Catholic nuns to drunken drabs”. Both their welcome and their quarters were chilly. Before they could occupy their room, eight nurses had to remove the corpse of an enemy Russian general. The water ration was just one pint per person per day. Food and medical supplies often didn’t arrive; there were no cots, mattresses,

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bandages or tables, even for operations. Rats prowled everywhere, the hospital was filthy and the privies were blocked. In charge of medical services was Dr John Hall, whom Nightingale called “a fossil of pure Red Sandstone”. To his superiors he reported smugly: “The whole hospital is on a very creditable footing and nothing is lacking.” Hall’s orders from Britain were to let the nurses enter the hospital, but the orders didn’t state that the nurses should actually nurse! At first the doctors just boycotted the new arrivals. While they waited, Nightingale organised food, kitchens, bandages and linen. In the first half-hour of the futile Charge of the Light Brigade at Balaclava, two-thirds of the British cavalry were killed or wounded. According to Huxley: [To reach hospital, the wounded had to survive] eight days’ passage across the Black Sea . . . in ill-equipped vessels, rolling about the open decks, often without drugs, dressings or even blankets. Then . . . crossing the Bosporus in Turkish caiques . . . to be dumped down in the stinking corridors of the two hospitals at Scutari.

To cope with the flood of wounded men, the doctors finally had to admit the nurses. Operations took place in the wards. Dr Hall opposed the use of chloroform anaesthesia, but luckily his colleagues were more humane. Florence Nightingale wrote: One poor fellow, exhausted with haemorrhage, has his leg amputated as a last hope, and dies ten minutes after . . . The mortality of the operations is frightful. We have Erysipelas [infection and fever] . . . We now have four miles of beds, and not eighteen inches apart.

By late 1855, nearly three-quarters of the British army were

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under medical treatment and unfit for duty. Most were not wounded but sick: malnutrition, scurvy, cholera and dysentery were rife. In winter, the cold steel of their weapons could bring on frostbite. Within three weeks, four of the surgeons died. Despite a severe attack of “Crimean fever”, Nightingale herself visited the front three times. Long before the discoveries of Koch, Pasteur and Lister, she fought infection with cleanliness and fresh air. Under the hospital lay a blocked sewer. Her pressure forced the authorities in London to send a Sanitary Commission led by Dr John Sutherland. They had the sewer cleared and flushed; they removed a horse’s carcass contaminating the water; from the courtyard they cleared 26 other dead animals. Dr Sutherland, a pioneer in public health, became her lifelong adviser, disciple and willing slave. By the summer of 1855, the death rate had dropped from 42 per cent to 2 per cent! Back in England, Florence never regained her health and could not travel again. Yet for her remaining 56 years, she wrote, published and lobbied people in power to help various underprivileged groups. Despite medical opposition, she raised 50,000 pounds to found the Nightingale Home for Training Nurses at St Thomas’s Hospital. Within 25 years, the bad old days of nursing were past. Better nursing care supported better medical care. She died in 1910, at the age of 90. On her death, Lord Stanley, the former chairman of the Sanitary Commission said: No person . . . within the past hundred years has voluntarily encountered dangers so imminent and undertaken offices so repulsive . . . in a pure spirit of duty towards God and compassion for man.

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Chapter

DISCOVERIES

6

AND

DISEASES

E A R LY

DENTISTRY WAS A H E A LT H H A Z A R D

Toothache is as old as history. Skulls as far back as the Bronze Age show dental decay, including cavities from root abscesses. Most sufferers of toothache had Hobson’s choice: suffer agonising toothache, or submit to painful extractions, usually leading to toothless misery and hunger. Only a few could afford artificial teeth. Tombs of the nobility in Tuscany dating from 700 BC have contained partial dentures, some of which were removable. The Roman poet Martial, writing in the 1st century AD, refers to teeth made of bone, ivory and even wood. “Maxima has three teeth, all . . . of boxwood and as black as pitch.” The Persian physician Rhazes (AD 850–923) was one of the first to recommend fillings, though the alum and mastic he used must have been too soft to last. The Italian university professor Arculanus (1412–84) was the first to refer to gold fillings.

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In 15th-century England, the drawers of teeth included barbersurgeons (who also cut hair and let blood), apothecaries, chemists, country doctors, shoemakers and blacksmiths. They all competed with impostors wearing teeth as necklaces or sewn onto their belts. At fairs and markets these impostors played loud music to drown the cries of their “painless” extractions. A popular saying was “to lie like a tooth-drawer”. Though she said she had faced the Spanish Armada with “the heart and stomach of a king”, Queen Elizabeth I dreaded the pain of extraction. In 1578, according to John Strype, Elizabeth passed “whole Nights without taking any Rest . . . her Physicians were . . . consulted . . . pulling it [the tooth] out was esteemed by all the safest way . . . to which the Queen was very averse.” Finally the Bishop of London had to set her a personal example, even though “he were an old man, and had not many teeth to spare . . . She was hereby encouraged to submit to the Operation herself.” Later, Elizabeth used to pad out her unsupported lips with rolls of cloth. Hogarth’s paintings show even young adults with few teeth. Until the end of the 19th century, some people had to crush their food with masticators (like large nut-crackers). Dentures made of ivory or bone soon blackened and decayed; halitosis made outcasts of their wearers. In the 1790s, Nicholas Dubois de Chemant fitted false teeth made in one solid piece of shiny, decay-proof porcelain. Later, Chemant worked in England with Wedgwood porcelain paste, claiming among his many happy clients Dr Edward Jenner, whom we honour for introducing vaccination against smallpox. In the late 18th century, tooth transplants became trendy; many poor people offering their teeth for sale. The heroine of Les Miserables had to sell first her hair, then her front teeth and finally her virtue. Anatomist–surgeon John Hunter, whose 1770s treatise The Natural History of Human Teeth revolutionised dentistry, advised operators to

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line up several donors. If the first donor’s tooth did not fit, try the next, and so on. After getting a reasonable fit, tie the transplanted tooth to the adjacent ones. If all went well, the teeth would settle down in a month or two and remain firm for three-to-five years. But sceptics claimed that “transplantings” were actually replantings; that the operator simply repaired the extracted bad tooth and put it back again! Live donors offered single teeth for transplants, but for dentures, dead donors were just as good. Even a badly decomposed corpse had valuable front teeth; a single burial vault could yield teeth worth 20 to 30 pounds — a fortune in the 1700s. A supplier told Hunter’s pupil Sir Astley Cooper: “Oh, Sir, only let there be a battle and there’ll be no want of teeth. I’ll draw them as fast as the men are knocked down.” Many people wore dentures containing teeth taken from young men slain at Waterloo. This was before the days of disinfectants, but perhaps some people boiled the teeth before recycling them! The first satisfactory dental cement (a zinc oxyphosphate) appeared in 1869. Soon after came the dentist’s drill, and a wax for taking impressions. Now permanent repairs became possible, but at first, filling of roots involved contamination with germs. As Dr Bremner says, in his Story of Dentistry: “Frequently the teeth under the well-constructed bridges would abscess and develop pus-discharging fistulae, but few dentists were disturbed.” It was the patients who were disturbed. In 1911, a London physician, Dr William Hunter, saw several patients with puzzling ailments. Some had had extensive restoration work (contemptuously called “American dentistry”) that was dirty and showed unhealthy roots. The media added fuel to the flames of dissent. Describing the bridges as “mausoleums of gold over a mass of sepsis”, Dr Hunter suggested removing the bridges and the roots holding them. Of the few patients who agreed to having their bridges and underlying roots removed, quite a number found their ailments improved.

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Doctors started thinking about the links between teeth, gums and the bloodstream. The felt that a tooth abscess may spread infection to other parts of the body. That was well and good, but some doctors blamed teeth for any puzzling illness. Patients indiscriminately had their teeth pulled, their mouths wrecked and their faces disfigured, and often without improvement to their health. Eventually, X-rays saved the day by showing which teeth did warrant removal. Over the centuries, poorly fitting, insecure dentures have caused untold misery. Not only could they slip out in company, but they often hindered eating! In Parliament Benjamin Disraeli tormented poor Lord Palmerston, saying: “[His dentures] would fall out of his mouth when speaking if he did not hesitate and halt so . . . ” Even in late Victorian England, refined women often ate alone in their bedrooms. Then they would replace their dentures to sit elegantly at dinner, seemingly living on thin air. A dentist fitted a fashionable lady with a partial row of human teeth mounted on ivory. Four years later, she returned with a very sore mouth, and her new teeth solidly fixed with tartar to her own — she had never removed her false teeth, lest her family know her secret. During a world cruise Ulysses Grant, president of the United States from 1869 to 1877, lost his teeth overboard; after which he gave up public speaking. But a sailor visiting the Solomon Islands met a far worse fate. He avoided being eaten by cannibals, only to see his false teeth fall overboard; when he jumped in after them, the sharks ate him. (GB)

THE

MYSTERY OF MAWSON’S ANTARCTIC DISEASE

A man from Australia, one from Switzerland, and one from

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England. Not an ethnic joke, but the Far-Eastern Sledge Team. It was part of the 1911–14 Australasian Antarctic Expedition, set up to explore that part of Antarctica closest to Australia. Douglas Mawson, Australian explorer, geologist and physicist was leader of this sledge team and of the whole expedition. He was 30 years old, and had already spent two years with Ernest Shackleton’s “Farthest South” expedition in 1908–09. Of the six sledge teams, Mawson’s had the farthest to go. His companions were the 28-year-old ski champion–mountaineer Xavier Mertz and 22-year-old Lieutenant Ninnis of the Royal Inniskilling Fusiliers. Mawson, Mertz and Ninnis left the Commonwealth Bay base camp on 10 November 1912. They had 17 husky dogs hauling three sledges, each about 3.5 metres long; their load was over 770 kilos. On good days, they covered up to 30 kilometres. But often gales up to 120 kilometres per hour stopped them from marching at all. Ninnis suffered a bout of snow-blindness, and then an agonising finger abscess, which Mawson lanced with a pocket knife. By 14 December they had abandoned one sled after using its supplies. Mertz was singing cheerfully while leading on skis, with Mawson second, riding one sled. Suddenly Mertz stopped singing and held up one stock to signal a crevasse. Mawson called a warning to Ninnis in the rear and went on. A little later, Mertz and Mawson looked back, but they could see no trace of Ninnis, his dogs or his sled! Where Mertz had signalled a crevasse, there was now a gaping hole, over three metres wide. Secured by a rope, Mawson leaned out over the edge. Well out of reach, on a ledge 45 metres below, he could see only two dogs, the tent and food packs. Below the ledge, nothing but darkness. Could Ninnis somehow still be alive? They took turns to hang over the edge and call him. But after three hours, they could hope no longer. Mawson and Mertz had lost not only their companion, but the main sled, most of their food, supplies and equipment, as well as the stronger dogs. They were 500 kilometres from base. The only hope was to supplement their food by eating the dogs.

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They killed and skinned the weakest dog, but the meat was stringy. Mawson wrote in his diary: “It was a happy relief when the liver appeared . . .” Nothing went to waste. They made themselves soup from old food bags, and threw the dogs old rawhide straps and gloves to gnaw on. Soon Mawson got snow-blindness and had to march with one eye bandaged. On Christmas Day, still 250 kilometres from base camp, they were already down to their last live dog. On New Year’s Eve the usually cheerful Mertz was silent. He thought the dog meat was upsetting him, so they agreed not to eat it for a few days. The next day, both had stomach pains and peeling skin. On 3 January Mertz got frostbite of the fingers, followed by diarrhoea; they covered only seven kilometres. The weather the next day was fine, but Mertz could not march at all; nor the day after. On 6 January Mawson, though he himself felt weak and dizzy, rigged up a sail on the sled and dragged Mertz along. When they camped, Mertz had vomiting and diarrhoea; that night, he was incontinent. In the morning, he had some kind of fit. Then delirium, more incontinence and more fits; his violent movements broke a tent-pole. Mawson wrote: “I cannot leave him . . . It is very hard for me — to be within 160 kilometres of the hut [base camp] . . . both our chances are going now.” During the night of 7 January, Mertz died quietly in his sleep. Two old sledge-runners became his cross. Mawson himself had still had severe stomach pains and persistent sores on his fingers. Several toes were blackening and festering. When the skin peeled off his feet, he bandaged it back on as protection. He wrote: “My whole body is . . . rotting . . . frost-bitten fingertips, festerings . . . skin coming off whole body.” On 14 January, while he was pulling the sledge with a rope, a bridge of snow collapsed under him. Mawson found himself

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dangling four metres down another crevasse. As the sled kept sliding towards the edge, the rope supporting him was slipping. At last, it caught hold in the snow. Reprieved for the moment, Mawson worked his way up the knotted rope. He had forced his head and shoulders up over the edge, when the snow gave way, but then caught hold again. He fell a second time, coming to rest even further down; one finger was now injured. Somehow Mawson forced himself up once more. Before setting out again, he made a rope ladder, attaching one end to his harness and the other to the sled. The next time he plunged into a crevasse, Mawson was able to climb out. Blizzards pinned him down for days on end. Mawson had to open a boil on his leg; his feet were getting worse. On 24 January he wrote: “Both my hands have shed the skin in large sheets . . .” Next day, deep snowfalls squashed the tent until it was no bigger than a coffin; a gloomy thought. By now he was overdue at base camp. On 26 January he pushed himself in high winds for 13 kilometres, and then battled for two hours to get the tent up. On 30 January he saw something black 300 metres north of his path; a cloth on snow-blocks. The relief party had left food and a note; he had missed them by just six hours! For 46 days, Mawson had navigated with a damaged theodolite, a compass affected by the proximity of the South Magnetic Pole, and a watch that kept stopping. He had had to measure distances with a damaged sledge cyclometer. Yet here he was returning to base within 300 metres of his expected route! Mawson reached base camp on 8 February 1913. He weighed only 48 kilograms; just over half his usual weight. His legs were swollen, he slept badly and had diarrhoea. Even seven weeks later, Mawson’s nerves were still bad, and he feared for his sanity. Luckily, his fears were groundless and he recovered. Mawson received a knighthood and returned to lead the two voyages of the British, Australian and New Zealand Antarctic

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Research Expedition (BANZARE) of 1929–31. His diary of 1913 described a condition that baffled scientists and doctors for the next 50 years. What strange disorder had killed Xavier Mertz and almost claimed Douglas Mawson as well? They had suffered weakness and depression, loss of skin and hair, abdominal pain, diarrhoea, muscle and joint pain, nose-bleeds and swollen legs. Mertz had suffered delirium and fits. There were clues to the diagnosis, not in medical journals, but from ancient tales of travellers and Eskimos. Way back in 1609, Gerrit de Veer had written The True and Perfect Description of Three Voyages so Strange and Wonderful the Like Hath Never Been Heard Before: The Navigation into the Northe Seas, etc. This described Willem Barents’s expedition of 1596, to find a northeast passage to Asia. When their ship became icebound, the party had to winter on the Arctic island of Novaya Zemlya. Hunger forced some of them to eat the liver of a polar bear: . . . the taste liked us well, but it made us all sicke . . . we verily thought that we should have lost them for all their skins came off from foote to heade; but yet they recovered again . . .

In the 19th century, Arctic explorers who had eaten polar-bear liver described a similar disorder. Moreover, Eskimos did not eat polarbear liver. During World War II, studies of two polar-bear livers showed no poisons. But the concentration of Vitamin A was about 100 times that of ox or lamb liver. Could polar-bear liver poisoning actually be Vitamin A toxicity? The Norwegian scientist Dr Kaara Rodahl tried feeding the liver to rats, but most would not touch it. Only five ate any; three of these stayed well, one became ill, and one died. Experiments with extract of liver were inconclusive. In 1947 Rodahl joined a Danish expedition to Greenland, where he collected livers of many Arctic animals. He found high

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concentrations of Vitamin A, not only in the liver of polar bears, but also in every Arctic animal whose liver was said to be poisonous. Conversely, animals like the walrus and Arctic hare, which the Eskimos said were safe, had low concentrations. By the time Rodahl published his findings, preparations of Vitamin A were available. Some enthusiasts were overdosing themselves, and some doctors were also prescribing it. The first cases of hypervitaminosis A in children were recognised in 1944; the first adult cases in 1951. In 1969 Professor Sir John Cleland and Dr R.V. Southcott suggested that Mawson and Mertz had contracted hypervitaminosis A by eating the livers of husky dogs. Mertz’s symptoms seemed to match the acute form, Mawson’s the more chronic form. In 1971 staff of the Australia National Antarctic Research Expedition (ANARE) collected the livers of husky dogs and found very high concentrations of Vitamin A: about 100 grams of husky liver contained a toxic dose. But Sir Douglas Mawson could not share these findings. He had died in 1958. Since 1959, the Mawson Institute of Antarctic Research in Adelaide has been carrying on his work. Australia is also preserving physical reminders of the trials and successes of Mawson and his team. In the summer of 1997–98, a team of 10 specialists repaired and conserved the huts that supported the 1911–14 Antarctic expeditions. (GB)

KURU

AND THE CANNIBALS

New Guinea, after Greenland the second largest island in the world, is Australia’s nearest neighbour. The island is divided politically into two: the Indonesian province of Irian Jaya to the west, and Papua New Guinea to the east (which achieved its independence from Australia in 1975). It was as recently as 1936 that the eastern highlands of New Guinea were first officially explored and gold prospector

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Ted Eubanks first came across the Fore people. The Fore were of short stature and lived in mainly an agricultural community where the men slept in a central lodge and the women and children in smaller peripheral huts. Strangers were treated with suspicion, and the Fore were not above a bit of cannibalism after a skirmish, to placate their fears of lurking sorcery and ghosts. In December 1953, Mr J.R. MacArthur, a patrol officer in the Fore’s region south of Kainantu, observed “an unusual occurrence”, as the jargon has it. He saw a small girl sitting by the fire shaking violently and jerking her head from side to side. He was told that she was a victim of sorcery and would die. The syndrome was called locally “Kuru”, which meant shaking, and was also the name given to a curse which condemned its victims to a sure death. To inflict the curse, it was said, a journeyman sorcerer bound some of the victim’s hair or clothing with a bundle of twigs and leaves, beat this with a stick while murmuring an incantation and then buried the whole. As it rotted, so the victim’s health languished. A bemused MacArthur thought the effect psychological, even though it had come close to wiping out some villages. The victim was usually a woman and the onset of the condition insidious. The gait was the first thing to be disturbed, to be followed by tremor and purposeless movements. Realisation that she had been struck down naturally made the sufferer nervous, almost paranoid, and she usually withdrew into the bush. Kinsfolk tried to identify the magician by a variety of well-tried methods; if someone was suspected strongly enough, he was waylaid and killed in a suitably grotesque manner. The victim usually moved back to her hut, but eventually walking and even sitting upright became impossible. Weakness became profound and eventually the voice gave out. It took about two years to die a miserable death. In 1955 a Government medical officer, Dr Vincent Zigas, discounted the sorcery mumbo jumbo and concluded that here was a hitherto undescribed organic lesion occurring in epidemic proportions. Specimens sent to the Walter and Eliza Hall Institute

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in Melbourne rendered up no clue as to the diagnosis. An impasse had been reached, when out of the West came a knight in shining armour in the form of an American, Dr Carleton Gajdusek. He had been working under Sir Macfarlane Burnet in Melbourne but had never seen anything like this, even in Victoria. So with no official backing or resources he attempted to unravel the mystery. To not put too fine a point on it, there was some establishment resistance, including at first from Macfarlane Burnet himself. But in the end Macfarlane Burnet graciously deferred by saying he had an exasperated affection for Gajdusek, so gave him his full support. The first thoughts were that the malady was a meningo encephalitis, an inflammation of the brain and its lining, but tests were negative. Anyway it did not seem to be infectious. No unrecognised toxic substance in common use could be implicated, nor could a dietary deficiency. The locals became dubious of the Western hype and not unreasonably suggested that examining the eyes with an ophthalmoscope may allow the viewer to catch sight of the sorcerer. Gajdusek tracked down cases throughout the region and established that the current epidemic was fairly recent, and occurred in a circumscribed area being prevalent where the Fore people had made contact with their neighbours. As no white person had ever contracted Kuru, Gajdusek postulated that it was genetic in origin. By now Kuru had made such inroads into the female population that the men began to move out. The Australian administration reasoned that if it was genetically spread, as was supposed, it could burgeon forth, so they placed the Fore people in quarantine. There the situation bogged down in uneasy stalemate until in 1959 a veterinary scientist in a letter to the Lancet wondered aloud about the similarity between Kuru and scrapie, a disease of sheep. Symptoms were similar, but, as was pointed out, lab tests had already been carried out on animals and found to be negative. But they had only been sustained for a few weeks, even though it was known that if the brain cells of an infected sheep are injected into a healthy

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animal it will take two to three years to develop the condition. With some reluctance at having to go over old ground, Gajdusek had specimens flown to America where they were injected into chimpanzees. That was in the summer of 1962. By late 1965 the first chimpanzees began to fall ill displaying all the signs of Kuru. It was now obvious that the malady could not be genetic, and to cut a long story short, further examination located a virus with an incredibly long incubation period; in fact, a so-called “slow virus”. Marvellous! But why only in the Fore, and why mainly women? Two anthropologists, Robert and Shirley Glasse, provided the last pieces in the jigsaw almost at once. They found that the first case had occurred in the early 20th century, and the spread, incredibly, was inexorably linked to cannibalism. While cannibalism had been usual among other tribes in Papua New Guinea, it was relatively new to the Fore. Visiting the Kamano peoples in 1915 the Fore had seen it for the first time, thought how splendid the idea was, and took it to their bosom. So enthusiastic did the Fore feel about the habit that it became an important part of their funeral ritual. The whole of the dead relative’s body was consumed and a pecking order developed, so to speak, clearly setting out who got which bit. For instance, the mother’s brother’s wife had first claim to the brain. Two features emerged. First, as the men thought such activity would impair their fighting ability and so was to be regarded with circumspection, it was the women and children who had the lion’s share. And second, insufficient cooking meant that germs were rarely destroyed. As the incubation period for the slow virus is between two and 20 years, the victims had contracted the disease before the appearance of white people. With the stopping of cannibalism, Kuru should die out, which is proving to be the case.

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So by the efforts of Carleton Gajdusek, the Fore people regained the harmony of their former lifestyle, and in 1976 Gajdusek gained the Nobel Prize for Medicine (with Baruch Blumberg). Thomas Gray, if he had been alive, may have come from contemplating Eton College, looked at the Fore people instead, and then have written: Alas, regardless of their doom, The little victims play! No sense of ills to come, Nor care beyond today. Those in the deeper vitals rage: Poverty filled and tireless That numbs the soul with icy hand And slow consuming virus.

THE

(JL)

SWINE FEVER: NON-EPIDEMIC OF 1976

Many of us have heard tell of the so-called “Spanish flu” epidemic of 1918, and some will remember the “Asian flu” pandemic of 1957 and the “Hong Kong flu” of 1968. But not many will recall the “swine flu” epidemic of 1976 — this is perhaps hardly surprising, because it never happened. In January 1976 at the American Army depot in Fort Dix, New Jersey, several soldiers became ill with a respiratory infection. Despite his fever, one foolhardy 19-year-old recruit went on an eight-kilometre march in the snow, then collapsed and died. Throat washings from him and four others identified two strains of influenza virus: A Victoria and another which the lab could not classify. If this proved to be a new breed of virus there could be no community immunity — the setting for an epidemic.

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On 12 February the elusive culprit was identified as swine flu, so named because it was passed around pigs, but never before, it seemed, passed from human to human. However, it was for another reason that a few eyebrows were raised in the Centre for Disease Control (CDC) in Atlanta: the germ genetically resembled the virus which had caused the infamous 1918 Spanish flu epidemic during which 20 million people worldwide had died. It had never recurred, hence by 1976 nobody under the age of about 55 had any circulating antibodies. There was some high-level anxiety. Two days later a medical conference of top brass was held where it was resolved to establish whether the infected four had had contact with pigs and if others were coming down with the fever. Was it the first rumblings of a pandemic? Such imponderables are, of course, the breath of life to laboratory people, and they were exhilarated by the prospect of the heroic decisions that were to come. They were not to be disappointed. At Fort Dix 77 soldiers were found to have swine flu antibodies, but were symptomless; 11 more were ill and positive. However, hundreds of others were in hospital with A Victoria flu alone. On the strength of these 11 it was concluded on 10 March that there was a “2 to 20 per cent” chance of a swine fever epidemic. There was division on the seriousness of the scenario, but the fact that there had been one death, plus the spectre of 1918 and the low immunity within the population helped shape conclusions. Less troubled pathologists felt the 1918 deaths were largely due to a now-treatable bacterial infection occurring on top of the virus. But either way, the epidemiologists sensed their day was at hand and a vaccine should be prepared. That being agreed, the next question was, should there be a prompt inoculation of everybody, or should it be stockpiled to await developments? More acrimony. It was pointed out that with 200 million plus doses, even a small percentage reacting unfavourably amounted to a sizeable number of people. But Dr David Sencer, the CDC’s director and a persuasive and respected scientist cum

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bureaucrat, was eager to proceed. He felt the vaccine was as “safe as water” and the issue was one of “lives versus dollars”. The price of the 213 million doses was put at $135 million. Vigorous prodding by Sencer forced a dithering David Mathews, Secretary of State for Health, not only to grow in enthusiasm but also to find it politically attractive to say “yes”. The watchdog of the country’s fiscal arrangements was more stubborn, until it was pointed out that he was dealing with death and, above all, it was a presidential election year, with all that that implied. If a clincher was needed, that was it. Gerald Ford was the incumbent in the White House, and was already seen as indecisive and bumbling: “He couldn’t walk and chew gum at the same time.” He tripped up aircraft steps and bounced golf balls off spectators’ heads, but the swine fever program offered him a heaven-sent opportunity to transform his image. If a pandemic did come it would not only have been morally delinquent but politically suicidal not to have offered protection. So, on 24 March 1976, flanked by Jonas Salk and Albert Sabin, of polio vaccine fame, President Ford launched the program to inoculate “every one of my fellow Americans” against swine fever. It was an unprecedented decision by an American president and at the time seemed a major triumph for preventative medicine. In the end it became a victim of Murphy’s Law — “whatever can go wrong, will”. Many public health workers thought the plan premature; no other country had such a scheme. Some said that 15 per cent would get side effects – about 30 million people. Money for other pressing health measures had to be diverted. Eggs for the culture became scarce. Swine fever was mild and not very contagious – none of the soldiers relatives seemed to have caught it. The dose for children was uncertain. And so on. By June there had been no new cases and the Press was asking questions. As early as April the manufacturers had said they could not produce 200 million doses by the autumn, the ideal time for inoculation. In the event only 21 million doses were ready when

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mass inoculations started on 1 October. Legal liability was feared, especially as insurance companies refused cover. But Ford saw much merit in the program and doggedly pressed on. On 11 October three elderly people died of heart attacks while receiving shots in the same clinic. Public response became cautious, so the President took his injection on national TV. In mid November the first case of the neurological GuillainBarre syndrome (GBS) occurred. Others followed, but the significance was questionable. However, by 9 December there had been 26 cases of GBS, including three deaths. It was getting troublesome. The rate was about four times greater in the vaccinated than unvaccinated, so the occurrence was hardly due to chance. This was the last straw for the detractors. So, after much soul searching, on 16 December Dr Sencer recommended the suspension of the program. The whole fiasco came to an end that afternoon, “in the interests of public safety”. Since Fort Dix there had been three cases in the whole country, and those were on pig farms. As a pandemic it was a complete non event. Ultimately, neither epidemiologists nor politicians received any kudos, indeed Sencer was sacked. Yet it was not just lack of cases which killed off the vaccination plan, but a mixture of the feared association of GBS (532 cases in the end), the problems of liability insurance allied with illunderstood informed consent and inadequate supplies. During the 77 days of the loudly touted and politically expedient program, 44 million people were vaccinated. The other presidential candidate, Jimmy Carter, did not have a shot and went on to win the election; there must be a message in there somewhere. (JL)

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Chapter

7

DISASTERS

BURKE

AND

HARE

From time to time medical schools ask for bodies for dissection. Nothing precipitous you understand; they do not want them until after the actual death of the owner. This requirement has not always been the case; in times past, some students got their material by other means. In the time of Hippocrates, about 2,400 years ago, human dissection was expressly forbidden, in either the dead or the living. This restriction delayed advances in medical expertise for hundreds of years, until, in fact, AD 1540. That year, the Belgian anatomist Andreas Vesalius, then in his twenties, defied this ancient restricting convention and became the first to do the heretical deed whilst having in mind to further learning rather than to satisfy an idle curiosity. In the very same year, Henry VIII allowed that surgeons were somehow more worthy than their then professional associates, barbers, and awarded them two executed criminals a year for dissection. A little niggardly for such sanguinary times, perhaps. Subsequently the gallows were a rich source of raw material, and 200 years later they gave William Hunter

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the chance to set up his School of Anatomy in Great Windmill Street, London. Today, if you can drag yourself away from the strip shows down this side street off Shaftesbury Avenue, you will see a plaque commemorating the event (high on a wall of the Lyric Theatre on the corner of the two roads). In Edinburgh the students, eager as ever, could sometimes be a little previous in getting the criminals off the gibbet. One poor unfortunate came round during an unseemly post-drop scramble. She lived on for years as Half-Hangit Maggie. Having now arrived in Edinburgh, let’s look at medicine’s most famous accumulators of bodies. For it was there that the redoubtable William Burke and William Hare conducted their grisly and dubious business activities to provide bodies for the medical school. In 1826 there succeeded to the Chair of Anatomy in Edinburgh an inspirational teacher, born orator and military surgeon veteran of Waterloo, Robert Knox. Such was his charisma that within a couple of years his class numbered over 500, comprising not just medical students but lawyers, artists and gentlemen with time on their hands. As all wanted a piece of the action, bodies came to be in short supply. Knox loved his job, especially the adoration it generated, but he had a logistic problem: he needed the meat. So he enlisted the aid of several sportive students as well as a number of devious menabout-town to supply bodies, no questions asked. On the night of 29 November 1827 two new suppliers brought Dr Knox an old man in a sack; he paid out £7 10s for the body. It should be stressed that the man was dead all right, and from natural causes. He had been, in fact, an army pensioner who had snuffed it at the lodging house of one of the vendors, William Hare. Hare owed his landlord £4 back rent, and fellow lodger William Burke had the sublime idea that cash may be turned over from this grave situation by selling to Knox. It took only a moment to crack open the coffin, pop the corpse back in bed, fill the empty box with the appropriate weight in

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tanners bark, and then let the pitifully few mourners in to wring their hands and squeeze out the odd tear. Doubtless none keened with greater vigour or managed more snivels than Messrs Burke and Hare themselves. Although to these two layabouts it may have seemed a mortal sin to let something rot underground when it could be sold for £7 10s on top of the ground, dead bodies were not in steady and guaranteed supply. They had a merchandise-flow problem, so they decided to create their own product. The first to present was a miller who lived in the house. He was ill anyway, so no qualms were felt over his suffocation. £10 was the negotiated fee. Next a passing beggarwoman was invited in, filled with whisky, strangled, nailed in a tea chest and delivered to the good doctor, who was delighted with the freshness of the goods. The fee was the same for each, but, as with all businesses, there were expenses — alcohol and a box, for instance. So the carve-up of profits was less. Two more unfortunates met similar fates. A prostitute, Mary Patterson, was met by Burke in a tavern, taken home to breakfast, filled with whisky, despatched before lunch and delivered in the afternoon. Her unforeseen appearance gave one of the students a nasty turn as he had known her professionally shortly before — in her profession, not his. This was young Fergusson, later to become Sir William Fergusson, Sergeant-Surgeon to Queen Victoria herself, no less. Doubtless he kept this bit of intelligence from her. Burke became so bold he even relieved two policemen of a drunken woman on the pretext that he knew where she lived and would conduct her home. The lads were honing their arcane skill into an art form. They had a rewarding day at the end of June 1828. An old lady and her grandson were dispatched, but on the way to Knox’s establishment by horse-drawn cart, the animal collapsed between the shafts of its cart, so Burke and Hare collected from both the medical school and the knacker’s yard. In all, their stock in trade garnered between 15 and 32

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unsuspecting and usually impoverished down-and-outs. The exact figure is unknown. It came to an end after nine months, when two other lodgers at the infamous boarding house grassed on them. The police found the last of the macabre line in Dr Knox’s cellar. Burke and Hare were arrested and charged with murder. Their trial started at 10 a.m. on the morning of Christmas Eve 1828 and continued non-stop until 9.30 on Christmas morning, when Burke was found guilty. Hare, of course, would have suffered a similar fate had he not turned king’s evidence and slipped through the system. The judge had no hesitation in passing a sentence of death by hanging, his only agony was to decide whether Burke’s body should hang in chains or his skeleton be preserved as a ghoulish warning to other like-minded villains. In the event, and fittingly, it was taken for dissection. The execution itself was carried out publicly before a morbidly curious audience who were prepared to pay anything between five and 20 shillings for a window seat. Some 25,000 people attended what was obviously a gala event. As the rope tightened, a shout went up for Knox to follow. He was a little hurt at the imprecations flung at him, considering it not to be within his academic duty to question the origins of stillwarm specimens. Knox himself appointed a committee of Scottish noblemen and gentry to examine his alleged connection. The committee’s subsequent whitewash job buttered no parsnips as far as the canny citizens of Auld Reeky were concerned, and in 1840 he was forced to leave Edinburgh, together with fame and fortune. He went to London, studied the anatomy of whales and died in obscurity in 1862. There were some sequels to the sordid episode. The government was compelled to regulate such matters as medical dissection by the passage of the Anatomy Act in 1832. Burke gained dubious posthumous glory by having his name pass into the language —

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“to burke”, meaning to kill secretly by suffocation or strangulation, or to hush up. Many years later a postscript to the story emerged. In 1986 Professor Matthew Kaufman was appointed to the Chair of Anatomy at Edinburgh and during his early explorations of the rambling department he came across a hitherto forgotten collection of about 300 plaster death masks. They had been bought by the anatomy unit from the Edinburgh Phrenological Society (who else) over a hundred years previously and promptly forgotten. Among them, besides the likeness of Mendelssohn, John Keats, Isaac Newton and Dr Samuel Johnson, was the cast of William Burke’s head. Although he appears to have been somewhat out his league, he was probably better known to the public at large than any of the other artistic or intellectual giants in the collection. (JL)

THE

BLIGHT OF THE

IRISH

“Having watched their oats, turnips and wheat . . . trampled, burned and raided by English armies, the peasants recognised the potato as a vegetable that could be cultivated and stored in secret . . . that could endure the malevolence of the English” — Andrew Nikiforuk

The potato first came from the mountains of Bolivia and Peru, and fed the crews of Spanish ships returning to the Old World. It is not known how the Irish first came across potatoes. Perhaps from hulks of Spanish ships washed onto their coast after the defeat of the Armada in 1588. Or perhaps Sir Walter Raleigh planted potatoes from Virginia on his Irish estates. In any case, Irish peasants took up the new plant far more eagerly than other Europeans. It was to prove both a blessing and a curse to the Irish. By the 1590s, the potato was a key part of

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their diet. No other crop grown on only one acre could feed a man, his wife and six children. For breakfast, lunch and dinner they had potatoes and milk. A working man would eat up to 6 kilograms of potatoes each day! Pigs, chickens, dairy cattle and family could all eat from the one cauldron. Peasants banked and spent potatoes almost like money. They had many names for the potato: pratie, prata, fata, taters and Murphy. They even called themselves “praties with a bone”. There were several warnings of the Great Famine. One came as early as 1740, when a bad frost killed most of the Irish crops. Starvation, typhus and dysentery (“fevers and fluxes”) killed about 300,000. But the ultimate tragedy came in 1845 after 17 shaky harvests, with various pests and diseases already affecting Ireland’s potatoes. According to J.S. Schapiro, “The failure of the potato crop . . . resulted in a great famine that brought the climax of suffering to a people already half starved.” The potato blight travelled from the United States and came to Ireland via England. Eventually it hit all the potato-growing countries of Northern Europe. The fungus had originally been a benign companion of the wild potato in the Andes. But the relationship went sour after the potato crossed the Atlantic. Several factors increased the ravages of the fungus and made this famine especially devastating. July 1845 was unusually cold and rainy. Moreover, potatoes in Ireland were planted close together, as most farms were so small. So the spores could easily spread over what started as Ireland’s largestever potato crop. The first sign of blight was the stench. Affected plants blackened and withered in the ground; even those tubers which looked sound rotted once they were stored. As Nikiforuk says, “the fungus . . . sucked the life out of both the potato and its cultivator”. Ironically, the potato itself had encouraged the population

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explosion which worsened the devastation of the blight. It has been estimated that between 1760 and 1840 the population grew from 1.5 million to 9 million; a sixfold increase in just 80 years! Disraeli called Ireland the most densely populated country in Europe. The overpopulation was worst in the west. It was Oliver Cromwell who, two centuries before, had forced many Irish into the barren western province of Connaught. The infestation killed over half the crop of 1845, wiped out that of the following year, and returned again in 1847 and 1848. Some historians believe the Famine continued until 1851. Famine was also widespread elsewhere in Northern Europe, but because of their dependence on the potato, it hit the Irish hardest. Among the deadly diseases were typhus (“black fever”) and relapsing (yellow) fever, both transmitted by the common louse which flourished. Whole families dragged themselves to cemeteries, dug their own graves and quietly lay down. Doctors and clergy did what they could; some of them died as well. Some Englishmen said the famine reports were exaggerated. Subsidised imports of corn came late, and were then poorly distributed; many Irishwomen didn’t know how to cook corn. By 1847 (the third year of the Famine), the English Treasurer Charles Trevelyan organised soup kitchens for 3 million people. According to Máire and Conor Cruise O’Brien: Historians, both English and Irish, generally see the outbreak of famine as inevitable, but think that disaster on the scale which actually occurred could have been avoided by more determined governmental action . . . Some individual Englishmen, and groups of Englishmen and Irishmen — notably the Society of Friends [Quakers] — did all that they could . . . but help on the great scale which alone would have sufficed to avert it was not forthcoming.

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In desperation, many Irish emigrated. Yet, as Cecil WoodhamSmith says, “they did not leave fever behind; fever went with them, and the path to a new life became a path of horror.” It took emigrants about two months of further starvation and disease to cross the Atlantic to America in “coffin ships”. These had too little food and water, were overcrowded and “dangerously antique in construction”, according to Woodham-Smith. Many captains buried half their passengers at sea. In America, the survivors rented damp, dark one-room cellars for families of a dozen plus a pig or two. Other, even poorer Irish, sank into the ghettos of Liverpool, Manchester or Glasgow. Yet others of course started afresh in Australia. When the Famine struck, the population of Ireland was perhaps 9 million. By 1851, famine and fever claimed between half a million and 2 million. Another 1–2 million emigrated, or died in the attempt. Since those terrible times, the Irish have controlled their population, which is now only about half of that before the Famine. Ireland commemorated the 150th anniversary of the Famine with the theme: “Look back in sorrow, not in anger.” (GB)

TYPHOID MARY It is 60 years since the death of Mary Mallon. “Mary who?” you may well ask. Mary Mallon, who for years strode through New York society like a grim reaper, dispensing typhoid bacteria with deadly and feckless abandon. The word “typhoid” is from the Greek typhos, meaning smoke or cloud, and refers to the floating confusion which occurs in the later stages of the malady. It is one of the so-called enteric fevers which cause gastroenteritis. The causative bacillus enters the body through contaminated food or water, and, once entrenched, there is an incubation period of seven to 14 days followed by malaise, loss of appetite and headache. At that stage it could be anything, but then a step like rise in temperature takes place to a hectic

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104 degrees Fahrenheit (40 degrees Centigrade). In the second week rose-coloured spots appear and later delirium. You then either recovery very slowly or you die, and in inadequately treated cases, about nine per cent do just that. Antibiotics are used now and are very effective. But in former days, about three per cent of sufferers who recovered remained long-term carriers, blissfully unaware they were shedding the bacteria from its hiding place in their gall bladder while at the same time suffering no ill effects themselves. If a carrier was a food handler and maintained poor hygiene, then he or she was a disaster waiting to happen. Such was Mary Mallon. The typhoid bacillus has never been fussy where it gathered its prey, and has had some pretty up-market victims in its time. Prince Albert, consort of Queen Victoria, died of it, and their son, later to be Edward the VII, almost did. An earlier English king, Henry I, the “Lion of England”, succumbed, it was said, to the effects of a “surfeit of lampreys”, which was probably a euphemism for typhoid. It caused almost 33 per cent of the deaths in the American Civil War, a conflict, incidentally, where another third died of other diseases, and only the remaining third of the deaths were in heroic circumstances. It was the cause of a major public health problem in the 1890s in Western Australia during the early rumbustious days of the discovery of gold in the Coolgardie and Kalgoorlie area. Poor sanitation was the culprit in this instance. Which brings us to the New York of 1900. In September that year a young man died of typhoid in the house in which Mary Mallon was staying. Nothing unusual about that; at the time such things were regarded as all part of life’s immutable laws. The next year she worked in a lawyer’s house in Maine, and within a fortnight seven of the eight members of the household were down with the disease. Mary worked unstintingly in the sickbay situation. So much so that she was given a $50 bonus. She and that outbreak were only connected years later. If she had but realised it then, of course, the tie up might have proved to have

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been a regular source of income for her — infect a family and then look after them. Fairly frequently she moved from house to house in her job as a cook. For as Saki prophetically wrote at the time in another situation: “The cook was a good cook, as cooks go. And as good cooks go, she went.” She took a job in a Long Island house in 1909, whereupon six out of 10 in the establishment promptly fell ill. Mind you, there were 3,467 cases in New York that year with 639 deaths, so at the time the disease was not regarded as the public-health scandal that it would be now. It was just the worm in the Big Apple, so to speak. But on this occasion the medical fraternity did not sit around sucking their teeth or pursing their lips as they bemoaned the course of events whilst waiting to hit off on the second tee. No. A Dr George Soper went and smelt the drains and poked in the privy and pondered long and suspiciously over the local delicacy of giant clams. Disappointingly, none had been eaten. “Well, has any other exotica been eaten, for goodness’ sake?” wondered the exasperated doctor. The cook’s tangy ice cream that had been everybody’s favourite was a lame afterthought. “Not the present cook, you understand, but the one who left three weeks ago just after the illness. Wait a minute, wait a minute. That’s right, just after the typhoid started.” Dr Soper took six harrowing months to track down Mary through a series of grief-stricken houses. In the end he knew she was a 40-year-old single woman and a migrant from Northern Ireland. Eventually, he ran her to ground in the kitchen of a topdrawer home in Park Avenue, New York. One can picture the good doctor leaning slightly forward, placing the tips of his fingers together, and affecting his best bedside manner and wheedling tone, as he wondered aloud if she could see any possible connection between herself and the trail of people with hectic temperatures, rose-coloured spots and greenish diarrhoea who had remained behind as she had moved on, and who displayed all the characteristics of, er, um typhoid.

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Her answer was short, to the point and impressive: she attacked him with a meat cleaver. He bolted, and so did she in the opposite direction — he to the police, she to the outside toilet. In a new-found coyness for New York’s finest, the sergeant shouted through the dunny door that he believed Miss Mallon could help with their enquires. Her answer was uncompromising, succinct and hurtful to any person’s sensitivities about his or her parentage. So, with an inspector sitting on her chest, she was removed kicking and screaming and sent to the Riverside Hospital for communicable diseases. There Dr Soper had her stools cultured, and it came as no surprise to anyone that they were teeming with typhoid bacilli. Again it fell to the lot of the luckless GP to explain to Mary that she was the carrier of a condition dangerous to other people, and that the germs were lodging in the stones in her gall bladder. Furthermore (and he must have braced himself as he told her this) the treatment was simple — have the gall bladder removed. It is not necessary to draw pictures for you regarding her response. Suffice it to say that the interview room had prudently been stripped of potential missiles. So she was kept incarcerated in the hospital for three years; brooding, malevolent, a study in suppressed anger. She worked in the laundry, retaining all the while those typhoid tombstones in her gall bladder, while at the same time honing to perfection a heartrending derring-do story for which her countryfolk are supposed to be famous. The upshot was that Mary Mallon was released after promising with all the vehemence she could muster, which was considerable, that she would stick to the copper rather than the casserole and report to the Health Department every three months. She promptly disappeared, seemingly from the face of the earth. In fact she did what probably any upright, downright and forthright person would have done. She changed her name to Mrs Brown, and her job, surprise, surprise, back to cook. For five more years Mary plied her deadly culinary art round

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New York city, while unsuspecting trenchermen wolfed her typhoid-ridden gobbets. In 1915 there was a serious outbreak in the Sloane Hospital for Women, where she was working. In a moment of ingenuous banter another cook called her Typhoid Mary, whereupon to everyone’s surprise she fled. The police were notified and she was caught on Long Island. Rather disappointingly, she went like a lamb. She was returned to the Riverside Hospital and given a life sentence of custodial care. By now the stuffing had been knocked out of her, even though the potent gall stones remained, and she went over to the enemy, so to speak, by becoming a worker in the hospital laboratory. The management even built her a small cottage in the grounds and she gave tea parties there. To accept an invitation no doubt meant playing rock-bun roulette, and perhaps was held as a kind of threat to the more obstructive patients. Mary had a stroke in 1932 and died in 1938, not, as you may suppose, of the long-term complications of typhoid, but of bronchopneumonia. You will be relieved to know that she secreted the typhoid bacillus to the end. When Mary Mallon died her score card was marked and the certainties came to 10 outbreaks of typhoid fever which involved 53 cases and caused three deaths. Besides that she was almost certainly responsible for the 1904 outbreak at Ithaca in upstate New York when there were 1,400 cases. On top of these there were very many likely but unattributable episodes stretching back some 30 years. Typhoid Mary touched scores of lives with her unique brand of ice cream; she terrorised dozens of policemen, insulted numerous public-health workers, and put the breeze up countless doctors. So spare her a passing thought as you abstractly drink your sparkling tap water, for it was by her polluting its likes that she accomplished much more in her lifetime than most of us are likely to do in ours. (JL)

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PAINTERS

DIAL

R

FOR DEATH

“Doctors learned about radium the same way they did about X-rays: by trial and error” — Catherine Caulfield

In 1898 Marie and Pierre Curie announced their discovery of a new element. Radium fever swept the world. In the United States, in 1915, Dr Sabin von Sochocky developed a luminous paint that he called “Undark”. Next he founded the US Radium Corporation. His plant in New Jersey was only two blocks from Thomas Edison’s laboratory, where Edison’s assistant had received the radiation that later killed him. Should von Sochocky have read that as a warning? US Radium’s staff painted numerals onto watch dials and made crucifixes that glowed in the dark. The workers were women and girls, some only 12 years old. They used very fine brushes, which they brought to a point by pressing them between their lips. Sometimes, for fun, they painted their teeth or fingernails to glow in the dark. In 1916 the medical journal Radium declared: “Radium has absolutely no toxic effects, it being accepted as harmoniously by the human system as is sunlight by the plant.” World War I stimulated the demand for luminous dials on all sorts of instruments. By 1920, America had over 2,000 dial painters. But within four years, nine had died, reportedly of phosphorus poisoning, stomach ulcer, syphilis, anaemia, and cancer of the jaw. Many others had severe problems with their jaws and teeth. Dr Theodore Blum, a dentist-doctor, reported a patient with an infected jaw “caused by some radioactive substance used in the manufacturing of luminous watch dials”. In 1925 Dr Frederick Hoffman, statistician to Prudential Life Insurance, blamed radium poisoning. Working with him was Dr von Sochocky, who had resigned from his own company. By now, von Sochocky’s own breath was more radioactive than that of

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his dial painters. A team from the Harvard School of Public Health found the US Radium work area spattered with radium paint. In a dark room, the “hair, faces, hands, arms, necks, dresses, underclothes . . . of the dial painters were luminous”, according to Caulfield. All 22 workers tested had abnormal blood tests. The team concluded that all workers were exposed to excess radiation, both externally and internally. The deaths and illnesses, the Harvard team said, were “due to radium”. The company threatened to sue if the team published its report. Dr Harrison Martland, medical examiner for Essex County, home of US Radium, saw two dial painters with high radioactivity levels just before their deaths. Researchers found that the optimists were wrong: radium does not pass straight through the body, but settles in bones, where it can cause cancer and damage the bone marrow. Dial painters were not the only ones at risk. Doctors were using radioactive substances for a hotchpotch of real and imaginary conditions: schizophrenia, rheumatism, high blood pressure, irregular periods, depression, poor sex drive and even debutante’s fatigue! In early 1925 US Radium’s own chemist, Edwin Lehman, was well; within a month, he was dead of acute anaemia. Unlike the dial painters, he had not swallowed any paint, but had breathed in the radium. Martland pressed for complete protective measures for workers using radioactive substances: in manufacturing plants, laboratories, hospitals and offices. But the lawyers still blamed poor hygiene and held up the publication of his report. From 1925 on, the company was seldom out of the courts or the news. In 1927 five former US Radium dial painters (the papers dubbed them “The Five Women Doomed to Die”) filed a case. Because workers’ compensation in New Jersey did not cover radium poisoning, each woman sought damages of $250,000. One had

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endured 20 operations on her jaw, and had paralysed legs from spinal-cord damage. Two had to be carried into court; one could not even raise her hand to take the oath. Defence lawyers invoked the two-year statute of limitations. Despite the media outcry, the court agreed; the women appealed. Legal wrangling held up the case for over a year, while the women faced painful deaths. Well-wishers around the world sent prayers and advice. From France, Marie Curie suggested raw calf’s liver. She herself was to die within a few years of radium-induced anaemia. In May 1928, the women won permission to sue in the Supreme Court. But how long would that take? Suddenly a mediator appeared; within five days, he negotiated a settlement. The company, “Actuated solely by humanitarian considerations”, gave each woman $10,000 and a yearly pension of $600, plus medical expenses. Less than six months later, Dr Sabin von Sochocky himself died of aplastic anaemia. Radium had eaten away at his hands, mouth and jaw. Martland wrote: “He . . . gave all that was in him to help and comfort others suffering from this disease.” It is sobering to consider that the painful deaths of these early victims led to safer working conditions for the makers of the atomic bomb, which in turn devastated the people of Hiroshima and Nagasaki. (GB)

WITTENOOM: THE

ASBESTOS TRAGEDY GOES ON AND ON

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Peter Garrett and Midnight Oil have a song about it; Rolf Harris worked there. But it was Lang Hancock who, in the late 1930s, launched blue asbestos mining at Wittenoom in the remote north of Western Australia. Then World War II boosted world demand for this popular,

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versatile material; it could insulate pipes in submarines and filter noxious gases in gas masks. In 1943 Hancock formed Australian Blue Asbestos Ltd, later bought out by CSR (Colonial Sugar Refineries). Dr Eric Saint became Government Medical Officer for the whole of north-west Australia. Even from the air and 30 kilometres away, he could see the blue-grey asbestos dust over Wittenoom. The offices alone had dust readings that would have been illegal down a mine. Thousands of tons of milling residue (tailings still containing asbestos) formed the roads and even coated the school playground. It was everywhere; dust levels were six to eight times the levels then considered “safe”. Inhaling asbestos particles causes asbestosis, a thickening or fibrosis of the lung tissue. In turn, this thickening blocks the flow of oxygen into the lungs and makes people breathless. One sufferer has compared it to “having your lungs slowly filled with wet concrete”. If asbestos levels are high enough, asbestosis may follow even fairly brief exposure, though it may not become apparent for many years after initial exposure. Malignant tumours that often follow asbestosis include lung cancer and mesothelioma. Already workers were getting sick. From 1948 Dr Saint tried to convince the mine manager of the dangers, and then wrote to the Head of Public Health in Perth, predicting “in a year or two, ABA will produce the richest and most lethal crop of asbestosis”. Why did this message to the health department fall on deaf ears? Because some public servant wrote on the letter that Dr Saint was misinformed, and that no action was needed. From 1959 Dr James McNulty was the local public health officer, but his best efforts were just as fruitless. Only the Mines Department could order the company to clean up the mine, or close it down altogether. Dr McNulty kept warning the managers, and pressing his own chiefs, who in turn warned the Mines Department, but according to journalist and author Ben Hills, “not a single prosecution was ever launched, no effective demands were ever made for safe ventilation . . . the

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operation was never shut down for a single day”. Dr McNulty’s efforts with the men were just as frustrating: “I must have told more than 100 of them: ‘you are sick, it is the asbestos, you must leave the mine’. I don’t think a single one of them ever took my advice.” Residents accused him of destroying their town, and taking away their top incomes. The union wanted jobs at any price and pushed for an extra 20 cents an hour dust allowance! In 1966 the Wittenoom mine and mill were shut down — not from guilt or remorse, but because the quarry was no longer economically viable. Not for another decade did the full health impact begin to emerge. It was not only those in the mine or the mill who suffered. In 1950 Joan Joosten had moved to the nearby township of Wittenoom Gorge, as her husband was foreman at the mill. She worked as a secretary in the office; even there, dust hung in the air and clogged the flyscreens. The boss told Joan not to worry, as the dust was “clean”. During her three years working for the mining company, she never had a chest X-ray. Some 25 years later, Joan was getting tired, losing weight and had pains in the arms and chest; she had malignant mesothelioma. Joan battled her growth, and battled the company as well. Her husband sold his sandwich bar to look after her and pay legal costs. But in 1979 Justice Wallace in the Supreme Court dismissed their case: “I do not condemn as negligence that which, in my opinion, was a sad misadventure.” This verdict seems to have overlooked all the evidence already available well before Joan came to Wittenoom in 1950. In 1931, Britain legislated to control dust levels in asbestos textile factories. In 1935, there were reports of lung cancer in patients with asbestosis. The tragedy was quite predictable; the evidence was right there. Doctors knew the score; managers who cared to look knew the score. But the public took longer to find out. Though Joan was going downhill, the Joostens appealed. In March 1980, a few hours before the hearing of the appeal, Joan

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died. Her memorial is the Joan Joosten Centre, headquarters of the Asbestos Diseases Society of Australia. Sadly, Joan Joosten is one of many — even by 1978, some 40 people had died of diseases related to the asbestos mining at Wittenoom. Rusting sheds now mark Wittenoom. In late 1996 about 30 people still lived in the township. The story is far from over. New cases of malignant mesothelioma are expected to rise to a peak around the year 2010. Of 6,912 former employees at Wittenoom, the number predicted to get asbestosis, mesothelioma or lung cancer is almost 2,000. Even children of Wittenoom workers have developed asbestos diseases. As Ben Hills wrote, “[Wittenoom] will go down in the history of this poisoned planet alongside Chernobyl, Bhopal and Minamata.” (GB)

SYPHILIS

IN

TUSKEGEE, ALABAMA

On 19 May 1997 Bill Clinton, President of the United States, apologised to survivors of a racist medical experiment that began in 1932 and ran for 40 years. In July 1972, some 25 years before Clinton’s apology, the American media were enjoying an abundance of news, scandals and controversy. After Senator Thomas Eagleton (running mate to George McGovern) revealed his past history of depression requiring hospital admissions and shock treatment, the public outcry forced him to withdraw as candidate for vice-president. Officials of the US Public Health Service (PHS) welcomed the Eagleton controversy since it diverted heat from the medical scandal that broke on the very same day. For 40 years from 1932, the PHS had been following, but not treating, 412 poor black sharecroppers who had advanced syphilis

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and who lived around the county seat of Tuskegee in Macon County, Alabama. According to James H. Jones, this was “the longest nontherapeutic experiment on human beings in medical history”. Why would reputable doctors take part in such an inhumane experiment? Remarkably, there was a precedent. Between 1891 and 1910, doctors at the Oslo Clinic in Norway had followed, but not treated, several hundred people with syphilis. Their report appeared in a leading German journal in 1929. One reason, though certainly no justification, for the American study was to confirm the common belief that syphilis in black people is very different from syphilis in whites. The Alabama subjects were not only black and poor; most were also illiterate. The PHS doctors, who were mostly white, had offered them free check-ups, free treatment for minor ailments, hot meals on clinic days, and burial stipends for their survivors. When pressed by the media, PHS officials couldn’t even find an experimental protocol. The experiment had just grown; it had included regular examinations, blood tests and above all, autopsies. Dr J. Williams served as an intern at Andrews Hospital in Alabama’s Tuskegee Institute. He said that despite official assurances about informed consent: “The people . . . were not told what was being done.” A survivor, Charles Pollard, said: “They come around from time to time and check me over and they say: ‘Charlie, you’ve got bad blood’ . . . they never mentioned syphilis to me.” Worst of all, the men believed that PHS doctors were treating them for their “bad blood”. An official letter offered “your last chance to get a second examination . . . and after it . . . you will be given a special treatment”. This was not treatment at all; it was a lumbar puncture (needle in the back to draw a sample of cerebrospinal fluid for testing). But to convince the men that this was treatment, the doctors called it a “spinal shot”. Most men had side-effects from their lumbar puncture; over 40 years later, one said: “I never have got over that shit.”

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Dr Reginald James — who was not involved with the experiments — worked in Macon County from 1939 to 1941. When he found a man with syphilis, Eunice Rivers, the black nurse who kept track of the men, would warn him off: “He’s under experiment and not to be treated.” If Dr James insisted on treating such patients, they never returned, since they knew they would lose their benefits. Moreover, they believed they were already having full treatment. Belonging to “Miss Rivers’ Lodge” made them feel special. How could they know that they were pawns in a deadly experiment? PHS spokesmen defended themselves by pointing out that the experiment had been the subject of many medical conferences and journal articles. How could 100,000 medical readers fail to ask questions? Moreover, PHS doctors convinced their private colleagues not to treat the experimental subjects for their syphilis. Instead, as the men fell ill, their doctors should just refer them to the hospital to ensure that they came to autopsy. Undeterred by blindness, paralysis, dementia and early death in some of their patients, the private doctors readily agreed to all this. Once the story broke, The Atlanta Constitution newspaper condemned the “moral astigmatism that saw these black sufferers simply as subjects in an experiment, not as human beings”. One citizen called the experiment “but another act of genocide by whites . . . that again exposed the nature of whitey: a savage barbarian and a devil”. Another asked: “How in the name of God can we look others in the eye and say ‘This is a decent country’?” Though he worked for the VD division of the Atlanta Centre for Disease Control, Dr Donald Printz said: “A literal death sentence was passed on some of those people.” But Dr John Heller, who had directed the VD division between 1943 and 1948, bluntly told reporters there had been nothing unethical or unscientific. Some other doctors were just as blind. Dr R.H. Kampmeir of the Vanderbilt University admitted that many patients with

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syphilis would die if not treated: “This is not surprising. No one has ever implied that syphilis is a benign infection.” Apologists claimed that, in 1932, the available treatments (mercury, arsenic and bismuth) were worse than the disease. They said the drugs were painful, slow to act, toxic, and sometimes even fatal. But no possible rationalisation could justify withholding penicillin after 1943 when it proved to be effective for syphilis. Public pressure led to an independent inquiry. A panel of nine (of whom five were black) damned the experiment as “ethically unjustified [even] in 1932”. Senator Edward Kennedy held hearings on human experimentation. Two survivors, Charles Pollard and Lester Scott, told their story of illiterate blacks trusting the educated whites who had betrayed them. Each had been told that his blood was bad; each had gone along for 40 years with doctors who said they were treating him. Outraged citizens of Tuskegee elected their first black mayor. Legislators passed tough regulations to protect subjects of medical experiments. Over a century ago, Boston physician Dr Oliver Wendell Holmes noted: “Medicine, professedly founded on observation, is as sensitive to outside influence, political, religious, philosophical, imaginative, as is the barometer to the atmospheric density.” Even today, the Tuskegee study should sound a warning to researchers who argue against the need for ethics committees to oversee medical research. (GB)

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Chapter

ADDICTIONS

8

AND

OBSESSIONS

THAT DROWSY NUMBNESS: OPIUM AND THE POETS Reports in the medical Press of the effects of hallucinogenic drugs on imagery and the spatial experience began early this century. But descriptions of similar blowouts had been part of literature long before that. It is no secret that opium, usually taken as laudanum, affected the writings of such luminaries as Samuel Taylor Coleridge, George Crabbe, Francis Thompson, even the sublime John Keats himself. Thomas De Quincey’s wellknown narrative on the narcotic experience is brazenly entitled Confessions of an English Opium-eater (1822), and in it he describes its pleasures thus: “Thou hast the keys of Paradise, oh just, subtle, and mighty opium.” Mind you, he also damns the pain as “An Iliad of woes”. Coleridge (1722–1834) is perhaps the best-known opium taker in this medley, and apparently it gave him the impetus to write his famous “Kubla Khan”. The story goes that during a drug-induced sleep the author imagined life’s impenetrable secret had been revealed to

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him. He woke, feverishly began to set it all down, was interrupted by an inopportune visitor, and never recaptured the mood when he departed. Nonetheless his last lines are significant: Weave a circle round them thrice, And close your eyes with holy dread: For he on honey dew hath fed, And drunk the milk of paradise.

Keats, Crabbe and Thompson were all medically trained, and their recreational use of opiates is revealed in some of their verses, though none attempts an objective account of the definitive drug experience. Clinically, hallucinations vary with dosage and frequency of use. The most common is a distortion of space and time in which both can seemingly expand to infinity. Visual hallucinations are more common than auditory and olfactory ones, and can range from bright lights to bizarre but recognisable images. A sense of depersonalisation and terror can be identified in several poems. All in all, true addiction is more often seen in poorly socialised and dependent personalities than in well-structured ones, and in poets no less than in anyone else. George Crabbe (1754–1832) became a surgeon apothecary after apprenticeship in the country. Travel to London to pursue a literary career was the preferred choice, but eventually he became a parson. He began taking opium in 1790 after having been given it for vertigo, and continued to imbibe it daily for the remaining 42 years of his life. The resulting delusions were mainly concerned with terror and pursuit. Crabbe’s most famous literary work is The Borough, on which Benjamin Britten’s 20th-century opera Peter Grimes was based. Francis Thompson (1859–1907) was first given laudanum on prescription for “lung fever” while a medical student at Manchester. He was a somewhat withdrawn and unstable person, and became habituated for the last 27 years of his life. He came from Preston,

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a cotton-spinning town in darkest Lancashire, seemingly a most unlikely place for a sensitive poet to emerge. Anyway, Thompson never enjoyed studying medicine, failed continually for as long as his doctor father would support him, until after six meaningless years he took himself off, together with a goodly supply of laudanum, to London. There he lived as a derelict, moving between monasteries, writing of his drug-induced fantasies until he died, not of opium poisoning but tuberculosis. His terrifying dreams he described as “in part the worst realities of my life”. He wrote one poem which with touching frankness he called “The Poppy”. It is full of narcotic-induced fantasies where the poppy emerges as “the withered flower of dreams”. Of all the English poets who dabbled in drugs his was the talent it most profoundly affected, reaching its apotheosis in The Hound of Heaven, where, in his mind, he is pursued by God: I fled Him down the night and down the days; I fled Him down the arches of the years; I fled Him down the labyrinthine ways Of my own mind.

In Thompson’s evocative piece “At Lords”, he describes a visit to watch his old county, Lancashire, play Middlesex at cricket at Lords. It finishes with these famous lines, which, notwithstanding the inferred symbolism, are very moving: The field is full of shades as I near the shadowy coast, And the ghostly batsman plays the bowling of a ghost, And I look through my tears on the soundless-clapping host As the run-stealers flicker too and fro, Too and fro: O my Hornby and my Barlow long ago!

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John Keats (1795–1824), the son of a livery-stable keeper, was an occasional laudanum taker, not an addict. He was apprenticed to a

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surgeon in Edmonton, Middlesex, but moved to Guy’s Hospital where he qualified as an apothecary in 1816. He abandoned medicine for literature after six months. In 1819 he was hit in the eye by a cricket ball, and his house mate, Charles Brown, wrote that he received opium after this event, as he had done on occasions before. The poet, though never admitting to taking the poppy, wrote the next day how he had slept in, felt languid, and was indifferent to pain and pleasure. If any of Keats’s poems imply the effect of opium, it is his “Ode to the Nightingale”. It was written within six weeks of the cricketball incident, and the first few lines are pretty explicit: My head aches and a drowsy numbness pains My senses, as though of hemlock I had drunk, Or emptied some dull opiate to the drains One minute past, and Lethe-wards had sunk.

In a trance-like state he hears the nightingale — possibly an auditory hallucination — and later pleads for escape: Fade far away, dissolve and quite forget.

Later Keats has thoughts of death: Now more than ever seems it rich to die, To cease upon the midnight with no pain.

And he concludes, as though rousing from an opium-induced sleep, confused over reality: Was it a vision or a waking dream? Fled is that music: — Do I wake or sleep?

William S. Burroughs, 20th-century author (The Naked Lunch) and self-confessed drug taker, has said that drugs heighten the awareness and imagination of a writer. Yet it seems to be a constant

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grievance of those who take hallucinogenic drugs that it is impossible to communicate in words the transcendental effects they produce. The great poets probably got nearer than anyone. (JL)

SIGMUND FREUD

AND COCAINE

“It makes you hyper and smarter, faster and better . . . you know, sort of like the Six Million Dollar Man” — 25-year-old male, in Dan Waldorf’s Cocaine Changes

In 1860 the German pharmacologist Albert Niemann isolated cocaine, one of the ingredients in the leaves of the South American coca plant. He wrote that it leaves “a peculiar numbness, followed by a sense of cold when applied to the tongue”. Despite this observation, Niemann overlooked cocaine’s potential as a local anaesthetic. Only a few years later, a French pharmacologist did suggest that cocaine might be a useful local anaesthetic. But he did not follow it up either. One of the first doctors to experiment with cocaine on humans was Dr Sigmund Freud. In 1884 he was only 28, a poor, little-known but ambitious doctor at the famous General Hospital in Vienna, when he wrote a letter to his fiancée Martha Bernays in which he enthused about cocaine, “which some Indian tribes chew to make themselves resistant to privation and fatigue”. Freud ordered one gram of cocaine, but was outraged to be charged about 10 times the expected price. But before sending the cocaine straight back, he took one-twentieth of a gram. After a few moments, all his anger evaporated and he felt dramatically brighter: “nothing at all one need worry about”. One month later, Freud noted: “I take small amounts regularly against depression and indigestion and with the most brilliant results.” He sent Martha cocaine to “make her strong and give her cheeks a rosy colour”.

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Soon Freud was mailing cocaine to relatives, sharing it with colleagues, and prescribing it for digestive disorders, weight loss and asthma, for morphine and alcohol addiction, and even as an aphrodisiac. Just on the strength of “some dozen experiments”, he wrote an enthusiastic paper. His biographer Dr Ernest Jones called him a “public menace” on cocaine. One of Freud’s friends, Dr Fleischl, had become a morphine addict. American doctors were treating morphine addicts with cocaine, and Freud did the same for his friend. Fleischl did well at first. Another friend, Dr Carl Koller, was searching for an effective local anaesthetic for eye surgery. He wrote about a colleague who “partook of some cocaine with me from the point of a penknife and remarked ‘How that numbs the tongue.’” The observation was not new, but it was Koller who took it further. Would cocaine numb the eye as it numbed the tongue? We [Koller and Freud] trickled the cocaine solution under the upraised lids of each other’s eyes. Then we put a mirror before us, took a pin in hand and tried to touch the cornea with its head . . . We could make a dent in the cornea without the slightest awareness of the touch . . .

Soon Koller presented his findings to the Viennese Medical Association. As the news spread, wags called Dr Carl Koller “Coca Koller”. Freud’s own father was one of the first patients to enjoy a painless operation for glaucoma, with Koller and Freud giving a local anaesthetic of cocaine. An American cavalry officer even wanted Koller to sail for the United States and examine his horse! William Martindale, future president of the Pharmaceutical Society of Great Britain, advised the English to give up tea and take coca instead.

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But by July 1885, Freud’s addicted friend Dr Fleischl was taking a full gram of cocaine each day. Worse, he had convulsions and hallucinations of white snakes. Freud sometimes sat up all night with his friend. The man who had hoped to become the first European to be cured of morphine addiction by cocaine was now the first European cocaine addict. Freud may have believed that cocaine was not addictive because it did not produce the dramatic withdrawal crisis of opium or morphine. One critic called cocaine “the third scourge of mankind”. The fiasco shattered Freud’s early reputation. But he reportedly continued not only to use, but also to prescribe cocaine until at least 1895. Was Freud just unlucky in this early cocaine phase of his career? Had he, like Koller, concentrated on its anaesthetic effects, would he have become a famous anaesthetist instead of the father of psychoanalysis? In his last paper on cocaine, Freud finally admitted that it did harm morphine addicts and produce: . . . physical and moral deterioration, hallucinatory states of agitation similar to delirium tremens, a chronic persecution mania . . . hallucinations of small animals moving in the skin and cocaine addiction instead of morphine addiction.

Four years after Fleischl’s death, Freud was still blaming himself: “I had been the first to recommend the use of cocaine . . . The misuse of that drug . . . hastened the death of a good friend”. But later, Freud omitted references to some of his early papers promoting cocaine. Was this deliberate? Did he just happen to forget? Or was the great Freud himself subject to Freudian slips? (GB)

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PERCY GRAINGER’S AND WILLIAM GLADSTONE’S CURIOUS OBSESSION The death in 1994 of a British politician who was found dressed in women’s stockings, and who had suffocated while allegedly engaging in some sort of solitary sexual burlesque brought attention to such goings on, especially when they involved prominent people. Such activities are almost certainly not as uncommon as we may think. Percy Grainger was born in Melbourne in 1882, and showed exceptional musical talent from early childhood. He became one of the foremost pianists of this century and probably Australia’s most highly regarded composer (“Handel in the Strand”, “Country Gardens”, etc.). On top of this he at once led an eccentric private existence and extroverted public life. Grainger’s father, John, was an architect, but also an alcoholic and syphilitic. Percy himself did not have the disease, but his mother, Rose, did. Although she doted on the talented boy, Rose feared he would follow his father’s decline, so she horsewhipped him when he showed signs of straying from his piano practice. Out of this there developed a most unusual relationship of mutual dependency between mother and son. She managed both his professional and private life, and though an incestuous relationship has been speculated upon, the many letters each left seem to exclude this. Suffering from neurosyphilis, Mrs Grainger committed suicide in 1922. The harsh discipline and perverse ambience of his childhood, buoyed by a fancy for literature associated with cruelty, had directed Percy’s sexual urges along an abnormal path: sadomasochism. From the age of 16, “wildness, recklessness and unbridled savagery were the keynotes of his existence . . . guilt and shame had little place in his life” as his biographer John Bird puts it.

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So diligent was he in beating himself — or getting others to do so — that blood usually flowed, and he laundered his own shirts to conceal the evidence. Girlfriends were drawn into these activities, and pleasure heightened by recording the excesses on film. As mute testimony, he would hold up to the camera a notice with details of the kind of whip used, number of lashes as well as type of film and exposure on which it had been recorded! In 1928 Grainger married Ella Ström, a Swedish artist and poet, the ceremony taking place at the Hollywood Bowl. Ella was under the impression that this was a kind of secluded glade and was astounded to find herself taking the vows in front of 28,000 people to the accompaniment of a 126-strong choir and orchestra performing her husband’s new piece, “To A Nordic Princess”. That’s style for you. The beatings continued, and shared sessions with his wife became so violent the musician felt it prudent to deposit a letter indicating that should death in either follow a bout of flogging, that, in fact, to him flagellation was the highest manifestation of love. Both survived the onslaught, however, and Percy died of carcinoma of the prostate at the age of 78. Quite apart from all this self-inflicted brutality, Percy Grainger showed a remarkable lack of proportion, an exaggerated emotionalism and a flamboyant eccentricity. He bequeathed his skeleton to the Percy Grainger Museum “for preservation and possible display”. Some of his whips are also in the museum’s collection. Such characteristics were quite unlike those displayed by our second flagellating VIP. Indeed, this second man was looked upon as the very model of Victorian virtue, piety and rectitude. He was William Ewart Gladstone, four times British prime minister, over 60 years in Parliament, unexcelled at verbal reticulation and master of the subordinate clause. In 1839, at the age of 29, Gladstone married Catherine Glynne. She was to bear him eight children and provide him with a secure

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home base. It was said she was a woman of wit, charm and complete discretion, which is just as well for all his life Gladstone kept a diary in which he wrote about “wounds from his secret conflict”. In 1843, at the age of 34, he speculated in his diary as to “how far satisfaction . . . delighting in pain may be a true phenomena of the human mind”. And then on 13 January 1849 he confided, “having been much tempted . . . I made a slight application of a new form of discipline . . . how thankful ought I to be if I should find it to so continue”. Regrettably for him, gratification declined and he confessed it was becoming a convenient cover for “unabated impurity”. He tentatively recommended to himself, via the diary, that rescue work among prostitutes may lift the effect. So Gladstone became a member of an Anglo-Catholic group which did a variety of “good works” among the underprivileged; the saving of “fallen women” he saw as his contribution. Thus in 1851 he got out into the world of the demimonde, where, incredibly, he distributed copies of Uncle Tom’s Cabin as a suitably uplifting tract. Whether he partook of these women’s professional charms is not certain, and vehemently denied later by his children, but in July he noted he “trod the path of danger”. His thoughts not being always altruistic, he felt shame at their sexual content, a feeling he gratifyingly found best overcome by self-flagellation. Flogging sessions would be indicated in the diary not by a word, but a drawing of a whip. Gladstone particularly sought the company of a young woman called Elizabeth Collins, and she is written up many times with tantalising vagueness. For instance, on 13 July 1851 he enigmatically wrote of a two-hour “strange and humbling scene”. Naturally, it led to the scourge. To the statesman, Elizabeth was “lovely beyond measure”. Indeed, her attractions were enough to make him take early leave of a dinner given by Lord Palmerston in order to spend two hours with her; to be followed, of course, by the chastening whip. I wonder what Palmerston and his guests would have made of it if they had known.

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Gladstone was both smitten and unnerved by Miss Collins, and after 17 meetings of mixing “impurity” and “rescue”, he wondered if it were not unlawful. It took an unconscionable time for the politician to make up his mind and he confided to his diary that, paradoxically, the beatings were as much an encouragement as a deterrent for impure temptation. For a man in his position the moral conflict must have been considerable. Nevertheless, when dear Miss Collins migrated to Australia the chance to stop was allowed to slip and she was replaced by others. Twice at least he was recognised. With one, blackmail was threatened. Gladstone, fearing for his public credibility, sued, won, and the blackmailer got 12 months’ hard labour! The other was even more embarrassing. A well-intentioned but unthinking observer sent a letter to the Times, no less, saying he had seen an elderly man annoying two ladies, but as he recognised the gent to be Gladstone, realised he must have been acting with the “highest honour”! If those in the public eye find gratification in behaviour which is liable to outrage middle-class morality, better they keep it under wraps; contemporary attitudes may prove to be less tolerant than was the case with W.E. Gladstone or G.P. Grainger. (JL)

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Chapter

9

LONGEVITY

THE

OLDEST OF THE OLD

In January 1995 Lady Elliot of Harewood died in England at the age of 90. Not a stupendous age nowadays, but two facets of her life made her remarkable. First, she was the first woman — apart from a queen — ever to speak in the House of Lords. Second, and more interestingly as a contributor to medical history, her father was born as long ago as 1823, when Napoleon was only two years dead and Beethoven finally became stone deaf. More than that, her grandfather was born in 1768, at the beginning of the Industrial Revolution and while Dr Johnson and Mozart were in full flight. So, incredibly, it took 227 years to complete three generations. The “oldest of the old” are a fascinating group of people; they are vintage models representing the most indestructible members of society. Mind you, in times past, ages were often exaggerated due to lack of records or poor memory or financial gain. For instance, Thomas Parr was reputed to have been 152 when he died in 1635. Despite any doubts which may have been harboured, in his dotage he was well

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regarded enough to have his portrait painted and later hung in the then new Ashmolean Museum in Oxford. It is still there over 300 years on. William Harvey examined the body but wisely made no comment on the age. Englishman Thomas Carn was born in 1471 and was said to have lived through 10 complete reigns until he died aged 207. Actually, on careful examination, the figure 2 has been superimposed over 1 on his tombstone. It was not until the 1830s that the recording of dates of births became compulsory in Western countries and we got some order into things. According to the Guinness Book of Records (1994 edition), the oldest person authentically recorded in Australia was Caroline Maud Mockridge. She was born on 11 December 1874 and died aged 112 years 330 days on 8 November 1987. In 1992 there were about 1,500 centenarians in Australia. For years it was claimed that the oldest person ever to have survived with provable dates was a man from a remote Japanese island. Born in 1865, he died in 1986 aged 120 years and 237 days. He worked on the farm until he was 105, took up smoking at the age of 70 and attributed his long life to “God, Buddha and the Sun” (not smoking, thank goodness). But even this great age has been superseded by a grand old lady, Jeanne Calment. She lived in Arles, France, and was born in 1875. As a girl she met Vincent Van Gogh, whom she described as “scruffy”. She died in 1997 aged 122. Famous people who have cracked the 100 are Grandma Moses, the “Primitive Painter” from America, who died aged 101, and Irving Berlin, the composer, also 101 at the end. Comedian George Burns at 97 said he could not die — he’s booked. He eventually succumbed in 1996 at the age of 100 years and two months. The last surviving soldier of the American Civil War died in 1959, 94 years after it had finished. According to the Weekly Telegraph of February 1994, the oldest working man in Britain was a 94-year-old motorcycle repair man in

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Birmingham who planned to ride his bike to see the Queen on his 100th birthday. The 20th century has seen a dramatic increase in Western average life expectancy, from about 47 in 1900 to about 74.5 in males and 80 in females in the late 1990s. It has been postulated that if the body could retain its teenage physiology we could live for about 700 years. Though there are grounds for believing there is a finite lifespan, it may be longer than currently thought. Though improving health status and independence are allowing more people to survive into very old age (over 85), there are no signs yet of any extension of the upper limit of human life. Between 1981 and 1991 the number of centenarians in the UK doubled, a trend projected to accelerate. In 1992 there were about 40,000 centenarians recorded worldwide, only 22 per cent of whom were men. It may be women encounter fewer hazards, such as war, work accidents, smoking and heart disease. Further, perinatal and some bacterial-caused mortality is greater in the male; perhaps the immune response is different in each. Genetic influences, immune response, stress levels and environmental aspects contribute to the prolongation of life. All are factors which could account for the disproportionate number of grand seniors in three unique areas of the world. Abkhazia, Georgia, in southern Russia between the Black and Caspian seas has always been on the crossroads of history and is well known for its centenarians. By contrast, Hunza, between Kashmir and Afghanistan, and Vilcabamba, Ecuador, in the Andean foothills breed their champions in remote splendour. Documentation is rare, so years are estimated by major events — marriage, war service, heavy winters and so on. Correlating all factors, researchers have found discrepancies. For instance, a father’s age may have been used to avoid military service and then retained. Nonetheless, old age is a proved and common characteristic of the areas, and to the accepted theories have been added: pace of life (compare the giant tortoise with an average age of 120), physical activity, diet, and lack of self-abuse with drugs including nicotine,

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alcohol and the like. What has never been found is a fountain of magical spring water. The longest living things of all are, of course, trees, the leader being a Bristlecone pine in Nevada at a verified 4,900 years. Fascinating stories of distant personal contacts occasionally occupy the correspondence columns of the Times. Each tries to outdo the others. My only claim is that as a boy I (J.L.) met a man who had sat through the whole of the first ever Test Match in 1877! Or so he said. Perhaps author Antonia Fraser has the best story. She recounts how as a child in Oxford in the 1930s she had met people who had known Dr Martin Routh of Magdalen College. He died in 1854 aged 99, and claimed that when young he had known an old lady who as a girl had seen Charles II walking his spaniels. As Charles died in 1685, this time stretch vies with that of Lady Elliot; perhaps akin to the tenuous contact in the song “I danced with a man who danced with a girl who danced with the Prince of Wales”. Can anyone challenge it? (JL)

A L C H E M Y,

BODY-FREEZING OR VIRGIN’S BLOOD?

“It’s not the men in my life that counts — it’s the life in my men” — Mae West

Have you heard of the man whose lifelong ambition was to live to be 90 and then be shot dead by a jealous husband? Alchemy, body-freezing, virgin’s blood and snake venom are just a few of the devices we have used in our quest for a vigorous long life. Movie actor George Burns’s formula was optimism: “With a little luck, there’s no reason why you can’t live to be 100. Then you’ve got it made, because very few people die over 100.” And of

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course, Burns did make 100. Englishwoman Edith Beck would have made a good match for George Burns; on her 103rd birthday, she decided to look after her health and give up smoking. At 117, Leliai Omar Bin Datuk Panglima of Malaysia cycled 43 kilometres to marry his 40-year-old fiancée (his 18th wife)! Many cultures hold that humans were once immortal. Tithonus, the Trojan, loved Eos, the goddess of dawn. She persuaded Zeus to make Tithonus immortal, but forgot to ask for his eternal youth. In the end, poor old Tithonus could only sit babbling in a locked room, so she changed him into a grasshopper. Elixirs of life are prominent in Hindu, Hebrew, Arab and Greek cultures. Over the centuries, many alchemists have been loonies, charlatans and plain quacks, but alchemy has also attracted respectable scientists like Isaac Newton. Alchemists pursued two main goals: to turn base metals into gold, and to produce an Elixir of Life. In the 1st century BC, a Chinese alchemist advised his emperor to transmute mercury into gold, turn it into cutlery, eat with it, and so become immortal. Nothing to it! The unconventional Swiss physician-alchemist Paracelsus (1493–1541) claimed to have distilled a potion of immortality from mercury. The Italian adventurer who called himself Count Alessandro di Cagliostro (1743–1795) was short, fat, ugly, unwashed, rude and boastful. But he toured Europe in great style as an alchemist, flogging two famous elixirs. The first merely stopped a man from aging further, but the second rejuvenated him by 10, 20 or even 30 years. The proof? Cagliostro himself. He was thousands of years old, and remembered everything: the building of the Pyramids, the Roman emperors — history’s greatest name-dropper! The first elixir was blood. Romans drank the blood of slain gladiators. Some despots killed young virgins so they could drink or bathe in their blood, while others merely sucked their milk or inhaled their breath. Consider also the Christian practice of Holy

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Communion, in which wine representing the blood of Jesus is drunk: “Whoso . . . drinketh my blood, hath eternal life” (John 6:54). Tribes in India reportedly lived 400 years by eating snakes. Prescriptions included an ounce of snake’s urine, taken every morning for 15 days, every year, especially in spring. Snakes moulting were thought to be rejuvenating themselves. Hence, snakeflesh would rejuvenate humans, as would chickens fed on minced snake and even eggs laid by snake-fed birds. In 1492, a Jewish physician transfused Pope Innocent VIII with the blood of several young men who then quickly died. When the pope died as well, the doctor had to make himself scarce. One recipe for a long and healthy life is to eat less. This is not a new idea. Ecclesiasticus (37:24) warns us about overeating: “By surfeiting many have perished: but he that is temperate, shall prolong life.” The Venetian nobleman Luigi Cornaro confessed in his Discourses on the Sober Life (1558) that riotous living had left him at the age of 45 with gout, fever and stomach pains. His doctors gave him up, but he became a model of temperance and lived to 103. The German physician Christoph Hufeland (1762–1836) wrote lifestyle and diet recipes that anticipated modern diets, not only in content, but also in the title: Makrobiotik. The message today is similar: eat less, but have enough fibre, protein, fat, vitamins and minerals. Animal experiments show that this actually works. Dairy farmers should forever toast the Russian Nobel Prize winner of 1908, microbiologist Ilya Metchnikoff (1845–1916). He attributed ageing largely to a “putrefying bowel” (slow poisoning by toxins produced by bowel bacteria). Among his fans was Louis Armstrong, who took nightly laxatives and lived to the age of 71, and Mae West, who was hooked on daily enemas and lived to 87. Metchnikoff attributed the longevity of Bulgarians partly to their yoghurt, in which he found bacteria that eliminated the

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noxious bacteria in the bowel. In his lab, Metchnikoff kept a large pot of Bulgarian yoghurt, which he offered to all visitors. To this day, New Zealand makes Metchnikoff yoghurt with natural acidophilus and bifidus “to aid digestion”. Another popular way to keep down the nasty bugs in your bowel was to have part of it surgically removed. In the 1920s Dr John Brinkley of Kansas ran his own radio station KFKB (“Kansas First, Kansas Best”). Between fundamentalist sermons and country music, he talked into his gold-plated microphone and promoted his method of rejuvenation: transplanting slices of goat testicles into grateful old men. Before losing his licence in 1929, he earned over US$1 million a year and was able to lend one of his three yachts to the Duke and Duchess of Windsor. By contrast, Henry Leighton Jones (1868–1943) of Morisset, New South Wales, who transplanted monkey glands in the 1930s, was a reputable mainstream GP. Swiss physician Paul Niehans injected cells from unborn lambs into Konrad Adenauer, Winston Churchill, Pope Pius XII and Charlie Chaplin. Dr Ana Aslan spent years promoting Gerovital, which contained novocaine (a local anaesthetic) plus a secret ingredient. During the 1950s she treated over 5,000 elderly patients, including Somerset Maugham, Charles de Gaulle, and Konrad Adenauer (who tried everything, but died in 1967 at the age of 81 nonetheless). Some optimists have frozen themselves into suspended animation and waited for medical miracles to revive them. This freeze–thaw technique (cryonics) started with physicist Robert Ettinger in the 1950s. Even now, the faithful lie patiently frozen in cryonics centres all over world. One of the cyronics centres, the Alcor Life Extension Foundation in California, hit the headlines in 1988. Inside a vat of liquid nitrogen somebody found the frozen bodyless head of Dora Kent, mother of cryonics guru Saul Kent. Allegedly, Kent had first transferred her from a convalescent home as she was near

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death (then 83), then had her decapitated and frozen without medical help. But was she alive before she lost her head? The police found four more frozen heads and a frozen body; the lawyers had a ball. There is an even simpler approach to death — denial. Columnist Peter Smark wrote in the Sydney Morning Herald of 15 November 1997: “The American middle class, for instance, firmly believes that death is optional. So when a member of the group dies, it is his or her own fault. Or a doctor’s. Or an accountant’s. A lawsuit often results.” As mentioned earlier in this chapter, there are three regions in the world — Abkhazia, Hunza and Vilcabamba — in which we still hear of active, healthy people living to even 150. We can speculate about these pockets of longevity. Is it their active lifestyles, freedom from stress or sparse diets? Or is it merely their poor record-keeping and illiteracy? Whereas trees have rings and fish have scales, there are no accurate markers of human age. The consensus view doubts whether people have actually lived beyond 110 or 120 years. Most of us will not get as far as that: our own biological clocks make it unlikely that we will match George Burns and reach 100. The maximum lifespan has probably not increased greatly over the centuries. What has changed is the average life expectancy at birth. As was mentioned earlier, there’s a definite gender difference in longevity: 78 per cent of the world’s recorded centenarians are female. Moreover, spinsters outlive married women, whereas married men outlive bachelors. All this reinforces the feminist messages: women are stronger, and marriage is great for guys, but woeful for women. If you’re looking for longevity, choose the right ancestors. To estimate your life expectancy, take the average years of life of your parents and all four grandparents.

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But don’t stop there: improve your odds by working on your lifestyle and risk factors. Some enthusiasts recommend taking melatonin, while others pin their hopes on DHEA (de-hydro-epi-androsterone). Travel can work wonders too. Japan has bathhouses with solidgold tubs. True believers pay heaps to soak there. Don’t laugh — the Japanese live longer than people of any other country. (GB)

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A CAN

FINAL WORD: IMMUNISATION

THIRD CHILDREN?

ALONE SAVE

WORLD

Fog had delayed the tiny plane; everyone in the tiny mountain village high in the Andes was still waiting. Then a message came: the pilot would have to come after dark. Children ran all around the village, calling out: “The pilot is coming; come and bring a torch for him.” Young and old doused sticks with kerosene, lit them, and lined up on the grass strip. The pilot landed safely, and everyone helped to unload his precious cargo. Half an hour later, the first outraged baby squawked as she got her jab of vaccine. How well does vaccination protect today’s Third World children against infectious diseases? The greatest killers of children in developing countries are diarrhoeal disease and acute respiratory (chest) infection, for many of which we lack good vaccines.

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Each year, six preventable diseases (tuberculosis, measles, tetanus, whooping cough, diphtheria, and polio) kill 1.5 million to 2 million children. The measles death rates are about 400 times those of the West. Almost half a million newborn babies in developing countries die each year of tetanus, an infection that doctors in the West hardly ever see in newborn babies. This form of tetanus follows lack of immunisation of mothers and contamination during childbirth. Local midwives often cut the umbilical cord with a dirty razor blade, a sliver of bamboo or even a blade of tough grass, and then cover the stump with dung or mud. The tragedies extend beyond the deaths: each year, there are about 100,000 new victims of polio. Malnutrition, measles, and whooping cough disable many others. The good news is that each year, increased immunisation is saving the lives of about 3 million children. Childhood measles deaths have fallen from 2 million in 1985 to 1.1 million in 1996. Since it started in 1974, the Expanded Program on Immunisation (EPI) of the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) has been very effective. For the six diseases mentioned (tuberculosis, measles, tetanus, whooping cough, diphtheria, and polio), EPI has raised the immunisation rate of children under one year of age from 5 per cent to 80 per cent. This 80 per cent represents over 100 million children. To receive the full course of eight doses, each infant requires five separate visits. That’s 500 million contacts a year! How can underdeveloped countries around the globe get imported heat-sensitive vaccines to children in isolated villages, and keep the vaccines potent? To keep up the vital “cold chain”, some countries use solarpowered refrigerators, but most rely on insulated boxes of ice or carbon dioxide. Heat-sensitive markers turn blue if the temperature rises above 10 degrees Celsius.

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During the civil war in El Salvador, guerilla leaders agreed to a cease-fire; for “three days of tranquillity”, the only shots fired were of vaccines. When Turkey organised a national immunisation day, civil servants, including the military, helped to immunise children. Is it worthwhile? Is it cost-effective? Can the world afford such intricate chains to continue the necessary mass campaigns? To give one child one extra year of life by measles immunisation costs 40 cents; one extra year of life in the USA by treating high blood pressure costs $10,000. Critics of immunisation and other public-health measures claim that saving the lives of young Third World children is futile if they simply die of other causes soon after. UNICEF accepts the need for other measures as well. To improve child health, UNICEF works towards seven priorities, the acronym of which is GOBIFFF: • Growth monitoring (weight and height) • Oral rehydration for diarrhoeal disease • Breast-feeding • Immunisation • Food • Female literacy • Family planning Every Third World problem interacts with the others: drought, floods, war, defence spending, poverty, corrupt governments, malnutrition, disposal of sewage and industrial waste, polluted drinking water, illiteracy, high death rates of mothers and children, high birth rates, overpopulation, and environmental damage. One link is crucial: that between child deaths, birth rate and population growth in developing countries. It may seem natural to believe that improvement in health care is futile, because it only causes a fall in death rates, and therefore a population explosion. This belief sounds plausible, and can too easily become a justification for us in the West to deny aid to the Third World.

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But there is strong evidence to the contrary: as they become confident that most of their children will survive, parents gradually have fewer children. As UNICEF says, there is no conflict between meeting the needs of people and controlling the growth of population. In 1960, many developing countries had high mortality rates for children under five years (between 200 and 350 deaths per 1000 live births). When these death rates first started to fall, birth rates did not all respond at once. But once child mortality fell below about 150, births also fell. By now, most Asian and Latin American countries have passed through this initial phase: they are approaching or entering the stage when further falls in child deaths will bring much steeper falls in births. Maurice Strong, Secretary of the 1992 World Conference on Environment and Health in Rio de Janeiro, summed up: “The effort to reduce child illness and malnutrition . . . is crucial, not only for its own sake, but . . . to slow population growth and make possible sustainable development in the 21st century and beyond.” Critics point out that the world population is still rising, and that falling mortality may be associated with (but not the cause of) falling birthrates. Even so, there is convincing evidence that aid and better health care need not cause a population explosion. Nevertheless, the case for wider use of family planning appears overwhelming. Each year, half a million women die from causes related to pregnancy and childbirth. There is also a ripple effect: many infants in developing countries do not survive the early death of their mother. Four types of pregnancy are especially dangerous for both mother and child: too young, too old, too many, or too close. That is, when the mother is under 18 or over 35 years old, and has already had four children or has had her last child within two years. UNICEF estimates that if all births could be spaced at least two years apart, this single change would reduce maternal deaths by about 30 per cent, and child deaths by 20 per cent.

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The potential for greater use of family planning is enormous. The proportion of couples using some form of contraception varies greatly: estimates are about 75 per cent for China and East Asia, 50 per cent for Latin America, 30 per cent for South Asia, and under 15 per cent for Africa. There are also perhaps 300 million couples worldwide who are not yet using effective family planning, but who do not want more children. One simple contraceptive method is full breast-feeding for four to six months, which also protects infants from many infectious diseases. But there are many obstacles to the spread of effective contraception. For example, to promote their infant formulas, multinational companies are exploiting the fear of AIDS being transmitted by breast-feeding. Reportedly it was pressure from the Vatican that removed birth control from the agenda at the Earth Summit in Rio. Just as problems of children in the Third World are varied, but closely linked, so must be our efforts to relieve them. Priorities should include immunisation, family planning, female literacy, raising the status of women, and the relief of poverty. (GB)

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BIBLIOGRAPHY

Chapter 1: Kings and queens Bernier, O., The Secrets of Marie Antoinette, Fromm, New York, 1985. Bindoff, S.T., Tudor England, Viking (Penguin), Harmondsworth, 1951. Brewer, C., The Medical History of the Kings and Queens of England, self published, London, 1996. Clarke, John, The Life and Times of George III, Weidenfeld & Nicolson, London, 1972. Dale, Marshall, Medical Biographies: The Ailments of ThirtyThree Famous Persons, University of Oklahama Press, Norman and London, 1987. Dean, Geoffrey, letter to British Medical Journal, 1968, vol. 2, pp. 243–44. Ellis, H., “Royal operations”, Medico Legal Journal, 1969, vol. 37, pp. 97–109. Erickson, C., To The Scaffold: The Life of Marie Antoinette, William Morrow & Co., New York, 1991. Hurst, Lindsay, “Porphyria revisited”, Medical History, 1982, issue 26, pp. 179–82.

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Larousse Encyclopedia of Modern History, Larousse, Paris, 1964. Macalpine, Ida & Hunter, Richard, “Porphyria in the royal houses of Stuart, Hanover, and Prussia: a follow-up study of George III’s illness”, British Medical Journal, 6 January 1968, vol. 1, pp. 7–18. Macalpine, Ida & Hunter, Richard, “The ‘insanity’ of King George III: a classic case of porphyria”, British Medical Journal, 1966, vol. 1, pp. 65–71. Macalpine, Ida & Hunter, Richard, George III and the Mad-Business, Allen Lane (Penguin), London, 1969. Medvei, V.C., “The illness and death of Mary Tudor”, Journal of Royal Society of Medicine, 1987, vol. 80, p. 766. Plumb, J.H., Foreword, in Geoffrey Parker, Philip II, Hutchinson, London, 1978. Plumb, J.H., The First Four Georges, Little, Brown & Co, Boston, 1975. Sobrino, L.G., et al., “Hyperprolactinaemia in women with paternal deprivation in childhood”, Obstet Gynaecology, 1984, vol. 64, p. 465. van Loon, Hendrik, Van Loon’s Lives, Simon & Schuster, New York, 1942.

Chapter 2: Eccentrics, reformers and pioneers Briant, K., Marie Stopes, A Biography, Hogarth Press, London, 1962. Burt, Cyril, The Gifted Child, Hodder & Stoughton, London, 1975. Cohn, Victor, Sister Kenny, the Woman who Challenged the Doctors, University of Minnesota Press, Minneapolis, 1975. Gillie, A., “Elizabeth Blackwell and the medical register from 1858”, British Medical Journal, 1958, vol. ii, pp. 1253–57. Grace, P., “First among women”, British Medical Journal, 1991, vol. 303, pp. 1582–83. Hall, R., Marie Stopes, A Biography, Andre Deutsch, London, 1977.

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Kevles, Daniel J., In the Name of Eugenics: Genetics and the Uses of Human Heredity, Knopf, New York, 1985. Manton, J., Elizabeth Garrett Anderson, Methuen & Co, London, 1965. Morgan, E.S., A Short History of Medical Women in Australia, Burroughs Wellcome, Sydney, 1970. Rae, Isobel, The Strange Story of Dr James Barry, Army Surgeon, Inspector-General of Hospitals, Discovered on Death to be a Woman, Longmans Green, London, 1958. Stopes, M.C., Married Love, A.C. Fifield, London, 1918. Wainer, Bertram, It Isn’t Nice, Alpha Books, Sydney, 1972. White, Paul, Alias Jungle Doctor: An Autobiography, Paternoster Press, Exeter, 1977.

Chapter 3: Quacks, pseudologists and other phoneys Haggard, H.W., Devils, Drugs and Doctors, Blue Ribbon Books, New York, 1929. Newman, Art, The Illustrated History of Medical Curiosa, McGrawHill, New York, 1988. Porter, D. & Porter, R., Patient’s Progress, Polity Press, London, 1989.

Chapter 4: Famous patients Bennett, A., Writing Home, Faber & Faber, London, 1994. Cecil, D., A Portrait of Jane Austen, Constable, London, 1978. Cope, Z., “Jane Austen’s last illness”, British Medical Journal, 1964, vol. 5402, pp. 182–83. Crome, L., “The medical history of V.I. Lenin”, History of Medicine, 1972, vol. 4, no. 2, pp. 20–22. Ellmann, R., Oscar Wilde, Hamish Hamilton, London, 1987. Gordon, Richard, The Great Medical Mysteries of History, Arrow, 1985.

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Halprin, J., The Life of Jane Austen, Harvester Press, Brighton, 1984. Hedayati., H, Barmada, R. & Skosey, J., “Acrolysis in pachydermoperiostosis”, Archives of Internal Medicine, 1980, vol. 140, pp. 1087–88. Khrushchev, N.S., Khrushchev Remembers, Andre Deutsch, London, 1971. Major, R.H., Classic Description of Disease, Blackwell, Oxford, 1948. Moran, Charles (Lord Moran), Winston Churchill: The Struggle for Survival, Constable, London, 1966. Noguchi, Thomas, Coroner at Large, Simon & Schuster, New York, 1985. Payne, R., The Rise and Fall of Stalin, Avon Books, New York, 1965. Sykes, Adam & Sproat, Ian, The Wit of Sir Winston, Leslie Frewin, London, 1965. Taylor, B., “J. Stalin: a medical case history”, MD State Medical Journal, November 1975, pp. 35–46. Thomas, Hugh, Hess: A Tale of Two Murders, Hodder & Stoughton, London, 1988. van Loon, Hendrik, Van Loon’s Lives, Simon & Schuster, New York, 1942.

Chapter 5: Warfare and medicine Crumplin, M.K., “Surgery at Waterloo”, Journal of the Royal Society of Medicine, January 1988, 81(1), pp. 38–42. Dalton, C., The Waterloo Roll Call, Arms and Armour Press, London, 1971. Huxley, Elspeth, Florence Nightingale, Weidenfeld & Nicholson, London, 1975. Richardson, R.G., Larrey: Surgeon to Napoleon’s Imperial Guard, John Murray, London, 1974.

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Chapter 6: Discoveries and diseases Bernstein, B.J., “The swine fever immunization program”, Medical Heritage, 1985, vol. 1, no. 4, pp. 236–66. Cleland, J. & Southcott, R.V., Hypervitaminosis A in the Antarctica in the Australian Antarctic Expedition of 1911–1914: a possible explanation of the illnesses of Mertz and Mawson, The Medical Journal of Australia, 1969, vol. 1, no. 26, pp. 1337–42. Eron, C., The Virus that Ate Cannibals, Macmillan, New York, 1981, pp. 105–36. Fraser, Antonia (ed.), The Lives of the Kings and Queens of England, Futura, London, 1977. Howell, Michael & Ford, Peter, Medical Mysteries, Viking, London, 1985. Lindenbaum, S., “Kuru sorcery”, in R.W. Hornabrook (ed.), Essays on Kuru, E.W. Classey, Faringdon, Berks, 1976, pp. 28–37. Woodforde, John, The Strange Story of False Teeth, Routledge & Kegan Paul, London, 1968.

Chapter 7: Disasters Caulfield, Catherine, Multiple Exposures: Chronicles of the Radiation Age, Secker & Warburg, London, 1989. Gordon, R., Great Medical Disasters, Hutchinson, London, 1983. Hills, Ben, Blue Murder, Two Thousand Doomed to Die: The Shocking Truth About Wittenoom’s Deadly Dust, Sun Books, Melbourne, 1989. Jones, James H., Bad Blood: The Tuskegee Syphilis Experiment, The Free Press, New York, 1993. Nikiforuk, Andrew, The Fourth Horseman: A Short Account of Epidemics, Plagues and Other Scourges, Fourth Estate, London, 1991. O’Brien, Màire & O’Brien, Conor Cruise, Ireland: A Concise History (3rd revd edn), Thames & Hudson, New York, 1985.

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Schapiro, J. Salwyn, Modern and Contemporary European History, Houghton Mifflin, Cambridge, Mass., 1953. Woodham-Smith, Cecil, The Great Hunger, Ireland 1845–49, Hamish Hamilton, London, 1962.

Chapter 8: Addictions and obsessions Bird, J., Percy Grainger, Elek Books, London, 1976. Freud, Sigmund, The Cocaine Papers, Robert Byck (ed.), New American Library, New York, 1974. O’Shea, J.G., “Percy Grainger”, Medical Journal of Australia, 1987, vol. 147, pp. 578–581. Ober, W.B., Boswell’s Clap and Other Essays: A Medical Analysis of Literary Men’s Afflictions, Southern Illinois University Press, Carbondale, 1979. Shannon, R., Gladstone, vol. I: 1809–1865, Hamish Hamilton, London, 1982. Waldorf, Dan, Cocaine Changes: The Experience of Using and Quitting, Temple University Press, Philadelphia, 1991.

Chapter 9: Longevity Brewer’s Dictionary of Phrase and Fable, E.H. Evans (ed.), Cassell, London, 1981. Copeman, Herbert, “Henry Leighton Jones and his contribution to gland grafting”, Medical Journal of Australia, 1977, vol. 2, pp. 868–71. Fraser, A., King Charles II, Weidenfield & Nicolson, London, 1979. Kurtzman, J. & Gordon, P., No More Dying, Dell, New York, 1977. Leaf, A., Youth in Old Age, McGraw-Hill, New York, 1975. Stout, R., et al., “Better ageing: longer useful life”, Update, 1993, vol. 47, no. 9, pp. 583–595. Sydney Morning Herald, 15 November 1997. Weekly Telegraph, issue 138, February 1994.

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Young, Harvey James, The Medical Messiahs, Princeton University Press, Princeton, New Jersey, 1967.

A final word: Can immunisation save Third World children? Goodfield, Jane, The Planned Miracle, Scribners, London, 1991.

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THE

HISTORY OF MEDICINE IN A NUTSHELL

2000 BC

Here, eat this root.

1000 AD

That root is heathen. Here, say this prayer.

1850 AD

That prayer is superstition. Here, drink this potion.

1940 AD

That potion is snake oil. Here, swallow this pill.

1985 AD

That pill is ineffective. Here, take this antibiotic.

2000 AD

That antibiotic doesn’t work anymore. Here, eat this root.

Chapter

MEDICINE

1

AND

THE ARTS

EUNUCHS,

CASTRATI AND THE LIKE

The last of the grand ‘castrato’ singers, Alessendro Moreschi, died as recently as 1922. In his time he was known as ‘The Angel of Rome’ and there still exists a recording of his unique voice. It was made in 1902, a year before the Pope banned that surgical whimsy which for three centuries had been performed on prepubescent boys so that they could maintain the high notes for years longer than nature intended. Regrettably, the voice of Moreschi comes to us as being thin and tremulous, quite unlike those of former operatic maestros whose pristine quality had the audience standing at the end of an aria shouting, ‘Long live the Knife!’. Together, Italians and the Roman Catholic Church have loved music from earliest times. Centuries ago in Venice, foundlings were left at a church door. They were

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accommodated (or ‘conserved’) next door at the ‘Conservatory’ where they were given succour, shelter and musical training. Frustratingly, just as a boy became skilled his voice broke. So in about 1600 it was decided that to preserve the purity and marketability of a young boy’s voice, castration was in order. You may recall from your childhood science classes that the longer a cord, the deeper the note it emits when plucked. The idea of castration was that if you stop the flow of the male hormone the larynx remains undeveloped, so the vocal cords do not lengthen in the normal way and the notes emitted would maintain their clear, high pitch for ever. Many died during the crude procedure, and of those who survived, only about 1 per cent finished up with the spectacular, pristine voice necessary to become an international star. As these men were highly paid, downtrodden families saw it as a way to escape their penury, so many packed off their sons to be ‘fixed up’. The big centre for doing the operation was Norcia, well away from Rome. The surgeons were highly paid and well respected. Besides stunting the larynx, the procedure allowed the chest to become more powerful, the limbs longer and there to be a female distribution of body fat. Indeed, in opera they commonly took female parts. Paradoxically, if performing as a male, they displayed a higher pitched and stronger voice than the women they were supposed to be seducing. Until the late eighteenth century the only opera of consequence was Italian, and it was there the idolised castrati sang their elaborate arias. Some of the musical greats wrote for them, including Mozart and Handel. Hogarth represented them in his series of paintings called ‘The Rake’s Progress’. If they did not succeed on the stage, they went into the choir to swell the volume of the songs of praise for years. As late as the end of the nineteenth century, the Vatican had 16 castrati still in its choir. Perhaps the greatest of them all was Carlo Broschi, better known as Farinelli (1705–1782). He appeared before rapturous audiences throughout Europe until he was headhunted by the

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Spanish. There he sang to an audience of one, Philip V. The King was a chronic depressive and only comforted, it seems, by the Italian’s dulcet tones. The singer’s room was next to the monarch’s, and incredibly, he sang to him every night for nine years. More incredibly still, he always sang one of only four arias. As it turned out, many of the castrati were neither impotent nor sterile. In 1667 a chorister married. This outraged the Church which made him swear to maintain only a platonic relationship. In 1685 he wrote a book, fittingly called The Capon Marriage, and he is said to have died of a broken heart. Another famous castrato singer by the name of Tenducci fathered two children, maintaining that originally he had three testicles and one escaped at the time of the operation! But tastes change, and the rise of the comic opera, especially those of Rossini, saw the beginning of the end for these men. Castration was practised in the Orient and Turkey for centuries where either the whole genitalia (true castrati), or just testes (spadones) were removed or crushed (thlibiae). From 1100 BC in China it was used not only to attain musical perfection, but also as a punitive measure. In its heyday the Emperor had 3000 eunuchs serving as slaves in his palace. The practice continued into the early part of the twentieth century. In fact, the last Chinese eunuch from the days of the Forbidden City died as recently as 1997. In the Turkish Empire most of the boys were operated on at a Coptic Monastery in upper Egypt. If successful, they became guardians in the Harem where equivocal surgical results made them popular with their charges. However, the death rate from the procedure was high, healing tedious, and contractures common. Intellect, however, was never impaired, as seen in the famous story of Abelard (1079–1142). Despite having his genitals struck off after seducing Héloïse, niece of a canon of Notre-Dame, he went on to become one of the greatest scholars of his time. This century, Sir Edward Marsh, rendered eunuchoid by severe mumps as a child, was Winston Churchill’s secretary for 23 years. Several pagan religions have had their goddesses attended by

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eunuch priests. The best known was a Roman sect associated with Cybele. In a fit of pique her lover, Attis, had castrated himself, so after that the wandering mendicants who worshipped her were castrated to ensure purity. Her Spring festival incited such throbbing fervour that young men are said to have castrated themselves on the spot with a thoughtfully provided sword. They then ran through the streets brandishing aloft their bloody handiwork. A clamp found below London Bridge in 1840 is thought to have been used in Cybele rites. It was the epoch-making Council of Nicaea in 325 AD that stopped castration in the priesthood. Worldwide, castration now seems to be a thing of the past. But as recently as 1890 there sat at the gates of Peking a raddled old crone who purveyed her arcane skill by removing penis, testes, scrotum — the complete set — with one blow of a sword. The position was hereditary and provided eunuchs for the Emperor and sweaty palms for the lads of the village. I think we had better stop there. I am beginning to feel queasy. (JL)

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THE

EMERGENCE OF THE CRIPPLE

As a boy in the 1930s and 40s I lived in Blackpool, a seaside holiday resort on the north-west coast of England, made famous by Stanley Holloway’s (Alfred P. Doolittle in My Fair Lady) monologue about Albert and the Lion. To quote him, it was a place of ‘fresh air and fun’. And so it was. Built in some of the more exposed and breezy spots were homes for sick or convalescent children who were brought there to be cheered up and to get over their chronic ill-health in the bracing seaside climate. In truth, these homes were a legacy of the collective conscience of Victorian Britain which had first been pricked by Charles Dickens’ novels, a number of which were concerned with the plight of sick and deprived children. In the mid-nineteenth century the majority of such waifs suffered from tuberculosis, usually of the joints, particularly the spine and hip. The disease itself was very common in the population at large and easily passed on in the crowded conditions in which most lived, especially in the north of England which comprised Blackpool’s hinterland. The malady had a high mortality rate, but those who survived childhood did so to become part of a society which generally regarded the lame with suspicion, if not revulsion. This prejudice was age-old as seen, for instance, in the loathing which Shakespeare’s Richard III and Victor Hugo’s hunchback Quasimodo attracted. But then in the middle of the last century Charles Dickens, novelist and social reformer, became interested in the circumstances of these unfortunates and wrote of them in a sympathetic, caring and deserving light. His interest seems to have dated from 1837 when he took a summer cottage at Broadstairs in Kent, on the south coast of England. Just along the coast at Margate was the Royal Sea Bathing Hospital, built in 1791 to provide sea air for the sick of

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London who in the normal course of events could never have afforded a holiday. It is still there and said to be the oldest orthopaedic hospital in the world. While at Broadstairs, the author planned his book Nicholas Nickleby (published in 1839). In Chapter XL Nicholas notices some flowers in the attic window of a tenement. On inquiry he finds that a ‘sickly, hump-backed boy on tiny crutches’ lived there and the flowers were his only pleasure. The boy slowly died in a squalor which was in significant contrast to the surroundings of the gypsy children he wrote about in the next chapter. They lived in the sun and their limbs were ‘free and not crippled by distortion’. Two years after completing Nicholas Nickleby, Dickens’ infant nephew, Harry Burnett, developed a kyphosis (a humping of the upper back due to collapse of the vertebrae and at this time usually due to TB) and was sent to Brighton for the air. His mother died of consumption shortly after and the boy followed her to the grave at the age of nine — not an altogether uncommon story of the era. The author was grief-stricken, which is reflected in his book Dombey and Son (written 1846–1848). The child, Paul Dombey, has a painful back and is sent to the seaside to recover. He initially improves, but later dies. Dickens’ readers loved this kind of pathos and doubtless there was barely a dry eye in the parlour. At the time Britain did not have a single children’s hospital. Not until three years later, in 1852, was Great Ormond Street Hospital in London opened. Even then a lack of patients and money almost led to its early closure, for the public were suspicious of workhouse infirmaries and the like. Dickens responded by mentioning the hospital in his novel Our Mutual Friend (published in 1865) and in the magazine Household Words, which he edited. He also raised £2000 from public readings of his perennial favourite, A Christmas Carol, which had first appeared in 1843. Dickens’ (perhaps the world’s) most famous cripple, Tiny Tim, was, of course, in this latter book. The sentiments expressed in it immediately entered the general consciousness of the population.

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Generations of readers have sobbed themselves to sleep as they read either how Tim sat close to his father who ‘held his withered little hand in his . . . and dreaded that he might be taken from him’, or at how the ghost of Christmas Present could see a vacant seat and ‘a crutch without an owner, carefully preserved’. Dickens’ contemporary, William Makepeace Thackeray, called the book ‘a national benefit, and to every man and woman who reads it, a personal kindness’. In the book Dickens highlighted the link between poverty and disease, and it was A Christmas Carol which finally awakened the national understanding to a problem it had studiously ignored. During the last decade of his life Dickens devoted much of his time to readings of his works. One of his listeners was the carpet manufacturer, William Treloar, who heard the tale of Tiny Tim and was inspired to devote his life to crippled children. He went on to become the Lord Mayor of London and opened a very successful fund to provide hospitals and holiday homes for them. After the death of Charles Dickens in 1870 other novelists kept up the pace and the rage until by around the turn of the century attitudes were reversed and concern about these forlorn sufferers became a major philanthropic activity, especially among the socially advantaged. The financially well-off vied with each other to prove their benevolence. One meritorious society matron, Mrs Grace Kimmings, squared her conscience by forming yet another charity which she styled ‘The League of Brave Poor Things’. Although nauseatingly patronising, I suppose her heart was in the right place. The League opened a hospital for children in the Sussex countryside, which is still there, though now mercifully known as the Chailey Heritage. To be crippled almost became an end in itself until some stability was introduced by Queen Alexandra, wife of Edward VII. Though not crippled, Queen Alexandra had had tubercular glands in the neck incised as a young person, so she had suffered from the disease. She was moved to respond by founding the annual Rose Day Appeal. Since its inception the Appeal has broadened its base but still raises

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money in Britain for children over 80 years on, and indeed, helps fund some of those homes I used to cycle past when I was a boy. Antibiotics have since become the mainstay of treatment for TB, replacing the prescribed fresh air, which preferably blew off some northern estuary or pristine Swiss alp, and hope has superseded the sense of fatalism associated with the disease. To see a tubercular hip now or an open ward of rugged-up children bending into a howling westerly as they get their ration of ozone, is a rarity. Mercifully, those bleak, carbolic-smelling homes up there in Blackpool have been put to other, less melancholic uses. Dickens would have been the first to have approved. (JL)

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MEDICINE AND CHARLES DICKENS There is no doubt about the greatness of Charles Dickens, both as a novelist and, as we have seen in the previous chapter, a mouthpiece for the public conscience. But besides social issues, he was fascinated by things medical and wrote of them with the characteristic warmth, felicity and humour of someone who has been close to the action. Take, for instance, the two irreverent medical students Bob Sawyer and Benjamin Allen who appeared in Pickwick Papers, a novel which first appeared in serial form in 1836, and was published as a book in 1837. These lads shared digs in Lant Street, Southwark — an actual place just round the corner from Guy’s Hospital where they studied, near Pickwick and Copperfield streets, and not far from the ‘Clink’, a gaol whose name has passed into the language. As a 12 year old, when working at Warren’s blackening warehouse, a job on which his partly autobiographical novel David Copperfield is based, Dickens himself lived in this same reeking lane. In Pickwick Papers he described it as an ally ‘which sheds a gentle melancholy upon the soul’. I am sure it did. The students, Sawyer and Allen, were chronically hard up and, along with their crony Jack Hopkins from St Bartholomew’s Medical School, were described by their landlady as ‘a parcel of young cutters and carvers of live people’s bodies . . . leaving her exposed to all manners of abuse’. It is Hopkins who describes the unusual incident of the child who was brought into the hospital after swallowing 25 wooden beads. Later, while playing, his father heard what he took to be a small hailstorm. ‘“Don’t do that, my boy”, said the father. “I ain’t doing nothing,” said the child. “Well don’t do it again”, said the father!’ The child was shaken and much rattling was heard. ‘“Why, it’s in the child!” said the father, “He’s got croup in the wrong place!”’

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The child was taken to St Bartholomew’s where he was muffled in a watchman’s coat for fear of waking the patients. The story is written with true Dickensian wit. After qualification, Bob Sawyer went into general practice in Bristol. His indolence continued for, as he pointed out to Mr Winkle, of the drawers in his surgery half had nothing in them and the other half would not open. The only medical aid on the premises were some leeches, ‘and they are second hand’. Dr Sawyer employed a boy to deliver medicines. Not to homes where illness lay within their portals, you understand, but to the doors of randomly chosen and quite unsuspecting households. As the young Sawbones has it, on being taken in, the incomprehensible labels were read by the bemused family, ‘pills as before — lotion as usual. From Sawyer’s; late Nockemorf’. Next day the boy returned, apologised for the mistake as he retrieved the bottle and put it down to pressure of work. He thus ensured the name not only became known, but that the practice was thought to be very busy and well regarded and therefore worth a visit. A simple ploy in which, as Bob explains, ‘We have one four ounce bottle that’s been to half the houses in Bristol’. If Sawyer and Allen became the two most famous medical students of Victorian times, out of the book Martin Chuzzlewit (published in 1844) comes the marvellous Sarah Gamp, certainly the most famous midwife of the era. Indeed, due to her habit of always carrying a bulky umbrella, ‘in colour like a faded leaf’, her name has passed into the language: ‘a gamp — an umbrella, especially a large, untidy one.’ She is also remembered for her immortal line regarding a patient: ‘He’d make a lovely corpse.’ Mrs Gamp lodged in a bird-fancier’s house, opposite a cat-meat warehouse. Her rooms were on the first floor, rented for being ‘easily assailable at night by pebbles, walking sticks and fragments of tobacco-pipe’. She was a fat woman whose rheumy eyes could roll into the back of her head so only the white showed. Her untidy gown was peppered with snuff and, ‘it was difficult to enjoy her company without becoming conscious of a smell of spirits’, as the author has it.

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Despite her advertised profession, she would go to a lying-in or a laying-out with ‘equal zest and relish’. The only time she had felt faint was when she saw her late husband on the slab at Guy’s Hospital, ‘with a penny piece on each eye and his wooden leg under his left arm’. Sarah Gamp had a drinking problem which she endeavoured to excuse by claiming to follow the advice of her fictitious friend, Mrs Harris. To new patients a bogus conversation between the two would be recounted, in which her friend had made a recommendation that the resolve of the nurse would be strengthened if a bottle be left on the chimney piece ‘just so I can put it to my lips, nothing more’. Although Dickens portrayed her wonderfully as the archetypal mid-Victorian, pre-Florence Nightingale midwife, a local handywoman in a filthy dress which concealed a bottle of gin and who had a penchant for ordering baths full of boiling water to occupy the time of anxious relatives, she herself saw an easier living was to be made in laying out the dead. For this chore she charged ‘eighteen pence for working people, and three and six for gentlefolk’, but protested that she would do it for nothing as long as the bottle was left, ‘and let me put my lips to it when I am so disposed’. In the novel Martin Chuzzlewit Mr Pecksniff brings Mrs Gamp to Mr Mould the undertaker for a laying-out. The situation allows Dickens to give an incomparable description of a funeral director: ‘a man with a face in which a queer attempt at melancholy was at odds with a smirk of satisfaction; so that he looked as a man might, who, in the very act of smacking his lips over choice old wine, tried to make believe it was physic’. Charles Dickens was born on 7 February 1812 and died on 9 June 1870. As regards his personal health, from his twenties onwards he suffered from tic douloureux, a spasmodic and very painful condition of a nerve in the face. In 1840, at the age of 28, he was operated on for bleeding piles and an anal fissure. As this was before the days of anaesthesia, the discomfort must have been

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intolerable. During his last years he suffered from bouts of depression, but usually managed to put on a brave face. In 1869 he began to suffer from transient ischaemic attacks, a temporary loss of consciousness following a spasm of cerebral blood vessels. He died of a cerebral haemorrhage at his home in Gad’s Hill, near Rochester, site of many of Mr Pickwick’s escapades. He was 58. Charles Dickens was the consummate writer: witty, imaginative, an absolute master of the language and rightly held in the highest regard. Although Bob Sawyer, Benjamin Allen and Sarah Gamp were fictitious characters, Dickens wrote about them with such warmth and sympathy they have come to represent the essence of mid-nineteenth century medicine. (JL)

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THE DIVINE SARAH When Sarah Bernhardt, the French actress, died in 1923 such was her universal popularity that it was said that between 600 000 and one million silent spectators lined the streets of Paris for her funeral. She was buried in a coffin which had stood in her bedroom for many years and in which she was given to sleeping in from time to time when the mood took her. Such bizarre longings were part of her Bohemian lifestyle, for over the years her bedroom contained such divertissements as stuffed bats, a complete skeleton, a caged lion and later a tiger cub. At one time she allowed an alligator to share her bed, a little whimsy which caused the abrupt departure of the man then in residence. He was the coincidental representative of one of the other constant features of her life; her penchant to take lovers, and lots of them. These battalions who came ravenously to her door ranged from the father of her only child, the Prince de Ligne, to two-bit actors and pimply youths to whom she often gave help and encouragement. She did in fact get married at one stage to a Greek actor, Jacques Daria, but it only lasted a short time and then it was back to the general free-for-all. However, as I am about to suggest, their tramping through her bedroom might possibly have had something to do with her interesting medical history, namely the amputation of her right leg. To start at the beginning, Sarah Bernhardt was born in 1844 and was always pale, thin, seemingly perpetually cold, easily fatigued and altogether rather waif-like. She was regarded as being so willowy that one unkind rival said of her when applying the asp to her breast during the climax of the play Antony and Cleopatra, that if it had been put there for succour it would starve to death. On the other hand, she was hardly the outdoors type, and her well publicised after-dark demimonde existence may have accounted at least partly for her being pale and interesting. Notwithstanding her

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pallid persona, all came together to form an ethereal beauty and quite rare talent for acting. Her younger sister died of TB in her youth; her other sister was a morphine addict. Following the example set by their mother, all three were high-class courtesans, indeed, Sarah was never sure who her father was. Despite such an unpromising beginning, or maybe because of it, Sarah became the consummate actress of the late nineteenth and early twentieth centuries. Although she only performed in French, she was loved throughout the world by nobility and hoi polloi alike. Her pièce de résistance was La Dame aux Camelias where the prolonged dying scene suited the incorporeal fragility of her physique as well as her sublime skill as a tragedienne. At the age of 45 in 1890, and already a grandmother, she took the lead in Barbier’s play, Joan of Arc. When it came to the trial scene where she was asked to state her age, she slowly turned from the inquisitors to face the audience and, fixing it with an unwavering stare, proclaimed with proud disdain, ‘Nineteen’. It was a coup de theátre which brought the house down every night, just as it did 20 years later when she acted the part when she was a great-grandmother. But from the medical history viewpoint, it was also that play which set her on the road to amputation, for she was called upon to repeatedly fall to her knees, an action which caused increasing pain. The right knee became swollen and reddened. It slowly got worse, and after six years it was noted she had difficulty in mounting stairs. But, like a real ‘trouper’, she soldiered on. In 1905 Sarah undertook a tour of America where she was particularly popular. By now she had to walk with a stick, frequently stopping to try and ease the discomfort. On arrival in Buenos Aires, a crisis arose when an abscess formed on the knee and had to be incised. Three months later, still in South America, when throwing herself from the parapet in the play Tosca, the mattresses below had been forgotten and she landed on the bare boards. That did it. Her bad knee swelled immediately and she returned to New

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York in great pain. With rest, it slowly settled. In 1912 she returned to the USA, but her knee was so painful she was reduced to giving 30-minute cameos while sitting most of the time. In August 1914 she had the leg put in a plaster cast to relieve the agony, but to no avail. It became especially painful as she dropped off to sleep and the guarding muscles surrounding the knee relaxed. So in February 1915 Sarah wrote asking her surgeon, Dr Pozzi, to remove the offending limb ‘a little above the knee’, as she put it. She threatened that if he refused she would shoot a bullet into her knee, ‘and then it will have to be cut off’. It was agreed that amputation should take place, but when it came to the crunch, so to speak, Pozzi’s nerve failed him and he asked his assistant, Dr Denuce, to do the job. As far as symptoms were concerned the operation was a big success, but Sarah had no luck with any number of wooden legs which were subsequently fitted. In the end she resolved the problem by throwing them out and being carried about in a kind of sedan chair in the manner of a Byzantine empress, a role which suited her down to the ground. She continued to act, mainly in excerpts which could be performed in a sitting position. At the end she would rise, balancing on her one leg to receive the deserved adulation she so enjoyed. Sarah Bernhardt died in 1923, after having been a legend in her own lifetime, a peerless performer and worthy of her sobriquet ‘The Divine Sarah’. But back to her medical condition. What could have been the pathology of her painful knee? Go back to those multiple lovers she garnered from all strata of society. Could it have been gonococcal arthritis from one of them? At the time it was not an uncommon manifestation of that particular venereal disease, but I must admit a history of 25 years seems a bit long. That particularly virulent form of bone cancer, a sarcoma, would

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have almost certainly seen her off long before the given time span. What about rheumatoid- or maybe osteo-arthritis? One joint only being affected does not seem to fit. It was certainly a chronic condition with exacerbations, and this coupled with the feature of it being in one joint only is very characteristic of tuberculosis. Further, there was a family history of phthisis (TB). Other symptoms include the development of a gradual impairment of movement and lastly the coughing-up blood, or haemoptysis, which it is recorded she suffered as a child. These are all characteristic of TB. On the other hand, neither a sinus (a discharging passage from the joint) nor ankylosis (rigidity) seems to have been noted and these are features of the disease. The ailment first manifest itself after trauma in the play Joan of Arc; intermittent pain was a dominant symptom and, as we have seen, at one stage an abscess had to be incised, all of which makes osteomyelitis (a bacterial infection of the bone) the frontrunner. Added to that, in line with surgical thinking of the time, amputation was regarded as acceptable to reduce the debilitating effects of prolonged toxaemia and persistent pain and reduce the chance of chronic amyloid disease, a condition which can slowly destroy the kidneys. So for my money, chronic osteomyelitis it was. Whatever the cause, Sarah Bernhardt was the most versatile actor of her time, a great and well-loved performer whose physical disability made her triumphs even more remarkable and memorable. (JL)

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Chapter

2

MURDER, MYSTERY AND MAYHEM

FAST

FOOD IN

SCOTLAND

In the sixteenth century, travel in the county of Galloway on the west coast of Scotland was often a one-way affair. Too often people just failed to return — they simply vanished without trace. Occasionally, locals or soldiers went out to investigate. The lucky ones found nothing and returned empty-handed; the unlucky ones disappeared as well. In those rough times, some innkeepers used to rob and even murder guests, so the authorities arrested them just in case. But even on the gallows, they still did not confess. The price of inns fell, but the disappearances continued. When the tide washed up occasional human heads, arms, legs, genitals and viscera, Galloway people took fright and spread tales of witchcraft.

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According to many reports, all this terror started with Sawney (Alexander) Bean, born near Edinburgh during the reign of King James VI of Scotland (1566–1625). Sawney’s father worked as a hedger and ditcher, but young Sawney wanted an easier life. He ran away, taking with him ‘a woman as viciously inclined as himself’. The two settled by the seaside of Galloway. They found a winding cave about one mile long, quite wide in parts. Its mouth was so close to the sea that the incoming tide filled up to 200 yards of the cave. At high tide, the entrance was inaccessible to anyone passing by. Here they lived in total isolation. Over the next 25 years they had eight sons, six daughters and 32 grandchildren: a grand total of 48 Beans. How did this superextended family survive? By ambushing, murdering, robbing and eating passers-by. Once the Beans had killed a man, woman or child, they would carry off the body to their den. There they cut it into quarters; large pieces of flesh they smoked over fires of seaweed and driftwood. Other chunks they pickled in brine. When they had more food than they needed, they simply ‘threw legs and arms of the unhappy wretches they had murdered into the sea, at a great distance from their bloody habitation: the limbs were often cast up by the tide in several parts of the country, to the astonishment and terror of all beholders.’ The whole family played their part in the ambushes, which went with military precision. Sometimes they attacked as many as six men on foot, but never more than two on horseback. Anyone who did escape the main ambush and tried to flee would fall victim to the second or even third ambush party. Finally the Beans came unstuck. They spotted a husband and wife mounted on a single horse, returning from a nearby fair. The female Beans pulled the woman off: ‘The female cannibals cut her throat, and fell to sucking her blood with as great a gust, as if it had been wine: this done, they ript up her belly, and pulled out her entrails.’

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Meanwhile, the males pressed the husband, but he fought back with sword and pistol. Rearing his horse, he even trampled some of his attackers underfoot. Then 20 horsemen, also returning from the fair, rode up, forcing Sawney’s gang to rush off. The husband and his rescuers rode to Glasgow where they alerted the magistrate. Soon the King himself set off with the husband, 400 horsemen, dog-handlers and bloodhounds. Some dismounted to search the woods and beaches. At first they took no notice of the cave mouth awash with the incoming tide, but then one of the hounds ventured in and started to bark furiously. With torches, the soldiers followed their dogs inside. Finally they halted in a vast chamber. The stench stopped them short, but the sight was far worse. Hanging from beams in the ceiling were arms, legs, haunches and quartered torsos drying in neat rows. Other human remains were soaking in brine; white bones lay everywhere. Pistols, cudgels, boots and saddles all around. The Beans were rounded up, the human remains buried and the booty loaded onto carts. Back in Edinburgh, people flocked to see the family that had broken so many taboos: incest, murder and cannibalism. All up, the Beans are thought to have killed and eaten over 1000 people! But spectators had little time to gawk. The next day, without the formality of a trial, the family suffered deaths just as brutal as their own crimes, for which they showed no repentance. The men had their genitals cut off and cast into a fire. After their hands and feet were severed, they bled to death in full view of the females. Then the females were thrown into the flames. This punishment may have seemed fitting for Sawney and his mistress, but the Bean children and grandchildren had been born and reared in the isolation of a cave. They knew absolutely no one outside their own savage, inbred family. To them, killing and eating people must have appeared perfectly natural. Some questions about this family are still unanswered. When did Sawney Bean live? As mentioned earlier some writers believe it was in the time of King James VI of Scotland. Others say

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it was under an earlier King James. Still others dispute that Sawney actually existed at all; they consider the story a legend. Either way, Sawney became as well known as Robin Hood, Dick Turpin or William Tell. Even now, his infamy lives on; the play Sawney Bean played to packed houses at the 1969 Edinburgh Festival. (GB)

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A R S E N I C A N D A D U LT E R Y : THE POISONED LIFE OF FLORENCE MAYBRICK On 23 October 1941 in a squalid, smelly shack in Connecticut, the milkman found the body of a 79-year-old recluse. It was the dozens of hungry cats she kept that were most upset. Locals called her ‘The Cat Woman’; harmless, but very odd. Even if they had heard of her earlier life, they may not have believed it. Florence Chandler, born in Alabama in 1862, had a dubious family background. Within two years of Florence’s birth, her mother had the misfortune of losing her husband from a sudden puzzling illness, remarrying and losing her next husband as well. Her inheritance may have eased her grief. After turning 17, pretty Florence met 41-year-old James Maybrick, a rich cotton-merchant, on a transatlantic liner. They married in London, but later settled in Liverpool. It was not a marriage made in heaven; James was a cad who soon resumed his drinking and womanising. Florence had two children and made the best of things. But in 1889 she met a rich young Texan cotton-dealer named Alfred Brierly. In March the Maybricks had their first public quarrel; back home James hit Florence in a fit of jealousy. His accusations must have sounded like the pot calling the kettle black. She packed her bags, but relatives talked her into staying ‘for the children’s sake’. This scoundrel of a husband was also a hypochondriac with a drug habit. After a doctor had prescribed him arsenic for malaria, James kept taking it up to five times a day as an aphrodisiac, hangover remedy and tonic. On the side, he took strychnine. On 24 April Florence bought a dozen arsenic-coated flypapers. Two days later James started to vomit violently so the doctor put him on a bland diet. But the suspicious James wrote to his brother Michael, begging that if he (James) should die, Michael should be

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sure to get a post-mortem. Five days later Florence bought more flypapers from another chemist. On 3 May Dr Richard Humphreys saw James for leg pains. He gave morphine and put him back to bed. Though Florence kept bringing him food and medicines, poor James just kept getting worse. Soon the talkative nanny told two neighbours about the flypapers she had seen soaking in water. Later Florence would claim that like many women she applied arsenic solutions to bring bloom to her cheeks. Rumours swept the neighbourhood. Michael Maybrick barred Florence from the sickroom. Dr Humphreys found a bottle of Valentine’s Meat Extract that contained a faint trace of arsenic. So he tested James’s urine and stools for arsenic, but found none. On 11 May 1889 James Maybrick died. Michael locked Florence in her room and called the police who searched the house from attic to basement. The haul included a package marked ‘Arsenic — poison for cats’ and 117 medicines from 29 chemists, all made up for James. Between them, the medicines contained enough arsenic to kill at least 50 people. At the post-mortem, held as usual in the dead man’s bedroom, doctors found the stomach and bowels to be inflamed. James was not long buried when the coroner ordered him dug up again. Other doctors found a little arsenic in his body, but nothing like a deadly dose. Mind you, there were also traces of strychnine, morphine and hyoscine. Despite her denials, Florence became the first American woman tried in Britain for murder. One expert said Maybrick had died of arsenic poisoning, while the defence doctors suggested gastroenteritis. They said the drugs found in Maybrick’s organs came from self-medication. As a friend had said: ‘Maybrick has got a dozen drug stores in his stomach.’ The prosecutor thundered against Florence branding her a woman taken in adultery (as though adultery were the charge). From the bench, the judge called her ‘that horrible woman, the epitome of all that is loathsome and evil’. What the public did not know was that he had recently had a stroke and was now losing his

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wits. A year or two later the judge ended up in a lunatic asylum, but that was no help to Florence. Once the jury found her guilty, he donned the Black Cap and sentenced her to be hanged. The United States President appealed to Queen Victoria. There were protest meetings, marches, letters and petitions with over half a million signatures. The women’s rights movement for once set aside gender equality to argue that no woman should be hanged. Hanging Florence might have cost the Tory party 100 000 votes. At the eleventh hour, the Home Secretary retried the case and commuted the sentence to life imprisonment. He based this new sentence on the view that Florence had at least attempted to murder James. But no one had ever tried her for attempted murder. Legally, both the trial and the retrial were a shambles. But there was some gain from James’s death and Florence’s pain; pressure for law reform. Under the legislation of the time, Florence could not give sworn evidence on her own behalf, nor even appeal against the verdict. In time, the Civil Evidence Act and the Court of Criminal Appeal Act corrected these deficiencies. The upright, uptight Queen Victoria expressed her ‘regret that so wicked a woman should escape (hanging) . . . The sentence must never be further commuted’. Indeed, Florence remained in prison while Victoria lived. But in 1904, having served 15 years as a model prisoner, she was released. She never saw her children again, but returned to the US, published her story and gave a few public lectures. Later she led a vagrant life, selling encyclopaedias door-to-door, then working as a domestic servant. At times the Salvation Army helped her out. In 1920 she started a new life under her maiden name and later built herself a shack in South Kent, Connecticut. There on a small pension she somehow supported herself and her horde of cats. Was she a ruthless murderer, or an innocent woman unjustly convicted? Reportedly, at one time when the cats became too much for her, she poisoned the lot. How? With arsenic!

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Since then her late husband James has upstaged Florence. Electricians rewiring the Maybrick house in Liverpool in about 1995 found a diary with a signed confession. This showed that Maybrick was actually Jack the Ripper and in 1888 had murdered several prostitutes to revenge himself on the unfaithful Florence. But investigators over the last century have named a host of other men as Jack the Ripper. We will never be sure of the real truth about either James or Florence Maybrick. (GB)

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DEATH

BY UMBRELLA

Georgi Ivanov Markov was a Bulgarian novelist and playwright who in 1978 met his death in a way which was as spectacular, quick, incisive and spine-chilling as any he may ever have written about. In 1969 Markov put on a politically hot production of one of his plays in his home country. After the performance he knew he had greatly disturbed his communist masters, so he slipped out of Bulgaria and roamed the Continent, eventually arriving in England in 1971. There he wrote and broadcast for the Overseas Service of the BBC in the Bulgarian section. In England his works created waves not only among his own community but in high places in Eastern Europe. As a result of all this he began to receive threatening phone calls. Nonetheless he pursued his political line with fearless and perhaps foolhardy abandon. On 7 September 1978, as Markov was standing in broad daylight at a bus stop at the south end of Waterloo Bridge in London, a most unusual event took place. As he abstractedly gazed about waiting for his transport he felt a blow on the back of his right thigh. Turning he saw a stranger bending to pick up an umbrella. The man apologised for stumbling into him and hailed a passing taxi. The writer thought little of it but was to recall later that his apparently accidental assailant spoke with a thick foreign accent. By the time our subject reached his office the leg was very painful and on rolling up his trousers, Markov noted an angry red spot on the back of his thigh and blood on his trousers. He shrugged it off and continued to work. That evening he felt washed out, the next morning feverish and distinctly off-colour. Later in the day he vomited and had difficulty speaking. By the evening of this second day he felt so ill that he elected to go to hospital. There he was not only found to be feverish, but enlarged groin glands were located and a hardened area 6 cm in

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diameter was seen on the right thigh, in the centre of which was a 2 mm puncture mark. An X-ray of the upper leg showed nothing abnormal and the diagnosis remained obscure. It was put down as a case of G.O.K. (God Only Knows). The following day, 9 September, Georgi Markov collapsed and, while still in hospital, it was thought septicaemia had set in and he was transferred to the intensive care unit. There his kidneys stopped functioning, his white blood cell count rose alarmingly and he went inexorably downhill to eventually die of renal failure on 11 September in what could only be called suspicious circumstances. This was certainly a case for the coroner. While a clear diagnosis was not established, there was an air of scepticism in the medical camp regarding the significance of those ‘cloak and dagger’ events purported to have occurred at Waterloo Bridge. Such carryings-on were ‘just not British’, especially in central London. In fact the favoured diagnosis at that time was, rather incredibly, diphtheria. Anyway, to satisfy the coroner, further investigations had to be carried out and tissue from the thigh sent off for detailed examination. It was all felt to be a waste of time, despite the unusual circumstances surrounding Markov’s death. Two pathologists were involved in the post-mortem investigations: Dr David Gall and Dr Rufus Crompton. As one did the dissection he noted what he thought was the head of a marker pin in the loose tissue of the specimen and which he concluded had been left by his colleague to indicate the site of the original umbrella thrust. But when he pushed it the visible pinhead moved and was seen to be a free piece of metal. Mercifully it was preserved and not swept down the drain as merely a medical aid. They came very close to disposing of a crucial bit of evidence. When at last the metal fragment was examined it was revealed to be a pellet about 1.5 mm in diameter with two minute holes drilled through the widest part at right angles to one another. For the first time the question was asked: did it contain poison? But contrary to expectation, no toxic substance could be identified in the thigh tissue or metal bead, despite the local

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reaction in the flesh around the puncture and despite countless tests. A confined bacterial infection was considered, as was a viral infection. Both were discarded. Tetanus, botulism, and chemical poisons were thought of, but the clinical picture was wrong. Dioxin poisoning is slow to act, and natural toxins in plants and animals occur in large quantities, so again the story was wrong. The medical establishment was careful not to leap to conclusions. However, in an inspired moment one of the pathologists dimly recalled that the symptoms following the ingestion of the toxin produced by the castor-oil plant could fit the clinical picture. High fever, a very high white cell count, local tissue damage and enlarged adjacent glands are all effects of such poisoning. In small animals the substance causes death in about four days. So the castor-oil toxin, or ricin, was left on the list. As the only documented work on the substance had been done on small animals, the pathologists decided to try it out on a pig of about Markov’s weight. So the unfortunate animal was injected with ricin. For six hours nothing happened, and then the pig suddenly sickened and some hours later died. This all happened within 24 hours, a shorter time than in the case of our Bulgarian friend. However, on post-mortem examination the pathological findings were identical in pig and human, so ricin poisoning by person or persons unknown was the ultimate finding. Before closing the file, however, another couple of odd and spine-chilling facts surfaced. About two weeks before the Markov incident another Bulgarian radio correspondent who worked in Paris had been sitting in the Metro, minding his own business, when to his surprise he was shot in the back with an air pistol. He fell ill and a red mark similar to the one on Markov’s thigh was found on his back. He spent 12 days in hospital but recovered. In retrospect it may have been a trial run to see which was the most effective method of rubbing out a backslider. After the Markov affair the Paris correspondent was visited by the British Anti-Terrorist Squad and another X-ray ordered.

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The first had been passed as clear: ‘such things do not happen in Paris.’ Doubtless to the discomfiture of the hospital authorities, a tiny foreign body was visible on this occasion. On 26 September the Paris victim was operated on and an identical pellet to that found in Markov was extracted. In fairness, I should remind you that the metal object in Markov’s thigh had not been detected on X-ray either. The other puzzling incident occurred in October that year when a newsreader from the BBC’s Bulgarian service died from a fall down the stairs at his home in London. He was fit, happy and sober at the time. I am sorry to have to tell you that no poison pellets were found on this occasion. Nonetheless, it was an odd coincidence and did give everyone an uncomfortable feeling. So perhaps the undercover world of 007 is not that fictional after all. I must say, though, I thought James Bond was more into fast cars and fast women than castor oil. (JL)

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DOCTOR’S DRAMATIC DEATH

DIET

The case of Dr Herman Tarnower and Mrs Jean Harris was one of the media sensations of 1980. It started with sex, a sadomasochistic relationship, drugs, and hypocrisy. It ended with scandal, violent death and retribution. Tarnower had grown up in Brooklyn in a Polish–Jewish family. His father made ends meet as a hat-maker until the Great Depression when things got tough. As a teenager Herman Tarnower made money by gambling. Later he kept a set of cards showing a royal flush on display in his dining room, because ‘it helped to build the house’. Though no one else in Herman’s family went to college, he graduated as a medico with honours from the University of Syracuse. Soon he set up in Scarsdale, an exclusive rural part of New York State. Tarnower trained in cardiology, which was not a popular field at the time. Tarnover explains that was the only reason ‘they opened it to a Jew’. But military intelligence dictated that this cardiologist’s longest tour of duty in World War II was to be in a psychiatric hospital! As a member of the Atomic Bomb Commission, he entered Nagasaki on the first plane after the Japanese surrender. Back home, as Tarnower’s practice flourished, he moved up in the world. He worked for years to get rid of his Brooklyn accent. Similarly, he kept practising until he mastered dancing, golf, tennis, fishing, and especially shooting and hunting. And not just animals; Tarnower hunted women too. On a trip to Morocco, a Muslim driver mentioned that he had two wives. Tarnower asked him why. ‘Because I can’t afford four. But even two is much better than one; with two, both try a little harder.’ Tarnower loved to repeat this story. He never actually married, but otherwise he followed this example. One of many women to fall under his spell was Jean Harris, a divorcee with two children.

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She met Tarnower in 1966 and remained his faithful mistress until his death 14 years later. Jean valued him as a self-made man, and even justified his selfishness: ‘He does what he wants, and that makes him damned good company! . . . If he found you interesting, or useful, he was a good friend . . . If he didn’t like you, you could go to hell.’ Nothing could shake Jean’s devotion. She became doubly dependent: on Tarnower himself, and on the drugs he prescribed her. For at least ten years he prescribed her a dangerous cocktail: speed (Methedrine, methamphetamine), the narcotic oxycodone, valium and barbiturates. Not only was Tarnower’s medication unwise, it was also illegal. When Jean moved to Virginia, where he was not licensed, he had scripts dispensed in other people’s names and then passed the drugs on to her. Jean was often depressed and irritable; she slept poorly and felt exhausted. Did her drug habit make these symptoms worse? We don’t know. Much later, a psychologist wrote: ‘She had truncated her life through her subjection to Dr Tarnower in such a manner as to kill part of herself in masochistic surrender. She had recurring bouts of depression . . .’ Tarnower received many personal gifts from ‘grateful patients’, but Jean was slow to catch on that these ‘patients’ were his other lovers. The most threatening of these was another divorcee: the attractive and much younger Lynne Tryforos, Tarnower’s personal assistant. Predictably, he gave Jean the flick. When asked why they tolerated Tarnower’s other affairs, both Jean and Lynne simply said they loved him. More and more wealthy, prominent people flocked to Tarnower’s care. In his concern for the diet of his patients with heart disease, he was actually ahead of his time. Since about 1960 he had been giving them a simple outline advising them to avoid fatty meats, butter, alcohol, and rich sweets. In 1978 The New York Times Sunday Magazine reminded its readers that it was but ‘six weeks to bikini season . . . the beautiful people of Scarsdale are now the skinny people of Scarsdale’, thanks to a new

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diet by Dr Tarnower. ‘A vice president of Bloomingdale’s . . . lost 20 pounds in 14 days and claims he was never hungry and never tired.’ That same Sunday, four publishers begged Tarnower to write a diet book. His ghost writer was Samm Baker. Tarnower gave him a diet sheet and some recipes. Samm gave him a book: The Complete Scarsdale Medical Diet. This appeared in early 1979, just after the Christmas eating binge. Readers had to stick to the diet for two weeks, then have two weeks off. Two weeks on the rigid Scarsdale diet must have felt like an eternity. But the public loved it. The book lasted 49 weeks as a bestseller and sold over 700 000 copies. By February 1980 Tarnower had started his second book: How to Live Longer and Enjoy Life More. How could he know that he himself would die within one month? The four bullets that killed Tarnower came from Jean’s gun. She was reportedly battling with methedrine withdrawal at the time. (Some wit actually claimed Jean shot Tarnower because she had not lost weight on his diet.) Her lawyers claimed she brought the gun to Tarnower’s house to kill herself there and that he had accidentally been shot when he tried to disarm her. The trial lasted three months. Although the drugs Tarnower had prescribed for her may have helped Jean’s case, the defence did not mention them. Her lawyer said: ‘I want to force that jury to choose either murder or acquittal — no compromise.’ In early 1981 the jury chose murder. Jean got the minimum sentence: prison for 15 years–to life. There she wrote the book Stranger in Two Worlds. Amazingly, she expressed no bitterness towards Tarnower: ‘There hasn’t been a day I haven’t mourned him.’ (GB)

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Chapter

EPIDEMICS

3

AND

DISEASES

CIVILISATION

OR SYPHILISATION?

For five centuries now syphilis has meddled in the politics, wars, literature and sex lives of the civilised world. With a little help from bed-hopping aristocrats, lonely soldiers and hard-pressed whores, it introduced the condom, the wig, antibiotics and . . . fear to European bedrooms. Civilisation and syphilisation have always been one and the same. — Andrew Nikiforuk

It is amusing that no country has ever wanted to own or claim syphilis. In Renaissance Italy, its popular title was the French disease, while the French called it the Italian or Neapolitan disease. Not only has syphilis had many names, there are still competing theories about when and how it first started in Europe.

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Some believe that Europe had syphilis long before the fifteenth century, and that what people in the Middle Ages called leprosy was actually syphilis or a close relative of the disease. Certainly syphilis could be confused with leprosy as both can disfigure the skin. Moreover, when leprosy disappeared from Europe (or at least from European writings), syphilis seemed to take its place. Some authorities read syphilis into Biblical references. For example, the penitent David, King of Israel, laments: ‘There is no soundness in my flesh, neither is there rest in my bones because of my sin. My wounds stink and are corrupt because of my foolishness. My loins are filled with a loathsome disease . . . ’ (Psalm 38: 3–7) Did Portuguese navigators import syphilis with the Negro slaves they brought back from Africa in 1442? Perhaps the most common view, and a popular one in Europe, is that the germ causing syphilis hitched a ride back from the New World inside the randy sailors who sailed with Columbus in 1492–1493. ‘Just as smallpox became the Old World’s calamitous gift to the New, syphilis was America’s biological surprise for Europe.’ To support this Columbian theory, an apparently new infectious disease broke out in Europe around 1493, very soon after Columbus’s return. Fifteenth-century syphilis could turn a healthy person into a leprous-looking mess in weeks and bury him within a year. The lucky ones died quickly. Despite the churches’ threats of eternal damnation for suicide, many sufferers killed themselves. The Italian poet and scientist Girolamo Fracastoro (Fracastorius, 1477–1553) was the first to use the word syphilis. His fictional hero, the shepherd Syphilus, was ‘smitten because he raised forbidden altars’ instead of worshipping Apollo. Fracastoro wrote his medical poem (Syphilis sive Morbi Gallicus) to warn readers of the disease’s venereal transmission — an early example of health education by the media. The brilliant sculptor Benvenuto Cellini, himself a victim, wrote: ‘In Rome, this . . . illness is very partial to the priests, and

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especially the richest of them (popes).’ Indeed, since syphilis affected many priests and popes, some simple people believed it could not be sexually transmitted. One chauvinistic medico simply blamed women: ‘This disease is contagious, chiefly if it chance through copulation of a man with an unclean woman.’ Another judgmental doctor wrote: ‘It (syphilis) begins in one of the most degrading and ignoble places in the body.’ Many medicos washed their hands of such patients, leaving them to the eager care of barbers, bath-attendants and quacks. The European syphilis epidemic hit the headlines in Naples. There the French army, reinforced by multinational mercenaries, was fighting to dislodge the Spanish defenders of Naples. Some of the Spaniards had sailed with Columbus to the New World two years before. Reportedly the besieged Spaniards drove the harlots out of the city to infect the enemy: an interesting use of biological warfare. Soon the French army of 30 000, led by King Charles VIII, captured Naples. But within a year syphilis forced the French to abandon the city. The French King Charles VIII himself died of syphilis aged only 28. Three centuries later the French writer Voltaire lamented: ‘France didn’t lose all she had won in this campaign. She kept the pox.’ The remaining mercenaries scattered to their own countries, spreading syphilis as they went. Within three years, the French disease had spread through France, Switzerland, Holland, Germany, England, Scotland and Russia. Sailors carried it to China, India, and Africa. By 1500 AD it was sweeping the known world. When a pope tried to expel 6000 prostitutes from Rome the citizens rioted. In Paris infected people faced the death penalty if they even talked to someone not infected. Though syphilis had become less virulent by the middle of the sixteenth century, it did not spare the famous. One report blames Cardinal Wolsey for giving syphilis to King Henry VIII by whispering in his ear, but sceptics suggest a more likely source of infection.

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Reportedly, Columbus himself died with syphilitic visions that he was ‘an ambassador of God’. Any list of people alleged to have had syphilis reads like a historical and artistic ‘Who’s Who’: Peter the Great, Catherine the Great and Ivan the Terrible of Russia, Albrecht Dürer, Pierre Charles Baudelaire, Francisco de Goya, John Keats, Napoleon Bonaparte, Franz Schubert, Paul Gaugin, Friedrich Nietzsche, Oscar Wilde and Randolph Churchill (Winston’s father). For centuries ‘a night with Venus meant a lifetime with Mercury’. But treatment with mercury was not a bed of roses. Sometimes it killed the germs that caused syphilis, but often it killed the patients. If syphilis did not remove their eyebrows, whiskers or scalp hair, mercury did. Shining pates made people an object of ridicule and ruined their love life — hence the popularity of wigs. Until the Wassermann test came along in 1906, syphilis remained not only hard to treat but also hard to diagnose. In 1909, after 605 failures, Paul Ehrlich produced his magic bullet, salvarsan, followed by the less toxic neosalvarsan. Now syphilis also became easier to treat. The advent of penicillin in the 1940s made treatment easier still. Even now, 50 years later, penicillin is still by far the most effective treatment for syphilis. Since the appearance of HIV/AIDS and the resurgence of syphilis, the latter has again become hard to diagnose and treat. The wheel has spun full circle. (GB)

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PLAGUE

IN

SYDNEY

On the morning of Friday, 19 January 1900, 33-year-old Arthur Paine was driving his horse-drawn van from Sydney’s Darling Harbour to a city warehouse, when he felt nauseated and giddy. After lying down at the warehouse, he unloaded his van and returned to the wharves. About four o’clock he was alarmed to feel a lump in his groin. At six o’clock he went home to bed. His wife called a doctor, who diagnosed bubonic plague! Paine lived near the corner of Windmill Street and Ferry Lane in the Rocks area. As was common at that time, the sewerage was defective. As well, the authorities found plague-infected rats around the wharf where Paine worked. Arthur Paine’s illness heralded the first major plague epidemic in Australia. The epidemic had spread slowly over seven years from South China and followed caravan and river routes to Hong Kong, then Singapore and Bombay. By 1900 it reached Europe, South Africa, the Americas and Australia. Plague hit Adelaide on 15 January 1900, Sydney on 19 January, Brisbane on 5 March, Fremantle on 5 April and Melbourne on 8 May. Sydney was the hardest hit. Infected rats on overseas vessels berthed at Darling Harbour invaded first the dockside area and then much of the city. At least 303 people caught the disease and 103 died. Not all doctors accepted that the plague organism spread from rats to fleas to man. Luckily, Dr John Ashburton Thompson, New South Wales Chief Medical Officer, was among those who did believe in the rat-flea-man chain. He asked Sydney residents to report any rise in the number of dead rats. In mid-February, many rats were dying at the wharf of Huddart, Parker and Company. Tests confirmed that the rats had indeed died of plague. Even before the plague, Sydney’s poor people were in ill-health. Lack of nourishment sapped their resistance to typhoid, smallpox,

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scarlet fever, measles, whooping cough, pneumonia, influenza and diarrhoea. Since 1850 returning gold-diggers and the rising population had triggered a boom in speculative building. Inner-city housing often lacked clean water and sewerage. Human waste ran along the street or open drains down to the harbour. Also attractive to rats were the heaps of filth and rubbish in many houses. Thompson described the dwellings as ‘places unfit for human habitation’. Billy Hughes, then state member for West Sydney, agreed: ‘The slums of London before the Great Fire could not have been any worse.’ In such miserable houses rats infected fleas and fleas infected people. Darling Harbour was the hub, not only of overseas and coastal shipping, but also of Sydney’s suburban transport. Here lived people at the bottom of the social heap: wharf labourers, seamen and unskilled workers. The wharves and nearby warehouses of hay, chaff, maize and potatoes attracted rats. The area between the wharves, Elizabeth Street and Central Station was the worst, but parts of Surry Hills, Waterloo and Botany were little better. The New South Wales government’s measures to curb the spread of the plague included quarantine of patients and contacts, immunisation, extermination of rats and closing and cleansing of the worst areas. Public Health doctors visited suspected patients to confirm the diagnosis. A nurse and ambulance took the patient and a wagonette took all contacts to the Woolloomoolloo Quarantine Depot. There they took a steam launch to North Head Quarantine Station. These transfers continued even in bad weather and sometimes in the dead of night. Over 1750 people were forcibly quarantined at North Head. Twenty-five-year-old Andrew Mills lived in Leichhardt. When he fell ill his fiancée pleaded in vain to the authorities that they let her nurse him herself. He died in quarantine on 2 April, the day he had planned to marry. The 200 patients who caught the plague but survived spent on average 45 days in quarantine. One man even had two terms there,

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first as a patient, then as a contact. Some contacts tried to avoid quarantine. One caught the express train to Goulburn, only to find police waiting for him there. A few did escape. When public immunisation started in early March 1900, the demand was overwhelming. People queued for hours, even standing on window ledges in the hope of receiving an immunisation. But after about 8000 injections the vaccine ran out. By the time more supplies came in May the epidemic was waning. Contacts could also ask for the vaccine, though most refused. But at North Head, all Chinese contacts were immunised, many against their will. In all, 10 700 people, about 10 per cent of the city’s population, were immunised. The Board of Health urged councils and residents to kill the rats. But instead, most of the effort at first was concentrated on general cleansing. He also pressed for a bounty for each killed rat. Reluctantly the New South Wales government offered twopence; soon it had to raise this to sixpence. Rat-killers carrying their haul to the Darling Island incinerator alarmed other passengers on trams. Crowds of bounty hunters flooded into the Leichhardt borough clerk’s office with their bags of dead rats! The government also appointed professional rat-catchers and issued free rat poison. But fumigating sewers with burning sulphur killed many of Sydney Harbour’s fish as well as rats. People devised other ways to wage war against rats. Some used dogs, sticks and firearms. In Melbourne they tried ferrets. Others baited a large trap on a wharf at night. ‘When morning came . . . the trap had captured two cats, but of course there were no rats.’ Officials killed over 108 000 rats, but residents killed many more. In late February council gangs started to clean up the city. When this enormous task proved too much, the State government stepped in. George McCredie, a capable engineer, took charge but did not issue the first area quarantine order until 23 March. Indignant newspapers blamed the delay on the colonial secretary, who allegedly owned a produce store within the infected area.

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Residents of quarantined areas could choose to go to North Head Quarantine or stay put. Those who stayed received six shillings a day. To allow them further income, McCredie gave locals the first offer of jobs in the workgangs. But many poor people were so desperate for work that they risked plague by moving from one quarantined area to the next. Gangs made house-to-house inspections, flushed and disinfected drains and water closets, cleansed 3800 premises and destroyed rats. They demolished some houses without notice and turned tenants out into the streets. Gangs burnt what they could of the rubbish. The rest went to the Moore Park Tip, or onto punts put out to sea. Around the wharves they dredged over 52 000 tons of silt and sewage. Nearby they also found dead sheep, pigs and fowls and nests of up to 30 rats, some killed by the plague. Suggested preventive measures ranged from the resourceful to the bizarre. Someone wrote: ‘. . . if the Fire Brigade hose had been turned on . . . the people in the quarantined area as well as on their premises, the cleansing would have been more complete.’ To prevent plague-carrying fleas jumping up onto their legs, many wore Metzler’s Protective Anklets. Others took bile beans, blood purifiers, Dr Morse’s Indian Root Pills and Colemane’s Eucalypte Extract. One sceptic wrote: ‘the best way to take most patent medicines is to take them out into the backyard and bury them.’ Like the great European epidemics, the plague of 1900 brought hysteria and panic. Those who could, fled their homes; many made ‘a mad rush to the Blue Mountains’. The other Australian colonies quarantined New South Wales ships and travellers, and boycotted Sydney goods. Churches held special services and declared a Day of Humiliation and Prayer. After the epidemic died out in late August the State government resumed land around Darling Harbour and the Rocks. In place of rotting wharves and decrepit houses, reformers built Hickson Road from Sussex Street to Dawes Point.

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Even today bubonic plague is still widespread in western USA, parts of Africa, Latin America and Asia. Can we be sure that Australia will never suffer another epidemic of plague? We have several things in our favour: better rat-proofing of international ships and better rat-control on wharves; fewer people living near the central wharves of our cities, and better health and living conditions. But there are no guarantees. (GB)

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COOLGARDIE’S

FEVERS

On Saturday, 17 September 1892, Arthur Bayley and Bill Ford walked into the Commercial Bank in Southern Cross, Western Australia and dumped on the counter 200 oz of gold. They had found it 200 km to the east of the town and until that moment had kept the news to themselves. But now the secret was out and the next day the dash was on for young and old, for this was the era of ‘gold fever’. However, it is not so much rags-to-riches stories with which I wish to regale you, but of the terrible privation and epidemic disease that was the lot of the starry-eyed and ever-optimistic digger. Michael Finnerty, the local mine warden who rode in the fore of the chase, established from the local natives the name of the adjacent rockpool (or gnamma hole as they called it), and anglicised the word to Coolgardie. An estimated 330 perspiring hopefuls were close behind him, a group large enough and rowdy enough for the local constable to send back for a couple of revolvers, a brace or two of handcuffs and a supplementary supply of official charge sheets. But water, or the lack of it, was the biggest problem faced by the diggers. Fortunately, at the time of the initial onslaught it was spring, so the soaks and gnamma holes had a fair supply of the precious stuff. But everyone knew the summer aridity of the area and it was unknown whether the idiosyncratic rainfall would be enough to sustain the camps. By November, 600 men were on-site, and due to rapidly diminishing water reserves, a gallon of the muddy liquid cost three shillings. The horses needed some too, of course, so precious little washing took place in the scattered tents. Sanitation facilities were non-existent, and care had to be taken where one trod. By early December with summer approaching, Finnerty was nailing notices on trees advising diggers to leave or suffer the consequences. But gold is a demanding mistress, and most thought that fame and fortune were just around the corner, so they hung on.

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That was until a case of the inevitable typhoid cropped up, sparking an exodus of all but about 120 diehards. Early rains brought the hopefuls back, together with the usual entrepreneurial hangers-on who set about establishing three licensed shanties, a brothel or two and a twice-weekly mail run. Thus there was a community feeling of camaraderie about the place. But once the men came, so did the typhoid, and to a place with no doctor and only an occasional wife to act as nurse. The nearest hospital was 350 km away at York. There was, however, a dentist, who doubtless was able to fill a few gaps. By September 1893 there were 4000 people in the town and a Dr Davies set up private practice among the hessian-walled hotels, and blacksmiths and butchers shops along Bayley Street. This was a thoroughfare of swirling red dust, fetid piles of animal manure, decaying refuse and a cacophony of snarling camels, snorting, thirsty horses and blowflies. What it did not have were the twin necessities of even elemental existence, namely a reliable water supply and sewage facilities. Clearly a major outbreak of disease could not be far behind. By mid-1893 the expected typhoid outbreak was in full swing, probably started by an infected person either handling food or befouling the water supply. There was no structure one could even loosely call a hospital until November when one sufferer brought his own tent which he set up behind Faahan’s Club Hotel on Bayley Street. Dr Davies and one nurse attended. The snag was that when the benefactor recovered, he took the ‘hospital’ with him. But a quick whip round the diggers plus some governmental help provided more crude cover. Then in April 1894, Matron Margaret O’Brien arrived from Adelaide with tents and some hospital-style furniture. She was a godsend, albeit a formidable godsend. In no time she had organised two tented hospitals adjacent to one another, one private, one government subsidised, and had enticed several nurses from the eastern states to come and help. All food was cooked on a communal camp stove, and, apart from nursing care, the only

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treatment that could be offered was sago or arrowroot mixed with condensed milk. Packing cases were used for coffins, and many went to meet their Maker with ‘This side up’, ‘Made in England’ or ‘Use no hooks’ stencilled on their wooden overcoat. The good matron was reimbursed £2.5 for each of the patients in the government hospital, and she charged £4 for her own private patients. The most precious commodity in town, water, cost her £20 per week. The nurses’ quarters were two rows of hessian tents, which, with grim humour, they dubbed Rotten Row and Piccadilly. For coolness the resting night nurse pulled her bed outside and lay on the bare springs, presumably fully clothed to maintain social propriety. Sick men were brought in from their solitary outlying campsites; if they were found, that is. Usually a notice was left on the tent flap saying the occupant had gone to hospital and not to touch his gear. Camaraderie was such that very few were robbed. It was one of the first examples of the legendary Australian ‘mateship’. Scores of infected men never made it to hospital, dying mainly of dehydration following high fever in an already stifling atmosphere and often alone in their camp. As a result, the final mortality figure will never be known, but between 1894 when the first incomplete records were kept, and 1900 when conditions were much better, 2454 cases of typhoid were recorded with 208 deaths. This amounts to an 8.5 per cent mortality rate. As many men had wandered delirious into the bush and were never found, the figure is probably underestimated by 50 per cent or more. In 1894, the worst year, the railway finally got through to Coolgardie, which meant that the sick could be evacuated and water brought in. Conditions then began to improve, and when the water pipeline arrived in 1903 the real pioneering days of gruelling hardship were just about over. But it was all too late for thousands of sufferers of both gold fever and typhoid fever. In those few years Coolgardie became known as ‘The Mecca of the West’ and the ‘Mother of the Goldfields’. The locals did not

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know it, but with the founding of Kalgoorlie by Paddy Hannan in 1893, its nemesis was at hand. There was gold aplenty in these new diggings, but Hannan did not benefit greatly as shortly after founding the town he fell victim to the fever himself. Nonetheless, Coolgardie had its moment of fame, for it was not only a clamorous, rip-roaring, rootin’ tootin’, hard-drinking prospecting frontier town, but also the site for one of the world’s greatest typhoid epidemics. (JL)

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WHAT

IS MORE LETHAL THAN SWORDS AND GUNS?

Swords and lances, arrows, machine guns and even high explosives have had far less power than the typhus louse, the plague flea and the yellow fever mosquito. — Hans Zinsser (microbiologist)

Over the centuries, epidemic typhus has been one of the great scourges of human history. Do you feel confused about the difference between typhus and typhoid? Join the club. Both are serious and infectious, but otherwise have little in common. Typhus comes on with headache, confusion, shivering and fever. About the fifth day a rash starts. The bad news is that typhus epidemics kill 10–30 per cent of those who catch it. There are several varieties of typhus, but all are caused by rickettsia (germs smaller than bacteria but larger than viruses). We now know that the bite of the human body louse is the means by which the most devastating variety (epidemic typhus) spreads from one human to another. That is not a cutting-edge discovery. A German doctor suggested this as early as 1606, but it took three centuries to confirm his theory. About 1909, Frenchman Charles Nicolle decided that to prove this he had to experiment on a human. Does this sound dangerous? You bet! How did he find such a brave subject? He experimented on himself! Yes, Nicolle survived to receive his Nobel prize. But not all biologists have been so lucky. In 1915, the Austrian Stanislaus von Prowazek, while studying the disease in prisoners, himself caught typhus and died. We now honour him by the name of the germ that causes epidemic typhus (Rickettsia prowazeki). What brings on epidemics or outbreaks of typhus? Anything that encourages lice to multiply and infest humans or anything that lowers our resistance to the disease, such as overcrowding, poor hygiene, poverty, starvation and poor health. The disease thrives on

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wars, refugees, prisons and ships. Since the louse loves to hide in thick winter clothing, epidemics are more common in winter. In 430 BC, during the war against Sparta, the Athenian historian Thucydides described an epidemic that may have been typhus or bubonic plague. Ever since, typhus has preyed on mankind. Spanish soldiers who had fought the Turks in Cyprus may have brought typhus back to Spain. A historian wrote: ‘At the beginning of 1490, 20 000 men were missing from the rolls, and of these, 3000 had been killed by the Moors and 17 000 had died of disease.’ Despite these losses, the Catholic forces of Ferdinand and Isabella prevailed, ending over seven centuries of Moorish rule in Granada. In 1528 French and Italian troops surrounded the imperial army of Charles V in Naples. Various diseases including typhus had swept through the defenders’ ranks. But then a typhus epidemic swept through the crowded, louse-ridden French camps and killed at least half the French soldiers. Had Naples fallen, European history would have been very different. As Zinsser wrote: ‘In 1530, Charles V was crowned ruler of the Roman Empire at Bologna, by the power of Typhus Fever.’ Even in peacetime, typhus did not rest. Most often it preyed on the poor, underfed, unwashed and literally lousy people. But even the upper classes were not fussy about hygiene. For instance, one of her subjects wrote admiringly of Queen Elizabeth I that she was so fastidious as to bathe once a month ‘whether she needed it or nay’. John Howard, the great English advocate of prison reform, himself died of typhus (also called Jayl Fever, Ship Fever or Camp Fever), caught on his tours of inspection. From the gaols, typhus sometimes spread to the courts. In 1750, after the ‘Black Assizes’ at the Old Bailey, it killed the Lord Mayor of London and 50 officials. A board of inspectors blamed the stench of the prisoners and called for better ventilation. Eleven workmen built a windmill to draw the foul air out of Newgate prison, but seven of them also came down with typhus!

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Not even Napoleon Bonaparte’s army could resist the devastation of epidemic typhus, dysentery and other diseases. These, combined with fierce battles, starvation and below-freezing temperatures, decimated his troops during the winter of 1812–1813. Of the half million who enlisted with Napoleon, only about 30 000 survived. Moreover, his retreat from Moscow brought lice and disease back to Western Europe. When the potato blight spread to Ireland, the 1840s became the ‘hungry forties’. Famine and disease joined hands to claim countless Irish lives; estimates vary from half to two million. About the same number emigrated; of these many started afresh in Australia. But typhus has also touched Australian history in other ways. Two months before the First Fleet sailed from England, a typhus epidemic broke out on the ships waiting outside Portsmouth. Aboard the Alexander, 16 convicts died. Typhus also contributed to the far higher death rate aboard the tragic Second Fleet. About one-third died on the way out, or within three weeks of landing. When the ships landed in Sydney, the Reverend R. Johnson found one convict who ‘had 10 000 lice upon his body and bed’. Even in the last century, typhus wreaked havoc in Australia. When the Emigrant sailed to Brisbane in 1850, typhus killed 55 passengers, the ship’s surgeon and even his replacement. Soon after, passengers from the Wanata spread epidemic typhus around the Victorian goldfields. During World War II, scrub typhus, a common variety in South-East Asia, affected Australian troops in New Guinea. Nowadays science protects people in developed countries against typhus. We have an effective vaccine, DDT kills lice, and for those who do catch typhus, we have effective antibiotics. But even today, typhus is still a threat to people in poorer countries. Professor Jonathan Mann of the World Health Organisation (WHO) may well have been thinking about typhus when he wrote that preventable illness, disability and premature death ‘are caused as much by societal discrimination, inequity and injustice as by viruses and parasites’. (GB)

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Chapter

FAMOUS

4

PATIENTS

WHAT KILLED GEORGE WASHINGTON? Had George Washington been a commoner, he would have seen far fewer consultants and probably would not have been bled to death for his sore throat. David Sackett

George Washington (1732–99) won his place in history as the father of his country. From a gentleman farmer with little military knowledge and a distaste for politics, he transformed himself into a victorious commander, the leader of a new nation, and its first President. First he led the Continental Army and won independence from Britain. Then he headed the convention that wrote the Constitution of the United States. Finally, he became its first President. At least twice, his doctors despaired of his life; in all, he survived about ten bouts of serious illness. From about the age of 30 he expected an early death. Did this spur him on to great achievement?

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Most of his life, Washington had active or dormant malaria. At 21, after visiting Barbados, he developed smallpox which left his face badly pitted. Soon after he had a ‘violent attack of pleurisy’, possibly tuberculosis caught from his half-brother who died of it. In 1757 he had violent fever and ‘bloody flux’ (diarrhoea) for months on end, which led his doctors to retire him from the army at 26. Four years later he was very ill for several weeks; it may have been typhoid. In 1775, Washington, the unanimous choice as commander-inchief for the War of Independence, made a major contribution to public health. A generation before Edward Jenner wrote his famous paper, Washington ordered inoculation against smallpox for all his troops. Before that, smallpox used to kill far more soldiers than bullets. God must have been an American; during the whole eight years of that war, Washington suffered no serious illness, casualty or accident. But the war did age him. After the British finally signed the Treaty of Paris, he said: ‘I resign with satisfaction the appointment I accepted with diffidence.’ Shortly before Washington became President, malaria struck him down again. This time his friend Dr James Craik prescribed cinchona (‘Jesuit’s Bark’) with great effect. Next Washington endured a large ‘malignant carbuncle’ which was thought to be anthrax. Though the doctors opened it, he very nearly died. Yet even in his early sixties, he hunted ducks, geese and turkeys. At 62 he injured his back while trying to save himself and his horse from falling among the rocks at the Lower Fall of the Potomac. After his second term as president he refused a third. In 1798 he lost 8 kg with a fever that required cinchona again. This treatment may have worsened Washington’s deafness. On 12 December 1799 there was rain, sleet, snow and wind, but as usual, Washington rode about his farm at Mount Vernon. The next day he had a sore throat and became hoarse. At 3 am on the third day he became breathless and could barely speak, but would not allow his wife to call anyone.

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At dawn they tried to give him molasses, butter and vinegar, which just made him choke. Washington asked the farm overseer to bleed him. Then they wrapped flannel soaked with sal volatile around his neck and bathed his feet in hot water. Next Dr Craik applied hot packs of cantharides (Spanish fly) to Washington’s throat and took more blood. A gargle of vinegar and sage tea nearly suffocated him. After he tried to inhale vinegar in hot water, they bled him again. Washington was worse by the time Dr Elisha Dick arrived. The latter suggested tracheotomy (cutting an opening into the windpipe to ease his breathing) and opposed further bleeding: ‘He needs all his strength; bleeding will diminish it.’ But Dick was the most junior of the doctors, and the other two overruled him on both counts. Having drained more blood, they found not ‘the smallest alleviation of the disease’, but the blood came ‘slow and thick’. No wonder! In all, they drained about half of his total blood volume. This might have killed a younger, fitter man. Somehow the poor patient swallowed repeated doses of calomel and tartar. For a while Washington persuaded his doctors to leave him be. He even sat up in bed and discussed his will, in which he freed his 100 slaves. About 8 pm they applied more blisters to the throat and wrapped his legs and feet in poultices of wheat bran. At 10 pm he became quieter, and at 11.30 pm, after an illness of only two days, the great man died. Though Washington had his critics, a grateful nation had already named the new federal capital in his honour. The House of Representatives heard his epitaph: ‘First in war, first in peace, and first in the hearts of his countrymen.’ In France, Napoleon Bonaparte ordered ten days of mourning. As a statesman, Washington showed more commonsense than eloquence; as a general, more willpower and courage than grand strategy. But many attribute the American victory over the British to his personality. Thomas Jefferson wrote: ‘His mind was great and powerful . . . no judgment was ever sounder . . . never did nature and fortune combine more perfectly to make a man great . . .’ Washington’s

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doctors were baffled when it came to the cause of his death. At first they determined it was quinsy (abscess of the tonsil), but later changed it to Cynanche trachealis, an indefinite term for the various airway inflammations that we now call tonsillitis, croup and so on. The ear, nose and throat specialist Dr Wells of Washington, DC also backed an infection causing obstruction of his airway. He pointed out that none of his doctors seems to have looked inside his throat. They probably would not have had adequate artificial light to do so anyway. George Washington’s doctors were the well-trained, elite professionals of the time; it is unfair to judge them with the wisdom of hindsight. Even now we cannot be sure what really killed George Washington. (GB)

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TWO

PAIRS OF HISTORIC LEGS

While Arthur Phillip, captain of the First Fleet which carried convicts from England to Australia in 1788 was making his way to Sydney Cove, the rest of the world neither held its collective breath nor stopped the even tenor of its ways. Births, marriages and deaths in the Motherland ground on with relentless predictability. Among the notices for these that year were two which I think deserve a second look, especially in respect of their lower limbs. In Britain’s Annual Register of 1788 on page 24 there appears a brief obituary. In part it states: He was an interesting converser; he had cultivated literature and was fond of art. In the pecuniary parts of character, happy he who can be as liberal.

Despite the quaint English, this paragon was not, as you may think, a beloved benefactor. No; he was one of those most pragmatic of men, a surgeon — Percival Pott. In his day he had been principal knife man at St Bartholemew’s Hospital, London (founded in 1123 and still going strong), and became the source of the eponymous title of a couple of well-known medical conditions: Pott’s fracture of the ankle and Pott’s disease of the spine. Time has allowed us to forget his social graces and has left only the memory of his two classic dissertations and one remarkable incident in his life, the remembering of which still makes the modern surgeon tremble when faced with the prospect of being treated by a fellow surgeon. For Pott broke a leg in a riding accident and was subsequently operated on in unusual circumstances. The story goes that in 1755, while riding on the Old Kent Road, London, Pott was thrown from his horse and sustained a compound fracture of the tibia. Regrettably for the tale, it was not the variety of fracture which later came to be known as a ‘Pott’s fracture’. Nor was it the inspirational moment when the special

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nature of that injury was first revealed to Pott. That did not come until 14 years later. But it was in the same anatomical area, and with the bone sticking through the flesh, it did not need a surgeon to recognise that here was a pretty nasty injury. He refused to be moved off the busy thoroughfare until two chairmen had been summoned. Then he sent for a door to be purchased, had the chairmen nail their poles to it, and was eased onto the contraption. It must have taken some time and it all sounds very painful. Guy’s Hospital was a mere 400 m away from where he lay, but such was the rivalry between his institution and this one that Pott elected to put up with the considerable discomfort and be carried past Guy’s, over London Bridge and a kilometre or more further on to his house in Watling Street. Once home, several of his colleagues were summoned, and after much pursing of lips and furrowing of brows the then standard treatment for such injuries, amputation, was deemed inevitable. But once the senior surgeon, Edward Nourse, arrived, he thought otherwise and with no more anaesthetic than a shot of spirits and a bung between the teeth, heaved the malalignment back into place. That Pott managed to avoid tetanus from the horse manure at the site of the accident was his and our great good fortune. The operation may have been a sickening orthopaedic tour de force, as well as a close call for the limb, but Pott put his convalescence to good use by writing a treatise on hernias, said to be his best work. Tuberculosis of the spine with humping of the back, or Pott’s disease, is seldom seen now, but a break of the fibula bone with dislocation of the ankle, or Pott’s fracture, I suppose will always be with us. If it falls to your lot to sustain that particular injury, I hope it is some comfort to know that its eponym’s suffering was infinitely greater than yours is ever likely to be. In the year of Pott’s death, 1788, was born a man who in his heyday was said to be ‘bad, mad and dangerous to know’ — Lord

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George Byron. It is not his literary skills, nor his well-known amorous nature, nor even his early obesity that concerns us here, but he is bracketed with Pott on account of his diverting leg and foot deformity. His childhood obesity may have been significant as far as weight on his gammy leg is concerned, for Lord Byron was a fat child who was treated with indifference by his fat mother. At the age of 18 he was 91.6 kg, and depressed with it. He dieted, binged then vomited, used laxatives, exercised and played cricket in several waistcoats and a greatcoat to sweat off the kilos. As a result, he did eventually get down to 62 kg. By continuing self-discipline, especially in view of the well-to-do social circles in which he moved, Byron continued to limit his food intake for years and in adult life refused most dinner invitations. Despite this and other idiosyncracies, what has really fascinated people over the last 150 years or so is the nature of his well-known limp, for which no firm diagnosis has ever been made. Indeed there is even disagreement as to which leg was affected. Byron’s bootmaker said only the left was affected, while his mother had it on the right, and a friend present at his death claimed both. Surely the truth lies in Byron’s two boots still in existence, now in the possession of the publishing firm John Murray. But unfortunately both fit the right foot. One was made for Byron when he was 11, and the other when he was 18. They are wedged along the entire length and raised about 1 cm on the outer side, indicating a minor inward turning of the foot. It is popularly thought that the poet had a club foot, but apart from being very narrow, the inside of the boot is essentially normal, so I think that can be ruled out. Further, (and this is the interesting bit) it seems his calf was markedly thin, for there is padding in this area within the long boot, a stratagem which would give the appearance of a normally fleshed out calf under the trousers. Descriptions of his gait give the clue. It is on record that Byron moved with a sliding movement on the balls of his feet. On entering a room he would attempt to hide his disability by running

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on tiptoe rather than walking, then he would rest with one foot on top of the other. If that were so, it rather sounds as though such an eccentricity would actually draw more attention to the deformity than if he had merely walked with a limp! However, he may not have been able to help this odd tiptoed gait on account of the pathology of the leg. He could have had either a fairly mild form of spastic paraplegia from a lesion in the brain following birth injury, or, more likely, a wasting disease of the muscles of the lower leg with a drop deformity of the feet causing him to walk on the toes. I have in mind the rather rare condition of peroneal muscular atrophy. In this malady of combined nerve and muscle disease, the calf wastes until eventually the leg looks like an inverted Indian club or upended champagne bottle. It is a local lesion and the rest of the body is unaffected. Usually it occurs in both legs, so we may have been put off all these years by the possession of only right boots, and his friend may have been correct, that both legs were affected. I suppose poliomyelitis, wasting one leg in a characteristically patchy way, is another possibility. In none of these conditions is the intellect impaired. Byron was certainly a bright man. Nonetheless he was distressed by his lameness for he was extremely self-conscious, constantly striving to keep his weight down. He was vain too, and not above putting his greatly admired golden hair in curlers each night to impress the ladies. Moreover, the padding in his boots would hide the wasting and help relieve the sensitivity he felt about his deformity. The disability did not completely incommode the poet, for he played cricket for Harrow against Eton in 1805, their first-ever encounter, and scored 11 and 7 for the losing side. Although granted a runner, he must have been a pretty good performer to have been selected with such a disadvantage. George Gordon Byron, the sixth Baron Byron of Rochdale, was 36 when he died. He was spared the progression of a wasting malady, if indeed that was his complaint.

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Both Byron and Percival Pott were touched by greatness, albeit in quite different spheres, and I suppose Lord Byron spoke for them both when he wrote in his, well, Byronic way — Eternal summer gilds them yet But all, except their sun, is set.

(JL)

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HOW ISAAC NEWTON

LOST HIS

MARBLES Newton became mad . . . twice he suffered periods of prolonged abnormal behaviour, bordering on psychosis. — Harold Klawans

When Isaac Newton was born in 1642 his father had already died. From a tiny premature baby, he became a delicate child. When his mother remarried, three-year-old Isaac was shunted off to his grandmother. He was doing badly at school until an attack by a bully stimulated Newton to shine scholastically. A schoolmate recalled, he was ‘always a sober, silent thinking lad . . . never known scarce to play with the boys abroad’. He must have been insufferable. When he left school, the servants were also glad to see the back of him, declaring that he was ‘fit for nothing but the ’Versity’. Indeed, at 18, Newton qualified for Trinity College, Cambridge. By 23, he had pioneered differential and integral calculus, though he did not publish his discovery for over 20 years. This delay led to a long, bitter dispute with the German mathematician Gottfried Leibniz. Perhaps Newton had got there first, but Leibniz certainly published first. Newton was so sensitive about scientific dispute and criticism that his friends always had to plead with him to publish even his most valuable discoveries. John Flamsteed, the first Astronomer Royal, called him ‘invidious, ambitious and excessively covetous of praise, and impatient of contradiction’. When still only 27, Newton became professor of mathematics and physics at Cambridge. He would sit on his bed half-dressed for hours at a time. A reclusive hypochondriac, often preoccupied with death, he had few amusements, no obvious enjoyment of life and never married.

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But much later, about the age of 57 when he moved to London as director of the Mint, Newton became a most efficient administrator. Queen Anne thought herself lucky to have known so great a man and knighted him. His achievements included the three laws of mechanics that transformed physics, the laws of gravity and his theory of planetary motion. At 83, he started to get acute attacks of pain, perhaps from heart disease. A few weeks before his death, the pain left him and he died peacefully in 1727. The biographies written during the next hundred years were based directly or indirectly on information collected by the man who had married Newton’s niece. But in 1820 the French astronomer Jean Biot set the cat among the pigeons by stating that for much of 1692–1693, Newton had suffered a ‘derangement of the intellect’. Moreover, Newton also had an earlier breakdown during the 1660s. So we are dealing with a unique genius who was odd, absentminded and quarrelled with many people. On top of all that, he had two periods where he went mad but recovered. We are not talking of Alzheimer’s disease or the dementia of later life. Newton recovered his wits, recognised that he had been unwell and again worked effectively. What caused his two attacks? During the second episode (1692–1693), Newton lost his memory, could not sleep, went off his food and felt depressed. He became even more withdrawn than usual and had the delusion that people were persecuting him. In 1693 he wrote to his friend the diarist Samuel Pepys (1633–1703): I am extremely troubled at the embroilment I am in, and have neither ate nor slept well this twelve months, nor have my former consistency of mind . . . I must withdraw from your acquaintance, and see neither you nor the rest of my friends any more . . .

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Pepys recognised that his friend was disturbed. These days even Newton’s supporters accept this. But what made him lose his marbles? Some blame Newton’s breakdowns on the various stressful events in his life. His first breakdown in the 1660s came around the time that he published his theory on the composition of white light. This caused academic dispute, which Newton hated. Or was it exhaustion from writing his Principia? Perhaps the fire that destroyed his records of years of chemistry experiments? Was it sexual frustration? Some reports say Newton carried his virginity to his grave. One psychiatrist wonders about repressed homosexuality, while others back manic-depressive illness, now called bipolar mood disorder. Another medical writer blames Newton’s madness on an infection of the gut or chest, with vitamin deficiency. But in 1979 two articles in the Notes Recods of the Royal Society of London diagnosed mercury poisoning. For many years Newton worked on alchemy (the transmuting of base metals into gold). He experimented with antimony, iron, tin, bismuth, lead, copper, arsenic and especially mercury. On his fire Newton often heated these metals to convert them into a gas. Not only did he inhale the fumes, but sometimes he even tasted the products. Some experiments took hours, and a few took days. During this work he often slept in his laboratory by the very same fire. If twentieth-century doctors were now seeing Newton, they would look for poisoning by checking his blood and urine. Instead Spargo and Pounds tracked down several locks of Newton’s hair and found an excess of not only mercury, but also gold, arsenic, antimony and lead. What is the bottom line? Though lead may have played some part, the likeliest cause of Newton’s madness is mercury poisoning. But as already outlined, not all writers accept poisoning as the cause of Newton’s attacks of madness.

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What we do know is that despite his attacks, Newton was the greatest intellect of his day. Albert Einstein said that without Newton’s discoveries his own work would have been impossible. Newton’s concepts ‘are even today still guiding our thinking in physics’. (GB)

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THE

GROSS DISABILITIES OF HENRI TOULOUSE-LAUTREC AND ALEXANDER POPE Watching the Paralympics we marvel at the athleticism of amputees, the visually impaired and the like. But rising to the top by the physically disabled is not new. Take for example two grossly deformed individuals who have remained famous and highly regarded for their artistic endeavours despite, or perhaps because of, their disabilities. I refer to Henri Toulouse-Lautrec, the nineteenthcentury painter, and Alexander Pope the eighteenth-century wit and writer. Count Henri Marie Raymond de Toulouse-Lautrec Montfa, to give him his full handle, was born in 1864 to a French aristocratic family which could trace its antecedents back to Charlemagne. His parents were first cousins, a consanguinity which may have been significant with regard to his condition, although there was no congenital deformity in the family. As a child Henri was alert and cheerful and, being the heir to the dynasty, pampered and indulged. At age five it was observed the fontanelles, or spaces between the skull bones present at birth, had not closed, though in truth much more notice was taken of his precocious sketching talent than any anatomical anomalies. Going on to the lycée he won many prizes, even though the margins of his books were filled with drawings of animals. On his thirteenth birthday he measured 4 ft 111⁄2 inches (151 cm), about average for his age. And then on 30 May 1878, aged thirteen and a half, Henri slipped on the polished floor of the drawing room and broke his left femur. It was encased in plaster and healed, but in August 1879 he fell while out walking and this time fractured his right thigh. This took much longer to unite and he was bedridden for six months. Thereafter he grew no more than 3⁄4 of an inch until by 18

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his adult height was 5 ft 1⁄2 inch (153 cm); small but not a dwarf. His trunk was normal but his legs were short. He needed a stick and his stiff knees and hips forced him to walk with a waddle. It is now thought that while the fractures were incidental to his growth defect, they were all part of an autosomal recessive condensing bone disorder called pycnodysostosis, derived from the Greek meaning a defective density of the bones. The malady is characterised by reduced stature, radiological evidence of density of fragile bones, malformation of the collarbone, short and wide feet and hands, underdeveloped jawbone with receding chin, overhung by a thick lip and failure of the skull bones to close properly. Toulouse-Lautrec fits the bill completely. While he had remarkably few fractures considering his pathology, Yvette Guilbert of his Moulin Rouge days once pointedly remarked: ‘What comical little hands.’ The painter went on to lead a dissolute life in Montmarte, drinking heavily and mixing with and sketching the local demimondaine, midinettes, chanteuse, circus artistes and the like. He caught syphilis from the improbably named Rosa la Rouge, and in 1899 an attack of delirium tremens saw him admitted to a private asylum where the subterfuge of a hollow walking-stick allowed him to maintain his alcohol intake. In September 1901, after several strokes, Toulouse-Lautrec died aged 36. Not quite regarded as a genius, he is remembered as a talented artist who found the accepting and uncritical inhabitants of the seamy side of Paris more tolerant of his disability than conventional society. In turn, purveyors of the low life saw him as a convivial and generous, if somewhat quaint, companion. Among them he was able to freely pursue his unique art to leave a legacy we still enjoy today. Alexander Pope was born in 1688. He became a literary giant whose main weapon was an acerbic wit said to have been sharpened on the whetstone of malice. His haunting fear was that someone, somewhere, may have been happy.

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Pope was born with a marked scoliosis, or a lateral curving of the back, and grew up a sickly child. Both parents were 46 when he was born, probably significant as regards that deformity, but which had nothing to do with the severe kyphosis, or humping of the chest part of the back, which he developed when 12. These marked deformities were with him for the rest of his life. Indeed, he used to describe his existence as: ‘This long disease, my life.’ The gross dual lesions stunted his growth and Sir Joshua Reynolds described the adult Pope as, ‘. . . about 4 ft 6 in (137 cm) high, very humped back and deformed . . . very large and fine eyes’. Samuel Johnson said of him: His stature was so low that to bring him to table it was necessary to raise the seat. One side was contracted and his hair had fallen almost all away.

To flesh out his legs, Pope wore three pairs of hose, and such was his weakness that a maid had to help him dress and lace up the stiff canvas corset he wore to keep himself upright and support his pathetic frame. Presenting as a dwarf with both a congenital and an acquired spinal deformity raises the question . . . from what did this genius suffer? Gargoylism is ruled out as he had no mental deficiency and his face was normal. With no blue sclera or fractures, osteogenesis imperfecta is unlikely. Rickets due to vitamin D deficiency is possible, but contemporary portraits do not show the classic ‘brow of a philosopher, legs of a grand piano, and abdomen of a poisoned pup’. Tuberculosis is the likely cause of the kyphosis or, just maybe, the whole represents the inherited disorder osteochondrodystrophy or Brailsford-Morquio syndrome, a progressive deformity of the long bones. It is a very rare condition and fewer than 100 genuine cases have been recorded.

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When the wit developed cardiac asthma, in vain he consulted a variety of fashionable charlatans declaring, ‘I am dying from a hundred good symptoms’. Alexander Pope died in 1744 aged 56 regarded by all as an irascible, pernickety and waspish man of whom Johnson observed, ‘He could hardly drink tea without a stratagem’. Like Toulouse-Lautrec, Pope’s terrible deformities had no effect on his intellect, and he is remembered today mainly for his pithy aphorisms such as ‘Fools rush in where angels fear to tread’, ‘A little learning is a dangerous thing’, and, poignantly perhaps, ‘Hope springs eternal in the human breast’. (JL)

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FANNY BURNEY’S

BATTLE WITH BREAST CANCER

Several centuries before Christ, the Greek physician Hippocrates was already teaching students about ‘karkinoma’ or malignant tumours, especially those of the breast. For many centuries the only treatment was surgery, which in the days before anaesthetic and antiseptics was always agonising and often fatal. This brings us to Fanny (Frances) Burney (1752–1840). Long before the days of women’s lib, she wrote a successful novel, Evelina, or the History of a Young Lady’s Entrance into the World. But the downside was that Fanny had to publish anonymously. Later she became second keeper of the robes to Queen Charlotte. At Windsor, she wrote her famous diaries, loyally omitting all mention of the madness of King George III. While Fanny was visiting France in 1802, the renewal of the Napoleonic Wars forced her to stay on for ten years! In 1810, at the age of 58, she first noticed a pain in her right breast but, like too many women even now, just hoped it would go away. Finally she did see Antoine Dubois, obstetrician to the second wife of Napoleon. Dubois said nothing to Fanny but did tell her husband she should have a ‘small operation . . . to avert evil consequences’. Since Dubois was busy awaiting the birth of Napoleon’s son, he also called in the famous army surgeon Dominique-Jean Larrey. At first poor Fanny’s doctors were optimistic but later they found a ‘change for the worse’. She must have felt totally confused. To ease her anxiety they said they would give her only four hours notice of her operation! She wrote her will. ‘I was in hourly expectation of a summons to execution; judge then, my surprise to be suffered to go on full three Weeks in the same state!’ Later, Fanny heard that Dubois had delayed the operation because he felt that her cancer was incurable. Finally a message came giving her only two hours’ notice and asking her to get her husband out of the house. Fanny herself had

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to prepare a large room: ‘The sight of the immense quantity of bandages, compresses, spunges, Lint — Made me a little sick.’ Then came word that she had to wait another two hours. Finally seven men in black stormed in: five doctors and two students. Larrey was pale as ashes. Through the handkerchief he placed over her face, she saw the glitter of polished steel. Though no one told her, Fanny guessed that they planned to remove her whole breast. She prided herself on being a good patient: ‘I bore it with all the courage I could exert, and never moved, nor stopt them, nor resisted, nor remonstrated, nor spoke . . . ’ Later she wrote to her sister: When the dreadful steel was plunged into the breast . . . I began a scream that lasted unintermittently during the whole . . . incision . . . I almost marvel that it rings not in my Ears still, so excruciating was the agony . . . But when again I felt the instrument — describing a curve — against the grain, then indeed I thought I must have expired . . . The instrument this second time withdrawn, I concluded the operation over — Oh no! Presently the terrible cutting was renewed — and worse than ever . . . I felt the knife rackling against the breast bone — scraping it! This performed, while I yet remained in utterly speechless torture, I heard the Voice of Mr Larrey, in a tone nearly tragic, desire every one present to pronounce if anything more remained to be done. The general voice was Yes . . . again began the scraping! . . . My dearest Esther, not for Days, not for Weeks, but for Months, I could not speak of this terrible business without nearly again going through it.

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After her ordeal, Fanny did very well. She lived another 29 years, dying back in England at 88. One author attributes her longevity to her daily cold sponges and careful diet. But I wonder whether she actually had cancer in the first place? Did she need surgery at

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all? In fairness to Fanny’s doctors, they had to make their decision long before the days when they could examine pieces of tissue with a microscope. Had she lived a century later, she would have enjoyed the benefit of accurate diagnosis and, if an operation became necessary, the comforts of anaesthesia. But Fanny might also have been advised to have a radical Halsted-type mastectomy (removal of the breast and also other tissues). Towards the end of the nineteenth century, the pioneering American surgeon William Halsted followed a series of women on whom he had done this operation. Over half of these women (up to three years after surgery) were still cancer-free. By the standards of the times, these were very good results. Until the 1940s and 1950s, some surgeons were still advising women to have mastectomies even more radical than Halsted’s. But since then, with new therapies becoming available, the pendulum has swung towards less radical surgery. In 1963 Dr Hugh Auchincloss of Columbia University condemned extensive surgery as being based on tradition, training and ‘personal prejudice tinged with emotion’. Be that as it may, even now, almost two centuries after Fanny Burney’s ordeal, breast cancer continues to devastate too many women. (GB)

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TWO

FAMOUS SKINS

The skin is the biggest organ in the body, but apart from Job and his boils, it rarely seems to rate a mention in the literature of medical history. Maybe people are too sensitive about their personal appearance to have some historian tell of any blemishes. Perhaps it has not got the dramatic impact of some obscure pathology which is more worthy of recording. But whatever the reason there are two well-recorded instances of dermatitis amongst the famous. In one case it killed its distinguished sufferer, albeit indirectly, and in the other it brought him close to death. Jean Paul Marat was born in 1743 in Switzerland. He qualified in medicine in Bordeaux and became a highly sought after doctor in London. He returned to France where he wrote several scientific papers and built up a practice among affluent middle-class and aristocratic patients. Despite earning a living from the ills of top people, he had a social conscience and harboured revolutionary fire in his belly. So he abandoned the comparatively leisurely life of medicine, and turned on the hands that fed him, to take up politics and become a vocal and fiery advocate of the emerging Revolution. Such was the vitriol of his publications that he was forced to hide in the sewers of Paris where, it has been said, he contracted the loathsome skin disease which would make his life such a misery. He eventually emerged into the full light of public approbation to become a member of the National Convention where, in a nicely turned quasi-medical phrase, he advocated, ‘the gangrene of the aristocracy and bourgeoisie should be amputated from the State’. But his skin is our main concern. What did he have? No firm diagnosis has ever been made, though we know he had to spend many hours in a hot bath to relieve the relentless irritation. The contemporary diagnosis was scrofula (a form of tuberculosis of the skin), and it was written that ‘a suppurating tetter ran from scrotum to perineum and maddened him with

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torment’. Apparently the skin was blistered and had open running sores and was accompanied by headaches, insomnia and insatiable thirst. It must have been an unedifying sight. Thomas Carlyle, the Scottish historian, essayist and general sage, thought it to be syphilis, but that would not have been relieved by bathing. Atopy, the rash commonly associated with asthma and other allergies, is mainly evident in children. Scabies comes to mind, especially in view of his subterranean habits, but from the description was too severe. In view of the polydipsia, or increased thirst, diabetic candidiasis (a fungal infection) is an attractive possibility as the two conditions commonly go together, but he survived too long. It was too itchy for seborrhoeic dermatitis, though it did occur in one of the usual places, and he was too young for pemphigoid, a severe blistering occurring in advanced years. This list of possible diagnoses is not exhaustive and the lesion could have been caused by a variety of reasons, but with its blisters, unremitting itch, site and disabling nature, perhaps the front runner is the rare dermatitis herpetiformis. A biopsy would have been handy, but this technology was in the future. What is certain is that the distemper was persistent, debilitating, irritating and defied cure by any of the contemporary methods of treatment. At the time of Marat’s ghastly political excesses, there lived in Caen, northern France, 24-year-old Charlotte Corday. Horrified by his policies, she journeyed to Paris and bought a long knife with the object of doing the rabblerouser in. On 13 July 1793 she went to Marat’s house on the pretext of seeking his protection. As usual Marat was trying to relieve his fearful itch in his slipper bath; pens, ink and paper before him on a board balanced across the sides. He wore a hot compress wound round his head concealing his hair. As he was not averse to seeing supplicants in his bath, Mademoiselle Corday gained entry and submitted a list of his opponents hiding in Caen. Marat replied that their heads would fall and started to write a list, whereupon the young woman drew the

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knife from her cleavage and plunged it in the naked chest below the clavicle. It pierced the aorta. Jean Paul Marat died immediately, with the blood-stained list in his hand. The moment has been dramatically captured in David’s famous Neoclassic masterpiece The Death of Marat. Charlotte gave herself up and was promptly guillotined. Marat, already styled ‘Friend of the People’, was held to be a martyr and his body exhibited, together with bathtub and inkstand, for all to see and grieve over. His heart was placed in an urn suspended from the ceiling of the Cordeliers Club. Such was his popularity, 21 towns in France came to be named after him! Skin lesions are rarely fatal, but if he had not been attending to his troublesome malady, none of this may have taken place, or at least he would have been better able to defend himself. Our second notable patient’s skin lesions were more severe and life-threatening than those of Marat. Despite that he survived. In his autobiography the sublime actor Laurence Olivier gives a first class run-down of his dermatological problem. It seems that in 1974, at the age of 67, he and his family went on holiday to Positano in Italy. After swimming he noticed some backache. Over a few days the pain spread to his neck and shoulders, then down the arms and eventually to the hips and thighs. On returning home he consulted an osteopath who put it down to a ricked back. The discomfort, however, persisted and was augmented by strange things happening to his skin. Olivier describes it as ‘an acute sort of dryness, and before I knew it my face was swelling up all over’. Both eyes were buried in the accumulated fluid or oedema, ‘through which they could be seen to peer like boot buttons’. Even more bizarre, the outer part of his fingernails began to get sore. Baron Olivier of Brighton, to give him his full title, then consulted an experienced physician, Dr Joanna Sheldon, whom he describes as ‘a very handsome woman’. Be that as it may, after some thought she pronounced it to be dermato polymyocitis, telling the alarmed actor it could be fatal and to be prepared for six to nine months stay in the Royal Sussex County Hospital.

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Having looked up the books, let me tell you the condition is a distinctly rare autoimmune disease and related to two other pretty uncommon but generally better-known maladies: lupus erythematosus and scleroderma. The oedema contains mucin and there is much damage to small blood vessels. In more than 40 per cent of cases it precedes a cancer of some kind. In 34 per cent the malignancy occurs first, and indeed in 1967 Olivier had been treated for prostatic cancer by radioactive cobalt. Large doses of steroids were administered to the actor, and later, on account of mental side effects, the immunosuppressant drug Immuran. Such was the severity of the illness, that for some time there was concern that the good baron might expire, but eventually he turned the corner and slowly improved. It left him so weak he could not lift his arms, let alone walk. After eight weeks physiotherapy was started and eventually after four months in hospital he was allowed home. It is difficult to imagine the man we remember as that fine, athletic Henry V and Hamlet being so incapacitated. His recovery was complete, though he took a maintenance dose of steroids until his death in 1989. This continued treatment enabled Lord Olivier to go on and take part in another 15 films, though I suspect that the vast majority of his adoring audience were quite unaware of his life-threatening disability. It is often claimed by their envious medical colleagues that dermatologists have a well ordered and anxiety-free life. Their patients, it is said, never present as a hectic emergency, never recover and never die. As we have seen, this is not always the case. (JL)

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VIVIEN LEIGH,

PHANTOM OF DELIGHT

She was a phantom of delight when first she gleamed upon my sight. A dancing shape, an image gay, To haunt, to startle and waylay. — William Wordsworth

A besotted critic quoted these lines when writing on one of the great actresses and beauties of the twentieth century, Vivien Leigh. And I am sure he was right. Beauty is an intangible quality which defies ready interpretation; it is perhaps best left as the old inadequate escape, ‘I cannot put my finger on it, but I know it when I see it’. The film producer Sydney Box rather stuffily regarded beauty as merely a perfection in the relationship between the eyes, the forehead and the bridge of the nose. A bit cynical for such an arresting characteristic. Yet for something which is supposed to be in the eye of the beholder, it is odd that there seems to be a general consensus as to who is at the very top of the select pile. In the 1940s and 1950s the list consisted of such classic beauties as Elizabeth Taylor, Ava Gardner, Grace Kelly and a small band of others including, of course, Vivien Leigh. Indeed such was Vivien Leigh’s appeal that in her prime Winston Churchill, having invited her to dinner at Chartwell, was reduced to unaccustomed silence during the meal. When asked to explain, he stated he just wanted to look at her and admire her at close quarters. Lucky him. However, despite her alluring appearance, medically all was not well with Vivien Leigh. Born Vivian [sic] Hartley in 1913 in India, her mother was a beautician, who, together with her father, led a bohemian life, with a somewhat ‘open’ marriage. The convent-educated young daughter

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wished to become an actress, so to be trained properly, she sailed for England to attend the Royal Academy of Dramatic Art. Hence her subsequent considerable acting skill was acquired in the usual way, although doubtless her beauty was a handy adjunct. In 1932 the actress married barrister, Leigh Holman; it was his first name that she took as her stage name, and altered the spelling of her first name at the same time. A month before her twentieth birthday in 1933, Mrs Holman was delivered of what was to be her only child, Suzanne. It was in 1934 that Leigh saw the then current British matinee idol, Laurence Olivier, for the first time on stage. As soon as she clapped eyes on the actor she confided in a friend that this was the man she would eventually marry. Olivier and Leigh met the following year and began a rather public and steamy love affair. As both were married to other people at the time, it caused quite a scandal, but they stuck it out and went on to make several films together. Miss Leigh’s most famous role was in the 1939 Gone With The Wind. Though lionised for her looks, at all times she wished to be thought of primarily as an actress rather than a towering beauty. She was known for her vivacity and a hectic lifestyle of late nights, partying and some drinking, but the health of the actress was never in question. And then in 1944, while appearing in a play called The Skin of Our Teeth, it became apparent to all those touring with her that Vivien was rapidly losing weight and tiring easily. While performing in Liverpool a cough developed and tuberculosis was diagnosed. She was advised to follow the standard treatment for the times: a lengthy stay in the fresh air of Scotland or Switzerland. Instead she spent six weeks resting in University College Hospital, London. This was hardly a restful location and, perhaps significantly in the light of subsequent events, the staff thought her a little excitable and tense. For instance, she used to block her telephone line for a couple of hours as she did the daily Times crossword with

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her friend Meriel Richardson, wife of actor Ralph Richardson. On discharge Miss Leigh spent nine months recuperating at Notely Abbey, a home she shared with her now husband, Laurence Olivier. She seemed to make a complete recovery. Despite the nature of this serious illness, medically Vivien Leigh is probably remembered more for her mental state, for she suffered grievously from a manic-depressive psychosis, or bipolar affective disorder, as doctors now call it. In 1944 (obviously a bad year) she had a miscarriage and following this became increasingly excited, talkative and sexually demanding. She would party on to all hours, drinking and smoking excessively and then go straight on to rehearsals. The following year she became depressed, lost her sense of selfworth, was overcome by fear and guilt and took to her bed. For the rest of her life she swung between these bipolar phases. When hyped up, Vivien Leigh was impossible to live and work with. For example, it was during such a period in 1957 that she attempted to address the House of Lords from the gallery while their Lordships were discussing the mooted demolition of St James theatre. Her outburst made little impact on the debate, for the theatre was dismantled the following year. However, despite her sad mental condition, such was her professionalism, high or low she could deliver a masterly performance on stage. In 1953 Miss Leigh went to Sri Lanka to make the film Elephant Walk with Peter Finch. Coincidently, she entered a manic phase keeping impossible hours while at the same time carrying on a torrid affair with Finch. Eventually, her behaviour and bouts of petulance forced her to be levered out of the film and given a round-the-clock nurse. Even so she would walk around naked tearing up money and reciting lines from a previous triumph, A Streetcar Named Desire. When she threatened to fly out of an upstairs window with actor and nightclub entertainer John Buckmaster, it was thought enough was enough, and she was flown home under heavy sedation.

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Back in England, Miss Leigh was admitted to Netherne Hospital, a private mental home where she was completely sedated for three weeks and later given shock therapy. She eventually settled, but behaviour which might have created a rip-roaring time for some of her friends placed such a strain on the marriage that she and Olivier parted in 1957. Her medical adviser was Dr Arthur Conachy who treated the actress over a number of years. In 1961 he wrote her a medical report which she could carry about and show a doctor abroad if necessary. In it he pointed out that Miss Leigh was a ‘person of very high intelligence, nimble wit and extremely good judgement and not suffering from psychoneurotic illness’. However he went on to point out that between 1949 and 1960 she suffered from ‘fairly regular periods of manic depressive phases’. While dejected, he observed, she became ‘increasingly depressed, finds it difficult to think and concentrate, loses appetite and weight and sleeps rather poorly’. Suicide was not a deemed risk. Of the manic phase, Dr Conachy observed that this was of sudden onset and that ‘she rapidly loses her natural restraint and normal reserve, talks freely . . . loses reasoning power and insight. She adopts lost causes . . . develops marked increase in libido and indiscriminate sexual activity.’ He observed that for a person in her position ‘. . . the manic phase is much more undesirable than the depressive phase’. In June 1960 he administered five E.C.T’s under a general anaesthetic within an eight-day period. She remained well for a year and began to live with a younger actor, Jack Merivale, stepson of Gladys Cooper. Her mental state remained unaltered. Once in Vienna, Vivien reverted to her old ways: she behaved irrationally, throwing bread rolls at the police. On stage in America in 1963 she abused and attacked a fellow actor. She then proceeded to harangue the audience and had to be restrained in the dressingroom. She was flown home to Dr Conachy under heavy sedation. He readmitted her, took away her clothes and gave her more shock treatment.

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Unfortunately, Conachy collapsed and died in his consulting rooms shortly afterwards, a great blow to the actress’ quick recovery. She settled enough, however, to read poetry in a celebration of Shakespeare’s 400th birthday in April 1964. But her days were numbered. In 1967 she came down with a flu-like illness, lost weight and started to cough up blood. She refused to acknowledge the obviously serious nature of the signs and symptoms until she collapsed. A chest X-ray showed a tubercular cavity the size of a fist in her lung. Strangely, at the same time Olivier had been diagnosed with cancer of the prostate. Although estranged for several years, Vivien seemed to worry more about his illness than her own. In fear of the likely outcome, Miss Leigh saw no reason not to increase her smoking and drinking. In the end it made no difference one way or the other as her tuberculosis progressed relentlessly. The fire faded until eventually the bacillus brought down that great talent and troubled mind. She was widely mourned throughout the film and play-going world, and West End theatres paid her the unique honour of dousing their lights for an hour on the following Saturday night. Vivien Leigh captured the imagination of the public for a variety of reasons. Above all, while portraying Scarlett O’Hara or Blanche DuBois, her legacy was a vision of consummate beauty, a ‘phantom of delight’, together with the memory of a beguiling, vivacious woman who always strove ‘to haunt, to startle and waylay’. (JL)

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DARWIN

SETS THE CAT AMONG THE CREATIONIST PIGEONS

You care for nothing but shooting, dogs and rat-catching, and you will be a disgrace to yourself and all your family. — His father berates the young Charles Darwin (1809–1882)

Though his family meant him to become a medico like his father, poor Charles couldn’t bear to see an operation. Instead, he went to Cambridge to prepare for the Church, but neglected theology for biology and geology. In 1831, when the Admiralty survey brig HMS Beagle set out to explore the globe, Darwin became the unpaid ship’s naturalist. He sailed ‘out of Devonport harbour and into fame, bigoted acrimony, and lifelong ill health’. In those days most people still accepted the contemporary church’s account of the Creation, which said that the earth was only about 6000 years old. According to a seventeenth-century theologian, ‘man was created by the Trinity on the twenty-third of October 4004 BC at nine o’clock in the morning’. As Darwin travelled down the coast of South America, he found various species of animals and plants, each slightly different. Then on the Galapagos Islands, 1000 km off Ecuador, he found plants, insects, fish, reptiles and birds quite different to those elsewhere. None of the finch species on the islands existed on the mainland. On one island, the finches had strong, short beaks to crack nuts. On another island where there were no nuts, the finches had delicate beaks to catch insects. On another, longer beaks for grubs. Still another, thicker beaks for fruit. Back in England, Darwin gradually concluded that the seedeating mainland finches must have colonised the islands long, long before. Then over the ages their descendants, in adapting to different habitats, had evolved into different species.

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Darwin read Thomas Malthus’s Essay on the Principle of Population. Malthus (1766–1834) stated that human populations tend to increase at a higher rate than food supplies, leading to starvation, disease and war. Darwin extended this concept to all organisms. He postulated that natural variation existed among all animals and plants. In any environment, some variants were better suited than others to survive and hence to reproduce. In brief, to explain the evolution of new species, Darwin cited: • • • • • •

Variation among individual organisms Overproduction of individual species Competition for resources Differential survival among variants Inheritance of variations that tended to better adaptation Gradual evolution of new forms (species) best fitted to survive.

Darwin came to this theory in rural Kent during about 40 years of sheltered life as a semi-invalid. When he married his cousin Emma Wedgewood, ‘the perfect nurse . . . (met) the perfect patient’. Darwin often complained of depression, fatigue, insomnia, palpitations, headache, nausea, vomiting and indigestion. Even in winter he took cold baths as his doctor prescribed and followed a rigid routine. But often for weeks at a time he could not work at all. By now he looked worn out and older than his years. But what was wrong with him? Peptic ulcer, heart disease or brucellosis perhaps? Some doctors have retrospectively suggested Chagas’ disease (an infection picked up in Chile), or self-medication with arsenicals. Others have labelled him a hypochondriac, neurotic, or mentally unstable. Did Darwin use his symptoms to keep out the outside world so he could concentrate on his life’s work? Serious physical disease seems unlikely, as he sired ten children and lived to the age of 73. Over decades Darwin obsessively collected, classified and analysed his findings. Not until 1856 did he start to compose his

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massive work on evolution. After Darwin had written ‘only’ 250 000 words, fate forced his hand. In 1858 a younger, bolder naturalist sent Darwin an outline of his theory of evolution. Alfred Wallace (1823–1913) had noted differences between the mammals of Asia and Australia: the latter were far more primitive. How had they survived? Only because, Wallace reasoned, Australia had split off from the Asian mainland before the more advanced Asian species had developed. The theories of Darwin and Wallace were remarkably similar. Both presented papers to the Linnean Society, but with no great impact. The storm did not break until 1859 when Darwin finally published On the Origin of Species by Means of Natural Selection, or the Preservation of Favoured Races in the Struggle for Life. He tried to skirt the religious issue, but his thesis did contradict the literal belief that God had created the whole world and all life on it, including mankind, over seven days and that life forever retains its original God-created form. Everyone from the Prime Minister to the commoner joined in the controversy. A bishop’s wife gasped: Descended from the apes! Let us hope that it is not true, but if it is, let us pray that it will not become generally known.

Darwin helped to transform the study of biology from a collection of unrelated facts to a science based on one broad theory. He ended The Origin of Species: There is grandeur in this view of life . . . from so simple a beginning, endless forms most beautiful and most wonderful have been, and are being evolved.

By the time he died in 1882, churchmen allowed Darwin to rest in Westminster Abbey. However they would not replace the Abbey’s stained-glass window depicting the Creation. For the centenary of The Origin of Species, the British Museum handbook read:

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Science can now celebrate the centenary of the first general principle . . . applicable to the entire realm of living beings.

Isaac Asimov wrote: The theory of evolution (was) the greatest challenge … to an age-old conception of the world since the days of Copernicus and Galileo.

(GB)

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MONKEY

BUSINESS IN THE DEEP SOUTH

If you head South (in the USA), you are more likely to find creationist theory taught now than in the 1920s. It is the evolutionists who are on the run. — The Sydney Morning Herald, 5 August 1995

In 1992, Clergyman and NSW Parliamentarian Fred Nile backed legislation to teach Australian schoolchildren that ‘God, not evolution, was responsible for life’. Fundamental creationism, evolution and education have always been an explosive mix. Over 70 years ago, crowds flocked to Dayton in Tennessee to hear national celebrities debate whether local schools may teach that man was descended from monkeys. This famous case started in a casual way, almost by accident. In 1925 the Governor of Tennessee signed an act that the legislature had equally reluctantly passed. This made it unlawful for any teacher . . . supported . . . by . . . funds of the State, to teach any theory that denies the story of the Divine Creation of man as taught in the Bible, and to teach instead that man has descended from . . . lower . . . animals.

The American Civil Liberties Union (ACLU) offered to defend any teacher who would risk arrest by challenging the creationist act. Locals were chewing this over at Dayton’s social centre, the ‘Drug Store’. Their small town was struggling to attract business: a controversial trial might be just the thing to put it on the map! John Scopes, a 24-year-old freethinker and school athletics coach, happened to be teaching biology to help an ill colleague. He was on the tennis court when he got a call to the powwow. This being the South, he finished his tennis before joining the locals who talked him into mounting a legal challenge.

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The resulting case was bigger than they could have hoped. It was the first trial ever broadcast, and made headlines throughout America and overseas. Later came the movie Inherit the Wind. Dayton was flooded with locals, hucksters, clergymen, holyrollers, spectators, and journalists. In one room off a grocer’s store, Western Union installed 22 telegraph operators. Outside were hot dogs, lemonade stalls, revivalist meetings under flares, and a chimpanzee parading around in a three-piece suit. Leading the defence was the famous lawyer Clarence Darrow, who had saved the lives of the young murderers Nathan Leopold and Richard Loeb. He was an agnostic radical and champion of the underdog. Legally, the case seemed simple. State law forbade the teaching of human evolution; Scopes had broken the law. In fact, what the defence wanted was not a win, but a quick conviction of Scopes, which would then allow a dramatic appeal to the Supreme Court. Darrow could only win by losing; his strategy was to secure his client’s conviction and then appeal . . . so the law could be declared unconstitutional.

Leading the prosecution was the 65-year-old passionate fundamentalist William Jennings Bryan. He had been a famous orator, Secretary of State, and three-times candidate for the presidency, but his best days were over. Journalist H. L. Mencken called him ‘a tinpot pope in the Coca-Cola belt’. Bryan prepared for a fight to the death against the forces of Satan. Many experts in evolutionary biology and in Christian conviction came to testify. A zoologist made the audience sit up when he testified that there had been life on Earth for 600 million years. A boy of 14 told the court that Scopes had taught him evolution and that it hadn’t hurt him. Darrow’s masterstroke was to persuade his opponent to testify as an expert on the Bible. Bryan said that the world was created in 4004 BC; that the Flood came about 2348 BC; that Eve was

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literally made out of Adam’s rib, and that the Tower of Babel caused the diversity of languages around the world. But then he changed tack and shocked literal-minded creationists by admitting that the seven days of creation might actually have stretched over thousands of years. Darrow spoke out against intolerance, recalling ‘the sixteenth century when bigots lighted faggots to burn the men who dared to bring intelligence and enlightenment and culture to the human mind’. But Mencken said the impact of this speech was as dramatic ‘as if he had bawled it up a rainspout in the interior of Afghanistan’. Judge Raulston set Scopes’s fine at a token $100, but Tennessee law required all fines over $50 to come from the jury. Though Scopes was convicted, the conviction lapsed on this technicality. The frustrated Darrow had no case to appeal to the Supreme Court! Only days after the trial, Bryan stole headlines by dying (some said of a broken heart, though he did have severe diabetes). His legacy is the continued flourishing of fundamentalist creationism. As biologist Stephen Jay Gould wrote: ‘They taught creationism in Dayton before John Scopes arrived, and they teach it today.’ The act survived in Tennessee until 1967, though it was not enforced. How many evolutionist teachers feared to teach their beliefs? How many children missed out on the most exciting concept in biology? In 1981, almost a century after the death of Charles Darwin, a trial of ‘creation science’ took place in nearby Arkansas. The judge ruled that biology teachers did not have to purvey religion in their lessons. But a local minister still blamed Darwinism for the four ‘p’s’: prostitution, perversion, pornography and permissiveness! Even now, creationist fundamentalism is alive and well; polls show that 47 per cent of Americans reject the theory of evolution. (GB)

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HOW

DID PRESIDENT JACKSON GET LEAD POISONING?

In Andrew Jackson, born in the backwoods, an orphan, self-taught, in turn workman, farmer, lawyer and the general who defeated the British at New Orleans, the passionately egalitarian American people recognised one of themselves.

Andrew Jackson was born of poor Irish parents in 1767. Was it in North Carolina or South Carolina? Both states proudly claim him! As a child he was skinny, plain and remarkable only for his fierce temper. Cockfighting and sports attracted him far more than schoolbooks. Yet he became the first man to climb the social ladder from a log cabin to the White House. At 13 he fought with the mounted militia in the American Revolution. After the British captured Andrew and his brother Robert, a subaltern ordered Andrew to clean his boots. When he refused, the officer swung his sword, wounding the boy on the wrist and head. After both brothers came down with smallpox, their desperate mother arranged an exchange of prisoners. But she and Robert died soon after, while Andrew lay helpless for weeks with malaria complicating his smallpox. Left to his own devices, the young orphan drifted; he worked here as a schoolteacher, there as a saddle-maker. A friend called him: ‘The most roaring, rollicking, game-cocking, horse-racing, card-playing, mischievous fellow that ever lived.’ Somehow at 21, Jackson qualified to practise law and went west. His new landlady’s daughter, Rachel, had just returned home to escape her impossible husband. Believing that he had divorced her in Kentucky, she felt free to marry Jackson in Tennessee. But as Rachel remarried long before her divorce actually came through, she was now a bigamist. The press called her a ‘harlot’. Among her critics was a young aristocrat, Charles Dickinson, the best shot in Tennessee. In 1806 Jackson challenged him.

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The two men stood eight paces apart. Each had a nine-inch barrel pistol loaded with a one-ounce lead ball. On the command Dickinson fired instantly; Jackson clutched his chest, but didn’t fall. Now it was his turn; he raised his pistol; Dickinson had to stand and wait. Jackson pulled his trigger; the hammer stopped at half-cock. He drew it to full cock, aimed again, and this time the pistol did work. Dickinson fell, bled copiously and died after 16 hours of agony. But Dickinson’s bullet had shattered some of Jackson’s ribs and entered his chest. Doctors thought the bullet was too close to his heart to remove safely, so Jackson carried it for the rest of his long life. Indeed, from this time, his health did decline. He often coughed up blood and endured diarrhoea, chills and fevers. The fevers were from malaria, but also from a chest abscess around Dickinson’s bullet. Jackson’s chest symptoms led to reports that he had tuberculosis. But Jackson just kept going. At various times, he served as a judge, ran two plantations, a general store and a stable. He also ran and backed racehorses and became Tennessee’s first representative to Congress. In 1813 General Jackson, as he was by then, was shot from behind; the bullet shattered his left shoulder and lodged there. He bled and bled; most of the doctors advised urgent amputation, but Jackson refused. Though he continued to endure chronic infection and sloughing of bone, he kept his crippled arm. When news came of a massacre by Creek Indians, Jackson left his sickbed and led his troops in two successful battles. Soldiers called him ‘Old Hickory’, after the toughest wood they knew. In 1822 Jackson suffered prolonged constipation with severe cramps — possibly lead poisoning. Not only did he have a oneounce lead ball in his chest and another in his shoulder, Jackson also used sugar of lead (the acetate) for many ailments: he bathed his eyes in it, poured it into his wounds, and even drank it for his cramps! By now, even Jackson felt the need to slow down: ‘I must take a rest, or my stay on Erth [sic] cannot be long.’ But in 1829 his

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admirers elected him President. On inauguration day, in a holiday mood, they stormed the White House, forcing him to withdraw through a window. Doctors feared he would not see out his four years. But he not only survived to serve a second term, but actually improved after a surgeon removed the bullet that he had carried in his shoulder for 19 years. For yet another severe bout of coughing up blood, his eager doctors bled him of over two litres. Old Hickory survived even this. In 1838, having finally left the White House, the ailing General wanted to visit one of Tennessee’s healing springs, but had no money. Instead, he started taking a tonic, the ‘Matchless Sanative’, which he swore made him ‘a new man’. Two years later he trekked to New Orleans to celebrate his victory over the British. Despite his breathlessness and weakness, Jackson weathered ten days and nights of receptions, banquets and speeches. But soon he wrote: ‘I am swollen from my toes to the crown of my head and in bandages to my hips.’ A doctor tapped his abdomen of ‘much water’, but with little relief. Even when his doctor gave him opium he would not sleep but talked lucidly of national and personal affairs. On 8 June 1845, ‘the tired old soldier beckoned his friend Death, who came and gently led him away into the darkness’. (GB)

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Chapter

QUACKS

5

AND

QUIRKS

JAMES GRAHAM,

PRINCE

OF QUACKS James Graham’s good looks and striking appearance turned women’s heads. He wore suits of white linen, carrying a gold-headed cane in one hand and a posy of flowers in the other. He was born in 1745, the son of a saddle-maker in Edinburgh. Though he studied medicine there, he did not graduate. After marrying he worked as a healer in America, where he met Benjamin Franklin. Did this stimulate Graham’s interest in the healing uses of electricity? Soon he was offering electrical treatments for anything from fever to rheumatism and deafness. He also devised an early version of the vibrator. Back in England he practised first in Bristol and then in trendy Bath, where many people, with complaints both real and imaginary, flocked to consult

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him. Graham’s grateful patients included Georgiana, Duchess of Devonshire. Where next? For an ambitious man, the answer had to be London. In 1780 Graham rented the centre house of the newly built Royal Terrace just off the Strand. This became his first ‘Temple of Health’. Over the entrance he hung a huge golden star and the words Templum Aesculapio Sacrum. An eyewitness account described the establishment: Carriages drawing up next to the door . . . At the door stood two gigantic porters . . . wearing superb liveries, with large, gold-laced cocked hats; each was near seven feet high . . .

For two guineas, visitors could wander through ten magnificent apartments hung with mirrors, sculptures and paintings, with musical accompaniment. They saw crutches, ear trumpets, spectacles and walking-sticks supposedly discarded by grateful patients. In the Great Apollo apartment, Graham himself lectured daily from 5 to 7 pm. Beautiful girls (‘Goddesses of Health’) posed in scanty costumes, pearls and feathers. One was probably 16-year-old Emma Lyons, later to become Lady Hamilton, mistress of Lord Nelson. She had ‘a perfect figure, fine regular features and an indescribable charm’. From time to time the wired chairs gave Graham’s audience mild shocks to impress the punters. To cap it all off, an enormous spectre came up through the floor and handed Graham bottles of his ‘Aetherial Balsam’ guaranteed to promote fertility. Just in case the balsam failed, there was Graham’s Celestial Bed in a separate room, with its own door to the street. Graham’s own description: The Grand Celestial Bed, whose magical influences are now celebrated from pole to pole and from the rising to the setting of the sun, is 12 feet long by 9 wide, supported by 40 pillars of brilliant glass . . . in richly variegated colours. The super-celestial

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dome of the bed, which contains odoriferous, balmy and ethereal spices, odours and essences . . . is covered with brilliant panes of looking-glass. On the utmost summit of the dome are placed two exquisite figures of Cupid and Psyche, with a figure of Hymen behind. At the head of the bed appears sparkling with electrical fire a great first commandment: Be Fruitful, Multiply and Replenish the Earth. The chief principle of my bed is produced by artificial lodestones. About 15 cwt of compound magnets are continually pouring forth in an everflowing circle . . .

Users of the bed ‘talked not . . . of the critical moment — no, they talked of the critical hour . . . The barren must certainly become fruitful when they are powerfully agitated in the delights of love.’ Somehow Graham omitted to mention his own childlessness. To recoup the £10 000 he paid for the bed, Graham charged £50 to £500 a night, for which he promised ‘at least a hundred years of good health’. But when one young Goddess fell ill and died, wags blamed the damp sheets of the bed for giving her a cold. His ‘Elixir of Life’ fetched up to £1000 a bottle. In treatment rooms that looked like lady’s bedrooms, up to 200 patients a day flocked to consult him with sexual problems, fading beauty or nerves. In 1781 Graham was able to take larger premises in Pall Mall. His success was as spectacular as it was short-lived. Despite his posters and pamphlets (‘let them now come . . . or forever . . . blame themselves and bewail their irremediable misfortune’), falling numbers made him drop his prices. Eventually he could not pay his bills, had to sell up and did time in Newgate Gaol. But Graham bounced back, calling himself ‘born again’ and preaching his own style of Christianity. He taught that life depended on the earth. To soak up its goodness, Graham and a young girl stripped and were buried up to their chins, their hair powdered. An observer said ‘they looked like a couple of fully grown cabbages’. He stayed there ‘buried, naked and fasting for

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days on end’. Graham now promised that his earth baths would bring not just 100, but 150 years of life! Sure he was a quack, but some of his advice was sound: frequent washing (unfashionable in those times), fresh air and only moderate consumption of meat and alcohol. After he returned to Edinburgh, magistrates banned Graham’s improper lectures on remedies for barrenness. He got out on bail, which his audience paid so he could resume his lectures. But his magic was fading. Despite a small annuity from a grateful patient, he got poorer and poorer, and odder and odder. In the street he would strip naked and give his clothes to the poor. Did he develop schizophrenia or opium addiction? The poet Robert Southey said Graham was half-mad and his madness at last got the better of his knavery. A modern psychiatrist called him ‘a luminary of the lunatic fringe’. In 1794 James Graham died in a lunatic asylum. The man who had promised his fans 100 to 150 healthy years did not even live to see 50. (GB)

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THE

RISE AND FALL OF A SUPER QUACK

From time to time Australians have visited Rarotonga in the Cook Islands, 2000 km north-east of New Zealand. Nowadays they usually go there for a holiday. But in 1977 patients with cancer flocked from Australia, New Zealand and even the United States to Milan Brych’s clinic in the hope of finding a cure for cancer. Brych claimed to have a new cancer treatment: from a blood sample, he could prepare and inject ‘chemoimmunotherapy’ specific to each patient’s own malignancy. His usual course was six treatments, each costing $680. The trip to Rarotonga could cost $16 000 all up; public subscriptions helped some families. Brych offered no physical examination, no pathology, no radiotherapy, no surgical backup, no follow-up. Senator Peter Baume, himself a physician, denounced Brych as a quack, charlatan and villain. But desperate people clutch at straws; many believed that he could even help when doctors could do no more. A Melbourne doctor referred patients to Brych after showing them a film featuring ‘miracle cures’. Two editorials in The Medical Journal of Australia outlined the facts behind the sensationalism. Milan Brych first came to New Zealand in 1968. He claimed to be an anti-Communist compelled to flee from the Russian invasion of Czechoslovakia, so he could not bring his medical degree with him. He never sat any exams in New Zealand, but conned the Chairperson of the Medical Council in an interview. Brych got work in the pathology department of Auckland Hospital. The next year, he gained provisional registration and became a hospital intern. After gaining full registration in 1972, Brych became a registrar at the Auckland Hospital Radiotherapy Unit. He said he was resuming his medical career which had been interrupted by his flight from Czechoslovakia. At one stage he even

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duped a Czech doctor working in Australia into agreeing that they had been medical students together. Some eminent doctors praised Brych. But when other doctors pressed him for details of his methods and results, he refused, claiming that the medical establishment was persecuting him. Rumour had it that he had treated the wife of an American president as well as one of the Kennedys. His supporters won seats on the Auckland Hospital Board. Private patients kept flocking to Brych. But his very public claims of an 80 per cent cure rate stirred up the New Zealand medical authorities. The resulting enquiry in 1974 found that Brych was using conventional chemotherapy. His secret cure (‘chemoimmunotherapy’) was just a myth. Moreover, his clinical results, which he never documented, were actually below average. Independent follow-up later showed that by 30 June 1978, 25 of the 40 Brych cancer patients featured in the Victorian press between April 1977 and May 1978, had already died! Brych was deregistered in New Zealand, but appealed and was reinstated pending the hearing. His admirers raised money for his legal costs, and he kept treating private patients. It was no simple thing to dig out the truth about Brych. Professor (now Sir) John Scott, Head of Medicine at Auckland Hospital, went to Czechoslovakia, Switzerland, Italy, Britain and the US to gather evidence. He found that Brych had not even qualified for entry to university. A medical laboratory had sacked him for faking results, and he had been in prison twice. Soon after all this evidence was lodged with the Supreme Court, Brych withdrew his appeal. He then moved his practice from New Zealand to the Cook Islands. It looked like a golden opportunity when Queensland Premier Joh Bjelke-Petersen invited Brych to run a clinic. In early 1978 Brych met the Premier, Minister for Health, Dr (now Sir) Llewellyn Edwards, AMA representatives and cancer experts. But Brych still refused to give details of his treatment; one expert compared his knowledge of cancer to that of a high school student. The Premier

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still wanted Brych registered in Queensland, but then Dr Edwards tabled damaging documents in Parliament. That was that. In August 1978 Brych suddenly pulled out from the Cook Islands as well, leaving behind 16 partly treated Australians. But they had the comfort of an assurance from the ‘Friends of Rarotonga’ that Brych had not forsaken them! Brych started afresh in the United States, but was arrested in 1980 on charges of fraud and of practising medicine without a licence. Professor Scott gave evidence at Brych’s trial in 1983 where the Los Angeles Superior Court found him guilty on nearly all charges. There were over 11 000 pages of official evidence. The court sentenced Brych to six years imprisonment but he was released in 1986. He returned to New Zealand, where he still found some public support. Then he moved to Geneva, but in 1992 returned to New Zealand. How could Brych fool so many people for so long? It seems he used a form of hypnotism on his more suggestible patients. Even his medical opponents agree that his charisma gave hope to the ill and dying. But Professor Scott says it was more than just charisma. Brych skilfully manipulated the media. Newspapers headlined his apparent cures, but seldom followed the patients or reported their deaths later on. Professor Scott blames: ‘. . . people in the newsmaking business . . . they have just as much to answer for . . . as the doctors and diplomats whose sympathy for refugees from Czechoslovakia . . . allowed Brych to enter New Zealand and then practice medicine.’ Brych often threatened his medical critics with legal action. He filed a libel suit against Professor Scott, but later withdrew it. Professor Scott believes Brych’s success also reflects on mainstream cancer services of that time: Brych got as far as he did because the medical, nursing and allied professions . . . had not been handling patients uniformly

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with the understanding they required and deserved. I fear that we have not seen the last of the successful cancer quacks.

The last word rests with Dr Morris Fishbein: Of all the ghouls who feed upon the bodies of the dead and the dying, the cancer quacks are the most vicious and the most heartless. Heaven speed the day when the advance of medical science . . . will deprive these ghouls of the sad soil on which they nourish themselves.

(GB)

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USELESS

MEDICINE AND SURGERY

Everyone who has been qualified in medicine for more than 35 years can look back and wonder what possessed the medical hierarchy to persist with some of their outrageous and supposed instant cures, especially in the field of surgery. These bogus procedures had started in the late-nineteenth century when, with the advent of safer anaesthetics, surgery became a less hectic activity. With the ability to get at previously untouched organs, new worlds of therapeutic wonders opened up before the surgeons’ eyes. And so before they are completely forgotten, let me remind you of some of the more ludicrous flights of fancy which were devised, usually with financial gain in mind rather than from any altruistic motives. Surgery on the abdomen, for instance, became a rich field for pursuing improbable, if not phoney goals. The supposed menace of constipation has been a medical whipping boy for centuries, and clysters, or enemas, had been the mainstay of treatment for years. Many mortgages have been paid off and children educated on treating this physiological variation of normality. The doctor advised, and the patient often demanded, treatment for the imagined pathology. Surgery became the cure-all for restoring robust good health, as there was little else in the medical armoury which had the same dramatic impact. By the beginning of this century, ‘auto-intoxication’ was the buzz word. Poisons which lurked in dark and fetid locations such as the roots of teeth or, most blamed, the appendix and colon, entered the bloodstream to cause all kinds of ambiguous symptoms such as lassitude, insomnia and pelvic pain. Surgery was mooted the moment the first wave of waxing peristalsis washed over the lower abdomen. Such advice reached its pinnacle when, in order to root out the purported source of the trouble, removal of the blameless colon and appendix came to be insisted upon.

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The most forthright exponent of this theory was the dazzling, Scottish-born Sir William Arbuthnot Lane (1856–1943) of Guy’s Hospital, London. He asserted that everything from brain tumour to clammy hands was caused by constipation or ‘chronic intestinal stasis’, as he preferred to call it. He viewed innards as little more than a problem in plumbing foisted onto humankind by a wayward quirk of nature. An overloaded colon, he asserted, could lead in this vital organ to what became known as ‘Lane’s kinks’. And he was just the man to iron them out. Lane became so unbalanced about colectomies that when a boy with an ununited fracture was sent to him for plating (a quite legitimate and reasonable proposal), he suggested removing the colon instead, or at least that the operation be performed as an encore. Another child is said to have mistaken the ear, nose and throat clinic for the surgical outpatients and proceeded to have his recurrent sore throats dealt with by removal of the lower bowel rather than his tonsils. Lane was not a man to let the obvious stand in the way of a rousing surgical bravura. Even more bizarre, the story goes that a man who attempted suicide following domestic differences was left to recover while his wife had her colon removed to make her better tempered! The patients, not unnaturally, were delighted to find a remediable internal cause for physical and psychological imperfections. While they queued up, Lane and many others did not seem to realise that normal bowel evacuation had a wide variation. Lane was a handsome man with a luxuriant moustache and assertive manner who, when called upon to open the abdomen, did not hesitate to expose the lot. His slashing incisions ran from ribs to the pubis, no messing about. He neither suffered any agonies of doubt, nor dillydallied over what was to be done or how to do it. Lane died in 1943 during World War II, after having been knocked down by a vehicle in the blackout. Another group of operations which has disappeared is that of ‘plications’. Anchoring a ‘floating kidney’ was in many hospitals a weekly case on the theatre list. Need for the operation was not based

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on any physiological principles, but on the neatly drawn pictures in Gray’s Anatomy which were based on post-mortem appearances showing the organ nestling in its seemingly God-given place. The agony for the well-meaning surgeon was not to decide if it was necessary, he knew it was, but to assess if the organ giving loin pain should be embedded in the perinephric fascia, or suspended from the twelfth rib by its own capsule ‘like a shirt hanging from a clothesline’, as Fraser has it. Nobody foresaw that it would be found that a transplanted kidney functions perfectly well attached to whichever vessels in whatever location. New-fangled barium (initially bismuth) meal X-rays showed that in many cases of vague abdominal pain the caecum, or large bowel, was lying low in the trunk. Ipso facto it must be transfixed in the right iliac fossa where the anatomy manuals showed it belonged. It did not seem to occur to even the most fertile surgical brain that to anchor any organ with constant peristaltic movements is bound to fail. Their dogged pursuit of the unrealistic was a monument to self-deception. To be charitable, I suppose they meant well, even though their good intentions didn’t have a hope of succeeding. The treatment of tuberculosis was another mine of confusion. Perhaps we should have more sympathy for the doctors involved with this disease since the advent of the antibiotics made all the difference. Scarred necks from incised tubercular glands are a thing of the past, as are phrenic nerve crushes to paralyse the diaphragm in order to rest the lung, cutting adhesions and extrapleural compression. The incision of neck glands did at least introduce a dress fashion early in the twentieth century. In her youth Queen Alexandra, consort of Edward VII, had had her TB neck glands incised, so to hide the resulting scar she wore a choker of beads around her throat. Pre-operative care has also changed a lot in the last 50 years. Not all that long ago it was insisted that two days of purgation followed by an enema (‘high, hot and a hell of a lot’) on the morning of the

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operation be endured. Gastric operations could not be carried out until all infection from teeth and gums had been rigorously dealt with. I can still remember my puzzlement in about 1939 when my own father emerged toothless following a stomach procedure. In the name of spotless cleanliness, some surgeons at that time used to remove their own dentures while operating. Lord Moynihan went so far as to wear white gloves to bed to keep his hands aseptic at all times. I wonder what his wife thought about that. The rectum was regarded not so much an organ of defecation in a downwards direction, but as a repository for fluids administered in an upwards direction. What a recalcitrant patient may object to by mouth was foisted on him or her via the uncomplaining back passage. A rectal drip could consist of tap water, the evil smelling sedative paraldehyde, brandy, hot coffee or even a so-called nutrient enema containing a mini mixed grill puréed. Many rather fanciful surgical instruments have gone forever. They frequently turn up in medical museums, often donated by a surgeon’s widow. For instance, in Perth recently we received at the West Australian Medical Museum a well-worn example of Pannett’s triple-bladed peritoneal forceps. A real find for the museum, but only 50 years ago, before the advent of muscle relaxants, these were used to seize and hold visible the edges of the peritoneum (the thin tissue lining the abdominal cavity), when they spasmodically and fleetingly heaved into view as the patient bucked and plunged under chloroform anaesthetic. There is no doubt that antibiotics and advances in anaesthetics, plus a more rational approach to medicine have been the death knell for these techniques. Horrifying as all these procedures may seem to us, they were well meant, the brain children of otherwise caring and dedicated medical men and women. Who is to say some of the procedures so lauded today may not be written about with humorous incredulity in a few years’ time? (JL)

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HOW

C O M M O N I S A D U LT E R Y ?

Can you still remember the good old days when loyal patients used to stay with the same doctor for years and years? When doctors passed on their practice to their own children, generations of doctors could even follow generations of patients. One such practice was that of the Huntingtons of New England. Dr George Huntington (1850–1916) practised there, as had his father and grandfather before him. In 1872, long before doctors understood the mechanisms of genetics, Huntington observed a disease with a dreadful combination: involuntary movements (chorea) and progressive mental deterioration (dementia). The hereditary chorea is spoken of with a kind of horror . . . increasing by degrees . . . until the hapless sufferer is but a quivering wreck of his former self. There are three marked peculiarities in this disease: its hereditary nature, a tendency to insanity and suicide, and its manifesting itself as a grave disease only in adult life.

Even in our own century, Huntington’s disease still devastates patients and their families. Mrs ‘Cooper’ was in her fifties when she consulted American neurologist Dr Harold Klawans about her second child, Walter. Dr Klawans suspected the diagnosis as soon as 28-year-old Walter shuffled, lurched and danced his way in. Two years before he had been an English teacher, but now he was a janitor. He could no longer concentrate and his memory was poor. Whereas he used to read, now he just watched children’s shows on TV. Even during the consultation, he couldn’t stay still; first one muscle jerked, then another. His CAT scan showed the brain changes usually seen in Huntington’s disease. To clinch the diagnosis, Dr Klawans looked for a positive family history (someone else in the family with the same disease). Most

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people with Huntington’s disease have inherited it from one or other parent; those who do not have it cannot pass it on. Walter’s mother was well; her father had been healthy and lived to 77 and her mother was still well at 83. Then Dr Klawans thought the disease must have come from Mr Cooper’s side of the family. Mr Cooper had died at 43 in a hunting accident. That was consistent; suicide and sudden death are common in Huntington’s disease. But the late Mr Cooper hadn’t had jerks, twitches, depression, personality change, memory loss or dementia. Moreover, both his parents and all four of his grandparents had also been clear. Despite the lack of a family history, Dr Klawans gave Huntington’s as the likeliest diagnosis. Soon after, Mrs Cooper rang him. As well as Walter, she also had another son and two daughters. If her husband had had Huntington’s, she asked, did her other children have an even chance of getting it? Yes, he said. And any of her children who got it might in turn pass it on to their own children? Yes. It was months later that a very emotional Mrs Cooper returned. She told Dr Klawans that he was quite wrong about the hereditary nature of Walter’s problem. A genetic counsellor had told her that Walter’s Huntington’s disease was just a spontaneous mutation (a random change in a gene); such mutations accounted for one-third of all patients with Huntington’s. Hence Mrs Cooper’s other children weren’t at risk; nor were her grandchildren. So why had Dr Klawans misled and alarmed her and her family? By now she was screaming at him. He told her that according to the only reliable study done, spontaneous mutation of the Huntington’s gene occurred only once in a million instances. He restrained himself from pointing out that adultery is much more common. Dr Klawans believed that the late Mr Cooper had been illegitimate; Walter’s grandmother must have had an affair with a man carrying the gene. Walter’s father, like many people with Huntington’s disease, must have become depressed, either as part of

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the disease, or as a reaction to it. Then he had gone hunting and killed himself. Mrs Cooper goaded him until Dr Klawans finally told her what he believed. She called him a bastard and stormed out. He was still worried that no one had told Walter’s brother and two sisters of their risk. Two days later, he got a letter of apology from Mrs Cooper. He had been right, but about the wrong generation. Her late husband Mr Cooper was not Walter’s father. Dr Klawans had been half-right about his death; it was no hunting accident. He had killed himself, but not because he had Huntington’s. During a quarrel, Mrs Cooper had taunted him that Walter was not his child; the true father was a neighbour who had later died in hospital, chained to his bed. This man’s insanity had required hospital care and his involuntary movements had required restraint. The Huntington’s disease had passed from the neighbour to Walter. What could Mrs Cooper tell her other three children? If she said nothing, they would live in dread that they too might develop the disease and perhaps pass it on to their own children. Or could she admit her long-past adultery? In the end, Dr Klawans wrote her a very official letter stating that Walter’s Huntington’s resulted from spontaneous mutation and that therefore her other children were safe. My old textbooks state that cases of Huntington’s disease from spontaneous mutation are relatively common. What they should say is that adultery is common. (GB)

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LY D I A P I N K H A M ’ S COMPOUND: THE

VEGETABLE CURE FOR FEMALE COMPLAINTS

She was the best-known woman in nineteenth-century America, the first successful businesswoman, and perhaps the first millionairess. Nature smiled on Lydia Pinkham (nee Estes). Born near Boston in 1819, she was tall with reddish hair, striking dark eyes and a vibrant personality. She had a good education and became a teacher, but unlike most New England ladies, Lydia held unconventional views. She supported temperance, women’s rights and the abolition of slavery. In 1843 Lydia married a widower, Isaac Pinkham. He was ‘of no great vigour’. First he failed at farming and manufacturing; later Isaac was the only man in real estate to lose money between 1843 and the crash of 1873. At 60 he was penniless, a broken man. Lydia was 54 and quite unbroken. Like many of her contemporaries she hated doctors. This was not surprising since the USA had many private medical schools at the time, some of which let doctors graduate after just one term of lectures. The verb ‘to doctor’ meant to bungle. Most women with specifically female complaints avoided doctors and treated themselves with whatever remedies they could find. ‘Lydia Pinkham’s Vegetable Compound’ proved to be just the thing. How did this success story begin? One version is that a machinist could not repay Isaac Pinkham’s loan of $25; all he could offer was some formula to ‘cure the weaknesses of females’. Isaac passed the formula on to Lydia, who was already using many herbal remedies. She added root of true unicorn, root of pleurisy and lots of alcohol, ‘solely as a solvent and preservative’. At first Lydia offered her remedy to family and friends without thought of profit. But after the 1873 crash, two prosperous strangers approached her; the first six bottles went for five dollars.

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Lydia scrubbed out her cellar and started brewing, bottling and distributing in earnest. Their daughter and three sons pitched in, while Isaac read aloud to amuse the family. As well as the Compound, they pushed ‘Pinkham’s Pink Pills’ for female complaints. The boys spread flyers everywhere: ‘Only a woman can understand a woman’s ills.’ Demand boomed. In 1876 the eldest son Dan invaded New York with a barrel of Compound and tried newspaper advertising. Lydia’s face, ‘so full of character and sympathy’ in the Boston Herald touched many hearts. If anyone could cure female complaints, surely it was this wise, grandmotherly figure, the ‘saviour of her sex’. As Lydia’s Compound passed into folklore, so did her picture. When Queen Victoria died, editors who did not have her photo ran the story with Lydia’s picture instead! When sales were slow, Dan found new markets: ‘We are missing out on . . . kidney complaints, as about half the people out here are troubled with kidney complaints or think they are.’ The ads were unrestrained: A FEARFUL TRAGEDY, a clergyman of Stratford, Connecticut, KILLED BY HIS OWN WIFE, Insanity Brought on by 16 years of Suffering with FEMALE COMPLAINTS THE CAUSE. Lydia E Pinkham’s Vegetable Compound, The Sure Cure for These Complaints, Would Have Prevented the Direful Deed.

A label promised relief from ‘Falling of the Womb’. Also ‘all female weaknesses . . . irregular and painful menstruation, efficacious and immediate . . . a great help in pregnancy and relieves pain during labour . . . it is for all weaknesses of the generative organs of either sex . . . for all diseases of the kidney.’ The label ended modestly: ‘the greatest remedy in the world’. Doctors scoffed, and demanded proof. But none of this worried Lydia or her fan club. She wrote a free booklet A Guide to Women, describing in simple language puberty, conception, birth,

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menopause, and various female disorders. It ran into millions of copies in five languages. The front read ‘Yours for Health, Lydia E Pinkham,’ while the back showed the enormous plant producing the Compound. By now this factory had 450 workers. Thousands of readers wrote to Lydia for advice. In some ways, she was on the ball. She reassured one anxious woman: ‘sterility is not always the fault of the wife — many husbands are sterile.’ By 1881, the Pinkhams were said to be grossing $30 000 per month! But now Dan, aged only 33, died of TB, which soon also claimed the youngest son and his wife. When Lydia herself died in 1883 the business passed to the remaining son, his sister and her husband William Gove. The Pinkhams and Goves spent about $1 000 000 a year just on advertising; their markets included Canada, Mexico and Spain. But in China there was a hiccup: no single women were buying the Compound. Vegetable compound had been translated as ‘Smooth Sea’s Pregnancy Womb Birth-Giving Magical 100% Effective Water’! In 1902, the hostile Ladies’ Home Journal reproduced a Pinkham ad which suggested that Lydia herself was still advising all the women who wrote to her. Right next to the ad they ran a photo of her gravestone. For a short time sales slumped but ten years later, they were twice as high again. Two accounts say the Compound contained some oestrogen (female hormone), but surely it was the alcohol which made it so popular. For a temperance worker, Lydia was pretty flexible. Apparently she opposed social drinking, but for illness, she did recommend whisky, sherry, or best of all, the Compound. The original Compound was about 18 per cent alcohol; two bottles gave about the same kick as one bottle of whisky! Not until the 1920s did increasing regulation force the company to reduce the alcohol content and drop its most extravagant claims. But Yankee enterprise takes such setbacks in its stride. Even in 1990, the American Pharmaceutical Association’s Handbook of

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Nonprescription Drugs still listed both ‘Pinkham Compound’ and ‘Pinkham Pills’. Lydia’s fame has already outlived her by over a century. The song lives on: And so we drink, we drink, we drink to Lydia Pink, Saviour of the human race, She invented the Vegetable Compound, Efficacious in every case.

(GB)

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150

CENTURIES OF LEFT-HANDEDNESS

A few days ago I went to a wedding and when it came to signing the register it was all done in the modern fashion right there on the altar table facing the dewy-eyed guests. Five did the job, including the trendy rector and a rather nonplussed organist. After the fourth had left the altar, I could hardly conceal my anticipation to see whether the fifth would complete a full house of what those in the know call ‘minor laterality’. And sure enough, when the last lifted the quill I realised I had just seen some kind of record — everyone had been left-handed. Let me admit at once to being an uncompromising right-hander. That being so, as soon as good manners would allow I rushed back to the books to calculate the odds of such an occurrence and see who else of note was in the club. I knew for a start the President of the United States, Bill Clinton, was, but what about other similar luminaries? Well, I guess the patron saint of left-handedness must be Leonardo da Vinci. Even the airport at Rome named in his honour has him welcoming the visitors with a left-handed salute. He wrote in a mirror script from right to left, and we know from his brushstrokes he drew with the left hand. Occasionally, however, he acquiesced and wrote place names, for instance, in what we ‘righties’ would call the ‘normal’ way. Some have wondered if in fact he was fooling us all and creating a code or an aura of mystery surrounding his undoubted genius. In passing, da Vinci’s rival, Michelangelo, was ambidextrous. This is probably a good thing if you spend a lot of time working on your back painting ceilings. It saves the discomfort of having to move about too much and you could presumably swap hands when you get tired. Among other such gifted people were the founder of the Boy Scout movement, Baden-Powell (later vice-president of the Ambidextral Cultural Society), and the Victorian artist Sir Edwin

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Landseer (of the lions in Trafalgar Square fame) who could draw a different picture with each hand at the same time. King George VI, who was good enough to play doubles on the back-hand court at the Wimbledon championships of 1924, was left-handed. Regrettably for the story he did not win a set. There are plenty of left-handed film stars led by Rex Harrison (as Professor Higgins he made notes with his dominant hand), Kim Novak, Judy Garland, Betty Grable and Olivia de Havilland. We may not have known that Charlie Chaplin was a leftie until he played the violin on the ‘wrong’ side in the film Limelight. It seems that until his late teens Chaplin assiduously practised the violin four to six hours a day with a view to a career in music. But then it dawned on him that in an orchestra it is impossible, if not downright dangerous, to play a violin that way round, so he gave up. In the end we all benefited from this twist of fate. Paul McCartney gave symmetry to the stage presentation of the Beatles by naturally playing his guitar on the other side. When Harpo Marx (the ‘dumb’ brother) first played the harp in an orchestra it was some time before the conductor could work out what was so strange about him, apart, that is, from his wide-eyed grin, vigorous appreciation of any gormless suggestion and mop of curly hair. The instrument was on the wrong shoulder. While on musicians, Harriet Cohen the British concert pianist had a left-handed concerto composed for her when she injured her right hand. And Cyril Smith took part in three-handed piano concertos with his wife Phyllis Sellick when he became paralysed down the right side. Other members of the animal kingdom are not immune. Aristotle, remembered as a philosopher, but who was also one of the first biologists, noted that in lobsters most have a larger right than left claw, and use it for preference. The shells of whelks possess whorls which go from right to left, but about one in every 50 go the other way. Flat fish either lie on their right or left side depending on whether they live in cold or tropical seas. So the single eye of the flounder, Dover sole and plaice is the right one, but it is the reverse in the halibut.

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One last piece of trivia about laterality: in the old baseball park in Chicago the pitcher faced due west, so the arm of a left-hander was on the south side, hence he became known as a southpaw, and the word has passed into common parlance. So what are the odds in humans of being left-handed? Perhaps the earliest account of ‘handedness’ appears in the Bible, Judges 20:15–16. The passage records that among the supporters of Benjamin were counted 700 left-handed men and 26 000 righthanders. This is a proportion of about 3 per cent. But ‘everyone could sling stones at an hair breadth, and not miss’, as the writer is careful to point out! Rather surprisingly, even with more accurate instruments, modern authors vary in their estimates of the proportion of left- to right-handedness. In 1929 Harrison found after examining 12 000 children that if one or two parents were left-handed, then 17 per cent of the offspring were similarly affected, whereas if both parents were right-handed only 2 per cent displayed the opposite. As there are many more dextrally rotated parents than not, the overall figure that seems to be given is about 7 per cent of any given population, irrespective of geographical location. But from the medical history viewpoint, what we want to know is has it always been this way? Well, there are two theories with respect to laterality in humans. First, it could be an inherited physiological predisposition which leads to the favouring of one hand over the other. Or second, social and environmental factors may be the dominant features which over time adapt and force the right hand to be used for the sake of, well, dexterity. To facilitate this attunement, it may be that inherited factors have been suppressed. Given this, if one could assess handedness throughout history, the social pressure theory would see an increase in human dextrality over the eons coincidental with the increase in the use of complex tools. On the other hand, if the condition is innate — nothing to do with environmental factors — there should be a relatively constant percentage of subjects over the millennia with no change

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in the percentage of right- or left-handedness. Written records, of course, are scant, but we have a sublime legacy of art in various forms which has survived for thousands of years, and it is reasonable to suppose that the dominant hand would always have been used to hold a brush or a chisel. Lateral preference is fairly easy to trace via the direction of strokes in drawings or stone work, so a record stretching way back does exist. Putting this theory to the test, in a remarkable piece of scholarship, Coran and Porac looked at over 12 000 reproductions of paintings and sculptures dating from 15 000 BC to 1950 AD. Most were from about 500 BC on, but all centuries were represented. To ensure fairness in their assessment, only those displaying unambiguous laterality were included. This brought the final figure to be critically examined down to about one-tenth of the original. They found that of the 1180 scorable pieces, 92.6 per cent depicted the use of the right hand exclusively. Further, there was no systematic trend towards increasing dextrality over more than 50 centuries; it was across the board. So the conclusion is that handedness is innate, rather than due to social conditioning. In 1964, 48 other studies of handedness were reviewed, and the mean incidence of dextrality was found to be 90.6 per cent (median 93.4 per cent) with a standard deviation of 7.5 per cent. None of the historical periods examined differed significantly from these figures. Nor did they vary when the art forms were divided into cross cultural or geographical parameters. Central Africa is the same as Central Asia which is the same as Central Europe. So it can reasonably be concluded that those five happy people at the wedding were merely showing what their forebears had passed onto them, and were not thus because of social conditioning. In passing, if we take the figure of 7 per cent of the population being left-handed, then the chances of all five at that wedding ceremony being thus blessed is about one in 1 000 000; pretty long odds. (JL)

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THE STOCKHOLM SYNDROME: WHY WE LOVE OUR CAPTORS Men, when they receive good from whence they expect evil feel the more indebted to their benefactor. — Niccolò Machiavelli (1469–1527)

The term Stockholm syndrome dates from 1973, when two robbers in Stockholm seized and held hostage four bank employees (three women and one man). For over five days, all six were confined in a claustrophobic vault only 16 by 4 by 2.5 metres. For all that time, the robbers had the hostages in fear of their lives. But as time went on, a strange thing happened; the captives became very attached to their captors, and vice versa. One of the robbers, Jan-Erik Olsson, allowed the women to call their families. He wiped away Elisabeth’s tears and gave Kristin a submachine gun bullet as a keepsake. He even allowed the nervous Birgitta to break the bank’s regulations against smoking. To impress the authorities, Olsson planned a dramatic gesture: to shoot the male hostage Sven Safstrom. But rather than kill him, Olsson agreed just to shoot him in the leg. To us, it sounds bizarre, but later Safstrom said: ‘All that comes back to me is how kind I thought he was for saying it was just my leg he would shoot.’ In the end, Olsson did not shoot him at all. The robbers allowed two hostages to go to the bathroom alone. Though the women passed police and were only a few steps from safety, they returned to their captors. In response to a whispered question, one did signal to the police the number of hostages. But even this act made her feel ‘like a traitor’. Finally, police drilled holes in the roof of the vault, through which they pumped tear gas. They called on the robbers to throw down their weapons and to send out the hostages first. But the hostages, fearing that police would shoot the robbbers, insisted on

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walking out together with them. In other such situations, captives have also refused to follow police orders. When police finally rescued the captives and captured the robbers, the three female hostages kissed their captors, while the male shook their hands. To a journalist who interviewed him in prison, Olsson confirmed his own emotional relationship with the hostages. Nearly a year later, Birgitta and her husband were driving by the prison; on impulse she visited the other robber. He did not apologise for anything, but in her view, he didn’t need to. But there was a downside as well. The hostages suffered sleep disturbances, nightmares, fears, startle reactions, flashbacks and depression. To enormous media attention, the ‘Stockholm syndrome’ gained an identity. Other cases followed. On 4 February 1974 the tiny revolutionary Symbionese Liberation Army (SLA) kidnapped Patricia (Patty) Hearst, daughter of the American media magnate Randolph Hearst, Jr. For two weeks they kept her in a padded closet about two-metres long and 60-cm wide, where she endured continuous loud soul music, verbal abuse and rape. Altogether they kept her for over 19 months. Later, in her book, Ms Hearst described: interrogations, the threats, the metallic clicking of the rifles when I thought they were going to kill me, the sex forced upon me in the closet, the offer to join them or die . . . my fears, my desire not to anger them, and my subsequent inability to escape or even to telephone anyone for help . . .

They christened her ‘Tania’ after a revolutionary who had fought and died alongside Che Guevara in Bolivia. They indoctrinated her with radical ideology and a hatred of the police (‘fascist pigs’). After two months of captivity, she announced that she now belonged to the SLA: I had joined the SLA because if I didn’t they would have killed me. And I remained with them because I truly believed that

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the FBI would kill me if they could . . .

On 15 April 1974 she joined other SLA members in an armed bank hold-up. In September 1975, the Federal Bureau of Investigation (FBI) arrested Patty. When asked her occupation, she replied ‘urban guerilla’. By now she was identifying completely with the SLA and expected the police to torture and perhaps even kill her. The wealthy Hearst family obtained the top legal and psychiatric consultants. Despite all this, she was convicted. But not all captives bond with their captors. In 1985 Terry Anderson and David Jacobsen were kidnapped in Beirut, Lebanon. Jacobsen, held for over one year, said: ‘I regard them as a gang of thugs who have committed a series of brutal crimes.’ Yet when they released him, his captors kissed him on the cheeks in traditional Arab fashion and begged for his forgiveness. Unbelievably, Anderson spent a total of almost seven years in captivity. His reported reaction to those lost years was mixed. His captors, ‘were not necessarily evil men, but they were certainly doing evil things’. Yet Anderson said he was ‘not bitter or angry’. After all those years, surely one would have expected far stronger feelings. A Lebanese man, Wadgid Duomoni was also captured. After one month, when his captors drove him home, he asked them in for tea! And they accepted! (GB)

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DO

YOU NEED YOUR HEAD READ?

In 1826 James Deville, a London phrenologist, examined 148 convicts embarking for Sydney Cove. He felt the shape of their heads and identified several men, of whom he singled out one as the most dangerous. Sure enough, this man did later lead the other desperadoes in a mutiny. So, could the phrenologist foretell the future? Maybe. Or perhaps, because they expected the worst from this man, did the crew treat him more harshly, causing him to mutiny? A century later, a door-to-door phrenologist told a young Sydney schoolgirl that she would grow up and work in law. She did indeed become a legal secretary. Was this another self-fulfilling prophecy? In the 1940s, Professor Abbott, principal of the Mental Science College of Sydney and Melbourne, was charging five shillings for a verbal phrenology report and ten and sixpence for a full written chart (‘43 faculties delineated’). Even in 1970 the charismatic phrenologist Haigwood Masters was still making a living, employed by David Jones to screen job applicants. The word among the young hopefuls was: ‘Send your resumé, pray for an interview and get your head read!’ So what was phrenology all about? It started with Gall and Spurzheim. When the German Franz Gall (1758–1828) was growing up, he noted that those schoolmates with prominent eyes also had good memories. Later, in gaols and asylums, he found pickpockets with large bumps in their skulls, which he claimed signified ‘acquisitiveness’. Becoming a successful physician in Vienna, Gall promoted phrenology as the first ‘complete science of man’.

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His teachings, in brief: • The brain is the organ of the mind. • Mental powers consist of a set number of independent and innate faculties. • Each faculty resides in a specific region of the brain surface. • The size of each region is an index of the strength of that faculty. The brain, just like a muscle, gets bigger with exercise. • The brain surface corresponds closely enough with the outer surface of the skull to enable assessment of the various faculties from the outside. But Gall’s teachings alarmed the church, which leaned on the Austrian government to ban him. After lecturing to great acclaim in Germany, Switzerland and Holland, Gall settled in Paris. Here he published the results of his meticulous research identifying 27 faculties, each represented on the skull surface. The first corresponded to instinct, the second to love of one’s offspring (‘philoprogenitiveness’), the third affection and friendship, the fourth courage, and so on. Gall acquired an ardent pupil, tall and handsome Dr Johann Spurzheim (1776–1832), who believed that phrenology would allow human beings to become perfect! Spurzheim preached his gospel to admiring audiences in the US. After he died suddenly while lecturing in Boston, many businesses stayed closed during his funeral. His followers pressed on; ‘they phrenologized America and Americanized phrenology’. They applied phrenology to everything from choosing a spouse to raising children and choosing a career! Mark Twain complained that he got inconsistent reports from repeated visits to the same phrenologist. Critics saw phrenology as atheistic, fatalistic and materialistic. But the true believers didn’t want to hear. A manual on phrenology by Edinburgh lawyer George Combe (1788–1858) shared a place in working-class homes with the Bible. Combe realised that gaols and asylums were ineffective and pressed for rehabilitation instead of revenge. Many scientists, psychologists,

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clergymen, writers and politicians who supported phrenology also pushed for social, political, economic, penal and educational reforms. Some radicals even supported women’s rights! Queen Victoria asked a phrenologist to Buckingham Palace to assess her children and advise on their education. Sherlock Holmes was following phrenological principles when he deduced from a large hat that the wearer was highly intellectual. The American poet Walt Whitman was so proud to be well-developed ‘in all faculties’ that he published a chart of his own head, bumps and all. Medical research supported the phrenologists’ teaching that various parts of the brain had various functions. Dr Francis Campbell, a devoted phrenologist, was superintendent of Tarban Creek Asylum for 20 years from 1848. Many now see him as the father of clinical psychiatry in Australia. By the 1870s phrenology had lost much of its scientific respectability, but it still had great popular appeal. Recently displayed at an exhibition in Sydney was a deathmask of the bushranger Captain Moonlite (born Andrew Scott), hanged in 1880 at Darlinghurst Gaol. One phrenologist said: Moonlite’s head was so peculiarly formed that it was impossible he should speak the truth or be honest . . . and that he cared not how he gained his ends.

Another, also with the benefit of hindsight, noted the ‘animal propensities’ in a drawing of Ned Kelly. Of course, cynics complain that, like psychoanalysis, phrenology can explain everything, but predict nothing. Though the beliefs of Gall and Spurzheim were incorrect, they did stimulate the advancement of science. Perhaps we should see phrenology as a necessary wrong turning in the search for truth; Dr Edward de Bono would approve. (GB)

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Chapter

TREATMENTS

6

AND

DISCOVERIES

THE

DISCOVERY OF INSULIN

Until the early 1920s the diagnosis of severe diabetes was a death sentence. Diabetics died young. Unable to produce sufficient insulin in their pancreas gland (sweetbread), they couldn’t use enough of the carbohydrates they ate. They hovered on the brink of starvation and poisoning caused by their own disturbed body chemistry. Doctors could do little: to keep down the levels of blood sugar and toxic chemicals, semi-starvation was the common treatment. Then in 1921 at the University of Toronto, Frederick Banting, a GP and Surgeon aged only 30 teamed up with Charles Best, a medical student. Both were new to medical research, but after working on a shoestring for only eight months, they extracted a chemical from a dog’s pancreas that lowered blood-sugar levels in humans.

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In October 1922, at a medical meeting in Adelaide, Professor Brailsford Robertson, who had worked with Banting and Best in Toronto, described their work. Soon he modified their methods and prepared insulin from beef pancreas. Within a year he increased the yield one hundredfold! Dr John Wilkinson, a physician at the Melbourne Hospital, persuaded the Insulin Committee in Toronto to license the Melbourne Commonwealth Serum Laboratories (CSL) to extract insulin. Within six months, Australian doctors had enough reliable insulin to treat 25 diabetics. By November 1923 insulin was available to physicians in the main hospitals in Brisbane, Townsville, Sydney, Melbourne, Bendigo, Adelaide, Perth and Fremantle. These were the hospitals that could accurately measure blood-sugar levels, an important part of controlling diabetes. But even at cost price, patients found insulin expensive: five pence per unit, later down to two pence. Many had to depend on the public charity hospitals. Some newspapers spread wild claims that insulin could actually cure diabetes. This was quite wrong; it is a question of control, not cure. At the other extreme, many doctors opposed its use altogether. A Cambridge researcher wrote in the British Medical Journal: The production of insulin originated in wrongly conceived, wrongly conducted and wrongly interpreted . . . experiments.

The respected Medical Journal of Australia was also negative: it is extremely unlikely that all the manifestations of human diabetes mellitus could be permanently kept in abeyance by insulin.

It predicted: ‘hundreds of diabetics . . . hastening to their graves . . .’ Some doctors feared that insulin would lower blood-sugar levels too much. For example, Sydney University’s Professor of Medicine did not even mention insulin when lecturing on diabetes in 1923.

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But Dr Wilkinson hailed insulin as ‘the greatest discovery of modern medicine’. By 1924 it was standard treatment for young people with diabetes. However, the severely restricted diets continued as well, and acute diabetic ketosis (chemical crises) still claimed many lives. To meet the demand, CSL staff found further sources of the chemical, such as frozen pancreas from interstate abattoirs. They also worked towards extracting purer insulin. In Canada one of Banting’s first patients called insulin ‘unspeakably wonderful’. This praise applies equally to the efforts of the Australians who produced it so quickly and reliably, and to the medicos who used it. They saved the lives of many dying children and young adults. Phyllis Adams of Mosman in Sydney was five when she developed diabetes in 1921. By late 1922 she was very ill and weighed only about 9 kg. Her daily diet was reportedly whey, a teaspoon of butter and one lettuce leaf. Her father Henry read about Banting’s work and wrote to him in Canada. A ship’s purser brought her insulin from Canada, with Henry on a tugboat meeting the ship in mid-harbour. Phyllis was waiting on the wharf with their doctor, who injected her on the spot. So Phyllis became the first patient in Australia to receive insulin. She had three injections a day, first by her GP, and later by her parents. She improved at once. Phyllis has led an active, full life. By 1992 she had been on insulin for 70 years, probably a world record. (GB)

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MALARIA

AND QUININE

Throughout history malaria has killed more people than every plague and war put together. Some historians even blame malaria for the fall of Greece and Rome. It is said to have turned Africa into ‘the white man’s graveyard’. In seventeenth-century Peru the Spaniards ruled royally over the poor native Indians, who were descended from the Incas. Perhaps the only thing the rulers and the ruled shared was the curse of malaria. In about 1630 Jesuit missionaries brought exciting news back to Spain. The bark of the cinchona tree from the high Andes, which the Indians used as a medicine, could suppress malaria. According to one report, the Indians were following the lead of jaguars that gnawed on the bark to cure themselves of fever! One story has it that the first European to discover this remedy was a Spanish soldier in the wilds of Peru. Because he was so ill and feverish with malaria, his comrades left him behind to die. Somehow he dragged himself to a pool of bitter water, where he drank. When he awoke next morning, he was miraculously recovered and he caught up with his friends. They all went back to check the pool, in which they found a cinchona log. The Indians called the tree quina-quina (the bark of barks); hence our term quinine. This was the first specific remedy for a specific disease, and probably more valuable than all the gold and silver that the Spaniards took home from the New World. Over the centuries, quinine has helped more people with infectious disease than any other drug. Carolus Linnaeus, the great Swedish naturalist, later named the tree cinchona in honour of the Countess of Chinchon, wife of the Spanish king’s viceroy in Peru. After the bark relieved her own malaria, she passed the remedy on to the poor and finally brought it to Europe. A fresco even shows the countess with a cup of extract of cinchona while a Peruvian Indian holding a bundle of the bark kneels humbly at her feet.

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This charming story has everything in its favour except the facts. The first Countess of Chinchon died without ever leaving Spain, while the second died in the New World without ever returning. As word of the remarkable remedy spread, demand soared. Since Jesuit priests held a virtual monopoly on its importation into Spain and Italy, people called it ‘Jesuit’s Bark’ or ‘Jesuit’s Powder’. But many doctors resisted new remedies, especially those linked with the detested Jesuits. From 1649 the Jesuit scholar Cardinal John de Lugo, though in his seventies and himself weakened by malaria, spent his last decade of life promoting the bark around the capitals of Europe. His instructions show that he understood the cyclical pattern of malaria attacks and hence the need to take repeated doses: This bark . . . is used against quartan and tertian fever . . . two drams of finely ground and sifted bark mixed in a glass of strong white wine, three hours before the fever is due.

De Lugo advised readers to take the cure under doctors’ orders, but most people just dosed themselves any old way. Those who recovered rushed out to tell all their friends. Many also mistakenly took the bark for other types of fevers, from bubonic plague (the ‘Black Death’) to pneumonia. Super-optimists even quilted it into the lining of their jackets! In 1652 the Archduke of Austria took the bark and recovered from his malaria, but he was hopping mad a month later when he suffered another attack. Unlike de Lugo, his doctor, Jacob Chiflet, did not realise the need for repeated doses, so the Archduke died. However, first he commanded Chiflet to denounce the futile treatment. Chiflet’s book The Exposure of the Febrifuge Powder from the American World reinforced the scepticism of his colleagues. The bark did not reach Protestant England until 1654, over 20 years after the first reports reached Europe. Malaria was so rampant at the time that London was like a large infirmary. Oliver Cromwell, the Lord Protector and devout Protestant, came down

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with it and since he could not bring himself to take Jesuit’s Powder, he took his principles to the grave. One man who benefited from the epidemic was Robert Talbor. He had picked up a touch of medical knowledge as apprentice to an apothecary and moved to Essex where the epidemic was especially rampant. Scorning all mainstream doctors, he quickly became the world’s leading alternative therapist. Reports of his dramatic cures trickled back to the Royal College of Physicians. ‘Ridiculous,’ they laughed. How could an ignorant quack cure malaria when London’s finest doctors could not? Of course, doctors in England still did not prescribe Jesuit’s Powder. No matter how many patients they lost, they bled them instead! According to a scurrilous verse, the well-known Dr John Lettsom used to boast: When people’s ill, they comes to I I physics, bleeds and sweats ’em. Sometimes they live, sometimes they die. What’s that to I? I lets ’em!

Soon Talbor set up in London itself, where the nobility flocked to him. He chose to bleed them financially rather than physically. Talbor stubbornly refused to specify the contents of his remedy. He warned: ‘Beware of all palliative cures, and especially Jesuit’s Powder, for I have seen most dangerous effects.’ When King Charles II himself got the dreaded malaria and called for Talbor, the royal physicians screamed blue murder. After Talbor duly cured the royal fever, Charles knighted him, made the doctors admit him to the College and warned them not to ‘give him any molestation or disturbance in his practice’. However, English Protestants were convinced the Jesuits were poisoning their king, and there were riots in Whitehall. Malaria struck another royal when the French King’s heir, later to become the great Louis XIV, fell ill. Naturally, Talbor was called in. Hoping to expose his ignorance, French doctors asked him:

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‘What is a fever?’ ‘I do not know. You gentlemen may explain the nature of a fever, but I can cure it, which you cannot!’

When Talbor refused to sell the formula of his ‘Wonderful Secret for Curing Agues and Fevers’, Louis upped his offer. If he would just write his prescription, Louis would lock the sealed envelope away in a safe until Talbor died. The ‘feverologist’ took his 3000 crowns plus his life pension back to England. When Talbor died in 1681, and Louis opened the envelope, the world was shocked. The secret: rose water, lime juice, wine and Jesuit’s Powder! Talbor had the last word. Years before, he had erected his own monument in Trinity Church Cambridge and written the inscription: The most honourable Robert Talbor, Knight and Singular Physician, unique in curing Fevers, of which he had delivered Charles II of England, Louis XIV, King of France . . . and a large number of lesser personages.

By the end of the seventeenth century, huge shipments of bark were leaving the New World. Jesuit’s Powder often fetched its weight in gold! In 1820 the French chemists Pierre Pelletier, 32, and Joseph Caventou, only 25, extracted quinine from cinchona bark. To let the world share its benefits, they did not patent their methods. Now chemists could compare the quinine content of various barks and doctors could prescribe measured, effective doses. But why was there still never enough bark or quinine? Firstly, malaria was (and still is) very common, affecting thousands of people worldwide. Secondly, cinchona trees take about ten years to mature. Though the Jesuits had warned that everyone who stripped bark and so killed a tree should plant a new tree, few barkcollectors bothered. Finally, only a dozen or so of the 40 species of cinchona tree have any effect against malaria. The best trees are scattered 1000–3000 metres above sea level in the remote,

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inaccessible areas of the Andes rainforests. Clearly, South America alone could never meet the enormous demand for quinine. Both the English and Dutch had millions of subjects living in malaria-ridden dominions. Both tried to find the best seeds or plants in South America, smuggle them out and grow cinchona trees in India and Java respectively. In 1859 Clements Markham led a British expedition to Peru. He was neither botanist nor horticulturist, but his dream was to protect everyone in India exposed to malaria for ‘less than a farthing a day’. On his return Markham claimed optimistically that the introduction of Peruvian bark trees into British India and Ceylon was a huge success. But he was dead wrong. In the end, the English chopped down over a million of his useless, quinine-free trees. While in South America Markham may have met the bark-trader Charles Ledger. Ledger sent his Indian servant Manuel to harvest seeds from a grove of especially rich trees in Bolivia, but since local law forbade the collection of seeds for export, poor Manuel ended up in gaol, where he was beaten and starved to death. Ledger sent Manuel’s 6 kg of seeds to London. He asked his brother George to offer them to the government for their cinchona plantations in India. However, after the Markham fiasco, the government would not touch the seeds. So George Ledger went to Holland, where to his dismay, the Dutch bought only half a kilo. Back in England, George finally found a planter, named Mr Money, who bought the remaining seeds. If only he had realised that those seeds would create a quinine monopoly worth over ten million dollars, Mr Money would have lived up to his name. Instead the poor man exchanged them at the British Indian plantation for another species of cinchona seed. As Charles Ledger had hoped, most of Manuel’s seeds finally did get to India. However the British lacked the touch and lost nearly all the seedlings. In 1865 the Dutch sent their half kilo of Manuel’s seeds to Java, where government planters tended them obsessively. Within a year

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or two they had 12 000 young seedlings. Some of the new bark yielded over 8 per cent quinine, compared with 3 per cent from the older trees! The grateful Dutch named the new trees Cinchona ledgeriana. Most of the other nations that later acquired the seeds (the English in India, Malay and Jamaica, the French in Indochina and the Belgians in the Congo) lacked a green thumb. The Dutch therefore controlled the plantations that were the main source of what was the only effective treatment for malaria. In Java they built the world’s largest quinine factory. Once the planters and manufacturers put their heads together in 1913, the Kina Bureau was born. The bureau set the quotas for planting, the amount of quinine to be manufactured and of course its price! The Dutch monopoly even managed to survive a challenge from the US government. In 1934 the League of Nations reported that one-third of the human race suffered from malaria. Compared with world demand the amount of quinine being produced was hardly significant. At the start of World War II, the Dutch still controlled 80–90 per cent of the world trade. Soon the Japanese seized the plantations in Java and cut off the quinine supply. Allied troops had to resort to quinine from specially collected South American bark. The acute quinine shortage also stimulated the continuing search for synthetic antimalarial drugs. In 1944, two Americans finally succeeded in making synthetic quinine, but it was too expensive for mass production. These newer drugs, and the use of DDT to control the mosquitoes that carried malaria, challenged the dominance of quinine. However some strains of the malaria parasite became resistant to the synthetic drugs. As we approach the new millennium, 250 million people each year will get malaria; at least 2.5 million each year will die from it. It will be a long wait before malaria, like smallpox, becomes a disease of the past. (GB)

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C URARE: THE ANAESTHETIST’S ARROW OF DESIRE That well-known soldier, sailor, pirate, courtier, poet and general layabout, Sir Walter Raleigh, is generally regarded as being the first to introduce the potato and tobacco into the Western world. Despite these dubious initiatives, his life was brought to an abrupt end on the scaffold in 1618. Not, however, before he had published a thesis which set off a cosmic chain reaction in medical circles. For in 1595 he wrote about the physical effects in humans of the poisoned arrows of the South American Indians. It is the refined derivatives of this substance which are used as muscle relaxants in anaesthetics today, and which have made modern surgery possible. Without turning your stomach too much, let me quote Raleigh who wrote of ‘a most ugly and lamentable death’, of paralysis and of ‘bowels breaking out of their bellies’. The secret of the concoction was passed from father to son, and all that the traveller could ascertain ‘either by gift or torment’ was that it was made from the juice of a root called ‘Tupara’. The odd thing was, he noted, that this same fluid if taken orally was not only apparently non-toxic, but ‘quenched marvellously the heat of burning fever, healed inward wounds and broken veins’. Regarded by contemporary society as an oddity of the New World, there the matter rested for 317 years. It wasn’t until Charles Waterton, a typically upright, if somewhat eccentric, Yorkshireman travelled to South America to collect specimens of these longforgotten poisons that the subject was raised again. The Watertons had lived in Walton Hall near Wakefield for centuries. Indeed in 1857, during Charles’s tenure, a swivel cannon was dredged from the estate lake, mute witness to the unsuccessful siege which Cromwell had laid on the place in the 1640s. Squire Waterton was an active, enterprising man who transformed the 300-acre grounds into England’s first nature sanctuary. It is said, that so as not to disturb bird fledglings, fish in

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the lake were not reeled in for the Friday meal, but shot with a bow and arrow. A further eccentricity is that to assuage his guilt feelings regarding his wife’s death, he chose to sleep on the floor with a wooden pillow for the next 30 years instead of going to bed. It is also said that he bled himself frequently and profusely for his health’s sake, and wore clothes of such a tattered and verminous nature that he was usually shown to the servants’ hall when visiting his neighbours. Nonetheless Charles Waterton lived to the age of 82, and sounded just the man to go and paddle up the Amazon to track down the legendary poison vine of Sir Walter Raleigh. Waterton made his first voyage in 1812, to Demerara, famous for nothing more lethal than brown sugar. He quickly located the suspected source of the poison, the Wourali vine, and ascertained that the strongest brew to be used on blowpipe darts and arrows was concocted by the Macoushi tribe. The arrows, he found, were made with detachable tips with protective caps which were slipped on when carried. When shot, a sloth died within ten minutes and an ox in 25. Although the main constituent was from the vine, other additives were part of the grand formula. These comprised extract of a bitter root, the juice from two unidentified bulbous plants and two species of ant crushed and added to taste, so to speak. To this was introduced strong Indian pepper and the powdered fangs of the Labarri and Counacouchi snakes. The whole was then boiled for two days, put in a pot and dried. To add to the mystique, no women must watch the manufacture and a new pot must be used each time. In the subsequent publication, with its delightfully low-key nineteenth century title, Wanderings in South America, he observed that the poison was harmless if it did not come into contact with the blood; indeed drinking the blood of the quarry was quite safe. After appraising the blend Waterton doubted whether all the ingredients were necessary and he started investigating the effects of each.

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The traveller brought some of the concoction back to England and tried it on various animals. And it is here at last, you will be glad to know, that the first possible medical implications appeared. Perhaps not unexpectedly, the cryptic signs of a wider use in humans were missed by the experimenter, but he was slowly stumbling towards a clinical application for the brew. While in the jungle Waterton had been told that a person rendered unconscious by the poison could be revived with the aid of bellows, provided the effort to inflate the lungs was carried on for long enough. With this in mind the experimenter proceeded so that, as he put it: a she-ass received the Wourali poison in the shoulder, and apparently died in ten minutes. An incision was made into the windpipe, and through it the lungs were regularly inflated for two hours with a pair of bellows. Suspended animation returned . . . but on stopping inflation she sunk once more into apparent death.

Artificial respiration was resumed, and the animal recovered completely. The donkey, aptly renamed Wourali, was subsequently turned out onto the estate at Walton Hall to see out the rest of her days in full consciousness, still to be spoken of fondly wherever anaesthetists are gathered together. The curious Yorkshireman had inadvertently stumbled upon the muscle-relaxing properties of the drug as distinct from its fatal effect. Regrettably, this aspect was not recognised until long after our hero had died, hence his presence in the footnotes of medical books rather than the text itself. While Waterton may have missed the real significance of the jungle juice, he did have an idea that the Wourali poison would cure the characteristic muscle spasms of hydrophobia (rabies). However, he never got to try his theory on a real live patient, for after having been summoned as a therapeutic expert

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of last resort, invariably when he arrived the victim had already succumbed. In 1841 Robert Schomburgk examined the pharmacology of the South American poison. He concluded that all those gobbets of snake and ants were unnecessary, and the active ingredient was the juice from the plant Strychnos toxifera, a ‘ligneous twiner or bushrope and only known to grow in three or four situations in Guiana’. He went on: The Macoushi call the poison itself Urari (pronounced ourahree) . . . and we find the proper name of the poison mentioned already by Keymis in Hakluyt (vol III, p. 687) where under the names of poisoned herbs occurs the plant “Ourari”.

Obviously, both names are pretty close to Curare, the name we now use. Years later, during the 1930s when it was being looked at seriously as a pharmacological tool for use during surgery, the raw material which the experimenters received from the importers was so crudely presented that it was named according to the vessel in which it arrived. If in a gourd it was known as ‘Gourd’ or ‘Calabash’ curare, if in an earthenware pot, ‘Pot’ curare, and if in bamboo tubes, ‘Tube’ curare! Tube curare was a black shiny resinoid mass, and it was from this variety that the crystalline extract ‘d-Tubocurare’ was obtained and named accordingly. In 1935 it was called d-tubocurarine by Dr Harold King. Schomburgk had also noted that if wounded by an arrow tipped with poison, the ensuing thirst was almost intolerable. Even stranger was the fact that death always followed if the thirst was quenched with water. Sir Walter Raleigh had made the same observation, and also noted that the concoction took at least two days of continuous boiling to bring up to battle standard, but once made, its potency was retained.

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In the last century the great French physiologist, Claude Bernard, showed that the paralysing effect of the drug was due to the interruption of the neuromuscular conduction mechanism involving acetylcholine. Initially it was used in the Western world as a treatment for tetanus, and in 1942 given for the first time as a muscle relaxant during an anaesthetic by Dr Harold Griffith of Montreal in that city’s Homeopathic Hospital. At the end of World War II, when gaining increasing recognition, it was in such short supply that if the anaesthetist had a bottle, he jealously guarded his supply by carrying it about in his waistcoat pocket. The stuff produced then was still a mixture of plant extracts with the constant element being Strychnos toxifera. Curare has generally been succeeded as a muscle relaxant by more refined synthetic products, but it is still obtainable. It provides a unique direct link between ancient and timeless jungle science and flashy modern technology. (JL)

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DYING

TO CONQUER YELLOW FEVER

During the short Spanish-American war of 1898, more American soldiers died from ‘Yellow Jack’ — yellow fever — than from Spanish bullets. The US victory forced Spain to give up Cuba and enabled the Americans to place a garrison there. But this foothold in the Caribbean was a mixed blessing. There was no treatment for yellow fever, and the death rate at times reached 85 per cent. Major Walter Reed was a top medical troubleshooter of the US Army. In early 1900 Reed’s commanding officer sent him to Havana to conquer yellow fever. Reed’s medical staff of four included James Carroll and Jesse Lazear. Several researchers believed they had already isolated the germ causing yellow fever. By careful tests on 18 yellow-fever patients, Reed’s doctors tried out these theories, only to dismiss them all. They could find no trace of a germ causing yellow fever (later it turned out to be a virus). So in desperation, they changed tack. If you couldn’t find the organism, find out how the disease spreads from one person to infect another. But they failed to infect any experimental animals with yellow fever. So, despite the risks, the doctors had to work on humans. Should they look for volunteers or become their own guinea pigs? They ended up doing both. Sir Ronald Ross’s recent identification of the mosquito as the carrier of malaria gave them something to test. The American doctors met Dr Carlos Finlay, a local physician, who had been preaching for 20 years that a specific mosquito (Aëdes aegypti) carried yellow fever. So the doctors hatched the mosquito eggs that Finlay had collected, kept each mosquito in a separate test tube and then experimented with these mosquitoes. On 11 August they let mosquitoes that had fed on patients ill with yellow fever bite Dr Carroll and eight other volunteers. No one

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fell ill. But, the doctors thought, yellow fever (like malaria) may need some time inside the mosquito (an incubation period) before the mosquito can infect another human. So they waited until 27 August and repeated the experiment with the same mosquitoes. This time, after four days, Carroll came down with a critical attack. For a week he hovered between life and death. In the end he survived, but with permanent heart damage that later killed him. Sadly, even this nearly fatal experiment was inconclusive. Yellow fever was everywhere. Carroll had been in Havana, in the wards, and the post-mortem room; he could have caught it anywhere. So they got the same mosquito to bite a cavalry trooper who had definitely not been exposed to yellow fever. He did get a mild attack. So far, so good; it looked like mosquitoes could spread yellow fever. Thirteen September 1900 was an unlucky day for Jesse Lazear. He was letting his mosquitoes in test tubes feed on the yellow fever patients when a stray mosquito bit him. Five days later, Lazear himself fell ill. First fever, then jaundice, then: ‘the black vomit would spurt from his mouth’. Lazear died, leaving destitute not only his wife and son, but a baby daughter he had never seen. A mile out of town his colleagues set up ‘Camp Lazear’. There Reed offered volunteers $200 to expose themselves. A soldier and a clerk came forward, but refused the money. First the men spent weeks in quarantine (to prevent accidental infection). Then the doctors exposed the soldier to the bites of five mosquitoes that had 15–19 days before bitten men dying of yellow fever. Good news; not only did he get yellow fever; but he recovered. Five Spanish volunteers were quarantined, then bitten; four got yellow fever. But still Reed wondered: could there be another path of transmission? In November 1900, three volunteers — a doctor and two soldiers — settled into a mosquito-proof house in Camp Lazear. They brought sheets and blankets soiled with the discharges of men dying of yellow fever. Their pillows were black with the mens’

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vomit. First they shook all the contaminated linen to spread any poison all around the house. Then they made up their beds and lived there for 20 days and nights. Lastly, they remained quarantined in a mosquito-proof tent. Not one man got yellow fever. Then Reed stepped up the exposure. He repeated the experiment with three more volunteers; as well as using the exposed linen, these men wore the pyjamas in which the yellow-fever patients had died. Next, another three men had the same exposure, but on top of that slept on pillows covered with the dying men’s blood. All nine remained healthy. But what if these nine were already immune to yellow fever? That would invalidate Reed’s conclusions. So he injected one of the nine with infected blood and had infected mosquitoes bite another. Both got yellow fever; both recovered; obviously they were not immune to the disease. Camp Lazear’s second house was clean and had a fine-meshed screen dividing it in half. Starting on 21 December the clerk exposed himself three times to 15 infected mosquitoes. His Christmas present was an almost fatal dose of yellow fever. But the two men who slept for 18 nights in the other half of the house, protected from the mosquitoes, were fine. Reed had shown that a dirty pesthole of a house, without mosquitoes, was safe; but a clean house with mosquitoes was dangerous. He reported that only the bite of the Aëdes mosquito allowed the yellow-fever organism (then still not identified) to pass from person to person. Moreover, direct person-to-person contact would not spread yellow fever. Then American army physician Dr William Gorgas applied Reed’s results with convincing success. He quarantined all patients suspected of having yellow fever to prevent mosquitoes biting them and then transmitting the disease. As well, he destroyed the mosquitoes’ breeding grounds. In only seven months in 1901 this dual strategy enabled Gorgas to eradicate yellow fever in Havana. Later, between 1904 and 1914, by attacking the mosquitoes

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carrying yellow fever and malaria, he enabled workers to complete the Panama Canal. It was some years later that South African Dr Max Theiler after working with monkeys and mice was able to produce the live yellow-fever vaccine that won him the Nobel prize. But there was no prize for Dr Jesse Lazear who had given his life for the cause. (GB)

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CONTRACEPTION

BECOMES UNSTOPPABLE

Whether you call it birth control or family planning, it’s been around for thousands of years. The measures have been as varied as their rates of success. Hence the frequent resort to abortion and infanticide. In ancient times, when health, medicine and religion were more closely intertwined, the Shamans or Witchdoctors reigned supreme. If a woman didn’t want any more children, they had ways to make her womb bend backwards. Successful herbal recipes included grain contaminated with ergot, and yam-like plants. The Euduna claimed that mothers who ate white bread would have half-white children. In Madagascar natives thought that once they lost their virginity women would just inevitably keep having children. So why bother with any further contraceptive? The Chinese promoted coitus reservatus (intercourse without ejaculation) as improving mind, body and potency. To prevent conception they also advised women to swallow 16 tadpoles fried in quicksilver. Women of Martinique in the West Indies used douches of lemon juice and an essence of mahogany husks. Pottery decorations show that the Indians of Peru practised both oral and anal intercourse. Canary Islanders practised no contraception, but got by in other ways. When food got scarce, they killed all the newborns after the first. Many cultures recognised the dangers of inbreeding; religious taboos and legal restraints were common. The ancient Hebrews had hazy views on heredity. They happily allowed marriage to nieces, but not godchildren or relatives by marriage! Coupled with Moses’ command to the children of Israel to multiply, the biblical instruction against intercourse too close to the time of menstruation suggest some ancients knew when women were fertile.

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When a woman has a discharge of blood that is her regular discharge from her body, she shall be in her impurity for seven days, and whoever touches her shall be unclean . . . (Leviticus 15:19)

To us this sounds obvious enough, but many others got it quite wrong. Some tribes believed that in humans, as in some animals, bleeding marks the fertile phase of the cycle. This furphy persisted in some quarters till modern times; it must have given the population quite a boost! The Roman philosopher Lucretius taught that women who remained passive during coitus were more likely to get pregnant, while the orientals taught the exact opposite. Sanskrit writings from India advised women to insert a pessary of rock salt dipped in oil: an unpleasant way to kill sperm. They also knew about coitus obstructus, in which either partner compresses the base of the penis, diverting the semen backwards into the bladder. From Egypt, the Petri Papirus describes pessaries containing crocodile dung, or honey and sodium carbonate. The greatest gynaecologist of ancient Greece was Soranos of Ephesus. To induce sterility, he advised women to drink water in which a blacksmith’s forceps had been cooled. This recipe remained popular for centuries. Some trendy Egyptian women even had their ovaries removed. Think about that: thousands of years before anaesthetics or antiseptics. Paintings and sculptures show women of the nobility as having few children and retaining their figures. The origins of the condom are uncertain. By about 1200 BC, the Egyptians wore a sheath over the penis. Was it just a protection against insect bites or injury? Or was it so they would be prepared whenever opportunity knocked? The Romans may have used a goat’s bladder as a male or female condom, but it was the inventive Japanese who first cornered the cute coloured-condom market. As well, they sometimes enclosed

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the penis in a helmet of tortoise shell! Other extras have included sheaths of gold, silver, lead, copper, ivory, wood and leather. African women used a hollowed-out okra pod as a vaginal pouch, or primitive female condom. In the Middle Ages, Muslims practised both contraception and abortion. As well as pessaries, they set great store by contraceptive amulets or charms. One contained a child’s milk tooth, and dangled near the anus. Another was made of myrtle and berries soaked in the milk of an ass, then wrapped in the skin of a hare. To remain effective, the amulet could not touch the ground! The famous Arab physician Rhazes hedged his bets. For starters, he listed many standard methods of contraception (including a condom of animal membrane). However he also advised a gymnastic approach for the woman to rid herself of semen: Immediately after ejaculation let the woman arise roughly, sneeze and blow her nose several times, call out in a loud voice, and jump violently backwards seven to nine paces.

Avicenna suggested inserting tar into the vagina. He also had advice for the guys: anoint the penis with white lead, tar, or oil; a later physician said try onion juice! The Roman Catholic Church in the Middle Ages set taboos, some of which remain in force to this day. Saint Thomas Aquinas wrote: Insofar as the generation of offspring is impeded, it is a vice against nature which happens in every carnal act from which generation cannot follow. Whenever pleasure is the chief motive . . . it is a mortal sin; when it is an indirect motive, it is a venial sin, and when it spurns pleasure altogether and is displeasing, it is wholly void of venial sin.

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In the sixteenth century, cautious condom lovers had a second incentive: to ward off the raging syphilis. About 1674 the great microscopist Leeuwenhoek saw the first human spermatozoa: ‘moving forward with a snakelike motion of

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the tail, as eels do.’ The male chauvinists of the time shared Aristotle’s belief that the spermatozoa themselves would grow into humans, the mother being only an incubator. They rushed to use the newfangled microscopes and reported seeing little humans with heads, legs and arms. One animal-lover even saw galloping horses in the semen of a stallion! The Italian adventurer Casanova (1725–98), used a smorgasbord of contraceptive devices. He trusted the condom, which he called ‘the English riding coat’ and also a squeezed out half-lemon as a vaginal cap. But Casanova’s greatest investment was an upmarket contraceptive pessary. From a Genoese goldsmith he bought three gold balls, which he soaked in an alkaline solution before each insertion. These balls served him well for 15 years. In the last century, a keen trader at London’s Petticoat Lane flea market made a mint selling condoms bearing the likeness of Queen Victoria. But once she sent word that she was not amused, that was that. (GB)

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DUTCH

DOCTOR DEFUSES DEFICIENCY DISEASE

A vitamin is a substance that makes you ill if you don’t eat it. — Albert Szent-Györgyi, biochemist

In 1993 the Japanese government restored the oldest known Japanese graves in Australia. These belonged to three Japanese sailors from the naval training ship Tsukuba, which made a goodwill visit to Melbourne in 1882 after being at sea for 43 days. The Argus reported: The men died . . . from the ‘berri-berri’ fever, after an average period of 41 days’ illness. The fever does not appear to be contagious, for Dr Figg reports the remainder of the . . . crew to be free from it. The bodies . . . will be interred with naval honours in the Williamstown cemetery.

These three sailors were among the last Japanese sailors to die of beriberi. The Australian doctor was well ahead of his time when he noted that the fever was not contagious. Beriberi may affect the nerves and so produce loss of feeling, weakness and even paralysis of the legs, hands and arms. Some people become breathless and their legs become swollen. Within two years of the sailors’ death, Dr Kanehiro Takaki, Director of the Japanese naval medical service, declared that beriberi had a dietary cause. Moreover, he persuaded the Japanese Navy to change sailors’ diets and so eliminate beriberi. In the early 1880s the disease was affecting about 1500 Japanese sailors each year. By 1887 there were no cases. How did this man know so much about a disease that still baffled most doctors? As a young man, Takaki had studied medicine in London. When he returned to Japan he decided that the key to beriberi lay

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in the diet. Then he tested his theory. Takaki was well ahead of his time in setting up a controlled human trial. He used two ships on voyages of similar lengths. The first ship carried the palatable, popular diet of white rice. As usual, over half of these sailors got beriberi and many died. For the second ship, Takaki designed an enriched, British-style diet, including not only rice, but also vegetables, bread and condensed milk. Those who accepted the diet stayed well. But those 14 sailors who could not cope with this barbarous foreign food did get beriberi. But Takaki was mistaken in blaming beriberi on lack of nitrogen or protein. That’s not surprising, since no one yet knew about vitamins. Takaki’s successes convinced the naval authorities, but Japanese army doctors and medical leaders in Europe were still sure they knew better. They continued to believe that beriberi was infectious. To this day, Takaki has not received the recognition he deserved. Most English-language historians still ignore his work and the Nobel prize went to two later researchers on beriberi. If only Dutch colonists in the East Indies (now Indonesia) had followed Takaki’s lead, thousands of their labourers would not have perished. Moreover, it was largely beriberi that prevented Dutch troops from suppressing native revolts. So during the 1890s the Dutch sent out Christiaan Eijkman (1858–1930), a young army doctor, to track down the germ that they were sure caused beriberi. In his military hospital laboratory, Eijkman tried for years to induce the disease by injecting chickens with ‘infected’ blood from patients with beriberi, but he had no luck. Then he noticed other chickens in the yard swaying, twitching and even dying. Louis Pasteur said fortune favours the prepared mind. Eijkman was prepared; he found out that the cook was feeding them leftover hospital rice. Of course this was the ‘superior’ polished white rice enjoyed by patients, including some with beriberi. Then came a new cook who refused to feed civilian

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chickens with military rice! When the cook switched them to the cheaper, ‘inferior’, unpolished brown rice, the chickens recovered. By switching the chickens’ diets, Eijkman could not only induce but cure beriberi. But still he could not transmit this ‘infectious’ disease by injection. Now he looked at prisons in Java. Here beriberi was common, but only where the inmates ate polished rice. Of 100 000 prisoners who ate unpolished brown rice, only nine had beriberi. But of the 150 000 who ate polished white rice, 4000 were ill. Still thinking of a germ or poison, Eijkman thought the polishing process must be infecting or contaminating the rice. He then made a brew from the rice bran discarded in polishing; when he fed this to the sick prisoners, they all recovered! Finally Eijkman realised that the cause of beriberi was not a germ, not a poison, but the lack of something. The Western-style steam-powered rice mills were actually removing the important bran coat of the rice seed and so causing a deficiency! Even now, many experts would not believe Eijkman, especially since he could not isolate the active component. Moreover, most doctors from other countries were not aware of his findings since they could not read his articles in Dutch medical journals. In 1912 Frederick Hopkins, a biochemist at Cambridge, used rats to prove the existence of the ‘accessory food factors’, that we now call vitamins. Hopkins and Eijkman shared the Nobel prize in 1929; by then Takaki had died. The Polish scientist Casimir Funk first extracted the antiberiberi factor from rice bran. Vitamin B1, also called thiamine, was the first vitamin to be identified. Scientists synthesised it about 1936. Vitamin B1 is vital to all animals and plants. This beriberithiamine link later turned the spotlight onto other deficiency diseases. We now suspect that a mixture of beriberi and scurvy (deficiency of vitamin C) killed our explorers Burke and Wills in 1861. But as we approach the year 2000, beriberi still afflicts and even kills people around the world. People who for long periods eat

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poorly. Among those at risk are alcoholics, people with mental diseases, prisoners and above all, the poor. Now that we know the cause, why can we not prevent beriberi? Medical advances come slowly, but their general applications come even more slowly. The practice of public health has more snakes than ladders. (GB)

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TRANSFUSIONS

AND BLOOD GROUPING

Blood transfusion has been carried out hazardously and spasmodically since the seventeenth century. Not until the discovery of blood groups in 1900 did it become comparatively safe, though transmission of the AIDS and Hepatitis C viruses shows it is not absolutely foolproof even now. Human-to-human blood transfusion was first proposed in 1640 by an Oxford parson, Francis Potter. He thought of it when mulling over Ovid’s story of Medea and Jason. In this essay, Talos, guardian of Crete, and a tormentor of Jason on his quest for the Golden Fleece, had a membrane in his foot through which his vital fluid flowed. Medea succeeded in cutting this and killing him. You have to have a special kind of mind to link that with blood transfusions but Francis Potter did. Anyway, after this flimsy and somewhat obtuse inspiration, the first actual transfusion was carried out between two dogs in 1665 by Dr Richard Lower, also of Oxford. This procedure was said to have been at the prompting of Christopher Wren. It caused some consternation in scientific circles and in response to a ‘please explain’ by Robert Boyle, President of the Royal Society, Lower wrote on 6 July 1666 how he had opened the cervical artery of the donor dog’s neck, and inserted ‘a quill in the direction of the heart’. In the recipient dog, the jugular vein in the neck was located and two quills inserted; one in the direction of the ‘trunk of the descending vena cava to receive blood’, the second pushed upwards ‘towards the brain and to discharge the animal’s own blood into suitable vessels’. The dogs were then fastened closely together and the blood let flow ‘until the second animal amid howls, fainting and spasms finally loses its life together with its vital fluid’. Doubtless this was the hoped for outcome, but it was a bit hard on the donor dog.

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Lower had the grace to go on and say: When the tragedy is over, remove both quills . . . sew up . . . let the dog jump down. It shakes itself a little . . . and runs away . . . more active and vigorous with the blood of its fellow than its own.

Well, possibly. In November 1666 Samuel P. Pepys reported in his diary a similar experiment and noted the accompanying coffee house ribaldry, especially if the experiment involved humans. For instance, there was much speculation about the effect of ‘the blood of a Quaker being let into an Archbishop’. In fact the first successful human-to-human transfusion was carried out by Jean Denis in Paris, in June 1667. Both subjects lived, I am certain more by good luck than good management. A refinement took place in November that year when Lower demonstrated to the Royal Society the transfusion of blood from a sheep to ‘a poor debauched man hired for 20 shillings’. Twelve ounces was transferred in one minute. The name of this unsung hero of medicine was Arthur Coga. He must have survived because he later wrote to the Royal Society saying ‘the experiment had transformed me into another species’. He shrewdly claimed that for another pound he ‘would hath more blood’; I am not sure that the hint was taken up. He signed himself off, ‘the meanest of your flock’. A wit, albeit a foolhardy one, for it was not until 1825 that Blundell showed that in humans only human blood should be transfused. Mr Coga was extremely lucky. The real stimulus for giving blood did not come until after 1900, when Landsteiner showed there were differences even in blood within the same species. He defined three groups in man; Decastello and Sturli added a fourth in 1901. Landsteiner’s paper was in German and, with the language difference producing less than ideal communications, two other workers independently demonstrated the same four groups shortly

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after — Jansky, who wrote it up in a Czech journal in 1907, and Moss in America in 1910. Despite working in the same field, it took Moss three years to come across the Czech paper. By then his effort was in publication, but he inserted a footnote graciously recognising Jansky’s precedence. Landsteiner called his groups A B and C; Sturli had no name for number four; Jansky and Moss used Roman numerals. By chance both used II for Landsteiner’s A and III for his B, but Jansky used I for C and IV for Sturli’s group, whereas Moss reversed this. Confusion reigned and the potential for a lethal transfusion was endless. Because it was written in English, Moss’s nomenclature was preferred in Britain, France and parts of the USA. Elsewhere Jansky’s held sway. In an attempt to bring about some order, in 1921 a special committee recommended the Czech method. As Moss’s was generally used in Europe, it would appear to have been an illconceived plan from the very beginning, and sure enough, bewilderment increased. In 1922 Landsteiner went to work in New York and suggested a compromise with the labels O, A, B and AB for Jansky’s I, II, III and IV and Moss’s IV, II, III and I. This nomenclature was finally adopted, but only after years of confusion. Initially, determining the groups in the lab was not easy on account of red cells clinging together to produce the so-called ‘rouleaux formation’. Testing for compatibility between donor and recipient was even more hazardous. Tzanck in Paris mixed the blood from each and injected them into the heart of a guinea pig. He then stood back and waited. If death occurred, not unreasonably, it was regarded as being a sign of incompatibility. The crudity of the method almost defies belief. Oehlecker in Hamburg injected three different amounts of donor blood into the patient. Breaking down of the cells by haemolytic reactions, if it occurs, were noted in two minutes. In his published paper he wrote with true scientific detachment, ‘in a series of fifty haemolytic reactions there was only one death’.

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Although the A B O classification is the well-known one, other minor subgroups were discovered in the 1930s. In the 1940s existence of the important Rhesus (Rh) factor was demonstrated. It was named after the Rhesus monkey, specimens of which were used in the original experiments. Eighty-five per cent of the population were found to have the factor in their blood. Its lack is especially important in pregnancy because if the mother is Rh negative and the baby Rh positive antibodies can form in the mother’s blood during delivery and affect future pregnancies. Blood transfusions are now an integral part of medical practice. Modern technology has ensured that they have emerged from the confusion of the naming process in the early days to be safe and life-saving. (JL)

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THE

MONKEY GLAND AFFAIR

We humans have always looked for ways to remain young and enjoy longer lives with sexual vigour and good health. Viagra is just the latest creation in this everlasting quest. From ancient times we have associated the testicles with sexual vigour, bravery and longevity. Between the World Wars one Australian and one French doctor offered grateful males a surgical elixir of potency, vigour and long life. Dr Serge Voronoff was born in Russia, but graduated in Paris in 1893. Later he became a fashionable Parisian doctor. Voronoff did his first testicular grafts on sheep, grafting old or castrated sheep with slices of testicle from young rams. Enthusiastically, he reported that some of the grafted sheep became fertile. Later, he announced not only that his gland transplants improved breeding and wool growth, but that these benefits extended to the offspring of the grafted animals! Never mind that experiments had already disproved such Lamarckian theories; generations of rats had had their tails cut off without producing tail-less offspring. In 1919 Voronoff started grafting testicles from live monkeys into aging men. Two early cases turned out badly. He transplanted two men whose own testes were destroyed by tuberculosis, but soon had to remove both grafts after they became infected. However, by 1921 he was doing grafts in the US. Not only the rich, famous or deluded joined the queue, but several doctors were also willing to pay the £500–1000 sterling for the operation. Voronoff admitted patients to his clinic a week or two in advance and discouraged drinking and smoking. He also warned them that the benefits may take months to appear. This allowed time for them to recover from surgery and for him to cash their cheques. The anti-vivisection Abolitionist thundered: ‘The idea . . . should disgust every normal healthy-minded person.’ A grafted monkey gland was ‘nothing more than a piece of dead meat put in the

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wrong place’. One insurance company refused to pay an old-age annuity to a grafted patient, since he had become younger than his chronological age! When some people worried that Voronoff would poison humanity with monkey genes, Bernard Shaw replied that becoming more monkey-like would be good for humans. Even Voronoff’s critics accepted that his transplants worked. His status rose after the British Medical Journal praised his work. During the 1920s Voronoff promised that gland-grafting bright children in early life would make them even brighter. I call for children of genius . . . I will create a new super-race.

Storms of protest followed. An international panel of animal experts visited Voronoff’s breeding station in 1927 to see for themselves. Before they could even report, Voronoff characteristically issued a glowing press statement, which made headlines. Remarkably, all the reports except the British were enthusiastic. The British pointed out Voronoff’s lack of randomisation, the exclusion of ‘graft failures’ and other serious problems. Moreover, independent attempts to repeat Voronoff’s sheep experiments failed dismally. At the 1929 International Congress of Physiology, Dr Casimir Funk announced that he had at last identified a hormone produced by the testicle. However, this hormone (testosterone) could not reverse either aging or sexual decline. Let us turn to the Australian scene. Dr Henry Leighton Jones was born in New South Wales in 1868. He made his name as a pharmacist, then dentist, and then general practitioner. In 1928, at the age of 60, he started his fourth career. First he taught himself French, then he spent months in Paris assisting Voronoff with his grafts. While there, Leighton Jones himself had a Voronoff monkey testis graft and married Voronoff’s English secretary. Back home, Leighton Jones started his transplant career about the time Voronoff was losing scientific support in Europe. Leighton

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Jones organised a supply of monkeys from his friend the Sultan of Johor. For about a decade, from 1931, he ran a small private clinic in Morisset in New South Wales. With the help of colleagues, he did about 30 grafts of testicles, four thyroid grafts and six ovary grafts. He continued until World War II cut off his supply of monkeys. Leighton Jones died in 1943, only hours before he was due to give a medical paper. His clinical records were destroyed after his death. We should not rush to dismiss either of these men as quacks. Voronoff’s enthusiasm, and poor scientific method as well as the general lack of knowledge of immunology of that time, led him into error. Dr David Hamilton, author of The Monkey Gland Affair, regards the monkey gland era as ‘one of the delusions which from time to time beguile the scientific community’. Voronoff, he writes, was not the first nor the last scientist honestly to deceive himself. Similarly, Leighton Jones had made his mark in a mainstream professional life before turning to grafts. He also performed his transplants in good faith. Moreover, in one sense, both were right. Since their time, animal-to-human transplants have indeed become a reality. (GB)

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Chapter

KINGS

7

AND

QUEENS

THE

KING WHO GREW LARGER THAN LIFE

In an exam, an imaginative schoolboy wrote: ‘King Henry VIII had eight wives and he killed them all.’ This sounds a bit much, but then Henry has always aroused controversy. His critics see him as a lecher. However Sir Arthur Salusbury McNalty says Henry was patriotic: he just wanted a legitimate male heir. Most writers have condemned Henry as selfish, cruel and ruthless. However the humanist scholar Erasmus was a fan, while Cardinal Pole named him ‘the greatest king that ever ruled that realm.’ The handsome young Henry excelled in archery, jousting, wrestling, hunting, tennis, dancing, poetry, French, Latin, theology, politics, government and music. Henry was lucky to escape the tuberculosis that killed his father and brother. His morbid fear of disease caused

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him to appoint capable doctors, but he seldom followed their advice and often treated himself. At 22 he recovered well from a disease which was probably smallpox or measles. Two years later came the first sign of his recurrent leg ulcer, for which he used an exclusive remedy containing ground pearls! From 29 on Henry suffered recurrent malaria. At 33, while jousting, he left his visor up and a lance shattered in his face. From then on, he suffered headaches, difficulty in concentrating and fits of anxiety. When his first wife Catherine of Aragon turned 42, her only living child was Mary, later to become Queen (‘Bloody Mary’). Henry still had no male heir. Was it this lack of an heir or Henry’s roving eye that attracted him to Anne Boleyn? In either case, the ambitious Anne insisted that the path to her bed lay via the altar. The pope refused to annul Henry’s first marriage, but in 1533 Thomas Cranmer, Archbishop of Canterbury, defied the pope and declared the marriage invalid so that the king could secretly marry Anne. She was already pregnant; the astrologers foolishly prophesied a son. Soon Henry’s tame parliament broke with the Roman Catholic Church and declared Henry (formerly Defender of the Catholic Faith) Supreme Head of the Church of England. This brought the Reformation to England. In 1536, while jousting at Greenwich, Henry was unhorsed and lay unconscious for two hours with his mailed horse on top of him. Two years later, his recurrent infected leg ulcers caused a crisis: ‘he was sometime without speaking, black in the face, and in great danger.’ Henry was well known for eating and drinking too much. As the handsome prince became a fat, sick man, he also became greedy, morose and suspicious. He had the best men in England to serve him, but sent many to the block. Anne Boleyn had several miscarriages and produced only one surviving child, the future Queen Elizabeth I. However, she failed to produce a son. But this wasn’t Anne’s only burden. In a moment of frustration, she complained:

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The king could not satisfy a woman . . . as he had neither skill nor virility.

Had Henry’s head injuries made him punch-drunk? Was it brain damage that caused Henry to order Anne’s arrest and prompt execution for alleged adultery? The very next day he married Jane Seymour. In 1537 this union finally gave Henry a son, the future King Edward VI, but Jane herself died of childbed fever. In 1544 Henry was obviously failing. An ambassador told the Queen of Hungary: ‘He can hardly stand.’ But a year later, Henry ignored his doctors and went to Portsmouth to repel a French invasion. His painful, smelly leg ulcers needed frequent dressings and lancing. He had fits of melancholy alternating with outbursts of rage, which only his sixth wife Catherine Parr could handle. By late 1546 his legs were grossly swollen and he reportedly weighed over 400 pounds. In his last years Henry needed lifts and pulleys to get him from room to room. On 1 January 1547 Henry rose from his sickbed to receive ambassadors. Though rumours said he was dying or even dead, on 16 January he discussed foreign policy. However, in the six and fiftieth year of his age . . . he fell into a languishing fever . . . Archbishop Cranmer desiring him to show some sign of his faith in Christ, he then wrung the Archbishop by the hand, and immediately gave up the Ghost.

Henry rests in St George’s Chapel at Windsor, near Jane Seymour, the one wife whose death he did mourn. Even now, fierce debate continues about his illnesses. To support the popular diagnosis of syphilis, C. MacLaurin cites the many premature births and dead children of Henry’s first two wives. However, others point out that syphilis in Henry’s day was far nastier and more obvious than it is now. If he had the repulsive skin changes then common, would not Catholic writers at least have said so? Moreover, the treatment of syphilis included weeks of

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mercury treatment, pushed to the point of copious salivation. Again, this would have been obvious and noteworthy. Another view is that Henry had Land Scurvy (a more chronic form than the sailor’s version), because he ate little fruit and fresh vegetables, especially in winter. Other possible diagnoses include chronic osteomyelitis (infection of the bones of his legs) or varicose ulcers, alcoholism with cirrhosis of the liver, gout, high blood pressure, heart failure, an underactive thyroid, kidney failure and severe personality disorder. (GB)

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A

SALUTARY TALE FOR COMPLAINING DOCTORS

Doctors commonly think they are hard done by nowadays, what with government regulations, long hours, threat of litigation and a lagging income, but it is nothing compared to the rough justice dealt out by government officials in Denmark to Dr John Struensee just over 200 years ago. Christian VII of Denmark was born to King Frederick and his Queen, Louisa, daughter of George II of England, on 29 January 1749. On the death of his mother, Christian’s father remarried and sired a second son, Ferdinand. Despite the stepmother’s attempts to get her son onto the throne, the elder boy was rightly regarded as the heir. So upon Frederick’s death in January 1766 Christian was crowned. Later that year, at the age of 15, Caroline Matilda, the youngest sister of the British monarch, George III, and great-aunt of the future Queen Victoria, was hurried away from the English court to marry her dissolute, decadent and debilitated first cousin, Christian VII. It was a marriage arranged for political expediency, of course, but surely even the English court’s spin doctors would have bridled at making the match if they had realised the Danish swain was a dedicated habitué of prostitutes, was syphilitic and already had cerebral changes from this disease. Christian’s sexually transmitted diseases were treated by Dr John Frederick Struensee, who also attended Queen Matilda and their new son. While the doctor tried in vain to dissuade the monarch from following his licentious ways, he also secretly coveted authority and by 1771 had wormed his way up the political ladder to become Prime Minister. Power being regarded by some as the greatest of all aphrodisiacs, the doctor and Queen’s relationship soon grew into more than discreet medical etiquette generally allows. The buxom 19-year-old, stuck in a loveless relationship, and the tall,

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flaxen-haired 33-year-old became lovers. The secret was soon uncovered and its shamelessness compounded when, after she was criticised by some courtiers for displaying more of her ample bosom than thought appropriate, Struensee dismissed the prurient officials with rash expedience. With that the court agreed that enough was enough and that Struensee had to go — sooner rather than later. The Queen Dowager needed no second bidding to lend her support, as for some time she had been looking for an excuse to dig the boots in. While the officials may have wanted to restore the old order, she was more devious and saw it as a back door to the throne for Ferdinand. The Queen Dowager bullied her stepson, the by now witless and rambling King, into signing an instrument of arrest for the wanton couple. Plans were laid for the deed to be done at a psychologically unguarded moment for the pair. It was resolved that it should take place on 16 January 1772, and to add to the drama and comic opera-like scenario, it was to be enacted following a grand ball which was to be given in the palace. All the top people were at the splendid affair, and Matilda and Struensee danced before their shocked gaze with unbecoming abandon. The depth of her décolletage is unrecorded, but it was certain they could not get away with it forever. Eventually the starcrossed lovers retired to her apartment in seeming ignorance of their impending doom. As the doctor left the arms of his royal lover and returned to his own quarters, guards apprehended him. He was hurried away to a nearby dungeon and the Queen, surprised en déshabillé, was escorted to Cronenborg castle. Struensee was chained to a wall so he could neither properly sit nor stand. Thumbscrews were used to extract a confession of what was obvious lese-majesty. The Queen had recently had a second child; he was declared the father and left to ponder his fate. In view of the husband’s parlous medical state, there may have been some truth in the paternity claim.

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The English court was outraged and George III sent his envoy to Denmark to vouchsafe a diplomatic solution regarding Matilda and her safety. This was accomplished and the outcome was that the royals were divorced, the two children stayed with the King and Matilda sailed for her homeland. The wicked stepmother was now in command, but her rapacious grasping of power was not the hoped for outcome by the Danish court, and there was some murmuring for the return of Matilda. Further diplomatic exchanges took place and she was eventually approached in England and agreed to go back to Denmark. The decision must have involved a very generous settlement since the tremendous risk she took was clear to everyone. And so it proved to be, for though apparently in perfect health at age 21, within seven weeks of her return, Matilda was dead. It happened with questionable rapidity, though it was claimed death was from ‘a contagious fever’ caught from one of her domestics. But what of the luckless Dr Struensee? If you are about to eat, I suggest you postpone reading on until later. Having been tortured over several months, on 28 April 1772, he was brought to the scaffold in chains and forced to watch his servant beheaded. A quick death was thought to be too good for the by then terrified physician, for he was first doused with his henchman’s blood and then had his hand chopped off. After a pause to allow that to sink in, he was then disembowelled and finally cut into four pieces. Struensee’s head was fixed on a post and his right hand nailed below it. The four quarters of the body were dragged to a refuse dump outside the city. The whole was then left to be devoured by scavenging dogs. So, however shabbily doctors think the Ministry of Health or the justice system treats them, just think, it could be worse. (JL)

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DID

MEDICAL MISHAP CAUSE WORLD WAR I?

Frederick III, who became Emperor of Germany on 9 March 1888, was . . . wise, brave, liberal and popular . . . had he lived as long as his father . . . before him, or his son after him, Germany would surely have entered a golden age. But . . . on 15 June, just ninety-nine days after his accession, Frederick was dead, and most blamed . . . his English doctor, Morell Mackenzie. Wilhelm II succeeded as Kaiser . . . Twenty-six years later, in 1914, this psychopath was to plunge the world into war. — Stevenson

What do you get when you mix together a German Crown Prince, his royal English wife, six German doctors, and an eminent British specialist? Bitter controversy that raged all over Europe. In January 1887, Crown Prince Frederick of Germany, though already aged 56, was still waiting to succeed his father as Emperor. After a bout of measles, Frederick became hoarse and started coughing. In March his doctor called in Professor Gerhardt, an authority on throat diseases. The latter saw on the left vocal cord a growth about 2 mm by 4 mm in size. Under a spray of cocaine, Gerhardt found he could not remove the growth. Instead he cauterised it daily (over 13 days) with an incandescent wire. This seemed to destroy the growth, but the sloughed area would not heal. The Prince’s voice improved, but swallowing remained painful and Gerhardt had ‘misgivings regarding the nature of the growth’. By May the growth was back and larger than before. All six German doctors consulted agreed it was cancer. All advised opening the voice box to remove the growth. However the Emperor, Chancellor Bismarck and the Crown Princess (daughter of Queen Victoria) demanded one more opinion.

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Dr Morell Mackenzie of London was the most famous throat specialist in England, perhaps even the best in Europe. All the German doctors agreed to accept his opinion. Mackenzie found a growth about the size of a split pea on the left cord. Pointing out that the German doctors’ diagnosis of cancer was purely a clinical one, he first advised biopsy and microscopic examination by an expert. Mackenzie’s emphasis on microscopic diagnosis was well ahead of medical practice of his time. So Mackenzie did get a specimen that Gerhardt confirmed came from ‘near the tumour’. But the report by Professor Rudolf Virchow, the founder of modern cellular pathology, was non-committal. He found nothing to contradict a simple irritative process. Without positive proof of malignancy, Mackenzie would not support open surgery. The doctors decided that Mackenzie should try to remove the lesion through the mouth. In early June he removed more of the tumour with forceps, but again Virchow’s pathology report was inconclusive. Since Frederick wanted to ride in Queen Victoria’s Jubilee procession, he took Mackenzie to London. There Mackenzie removed with forceps what seemed to be all of the remaining tumour. Still, Virchow did not commit himself. Within a month, Frederick was hoarse again; his tumour had indeed recurred. Mackenzie then cauterised it. Another month later, Mackenzie saw a recurrence that did look malignant. By now, the flames of public controversy were out of control. The British Medical Journal printed pessimistic editorials. The Times printed a Viennese doctor’s attack on Mackenzie’s treatment. Gerhardt accused Mackenzie of damaging Frederick’s vocal cord. Mackenzie blamed Gerhardt’s original electrocautery: ‘a delicate organ like the larynx cannot be brutalized in this manner with impunity.’ International correspondents hovered, waiting to report on Frederick’s illness. In November 1887 Mackenzie asked for yet more consultations.

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A Frankfurt laryngologist reportedly believed that Frederick’s disease was ‘of contagious origin’ (he meant syphilis). So he recommended large doses of potassium iodide, to which the other doctors agreed. Paradoxically, the next day, the same doctors told Frederick that he had a malignancy. The Prince decided against excision of his larynx. However, by January 1888 he was losing weight and coughing-up large pieces of tumour. In February only a tracheostomy (surgical opening into the windpipe) saved Frederick from suffocation. Finally, in early March, Frederick succeeded the throne, but by now he was a dying man. In April he experienced discomfort from the tracheostomy tube, so Mackenzie recommended a tube with a different curve. The German doctor inserting this tube made a false passage and damaged the neck tissues. There followed bleeding, pain and later an abscess in front of the trachea. After a few days the abscess burst. Surprisingly, in early June, the doctors announced that the Emperor was so well that there was no further need for regular bulletins! On 13 June, though Frederick was very breathless, he managed briefly to receive the King of Sweden. The next day he had pneumonia, and on 15 June 1888, just 99 days after his coronation, he died peacefully. In Mackenzie’s own words: ‘Thus passed away the noblest specimen of humanity it has ever been my privilege to know.’ Virchow had little time (before the lying-in-state) to perform his autopsy. However he reported that Frederick had died of a large cancer of the larynx and pneumonia. Mackenzie claimed he had relied upon the normal pathology report of the world’s leading pathologist. Virchow replied that Mackenzie had taken his tissue samples from a benign tumour on the vocal cords, but had missed the cancer below them. Gerhardt even suggested that Mackenzie had deliberately taken his first biopsy from the healthy cord. Mackenzie called Gerhardt ‘incompetent, indiscreet and obstructive’.

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Frederick’s widow supported Mackenzie, but he was ill and depressed when he returned to England. The College of Surgeons censured him, and he had to resign from the College of Physicians. Mackenzie had asthma and died only four years later, leaving a widow and five children. Many people have honoured Mackenzie as the Father of British throat surgery, but this tragic case overshadowed his real achievements. Twenty-five years after his death, the London Laryngological Society inscribed his grave with Longfellow’s words: Lives of great men all remind us, that we can make our lives sublime, and departing, leave behind us footprints in the sands of time.

(GB)

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EUTHANASIA AND THE OF GEORGE V

DEATH

Every now and again euthanasia hits the headlines, usually highlighted by stories of a doctor making a plea for the law to be modified. Indeed, for a brief time, until overruled at a Federal level, the so-called ‘mercy killing’ of people very close to the end of their life was on the statute books of the Northern Territory. In 1997 a television report claimed that about 45 per cent of Australian doctors had at some time acquiesced to patients’ or their relatives’ requests for euthanasia. Anyone who has been in general practice for a number of years will have received at least suggestions about easing the passing of a sick patient. In fact they are in distinguished company, for such a request, veiled or otherwise, can involve the most senior of the profession. A few years ago it was revealed that the then British Royal Physician, Lord Dawson of Penn, had done the same to his regal charge, George V, in 1936. And this after having saved his life eight years previously. George V came to the throne in 1910. He was a downright, forthright, ex-naval man with a gruff manner whose greatest pleasures were associated with an outdoor, rather earthy life. Like his father before him, Edward VII, he was insensitive and undemonstrative and seemed to possess few internal resources to call on in times of stress. His own children were in some awe of him and suffered emotionally from his criticisms and lack of warmth. Indeed, it has been said that this austere nature was the genesis of the future George VI’s stutter. The monarch’s doctor was the eminent and professionally highly regarded Lord Dawson. He had been physician-in-ordinary to Edward VII and, after George V, was eventually to care for Edward VIII, George VI and George V’s wife Queen Mary. He was clearly trusted by the royal family.

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Nonetheless the family, and the nation as a whole, were anxious when, in November 1928, the King developed a severe chest infection upon which Dawson was not making much impression. The Prince of Wales, heir to the throne, hurried home from his jaunt in East Africa to be at his bedside and was appalled to find his father barely conscious. Dawson recorded in his diary that ‘it was not a typical pleuropneumonia but a case of severe general blood infection and toxaemia’. Antibiotics were unknown then, of course, so it was mainly a case of making the patient comfortable and waiting. They did not have to wait long; an abscess developed on the lung. The physician knew there was an abscess all right, he was no fool, but neither X-rays nor several tappings with a needle could locate it. After 22 days of progressive illness the King was at death’s door and the distracted doctor decided to make one final stab. This time to everyone’s great pleasure, not least the medical attendant, pus welled out. Later a rib was removed to facilitate drainage of the abscess. Churches were kept open day and night for prayers of intercession and two weeks later the Lancet, the well-known, conservative medical journal, ventured the statement that ‘convalescence is now in sight’. Dawson was a hero. By February 1929 the King was semi-mobile and was taken to recuperate at Bognor, a holiday resort on the south coast of England renowned for its bracing air. While there he was allowed his first cigarette, a pleasure hitherto denied him. Six months later, Mr. J. H. Thomas, a Labour cabinet minister popular with the monarch on account of his earthy sense of humour, while on a trip to the palace regaled the King with a ribald joke. He laughed so heartily that a relapse occurred and the King had to have a second rib removed to facilitate further drainage. When it was all over it was generally accepted that the royal physician had saved George’s life and he was appointed head of a team of 11 doctors who would attend his majesty in future. To these were added five nurses led by Sister Catherine Black from the

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London Hospital who had proved to be so adept at managing the querulous and easily bored patient. All was well until November 1935 when the King became breathless again. Sister Black reported that her charge was restless at night when he sat up and sometimes needed oxygen. He was not one to be swayed by good advice, so there was no question of him giving up smoking. It was suggested that the King return to Bognor for recuperation. In reply George V produced the one memorable quote of his life: ‘Bugger Bognor.’ The King went to Sandringham as usual at Christmas and managed the Christmas Day broadcast. At the time this was a fairly newfangled way of communicating with the masses and one he was not too sure about, but he was badgered into it and it proved to be a great public relations success. However by mid-January 1936 he became very weak with ‘bronchial catarrh’. This was the reported diagnosis, but it sounds rather like heart failure, though there is no death certificate available from the Royal Archives to subsequently support this. At a meeting of the Privy Council, George sat for ten minutes unable to sign a decree as required by law. Dawson suggested trying the left hand. The King gruffly refused, as he did the offer to guide his hand. In the end he made two marks which might have been recognised as ‘GR’. He returned at once to bed and that night was obviously failing. Dawson was living with the royals by now and, while dining alone in his room at Sandringham, at 9 pm the King’s private secretary hurried in to tell him the King was sinking. At this Dawson took a menu card and wrote his now famous bulletin. He handed it to the secretary and from him it passed into history. The note simply said, ‘The King’s life is moving peacefully towards its close’. At 10 pm sleep passed gradually into a coma. The Prince of Wales had earlier told Lord Dawson that he and the Queen had no wish for the King’s life to be prolonged. Dawson was

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in complete sympathy, so talk of euthanasia was already in the air. At 11 pm Dawson noted in his diary that ‘the last stage might endure for many hours’. He went on, I therefore decided to determine the end and injected (myself) morphia gr3/4 (45 mg) and cocaine gr1 (60 mg) into the distended jugular vein . . . (I wrote) “myself” because it was obvious that Sister B was disturbed by this procedure. In about 1/4 hour . . . physical struggle gone.

The time was 11.55 pm and later Dawson conceded one of the considerations had been ‘the importance of the death receiving its first announcement in the morning papers rather than the less appropriate evening journals’. At that time it was considered that the evening papers were given more to scandal rather than serious news. To ensure that only the top news outlets got first bite at the cherry, he telephoned his wife to advise The Times to hold back publication as an announcement regarding the King was imminent. The embalmers were called at once, but missed their way in the dark, arriving at 6 am. Dawson was keen they get on with the job as he knew it would be a week or more before the funeral and he wanted to avoid at all costs the embarrassment which had happened at the funeral of the Duke of Teck. He had died of acute abdominal sepsis, and ‘the coffin had burst open with a loud report during the procession’. One final word: in his will George V left his eldest son, now Edward VIII, nothing. The new King remonstrated but to no avail. Within a year he too had departed, not because of a terminal illness, but another malady — lovesickness. In December 1936 he left England forever in the company of one Mrs Simpson; but that is another story. (JL)

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A

SMOKER’S FATE: THE LIFE AND DEATH OF GEORGE VI

When Diana, Princess of Wales died in 1997 there was a massive and very public outpouring of grief in Britain, a kind of national catharsis. When King George VI died in 1952 the sorrow people felt was largely internalised, blinds were drawn, voices lowered and black ties worn, but there were no banks of flowers at Buckingham Palace. The population was numbed because the monarch was not only well thought of, but had died suddenly in his mid-fifties and while seemingly in good health. Or was he? Let’s take a look. Albert George, known as Bertie, was the second of six children of George V. Five survived to adulthood; the youngest died in his early teens. As we have seen in ‘Euthanasia and the death of George V’, the king was a gruff, insensitive and critical man, characteristics which affected all the family members, not least Albert George. Young Prince Albert never enjoyed robust health and from his earliest years was plagued by a stammer. Various theories have been forwarded for this from the poor relationship he had with his domineering father to the fact that an attempt was made to change his natural left-handedness to fit a right-handed world. In passing, Lewis Carroll, of Alice in Wonderland fame, was a left-hander forced into more conventional ways and he too had a marked stutter. In the end, Albert was greatly helped with his disability by an Australian speech therapist. Nonetheless, he came ill-prepared to the throne as George VI in 1936, after the abdication of Edward, and his disability flared. I recall it was an agony to listen to him wrestling with his impediment while presenting his Christmas broadcast. George’s other ailment in the early part of his life was indigestion, and in 1917, while an active naval officer, he had a major operation to join the stomach to the small bowel, a so-called

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gastrojejunostomy, for a gastric ulcer. George VI was a lifelong heavy smoker, and though we now know that smoking worsens an ulcer, that was only discovered in the late 1950s, so he was never actively discouraged. Moveover, the habit also has a narrowing effect on the arteries and soon after World War II the King developed signs of severe circulatory impairment in the legs as a consequence of arterial constriction. Indeed, he was a prime example of the deleterious effects of smoking, and presents a salutary case study for those similarly addicted. Eventually the pain in his legs while walking really began to trouble George VI and by March 1949 it was obvious that ‘something had to be done’ to relieve this discomfort. To this end a lumbar sympathectomy was performed by James Learmouth from Edinburgh and James Patterson Ross of St Bartholomew’s Hospital, London. With this operation there is a division of the sympathetic nerves in the lower back which control the constriction and dilatation of the arteries. It was the common form of treatment at the time and enjoyed moderate success. The King made a good recovery and promptly knighted both surgeons. He himself continued to smoke. In view of this it is hardly surprising that he did not seem to improve; but there was more than the legs troubling him, a more sinister set of symptoms began to manifest themselves. On 1 June 1951 his quartet of physicians, Daniel Davies, Horace Evans, Geoffrey Marshall and John Weir issued a bulletin to say the monarch had had an attack of influenza which had left a ‘small area of catarrhal inflammation in the lung’. All had been knighted already, so there was no kudos in store for them. On 4 June another communiqué said the condition was persisting, rest was recommended and public engagements were cancelled for four weeks. During September a bronchoscopic examination was carried out and as a result of this internal visualisation ‘structural changes’ in the lung were reported. The result appeared in the national press

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and new names appeared on the official paper — Peter Kerley, a radiologist, and Clement Price-Thomas, a surgeon. On 21 September a bulletin stated that the lung was giving cause for concern and an operation was necessary. The word ‘cancer’ was never used, but few within the medical profession had any doubt as to the nature of the ‘structural changes’. A room in Buckingham Palace was converted into an exact replica of Price-Thomas’ operating theatre at the Westminster Hospital. The surgeon’s two senior residents, Charles Drew and Peter Jones, moved into the palace. Two anaesthetists and a haematologist did some last-minute revision for the ominous task ahead. On Sunday 23 September 1951 the offending lung was removed. The operation went like clockwork, but Price-Thomas was so preoccupied by the enormity of the responsibility he collided with another vehicle as he drove his car out of the palace forecourt. No charges were laid. In the following New Year’s honours all the names of the doctors appeared, including the young registrars’. The operating table which had been used was returned to routine use at Westminster Hospital, but had a suitably worded plaque attached to the plinth commemorating its place in history. The King seemed to improve and at the end of January 1952 waved off Princess Elizabeth as she set out for Australia via Africa. A week later, on 6 February and four-and-a-half months after the pneumonectomy, George VI was found dead in bed by his valet. He was 56 years old. Never a robust man, this distinguished patient’s death was markedly compromised by his cigarette-smoking habit; a salutary reminder to us all of its effects. (JL)

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Chapter

8

DOCTORS AND MEDICAL SERVICES

MEDICINE

AND CRICKET

Imagine now that out of space Comes the deep spirit voice of Grace — Old W.G. — whose mighty frame No more shall lumber through the game. — H. Farjeon

Of all athletic activities, cricket seems to have produced not only the richest literature, but possibly sport’s most memorable characters as well. Indeed, its rather contemplative tenor and tortuous subtleties have attracted all types and conditions of men and women, including a few doctors with time on their hands and usually money in their pockets. Of these, surely medicine’s greatest gift to cricket must be the mighty Dr William Gilbert Grace — ‘W. G.’.

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In the 1820s Henry Mills Grace went up from Somerset to London to enrol in the combined medical schools of St Thomas’s and Guy’s. He studied under the redoubtable Astley Cooper, the first man to do a vasectomy (on a dog), and a surgeon of such distinction that his manservant earned £600 a year in bribes from queue-jumpers seeking his advice. The student, however, was of a different ilk and much preferred the fine hunting country of Gloucestershire and playing cricket to pandering to the foibles of fashionable patients. So he set up his plate as a country GP in Downend, a village between Bristol and Chipping Sodbury in England’s beautiful and quaint West Country. Henry prospered and married a lady who was as keen on sport as he was, a fact which was to prove to be of great significance in the Grace story, as later in life she became a fastish and lethal underarm bowler who gave invaluable batting practice to her children. Of these she had nine, comprising five boys and four girls; the latter seemed to do most of the fielding to the batting of the former. The eldest son, Henry, became apprenticed to his father in an era when you could do such things if you wanted to become a doctor. Eventually he became medical officer to the Bristol workhouse. The second son, Alfred, also qualified in medicine to finish up as the medical superintendent of the Chipping Sodbury workhouse. The third boy, Edward, not only qualified as a doctor and became responsible for the Thornbury workhouse, but also was appointed the Coroner for West Bristol. More than that, at the age of 21 he was regarded as the most accomplished cricketer in the west of England. During his career, when not pronouncing on death in suspicious circumstances, he managed to take ten wickets in an innings an incredible 31 times. He toured Australia with George Parr’s team in 1863–64 and was known to all his cricketing mates as ‘The Coroner’. The fourth boy was the redoubtable William Gilbert. He was born in 1848 and was to become the most universally recognised man in Victorian England. This was, I suppose, not only due to his

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sporting prowess, but also his full beard, a luxuriant adornment he carried from the age of 17. Following family tradition, W.G. entered the Bristol Medical School. It soon became apparent that he was better at cricket than fusty exams, so he changed to an establishment which he felt would be less demanding of attendance or troubled by examination results and went up to Westminster Hospital in London. Doubtless he felt he could enter the profession by what he regarded as the back door, but in the end his course was to stretch over more years than the regulations usually quoted. Indeed he finished up at St Bartholomew’s Hospital to cram for his final surgery confrontation, which he passed after several attempts. The cricketer eventually managed to fluke it, and in 1879, at the unusually mature age of 31, W.G. Grace qualified as a Member of the Royal College of Surgeons (England) and Licentiate of the Royal College of Physicians (Edinburgh). That same year he had a batting average of 52.56 and was awarded a £1500 testimonial and two bronze ornaments for his efforts. Doubtless, his examiners were forgiving supporters. There was a last brother, George, always known as Fred, who tried to take up the profession. He was even less adept at the job than W.G. and never did satisfy the examiners; there were limits. However, he regularly scored centuries for Gloucestershire and was regarded as one of the best rifle shots in the county. He, W. G. and E. M. (‘the Coroner’) all played in the same England side against the Australians in 1880. Fred got a duck in each innings and died from pneumonia later that year. Dr W. G. Grace set up practice in Stapleton Road, Bristol, a less than salubrious area, and lived nearby in Throstle House. He was regarded as being bluff, jovial, candid in criticism and a strict disciplinarian, a set of assertive characteristics not only in keeping with his appearance, but which had been finely honed on the cricket pitch. Nonetheless, he was popular enough in his practice to have to engage a permanent assistant, and busy enough to have to employ two locums to cover him when he went away for long

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periods during the summer. Stories of his clinical acumen are scanty, unlike those of his cricketing prowess, but one old lady thought well enough of him to leave him £100 and a brace of silver candlesticks in her will. He did become a public vaccinator against smallpox, and is said to have been able to smell that particular disease (still around in England then) on entering a patient’s bedroom. W. G.’s most famous medical story to come down to us occurred during the Gloucester v Middlesex match at Clifton in 1885. W.G. batted all day for 163 not out and then went straight from the ground to the bedside of a lady he had promised to see through her confinement. Having been up most of the night, he returned the following morning to carry his bat for 221. That much is true, but the story goes on that when asked by his team-mates how things had fared during the night, he is said to have replied: ‘The child died. The mother died. But I saved the father.’ For cricketers (and doctors) the truth is seldom allowed to get in the way of a good story, and almost certainly this is another example. A well-documented incident did take place, however, in 1870 at Lords. Grace had not qualified at this stage and was playing for the M.C.C. against Nottinghamshire. George Summers, a Notts player, was knocked out by a fast-rising delivery. W.G., who was fielding nearby, went over, felt the pulse, turned to his approaching teammates and simply remarked, ‘He’s not dead’, and promptly withdrew. There was some relief at this ex-cathedra, if somewhat insensitive, statement, and Summers was carried insensible to his hotel. He took no further part in the game, but died two or three days later on the way home, presumably of a cerebral bleed from a fractured skull. Dr Grace played first-class cricket for 44 seasons, from 1868 to 1908, and during that time scored just under 55 000 runs. In his last Test in 1899, at the age of 50, he captained England against Australia, but his lack of alacrity in the field was all too obvious, so he retired himself — no one else dared do so. His very last match

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was in a club fixture in July 1914 when, at the age of 66, he scored 69 not out in a total of 155. However, this was a far cry from the occasion in 1866 when, at the age of 18, he scored 224 for England against Surrey and went from the ground to Crystal Palace to win the quarter-mile hurdle race of the National Olympian Association. Grace was a sportsman to the end, for after retirement he went on to captain the England lawn bowls team from 1903 to 1908. W. G. Grace continued his general practice in Bristol, but after 20 years fell out with the local health authorities and moved to Kent. Knowing his personality, I am surprised it had not happened before. He died of a stroke in 1915. W.G. Grace was recognised wherever he went and was perhaps the most famous general practitioner of the nineteenth century. This fame, of course, was due to his sporting ability rather than any clinical expertise he may have had. He is still remembered with a mixture of awe and affection. Old W.G. — whose burly beard No more is seen, no more is feared. — H. Farjeon

(JL)

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SURGEONS OF THE FIRST FLEET No band of medical brothers could have been more varied . . . their lives . . . combined medicine . . . with . . . high adventures. — Dr John Pearn

It was during the reign of ‘the mad farmer’, King George III, that the First Fleet sailed from Portsmouth on 13 May 1787. Chief Surgeon Dr John White was on the convict transport Charlotte. He received ten shillings a day and had three assistant surgeons: William Balmain on the Alexander, Denis Considen on the Scarborough and Thomas Arndell on the Friendship. Of the 11 ships, all except the storeships carried men appointed as doctors, though at least two had doubtful credentials. The Prince of Wales started without a doctor until John White appointed John Irving ship’s surgeon. Irving (alias Anderson, alias Law) had stolen a gold cup and been lucky to escape hanging. Transported for seven years, he turned out a very capable ship’s surgeon. Irving was the First Fleet’s only medical convict, but there were 15 in subsequent transports. Later he became our first emancipated convict and gave his name to Irving Street in Parramatta. The Lady Penrhyn carried John Altree, Australia’s first impaired doctor, who was not coping even before the fleet sailed. White and Governor Phillip appointed Arthur Bowes Smyth as his superior. The latter had no formal qualifications but had picked up snippets from the local midwife in Suffolk. He also did well as a de facto surgeon. Later, during a gale, poor Altree was almost washed overboard, but saved himself by clinging to the mizzenmast. To reach Botany Bay, 15 000 miles away, the fleet carried 1350–1500 people (reports vary as to the number) for over eight months. About half were convicts, already in poor health from long

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imprisonment. That only about 48 died (again reports vary) is a tribute to Governor Arthur Phillip, John White and the other surgeons. White made sure that the ships were kept clean. Moreover, he was one of the few to follow the precautions against scurvy first set down by Dr James Lind. Whenever the fleet berthed, everyone enjoyed fresh fruit, vegetables and meat, and the crew stocked up for the next leg. Between Rio de Janiero and Cape Town, one man went overboard. White wrote: a . . . convict, in bringing some clothes from the bowsprit end where he had hung them to dry, fell overboard . . . the ship was instantly hoved to and a boat hoisted out, but to no purpose.

Phoebe Norton who was being transported for stealing spoons and bed linen, had better luck. She also fell overboard, but was fished out successfully. She later became a well-known midwife in Parramatta. The last leg of the journey from Cape Town to Botany Bay was the longest, roughest, wettest and coldest. White describes epidemic dysentery (severe infectious diarrhoea) which raged for six weeks. At Port Jackson the settlers faced famine, scurvy and more dysentery. White flayed the English authorities for his inadequate supplies and set up the first Sydney Hospital. Every other night he fished, not for fun but for survival. Surgeon’s mate John Lowes of the Sirius wrote to the Dublin Chronicle: our clothes are worn threadbare . . . famine is staring us in the face. Two ounces of pork is the allowance for four and twenty hours, and happy is the man that can kill a rat or crow to make him a dainty meal . . . I dined most heartily the other day on a fine dog, and hope I shall soon again . . . the animals that were

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meant to stock the country are almost all butchered. Several of the convicts have perished by the hands of the natives, by rambling too far into the woods.

In 1790 the arrival of the ill-fated Second Fleet further tested the colony. About one-quarter of the 1000 convicts had died on the voyage, and 500 arrived seriously ill. William Balmain had to put up 100 tents next to the hospital. Despite all the shortages, the surgeons saved over half the sick. Not surprisingly, White and Balmain, both able but very headstrong men, had a falling out. After a dinner to celebrate a royal birthday they went out at midnight, to duel. Each fired five rounds, but luckily their aim was not as good as their doctoring: White was unhurt, while Balmain had only a small flesh wound in his right thigh. Lieutenant Ralph Clark records that Phillip stepped in to: ‘Convince the two Sons of Escalipious that it was much better to draw Blood . . . from their patients than to doe it with pistol Balls from each other.’ But that was not the end of the feud. In 1791 Phillip sent Balmain to care for the colony at Norfolk Island. Did he do this to keep the two quarrelsome surgeons apart? With Balmain sailed Margaret Dawson, his young convict consort. At Norfolk Island they used land granted by the government to raise stock and produce grain that they then sold back to the government! Meanwhile, White was also doing well. His grants of land included 30 acres fronting White Bay. In 1794 he took his illegitimate son back to England, where he married and had three more children. Rather than return to Australia, he resigned his commission and served on commercial ships. Only after White left the colony was Balmain brought back to Port Jackson as Acting Chief Surgeon. Even from England White kept trying to block Balmain’s promotion. These two wilful men had more in common than either would have admitted. Like White before him, Balmain kept pressing the

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authorities for more surgeons and more supplies for the growing colony. He improved the care of prisoners and orphans, served as a magistrate, honorary commander of civil volunteers and was a naval officer controlling imports and exports. Balmain kept lobbying for reforms, including better care on convict transports. He supported Governor Hunter’s attempts to curb the power of Captain John Macarthur, with whom he nearly fought a duel. Financially, Balmain flourished, acquiring 1480 acres, including the Sydney suburb named after him. His stock of spirits was at least 1000 gallons (worth a pound a gallon). In 1795 he asked for leave to settle his affairs in England, but he had to wait until 1801 before being allowed to sail with his de facto and two children. Like White, Balmain never returned to Australia. In 1803, when he was 41 and about to become a surgeon to the English forces, Balmain died. He would have been furious to know John White would survive him by 29 years and leave a large estate. White and Balmain were not the only colourful surgeons of the First Fleet. Just as quarrelsome was the super-strong Irishman Thomas Jamison, who shuttled between Port Jackson and Norfolk Island. As Chief Surgeon, Jamison court-martialled two assistant surgeons for neglecting women in labour. In 1804 he introduced smallpox vaccination to the colony. Another well-known medico was Thomas Arndell, a bit of a Casanova. There were rumours, perhaps of his own making, that he was a nephew of Baron Arundell. In 1781 his wife Susanna gave birth to a daughter in London’s Lying-in Hospital for the ‘distressed poor’ (married poor only, of course). Soon after, not far away, Arndell’s mistress Isabella Foscari, a Jewish–Italian singer, also gave birth. Unable to choose between wife and mistress, he left both to join a ship bound for India! A year later, Arndell returned to Susanna and fathered more children (making a total of eight, though many died). But then he took off again, this time to become Assistant Surgeon in New South Wales. He took charge of the hospital at Parramatta, but also

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found time for exploration. Arndell was with Captain Watkin Tench’s expedition when it found a river ‘nearly as broad as the Thames at Putney’: the Nepean. In 1792 a bushfire swept through Arndell’s farm, destroying the farmhouse, outbuildings and crops, but he bounced back. Under Governor Hunter, he became a magistrate, receiving grants of land and building a family home at Windsor. Arndell also improved his wool flock by bringing in a Spanish breed. He continued his production of children too, having six or seven by the convict Elizabeth Dalton. Thomas Arndell lived in Australia for 32 years, longer than any of his colleagues. At his death in 1821, he owned 750 acres, but his widow (still in the Old Country) had to ask the English government for financial support. Arndell is the only First Fleet surgeon with a memorial gravestone in Australia. (GB)

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GETTING

OFF AT

REDFERN

His enemies called him a jumped-up ex-convict. He beat a death sentence to become top doctor in New South Wales and the father of Australian medicine. Sir Edward Ford called him: ‘A pioneer of Australian medicine, agriculture and husbandry . . . who contributed greatly to the welfare of the early colony.’ Sydney now has not only a suburb but a method of contraception bearing his name. William Redfern, born in 1774 in Wiltshire, passed exams of the Company of Surgeons (precursor of the Royal College of Surgeons) and joined the navy as assistant surgeon in 1797. His timing could not have been worse. For supporting sailors who mutinied against their dreadful conditions, he was soon sentenced to hang. However his youth won him a life sentence instead. In 1801, after four years in Dartmoor Prison, he requested transportation to Botany Bay. During the voyage he made himself useful helping the surgeon. Next he was sent to the convict settlement at ‘that compendious and concentrated hell Norfolk Island’. Redfern’s task was to keep alive the convicts being abused by the Lieutenant-Governor Colonel Foveaux. By 1803 he had done so well that Governor King granted him a full pardon. When he left Norfolk Island in 1808 Redfern already owned land, two houses and a share in a vessel. In Sydney he passed an examination set by Principal Surgeon Thomas Jamison and so received the first medical diploma issued in Australia. He worked at the hospital at Dawes Point; a police station now marks this site in George Street North. From 1811 he was Assistant Surgeon, with an annual salary of 136 pounds 17 shillings and sixpence. Since the colony desperately needed a new hospital, Governor Macquarie financed it by granting the contractors a monopoly to import 45 000 gallons of spirits. Hence the name ‘Rum Hospital’ (later Sydney Hospital) in Macquarie Street.

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Redfern battled to improve conditions there. The convict nurses were often drunk. At sunset the overseer locked the wards, leaving patients overnight without nurses or attendants. Sanitation was dreadful. All patients, even those with dysentery, got just one pound of flour and one of meat each day, which they had to cook themselves, or trade for tea, milk or sugar. Redfern sometimes had meals from his own quarters brought for very ill patients. After morning rounds of the in-patients, Redfern personally issued stores, since he could not trust his helpers to do so. Then there were about 50 convict outpatients waiting to see him. Purging, cupping, bleeding and laudanum (tincture of opium) were common treatments. There were few operations; mostly amputations. Even those private patients who scorned Redfern’s convict past and rough manners recognised his medical skills. He became the family doctor to John Macarthur and Governors Bligh and Macquarie, delivering Macquarie’s son. While Redfern charged the wealthy £5 (sometimes even 20 guineas) for a confinement, he cared for paupers without charge. Epidemics of dysentery were often fatal. The transports brought convicts with scurvy and typhus (‘ship fever’). In 1814 preventable diseases ravaged three transports. On the Surry, which carried 200 convicts, typhus claimed 50 lives, including the captain, mates and surgeon. Macquarie consulted Redfern, who reported that most surgeons on convict ships were either raw students or drunkards. Instead of these, he urged the government to appoint ‘approved and skilful’ doctors. These would not be under the captain or shipowner, but act both as surgeons and as agents responsible for the convicts, with authority ‘to Cause the necessary powers to be carried into effect’. Redfern’s recommendations were a landmark in public health. Once these surgeon-superintendents sailed on both convict and emigrant ships, the voyage to Australia lost much of its terror. However, Redfern’s report may have actually hindered his career. The post of Principal Colonial Surgeon came up in 1818. Redfern

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had served with distinction for 18 years, and Whitehall had promised him the promotion. James Bowman, a naval surgeon, made his name on a convict ship as the first surgeon-superintendent under Redfern’s own reforms. Bowman’s success and Redfern’s influential enemies led Whitehall to appoint Bowman instead of Redfern! ‘My most sanguine hopes and best prospects in life are thus utterly blasted,’ said Redfern, resigning his government post. Macquarie made him a magistrate, but within a year, Whitehall cancelled the appointment. Ford writes: ‘At one stroke an emancipist was humiliated, the sympathetic Governor (Macquarie) reprimanded, and his policy of rehabilitating emancipists checked.’ Redfern’s fellow emancipists elected him chairman of a group to lobby for their basic rights, for example to buy, hold and sell property and to sue or give evidence in court. In 1821 he returned briefly to England where he successfully petitioned King George IV. Redfern was a founding director of the Bank of New South Wales. But ten years later, when the bank was in danger of closing, Robert Howe, editor of The Sydney Gazette, criticised Redfern in print. Redfern attacked Howe with a horsewhip, which cost him a fine of 30 shillings. By 1824 he was easing himself out of medicine, but kept busy importing vines from Madeira, cattle and Merino sheep. Redfern owned over 2000 acres in the Airds (now Campbelltown) district, as well as 100 acres of farmland stretching from what is now Central Station to Redfern. But what did William Redfern have to do with contraception? For centuries, people have practised coitus interruptus — what Sydney-siders still call ‘getting off at Redfern’ (rather than going all the way to Central). In 1828 he took his surviving son to Edinburgh for his schooling. William Redfern died there in 1833, aged 59. (GB)

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JAMES PARKINSON

AND THE SHAKING PALSY

James Parkinson was born in the middle of the eighteenth century — an era which, for some reason, seemed to spawn more towering intellects and affirmative leaders than any other time in recent history. Parkinson took his place among such people as Newton, Johnson, Constable, James Cook, Catherine the Great, Voltaire, Mozart, the Wesley brothers and others. He was renowned not only as an observant doctor, but as a geologist, political activist, social reformer and writer. Parkinson’s birth in 1755, his marriage in 1781 and his death in 1824 are all recorded in the parish register of St Leonards in Shoreditch, London. This church is perhaps more famous for the lines in the nursery rhyme, ‘Oranges and Lemons’ than for anything else: When will you pay me? Say the bells of Old Bailey When I grow rich? Say the bells of Shoreditch.

The district is said to have been named after Jane Shore, mistress of Edward IV in the mid-fifteenth century. Parkinson was Sunday School secretary at St Leonards, but regrettably that did not save him from the indignity of having his headstone vandalised, and now there is no trace of his last resting place. He lies in undeserved obscurity. He lived and practised where he had been born, at 1 Hoxton Square. In those days this was a locked square only open to the residents, people who generally regarded themselves as ‘gentry’, somewhere between ‘tradespeople’ and the ‘aristocracy’, and possessing elegance, artistic discrimination and that social ease which comes with accumulated wealth. In the sixteenth century Hoxton Square was also the site of the famous duel between the dramatist, Britain’s first Poet Laureate,

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Ben Jonson, and the actor Gabriel Spenser in which the latter was killed. Today, in common with other residential areas in the East End of London, the Square is run down and decayed. The house where Parkinson lived has gone, and in its place stands a furniture factory on which is affixed one of those famous blue plaques of the English Heritage Society which simply says ‘James Parkinson 1755–1824 Physician and Geologist Lived Here’. As regards the geologist bit, Parkinson was a keen palaeontologist when that science was in its infancy. His specialty was finding evidence of previous generations in the subsoil of London. To this end, he collected many specimens, and between 1804 and 1811 wrote what was then the definitive work on the subject: three volumes entitled, Organic Remains of a Former World. Rather unusually, it was for his work in palaeontology, not medicine, that Parkinson became the first recipient of the Honorary Gold Medal of the Royal College of Surgeons in 1823. His collection of fossils is now in the British Museum. Young Parkinson was a student at the London Hospital, attending lectures by John Hunter. The notes he took were published posthumously in 1893 by his eldest son under the title Hunterian Reminiscences. Parkinson entered practice when his father, also an apothecary, died in 1785. With the recent advent of the Industrial Revolution, together with the impending French Revolution, and the coincidental granting of American independence, to say nothing of the ‘discovery’ of Australia, it was a stirring time to start work. Parkinson recognised the political unrest of the times and felt that as an educated man he should have his say. As a result he joined a secret society given to social reform, circumspectly known as the London Corresponding Society. Through it he published a number of penny pamphlets, under the nom de plume ‘Old Hubert’. Under this guise he wrote pieces with such inflammatory titles as An Address to the Hon Edmund Burke from the Swinish Multitude, Whilst the Honest Poor are Wanting Bread — A Sketch and Revolutions Without Bloodshed.

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Parkinson appeared before the Privy Council on behalf of some imprisoned friends and was even cross-examined by William Pitt, the Prime Minister. Eventually the fire in his belly died down, and at the age of 40 Parkinson dropped politics to concentrate on medicine. This was not before he had written a notebook on the current state of chemistry, which ran to several editions. Back in the medical scene he wrote two bestsellers. One called Dangerous Sports was addressed to children, warning them ‘against wanton, careless, or mischievous exposure to situations from which alarming accidents so often occur’. The other was The Villager’s Friend and Physician which was a kind of Home Doctor manual purporting to have been written by a village apothecary of 30 years’ standing. Among other folksy observations it advises thrift and encourages bathing, but only while in good health. Later, Parkinson wrote several other medical books, the most interesting of which must have been the 22-page leaflet called Hints for the Improvement of Trusses published in 1802. The front cover blurb is somewhat less than snappy as it goes on to explain the booklet was ‘intended to Render their Use less inconvenient, and to Prevent the Necessity of the Understrap, with the Description of a Truss of Easy Construction and Slight Expense for the Use of the Labouring Poor, to whom this little tract is chiefly addressed’. The booklet cost ninepence and if it could get that much on the title page, think what the inside had to say. The gentle apothecary suffered from gout, a common ailment of the time due chiefly to dietary indiscretions. He wrote a book on its cure, and later helped his son report the first case of appendicitis recorded in British medical literature. It describes a fatal case in a boy of five. All this was leading up to Parkinson’s most famous work, which alone is responsible for the handing down of his memory to posterity. This was the paper written in 1817 entitled Essay on Shaking Palsy. Its publication was a burning-bush moment in medical history and his definition of the principal symptoms has not been

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surpassed. He explains that the syndrome consists of: ‘Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forwards, and to pass from a walking to a running pace: the senses and intellect being uninjured.’ The associated rigidity, which we now regard as a principle sign, is not mentioned. This probably indicates that Parkinson relied on observation rather than clinical examination. Indeed in the monograph only six patients are reviewed, and of those, three were casual acquaintances he met in the street. Further, nowhere in the dissertation is the characteristic mask-like face mentioned, the socalled Parkinson facies. Although the syndrome had not been written up before, Galen, the celebrated Greek clinician of the second century AD, had mentioned a shaking disease. He could offer no explanation for the condition and apologised that no autopsies had been carried out to establish a cause. This is hardly surprising as at the time it was against the law to undertake post-mortems. James Parkinson did not name the disease after himself; indeed he never heard it referred to as such, for it was not until 1877, 60 years after the original publication, that Charcot in Paris gave it its eponymous name. It has remained so since and the Shaking Palsy will always be Parkinson’s Disease in our minds. Regarding the man himself, he was described by a friend as being ‘rather below the middle stature, with an energetic, intelligent and pleasing countenance, and of mild and courteous manners readily imparting information in his favourite subjects’. Yet when he died in 1824 the medical profession did nothing to commemorate him, and no portrait of him has ever been found. This is perhaps due to his contentious political views. This lack of contemporary recognition is a pity, because James Parkinson accurately described a disease which has made his name one of the most recognised in medical history, both within the profession and to the lay public. (JL)

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THE GREAT WINDMILL STREET SCHOOL OF ANATOMY In the centre of London, just up from Piccadilly, there is a narrow side lane called Great Windmill Street, so called because in medieval times a windmill stood there. The inscription on what is now the Lyric Theatre states that William Hunter, founder of the Great Windmill Street School of Anatomy lived and worked here. Below the tablet is the stage door which originally was the entrance through which cadavers used to be taken in and out. Most West End theatres seem to have stories of ghosts and phantoms hanging about backstage; well, the Lyric can claim a more likely source than most. The Hunters were a remarkable family. There were ten children, all born at a tiny estate 11 km from Glasgow called Long Calderwood. Seven died either in childhood or early adulthood from tuberculosis. Of the remaining three, William, the seventh, was born in 1718; Dorothea, the eighth, lived until 1806 and bore a son and daughter who were both to become famous in their own right. The son, Matthew Baillie, went on to publish the first English textbook of pathology, and the daughter, Joanna, became a poet and playwright and confidante of Sir Walter Scott. John Hunter, the tenth child, was perhaps the most distinguished, as we shall see in the following chapter. He was born in 1728 and became a surgeon extraordinaire and memorable collector of medical specimens. William was 14 when he began studies in theology at Glasgow University, but became disillusioned with the church and turned to medicine. He did the appropriate three-year apprenticeship, then took himself off to London where he fell under the influence of such distinguished patrons as the well-known obstetricians William Smellie and James Douglas. He became an excellent accoucheur and attended at the birth of Queen Charlotte’s first (of 15) children, a boy who later became Prince Regent and then George IV.

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William Hunter also went to Paris to study anatomy and became accomplished in the so-called ‘French method’ of medical training, whereby the student actually did the work himself rather than merely observe. He returned to England with these newfangled ideas and went to live in Jermyn Street, London, a thoroughfare where you can now buy a nice line in expensive shirts. The launching of William Hunter into a career of teaching anatomy more or less coincided with the separation of the Barbers and Surgeons as a combined guild in 1745. This was a happy coincidence as it broke the monopoly that this union had on the teaching of anatomy, thus allowing private schools to be established. With this new freedom Hunter planned to found a national school of dissection and an anatomical museum. To this end he began collecting normal and pathological specimens and asked for a government grant to erect a suitable building. No reply was forthcoming and the piece of real estate he had in mind was put to another civic use years later — on it was built the National Gallery in what is now Trafalgar Square. That was in 1763 and the Battle of Trafalgar was yet to be fought. Hunter was not put off by bureaucratic inactivity, and in 1766 he bought a parcel of land in Great Windmill Street for £6000. For the outlay of a further £2000 he constructed a building which contained ‘a handsome amphitheatre and convenient apartments for dissections and lectures. Further, it had ‘one magnificent room fitted up with great elegance and propriety as a museum’. A skylight was constructed above the demonstration table and seats were arranged in tiers close to the table. Not only did Hunter add to the specimen collection from his own efforts, but he acquired rare examples from his former students and friends. He called his collection ‘a present to the public’. Besides collecting, his second passion was teaching, and it was this skill which attracted pupils, for his enthusiasm was infectious and his detailed knowledge monumental. His biographer, Samuel Simmons, felt he deserved this reputation partly because of his zeal

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for the subject and partly because he was such a good speaker (unlike his brother, John, who was hesitant and nervous). Simmons wrote, perhaps tongue in cheek, ‘his dialect had all the polish of the southern metropolis with enough of the northern recitative to preserve the close of his sentences with too abrupt a cadence’. Hunter was anxious that all classes should be attended so that continuity of learning was maintained. Beginners were dissuaded from taking notes so that the overall view could be absorbed. On the other hand, second-year students were encouraged to write up details and learn by reading as well as by performing their own dissections. Unlike other schools of anatomy, outsiders such as artists or law students interested in forensic medicine were not admitted. Or so it was said, but there appears to have been several notable exceptions. Edward Gibbon, historian and author of The Decline and Fall of the Roman Empire put off a trip to Paris in 1777 so that he could attend the course. Adam Smith, the economist and author of Wealth of Nations, also attended. The acerbic contemporary cartoonist T. Rowlandson did a drawing on the premises which he called ‘The Dissecting Room’. It is now in the possession of the Royal College of Surgeons of England. The senior Hunter brother, William, moved from Jermyn Street to live in the anatomy department itself, and the younger Hunter, John, took up his former residence. John had helped with the dissections and demonstrations for 12 years from 1748, but in 1760 he left to join the army so was not involved in Great Windmill Street School. William never married, but he was joined by other competent anatomists including a former assistant, William Hewson. The advertisements for the classes always referred to ‘Dr Hunter and Mr Hewson’s Course of Anatomical Lectures’. Hewson’s mother-in-law, Margaret Stevenson, ran lodgings at 7 Craven Street, off the Strand, and was the landlady of the then agent for Pennsylvania in London, the redoubtable Benjamin Franklin. He and Hunter became close friends.

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Hewson and Hunter eventually fell out over the ownership of several anatomical preparations. Franklin was asked to arbitrate and the upshot was that Hewson left and set up his own establishment in Craven Street, with Mrs Stevenson and Franklin. In 1771 William Cruikshank joined the Great Windmill Street School and had a special interest in the lymphatic system. His studies formed the basis of perhaps the greatest published work to come out of the school, The Anatomy of the Absorbing Vessels of the Body (1786). William Hunter died in 1783 following an acute attack of gout. As he lay dying he is said to have murmured, ‘If I had strength enough to hold a pen, I would write how easy and pleasant a thing it is to die’. Some years before, William and John had fallen out and in his will William left his brother nothing, neither money (of which he had plenty), nor the care of his beloved museum, nor the old home at Long Calderwood which he had inherited as the eldest son. His nephew, Matthew Baillie, and Cruikshank were left as coheirs to the freehold of the Great Windmill Street premises and the use of the museum for 30 years; it was then to go to Glasgow University. Glasgow tried to persuade Baillie to relinquish the museum at once, but he was young and felt he needed the income from the lectures to survive, so for the time being it stayed in London. Baillie proved to be as silver-tongued and enthusiastic as his uncle William. Out of his continued studies at the centre he wrote the first textbook on pathology, published in 1793 under the unpromising and tentative title Morbid Anatomy of Some of the Most Important Parts of the Human Body. Of the book’s engravings, 114 of the 207 figures were from Hunter’s museum and the rest were taken from specimens he had prepared at the Great Windmill Street School. Baillie left in 1799 but subsequent owners added to the collection, which was eventually sent from London to Glasgow in 1807. It is still there to browse through and marvel over.

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The teaching premises at Great Windmill Street were sold in 1812 to Charles Bell (of Bell’s Palsy fame, a paralysis of the facial nerve) for £2000 which Bell said was ‘all my money to the last penny and eighteen pence more’. Bell lectured there to classes of 80 to 100 students and increased the contents of the refurbished museum to eventually sell to the Royal College of Surgeons of Edinburgh. However, the days of the private medical school were numbered. As students went to large hospitals to learn, attendances at Great Windmill Street declined, and in July 1831 what was left of the demonstration rooms were dismantled and the place fell into disrepair. The job of the Great Windmill Street School of Anatomy was done. If you ever visit the ‘theatreland’ of London, go to the corner of Shaftesbury Avenue and Great Windmill Street and have a glance at that blue plaque on the side of the Lyric Theatre. Spare William Hunter a kindly thought and feel the chill of the ghostly presence of his long-gone dissecting room. (JL)

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‘DON’T

THINK, TRY’

‘Don’t think, try’ was perhaps the best-known quote of that illustrious English surgeon and anatomist of the eighteenth century, John Hunter. It was written in a letter dated 2 August 1775 which he sent to Edward Jenner, famous English country general practitioner and inventor of the smallpox vaccination. In full it reads, ‘I think your solution is just; but why think? Why not try the experiment?’ The correspondence was not concerned with advancing some eighteenth century clinical tour de force, as you may think, but with the life cycle of hedgehogs. As befitted educated gentlemen of the era, both men were interested in natural history, but while Jenner looked at its wonders right there in the Arcadian splendour of rural Gloucestershire, Hunter devoted his life to its more sanitised version as a scientific pursuit in London. In the end, the latter was to become the greatest collector and cataloguer of a whole panoply of anatomical specimens in medical history. Despite sustaining major damage during the Blitz in World War II, a substantial part of the collection can still be seen in the Royal College of Surgeons in Lincoln Inn Fields, London. Hunter’s disciplined interest can be well seen in the masterly and famous painting done of him in 1788 by his old friend, Sir Joshua Reynolds. The artist shows the surgeon contemplatively picking a hair from a wayward wart on his chin. Behind him is an open book which has several illustrations of the lower limbs of various animals on the left page, and on the right a series of skulls ranging from Caucasian to Australian Aboriginal (then a very new and sought-after collector’s item) to chimpanzee, monkey, dog and finally crocodile. By his lights he showed a descending order of development; I doubt whether he would have the courage to say that now. The odd bit of the picture is in the upper-right corner, where there is a drawing of the lower legs and feet of a human skeleton

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dangling on the back wall. These bones, still in the Hunterian collection, belonged to a Mr Charles Byrne, the famous giant. Byrne was born in Ireland in about 1761 and left home at the age of 19 to cash-in on his unique physical abnormality by touring Britain. He changed his name to O’Brien, styling himself ‘The Irish Giant’, but he enjoyed only a short career and died in 1783. The story regarding the skeleton goes that O’Brien had been in declining health for some time and had finished up in London. The ever-observant Hunter knew this and had set his heart on examining and keeping the unusually large skeleton when it became available. Nothing precipitous, you understand, but preferably sooner rather than later. To make sure the prize would not slip through his hands and into a Christian grave, the surgeon employed a minion to keep tabs on the giant’s slow deterioration. O’Brien got wind of the ghoulish arrangements and, feeling that ending up as a museum freak, as distinct from a sideshow freak, was not his idea of fun, he left strict orders that on his demise the person who attended his corpse should not let the body out of sight until a lead coffin had been made, his massive frame put in and the whole lot taken out to sea and dumped. The first part went according to plan; he died. The pressured undertaker engaged the bribed men to watch the body in shifts. Hunter was tipped off and hot-footed it round to the alehouse where O’Brien’s off-duty minder was having a bottle of lunch. This was not a moment for vacillation, and £50 was offered without ceremony. In 1783 that was a very acceptable bribe, so the first watcher went to consult his sidekick who was in the parlour by the body. The men thought it over and, spotting a sucker, demanded £50 each. Hunter was keen, too keen, and accepted at once. Knowing they were onto a good thing, the guards upped the ante to £500. A desperate Hunter agreed to this stupendous sum and borrowed from friends. That night the body was hurried away in a hackney carriage and

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conveyed to Earls Court, then just out of town and Hunter’s home at the time. With the urgency of guilt he cut the body up, boiled off the flesh and hung the 2.39-metre skeleton in his museum where not only does it appear as a prized possession in the Reynolds’ portrait, but is displayed to this day alongside the skeleton of a nine-year-old girl who was barely 50 cm tall. If you go and see the skeleton, you will notice that the bones are brownish. This is not from age, but from the haste of the initial preparation which only allowed for a half-baked job, so to speak. Many years later, in 1909, the endocrinologist, Harvey Cushing, was encouraged to examine the body at close quarters. He confirmed the obvious when he examined the sella turcica, the seat of the pituitary in the skull, which showed evidence of a pituitary tumour. Obviously in O’Brien’s pre-adult life it had secreted too much of its growth hormone and gigantism had resulted. But what of John Hunter himself? Why did he become so eminent in medical history circles? John Hunter was the youngest of ten children, born in 1728 at Long Calderwood just outside Glasgow. It is said that his education was poor and that he was mainly self-taught in the hedgerows and lanes of his part of Scotland. In 1748 he joined his celebrated brother, William, as a dissector in his School of Anatomy in London, about which we heard in the last chapter. Later he studied surgery under Percival Pott at St Bartholomew’s and then went on to St George’s Hospital. In 1760 he joined the army as a staff surgeon, mainly for financial reasons, but left three years later. In 1774 William Hunter published a paper entitled, ‘The Anatomy of the Human Gravid Uterus’. The older brother regarded himself as quite an authority on the subject, as indeed he was, and in the preface he acknowledged John’s ‘accuracy in anatomical researches . . . (it was an) opportunity of thanking him for that assistance’. In 1780 John Hunter presented a paper to the Royal Society, ‘On the Structure of the Placenta’, and while he mentioned his

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brother’s ‘very accurate and elaborate work’, he went on, ‘I consider myself as having a just claim to the discovery of the structure of the placenta and its communication with the uterus.’ William was outraged and wrote to the Royal Society in high dudgeon denying the preposterous claim. The Society prudently declined to take sides, but even by the time the elder brother died three years later, the rift was not healed. The odd thing is that John had done the original dissection all right, way back in 1754, but it was treated, as John was later to say, ‘with good-humoured raillery’ by William. This put-down must have rankled for 26 years until the junior brother eventually went into print. It may also have been the last straw in an internecine relationship, for gossip about the lecture rooms was that William had disapproved of John’s marriage nine years earlier in 1771. There had also been a dispute about the ownership of several anatomical specimens. John’s judgement may also have been weakened by ill-health. In the end each became renowned in the medical field in his own way, but the partnership which promised so much was not to be. Ultimately, the argument was carried on beyond the grave, for as we saw in the last chapter the elder brother cut the younger out of his will completely. However Matthew Baillie, their impecunious nephew who inherited the family home at Long Calderwood in William’s will, in an act of sensitive generosity gave it to John the year after William’s death. John Hunter seems to be best known, however, for supposedly inoculating himself with pus from a sufferer of venereal disease in order to follow the natural course of the disease and record a scientific observation. Qvist states that nowhere in his writings does he admit to this, whereas Paget, states that, ‘early in 1765 he inoculated himself by a most unhappy mistake in the experiment with the wrong virus, and suffered two years from the effects of it — an error which served only to support false notions in pathology’. Accepting the then ill-defined meaning of ‘virus’, Paget could

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well have been referring to venereal disease, which we now know is not a viral disease. All are agreed that Hunter thought syphilis and gonorrhoea to be the same malady, one manifesting on mucous membranes and the other on the skin. It was not until 1838 that Ricord finally established that they were separate and distinct diseases. We shall never know for certain if he used himself as a guinea pig. John Hunter had heart problems and suffered his first attack of angina in 1773, and the pain increased over the years. He was on the staff of St George’s Hospital and had the unhappy knack of falling out with his fellow surgeons, not a desirable state of affairs when he himself felt that anyone who chose to annoy him could cause his death. The rancour came to a head in 1793 when Hunter felt that the fees received from those students who registered under him should go to him personally, whereas the others concluded that they should go into a common pool. Angry letters were written and on 16 October 1793, a Board meeting was to be held to resolve things. Hunter arrived late and was flustered, but spoke immediately. A colleague flatly contradicted him, whereupon Hunter was gripped by severe chest pains. He got up to go into an adjacent room and was followed by his nephew Dr Matthew Baillie and Dr Robertson. After taking a few steps he turned, groaned and fell into the arms of Dr Robertson. He was dead. Hunter was buried in St Martins-in-the-Fields as his widow considered the fee for Westminster Abbey too great. Sixty-six years later Frank Buckland undertook to find the body. It took him 16 days during which time he viewed the nameplates on 3060 coffins. He found it when only three more remained. On 28 March 1859 John Hunter was reinterred with great honour in the North Aisle of Westminster Abbey. In 1952 a plaque was unveiled in St Martin’s Church to commemorate his original resting place. John Hunter was unprepossessing to look at, standing at only 157 cm and having a somewhat leonine appearance with his thick

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set body and sandy hair. His name is not associated with any single great discovery, and he was a hesitant lecturer, yet he is regarded as the founder of scientific surgery and was the first to apply the inductive system of observation and experiment to the study of disease. He was the unrivalled master of human anatomy and physiology, an expertise gained by careful and meticulous dissection of very many different forms of animal life, and was an original thinker in embryology, geology, and palaeontology. Hunter’s versatility was prodigious, but above all he respected Nature and her healing powers. Despite his undoubted surgical skill he had this to say about his chosen field: Operations are a reflection on the healing art; it is a tacit acknowledgment of the insufficiency of surgery. It is like an armed savage who attempts to get that by force which a civilised man would get by stratagem.

(JL)

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F LY I N G

HIGH

We have no family except our aircraft — six Beech Barons, two Beech Dukes and a Cessna 431 B. I really feel that they are my children. — Robin Miller (Flying Nurse)

Naturally, much of the Australian news in 1917 dealt with the war. But in August, an incident from far northern Western Australia stole the limelight. Outside the small town of Halls Creek, a stockman called Jimmy Darcy was badly hurt when he fell from his horse. Somehow his mates brought Jimmy the 50 km into town. The only local man who knew any first aid was the postmaster Fred Tuckett, but Tuckett knew Jimmy needed a doctor. Finally, he sent a Morse appeal all the way to a Dr J. Holland in Perth. Dr Holland diagnosed a ruptured bladder, decided that Jimmy urgently needed to have his bladder opened and instructed Tuckett to operate at once. But how could a postmaster with no experience, no instruments and no anaesthetics operate? Dr Holland answered: ‘If you don’t operate, Jimmy will certainly die.’ With a sharpened penknife, Tuckett made his first incision; then for seven hours, he shuttled to the telegraph for more instructions. The next day, Darcy was no better, so Dr Holland prescribed another operation. As Jimmy was still not improving, Dr Holland set out by sea to Derby, and then by car along dirt tracks. However, Jimmy died the day before the doctor reached him. Enter John Flynn, a Presbyterian minister in outback South Australia, who rose to become the first Superintendent of the Australian Inland Mission. Jimmy Darcy’s death brought home to Flynn the plight of inland Australians who had to do without doctors, nurses or ministers. They suffered falls, kicks from a horse, or wounds from the horn of an angry bull. Aboriginals settled arguments with spears and nulla-nullas. Boys suffered complications

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from circumcision with a rusty blade or broken glass but there was no medical help. (People) . . . either recovered with the help of . . . patent medicines . . . or died . . . ‘Fever’ was the most favoured description of illness, . . . usually treated with . . . quinine and Epsom salts. Naturally enough, this did not always effect a cure. Robin Miller, Flying Nurse

It was John Peel, a medical student turned fighter pilot, who convinced Flynn to combine medicine with aviation. A plane could take a doctor from Darwin to Oodnadatta in about 12 hours, compared to 12 days on the ground! ‘I can see a missionary doctor administering to the needs of men and women scattered between Wyndham and Cloncurry, Darwin and Moree . . .’ Peel dreamt. But how could outback people contact the flying doctors? Flynn knew that aviation and medicine were not enough. In 1925 he met a young Adelaide engineer, Alfred Traeger, who was to invent a pedal-operated generator powering a radio transmitter-receiver. The operator had to pedal hard, but his hands were free to tap out his Morse message. Since few homesteaders knew Morse, Traeger later devised a typewriter keyboard. The radio sets sold at £33 each. Altogether Traeger made over 3000 sets! In August 1927 Dr George Simpson and Mr Norman Evans, a Qantas pilot, brought a man with spinal injuries and fractures from Mount Isa back to Cloncurry. Dr Simpson set down the flying doctor’s duties: to give radio advice to out-stations, go to urgent cases, give first aid, decide whether to evacuate patients, consult with local doctors and start clinics where necessary. Australian aviation had a special year in 1928. Charles Kingsford Smith and Charles Ulm made the first trans-Pacific flight from California to Brisbane in the Southern Cross. Bert Hinkler took fewer than 16 days to fly solo from England to Darwin. Dr Kenyon St Vincent Welch, a Sydney surgeon, went to Queensland as the first salaried flying doctor. However, Flynn could not

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even afford to insure the planes, which had only basic instruments and no radio. Camels carried fuel and supplies to remote landing-grounds. The best airstrips were claypans, the worst were hastily cleared paddocks. Night-landings or even take-offs lit by flares were terrifying. The first female flying doctor, Dr Jean White, had never been in a plane before, but in her first year covered 70 000 km. In the Gulf country, during a forced landing, she managed to escape serious injury while the pilot was unscathed. Naturally, the accuracy of the information sent by radio from outback stations varied. After an accident with a vehicle, a man told the doctor of a problem with one leg. When the doctor asked about the colour of the toes, the bushie replied: ‘Wait a minute, doc, I’ll go outside and have a look.’ He had forgotten to mention that his leg was amputated! Another patient wanted to tell the doctor about an accident with a gun, but transmission was poor, so the doctor asked him to spell out the word: ‘G for Jesus, U for Onion and N for pneumonia.’ No problem. Message understood! During World War II, the famous Dr Harold Dicks also doubled as pilot, engineer and mining warden. The service lent many pedal radios to the Armed Forces. When the Reverend Dr John Flynn died in 1951, a colleague saluted him as ‘the man who loved the people beyond the end of the railway lines’. Four years later, the Flying Doctor Service became the Royal Flying Doctor Service of Australia. Even now, the RFDS network brings the School of the Air to isolated bush children. Each morning, women, often hundreds of miles apart, hear Australian and overseas news and chat together in their ‘Galah Sessions’. By now, people in the outback are always within 90 minutes flying time from a Flying Doctor base. About 35 doctors, 87 nurses and 83 pilots provide medical cover to 80 per cent of Australia. Each year the service helps about 150 000 people, many of whom see no other doctor or nurse. (GB)

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Chapter

WARS

9

AND

REVOLUTIONS

THE AZTECS,

SMALLPOX AND GENOCIDE

One of the greatest, and certainly most lethal, epidemics in recorded history was that caused by smallpox as it swept through Central and South America following the Spanish invasion at the beginning of the sixteenth century. Arising in antiquity and evident on Egyptian mummies, by 1500 AD smallpox had become endemic in Europe, where it flared up every five to 15 years. It mainly affected children, but fortunately those who survived to adulthood enjoyed a lifelong immunity. This age distribution of the vulnerable was to prove highly significant in the subsequent spread of the disease in the Americas. After sporadic outbreaks following Columbus, the first major epidemic arrived in the New World from Spain in 1518. It burst upon the virgin population of

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Hispaniola, and later Puerto Rico and Cuba, with a terrifying and rampaging ferocity, eventually killing almost half the population. In 1521 Cortés with 300 men attacked the Aztec capital, Tenochtitlán (later Mexico City), a town of 300 000 people. When he entered after a three-month siege, Cortés found 160 000 had died of smallpox, including the emperor, Montezuma. The city’s canals were choked with corpses, and to deal with the stench, houses had been pulled down over the dead inside. The malady took a particularly virulent course, with pustules from head to foot and the vulnerable flesh tearing off whenever the victim moved. Little wonder the followers of ‘stout Cortés’, on another later occasion, ‘looked at each other with wild surmise’, as Keats had it. A number of the Aztecs escaped south into Mayan territory, but as the incubation period is 10 to 14 days, unbeknown to them they carried the disease within their systems and into other previously uninfected areas. By 1527 the population throughout the whole of South America had been decimated. Consequently, when Pizarro sought to capture the Inca capital in Peru, Cuzco, the disease had outrun him and the defenders were so incapacitated they were incapable of serious resistance. More medical disasters were to follow, for measles succeeded smallpox as the major scourge, until by 1529 it had killed twothirds of those Cubans who had not already succumbed to smallpox. The Europeans, immune from their childhood attacks, remained comparatively untouched, but as indigenous labourers and emperors alike were wiped out, and cultures, religions and languages lost, both sides believed the epidemic was a punishment from the white man’s gods. The carnage continued until by 1548 the population of Mexico had shrunk from 30 million to three million, while incredibly, that of the island of Santo Domingo had been reduced from one million to a mere 500. A complete civilisation had been wiped out. Until recently it has been thought that as the population fled in all directions the epidemic ranged north as well as south. Unlike the spectacular Inca ruins, however, archaeological evidence of a

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northwards spread has been hard to find. Now recent research indicates that in what is now the USA the plague lagged behind by many decades. Why was this? In pre-European times there were no large cities in the north, just small settlements. The Mohawk Indians, for instance, packed up their village every decade or so and moved to agriculturally virgin pastures on good farming land, usually on hilltops. This was quite unlike European urban development, which was largely settled adjacent to waterways. Consequently, we have been left a series of village sites, which are not hidden beneath modern conurbations, and now occupy the site of original European settlements. Further, with these migrations the detritus of different eras did not pile high — one era on top of another, as was the case in Greece and Turkey, for instance. Their solitary nature makes artefacts easy to date. Also, what was good pasture then is good pasture now, so still ploughed to occasionally reveal datable pottery shards and the like. As a result, more than 50 such communities have been studied to give a full picture of contemporary life of the indigenous people. By good fortune, some eighteenth century European visitors counted local inhabitants and left sketches of Mohawk village floor plans. This has enabled population densities to be calculated. They show that there were huge stretches of unoccupied forest between settlements allowing scant direct contact between groups and so little chance for disease to spread in the wildfire pattern of the more populous Latin America. As a result of all this, it has now been established that far from a dramatic fall in the North American Indian population at the time of the disease holocaust, they actually flourished. At least that is until 1634. That year a smallpox epidemic broke out in the Connecticut River valley, and within 12 months 63 per cent of the Mohawks had been wiped out. What caused this outbreak, and why was there an over 100 year time lag?

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In the sixteenth century it took small ships six weeks to reach America. By the seventeenth century larger vessels took only four weeks, thereby increasing the chance of any infected travellers surviving long enough to carry the malady the whole way across and not dying en route. But that’s not all, there was another crucial factor. As I intimated at the beginning, it was children who contracted smallpox. They either died or they survived, and if they lived, as adults they become immune to further attacks. Spanish authorities wished to encourage swift colonisation in Central America, so from the beginning they transported entire families including, of course, infected youngsters. They carried the disease into the New World and, pathologically speaking, the results were disastrous. In contrast, North America was taken over by the Dutch and the English, who were driven by a different philosophy as far as colonisation was concerned. Conquest and trade were their goals, not family settlement. Consequently they dispatched men only, who then commonly married local women. Children from the homeland stayed with the infection in Europe. So however unwitting the authorities were of the clinical repercussions of their strategy, from the pathological viewpoint the plan was a success. Tragically, in ignorance of the medical outcome, the British changed the scheme of things and decided to ship children out. It was to be a momentous political decision. It was in 1634 that the first ship to carry children reached Quebec. There were 30 of them, some of whom had smallpox on embarkation which they passed on to others en route. On landing they came into contact with hunter-gatherers from the north of the St Lawrence River. The effect was as devastating as it had been on the vulnerable populations of Mexico a hundred or so years before. As in Latin America, smallpox and measles returned again and again. Half the Iroquois died in 1684, half the Cherokees in 1738, and almost all the Mandans in 1837. It has been estimated that out of a New World total population of about one hundred million, in the end 90 per cent succumbed.

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The effects were far-reaching; economic, political, social, and certainly not just medical. One of the consequences of the epidemic was a labour shortage. To solve the problem slaves from Africa were introduced. As smallpox was also endemic there, at least the new migrants had some immunity. The sweeping fatal epidemics of the early days of the Americas created not only problems for that period, but echoes of their effects are with us still. (JL)

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DR GUILLOTIN

AND HIS BRIGHT IDEA

Medicine has produced many men and women who have achieved greatness in areas other than the clinical; sportsmen, explorers, politicians and so on. Most are remembered with pride and affection, but some are not, and history has dealt harshly with one in particular. The diagnostic acumen and demonstrable kindness of Dr Joseph Ignace Guillotin is never recounted when we morbidly recall his extramural activities during the French Revolution. Let’s put the record straight. Guillotin was born in 1738 in a small town to the north of Bordeaux. In view of forthcoming events, he had what may be called a portentous start to life when he arrived prematurely, due, so the family claimed, to his mother having been startled by the screams of a man being broken on the wheel, a severe form of contemporary punishment. He trained initially as a Jesuit priest, but transferred to medicine to graduate in Paris in 1770. Guillotin continued on in academic life. He taught in the Paris Faculty of Medicine and among other things wrote reports on rabies, swamp drainage and the medicinal use of vinegar; all worthwhile and commendable medical pursuits. As regards rabies, however, being a man of the times, he concluded that convicts should be used in clinical trials. Later, he sat on a commission to investigate the activities of Antoine Mesmer and his hypnotic seances — or mesmerism — then sweeping the Continent. He joined a set of distinguished men, for among the Board Members were the French chemist Antoine Laurent Lavoisier, and the American patriot/scientist/printer Benjamin Franklin. Guillotin was certainly well thought of by the authorities. In the end, incidentally, Mesmer was dubbed a charlatan and his cures with ‘magnetic fluid’ regarded as simply a matter of his patients’ imagination.

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In the ambient political climate, Guillotin took up the cause of the common people (the Third Estate) and was elected to the National Assembly in 1789 — a propitious year, as it turned out. When the newly elected delegates found themselves locked out of the chamber, it was Guillotin who suggested the alternative venue — an adjacent tennis court. It was to be a historic move for it was here that the famous Tennis Court Oath was propounded. The National Assembly was ‘never to be dissolved until a solid and equitable Constitution was formed’. Guillotin drew attention to the terrible conditions in the main Paris hospital, the Hotel Dieu, where people were lying four to six to a bed. The central ward had 800 occupants who lay terrified while operations were done in the centre of the room. As the mortality rate from the procedures was about 20 per cent, they had every right to be frightened. Reform did eventually take place in 1794. Guillotin was also concerned with penal reform, wishing for a more humanitarian approach. This did not include abolition of the death penalty, of course, but he felt the form of death should be quick, the same for all, and be ‘by beheading by a simple mechanism’. Debate took place on the issue and several experts were called upon, including Charles-Henri Sanson, the public executioner. He explained that every blow of the sword dulled the blade. As he only had two, the delays for sharpening them caused even further apprehension by the victim. Sanson also deplored the nervousness of the condemned, who would not hold still. If only they could be tied down, it would make the job easier and less messy all round. Perhaps, he wondered, a mechanical method could be devised where a blade would fall by its own weight, guided by two vertical runners and the victim be secured firmly in place. In the ensuing debate, Guillotin, laudably supported the contention, not to ease the executioners lot, but on humanitarian grounds. But to his lasting misfortune, he is recorded as having described his ghoulish vision: ‘The device strikes like lightning, the head flies, blood spouts, and the man has ceased to live.’ It was a dramatic and most impressive plea for what he himself saw as

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painless justice, but which we have come to regard as monstrous. Hence, because of his passion, his name has always been unfairly associated with the grisly act; he did not invent the killing machine, he only supported its use. The device did not bring him instant fame, however, for at first the idea was ridiculed in song and satire, and Guillotin tried to distance himself from the debate. But the famous Comte de Mirabeau gave support, and the name ‘mirabelle’ was suggested for the device. The perpetual secretary of the Academy of Surgery, Antoine Louis, actually perfected the mechanics of the thing, and the name ‘louison’ or ‘louisette’ was put forward as an apt title. But ‘guillotine’, rhyming as it did with ‘machine’, and coupled with the good doctor’s popularity, proved an unstoppable combination and allowed his name to live on in chill remembrance. Dr Louis presented his plans on 17 March 1792. The apparatus was built in April and first used on Nicolas Jacques Pelletier on 25 April. Once launched it ran hot (1300 heads rolled during the last six weeks of the Terror), and it became the symbol of the Revolution. In actual fact the device had been widely known in England and Italy before the Terror, albeit in a slightly different form. Guillotin was scandalised by the unsought-for publicity and left Paris for Arras to become the director of a military hospital. I wonder if he did so in part to help expiate the burden of responsibility he may have felt, for doubtless he knew that Arras was the native town of the guillotine’s greatest exponent, Robespierre. In any event, it was in Arras that he took an interest in vaccination, even starting a correspondence with the great English GP, Edward Jenner of smallpox fame. Joseph Ignace Guillotin died without heirs in March 1814, having lived through the most momentous two decades in France’s history. He was a kindly and clever man who, almost absentmindedly, lent his name to an instrument he saw as being a humane compromise in a morbid business. Regrettably history has rewarded him with a gruesome immortality. (JL)

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THE EXECUTION OF EDITH CAVELL The death of nurses as a result of war is always emotive. Their gunning-down in the water by the Japanese, or the deaths of all the theatre staff at Salford (UK) Infirmary during an air raid in World War II stick in our memory when other atrocities fade. But one such event which perhaps caused even more outrage than any other was the execution of Nurse Edith Cavell by the Germans in 1915. Edith Cavell was born in Norfolk in 1865. At the age of 30, after some years as a governess in Brussels, a suitably genteel role befitting a parson’s daughter, she decided she wanted to become a nurse. Although not a job considered appropriate for a woman of her social class, in 1896 she enrolled as a probationer at the London Hospital. On graduation three years later, the Matron’s report stated that Miss Cavell was not a success as a nurse, was not methodical, overestimated her own ability and she had never been seen to smile. A pretty damning appraisal which was strangely negative in the light of subsequent events. After some hospital work in London, in 1907 Nurse Cavell took a post in Brussels as the Matron (or Directress) of that city’s first training school for nurses, the Berkendael Institute. With her background she seemed ideal for the position, but it was said she was cold and aloof, though fair, and that she expected that dedication from her pupils which she herself displayed. At the beginning of August 1914, while on leave in Norfolk, war became imminent, so she hurried back to Brussels. After appraising the situation, she sent most of her German and English nurses back to their respective countries. She was right, for within three weeks German troops were tramping past the Institute. With her remaining staff of 10, mainly Belgian, Edith Cavell resolved to treat any of the enemy if they presented. With her single-minded devotion to her vocation, the decision presented no

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dilemma, and indeed she was soon kept busy with the German wounded. However, after her initial treatment, most were sent back to Germany and that work ceased. However, there was plenty of other work with civilians and refugees to attend, and she was never idle. Among the refugees were Allied soldiers separated from their units who were making their perilous way back to their lines under thin disguises. The influx of patients of all kinds greatly increased when the Belgians opened the sluice gates of their dykes, flooding the countryside and reducing the Germans’ mobility. Of course this reduced everyone else’s chance of escape too. The Germans were aware of the stragglers’ movements and posted notices saying that any enemy soldiers caught would be shot, as would civilians who harboured them. This then was the situation when two wounded men from the Cheshire Regiment, Sgt Meachin and Col Bodger, found themselves holed-up at Mons, 30 km from the capital. On 24 August, with civilian help, they were led to the Berkendael Institute and to Edith Cavell. Miss Cavell did not hesitate to take them and put them in the surgical ward, where their wounds were treated. They were the first escapees Miss Cavell helped and they stayed for two weeks before being led to the Dutch frontier and to freedom. Word got around and others began to arrive in increasing numbers — up to 35 at a time. After rest and treatment, they were passed through a civilian network to the border. Most arrived from a chateau near Mons to be admitted in the guise of invalids if they could give the password, ‘I come from M. Yorc’. At first the Directress acted to save life. That may have been acceptable — just. But later, by aiding escape, her activities helped the Allies’ war effort. As that was treason, by so doing she had crossed her Rubicon and the firing squad was a distinct possibility. She never hesitated. The suspicions of the Germans were aroused by informants and on 20 June 1915 they came to interview her. Luckily there were no fugitives present at that time.

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On 31 July the main linkman between the hospital and the frontier, M. Baucq, was arrested and Miss Cavell knew her turn could not be far off. She saw where her duty lay, continued in her subversive work and made no attempt to flee. On 5 August 1915 she was apprehended and interrogated at the Kommandantur. Using the simple expedient of pretending they knew all about the network, the Germans extracted a full confession in which she gave details of names, routes and passwords. What was revealed was the truth and Edith Cavell had a pious and touching belief in the truth. She was transferred to St Giles Prison and put in solitary confinement where her deep Christian commitment helped sustain her. More interrogations and more confessions followed and she wrote to her staff anticipating severe punishment. On 6 October 1915 Miss Cavell and 34 others were taken to the Parliament House to stand trial. She wore a simple blue dress and straw hat. Later, and in retrospect, it was thought her uniform may have made a bigger impression on a German Court fond of such trappings. She did not understand German and everything had to be translated, but during the questioning she admitted to having helped about 200 escape to Holland, while denying the Institute was the headquarters of the whole operation. The trial took only two days. Four days later she and four others, including M. Baucq, were sentenced to death. The rest got various periods of imprisonment with hard labour. On 11 October the Prussian commandant of Brussels confirmed Edith Cavell’s and M. Baucq’s sentences, but with an appeal pending, delayed in the case of the other three. Their sentences were subsequently commuted. The American legation protested and, due to the seriousness of the charge, sought to contact the Kaiser himself. The commandant held firm, as allowed by law, affirming her immediate execution was necessary to ensure the safety of German troops! An American Minister did get to see Miss Cavell, however, and it was to him she made her famous statement: ‘I believe my sentence to be just . . . I know that patriotism is not enough.’

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The following morning, 12 October, at dawn she and Baucq were taken 2 km to the Tir National, tied to posts, blindfolded and shot. She was hurriedly buried in the clothes she wore at the execution, including her greatcoat. Although several women were executed during the war, none generated the degree of outrage in Britain and America as this one did. Army recruitment surged. There was also some soul-searching taking place in Germany, as it was thought that the commandant may have been drunk at the time he confirmed the sentence. In any case, shooting women was not part of the German ethos. After the war a grateful government loaded Edith Cavell with honours. She was disinterred, carried ceremonially, first by the navy across the Channel, then by the army on a gun carriage through London to Westminster Abbey for a memorial service. After this national salute she was transported to her home town and buried in Norwich Cathedral. Some of the men she had help escape acted as pallbearers. (JL)

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Chapter

10

DISASTERS

OPIUM IN WHITE AUSTRALIA Doctors compete with chemists and alternative therapists. White Australians hate Chinese and mistreat indigenous Australians. Just the latest stories from our papers? No, we are talking about nineteenth-century Australia. In 1858 the Melbourne Age declared: Medicine never was, nor is it now, more than a pretence to science.

As late as 1895, according to The Bulletin, little had changed: Whatever strides surgery may have made, medicine proper is still little better than a poking in the dark.

Registered medicos made up only one-quarter of health workers. In 1881, Victoria had 454 Anglo-Australian medicos; 35 Chinese doctors; 761 chemists, druggists and

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their assistants; nine herbalists; nine medical galvanists; two medical magnetists; one medical botanist and various others. Chemists could legally advertise, give advice and sell medicines without a prescription. Dubious cures, based on secret formulas, flourished. Any enterprising grocer could sell patent medicines, many of which were loaded with opium and sometimes with alcohol. There was ‘Ayer’s Cherry Pectoral’, ‘Godfrey’s Cordial’, laudanum and so on. Australians of all classes could easily take opium. No matter whether you wanted to ease acute pain, chronic pain, insomnia, women’s complaints or the blues, opium was the shot. The line between use and abuse was blurred. For much of the nineteenth century, people regarded the taking of opium and other drugs as an individual matter. Indeed, there was more pressure for legal controls on alcohol than on opium. How things change. However, towards the end of the century, the fierce prejudice against the Chinese turned public opinion against opium and especially the smoking of opium. In 1888 the Afghan and three other ships brought to Australia 600 Chinese intending to settle here. Since Melbourne would not even let them land, the Afghan came to Sydney, where it was not even allowed to dock. These actions of the Victorian and New South Wales governments, though quite illegal, did reflect popular opinion. For many Chinese, opium was a recreational drug; there were plenty of occasional users and regular users, as well as some abusers and addicts. While many Chinese smoked opium, few AngloAustralians did so. The latter grasped the issue as a weapon against the hated Chinese; smoking opium was first condemned and finally outlawed. Many Australians feared that women who were by some sinister means induced or forced to smoke opium lost all sexual control, or else were so heavily drugged that they could not resist seduction or rape. Opium, so the story went, enabled the sensual, criminal Chinese to have their evil way with Australian women! ‘Shall the monsters of sensuality grapple the youth and

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innocence of Australia?’ screamed The Bulletin. Such rhetoric tells us more about the phobias and fantasies of the writers than about opium. But there were also voices of reason. The New South Wales Royal Commission on Alleged Chinese Gambling and Immorality found ‘no ground for suspicion that our alien population is now a danger to youthful virtue’. The first laws specifically drafted to prohibit opium were aimed not only at the Chinese but also at another disadvantaged minority: Australian Aborigines. Queensland’s large Chinese and Aboriginal populations often used opium as wages and as currency for barter. However, the ‘Queensland Sale and Use of Poisons Act’ of 1891 penalised: ‘any person who supplies . . . any opium to any aboriginal native . . . except for medicinal purposes. . . ’ As well as reflecting white paternalism, this Act had a more practical motive. White rural employers could not compete for Aboriginal workers against Chinese who paid better wages (often in opium) and perhaps even treated them better. A policeman did suggest that if whites would only stop starving and mistreating their workers, they could get all the help they needed. But one carpenter had an easier answer: ‘The blacks should be taken from the Chinese and compelled to work for Europeans.’ A man named Pitt complained that the government had not fixed his problem: he still could not get Aboriginal help. Pitt could not see that his record of shooting 13 local Aborigines was relevant! Even now, a century later, we are still living with one result of the early prohibition of opium in Queensland and the Northern Territory: opium smuggling into the north of Australia began in earnest. (GB)

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KILLER

DOCTORS

Semmelweis found the cause of puerperal (childbirth) fever. He controlled it . . . He gave a practical method for its eradication. He died of its infection. — Dr Haggard

In 1773 a great epidemic ravaged hospitals in Europe. In the Italian region of Lombardy the fever killed nearly every woman giving birth. Most doctors and midwives remained fatalistic and talked of the ‘curse of Eve’. Englishman John Burton was the first to suggest that an attendant, such as a doctor or midwife, could infect a woman. Charles White, a surgeon and male midwife, agreed with Burton and pressed for simple hygiene, clean linen and fresh air. White’s book, A Treatise on the Management of Pregnant and Lying-in Women ran to five editions. Still the wise men of medicine would not listen. Many believed that the cause of childbed fever was a ‘miasma’ or infectious vapour in the atmosphere. This scourge was no new thing; it had been killing mothers for thousands of years. Within a week or two of giving birth, women had come down with childbed or puerperal fever, and many had died. The Greek physician Hippocrates (460–375 BC) described a 17year-old patient who became feverish after bearing a son: She suffered from thirst, nausea and a slight ache in the heart: her tongue was parched . . . she did not sleep.

After nine days she seemed better, but soon relapsed and died on the fourteenth day. By the eighteenth century, many European cities had lying-in (maternity) hospitals for the poor. Despite their good intentions, the hospitals led to more cases of the fever. At times it killed 20 per cent of women confined there. These deaths especially affected poor

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women, since those better off had their babies at home. Those in the know tried to keep out of hospital. In 1843 Oliver Wendell Holmes, a Boston gynaecologist, published an article with a simple message: ‘Women often died in childbed, poisoned by their medical attendants.’ His remedy also seemed simple enough: no doctor should care for a woman in childbirth if he had recently treated one with childbed fever. But Holmes made no more impression than had Burton or White. Professor Meigs of Philadelphia replied indignantly that doctors were gentlemen and ‘a gentleman’s hands are clean’. No one took any notice of Holmes’s remedy or his reports of the work of Dr Semmelweis in Europe. The Hungarian Ignaz Semmelweis (1818–1865) studied at Vienna University. Like Holmes, he first enrolled in law, but quickly found his niche in medicine. In 1844 he became assistant in obstetrics at the Vienna General Hospital, which had two maternity wards. These took admissions on alternate days. The first ward, in which medical students worked, had a death rate of 10 per cent, compared to the 4 per cent death rate in the other ward run by midwives. Semmelweis described women: ‘gravely ill with fever (who) assured me a few hours before death that they were entirely well, in order to escape treatment by the physicians’. Still the doctors did not want to know. When pressed to explain the difference between the two wards, they could only mumble: ‘It must be shame from having students examine the mothers.’ That was nonsense, of course, but just what was making the doctors so dangerous? Semmelweis needed proof. It took him a long time to put the clues together. For year after year he kept doing post-mortems to find a clue. Finally his friend Kolletschka, the director of post-mortems, died suddenly. During a postmortem on a victim of the fever a student had accidentally nicked Kolletschka’s finger. When Semmelweis dissected Kolletschka’s body he saw the same changes of blood-poisoning that he had seen in so many women who had died of childbed fever.

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Something had been spread from the body in the mortuary into the small cut on Kolletschka’s finger, or from one feverish patient to another through the large raw wound left in the womb when the afterbirth comes away. Now Semmelweis realised that he himself was part of the problem; he, the other doctors and the students were spreading the fever. Each morning he took his students through post-mortems at the mortuary. Then, without washing hands or changing their clothes, doctors took students around the ward doing internal examinations on the women. They wore no gloves and no gowns. By contrast, midwives who ran the other ward did not go to the mortuary and were careful about cleanliness. ‘God knows how many women I have prematurely brought down into the grave,’ Semmelweis lamented. At once he made students and staff scrub their hands with soap and water and then soak them in chloride of lime before letting them near any pregnant woman. The results were dramatic: fever deaths fell from 18 per cent in April 1846 to 2 per cent in June and only 1 per cent in July. Next he tried to extend these simple precautions to other maternity units. To us, it seems so logical. But remember that all this was still before Pasteur and Koch had shown that germs cause infectious diseases. Semmelweis was just one strident ill-bred voice in the wilderness; his superiors would not listen. Could he have convinced them if he had tempered his sharp tongue? Semmelweis threatened an eminent obstetrician: ‘I proclaim you before God and the world to be an assassin.’ In 1849 the professors dismissed him. Once he moved back to his birthplace, Budapest, death rates in Vienna shot up again. For 12 years he beavered away writing the work that he hoped would convince the world. In 1861 he published The Cause, Concept and Prophylaxis of Childbed Fever, but the book of this intemperate, quarrelsome man was long, confusing and quarrelsome. This work, the climax of Semmelweis’s life, failed to convince anyone of anything.

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He lost his memory and became depressed. Twelve days after his admission to a lunatic asylum, the poor frustrated Semmelweis died. What killed him? During one of his last operations, he had cut his hand; the wound had become infected. Ignaz Semmelweis died of blood-poisoning — the very same infection from which he had tried to shield his patients. In 1906 the citizens of Budapest unveiled a statue of Semmelweis. We now regard him as ‘one of medicine’s martyrs . . . one of its far-shining names, for every childbearing woman owes something to him’. (GB)

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IS

YOUR

IQ

A FRAUD?

Sir Cyril Burt’s deepest belief was straightforward: the English ruling class is the most intelligent . . . Jews were less intelligent . . . Irish were less intelligent . . . women were less intelligent . . . and Negroes, well, really. — David Dodanis, The Body Book

Politicians know how easily a rooster can turn into a featherduster. But surely academic research is not like that? How could the ‘dean of the world’s psychologists’ stand condemned for fraud? Everyone has an opinion on individual differences. Are some people more intelligent than others? Are some groups more intelligent? If so, is it genes or upbringing? Nature or nurture? And what should we do about all that? Such discussions often generate more heat than light. It was the French psychologist Alfred Binet (1857–1911) who devised the first successful, practical intelligence tests in 1905. He tried to help teachers find which children needed more attention. However, with his tests, he laid down definite cautions: • The scores do not measure anything absolute, innate or permanent. • The scores are a rough guide to identify children with a learning problem. They are not designed to assess normal children. The American psychologist Terman Lewis (1877–1956) adapted Binet’s tests to produce the Stanford-Binet test, and the related intelligence quotient (IQ). Since then, uncritical use of tests and IQ scores may have caused more harm than good. Critics have raised many concerns. They deny that one single score based on testing on just one day can summarise any child’s innate abilities or potential. Even on repeated testing, a low score may reflect environmental rather than innate or genetic disadvantage. A test developed for one group is unreliable if applied to another group. This casts grave doubts on studies that suggest differences between groups.

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Undeterred by such doubts, Lewis planned to test children so as to identify bad genes and eventually eliminate them: Intelligence tests will bring tens of thousands of . . . high-grade defectives under . . . surveillance and protection . . . This will ultimately result in curtailing the reproduction of feeblemindedness and in the elimination of an enormous amount of crime, pauperism.

Binet must have turned in his grave. Many IQ-testers since Lewis have also had a hereditarian bias that echoed the prejudices of their time and class. Intelligence testing in the US may have served largely to justify and maintain social inequality. One eminent psychologist who failed as an objective scientist was Sir Cyril Burt (1883–1971). He was professor of psychology at University College, London from 1931 to 1950; the first psychologist to gain a knighthood and the first governmentappointed educational psychologist in Britain. Burt was convinced that intelligence was chiefly hereditary. In 1937 he wrote: This general intellectual factor, central and all-pervading . . . appears to be inherited, or at least inborn. Neither knowledge nor practice, neither interest nor industry, will avail to increase it.

This hereditarian view remained his lifelong obsession. Burt attacked his critics as armchair theorists. He advised the committees that restructured the English educational system after World War II. Children aged 11 now took the 11-Plus test to assess their potential, and so to determine whether they entered higher or lower-quality education. ‘A small industry sprang up devoted to teaching children how to do well on tests.’ Burt’s eugenic vision was to save Britain by finding and educating the talented minority. But what of the other children? The 80 per

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cent who didn’t make the cut were labelled forever as having low intelligence and therefore being unfit for higher education. For years, the 11-Plus helped to perpetuate the British class system. In the 1950s, after Burt had retired, the 11-Plus and the selective system based on it came under attack. (Britain later scrapped the 11-Plus and replaced the selective system with a comprehensive one.) Burt replied with articles citing the world’s largest single series of identical twins reared separately. Again, his findings supported the view that heredity determines intelligence. Hereditarian psychologists in the USA also applied Burt’s results. Arthur Jensen argued in the Harvard Educational Review that since genetics determines 80 per cent of intelligence, it was futile to fund special education for lower-class children, be they black or white. Moreover, Jensen claimed, black Americans scored 10–15 points lower on IQ tests than whites. To him, this proved an innate, genetic difference in intelligence. Burt died in 1971, at age 88. The next year Leon Kamin, a psychologist at Princeton, read one of Burt’s papers and quickly concluded that he was a fraud. In Burt’s 1955 report he cited 21 pairs of separated twins. A second report in 1958 had ‘over 30’ pairs, and in 1966, he cited 53 pairs, by far the largest collection in the world. All three reports gave the correlation between the IQs of separated identical twins as exactly 0.771. For this figure to remain unchanged to three decimal places while new pairs of twins entered the study was unbelievable. Similarly, the correlation in IQ of identical twins reared together remained at exactly 0.944 through all three reports. There were 20 such coincidences in Burt’s table of 60 correlations. In 1974 Kamin’s book concluded: ‘The numbers left behind by Professor Burt are simply not worthy of our current scientific attention.’ Later, the London Sunday Times medical correspondent wrote that he could not confirm the existence of Burt’s two collaborators on

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his twin studies. He accused Burt (posthumously) of fraud. There were howls of outrage. Hans Eysenck, a leading expert, attributed the accusations to ‘left-wing environmentalists . . . play(ing) a political game with scientific facts’. Even now, Burt’s conclusions still have supporters, including Richard Herrnstein, author of The Bell Curve. Leslie Hearnshaw, professor of psychology at Liverpool, had given the eulogy at Burt’s funeral; his sister asked him to write Burt’s biography. From his diaries, Hearnshaw found: He had not carried out the research he claimed to have done. The data on twins were at least partly spurious . . . From 1943 onwards Burt’s research reports must be regarded with suspicion.

What had gone so dreadfully wrong? Hearnshaw condemned Burt as ‘overconfident, too much in a hurry, too eager for final results, too ready to adjust and paper over, to be a good scientist’. During World War II, Burt’s world had collapsed. His marriage failed, his own department excluded him when he wouldn’t retire at the agreed age; he also had to be removed as editor of the journal he himself had founded. Biologist Stephen Jay Gould sees Burt’s fakery as ‘the actions of a sick and tortured man’. But it was more than that: Gould also condemns Burt’s early work, right back to 1909. Burt’s frauds went on for 31 years. Until Kamin’s book in 1974, not even his opponents found him out. By . . . his mastery of statistics and brilliantly lucid exposition, Burt hoodwinked the community of educational psychologists . . . for some thirty years.

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While Burt was editor, the British Journal of Statistical Psychology, ran many articles praising his work and attacking his critics. These articles were in his own distinct style, but appeared under assumed

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names. Why did no one question these articles by unknown authors? One psychologist said: ‘there were certainly grave doubts, although nobody dared to put them into print, because Burt was enormously powerful.’ Another admitted: ‘It reflects on all of us . . . ’ Broad and Wade conclude: many scientific communities do not behave in the way they are supposed to . . . Scholars do not always read the scientific literature carefully . . . Dogma and prejudice, when suitably garbed, creep into science just as easily as into any other human enterprise . . . Against dogma disguised as science, objectivity failed.

(GB)

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A FINAL WORD: T H E H E A LT H O F DON BRADMAN

Having examined in this book the medical history of many famous people, drawn from all walks of life and spanning several centuries, let us conclude by looking at a living person, and one of the world’s, certainly Australia’s, greatest sporting icons. If you go into cricket’s holy of holies, the Long Room at Lord’s, at one end you will see five portraits. They are of those players most cherished by the Cricket Establishment. Featured are Sir Leonard Hutton, Lord (Colin) Cowdrey, Douglas Jardine and, by the door to the bar, the likeness of an aging Keith Miller. But hanging above them all, and rightly so, looking directly and resolutely down the length of the room, is the greatest exponent of the game, Sir Donald Bradman. The astounding record-breaking feats of ‘the boy from Bowral’, such as a Test average almost half as much again as that of his nearest rival are too familiar to reiterate,

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and as this is supposed to be a piece on medical history rather than cricket, let us look at what a recent biography had to say about Bradman’s medical history during his playing days. As the details of this history were not only fully recorded in Charles William’s biography, but also widely reported in its reviews in the Australian press, no medical secrets are going to be revealed. At 172 cm (5’8"), Bradman was below-average height, of a slight build, but strong across the chest and upper arms. Apart from motion sickness, from which it seems he was a lifelong sufferer, he had kept good health until he burst upon the cricketing world in 1928. As a country boy he was as unprepared for the singular acclaim accorded by his rapturous fans as he was for the sniping he often received from the press and some of his fellow players. All this was to take its toll on his nervous equilibrium. After early phenomenal success, stress began to show during the Bodyline series of 1932–33. His failure against the tourists in games before the Tests, together with disputes over his newspaper comments, had both a psychological and physical effect. He began to suffer from headaches and loss of energy. Bradman was examined by two Board of Control doctors. They reported he was thoroughly ‘run down’ and needed complete rest, and to the stunned disbelief of his fans, he was declared unfit for the first Test. There was speculation in the press about his ability to face fast-bowler Larwood; it was rumoured he had pernicious anaemia. One London paper even had an obituary lined up. In fact after three weeks’ rest he was his old self, and his batting figures silenced the critics. In 1934 he went on his second tour of England, but he was troubled by minor medical complaints. By the second Test at Lord’s he had not played well (by his standards), saying he had neither the stamina nor mental outlook to play a big innings. During the third Test he spent two days in bed with a sore throat and rumours spread about possible heart disease and/or a nervous breakdown. The press were beginning to feed on innuendo.

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Bradman dealt with this by scoring 304 in his next match! However, he pulled a muscle while fielding and went into retreat for the next month. Any suspected self-doubt or depression was squashed when, in the final Test, he and Ponsford put on a record 451 runs for the second wicket. As he was about to leave for home in September, Bradman felt pains in his lower abdomen. A surgeon, John Lee, was asked to see him. Lee was baffled and elected to wait and observe any changes. By the next morning his patient had worsened. Still he hesitated, until after two days obfuscation, a second opinion was sought of Australian surgeon Sir Douglas Shields. This surgeon did not harbour any doubts and operated within the hour. An inflamed appendix, now anchored by adhesions, was successfully removed. Postoperatively, peritonitis set in and the patient became extremely feverish. This was, of course, in pre-antibiotic days. The following day a bulletin was issued stating Don Bradman was gravely ill. The effect on the public was spectacular. The British press had him in extremis, if not in fact dead. The latter piece of news was transmitted to Mrs Bradman in Australia who immediately prepared to come to England. Obituaries were updated; complete strangers offered their blood for the newfangled transfusion procedure; the hospital switchboard could not cope with the inquiries. The Don slowly recovered in hospital over a period of five weeks and on discharge was told to play no more cricket for 12 months. He obeyed the order, which also gave him the chance to recover from all the other stresses and strains consequent on public adulation. These manifested themselves in headaches, malaise, lassitude and, difficulty with his vision, for which he briefly wore glasses. Bradman recovered, but on the 1938 tour of England began to suffer from back pains and was in doubt for the first Test. He played but the pains became a recurring problem during what turned out to be a rather unhappy tour. During the final Test, when Hutton scored his 364, Bradman

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put himself on to bowl. He made no more impact on the opposition than the rest, but turned his ankle and tore off a flake of bone. His team-mate Bill O’Riley, never one of his greatest friends, wryly commented that ‘. . . the crowd that came to cart him off, you’d have reckoned it was an aeroplane disaster’. During the war the cricketer wanted to join up as aircrew, but surprisingly in view of the speed with which he could pick a googly, the medical showed that his eyesight was defective. There must have been something in it because he could only manage 18 runs in two matches he played in 1940. The four innings included two ducks. Bradman transferred to the Army, but developed frequent muscle spasms of the back, could not raise his right arm to shave, and lost sensation in the right hand. In and out of hospital it was diagnosed as ‘fibrositis’, though it was more likely a ‘frozen shoulder’ syndrome. Anyway, nothing helped and he was invalided out in June 1941; a humiliation deeply felt by the superb athlete. With manipulation the symptoms eventually settled in 1946, and of course he did play again. Don Bradman’s quite unique record is even more remarkable when one remembers the dogged courage and single-minded resolve with which he overcame the immense psychological strain that his very public life imposed — pressures and adulation for which his upbringing had provided absolutely no preparation. A remarkable man whose great and enduring genius was to sport what Mozart’s was to music and Newton’s was to science. But then many of the individuals who have been examined in this book had a touch of genius. They all displayed a creative urge, were industrious, curious, persevering and commonly motivated by abnormal and obsessive compulsions. Not infrequently this enthusiasm was misplaced, but however famous or infamous they became, in the end each shared a characteristic common to us all — the liability to illness. (JL)

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BIBLIOGRAPHY

Chapter 1: Medicine and the arts Dickens, Charles, Martin Chuzzlewit, First published 1844. Dickens, Charles, Pickwick Papers, First published 1837. Gold, A., and Fitzdale, R., The Divine Sarah, Alfred A. Kropf, New York, 1991. Gordon, R., The Literary Companion to Medicine, Sinclair Stevenson, London, 1993. Leavesley, J. H., Medical Byways, ABC Enterprises, Sydney, 1984. Mack, W. S., ‘Ruminations on the Testes’, Proceedings of the Royal Society of Medicine, 1964, vol. 57, pp. 47–51. Oxford Classical Dictionary, Clarendon Press, Oxford, 1949.

Chapter 2: Murder, mystery and mayhem Alexander, Shana, Very Much a Lady: the untold story of Jean Harris and Dr Herman Tarnower, Little Brown, 1983. Crompton, R. & Gall, D., ‘Georgi Markov — Death by Pellet’, Medico-Legal Journal, 1980, vol. 48, no. 2, pp. 51–62. Harris, Jean, Stranger in Two Worlds, Macmillan, New

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York, 1986. Holmes, R., The Legend of Sawney Bean, Frederick Muller, 1975. Nicholson, John, Historical and traditional tales in prose and verse connected with the South of Scotland, Self-publication, 1843. Ryan, B., The Poisoned Life of Mrs Maybrick, Penguin, London, 1989. Trilling, Diana, Mrs Harris: the death of the Scarsdale diet doctor, Hamish Hamilton, 1982.

Chapter 3: Epidemics and diseases Curson, P. H. & McCracken, K., Plague in Sydney: The Anatomy of an Epidemic, NSW University Press, 1989. Nikiforuk, Andrew, The Fourth Horseman: A Short History of Epidemics, Plagues and Other Scourges, Fourth Estate, London, 1991. Whittington, V., Gold and Typhoid; Two Fevers, UWA Press, Nedlands, 1988. Zinsser, H., Rats, Lice and History, Little Brown, Boston, 1963.

Chapter 4: Famous patients Baron, J. H., ‘Illness and Creativity: Byron’s Appetite, James Joyce’s Gait and Melba’s Meals and Mésalliances’, British Medical Journal, 1997, vol. 315, pp. 1697–1703. Birch, C. A., Names We Remember, Ravenswood Publications, Beckenham, 1979. Burney, Fanny, The journals and letters of Fanny Burney (Madame D’Arblay), vol. 6, Clarendon Press, Oxford, 1975. Chambers Biographical Dictionary, Magnus Magnusson (ed.), Chambers, Edinburgh, 1990. Dale, P. M., Medical Biographies, The Ailments of Thirty-three Famous Persons, University of Oklahoma Press, 1987. Dotz, W., ‘Jean Paul Marat, His Life, Cutaneous Diseases and Death’, American Journal of Dermopathology, 1979, vol 1(3),

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pp. 247–250. Encyclopaedia Britannica, vol. 14, William Benton, Chicago, 1974. Gould, S. J., Further Reflections in Natural History, Norton, New York, 1983. Herbert, J., ‘Toulouse-Lautrec, A Tragic Life; An Inspired Work; A Difficult Diagnosis’, Clinical Orthopaedics and Related Research, 1972, vol. 89, pp. 37–51. Johnson, S., Lives of the English Poets, First published 1781. Klawans, H., Newton’s Madness; Further Tales of Clinical Neurology, Bodley Head, London, 1990. Olivier, L., Confessions of an Actor, Weidenfield and Nicolson, London, 1982. Sackett, David, Clinical Epidemiology: a basic science for clinical medicine, Little, Brown & Co, Boston, 1985. Spargo, P. E. & Pounds, C. A., ‘Newton’s “Derangement of the intellect”: a new light on an old problem’, Notes Records of the Royal Society of London, 1979, vol. 34 (i), pp. 11–32. Stevenson, R. S., Famous Illnesses in History, Eyre & Spottiswoode, London, 1962. Vicker, H., Vivien Leigh, Hamish Hamilton, London, 1988.

Chapter 5: Quacks and quirks Burton, Jean, Lydia Pinkham is her Name, Farrar, Strauss, 1949. Coran, S. & Porac, C., ‘Fifty Centuries of Right-Handedness: The Historical Record’, Science, vol. 198, 11 Nov 1977, pp. 631–632. Fishbein, M. A., ‘History of Cancer Quackery’, Perspectives in Biology and Medicine, 1965, vol. 8, pp. 139–166. Fraser, I., ‘The Discards of Surgery’ British Medical Journal, 1963 vol. 1, pp. 839–843. Gordon, R., The Alarming History of Medicine, Sinclair Stevenson, London, 1993. Hecaen, H. & de Ajuriaguerra, J., Left-Handedness, Grune and Stratton, New York, 1964. Holbrook, Stewart, The Golden Age of Quackery, Collier, New York,

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1962. Jameson, Eric, The Natural History of Quackery, Michael Joseph, London, 1961. Klawans, Harold, Toscanini’s Fumble and Other Tales of Clinical Neurology, Bodley Head, London, 1989. Machiavelli, Niccolo, The Prince, New American Library, New York, 1952. Medical Journal of Australia, ‘Cancer Treatment in the Cook Islands: A Warning’, (editorial), 1977, vol. 1, pp. 909–910. Medical Journal of Australia, ‘Milan Brych and the Medical Profession’, (editorial), 1978, vol. 1, pp. 195–196. Patrick, Ross, ‘When Milan Brych Came to Queensland’, Horsewhip the Doctor: Tales From Our Medical Past, University of Queensland Press, St Lucia, 1985. Scott, P. J., ‘The Milan Brych Affair’, Modern Medicine in Australia, May 1987, pp. 51–73.

Chapter 6: Treatments and discoveries Farr, A. D., ‘Blood Group Serology; The First Four Decades (1900–1939)’, Medical History, 1979, vol. 23, pp. 215–226. Fryer, P., The Birth Controllers, Stein & Day, 1965. Gray, T.C., & Halton, J., ‘Milestones in Anaestethics (d-Tubocurarine chloride)’, Proceedings of the Royal Society of Medicine, 1946, vol. 39, pp. 400–410. Green, S., The Curious History of Contraception, Elbury, 1971. Griffith, H. R., ‘Use of Curare in Anaesthesia and for Other Clinical Purposes’, Canadian Medical Association Journal, 1944, vol. 50, pp. 144–147. Hamilton, David, The Monkey Gland Affair, Chatto & Windus, London, 1986. Harrison, G. A., Mosquitoes, Malaria and Man, Murray, London, 1978. Hoff, E. C. & Hoff, P. M., ‘The Life and Times of Richard Lower,

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Physiologist and Physician 1631–1691’, Bulletin of the Institute of the History of Medicine, 1936, vol. 4, no. 7, pp. 517–535. Llewellyn-Jones, D., People Populating, Faber & Faber, 1975. Robertson, W. H., An Illustrated History of Contraception, Parthenon, 1990. Siedlecky, S. & Wyndham, D., Populate and Perish: Australian Women’s Fight for Birth Control, Allen & Unwin, 1990. West, R., ‘Curare in Man’, Proceedings of the Royal Society of Medicine, 1932, vol. 25, no. 2, pp. 1107–1116.

Chapter 7: Kings and queens Dale, P. M., Medical Biographies. The Ailments of Thirty-Three Famous Persons, University of Oklahoma Press, Norman, 1952. Ellis, H., Operations That Have Made History, Greenwich Medical Media, London, 1996. McInnes, W. D. et al, ‘The Management of Carcinoma of the Larynx in a Prominent Patient, or Did Morell Mackenzie Really Cause World War One?’, American Journal of Surgery, 1975, 132, pp. 515–522. McNalty, A., Henry VIII, A Difficult Patient, Johnson, London, 1952. MacLaurin, C., Mere Mortals: Medico-Historical Essays, Jonathan Cape, London, 1925. Nicholson, H., King George V. His Life and Reign, Constable & Co, London, 1952. Stevenson, R. S., Famous Illnesses in History, Eyre & Spottiswoode, London, 1962. Stevenson, R. S., Morell Mackenzie, Heinemann, London, 1946. Watson, F., ‘The Death of George V’, History Today, 1986, vol. 26, pp. 21–30. White, T. H., The Age of Scandal, Jonathan Cape, London, 1950.

Chapter 8: Doctors and medical services

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Altham, H. S., & Swanton, E. W., History of Cricket, Allen &

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Unwin, London, 1948. Birch, C. A., Names We Remember, Ravenswood Publications, Beckenham, 1979. Dicks, Dr Harold (ed.), Sugarbird Lady, Riby, Adelaide, 1979. Dunlop, Norman, ‘William Redfern, the First Australian Medical Graduate’, Medical Journal of Australia, 10 March 1928, pp. 294–310. Farjeon, H., Cricket Bag, Macdonald, London, 1946. Ford, Edward, ‘The Life and Work of William Redfern’, Annual Post-Graduate Oration, Australasian Medical Publishing Company, April 1953. Gordon, R.., Fifty Years a Cricketer, Harrop, London, 1986. Guthrie, D., A History of Medicine, Nelson, Edinburgh, 1945. Keith, A., ‘The Portraits and Personality of John Hunter’, British Medical Journal, 1928, vol. 1, pp. 205–207. McMenemy, W. H., James Parkinson Centenary Volume, Macmillan, London, 1935. Miller, Robin, Flying Nurse, Rigby, Adelaide, 1971. Paget, S., John Hunter: Man of Science and Surgeon, Fisher Unwin, London, 1897. Pearn, J. (ed.), Pioneer Medicine in Australia, Amphion Press, Brisbane, 1988. Preston, H. (ed.), Wisden’s Cricketer’s Almanack, Sporting Handbooks, London, 1949. Qvist, G., John Hunter 1728–1793, Heinemann, London, 1981. Rowntree, L. G., ‘James Parkinson’, Bulletin of Johns Hopkin Hospital, vol. XXIII, Feb 1912, pp. 33–45. Talbot, J. H., A Biographical History of Medicine, Grune & Stratton, New York, 1970. Thompson, S.C., The Great Windmill Street School, Bulletin of Medical History, 1942, vol. 12, pp. 377–380.

Chapter 9: Wars and revolutions Clarke-Kennedy, A. E., Edith Cavell, Pioneer and Patriot, Faber &

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Faber, London, 1965. Donegan, C. F., Dr Guillotin — Reformer and humanitarian, Journal of the Royal Society of Medicine, 1990, vol. 83, pp. 637–639. Karlen, A., Plague’s Progress, Indigo, London, 1996. Pringle, H., ‘The Plague That Never Was’, New Scientist, 1996, no. 2039, pp. 32–35. Weiner, D. B., The Real Dr Guillotin, Journal of the American Medical Association, 1972, vol. 220, pp. 85–89.

Chapter 10: Disasters Bodanis, David, The Body Book: A Fantastic Voyage to the World Within, Little Brown, Boston, 1984. Broad, W. & Wade, N., Betrayers of the Truth: Fraud and Deceit in Science, Simon & Schuster, New York, 1982. Haggard, H., Devils, Drugs and Doctors, Heinemann, London, 1929. Herrnstein, Richard, The Bell Curve: Intelligence and Class Structure in American Life, Free Press, New York, 1994. Manderson, Desmond, From Mr Sin to Mr Big, Oxford University Press, 1993.

A final word: The health of Don Bradman Williams, Charles, Bradman An Australian Hero, Little, Brown and Company, London, 1996.

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Dead flies cause the ointment of the apothecary to send forth a stinking savour . . .

(ECCLESIASTES 10:I) Romeo: I do remember an apothecary And hereabouts he dwells — whom late I noted In tatter’d weeds, with overwhelming brows, Culling of simples; meagre were his looks. Sharp misery had worn him to the bones

(ROMEO AND JULIET III:V) See one physician like a sculler plies The patient lingers and by inches dies; But two physicians like a pair of oars Waft him more swiftly to the Stygian shores

(ANON)

Chapter

1

PIONEERS

SIR NORMAN GREGG AND GERMAN MEASLES In 1915, just after graduating with First Class Honours, Dr Norman Gregg enlisted in the Royal Army Medical Corps. Had it not been for the First World War, he might have played Davis Cup tennis for Australia. As it was, he won the Military Cross. In late 1940, with Australia at war, Dr Gregg was the senior eye doctor at Sydney’s Royal Alexandra Hospital for Children. In his own practice he was finding an unusual number of birth defects. Colleagues confirmed his impression, but no-one knew the cause. Then two of the mothers mentioned that they had had German measles (rubella) early in their pregnancies. Gregg asked colleagues around Australia to help him follow this lead. He gathered histories of 78 children born with cataracts (opacities in the lens of the eye affecting vision) in early 1941; 13 were his own patients. Many of the children had other serious defects as well.

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Gregg suspected some sort of poison or infection. Most of the pregnancies had been normal, except for one thing: 68 of the 78 mothers had had rubella in the first or second month, or just before confirmation of the pregnancy. There had been an epidemic of rubella in 1940. In October 1941, Gregg read his historic paper “Congenital cataract following German measles in the mother”. By now 15 of the 78 babies (almost 20%) had already died. He noted that many also had serious heart defects and were of “small size, ill-nourished and difficult to feed”. An editorial in the Medical Journal of Australia supported Gregg’s findings: “The series is so striking and the sight of the children is so seriously affected that the facts must be made known . . . ” With foresight, Gregg suggested “other defects are not evident now, but will show up as development proceeds”. Two years later, reports from South Australia added deafness to the list. For several years, medical authorities overseas did not accept Gregg’s ideas, but in 1947 the New England Journal of Medicine ran an editorial on Gregg’s findings. In 1951, the Australian statistician Professor Oliver Lancaster extended Gregg’s work by tracing outbreaks of deafness in New South Wales back to the turn of the century. He blamed these on epidemics of rubella in pregnancy. There was a worldwide outbreak of rubella in 1964–65, with 20 000 affected American infants. Till then, the distinction of rubella from other rashes had been purely clinical. Now came diagnostic tests showing that children infected before birth remained infected for months, even years. This explained the onset of cataracts and other defects after birth. Gregg was knighted in 1953 and died in 1966 at the age of 74. By 1970, Australia had a vaccine against rubella. From 1977, the number of children born deaf fell. By 1983, 96% of pregnant Australian women were immune to rubella, compared with 82% in 1971. In 1989, Australia introduced vaccination of young children with the combined measles-mumps-rubella vaccine, while continuing

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vaccination of teenaged schoolgirls. Countries using widespread vaccination have reduced the rate of infection of the newborn and associated disabilities. Sir Macfarlane Burnet assessed Gregg’s work as “the most important contribution ever made to medicine in Australia”. The Australian Encyclopedia describes it in even broader terms as “one of the milestones in the history of medicine”. (GB)

WILLIAM HARVEY

AND THE

CIRCULATION OF THE BLOOD In 1628 a slim 72-page medical treatise was published in Frankfurt, Germany. At the time it was generally ignored by the profession, but over the years it has come to be regarded as arguably medical literature’s greatest book. It was dedicated to Charles I of England and was less than snappily entitled Excercitatio Anatomica De Motu Cordis et Sanguinis in Animalibus (The Anatomical Treatise on the Movement of the Heart and Blood in Animals), or De Motu Cordis for short. In it the author reached the then heretical conclusion that “the movement of the blood is constantly in a circle, and is brought about by the beat of the heart”. The author was William Harvey (1578–1657) and his description of the circulation of the blood allowed medicine to move out of the Dark Ages and medicinal practice to open up into the discipline we now know. Before Harvey’s time it was certainly known that blood moved, no doubt about that, but it was thought to do so in an ebbing and flowing manner, initiated by dilatation of the heart and blood vessels and then passing from the heart’s right to left ventricle through minute pores in the septum which separated them. True enough, it was admitted these pores had not be seen, but it was felt they must be there nonetheless.

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Then along came the Belgium anatomist Andreas Vesalius (1514–1564), who arrived on the scene almost a hundred years before Harvey. Vesalius showed that these microscopic heart channels were a figment of the imagination. Predictably, contemporary medical thinking dismissed this opinion. The almost universal and wellentrenched view was that, besides the microscopic pores, the liver was the main organ in the blood system, a fiction which had been held dear, with sundry other medical myths, since the time of Galen, the Greek physician, 1400 years previously. It would take a courageous man to question such a lineage. But came the moment, came the man, and William Harvey had the drive to be just such an adversary. The genius of Harvey was that, unlike his predecessors, step by step he double-checked repeatable experiments before reaching the irrefutable conclusion that the heart was the crucial driving force of the blood system. Further, he demonstrated that the heart and veins had valves preventing backflow, and his experiments included noting the effect of ligation of the arteries and veins at various points. He compared the sequence of events within the hollow muscular organ, the heart, to a flintlock; the flint strikes the steel which ignites the powder to cause an explosion and thus ejects the bullet. He calculated the volume of blood at each heartbeat and showed its total amount would pass through the system in a comparatively short time. Unfortunately, due to his terrible handwriting, De Motu Cordis contains a number of errors perpetuated by a baffled editor. Notes still preserved in the British Museum show a curious mixture of Latin and English held together by a lattice of lines, arrows and erasures. Transcription must have defied all but the most adept proofreader. Nonetheless, Harvey’s publishers managed to get the basic stuff right and follow his dictum, “I avow myself the partisan of truth alone.” The singular result was that for the first time someone had demonstrated the anatomy of the circulatory system. But with a reticence typical of great researchers, Harvey hesitated to draw cast-

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iron conclusions, stating merely that whether the whole process was “for the sake of nourishment or for the communication of heat, is not certain”. What of the man himself? Harvey was born in Folkstone on 1 April 1578, the eldest of seven sons of Thomas Harvey, mayor of the town. Five of the sons became rich turkey merchants in the City of London. William alone pursued an acedemic career, avoiding poverty only because his brother Eliab managed his affairs. Leaving school at the age of 15 he went up to Caius College, Cambridge, a college which had the special privilege of each year being able to appropriate for its own use the bodies of two executed criminals. Harvey won a scholarship with an annual worth of £3 8d. It ran for six years, thus enabling him to go to Padua in Italy and study medicine. This school was then at the apex of medical teaching in Europe, and young Harvey was able to soak up the influence left by the legendary Andreas Vesalius as well as other luminaries such as Fallopio and Fabricius, who are still remembered as having lent their names to bits of the human anatomy. He graduated in 1602 and returned to England. A swarthy and testy man, Harvey invariably wore a dagger, but despite his rough edges he gained a wide following as a physician over the next few years, and was on the staff of St Bartholomew’s Hospital for 37 years. He became court physician to James I and later Charles I. His fame was such that he was occasionally called upon to be the final arbiter in odd medical cases. For example, he was asked to examine a couple of the famous Lancashire witches for skin blemishes from which they could suckle their supposed “familiar” or supernatural spirit. He made short shift of that nonsense. He also was called upon to do a postmortem on Thomas Parr, allegedly 153 when he died and whose portrait still hangs in the Ashmolian Museum in Oxford. Not to be drawn too far into the controvery, Harvey merely observed that the organs looked “remarkably healthy”. King Charles took a great interest in Harvey’s experiments and placed at his disposal the royal deer in Richmond Park to be used

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in his groundbreaking work. For his part, Harvey was in charge of the King’s two young sons at the Battle of Edgehill in 1642. Later in the Civil War, parliamentary troops ransacked his house in Whitehall and many of his clinical and anatomical records were destroyed. Harvey married but never had children, he and his wife doting for many years on a parrot. At least here he showed human failings, for though he always considered the bird to be male, when it died a postmortem showed an egg in the oviduct. The appointment which brought Harvey his greatest renown came in 1616 when he was elevated to Lumleian Lecturer in Anatomy and Surgery to the College of Physicians. This legacy provided for two lectures a week throughout the year for six years, by which time it was reckoned that the subject had been covered; I am sure it had. The regulations also stipulated that each year the lecturer was “to dissect all the body of man for five days together, before and after dinner; if the bodies last so long without annoy”. His preserved notes show that it was during these lectures that he formulated the idea of circulation, though they were not published until 12 years later. When his book did appear his private practice fell away as his patients did not favour unorthodox views. However, he advanced in the College of Physicians, though due to infirmity (he had gout) was never the president. To demonstrate his versatility, Harvey wrote several books on aspects of medicine, including in 1651 his second greatest work, De Generatione Animalium, regarded as the first original book on midwifery by an English author. It was to be his last publication. William Harvey died of a cerebral haemorrhage on 3 June 1657 at the age of 79. He was buried uncoffined but “lapped in lead” at the tiny village of Hempstead in Essex near Cambridge (famous also for being the birthplace of Dick Turpin, the renowned highwayman). His body was exhumed in 1833, and a special Harvey Chapel was constructed in the small Hempstead church, where he was

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reburied in a proper coffin. Despite his pre-eminence he is still there, deep in rural England, rarely visited and lying beneath a stone effigy said to be the best extant likeness of this towering medical genius. (JL)

AUSTRALIAN

MEDICAL WOMEN TROD A STONY PATH

The contribution of the . . . Drs [Clara and Constance] Stone to the initial group of medical women and to the health of Melbourne’s poor was inestimable. — Australian Dictionary of Biography

The recent film Her Majesty, Mrs Brown showed the softer side of Queen Victoria, the human heart underneath her stiff, public image. But hers was a conservative reign. The Queen denounced “this mad wicked folly of women’s rights”. The idea of women aspiring to university she found not at all amusing; as for women doctors, well really . . . During Victoria’s reign, women in Australia who wanted to become doctors kept bruising themselves not on glass ceilings but on concrete barriers. In 1865, an American woman, Winifred Ferguson, arrived as ship’s doctor on a freighter and applied for registration to the Victorian Medical Board. The Medical Journal of Australia spoke up: “There is little fear that in any British community medical women will exist as a class. They will occasionally be imported, like other curiosities, and the public will wonder at them, just as it wonders at dancing dogs, fat boys and bearded ladies.” Exit Winifred Ferguson. In 1880, doctors were among the crowd at Melbourne gaol to see Ned Kelly hanged. The same year, Melbourne University admitted some female students for the first time. But it refused to

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admit Constance Stone to study medicine, so she graduated from the Women’s Medical College in Pennsylvania, USA, then gained first-class honours at the University of Trinity College, Canada. After two more years at London’s New Hospital for Women, now aged 34, she returned home. In 1890, Dr Constance Stone became the first woman registered as a medico in Australia by the Medical Board of Victoria. The next year, again in Melbourne, the first women doctors qualified from an Australian university: Clara Stone (Constance’s younger sister) and Margaret Whyte (who topped the honours list). Winning admission to the medical faculty was one battle, becoming a resident doctor was another. The Melbourne Hospital rejected Margaret’s application for a residency; it was their loss when she became the first resident at the Women’s Hospital. In 1896, the Melbourne Hospital was to appoint six residents, but no women. The top graduates included Dr Alfreda Gamble and Dr Janet Greig, who both fought for their appointments. Finally, and with poor grace, the authorities backed down. When Drs Gamble and Greig became the first female residents in an Australian general public hospital, a magazine celebrated: If you’ve been on the ramble And broken your leig, ´Twill be fixed by Miss Gamble or set by Miss Greig.

They never looked back. Dr Greig became the first accredited anaesthetist at an Australian hospital and later a member of the Royal Australian College of Physicians. At least in Melbourne, the barriers were falling. Now women could study medicine, graduate, and even become hospital residents. But for many years, only the Women’s Hospital appointed women to the honorary (visiting) staff. What drove this first generation of medical women to set up a new hospital for female doctors to care for women? The medical women could not stomach the way their male colleagues put down poor

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female hospital patients. In 1995, Dr Shirley Roberts wrote: “. . . the medical staffs of Melbourne’s overcrowded public hospitals were less concerned than ever about the finer feelings of destitute patients. Women . . . were treated with such disregard for their modesty that many could not bring themselves to make a second visit.” Caring for her affluent private patients in Collins Street was not enough to fulfil Dr Constance. She also spent a day each week at the free “mission dispensary” in Collingwood, to which over 16 000 patients flocked every year. Between them, the two Stone sisters saw 50–60 patients a session. Constance married Egryn Jones, a gem of a man: feminist, medico and priest in the Welsh Church. In 1896, ten medical women founded the Victorian Medical Women’s Society, with Clara as the first president. They also set up medical services for poor women and their children. The Queen Victoria Hospital started as a new service, not a new building. In October 1896, it opened a free outpatient clinic three mornings a week in a hall in Latrobe Street provided by Constance’s husband. Whole families came from as far away as Dandenong or Box Hill. There were women to whom “the idea [of checkups during pregnancy] and the possibility alike were new”. Women with diabetes or tuberculosis followed one another “among every other ailment and disease in an unending series”. The doctors interviewed patients in the vestry; one doctor sat at each end of the table with a plate for contributions between them. Then the doctors washed medicine bottles and dispensed their own scripts in a cupboard one metre wide and two metres tall. Eventually, these services grew into the Queen Victoria Memorial Hospital, where women doctors treated women patients. During the First World War, the Inspector of Charities reported: “This hospital does very good work, is well and economically managed, and is worthy of better support.” With the returning troop ships, pneumonic (“Spanish”) influenza reached Australia. By early 1919, the Queen Victoria became an emergency hospital. Dr Constance Stone would have

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been proud if she could have seen all this. But she had died of tuberculosis in 1902 aged only 46. (GB)

EDWARD JENNER, LADY MARY WORTLEY MONTAGU AND SMALLPOX VACCINATION It is just over 200 years since what is regarded as one of the most famous ideas to emerge from general practice was suggested. In May 1796 an English country GP, Edward Jenner (1749–1823), following his observation that milkmaids who suffered from cowpox enjoyed immunity to smallpox, came up with the fancy that vaccination with a comparatively mild malady would prevent infection from what was one of the most deadly diseases of the era. Jenner is held in high regard, almost reverential awe, by the medical profession for this single influential piece of deduction. But was he really the first? In fact, the procedure has a long lineage. The ancient Chinese are said to have inoculated against smallpox by inhaling a snuff made from the dried pus of the scabs. For generations old women in Turkey had scratched smallpox pus into the arms of friends and family, alleging a minor dose now would abort a major attack later. We know a great deal about smallpox in Turkey because early in the eighteenth century, nearly 100 years before Jenner, the British ambassador’s wife attended gatherings involving the dissemination of infected pus and recorded the details. She took a particular interest because at the age of 26 she herself had been disfigured by smallpox and her younger brother had died of the disease. More than that, the lady in question, Lady Mary Wortley Montagu (1689–1762), was no ordinary wifely appendage about the embassy. She was resolute, intelligent, articulate, flamboyant, one of the first great women travellers of the Orient and altogether

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a force to be reckoned with. Daughter of the Earl of Kingston, Mary was born in 1689. As a teenager, rather than go through with an arranged marriage, she eloped with Edward Wortley Montagu, a member of parliament. Despite the scandal, in 1716 he was appointed ambassador to Turkey, and they went to live in Constantinople. On 1 April 1717 Mary wrote to a friend: I am going to tell you a thing that I imagine will make you wish you were here. The smallpox . . . is here, entirely harmless by the invention of grafting. Old women . . . perform the operation in September when the heat has abated. People send to know if any of their families have a mind to have smallpox. They make parties (commonly 15 or 16 together) . . . the old woman comes with a nutshell full of matter . . . asks what vein you are pleased to have open. She rips it open with a needle . . . puts in as much venom as can lie on the end of a needle. The children are in perfect health until the eighth day, the fever then seizes them . . . in bed 2 days. About 20 pock marks . . . on the face. They take the smallpox here by way of a diversion, as they take the waters in other countries.

Reading about it now the procedure seems to have been a very chancy exercise, the aim of which was to induce a mild dose of the malady so as to confer lifelong protection without pock marking. But how mild is mild? On the diplomat’s return in 1718 the couple lived in Twickenham where the marriage began to fall apart. But Lady Mary was enthusiastic in her desire to introduce the so-called “variolation” prophylactic method into England. The disease had killed onefourteenth of the population of London during a 42-year period before 1723, and during bad epidemics up to 40% of those stricken had died. One of the snags of variolation was that, as often as not, the recipient contracted the full-blown disease, not infrequently fatally. Several members of the British royal family tried it, as did

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several other Continental royal families including that of Catherine the Great in Russia. Indeed, the English surgeon who did their minor operation was awarded £10 000 and a Russian barony. Mercifully, there were no dire effects from the procedure. However, trying to enlighten her countrymen proved to be a thankless task and Mary was hooted at in the street and roundly condemned by Church and Parliament. Her revolutionary ideas about the prevention of smallpox faded, but Lady Mary continued to write with brilliance and versatility until she died in 1762. Was she ignored and vilified because the idea of vaccination came from what was regarded as a socially different, and thus medically suspect, country? Or was it because it did not develop through the usual medical collegiate channel? Or could it be that the idea was brought into the country by a woman, and therefore regarded by the dominent male society with reservations from the start? Whatever it was, today Lady Mary Wortley Montagu is discounted as a medical innovator and is regarded merely as a colourful, eccentric, observant traveller, author and early feminist, while it is the name of Edward Jenner that is bracketed with smallpox and its prevention. Born in 1749, Jenner was the ninth child of the vicar of Berkeley, a village in the pretty West Country county of Gloucestershire, near the Cotswolds. Orphaned at the age of five, he went to school at Cirencester where, along with being purged and bled for various childhood ills, he was inoculated with pus from a smallpox sufferer, or variolation, à la Lady Mary Wortley Montagu. Jenner got the disease but mercifully recovered. The boy developed a keen interest in natural history while at school, a diversion which persisted throughout his life. At the age of 14 Jenner became apprenticed to Mr Ludlow, a surgeon in the nearby town of Chipping Sodbury. One day a milkmaid presented with a rash. While pondering the diagnosis she interjected with what became the immortal words, “Well, whatever it is, it can’t be smallpox because I’ve had cowpox, and no-one who gets that ever gets smallpox”. This verity stuck in

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young Edward’s mind. After seven years’ apprenticeship, the 21-year-old went on to St George’s Hospital, London, as the junior resident of the famous anatomist and surgeon, John Hunter. While there, and knowing his interest in nature, Joseph Banks invited Jenner to go to the Antipodes as a botanist. Jenner refused, which was a pity for the medical history of Australia. In 1772, the young graduate returned to Berkeley as the village GP. His small workload allowed him to pursue his interest in natural history, a course encouraged by Hunter who, when asked by Jenner about the lifestyle of hedgehogs, proffered his immortal advice, “Why think, why not try the experiment?” Jenner’s first publication came out in 1783. Its title, Observations on Emetic Tarter, gave no hint of the riches to come. The breakthrough came in 1788 in a paper read to the Royal Society. In it he described for the first time ever how the cuckoo ejects the rightful eggs from the nest. Conclusive photographs of this unique act were not forthcoming until 1929, but the observations earned Jenner a prestigious Fellowship of the Royal Society. The same year he presented a paper at the Gloucestershire Medical Society which contained the first description of mitral stenosis (a narrowing of the mitral valve in the heart) and its relationship to rheumatic heart disease. This is now well recognised. All this time he lived and practised at Berkeley in a commodious house he called the Chantry. Mindful of the milkmaid’s comments of years before, he collected cases of cowpox, some of whom he challenged with variolation. None contracted smallpox. Finally, on 14 May 1796, he saw milkmaid Sarah Nelmes who presented as a classic case of cowpox caught from her cow, Blossom. Jenner’s burning-bush moment had arrived. Taking discharge from her lesions, he inoculated eight-year-old James Phipps with cowpox. Two months later he scratched smallpox pus into the boy’s arm. Nothing untoward happened. Frustratingly for the experimenter, there was no more cowpox in the village for two years. When it did recur, he inoculated a child from the cow. From

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the resulting lesion, Jenner transferred the material to a second patient and from him to several more through three generations. None subsequently caught smallpox. As he was not inoculating the actual smallpox germ without first protecting the subject with cowpox, the full-blown cases and significant mortality associated with variolation, where smallpox pus alone is used, did not occur. He published his observations in 1798; the book became an instant bestseller. He dedicated the second edition in 1799 to George III and presented a copy to the King in person. Jenner had his detractors. Gillray, the famous cartoonist, portrayed vaccinated people with cow’s heads sprouting from their noses and arms. A Dr Moseley from Chelsea predicted a new race of minotaurs. But the majority were believers and much of his time became taken up with answering questions from all over the world. Dried vaccine was sent abroad in a quill or on linen threads. Parliament made him a grant of £10 000 (less £900 in tax!), and he received many international honours. “But honours won’t buy mutton,” as he once wrote, so in 1802, he put up his plate in London. He hated it so he returned to the country where he was to spend the rest of his life, sustained no doubt by a further grant of £20 000 from a grateful government. On 24 January 1823 he had a stroke and died two days later. He is buried in Berkeley Church, next door to the Chantry. The sorrowing locals went somewhat overboard on the wall plaque which records “. . . Immortal Jenner, whose gigantic mind brought life and health to more than half mankind. Let rescued infancy . . . lisp out blessings to his honoured name.” But I suppose their hearts were in the right place. The village of Berkeley, on the Bristol Channel and near Slimbridge, the late Peter Scott’s famous bird sanctuary, seems to have altered little since the days of Jenner. His Georgian house, four square and sensible, is now a museum. Until 1983 the display was in the nearby house which Jenner had given to James Phipps when he became gardener to the doctor. That year the Jenner Trust bought the Chantry from the church, thanks mainly to a gift of

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£500 000 from a Japanese admirer of Jenner’s, Mr Sasakawa. In the museum can be seen the horns and some hair from Blossom. Her hide is located at St George’s Hospital. The study has contemporary furniture and some original instruments. In the garden there still stands the bark hut in which Jenner vaccinated the local poor free of charge. He called it the Temple of Vaccinia. The last recorded case of smallpox in the world occurred in Somalia on 26 October 1977. Exactly 200 years after Jenner’s groundbreaking work, the WHO gave the deadline for the destruction of all remaining stocks of the inoculum — 30 June 1999. In the event, when the date came around it was thought prudent to retain several million doses, which are now stored in a Russian vault. Lady Mary Wortley Montagu’s “variolation” and Edward Jenner’s “vaccination” were different in that one involved the use of pus from a smallpox victim, so fraught with danger, while the other did not, so was comparatively safe. Rightly, Jenner’s method won the day, but Lady Mary was first on the scene and justly deserves more than a passing mention and a kindly thought. (JL)

ASPIRIN: A

H E A D A C H E T O E A R LY CHEMISTS

How many drugs do you know that are truly out of this world? When the rocket Apollo landed on the moon in 1969, it carried aspirin. Aspirin is the most popular remedy of all time and probably the world’s most widely used medicinal drug. Each year people in developed countries use about 100 tablets each. Australians take more than the British or Canadians. Aspirin and related chemicals occur in the bark or leaves of many trees and shrubs. These include willow, myrtle, poplar, black haw, wintergreen and sweet birch. About 3500 years ago, the Ebers Papyrus advised ancient Egyptians with rheumatic pains to apply an

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extract of dried myrtle leaves. In ancient Greece, the father of medicine, Hippocrates, used poplar juice for eye ailments and willow bark for fever and childbirth. The Chinese, North American Indians and African Hottentots have all used aspirin-containing plants. In England the Reverend Edward Stone noted the bitter taste of willow bark which reminded him of cinchona, the source of quinine. Because cinchona was so costly, he gathered half a kilo of willow bark, dried it for three months in an oven and then ground it into powder. In 1763, he told the Royal Society that taking this extract eased his ague (fever). Moreover, he had also successfully treated about 50 grateful patients similarly, but the Royal Society didn’t want to know. Forty years later, Napoleon’s blockade of Europe stopped imports of cinchona. This made demand for aspirin-type substitutes boom. People started to look for other natural sources. In 1876, Dr T. MacLagan found that extract of willow helped patients with rheumatic fever. By now other doctors were using synthetic salicylic acid made by a German professor. Such synthetics quickly replaced the dearer natural compounds. But patients disliked the bitter taste and stomach upsets from salicylic acid; they said the cure was worse than the disease. Felix Hoffman was a chemist working for Bayer Pharmaceuticals. His father had painful, crippling arthritis but could not tolerate salicylic acid. Felix thought a related compound (acetylsalicylic acid) might be more acceptable. After animal tests came a year of successful human trials. The Patents Office registered aspirin as a Bayer trademark. Within three years, 160 scientific studies on aspirin appeared. Patients recommended it to ease pain in arthritis, rheumatic fever, period pains, gout and cancer. The leading Czech novelist Franz Kafka found aspirin could even ease his unbearable pain of being. Originally sold as a powder, aspirin became the first major medicine in tablet form. Sales boomed. Bayer reaped large profits, though Hoffman himself apparently missed out. Until 1914, Australians took aspirin imported from Germany.

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Then the British government offered £20 000 for a new way to produce aspirin. To this reward, Australian Attorney-General Billy Hughes added £5 000. Melbourne pharmacist George Nicholas, who had lost most of his eyesight in an explosion with ether, joined Henry Shmith to take up the challenge. To purify their aspirin, they used kerosene tins and Mrs Nicholas’s kitchen gear, caused another explosion and nearly killed themselves. They sold the new product as Aspro (Nicholas product). It became the biggest selling aspirin outside the USA. More recently we have found other important uses for aspirin. Apart from its effect on pain and fever, doctors use it to prevent recurrent strokes and heart attacks, and to reduce the risk of developing bowel cancer. The aspirin story rolls on and on. (GB)

JOHN SNOW, CHOLERA, AND THE BROAD STREET PUMP Between 1947 and 1953 I was a medical student in Liverpool, England, and in 1952 I did my student obstetrical residency at the Liverpool Maternity Hospital. Between this hospital and the Myrtle Street Children’s Hospital 200 metres away there was a vacant piece of land. It was about two hectares of derelict ground, chest high in weeds and littered with rusty old bicycle or pram frames and the like, and surrounded by a fence high enough to keep out the common gaze. We were near the city centre, you understand, so it must have been very valuable. The cafe for the lower social orders of the hospital’s medical hierarchy, people such as we medical students and probationer nurses, was on the top floor of the hospital, five storeys up. Actually, we all enjoyed the arrangements and appreciated being thus thrown together. One day while gazing from one of the elevated windows, I observed that earthmoving equipment was

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digging up the vacant ground next door. As they went about their destructive way, to our great surprise some long rotting boxes were unearthed together with leg bones, vertebrae, skulls and other skeletal bits and pieces. As we watched they were whisked away with guilty urgency. What in fact we were looking at was a mass grave of the great cholera epidemic of 1832. It had remained hallowed ground for 120 years but was now considered by the city fathers to be far too valuable to remain an overgrown repository for any useless detritus the locals cared to throw onto it. All was cleared and on the spot now stands, perhaps not inappropriately, a huge waste disposal incinerator. I dare not think what happened to the bones. Twenty-five years after this incident I went to India and visited Varanasi, or Benares as it used to be called. Opposite Clarkes Hotel where I stayed on the outskirts of the city is an Anglican church, a legacy of the days of the British Raj. I went in. In the hubbub of India it is a quiet, cool, sequestered place. But the thing which struck me was that the walls are completely lined with plaques bearing the names of soldiers who had died in that hot and dusty outpost of empire 150 or more years ago. Most were in their late teens or early twenties and the brass plates record with gut-wrenching poignancy that the vast majority had died not of gunshot wounds, as you would think, but of cholera. So in these two diverse, but, I suppose, moving episodes, I saw with my own eyes evidence of a scourge in the last century the cause of which was then unknown but the control of which was ripe for a rigorous policy of public health. So what happened? Well, in England at least, came the moment, came the man. He was Dr John Snow (1813—1858) and if ever there was a man who worked for the good of the public wellbeing, John Snow was he. It is not heart transplants or other clinical heroics, but public health measures initiated by the likes of Dr Snow which have been

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medicine’s greatest contribution to the common good. The story of how he stopped a cholera epidemic by removing the handle of the Broad Street pump in London in 1854 has now passed into both folk and scientific lore. So let’s see how it all came about and then revisit the old sites of his dramatic actions and look at how they have stood up to the test of time. Cholera is a water-borne disease caused by a comma-shaped bacillus, Vibrio Cholera. It is recorded from antiquity. For instance, there are Sanskrit writings from 2500 years ago of epidemic diarrhoea and vomiting with the faces of victims haggard from dehydration. There are stories of it in the Ebers Papyrus of ancient Egypt and in the writings of Hippocrates, the father of medicine, who lived on the Aegean island of Cos about 350 BC. But it was mainly a malady of the Indian subcontinent, with flurries in Europe in medieval times. It especially flourished where pilgrims gathered together; in Varanasi, for instance. The infected devotees bathed upstream and the supplicants drank the water downstream. Its impact was not just the diarrhoea and vomiting, which in itself was rapid, frightening and dramatic, but lay in the severe dehydration, a symptom which caused victims to become almost unrecognisable and appearing more like wizened caricatures of themselves. Although the incubation period is five days, once florid it kills within hours, the subject dying of circulatory collapse and shock to the accompaniment of abdominal pain and superficial capillary bleeding which gives a blackened or bluish appearance. It not unnaturally causes a sense of hopelessness and despair in both the observer and observed, and altogether is less than an edifying sight. Never a tremendous problem in Europe, the condition seemed to disappear completely from that continent in about 1500. It lingered on in India, however, and there was a particularly severe outbreak in 1817 which coincided with British troops being stationed in Calcutta and along the Ganges River on which Varanasi is situated. There were many cases, and when the troops were moved first to

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Nepal and then Arabia the disease tagged along. When the troops reached the Middle East the disease was on virgin ground, so to speak, and went wild, especially in Mecca, again with its pilgrims. As the natural history and cause of the malady was not then known, suitable management was not instigated and it persisted. In 1831 in Cairo it killed 13% of the population. In the same year 100 000 died in Hungary and, perhaps with some justification, the peasants turned on the doctors and nobles, blaming them for the scourge and killing them willy nilly. Cholera seemed to leap any quarantine rules with ease and soon such measures were abandoned. Eventually, it spread across the North Sea to north-east England to make, as far as this story is concerned, its dramatic debut in Sunderland in 1831. It was then, you will be at last glad to know, that Dr John Snow made his lowkey and somewhat self-effacing entry into the story. There was an outbreak of cholera at Killingworth colliery near Sunderland where the 28-year-old Snow was a working as a young medical apprentice. He saw the deaths all around him and came up with the then heretical idea that the disease was spread via the diarrhoea it caused rather than the inhalation of “bad air” arising from the corpses. For it was this so-called “miasma” theory that was the contemporary view of the medical establishment and which, incidentally, they applied to a number of diseases. Snow regarded the colliery as a huge privy and believed that unwashed hands, shared food and, above all, faecal contamination of the drinking water was at the bottom of it all, so to speak. As the existence of bacteria was then unknown, he had no proof; it was just a hunch. Anyway, whatever his personal opinions, he was much too far down the medical ladder to make any impact, so he kept his council. Anyway, basic hygienic methods were considered a private matter and to try to change things was seen as an assault on individual liberty. Other centres were affected, including Liverpool, as we have seen. Characteristically, the epidemic eventually ran its course and by about 1838 things had settled down.

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The following year Dr Snow moved away from the rather damp and depressing north-east of the country into upmarket Golden Square in Soho, London, where he set up as a general practitioner. He was a progressive thinker and an enterprising man who later specialised in the new-fangled science of anaesthetics. He became so adept at administering these that he gave Queen Victoria chloroform during the birth of her eighth child, Prince Leopold, in 1853. But that was a bit in the future. In 1848–49 there was an outbreak of cholera in London which claimed 11 000 lives: no small event. Recalling his former thoughts, Snow viewed with some consternation the general lack of hygiene and squalor in which his near neighbours lived. It looked uncomfortably like the fetid coalmine of his youth. He could understand the spread of the disease within a family, but how did it get to other households, even the well-to-do? He again felt that somehow the infection was spread by faecal matter getting into the drinking water. But again, any theories he had he kept to himself. Six years later, however, he got his chance and he held back no longer. In 1854 there was an explosive outbreak of cholera right in the region of Golden Square where Snow lived and worked. Within 10 days there were 500 deaths in his general area. Over three days in early September there were 83 casualties, 73 of whom lived close by. Significantly, he observed that they had all used the same street pump to get their household water. Eight lived further away but came to use that pump as they considered it the sweetest water around. That meant 81 out of 83 had drawn water from the nearby, and soon to be world famous, communal Broad Street pump. He knew in his bones the cause lay in the water outlet. He put the other two deaths down to ordinary mortality. From 1582 the London water supply had been pumped from the Thames. In 1619 water pipes were laid to street pumps and some private houses. As can be imagined, the water was heavily polluted and by the nineteenth century this was a matter of concern. By then the supply came downstream from a sewage outlet, which received

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effluvia from not only households but abattoirs, hospitals, tanneries and other noxious sources. There were eight separate water companies on the Thames and only one had any filtration system. The already highly polluted water then coursed from the river via cracked pipes which, in turn, enabled insult to be added to injury by running close to overflowing cesspools. Snow, however, did not know this at the time, but it came out in his subsequent investigations. Remembering Killingworth and his feeling about contaminated water, Snow demanded a meeting regarding the water supply with the Board of Guardians of St James Parish in which Broad Street lay. His ideas were heretical, so, as you can imagine, there was acrimony, recriminations and raised voices. This was the era of putting boys up chimneys to sweep them and sending children down the mines to drag the trucks while they were bent double, so polluted water, which in its ordinary state looked fine, was not high on anyone’s agenda. Except, that is, Dr Snow’s, and he was not a man to be trifled with. He stood his ground. When the Board eventually asked him to make a practical and certainly inexpensive suggestion, the blindingly simple reply has gone down into medical folklore, “Take the damned handle off the Broad Street pump.” So they did and no further cases occurred. Having said that, Dr Snow was in fact a trifle fortunate with his inspired guess, because not until 1883, about 40 years later, was the causative organism eventually found by the German bacteriologist Robert Koch, who proved for all time that the ambient noisome smells had nothing to do with it. Flushed with success, as it were, Snow went on to examine distant pipes and found cracks and overflowing cesspools in many areas of London. With his newfound standing, he forced other parishes to do repairs. John Snow was a man of his times, for the nineteenth century saw the first stirrings of consciousness as regards the public good. As well as Snow, Edwin Chadwick, though an irascible, arrogant man and sensitive to criticism, made a great impact on the

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government of the day to improve sanitation. He has never caught the public imagination like Snow, clean water and sewage disposal never do, it is unglamerous and not spoken of in polite society, and we like our heros to be paragons of good manners and preferably good-looking and athletic; Chadwick had none of these virtues. Other contemporary social reformers included Elizabeth Fry with her penal improvements, Lord Shaftesbury who stopped child labour and Charles Dickens, the influential novelist, who stirred people with his writings of the disadvantaged and down-at-heel. There was no hospital specifically for children in England until 1852 when the The Hospital for Sick Children, Great Ormond Street, was opened largely with money raised by Dickens. He so stimulated major philanthropic activities that one meritorious matron, Mrs Grace Kimming, squared her troubled conscience by forming a charity which she called “The League for Brave Poor Things”. Although the name was nauseatingly patronising, I suppose she meant well. It is still there in the Sussex countryside, now mercifully renamed Chailey Heritage. All these dramas of Golden Square and the great Broad Street pump saga took place nearly 150 years ago, so what are Golden Square and its environs like now? Is John Snow still remembered? In 1996 I went to find out. Golden Square is still there in Soho, all right, not far from Regent Street with its upmarket shops, Carnaby Street with its trendy gear and Shaftesbury Avenue with its theatres. It is a smallish square by London standards, with a fenced-off grassy centre, obviously a favourite al fresco luncheon spot for local office workers. In the centre is a statue of King George II, rather incongruously dressed in a Roman toga. A notice at the gate indicates that only three of the original nineteenth-century houses are still standing, and that one of the characters from Dickens’s Nicholas Nickelby had lived there. Of John Snow, there is not a word. A couple of buildings carry the famous blue plaques of the London Historical Society. Both are of medical interest. One marks the site of the country’s first Throat Hospital, founded by Morrel

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Mackenzie in 1865, and, tucked in a corner, the other shows the location of the house of John Hunter, the eighteenth-century surgeon and anatomist. An enquiry about Snow at a couple of shops brought blank stares and a complete ignorance of the whereabouts of Broad Street. Disappointed, I left the square via Lexington Street. Two hundred metres or so down the road it formed a T-junction with Broadwick Street. And there, right on the corner, garlanded with hanging baskets and bustling with customers, was a small pub called (surprise, surprise) “The John Snow”. After the pump fiasco, it seems Broad Street had been renamed. They knew all about Snow here, all right. In fact not only is the pub sign a painting of the great man himself, but they do a brisk trade in John Snow ephemera. Upstairs there is a collage of contemporary newspaper and magazine clippings of the famous events, plus another fine picture of our hero. “Always getting foreigners in here,” the landlord assured me. “Where did you say you were from, sir?” I told him again, trying to disguise my English accent. “Marvellous! Here, sign the book.” The visitors book was full of the names of other dewy-eyed medicos on a similar pilgrimage. They came from America, Chile, France, in fact all over the world. I added my name with some pride. Even though I knew my figure is not cut out for such fol-de-rols, I was shamed into buying a John Snow T-shirt with his story emblazoned on the back. “But what of the pump,” I enquired of my host. Diagonally across the road was pointed out the replica set up by the local council within the last 20 years. It looked innocent enough, and I noted with some satisfaction that it had no handle. The inevitable plaque told the story yet again. But the landlord pulled me aside and I was aware that he had dropped his voice and was stooping to get closer to my ear. “Never mind that rubbish, this is what gentlemen like you want to see.” He took me outside where, directly under the swinging painting of Snow, he pointed to the edge of the road. What I saw

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was a granite kerbstone, twice the size of its neighbours and red rather than grey. Its irregularity made it look strangely out of place. The publican bent close and took my elbow, perhaps thinking I was going to swoon from the enormity of the moment. “That,” he hissed conspiratorially, “that is the very site of the pump.” And so it was. The plaque on the wall confirmed the fact. Although the stone itself was anything but inspiring, I felt oddly moved by what the site and story had come to represent to so many people, and I could not help but remember the words of the great Pericles when in 429 BC he wrote: For the whole world is a sepulchre of famous men, And their story is not graven on stone over their native earth, But lives far away without visible symbol, Woven into the stuff of other men’s lives.

I went away contented. (JL)

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Chapter

2

FRAUDS

DOCTOR SUMMERLIN AND HIS MICE As the elevator carried him towards the director’s office, it propelled him towards imminent extinction. The problem concerned the mice, which were the wrong colour. Summerlin coloured in the patches of transplanted skin on the white mice. In an instant he had succeeded in producing the vital skin graft that years of research had not yielded. — Youngson and Schott, Medical Blunders

In 1972, American President Richard Nixon declared a $1.7 billion research war on cancer. Immunologist Dr Robert Good was Director of New York’s elite Sloan-Kettering Institute for Cancer Research. Still only in his fifties, his photo appeared on the cover of Time magazine. Then 35-year-old Dr William Summerlin, tall, charming and persuasive, came to work under Dr Good. These two looked like setting the fiercely competitive world of cancer research on fire.

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The Time article on Good also promoted Summerlin as having made: a discovery that may well make tissue typing unnecessary. [He has] found that when skin is kept in tissue culture for several weeks, its antigens (chemicals that stimulate an immune response and so cause rejection after organ transplantation) are somehow lost. The skin can then be grafted on to any patient without being rejected. Summerlin’s work . . . could eventually eliminate both the rejection problem and the need to match donor and recipient, enabling transplant surgeons to make wider use of organs taken from cadavers (corpses).

Summerlin certainly looked like a young man with a great future. But only a year later, on 26 March 1974, he not only destroyed his own career but also made waves that affected the credibility of medical research generally. He did this by drawing black patches onto two of the mice in the cage he was about to show Dr Good. Summerlin had been culturing and then trying to graft black skin onto white mice. By darkening the colour of the donor areas, he made it appear that his grafts had taken. How did such a promising rooster turn so quickly into a featherduster? During the peak of the Vietnam War (from 1965) Summerlin worked at a hospital burns centre in Texas. The problem of covering large burns stimulated him to turn from surgery to research. A black man had a third-degree burn of about 10 cm on his flank. Summerlin set up cultures of pieces of skin from a live white donor. After a week of culture, he tried to graft the white skin, but the patient rejected it. After two weeks, the same thing happened. After three weeks, the white skin lasted longer. After about four weeks of culture, the black man was no longer rejecting the white skin.

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Turning to mice, Summerlin reportedly found that culturing skin or other organs for some weeks before transplantation made them immunologically neutral (so they no longer caused rejection). He had similar results with corneas from eyes. His technique, he claimed, even allowed him to transplant from one species to another! That was unheard of. But other workers could not confirm his results. Despite his high media profile, Summerlin faced growing scepticism among his peers. In fact, a junior member of Summerlin’s own team was pressing to publish a paper announcing his own failure to reproduce Summerlin’s transplant successes. At 4 a.m. on 26 March 1974, Summerlin rose from the cot on which he often slept in his office. It was on the way to his 7 a.m. meeting with Dr Good that he inked the black patches onto the scars on the white mice that he had grafted with skin from black mice. If Summerlin had only known how futile his clumsy fraud was. Dr Good hardly looked at the mice. It was the lab assistant to whom Summerlin returned the mice who found that alcohol washed away the “skin grafts”. Once he reported it, Summerlin’s superiors suspended him. Dr Good reproached his protege: “We could have gone together to Stockholm [to receive the Nobel Prize]. But now you are dead, dead, dead.” They allowed him up to one year’s leave on full pay “to enable him to obtain the rest and professional [read psychiatric] care which his condition may require.” It suited his superiors to imply that Summerlin had gone out of his mind. But a committee also blamed Dr Good himself for allowing Summerlin to publicise his findings so widely before they had been confirmed. “Good was slow to respond to a suggestion of dishonesty against Dr Summerlin . . . when several investigators were experiencing great difficulty in repeating [his] experiments.” How could Summerlin expect such a gross scam to succeed? A colleague said: “The man had everything going for him. Then he threw it away; it’s almost like Rembrandt putting his foot through

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one of his paintings.” In his own defence, Summerlin spoke of the extreme pressure to produce results and so support applications for research grants. Robert Youngson and Ian Schott sum up: “While Summerlin was principally to blame, he was very much the product of a research environment that required, for prestige and funding from the drug companies, continuous new discoveries.” Before this scandal broke, idealists liked to believe that scientific fraud was rare. How many cases remain undetected? (GB)

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Chapter

VERSATILE

SPIES,

3

DOCTORS

LIES AND SECRETS

In 1954, Vladimir Petrov, the senior Soviet intelligence officer in Australia, defected to ASIO (Australian Security Intelligence Organisation), taking with him a bag stuffed with documents. His defection led to intense political controversy, a Royal Commission, the re-election of the Menzies Liberal Government, a split in the Australian Labor Party (ALP) and the political death of Dr H. V. Evatt, leader of the ALP. Dr Michael Bialoguski, the man behind the Petrov defection, was born in 1917 to Polish parents in the Ukranian capital, Kiev. How did this man have such an effect on a country so far away? By 1920, Kiev had been a First World War and Russian Civil War battleground occupied by the Bolsheviks, Germans, White Russians and Polish–Ukranian forces. Bolsheviks were about to shoot three-year-old Michael and his family, when Michael’s father managed to bribe them with his gold watch. The family had to flee on the spot. They wound up in the Lithuanian capital Vilnius, then

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occupied by Poland. As he grew up there, Michael learned to play the violin and in 1935, he started medical school. When the Germans and Russians invaded Poland in 1939, police arrested Michael for possessing firearms. Released after three months in gaol, he led the orchestra of a musical comedy troupe, laundered money, worked the blackmarket and endured another spell in gaol. His first marriage failed. In early 1941, carrying a one-carat diamond hidden in a toothpaste tube, Michael set off on the Trans-Siberian Railway and crossed the whole Soviet Union (about 10 000 kilometres) to Vladivostok on the Pacific Coast. Here he used his fluent Russian to talk his way onto a ship bound for Japan. In Tokyo, he sold his diamond and spent some weeks wangling the documents to migrate to Australia. When Michael walked alone down the gangplank in Sydney in June 1941, he spoke no English, knew no-one and owned only a violin, a few shirts and £13. At first he supported himself playing the violin at concerts and on the radio. Within a year, he had served briefly in the Auxiliary Medical Corps and resumed his medical studies (paid for by the Repatriation Department). His good looks, smooth Continental manner and strong personality won him many hearts, including that of Patricia Humphrey, who divorced her husband to marry him. In 1945, with the Red Army spreading across Eastern Europe, the Commonwealth Investigation Service (CIS) engaged Michael to “unmask foreign agents”. To find these subversives, he joined the NSW Peace Council and the pro-Bolshevik Russian Social Club. Later he moved to ASIO, where he earned £4 a week. At his general practice in Macquarie Street, Sydney, he treated many refugees from the Soviet Union and also did illegal abortions. Sir Eugene Goossens persuaded him to play first violin with the Sydney Symphony Orchestra. In 1951 at the Russian Social Club, Michael met Vladimir Petrov, who had joined the Soviet Embassy in Canberra. Though he was nominally Third Secretary, ASIO suspected Petrov of being a top intelligence officer.

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So started a bizarre courtship. For almost three years, the Polish spy–doctor and the Russian spy–diplomat circled, manipulated and exploited each other. Each spent more energy on this relationship than on his own marriage. Whenever Petrov visited Sydney, they would cruise the town in search of prostitutes and drink. As Petrov slept off the drink, Michael emptied his pockets and copied the contents. Not suspecting that Michael worked for ASIO, Petrov gave him some minor espionage tasks. Michael insisted that Petrov was a potential defector and resented ASIO’s refusal to believe him. His superiors in turn called Michael presumptuous, avaricious and unreliable; they even hired an agent to watch him! Several times Moscow reprimanded Petrov and his wife Evdokia (also an undercover spy) on their work and on his drinking. When Moscow summoned Petrov home, he feared the worst. He complained of an eye problem, for which Michael took him to specialist Dr H. C. Beckett. By now ASIO hoped that Petrov would indeed defect but wanted to bypass Michael. So they approached Petrov through Dr Beckett, who had no intelligence background. Soon ASIO head Colonel Charles Spry dismissed Michael altogether. Finally, after an infuriating three-year saga of coaxing, hesitations and delays, Petrov did defect. On 3 April 1954, at a safe house on Sydney’s North Shore, an ASIO agent handed him £5000 in exchange for intelligence documents. He was the most senior Soviet spy to defect to the West since the 1930s. “Without this extraordinary character [Michael] there would have been no Petrov defection,” wrote Robert Manne, author of The Petrov Affair. On announcing Petrov’s defection, Prime Minister Robert Menzies set up a Royal Commission to investigate Soviet espionage in Australia. Federal Labor Leader Dr H. V. Evatt convinced himself that the whole defection was a sham, or else timed by Menzies and ASIO to coincide with the 1954 Federal election. Evatt’s outbursts against ASIO became so outlandish and grave that the Royal Commission felt obliged to let ASIO defend its honour.

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Michael Bialoguski’s lengthy cross-examination enabled him to speak in public about his key role in the defection. But what drove Michael? His second wife, Patricia, said that he was fascinated by espionage: “[he was] supremely ambitious, both for wealth and fame . . . self-pitying, resentful and vengeful . . . prone to fits of irrational jealousy”. She quoted Michael: “No law can hold me. I am my own law.” In 1957, after writing his own book on the Petrov affair in 1955, Michael married for the third time; this marriage produced three children. I heard the story in 1998 from his last wife Nonnie and their son Stefan. She described their time in Australia after the Royal Commission as hell, with both sides of politics gunning for Michael. The left reviled him as part of the Petrov conspiracy and a lackey of the conservative government. On the right, ASIO did not want to share the credit for Petrov’s defection. The family moved to England in 1964, where Michael settled into general practice but made a musical stir as well. Once he hired the Albert Hall and a symphony orchestra that he conducted before a large audience. Dr Michael Bialoguski died in 1984. The last word about him rests with Nonnie. She admits he was arrogant, difficult and paranoid. “He was always the alien — the outsider. Perhaps he over-compensated — fighting the world. Alone!” (GB)

DOCTORS

AND BUCCANEERS

Buccaneers and doctors always enjoyed a close relationship. By the nature of their trade, pirates often had to call on medical services, however crude, and doctors have never been averse to investing their energies into business ventures, however risky. Indeed, the word “buccaneer” was coined by a doctor. During their heyday in the second half of the seventeenth century they were usually called “privateers”. But in 1684 there appeared a book

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called Buccaneers of America, written by Dutch surgeon/pirate Alexander Esquemeling. Unlike many of his fellow so-called “Brethren of the Coast”, Esquemeling was articulate and well read; his book became a classic and the word itself, derived from the French boucan, a grill for smoking dried meat on ships at sea, passed into the language. Presumably, this form of cooking was standard among the sailors of that kind. Alexander Esquemeling had arrived on Tortuga Island near Haiti in 1666, footloose, untrained for any gainful employment and bent on adventure: an ideal candidate for some unlawful pursuit. Lax French government officials allowed the island to be a base for pirates and he soon joined up. After three years of harsh, but doubtless lucrative seafaring, he was sold to a surgeon who taught him the rudiments of the craft. An adept student, Esquemeling subsequently became an authority on the therapeutic worth of local plants while serving as a surgeon during many of the exploits of the great pirate, Henry Morgan, as well as other villains. From the rough and ready experiences gleaned, he wrote his book which contained a first-hand account of the piratical excesses of rape and murder. Rather incredibly, Morgan himself was later to succeed in sueing the English publishers of the book for “many false, scandalous and malicious reflections” on his life. An interesting medical twist in the book concerns how the booty was divided after Morgan had sacked Panama City in 1671. The captain himself was allotted 100 parts of the plunder. The surgeon merely got 200 pieces of silver for the use of his medicine chest. That may not sound too bad, but when you consider that at the drum head division of loot, compensation for injuries sustained in the course of their nefarious activities included 1500 pieces of eight or 15 slaves for the loss of both legs, or 600 pieces of eight or six slaves for the loss of one hand, the surgeon came pretty cheap. Henry Morgan himself was an outstanding leader, the pinnacle of whose career was famously leading 36 ships in the sacking of Panama. It was his swan song, for shortly afterwards he “swallowed the anchor” and became a pillar of society. He retired to Jamaica,

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becoming Lieutenant Governor then a judge, and was eventually knighted by Charles II! Morgan led a strangely abstemious life for the rumbustious times in which he lived and fought and he enjoyed good health as a pirate. However, in 1688 he fell ill and was treated with dubious success by a young doctor who was to attain an even greater fame in the medical profession than had Morgan privateering on the Spanish Main. He was Hans Sloane, later Sir Hans Sloane, founder of the British Museum, the Chelsea Physic Garden, and President of both the Royal Society and the Royal College of Physicians of London. Sloane Square in fashionable London, and in recent years epicentre of the “Sloane Rangers”, is named after him. This medical man has left us an account of Morgan’s last illness when the retired villain was 53. He suffered from “dropsy” due, it seems, to kidney disease and for which Sloane gave a host of poultices, clysters (enemas) and emetics. They had no effect and a wrung-out Morgan eventually sent for another doctor. But he died just the same. Perhaps the best-known name among the ranks of buccaneer/doctors was that of the Cambridge graduate Thomas Dover, of Dover’s Powder fame, a concoction which can still be found in the backroom of some old pharmacies and which was in occasional use as recently as 30 years ago. It was a mixture of opium and ipecacuanha to be used as a sedative-cum-analgesic, and especially useful if diarrhoea was present. It last appeared in the 29th edition of The Complete Drug Reference, the pharmacists’ bible. I remember the powder well, mainly for the sweating it used to cause. Dover (1660–1742) was a successful Bristol doctor who became a medical officer on a privateering voyage which circumnavigated the globe. Besides his powder, his main claim to fame was his part in the rescue of Alexander Selkirk from Juan Fernandez Island off the coast of Chile on 2 February 1709. This castaway had survived alone there for four and a half years, and became the role model for Daniel Defoe’s book Robinson Crusoe, written ten years later in 1719. Dover also popularised the use of quicksilver (mercury) for syphilis, infertility and indigestion — an odd case mix and useless in them all.

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Lionel Wafer was a surgeon who joined the Caribbean adventurers. He wrote of his life of looting combined with surgery but is best remembered for his account of local Indians and wildlife. Of interest in Australia is the famous pirate William Dampier (1652–1715). Between 1678 and 1691 he was engaged in piracy off South America, during which time he reached Australia but found nothing to plunder. He reformed, and in 1699 was sent by the Admiralty to explore the Antipodes in the Roebuck. He reached Shark Bay off the Western Australia coast and journeyed north to name the Dampier Archipelago and Roebuck Bay. Later he briefly returned to piracy, but by then the buccaneer’s halcyon days of looting, pillage and rape were just about over. Dampier was concerned about the health of his crew. He recorded that he found it very beneficial to wash morning and night, especially if suffering from the flux (diarrhoea); that old betel nuts caused giddiness but were excellent for sore gums; that too much “penguin fruit” produced “heat or tickling in the fundament” (I’m not sure what penguin fruit is or what its effect means, but the mind boggles). He became expert in the therapeutic use of many native plants. By about 1690 various international conflicts allowed these freebooters to become legitimate privateers in the service of their respective countries. With respectability, the romantic, though bloodthirsty age of buccaneers and their surgical hangers-on came to an end. (JL)

SUN YAT-SEN: DOCTOR

TO ALL

HIS COUNTRYMEN The top physician cures the nation first, and then the people. — Guo Yu, Ancient Chinese book of history

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Dr Sun Yat-sen made his name by freeing China from the Manchu dynasty’s despotic rule. His people honoured him as “Father of the Revolution”; many revere him still as the father of modern China.

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Sun Yat-sen was born in 1866 to a Christian peasant family in a village in Kwangtung (Canton) province. With sweet potato as their staple food, the family survived on their one-acre tenanted field. At the age of 14, Sun stowed away to join his older brother in Hawaii. There at an Anglican mission school, he became so fond of English ways that his brother shipped him back home. At the age of 18, as was the custom, he entered an arranged marriage. Next he moved to Hong Kong, where he very nearly became a Christian missionary, but instead graduated as a doctor. What, then, made him take up the life of a reformer and revolutionary instead? Perhaps it was outrage at the slave system in China, under which families sold their daughters for prostitution and their sons into bondage. Somehow Sun juggled medicine with top cricket and undercover activity. Since the Hong Kong General Medical Council did not recognise Sun’s qualifications, he set up instead as a herbalist and offered both traditional Chinese and Western medicines. From 1892, he practised in Macao (Macau), becoming the first doctor trained in Western medicine to work in a traditional Chinese hospital. There he persuaded the governors to devote one wing of the hospital to European methods, the other to Chinese practice, and then to compare results. When Sun was operating, the governors would sit near the operating table, with the patient’s relatives and friends standing nearby. Sun’s skill impressed them all. He also borrowed money to set up a Chinese and Western pharmacy, where he saw patients and dispensed medicines without charge. But Portuguese physicians, resenting his success, forced Sun out of Macao. Gradually, the reformer displaced the doctor. He pressed for political reform, universal education, improved agriculture and the prohibition of opium. But while he worked inside the existing political system, all Sun’s efforts at reform remained futile. In 1894–95, defeat in the war with Japan forced China to give up Taiwan; then Britain, France, Germany and Russia grabbed more Chinese territory. Clearly, the weak, corrupt Manchu government could not protect his country. Sun set up his own activist group,

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“Dare to Die”. When the authorities executed his comrades, he himself was lucky to escape. So began his lifelong succession of crises, unsuccessful plots and coups, flight from murdering Manchu agents, exile and wandering. For years on end, Sun shuttled between Hawaii, Japan, Europe and the USA, to raise money to overthrow the despotic government of China. In all, he was behind ten uprisings. By 1896, he had a price of £100 000 on his head. While walking near Portland Place, in London, Sun was kidnapped and held for 12 days inside the Chinese legation. His captors were about to ship him back to a certain death in Beijing when a maid from the legation secretly notified Sun’s old teacher Dr James Cantlie, now living in London. All that night Cantlie and Dr Patrick Manson (of malaria fame) kept vigil outside the legation until the morning when the Foreign Office, Scotland Yard and The Times all demanded Sun’s release. Sun’s international reputation soared when he published his account Kidnapped in London. Like Karl Marx and Vladimir Lenin before him, Sun spent months of study in the British Museum library. A bomb explosion in Hankow in late 1911 marked the beginning of yet another revolution, but this one succeeded and the boy emperor abdicated. At a convention in Nanking, Sun was sworn in as president. But the republic had little support and an inevitable power struggle followed. Realising that he could not keep the country united under his own rule, he resigned in favour of Yuan Shih-k’ai who at first seemed to be another reformer. But Yuan soon declared himself emperor. Within a year, Sun and Yuan were leading armies against each other. The country was plunged into anarchy and terror; Sun had to flee once more and could not return until Yuan died. Even then, North and South China were still divided; Sun worked towards an independent republic of South China, of which he became president. Unable to work with the army leaders in Canton, he resigned once more. There followed a military dictatorship. In 1921, this fell and Sun became president yet again. New alliances formed and dissolved with bewildering speed.

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Since the Western democracies would not support the Chinese revolutionaries and were profiting from China’s weakness, Sun felt he had to sign a pact with the Soviet Union. In 1923, Communist Russia sent money, arms and advisers to Sun’s government. While in Peking for a People’s Conference, Sun came down with a raging fever. An operation showed advanced cancer; now neither Western nor Chinese medicine could help him. On 12 March 1925, at the age of 59, Sun Yat-sen died. Four years later, his body was interred in his own mausoleum in Nanking. Sun’s critics saw him as too idealistic. He sometimes planned badly, failed to act decisively and trusted generals who betrayed him. So what was his appeal? Sun had a magnetic personality, ambition for power and outstanding knowledge of the West. Politically, Sun dead was even more effective than Sun alive. His Three People’s Principles — socialism, democracy and nationalism (unification of the many peoples of China and an end to their exploitation by Europeans) — inspired his successors. Both nationalists and communists revered Sun as the founder of the Republic of China. In 1946, the nationalist Chiang Kai-shek (who had been a protegé of Sun) formed a government and fleetingly achieved Sun’s dream of unifying China. But the communists overthrew him. In 1949, Mao Zedong headed the People’s Republic of China, forcing Chiang and his nationalists to withdraw to Taiwan. Sun’s young widow, Soong Ch’ing-Ling, became a prominent figure in the Communist government. Even now, over 70 years after his death, Sun’s dream of a unified China remains just that: a dream. Even now, we cannot foretell the end of the story of modern China. What we do know is that without Dr Sun Yat-sen there would not even have been a beginning. (GB)

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DR LIVINGSTONE, I

PRESUME?

One of the great, understated epigrams typical of the Victorian era was “Dr Livingstone, I presume?”. It was reputed to have been said by H. M. Stanley, a journalist from the New York Herald, when, after 10 months trekking from the coast of East Africa to find the supposedly lost David Livingstone, he eventually confronted the doctor/missionary on 28 October 1871 at Ujiji, the Arab slavetrading centre on Lake Tanganyika. So who was this great medical missionary-cum-explorer who worked in Africa for over 30 years, and why was he lost (if indeed he was lost)? Although Livingstone’s most well-known exploration was when he went down the Zambesi River to find the falls of Mosi-oa-tunya (“the smoke that thunders”) which, with a jingoism typical of his times, he immediately renamed the Victoria Falls, being an explorer was definitely his third priority in life, and only seriously undertaken after his first two loves had been satisfied. First and foremost Livingstone (1813–1873) was a committed Christian who, again typical of the era, believed that the British were the most suitable race to convert the African “heathen”, and he himself more suited than most. He saw spreading The Word as his mission, and believed that divine guidance would eventually lead him to his ultimate goal — the spot where Moses once bathed in the Nile. Such was his devotion to this primary duty that in the hope of preaching more clearly, Livingstone had his uvula removed in Cape Town in 1852. The uvula is that small piece of tissue that hangs down at the back of the throat. I hope it worked, though the effect of surgery on a Scottish brogue must have be equivocal at best. As curing the indigent sick was seen to be an essential part of this ministry work, so it was that medicine became his second love. In the context of medical history, it is this aspect of his life that is of more interest to us. David Livingstone was born in Blantyre, Scotland, in 1813 into

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a deeply religious family. To augment the family income, at the age of ten he left school to work in a cotton mill. By the age of 13 he was working 14 hours a day, but such was his desire to be educated that he attended classes in the evening for another three hours. During the day he propped up his textbooks on the spinning jenny. At 20 he joined the London Missionary Society with a view to foreign pastoral work and was told that medical expertise was a highly desirable sideline. So with money from his brother, Livingstone walked from Blantyre to Glasgow to enter the Andersonian Medical College. Fees were £12 a year and his lodgings cost 2s 6d a week. During the holidays he went back to work in the mill to help pay the fees. After two years he travelled to London to study theology, coupling it with clinical studies carried out at the Charing Cross Hospital. As he could not afford to pay the fee for the London examination, Livingstone returned to Glasgow to sit the papers and qualified Licentiate of the Faculty of Physicians and Surgeons of Glasgow in 1840. Within a week he was ordained a missionary and a fortnight later sailed for Africa and into history. At the time the diseases of that continent were a complete mystery. Over the years Livingstone was to make many clinical observations, though he never got them together to formulate any great medical discoveries, and in the light of his nineteenth-century medical knowledge he often drew erroneous conclusions. For instance, he knew malaria was the main scourge of the continent, though its relationship with the mosquito was quite unknown. He felt that victims who kept active suffered least and advised accordingly. He also devised the “Livingstone Pill” for the condition; it contained resin, jalap, calomel, quinine and rhubarb. Doubtless the quinine, empirically given as it was, may have had some therapeutic effect; the purgative nature of the rest would at least take your mind off things. He gleaned other odd observations from native culture, including the putting to death of a child who cut the upper before the lower incisor teeth. Another was the eating of earth, mainly

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among slaves and pregnant women. He could not explain this, but nowadays we would put it down to an iron deficiency within the subject. Livingstone was among the first to note the effect of the bloodsucking tsetse fly on cattle, yet wrongly thought humans immune from any diseases these insects may carry. In fact, they are a vector in the life cycle of various maladies, especially sleeping sickness. He recorded that goitre, endemic in the highlands, disappeared within a few days of drinking water from Lake Tanganyika, which was a perceptive observation, but as the necessity of iodine water to prevent this condition was quite unknown to him, it meant nothing. He was a man before his time. In the countryside Livingstone soon became more popular as a doctor than a man of a strange God. However small his therapeutic armamentarium, the locals thought that, like his firearms, his medicine was magic. Indeed, they were always pressing him to show them the secret of his “gun medicine”, as they called it. Over the years he himself suffered over 30 attacks of malaria, as well as many other extremely debilitating exotic tropical diseases. He saw them as being divinely inspired tests of his devotion; he never wavered from his chosen path. But after 33 years it was probably none of these exotica that finally killed him. Livingstone had always been troubled by haemorrhoids but refused surgical treatment when on leave, believing that the blood loss relieved his headaches (another false conclusion). However, by 1871 the loss was almost continuous. Becoming debilitated from this bleeding, he decided to make for the coast and seek help. As he made his slow and tortured way, the missionary became weaker and weaker. Attacked by driver ants, squelching through marshes, feverish, exsanguinated and emaciated, in the end his men had to carry him by litter. It was all too much for even such a hardy battler and on 1 May 1873 he died in Chitambo’s village on Lake Bangweulu (Zambia). There then occurred a most remarkable sequence of events. Livingstone’s bearers opened up the body, removed the internal

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organs and heart and buried them. They were replaced by salt. The corpse was then exposed to the sun for 14 days to dry, after which it was tied in calico and strips from the myonga tree. The whole body was coated with tar and strung to a pole to be carried between two men, Susi and Chuma. It took until February 1874 to reach the coast, and until April to sail to England. With contraction and flexing of the legs, the package was only 1.2 metres in length when it arrived. A postmortem was undertaken by Sir William Fergusson, President of the Royal College of Surgeons and surgeon to Queen Victoria. He recorded that the face was unrecognisable, but that one feature clinched the identity; at some time in the past the left humerus bone in the upper arm had been fractured and now displayed an oblique disunited fracture with a false joint. The surgeon recognised it, for thirty years before Livingstone had been mauled by a lion and sustained a compound fracture of the left upper arm. It became infected and never properly healed, and, incredibly, while on leave the missionary had consulted this self-same William Fergusson about the unsatisfactory union of the bone. The story of David Livingstone’s selfless life and tragic death touched all strata of society and earned him a burial in Westminster Abbey. In part his epitaph reads: Brought by faithful hands Over sea and land Here rests David Livingstone, Missionary, Traveller and Philanthropist.

His vast impact on medicine does not get a mention. Nonetheless, to help enact the final rites there were present in the Abbey not only the redoubtable H. M. Stanley, but also Susi and Chuma, who revered his spiritual and clinical dedication enough to have carried the body over 1000 kilometres, keeping the faith for over eight months. (JL)

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SERVETUS

SHOULD HAVE STUCK TO DOCTORING

In 1628, William Harvey described the pumping action of the heart and the circulation of the blood. But Harvey, like most pioneers, was building on the work of his predecessors. As early as the second century, the Greek physician Galen saw one side of the heart contracting before the other. From this, he theorised that blood passed through tiny holes in the muscle separating the two sides of the heart. Though no-one could ever see these pores, Galen’s godlike authority led physicians to accept their existence for 1400 years. A thirteenth-century Arab, Ibn An-Nafis, described the circulation of blood from the heart through the lungs and back again, but his findings made little impact. The first European to confirm them was the Spaniard Michael Servetus (Miguel Serveto, Servede — c. 1511–1553). Physician, physiologist, astrologer, geographer, mathematician and fearless theologian, Servetus had the breadth of a true Renaissance figure. But his contemporaries never acclaimed his genius; they shunned him as a threat to religious orthodoxy and hence to political stability. Servetus was a precocious youth. After convent school, he probably attended the University of Saragossa, where he excelled in Latin, Greek and Hebrew. Then he went to France, to study law at Toulouse. Like other religious reformers, Servetus could not stomach the worldliness and corruption of the papacy. Nor could he accept the Church’s absolute authority: “It would be easy enough, indeed, to judge dispassionately of everything, were we but suffered without molestation by the churches freely to speak our minds.” In 1531, Servetus published a text against the doctrine of the Holy Trinity (De Trinitatis Erroribus). He expected support from the more liberal reformers, but both Protestants and Catholics were outraged. Bucer, reputedly a kind man, said the author deserved to be disembowelled and torn in pieces!

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In Paris, Servetus studied medicine. He came under the influence of “the anatomical arch-heretic” Andreas Vesalius. Unlike the followers of Galen, Vesalius learnt his anatomy not from old books but in the dissecting room, and was sure that Galen was fallible. Their spirit of inquiry, painstaking dissection and observation bore fruit in Servetus’s discovery of the pulmonary circulation. Servetus wrote a medical book that contradicted Galen. He also outraged his faculty by lecturing on the forbidden topic of astrology (fortunetelling: the belief that the stars influenced health). Despite all this, Servetus graduated as a physician in 1538. He went to practise medicine and study theology at Louvain in France. He was a good, kind doctor. Had he stayed quiet and stuck to medicine, all might have been well. Instead, his questioning and wandering brought him into perpetual conflict and finally precipitated his death. Servetus’s life had the inevitability of a Greek tragedy. Few heretics managed to get so seriously offside with both camps. After the Catholics burned Servetus in effigy, he provoked the Protestants to do so in the flesh. Was he just naive? Or did he have a death wish? Medicine was his livelihood, but theology was always his passion. By 1546, Servetus had drafted his major work The Restitution of Christianity (Christianismi restitutio). He hoped this work would purify the Church from its errors of doctrine, and so win the world to Christ. He sent a copy to the Protestant reformer John Calvin in Geneva, asking Calvin to meet him to talk. Had he forgotten his criticisms of Calvin’s major work, The Institutes of the Christian Religion? Calvin declared: “This limb of Satan . . . if this creature ever dares to visit Geneva, he shall not . . . leave alive.” In 1553, Servetus published 1000 anonymous copies of his revised Restitution. It was 700 pages long. Tucked away among the theology was his rediscovery of the pulmonary circulation. But it was the theological content of Restitution that provoked his arrest. Was it John Calvin who denounced him to the Catholic Inquisition in France?

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Though tried and convicted of heresy in France, Servetus escaped from prison and planned to flee to Italy. Whatever drew him instead to Geneva? Perhaps he expected the more liberal Protestants, who opposed Calvin, to prevail there. A forlorn hope. This time it was Calvin’s supporters who arrested him. Servetus’s condemnation for heresy had ten headings; the two most important dealt with the Trinity and Infant Baptism. Calvin pressed for execution but, to his credit, endorsed Servetus’s request for a merciful mode of death. In vain. Within sight of beautiful Lake Geneva, they led him to the stake. Even then, he might have saved himself by recanting. To prolong his agony, they used green, moist wood. Around his waist they tied his manuscripts and his Restitution, of which only three copies have survived. Sir William Osler’s view: “Judged by his age, Servetus was a rank heretic, and as deserving of death as any ever tied to a stake. We can scarce call him a martyr of the Church. What Church would own him? All the same, we honour his memory as a martyr to the truth as he saw it.” (GB)

DOCTOR WAKLEY

JUGGLED THREE CAREERS

Wakley pursued careers in . . . three areas . . . any of these would have been a full-time assignment for the average man. He was founder, owner, and editor of what has been perhaps the most influential medical journal in the world. He was a Radical politician, a member of the British parliament . . . he was a combative coroner and leader of a movement to have physicians be coroners in a day when that was unheard of. — Charles G. Roland, Introduction to S. Squire Sprigge, The Life and Times of Thomas Wakley

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As a youth, Thomas Wakley (1795–1862) excelled at billiards, boxing and cricket. As an adult, he followed a more serious trifecta, becoming founding editor of the Lancet, a coroner and a member of parliament. His father was a farmer in Devon. At the age of 15, Thomas became an apprentice to an apothecary and then to a surgeon. In 1815 (aged 20), he went to London. At the Royal College of Surgeons of England (RCSE), he competed with his fellow students for bodies “resurrected” from the gallows. Body snatching was still rampant. After qualifying, he used £400 from his future father-inlaw to buy a West End practice, but soon took on the first of his three new careers.

Wakley the editor In 1823, aged only 28, he launched a new medical journal, the Lancet. His goals were to inform and to reform. Without seeking permission, he printed verbatim reports of lectures by medical teachers. Leading surgeon Sir Astley Cooper took the public airing well. Not so his colleagues. A few London practitioners were earning large fees from the compulsory lectures they gave to students. They did not fancy seeing their teaching on sale for sixpence a week; they also resented seeing their inadequacies exposed in print. Further, these same powerful men channelled the choice teaching posts to relatives and friends. Even Sir Astley Cooper made no bones about it when he listed the surgeons of a London hospital: “Mr Travers was my apprentice, Mr Green is my godson, Mr Tyrrell is my nephew, Mr Key is my nephew, Mr Morgan was my apprentice.” Wakley wrote in the Lancet: “The manner in which the appointments are managed is the most nefarious . . . ignorant pretenders exclude men of sound talent.” Again without permission, he printed many pointed case reports from London hospitals.

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In 1825, a man was admitted to St George’s Hospital with pneumonia. While bleeding him, the dresser wounded the large artery in his arm. The man was placed under one of the surgeons, who consulted a physician. They agreed that the pneumonia was too severe to operate on the artery. Instead, they applied a tight bandage to the arm above the wound. The bandage remained untouched for three days, gangrene set in and the patient died. The verdict of the coroner’s jury: the man died from the “accidental opening of an artery and from the want of proper attention . . . ”. In reporting such cases, the Lancet fearlessly named all concerned. Over 10 years, Wakley fought ten legal actions. Except for the leniency of the libel laws, he might have spent a long time in jail or in bankruptcy. But he took in his stride the few verdicts that went against him. To further his medical and social reforms, Wakley took on two other roles: coroner for West Middlesex and MP for Finsbury — no, not instead of editing the Lancet, but as well as!

Wakley the coroner Wakley produced evidence of incompetence by coroners, which he blamed on the fact that they were not medically qualified. After being easily elected as coroner in 1839, Wakley insisted on holding inquests whenever the cause of death was in doubt. Frederick White, a private in the Seventh Hussars, assaulted his sergeant. On 15 June 1846, he received 150 lashes; on 11 July he died. After an autopsy, three army surgeons said, “The cause of death was in nowise connected with corporal punishment.” But a vicar reported the case to Wakley. After further examination of the disinterred body, the coroner’s jury overturned the army verdict and ruled that the death was indeed related to the flogging. Because of this verdict, flogging became rare, though it was not outlawed until 1881.

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Wakley the MP Soon after his election in 1835, Wakley made his mark in Parliament. He challenged the harsh penalties dealt out to six agricultural labourers in the Dorset village of Tolpuddle (the Tolpuddle Martyrs). Their punishment was transportation for seven years to New South Wales for “unlawfully administering a secret oath”. Their crime was forming a trade union and protesting at the reduction in their weekly wages from seven to six shillings! By presenting 16 petitions with over 13 000 signatures, Wakley won the release of all six men. He argued that legislators must correct the causes underlying social problems. Hence Wakley deplored any move to increase penalties for infanticide. His reason? The cause of infanticide was increasing illegitimacy, which was caused by the inability of the poor to marry, which was caused in turn by the gross inadequacy of wages for the labouring classes. During 1851 Wakley had a physical collapse and retired from the House of Commons. By 1861, he had tuberculosis. The next year, while convalescing in Madeira, he coughed up a lot of blood and died. S. Squire Sprigge sums up Wakley’s medical reforms: In 1823, when the “Lancet” was founded, there was no Medical Act either protecting the public or regulating the medical profession; nepotism was the one prevailing force at the metropolitan hospitals; favouritism determined all official appointments and elections; the horrible trade of the resurrectionist was thriving; and the provisions for medical education were disgraceful. Within forty years the hospitals of London had resolved that . . . their staffs must have merit; the Anatomy Act had abolished the resurrectionist; the Medical Act had met many of the crying grievances of the profession; and the London medical student was receiving a magnificent education. To obtain this education he had no

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longer to pay exorbitant fees; and to become in turn a teacher and a hospital official himself he had to buy out no predecessor. In the fight for all these reforms, Wakley led the way.

(GB)

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Chapter

MEDICINE

4

AND

THE ARTS

SOMERSET MAUGHAM’S DARK SECRET When William Somerset Maugham died in 1965, he was the most widely read author of his day, a qualified doctor with no practice, but about 24 published novels, 24 plays and over 100 short stories to his name. Robert Maugham was solicitor to the British Embassy in Paris when his fourth son, William Somerset, was born in 1874. Robert was short and ugly, while Maugham’s mother, Edith, was lovely. Their nicknames? Beauty and the Beast. The young Maugham told wonderful stories and made up games to play with friends. His mother died of tuberculosis when he was still a boy; he kept her photograph near his bed for the rest of his life. Two years later, his father died of grief and cancer. Now the family was poor. Maugham’s brothers were all in England. What was to become of 10-year-old William?

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His mother’s maid took him to England, but Maugham knew little English. Later he described himself standing on the quay at Dover vainly calling out “Porteur. Cabriolet!” Maugham was wished onto his childless aunt and joyless uncle who lived in the gloomy port of Whitstable in Kent. At once they sent away the maid, his only link with his happy childhood in Paris; he found himself a stranger in a strange country. His aunt and uncle were no happier to have him than he was to live with them. They were unused to children and thought him sullen. Actually, he was very shy; his stammer got worse in England. At the King’s School in Cambridge he was an outsider, ridiculed because of his speech impediment. Once he had to go back to the end of a long queue at Victoria Station when he could not tell the ticket seller where he wanted to go. In 1890, a chest infection, probably tuberculosis, interrupted his schooling. While convalescing on the Riviera, he enjoyed French literature and the short stories of Guy de Maupassant, which he later emulated. On his return, he responded to family pressure and became a medical student at St Thomas’s, the teaching hospital of South London. Polite society, including his Christian uncle, preferred to ignore the seamy side of life which Maugham saw as a student. In 1895, with a midwife, he attended 63 home confinements in the slums of Lambeth near the hospital. From this came his first novel, Liza of Lambeth, published even before he graduated. It is a simple, tragic love story, set among the Cockneys Maugham had observed. Though he gave up medicine and turned entirely to writing, Maugham said that his medical training had been vital for his writing. Indeed, he spent his life observing and describing his fellow humans in a clinical, detached way. Though he himself remained withdrawn, Maugham did reveal himself in his works. He wrote an autobiographical novel, Of Human Bondage, about his unhappy childhood. The young hero of that book had a clubfoot, while Maugham himself had suffered similarly from his stammer. By 1908, Maugham had four plays running in the West End.

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During the First World War, he was nearly killed by a shell at Ypres. He worked in the ambulance service and described the injuries with which they dealt: “There are great wounds of the shoulder, the bone all shattered, running with pus, stinking . . . gaping wounds in the back . . . where a bullet has passed through the lungs.” Maugham met Gerald Haxton, a handsome, dashing young American. He also turned out to be a wild gambler and alcoholic, excluded as undesirable from England. Haxton became secretary and close companion to Maugham. In 1916, Maugham and Haxton sailed to the South Seas. A Miss Thompson was on the same steamer from Honolulu to Apia. A quarantine inspection delayed them and all the passengers had to spend days cooped up together in a scruffy lodging house. The constant rain kept pounding on the corrugated iron roof. This meeting led to Maugham’s famous story Sadie Thompson, later renamed Rain, which led to several film versions. Later, in the war, Maugham spent two years on secret government missions. He went to Russia and saw the politician Kerensky. Maugham’s mission? Nothing less than to prevent the Bolshevik revolution and so keep Russia in the war. Later he drew on these experiences in his stories about the secret agent Willie Ashenden. Maugham used many people whom he met as a foundation for his writing. Indeed, fact and fiction, he said, were closely interwoven until he no longer knew which was which. I find it striking that some biographies fail to mention Maugham’s bisexuality. In his day, gays stayed in the closet. Society’s attitude was: “Men who are like that shoot themselves”. Maugham had been 22 when Oscar Wilde was tried in 1895. Wilde then spent two years doing hard labour in Reading Gaol and died soon after. An ambitious author like Maugham could not afford to rock the boat. At the age of 42, Maugham married the divorcee Syrie Barnardo, daughter of Dr Barnardo. They had a daughter, to whom he was a poor father: “I have a notion that children are all the better for not being burdened with too much parental love.”

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Syrie could never dislodge Haxton (whom she called “a liar, a forger and a cheat”) from Maugham’s affections. They divorced in 1927. Much later, when Maugham was 80, they met again by chance. Syrie said their divorce had been a sad mistake. He replied that their mistake had been to marry in the first place: “The tragedy of love isn’t death or separation. The tragedy of love is indifference.” So why had Maugham married at all? “You see, I was a quarter normal and three-quarters queer, but I tried to convince myself it was the other way around. That was my greatest mistake.” At his daughter’s wedding, Maugham found the groom “a most beautiful young man”. In 1944, aged only 53, Haxton caught tuberculosis and drank himself to death. Maugham was heartbroken. Later he found a new lover and secretary, Alan Searle. Maugham had to bear the lifelong contempt of his older brother Frederic, who rose to become Lord Chancellor. Frederic shared the common view of gays; moreover, in polite society, writers, especially writers of fiction, had no social standing. Interestingly, Frederic’s own son was Robin Maugham, who became well known as a gay author and even wrote about his uncle. Public opinion was kinder than the critics to Maugham’s reputation. Maugham himself said that in his 20s, critics had called him brutal; later in his 30s, they called him flippant, then cynical, then competent and finally superficial. At his villa on the French Riviera, he entertained people like Winston Churchill, Max Beerbohm, Noel Coward and General Eisenhower. But as he grew older, he grew more bitter. Maugham had undignified public battles not only with his ex-wife Syrie, but also with his daughter Liza. At 91, he told his nephew Robin, “You know, I’m at death’s door. But . . . I’m afraid to knock . . . Dying is a very dull, dreary affair. And my advice to you is to have nothing whatever to do with it.” Maugham died in 1965. (GB)

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AND GIBBON: THE UROLOGICAL VAGARIES OF TWO FAMOUS PATIENTS

PEPYS

(Adapted from the Harris Oration given to the Australasian Urological Society in 1986) The therapeutic arsenal available to the medical practitioner of two or three hundred years ago was pretty small. There was bloodletting, often to virtual exsanguination, especially if you were a VIP; the application of leeches in unspeakable places; clysters (or enemas as we now call them) which usually contained the leaves of exotic plants, the stomach contents of a rare Eastern animal, or some other impossibly expensive or unobtainable compound; blistering; poultices; and precious little else. Surgery did exist but was almost completely confined to the tapping of fluid from various body cavities (or paracentesis, to give it its proper name) and the much more dramatic surgical tour de force of lithotomy, or cutting for the stone. This later was a gruesome procedure used to deal with the then apparently fairly common condition of bladder stones. If the instruments used were new then not only were they sharp but comparatively sterile (well, clean) so your chances of survival were markedly better. It must be admitted, however, that because the surgeons had so few procedures on which to hone their art, they were well practised at those which they did perform, and they operated with speed and dexterity as well as with a certain dramatic flair. If you did come through the ordeal, then the bonus was that you had a story with which to regale your friends for life. It was the coming through that was the problem. Two famous men of letters of the seventeenth and eighteenth centuries each endured one of these two surgical procedures associated with the urinary tract, and have left written memories of

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the experience for us all to read and wince over. So let us for a time abandon our cosy world of gene manipulation, organ transplants and cardiac monitoring and enter a period of frontier-style and folksy medicine with no anaesthesia, no knowledge of infection and little caring finesse, and see what happened to each of these men when their different diseases were surgically treated. Follow me, then, back past a few genito-urinary landmarks: past, for instance, the 1930s when Harry Harris was pioneering surgery on the prostate in Sydney, and getting a world reputation for himself by so doing; past 1895 when Harrison did the first vasectomy on a human; back past 1829 when Ashley Cooper did the first vasectomy of all — on a dog (I am glad that was the order of events). Let’s keep going on past 1812 when Napoleon was reported to have lost momentum and paused fatally at the gates of Moscow while he got over an attack of renal colic caused by kidney stones. We can give a sideways glance at the First Fleet in 1788 under Captain Phillip while we dash through the reign of George III, a monarch who noted three times in his 80 years that his urine had turned blueish red on standing, a clue which led to the proposal that his so-called madness was a result of porphyria, a rare metabolic condition with renal manifestations. And we can keep going past Queen Anne, who at the time of her death was so swollen with dropsy from kidney disease that she had to be buried in an almost square coffin. So into seventeenth-century England, specifically London, at last descending by passing over the Great Fire and Plague to alight gently from our time capsule in 1658, specifically on 26 March, the day on which Samuel Pepys was cut for the stone.

Samuel Pepys Pepys was born the son of a London tailor in 1633. His mother’s brother was a butcher, and other relatives were “in trade”. But he overcame this despised and downmarket background to become, in

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his time, England’s first Secretary of the Navy; Member of Parliament for Howich; graduate of Cambridge University; Master of Trinity House; Baron of the Cinque Ports; Master of the Clothier Company; President of the Royal Society; confidant of kings and at ease in any company the cream of seventeenth-century England society could produce. In 1655 he married a 15-year-old Irish girl, Elizabeth. She was said to be untidy, profligate and quarrelsome, though Samuel thought she was a full-bosomed beauty — few were better judges of female charms than he — and “very good company when she was well”. Mind you, in her husband she had a lot to put up with, and a little peevishness could perhaps be excused on the grounds of provocation. It seems that she also suffered from painful periods, or dysmenorrhoea. She died at the early age of 29 “from fever”; unspecified, but malaria was endemic in England at the time and could have been the cause. Samuel Pepys himself, of course, is best known for his diary which he began on 1 January 1660. This, you will note, is two years after the date of his operation. The rigour of the surgical experience was never far from his mind, for, following the operation in 1658, he resolved thereafter always to celebrate its anniversary. And, sure enough, on 26 March 1660 he records, “This day it is two years since it pleased God that I was cut for the stone at Mrs Turners in Salisbury Court. And did resolve while I live to keep it a festival as I did this last year at my house, and for ever to have Mrs Turner and her company with me.” Salisbury Court, incidentally, is a short street near St Bride’s Church, off Fleet Street. Pepys was born in the street, and the novelist Samuel Richardson wrote his groundbreaking book Pamela while living there about a hundred years later. It is now packed with office blocks with no sign of any of the old houses. Two years to the day after this first entry, the diarist wrote, “Up early, this being by God’s blessing the fourth solemn day of my cutting the stone. At noon came my good guests. I had a pretty dinner for them, viz. a brace of stewed carps, six roasted chickens,

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and a jowl of salmon hot for the first course; a tansy [a kind of herb] and two neat tongues and cheese second, and we’re very merry all afternoon, talking and singing and piping on the flageolet. We had a man cook to dress the dinner and sent for Jane to help us.” One feels he should have added “And so to bed”, but he did not. Anxiety regarding the presumed calculus, or stone, started in 1653 while he was an undergraduate at Cambridge. He had been walking with a friend on a very hot day, eventually to arrive at a well where he downed copious draughts of cold water. Soon after returning home, Pepys suffered a severe attack of renal colic. After two or three very uncomfortable days the pain eased as the stone passed into the bladder where it remained. Knowing the mortality of surgical intervention to be about 20% at the time, sufferers did not lightly undertake to have the offending stone removed in case the treatment was much worse than the complaint. So it was left well alone. After five years of indecision with recurrent bouts of pain, enough was enough, and Pepys enlisted the aid of Thomas Hollyer to remove the irritation. Hollyer was surgeon and lithotomist to St Thomas’s Hospital, then situated in Southwark on the south side of the Thames, and a man who had been said to have cut 30 persons in one year without one death. Regrettably, the next four went to meet their Maker straight from the operating table. As I say, I think the mortality was a matter of how old and contaminated the instruments were, rather than any lack of surgical dexterity. Nonetheless, to be the next in line after this must have been an unnerving experience for all concerned. The method of doing the job is well recorded, and for the nonurological minded and for those who have finished their lunch, let me briefly describe the procedure. The patient was placed on a table with the head raised and the buttocks projecting beyond the end. The legs were flexed at the knees and held securely in that position with the aid of a rope. The resulting position was as inelegant then as it is today when used for some gynaecological operations. Indeed, it is still called the “lithotomy” position on such occasions, in

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memory of its original use. It comes from the Greek lithos, meaning a stone and tomia, cutting. Two or three assistants held the patient securely as movement at a critical moment may have resulted in a castration rather than a lithotomy, which was certainly not the object of the exercise. Some sedation was then administered in the form of extract of mandrake root or solution of opium. This usually proved to be so inefficient that it was administered more to stiffen the surgeon’s resolve than to mollify the victim. The actual operation involved either inserting the finger into the rectum to steady the stone, or pulling it down to bulge at the skin area in front on the anus, the so called “perineum”. This skin was then incised and the stone either flicked out or seized with forceps. There was an alternative and more refined method in which a grooved staff was passed down the passage from the bladder to the outside, or urethra, until it reached the neck of the bladder. When the staff was felt in the perineum the surgeon cut down onto it, entering his knife in the groove and carrying it up to its end in the bladder entrance. The stone was then located and pulled. The skill lay in the rapidity with which the operator could locate the calculus and get it out; in practised hands it took less than a minute. But whatever method was used and however quick, the whole affair must have been terrifying and gruesome, and well worth celebrating each year with salmon jowls, stewed carp and the like. The stone removed from our hero was two ounces (about 56 grams) by weight and after five years rolling around in the bladder had reached the size of a tennis ball. That, of course, refers to the tennis ball used in “real tennis”, a lesser size than that used in the “lawn” tennis today, you will be relieved to know. All this is public knowledge because a fellow diarist, John Evelyn, saw it when he took Pepys along to cheer up his brother who was also affected by a stone and understandably hesitant over surgery. Pepys showed the sufferer the offending pathological specimen and encouraged him to go through with the operation.

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The concretion itself was kept for years by the smug owner as a kind of talisman. Indeed, he had a special case made for the object, the better for its display. It seems he showed it off as a nineteenth-century Heidelberg student would a duelling scar — with insolent pride. Despite the visible reward of the surgical virtuosity (though truth to tell most lithotomists kept a spare stone about their person to cheer up wrung-out patients in case of failure), Mr Pepys continued to suffer from renal colic for the rest of his life. Not unreasonably, he did not feel up to another dash on the operating table, and he tried to ward off attacks by the much more harmless expedient of keeping a hare’s foot in his pocket. Success from this was equivocal until it was pointed out to Samuel that the charm was not working efficiently because it was lacking a joint. When this was rectified the ever honest diarist recorded, “I no sooner handled the foot but my belly began to be loose and to break wind, and whereas I was in some pain yesterday, and in fear of more today, I became very well and so continued.” He seems to have got his vital systems mixed up. When Pepys eventually died aged 70 in 1703, his left kidney was found to be disorganised and contained several calculi linked together and weighing a total of four ounces (about 113 grams). Samuel Pepys never sired any children, despite his well-recorded sexual athleticism. It is thought that during the operation the tubes which carry sperm from the testes, or vasa deferentia, were injured, thus rendering him sterile, but certainly not impotent. When he crossed his legs for any length of time he got a mild inflammation in the upper part of the tubular system of the testes, a condition called epididymitis. This caused some discomfort and was a source of innocent merriment to those of his friends in on the secret. He described it with less than politeness in the diary. A cold snap in the weather would also bring on perineal pain. It has also been claimed that his more or less constant state of sexual excitation was due to the continual irritation of the perineal scar. So when all else fails, have a lithotomy.

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There are still in existence two prescriptions given to the distinguished patient after the operation. The main constituents were lemon juice and syrup of radish; rather insipid additives by the rip-roaring Restoration standards of the day, I would have thought. In 1662 Pepys dined at the Chirurgeon’s Hall in London and saw for himself the anatomy of the genito-urinary tract laid bare in a dissected and preserved specimen from, as he says, “a lusty fellow, a seaman who was hanged for robbery. I did not touch the body, but me thoughts it was a very unpleasant sight.” He stopped writing his diary in May 1669 because he thought the concentration was affecting his vision. It was put down in a kind of cipher and the code was not cracked until a translation appeared in the 1820s. In the 1 250 000 words of his diaries Pepys recorded great social events as well as details of his day-to-day living. He never seemed to suffer a dull moment and this curious, hardworking, pleasure-seeking and lithotomised man produced not just diaries but supreme works of literary art.

Edward Gibbon Exactly the same can be said of the second famous patient, for he wrote what is, I suppose, the definitive book on history in the English language; the yardstick by which similar works are measured. So come forward with me a hundred or so years from the time of Pepys and into the eighteenth century, a period redolent with the names of many great pedagogues — Newton, Defoe, Swift, Goldsmith, Johnson, Boswell, Pope, Reynolds, Handel. Follow this line and towards the end of the century you arrive in the presence of another massive intellect, Edward Gibbon, author of the Decline and Fall of the Roman Empire, England’s greatest historian and our second patient. His medical history is more quickly told, for, unlike Pepys, Gibbon was a self-effacing and self-conscious man. Indeed, for

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32 years up to 1793, the year before he died, he deluded himself into thinking that he had kept secret a physical condition which, with the skin-tight trousers and cut-away coats then fashionable, was in fact obvious for all to see. For Gibbon had a hydrocoele, a pathological condition of the scrotum which produces a fluid accumulation in that organ. The point in selecting this particular hydrocoele for mention is not because of its intimate association with a famous sufferer, but the fact that it was not just any old hydrocoele, but one of such monstrous proportions that it hung to its distinguished custodian’s knees, and has been freely canvassed as the biggest and best on record — a kind of Bradman among hydrocoeles. Edward Gibbon was born in Putney, then a village outside London, in 1737. His father was a man of means with the extravagant habits such wealth can bring. Of the seven children born to the Gibbons, Edward was the only one to survive to adulthood, this despite the fact that he was a weakly child and easily bullied by his schoolmates at Dr Wooddeson’s institution at Kingston. Later he went to Westminster School, but his attendance was fitful, as he spent much time either recovering from one illness or coming down with another. When he was 16 his health suddenly improved, his prostrating headaches vanished and he went up to Oxford. He never married, although at one time he did fancy a Miss Suzanne Curchod, but she dallied so long over making any firm commitment his passion faded and the moment passed. In any case, his father opposed the union, and Edward, perhaps with some relief, later wrote, “I sighed as a lover, but obeyed as a son.” If he had married, the story of the hydrocoele would probably never have occurred, for any self-respecting partner would have hurried him off to the doctor very early in the piece. In the event its record-breaking presence of over 30 years’ standing was ultimately revealed to Lord Sheffield, a close friend of Gibbon, in a beautifully circumlocutory letter from the overburdened wretch. It reads in part, “Have you ever observed, through my inexpressibles [the word trousers was quite taboo] a large prominency circa genitalia, which,

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as it was not at all painful and very little troublesome, I have strangely neglected for many years?” What grace and finesse! What sensitivity and how humble! No-one’s aesthetic sensibilities could possibly be injured. Sheffield, on the other hand, was much more downright and forthright. A Dr Farquhar was summoned who in turn called out Mr Cline, the surgeon. The mass was viewed, prodded, walked round and wondered at. It was pronounced a hydrocoele and drainage was recommended before a barrow became necessary to support it about town. So 4.5 litres or eight pints was withdrawn by the surgeon on 14 November 1793. This is about the capacity of the largest cardboard wine cask. The swelling was diminished merely by half, but what remained formed a soft irregular mass, which puzzled the attendants. Evidently, there was more there than the fluid. Two weeks later a second tapping was assayed, and although this effort was more probing and more painful it produced only 3.4 litres. This is not the stuff of which records are made, so more rest was ordered to see what would happen. Events took a turn for the worse, for a few days later the area became painful and movement difficult. Inflammation appeared and Gibbon became feverish. On 13 January 1794, although the mass was now ulcerated, a third tapping was undertaken and 6.8 litres or 12 pints withdrawn, making a grand total of 14.7 litres. That’s more like it. But regrettably it was all too much, and on 15 January pain returned. The following day the peerless Edward Gibbon suddenly collapsed and died. So it appears that he originally had two conditions, the fluid accumulation and the softish mass of a hernia which was undetectable behind all that liquid. As he lived a quiet life, was of a placid nature, took no exercise and had an unruffled mind, he was never incommoded by the growing monstrosity. The tapping had almost certainly introduced infection and the distinguished historian died of complications from this, namely peritonitis and septicaemia, and not the hydrocoele per se.

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A postmortem was done by Cline. He noted that the tumour extended from groin to knee. The upper part was occupied by globules of fat normally fixed to the bowel (the omentum), as well as the greater part of the large bowel itself. In parts these areas were gangrenous. The stomach, usually located under the ribs in the upper abdomen, was in the groin at the entrance to the hernial sac. Cline rather laconically concluded his report by stating that the other viscera seemed to be in a perfectly sound condition. In truth there was precious little left to display pathology; I wonder what he wanted for his money. In passing, Henry Cline was later to be tutor of that other distinguished man of letters, John Keats, while the poet was a medical student at St Thomas’s Hospital, London. Edward Gibbon was a cultivated man who wrote in the grand style of the century in which he lived and withal affected an air of learned and untroubled candour. When the first volume (of six) of his magnus opus appeared, Horace Walpole, despite a prostrating attack of gout he was enduring at the time, was moved to observe, “Lo, there has just appeared a truly classic work . . . The style is as smooth as a Flemish picture . . . ” The opening paragraph is compelling and immediately awakens interest, and in part reads “. . . the Empire of Rome comprehended the fairest part of the earth, and the most civilised portion of mankind. The frontiers . . . were guarded by ancient renown and disciplined valour . . . Their peaceful inhabitants enjoyed and abused the advantage of wealth and luxury. The image of a free constitution was preserved with decent reverence.” He closed his life’s work when he wrote in 1787 words which proved to be prophetic: The present is a fleeting moment, the past is no more; and our prospect of futurity is dark and doubtful. This day may possibly be my last; but the laws of probability, so true in general, so fallacious in particular, still allow about fifteen years [in the end it turned out to be seven]. I shall soon enter into a period which, as the most agreeable of his long life, was selected by

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the judgement and experience of the sage Fontenelle . . . in which our passions are supposed to be calmed, our duties fulfilled, our fame and fortune established on a solid basis . . . and this autumnal felicity might be exemplified in the lives of Voltaire, Hume, and many other men of letters. I am far more inclined to embrace than to dispute this comfortable doctrine. I will not suppose any premature decay of the mind or body; but I must reluctantly observe that the two causes, the abbreviation of time, and the failure of hope, will always tinge with a browner shade the evening of life.

He was 57 when he died. Let me debrief you now, and rapidly bring you back into the twenty-first century. On its return, our time machine has been programmed to set you down at the entrance to Tower Hill underground station. Let the family go and visit the Tower standing by the river in front of you. For your part, turn and walk towards Fenchurch Street, into Seething Lane and then Hart Street. There, in a small well-manicured garden, you will see a plaque set beneath a tree. It simply states that Samuel Pepys worked and lived on this site three hundred or so years ago. The site is now a green oasis in the bustling heart of the City of London. If you turn and look diagonally across the road you will see the church of St Olaves, tucked away between towering office buildings. In it are buried Samuel and Elizabeth Pepys and busts of their likenesses can be seen there. The skulls on the gate of the church signify that it was used as a burial ground during the Great Plague in 1665, a fact recorded by Pepys. As the Great Fire was blown away from the building, the church was spared, as was Pepys’s house and the Navy Office. They were razed in another conflagration about 20 years later when 30 houses, including theirs, were destroyed. Leaving the family still queuing to look at such hackneyed attractions as the Crown Jewels, Henry VIII’s armour and the tame ravens, be more discriminating and go west to St James Street near

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Piccadilly in the heart of London’s clubland. Seek out number 76, for it was here that poor Edward Gibbon died. Incidentally, to add to the lustre of the address, a few years later here too lived Lord Byron. Having done all that, and as you go back to rejoin the rest of the world, you can look back and reflect on two people who actually existed, and who laughed and loved and were curious and bore grudges, but who, perhaps above all, despite their pre-eminence in contemporary society, were subject to urological ailments, insults and vagaries just like you and me. (JL)

WHAT

KILLED

MOZART?

It was with the appearance of Peter Shaffer’s play, Amadeus, in 1979 that the once widely held supposition that Mozart had died of poisoning again came to public notice. — M. Keynes, “The personality and illnesses of Wolfgang Amadeus Mozart”, Journal of Medical Biography It may prove difficult to dissuade the public from the current Shafferian view of the composer as a divinely gifted drunken lout, pursued by a vengeful Salieri. — H. C. Robbins Landon, 1791: Mozart’s Last Year

Despite the spilling of gallons of ink, doctors still disagree about Mozart’s various illnesses and especially about the cause of his death. Wolfgang Mozart was born in Salzburg on a freezing January day in 1756. Of the seven children born to this family, only two survived to adulthood. His father, Leopold, was a scholar, distinguished violinist and composer who also directed the orchestra of the Archbishop of Salzburg. Mozart began to play the harpsichord at three; at five, he had mastered the violin, composed an andante and allegro and given his

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first public performance. At six he played at the imperial court of the Empress Maria Theresa. Leopold paraded Mozart and his sister Maria Anna on an extended tour of European courts. A nobleman wrote: “We fall into utter amazement on seeing a boy of six at the keyboard and hear him play . . . like a grown man, and improvise moreover for hours on end out of his own head . . . I saw them cover the keyboard with a handkerchief; and he plays just as well . . . ” Soon Mozart was in London playing for King George III and meeting J. C. Bach. He performed at court, in public and in churches. At 13, he toured Italy, where Pope Clement XIV made him a Knight of the Golden Spur. As a child prodigy, Mozart lapped up attention. But there was a downside: travel by draughty unheated carriages over rough roads with overnight stops at dodgy inns. Some believe that these hardships affected his health. As he grew up, the establishment did not respond to him as warmly as before. Mozart quarrelled with his employer, the PrinceArchbishop of Salzburg. Finally, in 1781, the archbishop sacked him. For most of his remaining ten years, Mozart had neither a regular post nor a regular income. “To the end of his life he was convinced that he would find a good and profitable post . . . to the end of his life he was wrong.” (McLeish & McLeish, 1978) How much longer, happier and even more productive might Mozart’s life have been if he had enjoyed a regular income? Basing himself in Vienna, he became a freelance artist. He earned enough to live, but lived beyond his means. To make ends meet, he borrowed money, sold his compositions, played piano and violin at many concerts, taught piano, and arranged dance music and salon pieces. In 1782, he married Constanze Weber; his loving but domineering father, Leopold, disapproved of this choice. Only two of their six children survived infancy. Mozart had many friends and liked puns and practical jokes. But some people called him arrogant, capricious, tactless and spiteful. Was this because he had a chip on his shoulder when dealing with the privileged classes, which valued birth above genius?

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What of Mozart’s health? At six, he had some kind of rheumatic fever or scarlet fever. At least twice he also had feverish illnesses when his feet and knees were so painful that he could not walk. Once he nearly died of typhoid. When aged 12, he had an eruptive fever, diagnosed as smallpox, which left him with pock marks on his face. Later he had a recurrent sore throat and pain that may have come from his kidneys. In 1784, he had rheumatic fever for six weeks. Some writers state that ill health and overwork sometimes made him depressed. Others say he must have been healthy, since he managed to compose almost 300 works between 1780 and 1790. But in late 1791, he fell sick with weakness, pallor, pain in the loins, depression and paranoid delusions. On 20 November, he told Constanze that the famous “Requiem” (which he never finished) was for himself and that he was being poisoned. But there is little to suggest that Salieri (or anyone else) poisoned Mozart. The repeated bleedings and vomiting induced by his doctors may have hastened his end. Over his last 15 days, he had fever, painful swelling of the hands and feet and then vomiting, diarrhoea, and what he called the taste of death on his tongue. Constanze crawled into his bed, hoping in vain to catch his illness and join him in death. Even the four doctors who signed his death certificate could not agree on the cause of death and there was no postmortem. Nowadays one popular diagnosis is recurrent rheumatic fever with heart failure. But there have been over a hundred others which include blood poisoning, severe kidney failure, typhoid, typhus, meningitis, an overactive thyroid gland, syphilis, and poisoning with mercury or antimony. About his musical genius there is no dispute; he excelled at every medium of his time. Many critics honour Mozart as the most universal composer in the history of Western music. Though he died before turning 36, he left us over 600 works. Many regard Don Giovanni as the world’s greatest opera. His seven piano concertos make him a pioneer of this form. But no mourners went with his funeral wagon to the cemetery

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where he was buried in an unmarked common grave. Visitors today can still see a skull, said to belong to Mozart, at the Salzburg Mozarteum. (GB)

ROBERT LOUIS STEVENSON

AND

HIS CHEST Robert Louis Stevenson was an adventure storyteller, South Sea traveller and chronic invalid. A consummate writer, yet an odd man, who, while doggedly pursuing relief from his presumed tuberculosis, at the same time appears to have seen his invalidism as a merciful preparation for death. He once wrote, “I have wakened sick and gone to bed weary. I have written in bed, written out of it, written in haemorrhages, written torn by coughing. My case is a sport. I may die tonight or live till sixty.” He actually died in 1894 at the age of 44 and not, in the end, from tuberculosis, but from a sub-arachnoid haemorrhage or haemorrhage onto the surface of the brain. Stevenson was born in Edinburgh in 1850, the only son of a lighthouse engineer and tubercular mother. He was a frail youth whose precarious physical state made regular schooling difficult. Nonetheless, he went on to Edinburgh University to study engineering, but then transferred to law, becoming an advocate in 1875. He never practised his profession, but pursued his true inclination — writing. A wandering lifestyle in search of a healthy climate followed. At first, any benefit gained was offset by his impoverished lifestyle and the writing he carried out was punctuated by bouts of pneumonia, pleurisy and coughing up blood. His roamings took him mainly to France, where, among other pieces, he wrote Travels with a Donkey. In 1876, while still in France, Stevenson met an American divorcee, Fanny Osbourne, whom he followed to America and eventually married in 1880. The pair travelled extensively together,

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and the masterpiece which at last brought him fame in 1883, Treasure Island, was written while oscillating between Scotland and Switzerland. Struggling with his ailments, he and Fanny doggedly chased the sun and warmer climes, eventually deciding to settle in the South of France. They could not seem to take a trick, though, as insult was added to injury when a cholera epidemic drove them out. Bournemouth in the South of England was the nearest they could find to an equitable and harmonious existence. Paradoxically, it was during the three years spent there (1884–86) that Stevenson was both at his most consumptive and literally productive. So marked were his chest symptoms that his doctor forebade the author to speak aloud for fear of precipitating a bleed. I suppose at least this allowed him to get on uninterrupted with Kidnapped and The Strange Case of Dr Jekyll and Mr Hyde which emerged from that period. Jekyll and Hyde was written in three days of frenetic activity. The author destroyed the first draft, but immediately rewrote it and corrected another 30 000 words written, of course, in longhand in three more days and nights. It seems that for him the fire which wasted the body made the mind shine with brighter light. Or was it something else; his treatment, perhaps? Even the bacterial cause of tuberculosis, let alone specific therapies, were unknown at that time. Opium, or its alcoholic tincture, laudanum, was commonly given for cough suppression. This certainly gave symptomatic relief, but significantly in the kind of author Stevenson was, it also gives a relaxed mind, and allows flights of fancy. We know for certain that Stevenson took morphine, for in 1884 he wrote, “. . . the morphine I have been taking . . . moderates the bray, but I think sews up the donkey”. But there is more to it than that. In the July 1885 edition of the highly regarded medical journal the Lancet, the newly researched drug cocaine was given an enthusiastic write-up, especially as a cure for hay fever and asthma. In September it got a further warm appraisal as an application to the larynx for chronic cough. Now we know from her son, Lloyd Osbourne, that Fanny

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Stevenson was an avid reader of the Lancet. Together with Robert’s doctor, Thomas Bodley Scott, she could well have persuaded the invalid to take the new drug as a therapeutic trial for his chronic cough. Little was known at the time of its side effects, but perhaps significantly two months after the Lancet article appeared, during September 1885, the chilling story of Jekyll and Hyde was written. As we have seen, this was during a period of unsurpassed psychic energy, and quite possibly the author’s drug intake may have been at the bottom of it all. It is also worth noting that in the story Jekyll takes a powder to transform his personality: cocaine came in that form. As is well known, Sherlock Holmes, Conan Doyle’s fictional master sleuth who appeared on the bookstalls at a slightly later date than Stevenson’s work, took cocaine throughout much of his illustrious career. Conan Doyle was a general practitioner in Southsea near Portsmouth and presumably knew all about the new drug which was quite the rage in the 1880s and 1890s. The odd thing is that normally Stevenson was a brilliant and sensitive writer of adventure stories, whereas Jekyll and Hyde uncharacteristically belongs to a different and more brutal genre. Was it written under a different driving force? Who knows? Eventually, Robert’s ill health forced the Stevensons to leave Bournemouth. In 1887 he and his wife went to America and in 1888 to the South Seas, wandering from place to place before finally settling in Valmia, Samoa. The balmy climate suited the author and on 3 December 1894 he was working on The Weir of Hermiston, a book which some contend may have become his masterpiece. That night Stevenson got up from the dinner table, cried, “What’s that?” and clutched his head. With a sub-arachnoid haemorrhage a small blood vessel situated at the base of the brain ruptures and often the sufferer describes a sudden crashing noise in the head. I am sure that was what the writer was experiencing. The condition is commonly fatal and in fact Stevenson died within the hour from this cerebral bleed.

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There is one oddity about the great man’s condition, which troubled Dr Livingstone Trudeau, a tuberculosis expert with whom Stevenson lived for a short time in New York State. If the writer’s consumptive condition was as putrescent as history would have us believe, how was it that he lasted for as long as he did? Mind you, as has been observed, the genesis of tuberculosis was ill understood in 1893, but at least the existence of the tubercle bacillus was known and could be recognised under the microscope. Its identity had been first revealed to the medical world on 24 March 1882 when Robert Koch, the German bacteriologist and discoverer of the Mycobacterium tuberculosis, read a paper giving its details at the Berlin Physiological Society. Trudeau was aware of this and his scepticism about the severity of the writer’s malady was fuelled by the fact that he never found any of the diagnostic socalled “acid fast tubercle bacilli” in Stevenson’s spit. If his observations can be relied upon, it seems a pretty strong argument against that disease being the cause of his chronic ill health. Perhaps after all Robert Louis Stevenson was “a sport”, a one-off, as he used to claim. Or could there have been another cause for his persistent signs and symptoms, possibly bronchiectasis, a chronic low-grade and debilitating lung infection caused by a germ other than tuberculosis? We shall never know, but maybe in the end, all that enervating travelling was unnecessary. (JL)

THE

MACHO LIFE AND DEATH OF ERNEST HEMINGWAY

I still remember how thrilled I was as a teenager to read Ernest Hemingway’s short novel The Old Man and the Sea. But Ernest’s own life was as remarkable as his fiction; indeed, fact and fiction merge together. For instance, he boasted of sleeping with Mata Hari, whom he never even met. Anthony Burgess wrote: “Hemingway the man was as much a creation as his books.”

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Before he turned five, Ernest told his grandfather that he had singlehandedly stopped a runaway horse. The old man predicted that with such an imagination, the boy would become either a jailbird or famous. His father taught him to love the outdoors; Ernest got his first shotgun when he was ten. At school, he enjoyed football and boxing; the latter remained a lifelong habit. But at training he twice received a broken nose and an eye injury left him with a slight squint. Twice he ran away from both home and school. When the First World War broke out, he tried to enlist. When his eye injury debarred him from the army itself, he volunteered to drive an ambulance with the Italian army. He was in the Italian frontlines in 1918 when a shell landed only a metre away and riddled his right leg with shrapnel. Ernest, still only aged 18, carried a wounded soldier back to the first-aid dugout. The next three months he spent in a military hospital, where he won out against his doctors who wanted to saw off his leg. By his bedside he kept the 227 metal fragments they had removed. Ernest gave these to visitors as souvenirs. The two medals he had won he threw into the bowl “with the other scrap metal”.

Ernest returned to America as a hero but suffered nightmares and insomnia and was already drinking. During the 1920s, he suffered malaria, anthrax, a broken arm and an injury to his good eye. Aged 22, he married 30-year-old pianist Hadley Richardson. She admired his “boxing, fishing, writing . . . getting war medals . . . charm, good looks”. Ernest roamed Europe as a roving reporter for the Toronto Star and interviewed Mussolini. In Spain he began his lifelong obsession with bullfighting and bullfighters. In 1924, he risked life and limb in the running of the bulls through the streets of Pamplona. Later he used bullfighting as the background for Death in the Afternoon. By 1926, Ernest was having an affair with an American reporter,

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Pauline Pfeiffer, who became his second wife. In 1933, they spent five months on safari in Africa, where he bagged four lions, a buffalo and a rhinoceros. Back home, he caught a huge shark, but shot himself in the foot while gaffing it. In 1936, the Spanish Civil War broke out. Having seen Fascism in Italy, Ernest opposed Franco and sent $40 000 to the Spanish Republicans for medicines and ambulances. As a non-combatant war correspondent, he stayed at the Hotel Florida in Madrid. When a shell hit the hotwater tank at night, guests rushed out of their rooms. Among them were Ernest and Martha Gellhorn; Martha later became his third wife. But Pauline still wanted to save her marriage and threatened to kill herself when he asked for a divorce. By 1938, his drinking had affected his liver. He achieved a hit with For Whom the Bell Tolls, a novel based on the Spanish Civil War. When the USA entered the Second World War, Ernest wangled approval to arm his large deep-sea fishing boat with machine guns and chase German submarines. The crew carried grenades to throw down the conning towers of submarines; whether they even saw any subs is not clear. Either way, they carried enough booze to keep them happy. Soon Martha was complaining that they drank too much and washed too little. In 1944, he suffered concussion in London during the blackout when his car crashed into a water tank, but he slipped out of hospital and got a ride on a reconnaissance flight over enemy lines in France. Next he embarked with the American Fourth Infantry Division to cover the invasion of Normandy. The stories he sent to Collier’s magazine were “wildly inaccurate but full of life”. Though officially a non-combatant, he organised his own partisan group and defied the Geneva Convention by lobbing grenades into a cellar where Germans may have been hiding. Ernest’s irregulars got 60 miles ahead of the allied army, reached Paris before the Free French troops and then skirmished with the Germans. A military enquiry failed to convict him; indeed, Ernest won the Bronze Star. After his disastrous third marriage (to Martha) ended, he pined again for Pauline (“the best wife a man could ever hope to have”).

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I doubt whether even one of his four wives would have thus praised Ernest. Soon he fell in love with journalist Mary Welsh. When her husband opposed a divorce, Ernest emptied a machine pistol at his portrait. By 1947, he had high blood pressure. On a duck hunt in Italy, cartridge wadding hit him in the eye. Doctors saved the eye with penicillin, but he lost part of his vision. When reviewers panned his novel Across the River and into the Trees, Ernest threatened to crack their empty heads. He quarrelled with many of his fellow writers. Rather than discuss writing, he preferred to box or arm-wrestle them. He was also, to many minds, prejudiced against Jews. Next he was clawed while playing with a lion! In 1953, Ernest and Mary were lucky to survive a safari in Kenya. Depressed by Pauline’s death, he was still drinking heavily. They boarded a plane to see Victoria Falls, but a flock of ibises crossed their path; the pilot turned to avoid the birds, hit an old telegraph line and crashed. Sharing one bottle of water, one of Scotch and four beers, the trio spent the night in the open near a herd of elephants. The noise of the falls drowned out the sound of the search plane. The circling pilot saw the wreckage, but no signs of survivors; reports of Ernest’s death flashed around the world. But a passing riverboat picked them up. When they boarded another small plane (perhaps overloaded) this crashed and burst into flames. He butted the jammed door open with his head and injured shoulder. It was reported that Ernest ended up with a dislocated right shoulder, a fractured skull, a ruptured liver, spleen and right kidney, and first-degree burns. If all this were true, he could not have survived. Later he joked that his cracked vertebrae left him with a permanent erection. In 1954, Ernest won the Nobel Prize for Literature. But by now, he had high blood pressure, high cholesterol, alcoholism, liver damage and kidney problems as well as failing eyesight, diabetes and impotence. An unrealistic doctor told him to cut out alcohol. When a crew were shooting a film of the Old Man and the Sea,

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he insisted that they film a real duel with the biggest swordfish ever caught. They had to go to the Pacific and the film finally cost $60 million. Mary threw him a huge party for his 60th birthday. Ernest had a visiting bullfighter stand still with a lighted cigarette in his mouth. Then Ernest shot it out seven times with a rifle, the butt in the man’s mouth getting shorter each time. In 1960, Ernest slid into depression. He avoided his friends and would not even go to bullfights. “He had developed delusions of persecution and was frightened, lonely, guilty, full of remorse and drinking heavily.” Mary said: “He was . . . exactly the opposite of what he had been before — outgoing and exuberant and articulate and full of life . . . ” By now Ernest and Mary were threatening each other with guns. Four times he seriously attempted suicide before entering the Mayo Clinic for twice-weekly bouts of electroconvulsive (ECT or shock) therapy. Twice he entered the clinic, twice he talked his doctors into believing he was better and letting him go, even though Mary knew how depressed he really was. Ernest was asked to write just one sentence for a presentation volume to the new President John Kennedy. Despite a heartbreaking whole day’s struggle, he could no longer write. He blamed this writer’s block on the ECT. On 2 July 1961, while Mary was still sleeping, he went down to the basement, got out his favourite shotgun, came back up into the hallway (where Mary was sure to find him), put the double barrel into his mouth and blew out his brains. Did his long-suffering fourth wife Mary have a hand in this tragedy? Was she ambivalent about preventing his suicide? She locked all his guns in the basement but left the basement keys in the kitchen! All his life Ernest had suffered many near-fatal accidents and injuries. Is it fanciful to see these as self-destructive? His life combined genius, the unceasing need to prove his masculinity and a lust for life, but also an obsession with blood, weapons, killing and suicide.

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It is said that his mother had wanted a girl; she called him Ernestine and dressed him in girl’s clothes. Fellow writer Sydney Franklin wrote: “Ernest’s big problem all his life, I’ve always thought, was he was always worried about his Picha (penis) . . . the size of a 30/30 shell.” His reputation as a writer fluctuated wildly; he was praised in the 1920s but flopped in the 1930s. It rose again in 1940 with For Whom the Bell Tolls; another triumph was the Pulitzer Prize for The Old Man and the Sea. His terse, bare prose style was probably the most widely imitated (and most widely satirised) of any writer of English in his century. Meyers (1985) sums up Ernest the writer: “He created unsurpassed images of Italy, France, Spain and Africa . . . He wrote as naturally as a hawk flies and as clearly as a lake reflects.” (GB)

A VERY CLUBBABLE MAN: A MEDICAL HISTORY OF SAMUEL JOHNSON Boswell’s “The Life of Samuel Johnson L.L.D.” came out over two hundred years ago in May 1791, but despite its well-recognised scholarship and personal details it is mainly from other sources that we learn about the lifelong and burdensome ill health which oppressed the great lexicographer himself. Of his many pathologies, certainly the most interesting was the one which produced in him the involuntary jerky movements, uncontrolled vocalisation and compulsive actions which caused such consternation in his friends and discomposure in his foes. It is now thought to have been due to Gilles de la Tourette syndrome. But don’t let us get ahead of the story, so more of that later. Johnson was born in 1709 and defided convention from the start, for he was delivered by “a man midwife”, a very unusual

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health professional at the time, when midwives and handy women were the customary accoucheuses. As an infant he developed tubercular glands in the neck, or scrofula, caught, it was said, from his wet nurse. Contemporary thinking was that the one certain cure for the tuberculosis, or the King’s Evil as it was called, was to be touched by the monarch. So with this in mind, in 1712, at the age of 30 months, he was taken to London to see Queen Anne. In the event, Johnson became one of the last people in Britain to be so treated as the practice was abandoned shortly afterwards. The British Museum still has the medallion he was given by the Queen for a form of therapy which was as dramatic as it was useless. On one side the medal shows a ship in full sail and on the other side the Archangel Michael slaying a dragon. Johnson wore it all his life as an abiding testimony of the regal fingerwork. Naturally, the touching had little effect and the glands were eventually drained; the scar can be seen on his death mask. From early childhood it was obvious Samuel had poor eyesight. The contemporary treatment was to incise the left arm to allow the bad humours to escape. The wound was kept open by inserting a small foreign body, such as a pea. This treatment was as useless as the royal medallion, so our hero remained short-sighted all his life, and, amazingly for such a literary giant, had difficulty reading and never corrected his copy. It is said he often singed his wig bending too near the candle to make out the print. The portrait by Reynolds done in 1775 shows him squinting at a book held uncomfortably close to his face. Johnson was also hard of hearing, possibly a legacy of his incised scrofulous glands. He had a special pew near the preacher and was often heard to say, with some exasperation, “Louder, my dear Sir, louder, I entreat you, or you pray in vain.” His bouts of depression lead to morbid introspection and were so enervating that he often felt he was going mad. He referred to it as “a vile melancholy I inherited from my father”, and dreaded being carried off to Bedlam, the public “madhouse”. He entrusted his friend and confidant, Hester Thrale, with a padlock so she could

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lock him up and look after him privately if it came to that. He dreaded solitude and delayed returning home at night where he knew he would brood and be tormented by nightmares. Added to all this, for the last 40 years of his life he had chronic bronchitis and gout. So, in the end, the unedifying picture of a broken reed emerges, far removed from the usual picture of him portrayed as a bear-like, forceful, positive man, and a towering intellect taking his place among similar geniuses, including the likes of Pope, Hogarth, Garrick, Goldsmith, Reynolds, and alive at the same time as Mozart, Beethoven, Newton and Gibbon. He died of congestive cardiac failure in 1784 and packed a great deal of living into his 75 years. All that is pretty mundane and could have happened to any sociable scribbler, so let us hurry back to the fascinating clinical aspect of his life — his tics and gesticulations. Like many others on first acquaintance, Fanny Burney was shocked at Johnson’s behaviour and wrote: His mouth is almost constantly opening and shutting as if he were chewing. He has a strange method of frequently twirling his fingers and twisting his hands [skilfully depicted, incidentally, in the 1769 Reynolds portrait of Johnson]. His body is in constant agitation, see-sawing up and down; his feet are never a moment quiet . . .

Alexander Pope wrote, when his friend Johnson had been rejected as a schoolmaster, “He has an infirmity of the convulsive kind . . . so as to make him a sad spectacle.” Boswell also mentions how Johnson held his head to one side, shook and rubbed his left knee in a persistent circular motion. There are numerous descriptions of his repetitive movements, but they grew fewer over the years as people became used to them, and never did the movements interfere with his motor ability, or cramp his handwriting. The muscular movements were accompanied by grunts, clucking, sighing, whistling and continual talking under his breath, saying things like, “too, too, too”, or bits of the Lord’s

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prayer or verses from the classics or repeating snippets of conversation over and over again. The symptoms, especially this echolalia, were more pronounced when he was alone or in reverie. The sister of Joshua Reynolds records some strange habits such as always springing over a threshold as though to see how far he could stride. Or in company, while breathing hard, he would stretch out his arm while holding a full cup of tea, to the great discomfort of those nearby. He avoided the cracks in the pavement and touched every post in the street. If he missed one he would return to make good the error. It would seem that the picture to emerge is one of repetitive involuntary tics of limbs and head accompanied by vocalisation, but unimpared intellect. Although the well-known clinical feature of obscenities, or coprolalia, does not seem to have been very evident, it looks very much as though Johnson suffered from that well-known disease eponymously known as the Gilles de la Tourette syndrome. Some years later, in 1825, Itard described the strange case of a seven-year-old with involuntary movements and coprolalia (literally “talking faeces”). In 1885 Gilles de la Tourette described the same person who had “ticked and blasphemed” for 60 years. He was able to add eight other cases to his collection. The syndrome usually develops between the ages of five and ten and initially the rapid involuntary movements are characteristically round the eyes and are often complex and multiple. Later they occur in the limbs and torso. Sufferers learn to convert the movements into purposeful actions so they are less conspicuous. Johnson could do this. They are more marked in stress and disappear during sleep. Repeating words or phrases, so called echolalia, is common, but uncontrollable foul language is not universal. If the desire to utter obscenities does occur at socially inappropriate times, a growing inner tension is felt and privacy may be sought to relieve the stress; the so-called and diagnostic “lavatory coprolalia”. Tourette’s syndrome is not nowadays regarded as being particularly rare, but a commonly undiagnosed disorder genetically

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transmitted by a specific mutated gene, and which responds quite well to drugs such as Haloperidol. Boswell thought that Johnson’s habits were “of the nature of that distemper called St Vitus Dance . . . the description which Sydenham gives to the disease”. Joshua Reynolds thought them psychogenic, saying, “the great business of his life was to escape from himself . . . considered as the disease of the mind, which nothing cured but company”. Other modern writers have forwarded psychogenic theories, but it seems there is sufficient evidence to support the Tourette theory. Gilles de la Tourette himself was born in the French village of Saint-Gervais-les-Trois-Clochers in the Poitou district in 1855. He was a gifted child and studied medicine first at Poitiers and subsequently at Paris. He became a junior hospital resident of Jean Charcot, the great Parisian physician who is regarded as the founder of modern neurology. He went on to become a prolific writer in the field of neurology and psychiatry, as well as in art, literature and mesmerism. The young man was brash, forthright and unconventional, and in 1896 at the age of 41 was shot in the head by a paranoid patient (deservedly so, some thought!). Thereafter, his mood fluctuated between depression and hypomania and in the end he was stripped of his academic posts. He died in a mental home in 1904. All that, of course, was long after Johnson’s time, so there never could be a firm diagnosis of the eighteenth-century sage’s odd behaviour. Nonetheless, Dr Johnson was a remarkable man who, despite his multiple lesions, enjoyed life to the full in the remarkably illustrious company of his time. Between 1748 and 1759, while compiling his dictionary, he lived in Gough Square off Fleet Street. The house is still there and can be visited. It is just around the corner from his favourite eating place and debating chamber, the Cheshire Cheese, which is also still intact and still serving typical British fare. In it is displayed the chair in which the great man is said to have sat while holding forth with his friends.

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Samuel Johnson was regarded then, as he is now, with admiration and reverence, and it may be that the glittering intellectual stimulus in which he lived and revelled not only helped him to come to terms with his maladies, but provided the impetus for his greatness. (JL)

A

RAKE’S PROGRESS: A HISTORY OF JAMES BOSWELL AND HIS SOCIAL DISEASE

James Boswell was a man of his times, being at once urbane, cultivated, industrious, resilient, and the possessor of literary skills of a rare kind. But on top of all this diversity he had one further talent — he harboured an almost insatiable sexual appetite. In fact, it was of such a degree as to be regarded as remarkable even by the licentious standards of the eighteenth century in which he lived. He is, of course, better known for the biography he wrote of Dr Samuel Johnson than the details of his own life, but he was a compulsive and frank diarist and as such has left us a penetrating insight into the manners and morals of the era, more especially his own. In the genre of this book, one feature of those somewhat meretricious and priapic days about which he wrote is worthy of a closer look, for from it emerges not only his own rumbustious story but also the history of a medical and social condition which is usually kept veiled from decent society: gonorrhoea. Boswell was born in Edinburgh in 1740 in a gloomy alley within the shade of St Giles Cathedral on the one hand and the Tolbooth gaol (the “Heart of Midlothian”) on the other. His father was a lawyer who became a judge in 1754 and later became Lord Auchinleck. This was not a hereditary honour, so his eldest son, James, remained plain mister for the rest of his life. His mother was described as being extremely pious and was a

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key figure in James’s childhood. A staunch Calvinist, she instilled into the young lad stories of hellfire and the doctrine of the eternity of punishment with accompanying flames, rather than the bliss of heaven. So he was forever consumed by guilt about his subsequent sexual jousts. Fortunately for our story, he easily overcame such dark thoughts, and led a life untrammelled by any waves of high moral tone: nothing could stop him undertaking numerous illicit bedroom campaigns. Boswell was a moody man to the point of being a manic depressive. Consequently, he frequently displayed a zest for life to be then plunged into profound melancholy. This was a characteristic which may have explained the first bouts of rather odd behaviour in his life, namely his extraordinary religious vacillations as a youth. He was brought up, as I say, a Calvinist, but at university, where he studied logic and metaphysics and later law, he converted to Methodism. This form of faith was the opposite to his childhood teachings, but was modish at the time. However, never one to go with the crowd, this proved to be a temporary aberration, and young James changed to become, of all things, a Pythagorean vegetarian. This rigorous and deviant discipline never seemed to catch on, so he converted to Catholicism. Confessions and such like proved to be somewhat restrictive to his lusty nature, so, after a few months, Boswell embraced Deism, a hedonistic faith given over to the pleasures of sex. This was more in his line, and he was a willing devotee for five years. In 1764 he emerged from its teachings, presumably jaded but sated, to be admitted into the Anglican Church, an institution of which his hero, that old bigot Dr Johnson, was a pillar. The two had met for the first time the year before and Boswell developed an admiration for Johnson enough to prompt him to change his church so as to be nearer his paragon’s way of thinking. Initially, his religious anxieties seem to have been generated by uncertainty regarding the afterlife. In this context he appears to have been preoccupied with death; he rarely missed a good hanging

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at Tyburn. There was more to it than that, though. His heavyhanded early religious background with promise of nothing less than damnation for transgressors may have been the impetus for his rejecting the mores of so-called decent society and pursuing a life of lechery and depravity. It is this hedonistic aspect of his life and the diseases that it brought that fit more into this book. Early on in life Boswell found himself blessed, or was it burdened, with this overwhelming sexual drive. It provided him with an identity crisis, the magnitude of which was compounded, as I say, by his religious vacillations and doubts, for the feelings generated were crude, direct and urgent. He wrote of himself, “I am of a warm constitution; a complexion, as the physicians say, exceedingly amorous; I ought to be a Turk.” I have never heard a physician say that. As a result of this obsession and despite his expressed fears of unwanted pregnancies, venereal disease and moral decay, he was forever plotting new sexual adventures. He wrote, “I was laying plans for having women, and yet I had a most sincere feeling of religion.” Boswell met Rousseau in 1764 and discussed that philosopher’s own admitted boundless sexual energy and fantasies, hoping for some fellow feeling, and maybe a night out. He misjudged his man, for the Frenchman, though libidinous, was more into sensual mysticism, considering pleasures of the flesh to be ephemeral when compared with their spiritual virtue. This was at variance with Boswell’s approach which had no time for bandying theories in a field of activity which demanded direct, basic, uncomplicated physical congress, no questions asked, no leave sought. The upshot was that between the ages of 20 and 29 Boswell succeeded in acquiring a string of conquests, which included taking as his mistress three married women from the upper ranks of society, having liaisons with four actresses, a brief but passionate affair with Rousseau’s lifelong mistress, keeping at least three of what he called “lower class women” as mistresses and producing two illegitimate children by them, and making a swift earlymorning foray upon the pregnant wife of the King of Prussia’s guard. The main recorded outlet for his insatiable sexual appetite

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was over 60 different prostitutes in London, Edinburgh, Berlin, Naples, Venice, Paris and sundry other places. Added to all that, he claimed to have laid unsuccessful siege to many other “ladies of quality”. This was all before he was 30 years old. He records that he lost his virginity at the age of 20 during his brief period of flirting with the Catholic Church. He recorded this as taking place in the Blue Periwig tavern in Southampton Street, London, with a lady called Sally Forrester. He later wrote how he looked back fondly on this introduction into “the melting and transporting rites of love”, and under the seasoned tutelage of a couple of streetwise lechers, shortly after was off on what he probably thought was to be a lifelong titillating idyll. It was to be brought to a juddering halt by his first medical problem, an attack of gonorrhoea. This was to be the first of at least 17, probably 19, doses of this venereal disease. He managed to crowd them into what must have been an extraordinary 55 years. With a record like that he must have become quite an expert on “the clap”, as it was called. So let us take a diversion from the life of James Boswell itself to look at the position of this condition in history, and at some of his fellow sufferers. Gonorrhoea is perhaps the most ubiquitous of those infections which peak in times of war, mass migration, poverty and, perhaps paradoxically, more recently, prosperity. The first scientific observations are attributed to Hippocrates, the “Father of Medicine”. He lived between 460 and 355 BC and wrote, “Those suffering from tubercle and carnosities in their pipes will get well by suppuration and flow of pus”. It sounds ghastly, and probably was. To “carny” is an old verb meaning to coax or wheedle, and carnosities are probably growths causing stricture of the passage from the bladder (or urethra) and which had to be teased out. Galen (c. 130–210) a well-regarded physician from Pergamum, now in Turkey but then in Greece, was in his time medical officer to the school of gladiators so could probably be regarded as an expert on social diseases, and it was he who gave us the word “gonorrhoea”, by which he meant “flow of semen” (from the Greek

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gonos, meaning semen, and rhoia, meaning flux). Though an influential writer, Galen was wrong in many areas of medicine and this may well be another, for the name he gave implies that he thought it was an extention of a fighter’s normal physiological processes and did not appreciate that gonorrhoea was an inflammatory and pathological process in its own right. A contemporary of Galen’s, Areteaus, was the first to recommend treatment. This included poultices, sexual abstinence, wrapping the genitals in wool and that good old standby in matters sexual, cold baths. The Persian physician, Avicenna, appears to have felt there was not enough punishment in this not unpleasant regime and augmented it by recommending that in obstinate cases a flea be introduced into the end of the urethra. The therapeutic worth of this would seem to be dubious, but doubtless it would serve to concentrate the mind on past sins. In 1161 an Act was proclaimed in London which forbade the brothel keepers of Southwark from housing “women suffering from the perilous infirmity of burning”. The word “clap” first appeared in a manuscript of 1378 written by John Ardenne, surgeon to Richard II. Prostitutes in the Paris district of “le Clapier” were quartered in “clapisses”, and the word may have come from this. The first cases of syphilis appeared in Europe at the end of the fifteenth century, and it was thought even by the great and wellrespected doctor of the Renaissance period, Paracelsus (1493–1541), that gonorrhoea was an early symptom of syphilis, and not a separate disease in its own right, an error that was to persist in many minds for two and a half centuries. Ambroise Paré (1510—1590), the so-called father of surgery, despite his renowned clinical judgment and the fact that he served with the French army on many campaigns, was fooled by the truth that concomitant syphilis and gonorrhoea was a common presentation in fighting men. He wrote in 1564 in his work Des Chaudes Pisses et Carnosities Engendrees au Meat Urinal, “The clap is due to three causes — sweating, starvation and infection.” He

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recommended bleeding, purging and, again, cold baths. Local treatment comprised an emollient ointment applied on linen wrapped round a thin candle and introduced up the urethra. He also forbade the company of women or even looking at paintings of them for fear it would heat the blood. The advice seems to have had more sadistic overtones than therapeutic worth. That great humorist, satirist and doctor, Francois Rabelais (1494–1553) tells that the son of Gargantuan caught the clap and was given drugs “to piss away his misfortune”. The confusion of the two venereal diseases being manifestations of the same malady persisted and made rational treatment difficult. Truth to tell, it mattered little as there was no rational treatment anyway and mercury was given for both. All that particular drug usually succeeded in doing was to give the sufferer a metallic taste and greatly increase salivation, and to cause the teeth to fall out and produce mental disturbance. In 1736 Nicholas Robinson, wise before his time, wrote, “I wish the libertines of our times would take example from the numbers that daily die martyrs to the pleasures of Venus.” As all medical students know, the great British surgeon and anatomist, John Hunter (1728–1793), is said to have sustained the fallacy of the single disease when he carried out his famous autoinoculation experiment in 1767. He rubbed “the matter of a gonorrhoea” onto two puncture marks on his own genitals. Unfortunately, he chose the inoculum from a patient suffering from both syphilis and gonorrhoea, hence caught both, thereby declaring that they were in fact one and the same disease. Such was his contemporary eminence that he held up progress in venereology for over 30 years by this one assertion. The state of the art was thus far advanced at the time of our leading subject, for the experiment was carried out during the period that James Boswell was acquiring his 17 attacks from one of the 2000 or so brothels which provided a working environment for the 50 000 harlots said to be in London at the time. The two conditions were finally separated by Benjamin Bell in

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Edinburgh in 1793. He was a more canny Scot than Hunter. He did not carry out life-threatening and messy experiments on himself. Certainly not: he inoculated medical students instead. Their names are lost to posterity, but it seems a pernicious way of ensuring examination success. In the nineteenth century, for the first time, hospital beds were set aside for suffers of venereal disease. In England they were known as lock wards, not because the patients had to be locked in, but because “lock” is derived from logue, meaning a rag such as lepers found in baskets at the gates of lazar houses and used to wipe their sores before entering. By the fifteenth century leprosy had declined to such a degree that the lazar houses provided by the monasteries for the use of lepers were half-empty and so were pressed into service for venereal diseases sufferers instead. One of the great venereologists of the nineteenth century, the Frenchman Philip Ricord, was said to be have been an engaging personality, frank but discreet. His extroverted nature made him a sought-after lecturer, and he was famous for his “recipe for getting the clap”. Politically incorrect though it may be when viewed nowadays, in part it ran: Take a lymphatic, pale and preferably blond women. Dine with her; begin with oysters, continue with asparagus, drink heavily with white wine and champagne. You will be well on your way then. To expedite matters, dance together until you feel hot. Once the night has come on, set to work energetically; two or three connections are by no means too much — the more the better. If you live up to this programme and do not get ill, you must be under the special protection of a god.

Naval personnel have a reputation for having a girl in every port and there is no doubt that in the same century the medical chest on Nelson’s HMS Victory contained more metal bougies for dilating the gonorrhoea-constricted urethras of the naval personnel than it had guns for engaging the enemy.

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In 1879 Albert Neisser, working in the Breslau Skin Diseases Clinic, gave the first detailed description of the gonococcus, the germ that causes the complaint, and in medical circles ever since it has been known as the Neisseria gonorrhoea in his honour. In this century antibiotics have been very successful in the treatment of the condition, but with growing resistance their days may be numbered. For a variety of social reasons, gonorrhoea is as common now, if not commoner, than in the days of that longsuffering and dedicated rake, James Boswell. So let us return to him. We have seen his first infection was from a sexual joust with Sally Forester; the second was from Ann Lewis, a Covent Garden actress also known as Louisa, whom he had hoped would give him “a winter’s safe copulation”. It was not to be. Of what symptoms and signs would Boswell have complained? Well, he would probably have admitted to a sexual contact and not have cited a variety of bizarre postulates which seem to be common among some present-day sufferers; reasons such as unaccustomed exercise, a blow from a cricket ball, strange lavatory seats or urinating on hot stones are still surprisingly common — anything, in fact, except sexual intercourse. Following an incubation period of two to five days Boswell would have noticed some discomfort on urinating, to be succeeded by a urethral discharge, usually purulent. Indeed, Boswell’s description itself cannot be bettered when he wrote, “I felt a little heat in the members of my body sacred to Cupid, and by the next day it too, too plain was Signor Gonorrhoea again.” There would also have been frequency of passing water which was probably due to the infection, but could have been due to guilt, remorse or introspection. As we have seen, Boswell did suffer from feelings of guilt, despite his unenviable track record. This was especially so early on in his lechery, as witnessed when he had a liaison with Mrs Jean Heron, the 17-year-old wife of a close friend. He was so mortified by his behaviour he took up with two middle-aged actresses to dilute the feeling.

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When he caught the dose from Louisa he retired to his room to live on bread and water and take physic for five weeks. A friend of his father’s visited him and left with a stinging pun, “Who in the performance of the manly parts would not wish to get claps?” The profligate life continued, and Boswell in turn continued to feel self-disgust, not so much at the immorality of his behaviour but at its brutishness. But the loathing was not strong enough to make him stop: the masochism would appear to have been as pleasurable as the conquest. He tells us that he longed for a “genteel girl” as a mistress. But before such a paragon could materialise, in June 1763 he met Dr Johnson. He at once admired the larger than life bon vivant and it was to him that he confided his sexual problems. As can be imagined, in reply the proffered advice was stern and morally uplifting. It may not have stopped Boswell in his activities, but it did stiffen his moral fibre. Later that year Boswell went on the Grand Tour of Europe where he had “many victories”, including Rousseau’s mistress who told him, “you are a hardy and vigorous lover, but you have no art”. In Dublin he caught a dose of gonorrhoea which was so severe that he had to return to London for the cure. This consisted of camphor liniment and mercury plaster on the affected parts, a daily draught of a couple of pints of Kennedy’s Lisbon Diet Drink (at half a guinea a bottle and a recommended dose of two bottles daily, it was clearly for the affluent lecher; he must vainly have willed it to work) and some minor surgery, presumably dilatation. In a moment of inspiration and uncharacteristic perspicacity in 1769, he married Margaret Montgomerie. Though she had neither wealth nor title, she loved him, she understood him and above all she was tolerant of his quirks and foibles. Indeed, she possessed treasures which made her worth above that of rubies. And he knew it. In his own odd way he loved her in return and paid her the compliment of (almost) always being frank with her regarding his backslidings. They lived in Edinburgh where Boswell had a law practice, but he often used to venture up to London to meet Johnson

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and fall to the old temptations of drinking and womanising. He had had 10 attacks of gonorrhoea before his marriage, but only two between 1769 and 1779, something of a record for him. James Boswell kept a very detailed diary, not only recording the famous bon mots of his mentor but also details of his own sexual outings. He does not seem to have visited James Graham’s wellknown Temple of Love and its celestial bed, or been known to have met Emma Hart (later Emma Hamilton and paramour of Admiral Lord Nelson), who is said to have worked in the establishment. He probably had no need of such bogus stimulants of the flesh, and while in town sought out more intellectual stimulants such as Samuel Johnson, Sir Joshua Reynolds, Edmund Burke, Oliver Goldsmith, Alexander Pope and other literary giants of the day, probably at the Cheshire Cheese in Fleet Street. Margaret died in January 1789 while Boswell was away yet again in London trying to shape a legal or political or literary career. Her death depressed him and he slowly became a habitual drunken lecher, a familiar figure lurching through the less reputable streets of the capital. More attacks of his old trouble occurred, and he once had total stricture of the urinary outlet necessitating surgical intervention. The vulgar debauchery continued until May 1795 when he eventually succumbed to, it was said, a bladder tumour, although complications of his chronic disease would surely have played a part. Furthermore, the mental degeneration of the last few years may have been due in part at least to repeated ingestion of the mercury pills he took for his condition. As a man he had two endearing qualities. The first was his capacity to make friends; he seems to have had boundless good humour, a characteristic which would stand him in good stead in dealing with the demimonde of the seamy side of his life. The other was his intrinsic honesty, so that we know from his jottings more of the quirks and shortcomings of this man than perhaps anyone else in history. He spared his diary nothing. His libido had been liberated by his rejection of a strict

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Calvinistic upbringing. That childhood, however, had created in him a sexual behaviour pattern which oscillated between selfreproach and swaggering machismo. Boswell was not a reticent man, but whatever his mood the recordings of it bear a ring of truth. It is perhaps this characteristic which eventually brought forth his great and polished literary product, his Life of Johnson. He was also, of course, promiscuous even by the standards of the freewheeling times in which he lived. Gonorrhoea was the greatest risk and he contracted it on numerous occasions. In itself this had serious physical consequences, but more than that, the treatment was almost as dangerous as the complaint. The disease was so widespread in the eighteenth century that the commonest advertisements in the contemporary periodicals were concerned with venereal disease, cosmetics and books in that order. Hunter’s Restorative Balsamic Pills were claimed to restore and reinvigorate the constitutions of persons weakened by a course of dissipated pleasures. The Bath Restorative was for “those who have been almost worn out by women or wine”. Cures for venereal diseases bore such exotic titles that they almost invited the simpler souls to catch the disease in order to try them — Lisbon Diet Drink, Dr Solander’s Vegetable Juice, The Specifi, and last but not least, Leake’s Pills The Best Known Cure for Gonorrhoea, which were depicted in a Rowlandson cartoon of 1786. Boswell also used condoms as a protection against disease rather than as a contraception, and they were purchased at Mrs Phillips’s shop, The Green Canister, in Half Moon Street, Leicester Fields. Eighteenth-century England was a rip-roaring world of abject poverty, drunkenness, political graft and loose sexual morals with accompanying social disease. But out of this miasma grew many towering intellects, a cultivated and leisured society for those with money and status, and for those without, an industrial revolution which changed the world. Boswell was a part of all this, and whatever one may think of his licentious ways, his passionate and introspective honesty has given

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us a unique insight into a medical condition which is even now more known for its furtiveness and clandestinity than its ventilation. Besides being a libertine, of course, James Boswell produced a biography of such scholarly proportions that it is still held as the yardstick by which similar works are measured. If he had thought of it, he could, in the end, have anticipated Hilaire Belloc and written : When I am dead, I hope it may be said: “His sins were scarlet, but his books were read.”

(JL)

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Chapter

5

OPIUM

SHAMEFUL

START TO BRITISH RULE IN HONG KONG

Not long ago the British were lamenting the return of Hong Kong to Chinese rule. But they prefer to forget how their forefathers first acquired the colony. It was a shameful, sordid affair, based on hypocrisy, greed and the exploitation of opium addiction. The opium wars of the nineteenth century were, according to one writer, “precipitated by the Chinese government’s effort to suppress a pernicious contraband trade in opium, concluded by the superior firepower of British warships, and followed by humiliating treaties that gave Westerners special privileges in China”. How did all this come about? Way back in 1599, Queen Elizabeth I granted 218 London merchants monopoly rights over all trade in the East Indies (south-eastern Asia). So started the East India Company, which conquered and governed much of India as a company colony. During the eighteenth century, Londoners were drinking so much tea (mostly from

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China) that they spent about 5% of their earnings on it. The government was equally dependent on excise duties from tea. By the early 1800s, the East India Company was financing its tea trade by illegal exports of opium to China. For over a thousand years, the Chinese had used opium, but mainly for medicinal pruposes. Then, during the eighteenth century, recreational smoking spread. The Chinese government passed edicts that proved to be as ineffective as Prohibition in the United States. Pressure for free trade ended the East India Company’s monopoly in 1834. Soon a vast network was moving opium, even into northern China. Missionaries described the effects: Those who begin its use at twenty may expect to die at thirty . . . a frightful . . . atrophy reduces the victim to a ghastly spectacle who has ceased to live before he has ceased to exist.

Since opium provided one-sixth of Britain’s national revenue, the British government supported the trade. No wonder the Chinese loathed the British. But the British said they were just meeting the demand. Never mind that they encouraged addiction by distributing free opium, and bribed police to turn a blind eye. The Emperor of China proclaimed the death penalty for Chinese opium growers, distributors and users, and even for foreign importers. He sent to Canton Commissioner Lin, who had reduced opium problems in central China. Lin offered addicts who gave up opium medical care to ease their withdrawal. He wrote futile letters to the British ruler, asking for the shipments to stop. But in Canton, Lin smashed the domestic opium network; by early 1839, the trade seemed dead. Surrounding the foreign factory area with troops, Lin demanded the surrender of the opium stocks. To protect the 350 European and American traders there, Captain Elliot, the British superintendent of trade (who himself despised the trade), promised to indemnify British dealers who complied. Elliot’s expensive capitulation did not amuse Queen Victoria. While destroying the

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confiscated 1000 tons of opium (which took 23 days), Lin beheaded a coolie who tried to sneak a little for himself. But the British dealers refused Lin’s demand to sign bonds promising never to trade in opium again. In July 1839, after drunken British and American sailors assaulted a Chinese man who died, Elliot refused to surrender them to Chinese justice. Instead, he himself tried them, found them guilty, but only jailed and fined them. This leniency infuriated Lin. So started the still undeclared Opium War of 1839–1842. In September, Elliot fired on Chinese forces in Kowloon. In November, the British sank four Chinese war junks. The first phase of the war brought only a short-lived peace. In January 1841, Elliot and Qishan, the new commissioner replacing Lin, reached an agreement, which both their masters promptly repudiated. Foreign secretary Palmerston blamed Elliot for accepting too small an indemnity, which included the rocky, arid island of Hong Kong! Palmerston had no inkling of the enormous potential of Hong Kong as a free port, which it became in 1841. The Emperor was furious that Qishan had yielded any Chinese territory at all; Qishan returned to Peking (Beijing) in chains. For the second phase of the war, from 1842, the British had a new leader, the daring veteran Sir Henry Pottinger. Pre-industrial China had no hope against British muskets, heavy artillery and paddlewheel gunboats. By August 1842, the British ships had reached the outskirts of the southern capital Nanking (Nanjing) and prepared to shell the city. About 10 000 British had overcome an empire of 370 million. The Treaty of Nanking opened China to the West and marked the beginning of a century of foreign exploitation. This was the start of the humiliating “unequal treaties” imposed on China first by Britain, then the USA, and then France. Surprisingly, the treaties said nothing at all about opium. Not surprisingly, the British continued to import opium illegally. In Britain, the humanitarian Lord Ashley spoke out against “one of the most lawless, unnecessary and unfair struggles in the records

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of history”. Once opium in China became legal in 1856, smuggling quickly ceased. Though opium remained a serious social problem, the edicts forbidding its use were not revived until 1906. In the 1920s, regional warlords in China started growing opium to finance their armies. Even now, smuggling from the Golden Triangle into China remains a major problem. (GB)

TAKING

OPIUM WAS LIKE PLAYING RUSSIAN ROULETTE

More than three centuries ago a famous physician declared, “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.” In those days a popular remedy was laudanum (opium mixed with alcohol). Its users were actually getting two fixes. Even in the late eighteenth century, pharmacists still got their drugs from plants. But, like other plant extracts, opium had one major downside: the varying strength made its effect variable. Sometimes it had little effect, other times it killed people. Modern chemistry was only in its infancy. When its founder Antoine Lavoisier went to the guillotine in 1794, Friedrich Serturner was still a boy in Westphalia, Germany. His family was poor, and things got worse after his father died. At 16, he became apprenticed to the royal pharmacist. Shuttling between the pharmacy and his improvised basement laboratory, Serturner started experimenting. Frustrated by the unpredictability of opium, he took on a huge task: to find its active ingredient. After 57 experiments over four years, he managed to isolate the active component (bitter, odourless crystals of morphine). Now Serturner found that adding it to the food of mice and stray dogs put them to sleep; larger doses killed them.

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But he went beyond animal tests and tried it on himself and three 17-year-old friends. They were lucky to survive. First, each took 30 mg (a large dose) of morphine, dissolved in alcohol and water. They felt flushed and feverish. After half an hour, they boldly repeated the dose; they became nauseated and dizzy as well. After 15 minutes, they took their third dose. The young men got sharp pain in their stomachs and felt faint. Serturner lay down and dozed off. Luckily, when he woke he had his wits about him; he gave everyone enough vinegar to make them vomit violently. One boy was still seriously ill, so Serturner also gave him carbonate of magnesia. For some days, all four suffered stomach pains. In 1817, he named his active principle morphine, after Morpheus, the Greek god of dreams. In the long run, this discovery pointed the way to precise, predictable dosages of pure drugs. But when he published his work, the journal editor fiercely attacked him. Serturner responded to criticisms by doing further meticulous experiments. Controversy dogged Serturner for the rest of his life. Fourteen years before he had isolated morphine, a French pharmacist had done similar work, though his extracts were very crude. There followed the usual disputes about priority and even charges of plagiarism. Eventually, the Institut de France awarded Serturner a prize of 2000 francs for his discovery. It was fitting that morphine eased the agonies of the gout that gradually immobilised Serturner himself. His was a giant intellect ranging far beyond his own specialty. He spread himself over chemistry, physics and even medicine. Before the pioneer work of Pasteur and Koch on germs that caused infectious diseases, Serturner described the cause of cholera as a poisonous, animated being that can reproduce itself. When a cholera epidemic hit Europe in 1831, he printed pamphlets at his own expense, urging people to avoid cholera by boiling drinking water. Millions of those who failed to heed Serturner’s advice died of cholera. Though Serturner isolated morphine in 1803, it was not until

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the twentieth century that chemistry advanced far enough to determine its chemical structure. In 1952, chemists finally synthesised morphine. In 1841, Serturner collapsed and died while drinking tea. Surely if the Nobel Prize had existed then, he would have won it. One biographer wrote: “Serturner’s discovery stands well alongside the greatest discoveries which have benefited the human race.” The story of new, powerful painkillers rolls on. Serturner started with opium from which he derived morphine; later, he warned people that morphine was addictive. Later still heroin (derived from morphine) came into use as the non-addictive answer to morphine addiction. In 1900, Bayer Pharmaceuticals was advertising heroin as the “sedative for coughs”. Now about 500 Australians are dying each year of heroin overdoses. But we cannot put the genie back in the bottle. (GB)

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Chapter

FAMOUS

6

AND

INFAMOUS PEOPLE

ATATURK

AND THE

ANZACS

We are Aussies on a tour of Gallipoli. Geoff has come on a pilgrimage to the grave of his grandfather. He and our Turkish guide Ali share a bond: Ali also lost his grandfather here. My eyes grow misty as I read the inscription on the monument: There is no difference between the Johnnies and the Mehmets where they lie side by side . . . Your sons are now lying in our bosom and are at peace . . . They have become our sons also.

The last words are “Ataturk 1934”. Who was this Ataturk? Mustafa Kemal, not yet known as Ataturk, was born to an undistinguished family in 1881 in Macedon, then part of Turkey. Though arrogant, prickly, stubborn and rebellious, he excelled at military school. He was able, ambitious and fearless. Turkey was “the sick man of Europe”.

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Russia had taken the Crimea, France had annexed Algeria, the British had taken Egypt and Greece had taken Crete. The corrupt, despotic sultan ruled from Constantinople; his spies were everywhere. Arrested as a leader of a revolutionary group, Kemal languished in solitary confinement and was nearly executed. He took up his lifelong mission: to deliver Turkey from what he saw as its tyrannical rulers, obsolete customs, illiteracy and Muslim conservatism. During the First World War, Turkey allied itself with Germany. In April 1915, British, French, Australian and New Zealand troops landed at Gallipoli, where Kemal, now a general, had charge of a half-formed division. Ignoring orders, he threw every available Turk into a desperate defence. Despite an attack of malaria, he led his troops from the front throughout three sleepless days and nights. Kemal escaped death when the watch he carried in a breast pocket blocked a piece of shrapnel. Altogether, on both sides, there were about half a million casualties at Gallipoli; that is, incredibly, half of those who fought there! Some accounts state that deception by the Anzacs kept the Turks unaware of their withdrawal from Gallipoli and so prevented further casualties. But our guide Ali insists that the trenches of the two sides were far too close for such deception. The Turks, he says, had come to respect the Anzacs and would not shoot at withdrawing men. He tells us a tale of fraternisation at Gallipoli. One day late in 1915 the Turks dropped a bag of tobacco into the Australian trenches with a note: “We have tobacco, you have paper.” Next day, the Aussies threw back half the tobacco, rolled up in odd bits of paper: old newspapers, even letters from home. Kemal’s defence at Gallipoli made him famous as “The Saviour of the Dardanelles”. But Turkey was in terrible shape. Famine and disease were widespread. The politicians were obeying the allied orders to disarm. They in turn ordered Kemal to demobilise the remaining Turkish forces on the Black Sea coast. Instead, in May 1919, Kemal set about inspiring and organising them.

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In August 1920, the helpless sultan signed the Treaty of Sevres. This capitulation would have reduced Turkey to a puppet state at the mercy of its neighbours, but the nation rallied behind Kemal and rejected it. In 1922, his nationalist forces finally drove the Greek invaders from Turkey. It is said that one disturbed Greek general stayed in bed, since he believed his legs were made of glass and would break if he got up! The National Assembly abolished the office of sultan. Russia, France and Italy signed the Treaty of Lausanne, which set Turkey’s borders about where they are now. On 20 October 1923 Turkey became a republic, Ankara its new capital and Kemal its president. Turkey, he declared, must adopt Western dress, laws, education and constitution. Kemal made Turkey a secular state and did away with Muslim schools, the Islamic legal system, and the wearing of veils by women and the fez by men. He cleaned up the corrupt civil service and granted women the right to vote and to hold public office. When he made family names compulsory, the assembly granted him the surname Ataturk (Father of the Turks). Kemal controlled the assembly and could appoint and dismiss the prime minister and cabinet. He censored newspapers, and tortured and hanged hundreds of Turks. Police tearing fezzes from Muslim heads led to riots and the stoning of officials. Religious leaders denounced him. Kemal savagely put down a Kurdish revolt in 1925. Vivian Green attributes his ruthlessness to psychosis (mental disturbance) caused by a lack of the vitamin thiamine in his poor diet brought about by alcoholism. Certainly, Kemal did not hide his heavy off-duty drinking. A French journalist wrote that Turkey was governed by one drunkard, one deaf man (Kemal’s prime minister) and 300 deaf-mutes (the deputies). Kemal replied: “This man is mistaken. Turkey is governed by one drunkard.” By 1937, Kemal was very ill. When he complained of an itch, officials started a futile search of the presidential palace for the insects that must surely be biting him. His own doctors failed to diagnose his illness, though he developed the swollen belly and jaundiced skin of terminal liver failure.

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On 10 November 1938, Kemal Ataturk died in the Dolmabahce Palace in Istanbul, where the clocks still remain stopped at 9.05 a.m., the time of his death. Even now, more than 60 years later, Turks honour him with his likeness on banknotes, stamps, statues and portraits. Ambitious politicians still claim to be the inheritors of his mantle. History will record Kemal as a ruthless dictator, but also as the greatest figure in modern Turkish history. His monument is modern Turkey itself. (GB)

KING EDWARD VII: A ROYAL BON VIVANT On 6 May 1910 George, eldest son of the reigning monarch of Great Britain and her dominions across the sea, including Australia, bent down close to the puce-coloured face of his dying father and whispered not that the Empire was safe, as you may think, but that the king’s horse “Witch of the Air” had won that afternoon at the Kempton Park racecourse. The breathless old man managed a thin smile and gasped in reply, “I’m very glad.” Hardly memorable as last words go, they were to be his final pronouncement before succumbing shortly afterwards to a final heart attack following on from his severe bronchitis. The son was later to say, “I have lost my best friend and best of fathers. I am heartbroken and overwhelmed with grief.” I am sure he was, but they had not always seen eye to eye, and indeed his father, Edward VII, had led a strange, dissolute life seemingly at variance with both that of his mother Queen Victoria (and who more Victorian than she?), and of his rather inflexible son, who became George V. This could well have been a result of the strained relationship that existed between himself and his mother, and the general lifestyle of his social set.

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So let us look first at his lifestyle, the medical high point of which was the stopping of his coronation for good clinical reasons, and then turn to his well-known sexual athleticism, when the appellation “Father of the Nation” took on a whole new meaning. Albert Edward was born in London in 1841 and was the second child and first son of Queen Victoria and her consort, Prince Albert. The elder child, Victoria or Vicki as she was always known, had been a difficult labour, and the Queen looked forward to the second pregnancy with ill-concealed apprehension. She was not to be disappointed, for during it she wrote that she felt “very wretched, low and depressed”. The actual labour was accompanied by a suffering which “was really very great”. As well as a distaste for labour itself, Victoria had a well-known dislike for small children. So all in all there must have been a general air of gloom and impatience at the palace. As a boy Albert Edward was known as “Boy” or “Bertie”. In later life he came to be known under several sobriquets from “Kingy”, “Tum Tum” to “Edward the Caresser” and other even more scurrilous nicknames. But we’re getting ahead of ourselves here. His early education was undertaken by an old-timer who had himself been educated during the French Revolution and was quite out of touch with the general mores of the day. He must have been interesting to talk to if you could steer him away from Euclid or Virgil, a ploy quickly spotted by such tearaways as Bertie and his brother. Victoria herself kept Edward in the dark as far as state matters were concerned, despite the fact that he was heir to the throne, and that he wished to be involved. So here we have a set of circumstances of a loathed pregnancy, a strict and inept education, and a spurned enthusiasm on the one hand, and youthful boisterousness, wealth and persuasive friends on the other. Well, what would you have done? He did the same. Psychologists could have a field day explaining the events of his adult years, but whatever the reason he led the fascinating life of a bon vivant and rake. Let’s start with his eating habits. Because there is no stronger label, they could only be described as gluttonous. Admittedly, it was

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an age of the hearty appetite, but like a true king, Edward led from the front. He devoured five solid meals a day (tea and supper were both full meals). He started with a glass of milk in bed. Up to toast and coffee, and just before the morning shoot platefuls of bacon, egg, haddock, chicken, toast and coffee. He ate rapidly and with relish. The fresh air sharpened his appetite and a bowl of soup was put away mid-morning. A multi-course lunch at 2.30 p.m. would not put him off having tea two hours later. The band played at this indulgence as he tucked into poached eggs, petits fours and preserved ginger, hot cakes, scones and his favourite, Scottish shortcakes. Dinner followed at 8.30 p.m. and was, of course, the main meal of the day for the by-now ravenous monarch. It comprised 12 courses and he usually never missed a beat. Oysters were followed by maybe plover’s eggs, poached sole, turkey in aspic, quail pie, grouse, snipe, woodcock and other birds he had earlier blasted out of the skies in their hundreds. The thicker the dressing, the richer the stuffing, the creamier the sauce, the greater the enjoyment. He never grew tired of partridge stuffed with truffles or of boned pheasant laced with paté de foie gras. The only thing he did not like was macaroni, perhaps because it had not been shot, reeled in or hunted to exhaustion. The edge of his appetite was not dulled by his smoking habits. By the time he had reached breakfast the King had had two Egyptian cigarettes and one cigar. By the end of the day he had got through 20 cigarettes and about 12 Corona y Corona cigars, his favourite. If smoking ever blunted his appetite, which it did not, it could be revived again by a snifter or two. In his younger days he used to decant a bottle of champagne into a jug and help himself during the meal. When he became king he rarely had more than two glasses. He hardly drank wine and finished the meal with a cognac. Edward may have had several vices, but heavy drinking was not one of them. Like many who guzzle their food, he ate quickly and was resentful if conversation interrupted the relentless shovelling down

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of food. The story is told of his grandson, the future Edward VIII, beginning to speak during a meal to be instantly silenced by the gruff king. As the plates were being taken away the boy was asked what it was he had wished to say. The reply came back, “It’s too late now, Grandpa. It was a caterpillar on your lettuce, but you’ve eaten it.” He was impatient with people who ate slowly, so when he finished everyone put their cutlery down. As a result no-one left the best bits till last, and many a lifelong habit had to be broken. Prince Edward’s feasting was common knowledge and a source of secret wonder. Eventually Parisian nightclub singers began to mock the regal gourmandising, so it was decided that, as a sop to public disdain, for a short time each year a diet be undertaken at such desirable and chic places as Marienbad or Biarritz. If you are going to attempt the impossible, it might as well be done in style. Bertie drank the mineral waters with as much grace as he could muster and did away with the half-chicken which customarily stood on his bedside table in case he awoke peckish in the night. But the local hoteliers in these parts did not wish to appear niggardly to a visiting monarch, and, by force of habit when in the presence of royalty, put little culinary temptations in his way in the form of goose stuffed with aubergines and other calorie-laden snippets. Their meals seemed to be the epitome of luxurious habits instead of a disincentive to overeat. The most the king ever lost was three and a half kilos in two weeks. I suppose even that was a minor triumph in view of the irresolute way the problem was tackled. Paradoxically, he was weighed every day by the local cake-shop proprietress. I wonder where her interests lay. There can be no doubt, of course, that his overindulgence affected his health and feeling of wellbeing. After all, he was only human. So let’s consider his health. In 1871 Bertie had an illness which strangely enough helped bolster the flagging interest in the royal family in England. Since the death from typhoid of “Dear Albert”, the Prince Consort, in 1861, Queen Victoria had retired from public life. After ten years

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the populace not unreasonably thought that enough was enough, and there were rumblings about the country of getting rid of the unseen monarch. By what in retrospect was a most fortunate if somewhat serious illness, Bertie’s recovery lead to a warm burst of royal approbation and no more anti-monarchist murmurings were heard. It seems that in late October 1871 the prince was a house guest at the country residence of the Earl and Countess Londesborough. A few days after his return to Sandringham, the royal residence in Norfolk, the prince fell ill. Ten days later, on 23 November, it was announced that he had typhoid fever. Evidently, the Londesboroughs’ drains were not on a par with their hospitality. A week later, to everyone’s horror, a fellow guest, the Earl of Chesterfield, died of the same disease. Worse, the prince’s groom followed Chesterfield to the cemetery. It was known that Edward’s father had died of the self-same malady, so by now the court had the breeze up. On 29 November the royal patient began to rave and shout indiscretions in his ramblings. As names were being named, the Princess of Wales was kept out to save unnecessary embarrassment all round. She divided most of her time between praying, handwringing and having attacks of the vapours. That day Queen Victoria herself arrived to add to the social complications. By 7 December it seemed all hope of recovery had gone. A day of national prayer was declared and five bulletins were issued over 24 hours. But the delirium eased, and, as the Queen was to write in her diary, “he was brought back from the very verge of the grave”. On 15 December Edward smiled at the assembled Jonahs and asked for a glass of Bass’s beer. He took some weeks to recover completely and finally receive the warm acclaim of the people. In 1895 Prince Albert Edward developed rheumatism in his right shoulder brought on by the vigour with which countless thousands of loyal subjects shook his hand. On account of this he devised “The Prince of Wales” handshake, whereby he kept the elbow tucked into the chest wall. Being the leader of society that

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he was, he changed the fashion for formal recognition as people adopted this rather stiff greeting. Many years later his grandson, Edward VIII, suffered hand pain from the same thing and took to using the left hand for such courtesy. But the illness for which Edward VII is best remembered, of course, is an attack of appendicitis a couple of days before his coronation. By the time his number came up to be king he was balding and middle-aged, and doubtless wondered if the moment would ever arrive, or if he would die first of overindulgence, boredom or sheer frustration. He planned it with much joy and nitpicking detail for it was the first such event for 64 years. Suddenly here it was; 26 June 1902 was the appointed day. May was particularly wet that year, even by British standards, and on 11 June the uncrowned heir was said to be suffering from a chill. He missed two of his favourite outings, a military parade at Aldershot and the horse racing at Royal Ascot, so something must have been wrong. He elected to rest at Windsor, but neither the court nor the general public thought too much of it. But the inner circle had noted a few changes. After the so-called chill, there had been loss of appetite, a very significant symptom in this particular patient. His drinking, on the other hand, increased and he became irritable and sleepy. On 23 June he returned to Buckingham Palace, insisting that the plans were to go ahead. That night he developed severe pain in the lower abdomen and despite his at that time 48-inch waist, his doctor Sir Francis Laking was brave enough to diagnose perityphlitis, as acute appendicitis was then called. At that time operative treatment for this condition was in its infancy; indeed, the diagnosis was a new trend and the pathology poorly understood. It had usually been treated by diet and carminatives. The mortality rate was uncomfortably high. Laking was on the horns of a dilemma. He knew the risk of operating on the one hand and of conservative treatment on the other, and also knew there was not a lot in it: both could be pretty disastrous.

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Further, he knew, poor devil, the eminence of his patient, his temper, and the ominous ceremony ahead. He came down on the side of a milk diet and bed rest. And who can blame him! The patient got worse and peritonitis set in. Even so, Edward was unrelenting in the way he fretted about the details of the forthcoming celebrations. He even called in a gypsy to forecast the outcome and was alarmed at the given prognostication that he would not be crowned, and, worse, her own imminent death would soon be followed by his. She did, in fact, die about a week later but must have told the right forecast to the wrong man. Sir Francis Laking called in Sir Thomas Barlow and both now agreed that operative intervention was essential. Without asking the authorities, they alerted yet another medical knight, Sir Frederick Treves, to lay out his best suit and sharpen his scalpel, and had a room in Buckingham Palace set up as a theatre. The distinguished patient was approached. Operation was essential, or death would follow, as night follows day. The heir was intransigent. “Laking,” he said, “I will stand no more of this. Leave the room at once.” Barlow left, but the valiant Laking stayed to tough it out. At last a compromise was reached: Treves would be seen; no promises, mind. The smooth-talking surgeon succeeded where the others had failed, and at noon the next day Edward walked into the makeshift operating theatre wearing his old dressing gown and carpet slippers. I wonder if he gave a thought to his predecessor Charles I walking to the scaffold about 250 years previously: Edward’s chances were only marginally better. Queen Alexandra helped hold him down as he bucked and plunged under the chloroform. Treves had to ask her to leave so that he could roll up his sleeves and don his apron for the actual cutting. Sterile masks and gowns were a thing of the future, just as old-world charm was a thing of the present. The operation took forty minutes, and as the anaesthetic wore off the King opened his eyes and said, “Where’s George?” George, Prince of Wales, saw him the next morning when he found him sitting up in bed smoking a cigar. When the Queen visited he

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pretended to be asleep, as he found shouting to counter her deafness hurt his wound. Laking and Treves were created baronets, and I would say thoroughly deserved the accolade. Indeed, rabbiting away through the 48-inch waistline of the foremost in the land is probably worth an earldom plus a week of rough shooting at Balmoral at the very least. The king was declared out of danger on 5 July and the coronation eventually took place on 9 August 1902. During his reign the king went on his merry gourmandising way, but by now he was in his 60s and the good life was having an impact. He began to get rheumatism in the knees, a situation not helped by his excess weight. In 1909 on a visit to Germany, and while trussed up in the high-necked Prussian uniform which protocol demanded, he had a fainting fit. The dear lady whose hand he was pressing at the time thought he had died and had herself to be revived. On that same trip the locals noted that the king was so obese that he gasped and choked as he went upstairs, and the effects of chronic bronchitis began to manifest themselves with a morning cough and some wheezy breathlessness. Sometimes he spluttered incessantly all day. He had frequent sore throats and bouts of fatigue. Yet he could not be persuaded to stop his obnoxious cigars, the puffing of which seemed to be as prominent a part of his appearance as his straining waistcoat buttons, ample thighs and hooded eyes. While he was prickly with his doctors and dismissive of their advice, he actually became depressed with the stresses of office and fearful of old age. In February 1910 the king suffered an attack of sudden chest pain and breathlessness. Could it have been an unrecognised coronary thrombosis? Whatever it was, he recovered but in April again came down with bronchitis. On 2 May he spent several hours in the open sitting astride his horse in inclement weather. And on 6 May, as we have seen, he died. But he was a merry monarch and I do not think he would have liked us to have taken our leave of him on his death bed. It is more

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fitting that we should salute his passing with an irreverent review of that part of his life for which in later years he has become most well known: not the Entente Cordiale, not his freelance diplomacy, not even his epicurism, but his legendary sexual dynamism. Throughout his life Edward was a rake of Catholic tastes and as prepared to sleep with a fashionable harlot as a duchess. More than that, he was a rake who loved the rakish world in which he moved. He was untrammelled by finer feelings or doubts about his life. His girth was no bar to his exploits, possibly because it was regarded as an honour to be invited into his boudoir, possibly because it was regarded as bad taste to mention any shortcomings that may have been experienced on account of it. He himself seemed to regard it as his birthright and early on commented, “High station has, after all, some merits, some advantages.” He doggedly pursued his libidinous habits which became a riproaring way of life and an outlet for his considerable energy and a prop to shore up his otherwise rather meaningless existence. It is said that he lost his virginity in 1861 at the age of 20 while in Ireland at a military camp. The story goes that his madcap fellow officers persuaded a notoriously promiscuous actress called Nellie Clifden to climb through his window or under his tent flap (accounts vary) and insinuate herself into his bed. A jape like that was soon the talk of the mess, and it eventually came to the ears of a sickened Prince Consort. There was a parental showdown of monumental proportions and not long afterward Albert died. Queen Victoria blamed her eldest son for the death (in fact, as we have seen, Albert died of typhoid) and wrote to Princess Victoria, “I never can or shall look at him without a shudder. He does not know that I know all — Beloved Papa told him I could not be told all the disgusting details . . . ” Well, whatever the disgusting details were, bold and brazen Miss Clifden had opened up a whole new world for Bertie, and one he basked in for the rest of his life. He found that in his role of heir to the throne he had extraordinary licence and was presented with far more sexual opportunities than was

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good for a young lad or he was able to cope with. Rumour gathered, as rumour has a habit of doing, that he was one of the generation’s lecherous greats, a byword in stamina and strength. It was said that for a husband it was more duty than dishonour to allow a wife the chance of royal, nay regal, pleasure. Well, maybe. He was not into young, unmarried girls — too many potential complications. But he did like variety, and, rather dangerously, excitement. He appeared to consume his women with the same gusto and lip-smacking enjoyment that he did his food. His basic plat du jour diet was from a menu of carefully chosen actresses. The à la carte were the married women of his fast set. These schemers were usually visited at their homes in the afternoon while their conniving husbands were at their clubs. By tacit consent nobody questioned the presence of the prince’s cab parked in a Mayfair or Belgravia street. The main course, or specialité de la maison, was the current favourite or society beauty whose favours were fawned over in the joyous licence of a weekend house party or autumn shoot. Bertie’s invaluable and extremely discreet secretary, Francis Knollys, commonly arranged the various trysts and there was a general cover-up by society, particularly within his own clique, so no breath of scandal emerged. Indeed, at his coronation at Westminster Abbey in 1902 a special stall for his entourage was set aside. To those in the know it was euphemistically called “the King’s loose box”. Among his well-known conquests were “the divine” Sarah Bernhardt (I wonder if her wooden leg added special piquancy to a jaded sexual palate); “the Jersey Lily” or Lillie Langtry; Catherine Walters, also known as “Skittles”, one of the best known high-class prostitutes of the Victorian era; the Countess of Warwick, also known as “Darling Daisy”; and Mrs George Keppel, the last of a mostly graceful and elegant line. In a pleasing act of contrition Queen Alexandra allowed Mrs Keppel a few private minutes with Edward VII when he was on his death bed. There were many others, and today visitors to England are constantly pointed out country houses said to be the scene of Edwardian sybaritism.

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Queen Alexandra knew of all the royal goings on, and, whilst not approving, turned a deaf ear. This is not so fanciful as it sounds, for she was in fact quite hard of hearing, a disability which worsened with age. As a child she had had tubercular glands of the neck incised. This procedure had left a scar and in later years she hid it by the wearing of a high jewelled “dog collar”, thereby setting a fashion which was to last for years. She was also taller than the king. Whatever else she may have been, such as a chronically poor time-keeper, Alex was loved by Bertie and she in turn was loyal to him. There was never any question of separation. Edward was entangled in one scandal from which he derived some public sympathy. This was the Mordaunt case in which Sir Charles Mordaunt brought a divorce case against his wife, who by then was in a mental institution. It seemed that the prince had corresponded with this lady in happier times, and he was called as a witness. To his mortification his letters were read out in court. It was all very embarrassing, but no stigma appears to have been attached to him. His widowed and imperial mother was not so easily placated and wrote, “. . . the Prince of Wales’s intimate acquaintance with a young married woman being publicly proclaimed will show an amount of imprudence which cannot but damage him in the eyes of the middle and lower classes, which is to be lamented in these days when the higher classes, in their frivolous, selfish and self-seeking lives, do more to increase the spirit of democracy than anything else”. Tortuous though the sentiments are, I think I know what she means. But the fact remains that it did not do Edward much harm in the country’s eyes. Perhaps people just did not care. But when all is said and done, Albert Edward had a single overwhelming talent — an ability to put people at ease. He was likeable and personable and, of course, had an unwavering eye for a pretty woman. From a medical point of view he did everything wrong. He smoked too much, he ate too much, he paid scant attention to bodily ailments, and apart from riding he took little exercise. He was popular and led English society to the manner

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born so that any affectation such as using a walking stick, wearing a homburg hat or having his appendix removed gained instant respectability and set a fashion. Looking at him now, a century on, the capacity to enjoy himself in a completely unabashed way is still as refreshing as it was contemporaneously unique; a characteristic worthy of a king. (JL)

E LV I S P R E S L E Y : W H A T THE KING?

KILLED

As the ambulance pulled up, a swarm of men surrounded the stretcher. Hospital staff worked frantically until at last a young nurse demanded, “Why are we still working on this corpse?” “Because he’s Elvis Presley.” That was August 1977. Elvis was only 42 years old. Elvis and his stillborn twin brother were born in 1935 in a tworoomed shack in Mississippi. As a toddler, Elvis first sang along with the choir of the Church of God. Later, his manager, “Colonel” Tom Parker, boasted: “When I met him, he only had a million dollars worth of talent. Now he’s got a million dollars.” In 1956, Elvis recorded Heartbreak Hotel, the first of his 45 records that sold over one million copies. He also made his first film, Love Me Tender. But it was live shows that made his name. Critics accused his hip-shaking “Elvis the Pelvis” style of “sexually setting young women on fire”. Under all the hype, wealth and glitter, the real Elvis was a vulnerable man shattered by his mother’s early death. To fill the void inside him, he tried flash cars, karate, religion, marriage and fatherhood. He sometimes gave away a Cadillac to a perfect stranger. But none of this satisfied him; nor did all the women he kept bedding. Several doctors pandered to his growing drug dependencies: uppers before a show, downers to sleep and testosterone for a

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flagging sex drive. With massive doses of cough medicine (Hycodan), he and a playmate almost overdosed in bed. Elvis also liked to play with guns. While stoned, he was a double menace and once nearly shot a girlfriend. Towards the end, he became paranoid, not only about people, but also about germs. His minders (“the Memphis Mafia”) covered up whatever they could. When Elvis missed out on playing James Dean in a film, he blamed them; by this time he weighed over 110 kilos. Finally, his wife Priscilla divorced him. In December 1976, he wrote: “I feel so alone sometimes . . . Help me, Lord.” When Elvis died on 16 August 1977, hundreds of thousands mourned outside his estate. One rumour had it that he had died of bone cancer, another that it was suicide or even murder. In the cemetery, police picked up three men carrying crowbars, wire cutters, shotguns and hand grenades! Suspicious people said they were about to steal the body and hold it for ransom. But they said they were fans who just wanted to open the casket. Why? To show that it was empty and so prove that Elvis still lived. Police dropped the charges. But what did kill the King? The medical examiner blamed high blood pressure and denied any evidence of drug abuse. But he would not release the autopsy report. After two years of investigation, the American Broadcasting Corporation went public. It turned out that a second set of blood samples had gone to an independent laboratory. On television, pathologist Dr Cyril Wecht said this new evidence showed that Elvis had died of an accidental overdose: codeine, Valium and a host of other drugs. In the seven months before Elvis died, he had taken more than 5300 tablets, which is over 25 a day. One question remains: did Elvis deserve to be a superstar? A San Francisco journalist wrote: “That someone with so little ability became the most popular singer in history says something significant about our cultural standards.” Bing Crosby had a bit each way, saying: “He [Elvis] never contributed a thing to music”, but also “The things that he did . . . that he created, are really

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something important.” In a way, the King still lives on. Over 20 years later, his fans console themselves with the host of Elvis impersonators who keep popping up. What’s more, people continue to write books about him. One sums up his whole life in just four words. It’s called The World’s Wealthiest Losers. (GB)

WAS JOHN CURTIN C A S U A LT Y ?

A WAR

John Curtin, Franklin Roosevelt and Winston Churchill led their countries in the Second World War. But by 1944, they were so sick that no employer of today would have let them even push a pen. Did poor health affect these men’s capacity to lead? Conversely, did the pressures of leadership affect their health or even shorten their lives? In the case of John Curtin (1885–1945), my answers are yes, yes and yes again. Curtin was the eldest of four children of poor Irish-born Catholic parents in Melbourne. Curtin started work as a copyboy at the Age. As well as playing football and cricket, he liked to read ‘serious books’ at the public library. He joined the Victorian Socialist Party and in 1911 was appointed secretary of the Timber Workers’ Union. Friends admired his intellect and idealism, but by 1914, they also worried about his drinking. Soon he resigned from his union post to convalesce from alcoholism. By 1916, he was drying out. After Curtin married and moved to Perth, he remained dry for most of the next ten years. He stood as a candidate for the seat of Fremantle at the 1919 Federal election, but lost badly. Exhausted and depressed, he had to take six months complete rest. In 1927–28, his work as the editor of a union newspaper often took him away from Perth and he was drinking again. Even so, he won the marginal Federal seat of Fremantle. Despite his intellect

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and broad experience, Curtin did not become a minister under James Scullin. “For two years he was frustrated, underemployed, morose, lonely and drinking — at his worst.” In 1935, the ailing Scullin resigned from the federal Labor leadership. Curtin’s colleagues gained his pledge to remain dry (which he apparently kept for the rest of his life) and surprised the country by electing him leader of the Australian Labor Party. In October 1941, Curtin became PM and also took on most of the wartime burden of defence. When the Japanese attack on Pearl Harbor brought the United States into the war, Curtin declared war on Japan without consulting Britain. He said quite bluntly: “[For its defence], Australia looks to America, free of any pangs as to our traditional links or kinship with the United Kingdom.” For an Australian statesman, this represented a quantum leap; Winston Churchill was outraged. Is it fanciful to see John Curtin as a forerunner of our present republicans? Soon Curtin had to withstand more heavy pressure from Churchill who kept pressing to redirect the 7th Division from the Middle East to Burma. Curtin stood firm and brought our troops back to defend Australia. Later in 1942, he won another bitter battle. Somehow Curtin was able to reverse the Labor policy that had prevented Australia from sending conscripts to fight overseas. This was a dramatic turnaround, not only for his party, but also for John Curtin himself. Way back in 1916, he had bitterly opposed conscription for overseas service and even gone to gaol for his beliefs. When Arthur Calwell and other party traditionalists viciously attacked him on conscription, Curtin offered to resign. Caucus unanimously backed him, but the victory cost him dearly. A biographer wrote: “The strain on Curtin progressively increased.” As well as his physical complaints, he was exhausted and depressed. He endured neverending travel by train or car to Melbourne and Sydney, as well as long trips over the Nullarbor. Why not fly? Because three leading members of the Menzies ministry had died in

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the Canberra crash of 1940. His ailments included psoriasis (a skin complaint), pneumonia (in 1941) and, as noted above, episodes of depression. In April–June 1944, while in Washington to meet President Roosevelt, Curtin spent several days in bed with high blood pressure and neuritis. After his return, he became more irritable, touchy and lonely. Labor icon Dame Enid Lyons implored him to retire. “Easily tired, beset by endless problems his failing strength would not allow him to handle, he became irritable.” In November 1944, a heart attack kept him in hospital for two months. Historian David Day called this illness “the culmination of years of stress, heavy smoking, alcoholic binges and a simple but poor diet.” Returning to duty in late January 1945, Curtin could no longer cope; the government was hamstrung. Later one official complained: “It was impossible. Almost — almost — one could be glad he’s dead so we can do things.” In April, Curtin’s lungs became congested, but after several more weeks in hospital, he insisted on returning to the Lodge. Curtin himself said he was no longer fit for office, but a friend advised him: “Carry on quietly, and when you recover, then come to a decision.” He did not recover, but died in office on 5 July (only a few weeks before the war ended) “a war casualty if ever there was one”. Even his political opponents mourned their loss. To this day, many see him as our greatest Prime Minister. The inscription on his gravestone read: His country was his pride His brother man was his cause.

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So what can we say about Curtin’s health and his fitness to lead? He certainly had a drinking problem, though historians disagree as to when he finally stopped drinking. Moreover, before we all knew about the dangers of tobacco, he smoked about 40 cigarettes a day. Just from the smell of cigarettes, his daughter always knew when he was home. Did poor health affect Curtin’s performance? His contemporaries

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say yes, at least during the last year of his life. Did the demands of office affect his health? Yes. Did these demands shorten Curtin’s life? Surely. (GB)

WHAT

KILLED FRANKLIN R O O S E V E LT ?

In 1999, the Sydney Morning Herald ran a quiz in which readers had to elect a world leader. Candidate A was said to have crooked friends and to consult astrologers; he drank eight martinis a day, smoked heavily and had two mistresses. Candidate B was a decorated war hero, a vegetarian and non-smoker. If you went for B, you’d just elected Adolf Hitler. A would have got you Franklin D. Roosevelt. Born into a patrician American family in 1882, young Franklin enjoyed many advantages, but good health was not one of them. He had frequent colds, pneumonia, typhoid, appendicitis and tonsillitis. Then in 1921, at the age of 39, he caught polio, which was misdiagnosed at first. It is said that for some time he could not even hold a pen. Despite all his treatments and exercises, Roosevelt could never again walk unaided. He could only get about in a wheelchair, or else by leaning on someone’s arm while using a cane and wearing leg braces. Roosevelt himself and the media treated his disability largely by denying it. Press photos never showed his wheelchair. He went on to become Governor of New York in 1928 and President of the United States of America during the Great Depression. Roosevelt started his third term in 1941 at the age of 58. In December 1941, the Japanese attack on Pearl Harbor brought the USA into the Second World War. Later, Roosevelt, Winston Churchill and Joseph Stalin, the “Big Three” allied leaders, met at Tehran and at Yalta. Admiral Ross McIntire, an ear, nose and throat specialist, treated (perhaps overtreated) Roosevelt for his chronic sinus infection. But there were other problems, too: by 1943, McIntire

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was secretly limiting the altitudes at which the president could fly. The next year, Roosevelt would occasionally nod off while talking. Once he even blacked out while signing a letter. Accordingly, in March 1944, he had a hospital check-up. His blood pressure was high, he was blue, breathless on movement and kept coughing up yellow phlegm. In brief, he had hypertension, a heart that was failing to pump blood effectively and chronic bronchitis or obstructive lung disease. Cardiologist Dr Howard Bruenn was shocked, but Dr McIntire, as his senior, put out yet another reassuring public statement. A medical panel recommended digitalis to help the heart to pump, a reducing diet, less smoking and more rest. Roosevelt followed this advice and for the last year of his life, Dr Bruenn stayed constantly at his side. But reportedly no-one told him how ill he was; nor did he ask. On Inauguration Day, January 1945, as Roosevelt started his fourth term, his son James wrote: “He looked awful, and regardless of what the doctors said, I knew in my heart that his days were numbered.” Indeed, his father gave James instructions about his (Franklin’s) funeral. Later, James said, “I never have been reconciled to the fact that Father’s physicians did not flatly forbid him to run.” It is said that during his last few months of life, Roosevelt’s systolic blood pressure sometimes reached 300 (about double the normal level). Now let’s turn to the Yalta Conference of February 1945. Dr Ronald Winton wrote: “There [at Yalta] Roosevelt, Churchill and Stalin — three men of whom all were sick but not all were equally wily — redrew the map of Europe . . . ” Supporting Dr Winton’s reference to Stalin’s wiliness are several accounts stating that Stalin manipulated both Roosevelt and Churchill. How? Stalin induced them to make long arduous journeys to meet him. At Tehran, he kept them waiting a full day before showing up. By placing Roosevelt and Churchill in widely separated residences, Stalin even made it hard for them to meet without him. At dinners, Stalin liked to get foreigners drunk by

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proposing toast after toast. He kept refilling his own glass with what looked like vodka but really was only iced water. By now, Roosevelt was very ill. At Yalta, Sir Alexander Cadogan, of the British Foreign Office wrote: “Whenever he was called on to preside over any meeting, he failed to make any attempt to grip it or guide it, and sat generally speechless.” Churchill’s physician Lord Moran called Roosevelt “a very sick man . . . I give him only a few months to live”. Moran was spot on. Doctors attributed Roosevelt’s death in April 1945 to a sudden large bleed into his brain, but the absence of an autopsy fuelled speculation. I believe that prominent men should have a postmortem and the findings should be made public. What did kill Roosevelt? Surely it was not just his diet that caused Roosevelt to lose about 10 kilograms? Colleagues noted his poor appetite and weight loss, while minders censored photos taken of him in 1945. During the 1930s and early 1940s, some photos show a slowly growing mole over Roosevelt’s left eye. In 1943, the mole was gone, but a scar was left behind. Had doctors removed a melanoma (a very malignant skin cancer) and kept it very quiet? Some kind of cancer seems likely, especially in a heavy smoker. It is natural to agree with the critics who argue that Roosevelt was quite unfit for office for his fourth term in 1945: “It was irresponsible and dangerous to allow an invalid, possibly a dying man, to engage in negotiations with Stalin and Churchill at Yalta that would virtually recast the maps of Europe and Asia and influence the lives of millions of people.” (GB)

HORATIO NELSON: HERO

AND

A D U LT E R E R Way back in 1966, when I was a poor young Aussie in England, I used to enjoy the advertisement for Cockburn Port in the London

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tube. It went something like this: Said Lord Nelson to Lady Emma: “Though Cockburn’s a drink well-known and renowned, When I try to pronounce it, my tongue runs aground.” Replied Lady Emma, with a twinkle: “My Lord, it’s quite simple, The O is as long as a midsummer’s day, And you just turn your blind eye to the C and the K.”

All these years, I’ve been wondering about Horatio Nelson (1758–1805), his blind eye and Lady Emma. We still remember him for his naval victories and his extramarital affair with Emma Hamilton — “the worst-kept secret in the long history of British hypocrisy”. Let’s look at Nelson’s naval career first. As a boy, Nelson was frail and often ailing; whenever he ventured onto a boat, he even got seasick. But he must have had the right stuff. At 14, on an expedition to the North Pole, he nearly became dinner for a polar bear that he was trying to shoot. At 16, he sailed as a midshipman to the East Indies. There he contracted malaria, which kept recurring. Nelson was only 20 when he became post-captain of the frigate Hinchinbrook. Most of his crew died of a fever. Later, while in action against the Spaniards in Nicaragua, he was lucky to survive “Yellow Jack” (perhaps yellow fever). In 1780, he was invalided home with excruciating pains, paralysis and loss of feeling in his limbs. The next year, Nelson wrote: “. . . knocked up with scurvy; having, for eight weeks, myself and all the Officers lived upon salt beef . . .” Sad to say, this was a generation after James Lind’s treatise on preventing sailors from getting scurvy. When Nelson married a widow, Frances Nisbet, a guest observed that the groom was “more in need of a nurse than a wife”. In 1794, Nelson was ashore besieging Calvi in Corsica when a shell from a French 18-pounder exploded near him. Hence the legend of his blind right eye. We cannot now be sure just what eye

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injury Nelson suffered, perhaps a fragment in the eye or a bleed inside the eye. Nelson himself wrote, “The surgeons flatter me that I shall not entirely lose the sight; at present I can distinguish light from dark but no object.” In 1797, during a disastrous assault on the island of Tenerife, a musket ball smashed his right arm. The operation report stated: “Admiral Nelson: Compound fracture of right arm by a musket ball passing a little above the elbow, an artery divided; the arm was immediately amputated.” Within two days, he was writing letters with his left hand. In 1798, Nelson on the Vanguard attacked 16 line-of-battle French ships to win the historic Battle of the Nile. This victory cut off Napoleon’s army in Egypt and ruined his Egyptian campaign. But a metal fragment cut open Nelson’s forehead to the bone, and a flap of scalp poured blood as it fell over his good eye. At the battle of Copenhagen in 1801, he claimed to have put his telescope to his “blind” eye and hence missed seeing the signal to leave the action. This was the second time Nelson ensured a major victory by openly disobeying orders. Not long after, he complained of “terrible spasms of heart-stroke which nearly carried me off”, and thought that his heart was actually breaking. Nelson’s greatest victory came in 1805 at the Battle of Trafalgar, fought between Cadiz and the Strait of Gibraltar. Here 27 English ships faced a larger Spanish and French fleet. He insisted on leading his fleet into action. Even worse, he stayed on the quarterdeck of the Victory in full view of a French sharpshooter only 15 metres above him in the mizzenmast of La Redoubtable. Inevitably, a musket ball struck him. When he heard that his fleet was winning, the dying Nelson murmured: “Thank God, I have done my duty . . . Remember that I leave Lady Hamilton and my daughter to my country.” Nothing about the faithful wife he had deserted! Nelson’s victory not only shattered Napoleon’s plans to invade Britain but also secured British naval supremacy for over 100 years.

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The Times wrote: “We know not whether we should mourn or rejoice. The country has gained the most splendid and decisive Victory . . . but the great and gallant Nelson is no more.” None mourned more bitterly than Nelson’s own sailors: “Chaps that fought like the Devil sit down and cry like a wench.” After lying in state in the Royal Hospital at Greenwich, Nelson was buried in the crypt of St Paul’s Cathedral. Nelson may have been a naval hero, but he outraged English society with his lifelong extramarital affair with Emma Hamilton, the wife of Sir William Hamilton, British ambassador to the Court of Naples. Daughter of an illiterate blacksmith, Emma was pregnant by the age of 16. Her beauty had gained her a protector who paid for her to learn dancing, singing and acting. Later, this young man, being hard up, sold her to his uncle, Sir William Hamilton, British ambassador to the court of Naples. She so entranced Hamilton, 35 years her senior, that he married her. After his victory over the French at the Nile in 1798, Horatio Nelson came as a conquering hero to Naples. The Hamiltons welcomed him into their house and Emma welcomed him into her bed. She was 33, he was 40; they remained lovers while both lived. But Emma never left her husband; she, her husband and her lover went everywhere together, almost like Siamese triplets. People in Naples were relaxed about this, but when the trio returned to England and Nelson did not return to his wife, Fanny, society was outraged. Nor did the English approve when Emma bore Nelson a daughter, Horatia, though Emma tried to pass her off as her goddaughter. Emma in her prime was a beauty, painted by many artists. Her many friends praised her intelligence, generosity and high spirits, while her many enemies complained of her coarse manners and heavy drinking, eating and gambling. Hamilton died in the arms of Nelson and Emma. Two years later, Nelson died in the arms of victory at Trafalgar. Both men left Emma generous bequests, but her extravagance and gambling soon

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left her penniless. In 1813, she went to debtor’s prison for a year. Emma’s lonely descent into poverty, illness and drink ended when she died in Calais in 1815. And poor, deserted Fanny? She had the last laugh, outliving both Nelson and Emma. (GB)

RASPUTIN: THE

MAN WHO WOULD NOT DIE

On 18 December 1916, divers fished a frozen body out of the River Neva in the Russian capital Petrograd (St Petersburg). The death of Grigori Yefimovich Rasputin was as violent and brutal as his life. He was born circa 1869. At 18, in a monastery he met the Khlysty (Flagellants) sect. He perverted their beliefs into his own teaching that one was nearest to God when one felt “holy passionlessness”. One could best reach this state through debauchery and sexual exhaustion. So to be saved, you had to sin! Preaching that contact with him had a purifying, healing effect, Rasputin seduced many eminent women. He married but did not settle down. Instead, he wandered to Greece and Jerusalem, living off donations from peasants and promoting himself as a holy man, prophet and healer. Rasputin was strongly built, with wide shoulders and long arms. His unkempt beard reached to his chest. Above all, it was his piercing blue-grey eyes that commanded attention. His enemies could not stand his atrocious table manners, body odour or illiteracy, but when he reached the Russian capital in 1903, he made a big impression. Tsar Nicholas II noted breathlessly in his diary: “We have got to know a man of God, Grigori.” Nicholas’s wife, Tsarina Alexandra, granddaughter of Queen Victoria, carried the gene for haemophilia (a hereditary disorder in which blood does not clot adequately), and her fifth child and only

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son, Alexis, heir to the Russian Empire, had the disease. At that time there was no specific treatment for it. His parents had tried both orthodox and alternate healers, with no luck. In some unknown way, Rasputin could relieve the boy’s agonising, terrifying attacks of internal bleeding. He did this not just once but many times, over at least eight years. He soon became indispensable to Alexandra and Nicholas. Rasputin dominated Alexandra who dominated Tsar Nicholas. Rasputin even advised the Tsar on ministerial appointments. Anyone who spoke against him risked dismissal. The hatred that most of the capital felt for Rasputin dragged the Romanov dynasty into disrepute. In time, his very name became a byword for corruption, evil and debauchery, and he survived an assassinationn attempt in 1914. During the First World War, when Nicholas went to the front to command his troops, the unpopular Alexandra took over political command in the capital. Many people assumed the worst: that the despised Rasputin was the power behind the throne and also a German spy, while Alexandra was his lover. By November 1916, the Russian Empire was on the brink of collapse from the devastation of war, rampant inflation and political instability. In late 1916, the young Prince Youssoupov enlisted a doctor and three other conspirators (including two relatives of the Romanovs) in his plan to murder Rasputin. He invited Rasputin to visit him at midnight in a basement room of Youssoupov’s palace to meet a beautiful lady. It is said that Dr Stanislaus Lazovert ground up enough poison (thought to be cyanide) to kill a dozen men and mixed it inside a chocolate cake. He also laced some wine with poison. Even before he arrived, Rasputin reportedly had already drunk at least a dozen bottles of Madeira. Though Youssoupov fed him poisoned cake and wine, Rasputin did not turn a hair. At last the panicky prince shot his guest in the chest with a Browning pistol. Rasputin collapsed; blood was oozing across his white silk shirt; Dr Lazovert confirmed the death. At three in the morning, the conspirators went upstairs to celebrate.

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But something made Youssoupov return to the basement and check the body; he found no pulse. But then Youssoupov was terrified to see Rasputin’s eyes twitch, then open (“the green eyes of a viper — staring at me with an expression of diabolical hatred”). With a wild roar, Rasputin rose; Youssoupov fled with the “corpse” following. Finally, another conspirator shot Rasputin in the back and the head while Youssoupov beat him around the head with a club. This time they tied up Rasputin, before driving to the river, where they pushed him through a hole in the ice. But in their haste they forgot to attach the weights they had brought along. In less than 24 hours, all of Petrograd celebrated Rasputin’s death. Crowds sang, men embraced each other and champagne flowed. The Times of London called Youssoupov “The Saviour of Russia”. But censorship prevented the Russian press actually mentioning names. One intriguing account started: “A certain person visited another person with some other persons. After the first person vanished . . . ” The body was found 200 metres downstream and retrieved with grappling hooks. Surprisingly, it is said that the autopsy showed that Rasputin had not been dead when he was dumped in the river, but had drowned there. Hearing of the autopsy in progress, Alexandra had it halted at once. But no-one has found the report of any autopsy. Hence many doubts remain; for example, had the conspirators castrated him, as it has been claimed? By killing Rasputin, the conspirators hoped to destroy the proGerman influence at court and to save Russia. But nothing changed; the incompetent ministers stayed on, as did the Romanov policy of repression. In a prophetic letter to Nicholas, Rasputin himself predicted that if nobles or Nicholas’s relatives killed him (Rasputin), “none of your children or relations will remain alive. They will be killed by the Russian people.” Within three months, bloody revolution swept away the whole regime. The Bolsheviks came into power, dug up Rasputin’s body and burned it.

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(GB)

PIZARRO: THE

MISPLACED

CONQUISTADOR In the name of Christ, he destroyed a fruitful empire, bringing nothing but disaster . . . He represents the dark side of man — Man the Destroyer. — Hammond Innes, The Conquistadors

Born in Spain about 1478, young Francisco Pizarro was illegitimate, illiterate and neglected by his poor parents. When some of the pigs he was tending escaped, Pizarro also ran away. After fighting with the army in Italy, he made his way to the New World and became chief lieutenant of the explorer-soldier Vasco de Balboa. In 1513, they marched across the Isthmus of Panama and were the first Europeans to reach the Pacific Ocean. This discovery opened the way to new conquests. The smallpox that the Spanish brought to Panama also helped to overcome indigenous resistance. Soon Pizarro became a partner of another soldier, Diego de Almagro, and Fernando de Luque, a priest, agreeing to share all spoils equally. They could not resist rumours of the rich southern kingdom of the Incas. On their first two expeditions during the 1520s, supplies ran out, many men died in the jungle and Indians attacked them. Pizarro himself suffered seven arrow wounds. After crossing what is now Ecuador, they explored to nine degrees south but finally had to turn back. Pizarro returned to Spain to ask the Emperor Charles V to authorise another mission. In return for Pizarro’s promises of treasure, the Emperor named him governor of the province of New Castile along the west coast for almost 1000 km south of Panama. In 1531, Pizarro set out again from Panama with 180 men and 37 horses. Disease and skirmishes plagued them. It took nearly two

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years for the survivors to enter present-day Peru and make contact with the Inca emperor. The emperor Atahualpa’s army of over 30 000 was camped outside the town of Cajamarca. Messengers told him of men with strange clothes, beards and unknown animals advancing through the deep valleys of the Andes. Did Atahualpa believe he was immortal? Or did he see no danger from the tiny band of Spaniards? At any rate, it is said that he and 6000 soldiers came unarmed to meet them. A story goes that a Spanish priest held out a Bible and asked the Emperor to accept Christianity and the authority of Emperor Charles V. Atahualpa, who in Inca culture was himself divine, flung down the Bible. At Pizarro’s signal, the hidden cavalry charged. They killed thousands and took many prisoners. Pizarro offered to spare Atahualpa in return for a large hall filled with gold. Though the Indians collected much of the ransom, Pizarro broke his promise. Rather than be burned alive as a heathen, Atahualpa chose to be baptised and then garrotted. For eight years, Pizarro ruled the greatest of all the Spanish American provinces. But, wrote Hammond Innes, “the seeds of disaster were ingrained in his own nature”. It was a rule of terror, murder, rape and plunder. Pizarro’s partner Diego de Almagro conquered much of Chile, but finding little booty there, returned to Peru. The two fell out and in 1538 Pizarro had his partner tried and executed. Inevitably, Almagro’s son sought to avenge the death of his father. On Sunday 26 June 1541, Pizarro was dining with about 20 supporters. When he heard a tumult outside, he ordered the front door locked, but the conspirators broke through. Were there only seven, or as many as 25? Accounts disagree. Many guests fled. Pizarro himself did not even have time to put on his armour, but he killed two men. After he stabbed a third man, the conspirator standing behind this man shoved him forward, impaling the dying man on Pizarro’s sword. While Pizarro tried to pull his weapon free, he received a disabling rapier blow to the throat. All the conspirators dipped their swords in the tyrant’s

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blood. Pizarro died, as he had lived, by the sword. Carlos Fuentes in his Republics of the Indies, quotes Roman y Zamora, who calls Pizarro’s soldiers “the worst men who ever set out from any nation and who . . . brought the greatest dishonour to the kings of Spain”. He and his conquistadors had wiped out the whole Inca nobility and destroyed Inca culture. Innes Hammond wrote: “Despite his base qualities, Francisco Pizarro remains a perversely heroic figure.” Indeed, over the centuries, he has had many admirers, even worshippers. At first Pizarro was buried behind the cathedral in Lima, but his remains were as restless as the man himself. They were moved twice in the sixteenth century. In 1606, when the cathedral was rebuilt, the remains went into the new church. Earthquake damage later led to other moves. 1891 was the 350th anniversary of Pizarro’s death. The mummified body was blessed and reburied in a beautiful stone coffin. Since then hundreds of thousands have come to pay homage; some knelt to pray there. But in 1977, workmen cleaning the crypt behind the altar found a recess with two wooden boxes filled with human bones and a lead casket on the lid of which was inscribed: “Here is the skull of the Marquis Don Francisco Pizarro who discovered and won Peru and placed it under the crown of Castile.” Authorities called in an eminent Peruvian historian, two radiologists and an anthropologist. These experts agreed that the newly found skull was that of Pizarro, but many people kept their money on the mummy. In 1984, American forensic anthropologist Professor William Marples matched the skull, which had few teeth left, with a skullless skeleton from the second box. The reunited skeleton was that of a white male aged at least 60. The bones had traces of terrible wounds: four sword thrusts to the neck. Another thrust must have nearly split open the spinal cord. A rapier or dagger had passed through the neck up into the brain. Another thrust had passed through the left eye socket. There were also other wounds: to the

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arms and hands (probably defensive wounds). All up, there were 11–14 stab wounds that had marked the bones. Clearly, this man had suffered a dreadful, violent death. Green stains on the heelbones also matched reports that Pizarro had been buried with a Moorish spur. The green was probably verdigris (staining from copper in the spur). Dr Maples was sure that these were indeed the remains of Pizarro. But if that were so, who was the mummy in the stone coffin? Thorough examination of every bit of remaining skin showed no wounds at all. Even under magnification, the bones showed no fractures, chips, scratches or cuts. This man had led a quiet life and died a quiet death. He may have been a scholar or churchman, but certainly not a conquistador. Now Pizarro’s bones rest in a chapel of Lima’s cathedral. Francisco Pizarro has finally displaced the impostor. (GB)

P R E S I D E NT G R A NT: F R O M W E ST POINT TO THE WHITE HOUSE Ulysses S. Grant won fame as the most successful Yankee general during the American Civil War. Later, he became the first West Point graduate to make it to the White House. He was born in Ohio in 1822. As a boy he enjoyed farming and riding horses. Later, at West Point, he was a superb horseman, so military intelligence drafted him into the infantry. Grant got engaged to be married, but the threat of war with Mexico delayed the wedding. He distinguished himself at the capture of Mexico City. By 1854, he was a captain, but still could not support a family on his army pay, so he left. Or did his drinking and an unsympathetic commanding officer force him out of the army? In any case, Grant resigned and settled in St Louis.

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During the next six years, Grant went from one failure to another. He tried farming (crop prices were low), real estate (he could not collect rents) and clerking, first in a customs house and then in a store. In vain, he stood for county engineer; sometimes he resorted to peddling wood. In 1861, when the Civil War began, Grant was 38 years old; he had already freed his one slave and was happy to re-enlist. His victory at Vicksburg on the Mississippi divided the Confederate (southern) states. Finally, Lincoln made Grant supreme commander of Union forces. On 9 April 1865, at Appomattox, Grant accepted General Lee’s surrender. He released Lee and his soldiers on their honour and let the men keep their horses “for the spring plowing”. His victory made him a hero in the North, and even Southerners appreciated his generous terms. In 1868, the Republicans drafted him for the presidential election, which Grant won decisively. He started well, admitting his lack of political experience: “The office has come to me unsought; I commence its duties untrammelled.” But he appointed too many personal friends and relatives. Though no-one questioned Grant’s own integrity, scandals and frauds implicated his protégés. After his military successes, Grant’s presidency was an anticlimax. He left office in 1877, to travel with family in Europe and the Far East. But during a cruise, he lost his dentures overboard and had to give up public speaking. Back home, Grant retired with savings of about $100 000, which he invested in the banking firm of Grant & Ward. His son, a partner, promised Grant that Ward was a financial genius, but Ward turned out to be a swindler and the bank failed. To avoid the poorhouse, Grant started writing magazine articles about his wartime experiences. In June 1884, while biting into a peach, he suffered severe throat and facial pain, which soon became chronic. Finally, a surgeon saw a growth at the base of Grant’s tongue and advised Grant to see his own doctor (Barker) at once. But since Barker was in Europe, the stoical Grant did nothing and so lost three months.

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By October, Grant had an enlarged gland under his jaw. Barker sent Grant to John Douglas, an ear, nose and throat man. A biopsy showed cancer of the right tonsil. Plastic surgeon George Shrady advised against surgery: a controversial decision. Local treatment included iodoform, gargles of salt water, dilute carbolic acid, and yeast with permanganate of potash. Twice a day, Grant (to save money) took the streetcar to Douglas’s office where the latter sprayed his throat with cocaine. At times, Grant also had injections of morphine, cocaine, and reportedly even brandy! Though Grant’s drinking and smoking had probably contributed to his cancer, Shrady did allow him the comfort of a few cigars. Shrady, who also edited the Medical Record, published weekly bulletins on the general’s condition. Grant’s weight dropped from nearly 200 to 146 pounds. After a night of threatened suffocation in March 1855, he spent his days and nights sitting up with his feet resting on a chair. Once Grant lost his voice, he had to write scrappy notes to his family, friends and doctors. To provide for his family, Grant pushed himself to write or dictate his memoirs, with his friend Mark Twain as publisher. Twain took the risk of guaranteeing royalties on an unwritten work by a man who had never written a book before and was dying of an agonising, incurable illness. On 10 July 1885 Grant predicted that in two weeks, his “work would be done”. On 23 July with the work off to the printer, he died, at the age of 63. The memoirs were a huge success: “one of the great classics of military literature”. In the decade after Grant died, his book sold 312 000 copies. In New York city, Grant’s body lies in a tomb in the General Grant National Memorial. (GB)

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Chapter

7

DEATH

DEATHS

OF THE FAMOUS

In the midst of life, we are in death. — The Book of Common Prayer

Mary, Queen of Scots If Mary Stuart, Queen of Scots, were living now, she would surely feature every week in our women’s magazines. Married three times; a rallying point for the Catholic cause; deposed from her throne; imprisoned for two decades by her cousin Queen Elizabeth I of England. Finally, in October 1586, at Fotheringay Castle, the English convicted Mary of treason. In February 1587, 300 knights and gentlemen watched her enter the hall, tall and majestic, in a black robe and white veil, with a gold crucifix around her neck. Mary’s crowning glory was her head of thick red hair. She sat calmly on the scaffold while Lord Shrewsbury proclaimed her death sentence. Mary snubbed the prayers offered by the Anglican dean of Peterborough: “I am a

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Catholic and shall die a Catholic. Your prayers will avail me little.” After she finished her own prayers, attendants helped Mary to disrobe and reveal crimson undergarments. She knelt and, smiling at her ladies, wished them “Adieu! Au revoir.” The first blow missed her neck and cut into the back of her head. She did not flinch, but only whispered “Sweet Jesus”. The second stroke severed her neck except for one tendon, which the executioner had to saw through with his axe. As he grasped her red hair to hold up her severed head, Mary’s head separated from her wig and bounced onto the floor. Onlookers saw a bald, wrinkled old woman; some claimed that her lips moved for another 15 minutes. Her small Skye terrier scurried from under her robe and lay down “betwixt her head and body, and being besmeared with blood, was caused to be washed”.

Emperor Charles V The Holy Roman Emperor Charles V (1500–1558) wanted to make sure that officials ran his funeral just as he wanted it. So he kept rehearsing it, again and again. He ordered his tomb be erected in a monastery chapel and had a procession of his servants, each holding a black taper. Following them came Charles himself dressed in a shroud. As the hymns struck up, he would lie in the coffin, joining in the prayers for his immortal soul. As he wept, the priests would sprinkle holy water over him. After the congregation filed out, Charles would rise from his coffin and head back to his bed.

Jeremy Bentham Philosopher Jeremy Bentham (1748–1832) set out the principle of Utilitarianism: “the greatest good for the greatest number”.

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Naturally he encouraged people to donate their bodies for dissection and so advance medicine. When he himself died, select people got an invitation: Sir It was the earnest desire of the late JEREMY BENTHAM that his Body should be appropriated to an illustration of the Structure and Functions of the Human Frame . . . the honour of your presence . . . is requested . . .

It was a dramatic dissection, with a violent thunderstorm shaking the building. The surgeon, his face “as white as that of the dead philosopher before him” had to operate between the flashes of lightning. In his will, Bentham instructed the surgeon to reassemble his skeleton, wire together the joints and pad out the whole with straw and hay. But instead of keeping Bentham’s head, he fitted a wax model. The end result, Bentham’s auto-icon, still sits grandly behind glass in University College, London. Bentham’s actual head sits between his feet!

Franklin D. Roosevelt American president Franklin D. Roosevelt (1882–1945) wanted a simple funeral. In 1937, he wrote four pages of instructions: he should not lie in state; no hearse; a simple dark wood coffin; no embalming; his grave not to be lined with cement, bricks or stones. Clear enough? So he was embalmed, did have a copper coffin, did go in a Cadillac hearse to a vault that was cement-lined. Why? He had left his orders in a private safe, which no-one found until after his funeral.

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William Shakespeare We remember some famous people by verse. That on Shakespeare’s tomb reads: Good friend, for Jesus’ sake, forbear To dig the dust enclosed here: Blest be the man that spares these stones, And curst be he that moves my bones.

Prince Frederick Louis Then there was Prince Frederick Louis (1701–1751), son of King George II and father of George III. Fred was an intriguer whom even his parents could not stand. This anonymous verse expresses the English dislike of not just Fred but the whole brood of Hanoverians: Here lies Fred, Who was alive and is dead; Had it been his father, I had much rather; Had it been his brother, Still better than another; Had it been his sister, No one would have missed her; Had it been the whole generation, Still better for the nation; But since ’tis only Fred, Who was alive and is dead, There’s no more to be said.

A few last words James Rodgers, American criminal, shot in 1960, when offered a last request, asked for a bulletproof vest.

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General Sedgwick, American Civil War commander, peering over a parapet: “They couldn’t hit an elephant at this dist . . . ” Dr William Palmer, Victorian poisoner, hanged in 1856, as he stepped onto the gallows: “Are you sure it’s safe?” Finally, Ned Kelly, hanged in 1880: “Such is life.” (GB)

WHAT

R E A L LY K I L L E D

SOCRATES?

Even those Western countries that still have capital punishment reserve it for the most serious crimes. We do not expect civilised nations to execute citizens for their political ideas. But in 399 BC, the city-state of Athens, renowned as the cradle of democracy, put to death the 70-year-old Socrates. He was the first of the three great Greeks (the others being Plato and Aristotle) who laid the philosophical foundations of Western culture. Socrates’s crimes? His scepticism, his beliefs and his teachings. He was short, stout and ugly with thick lips, bulging eyes and a flat nose. He may have trained as a stonemason, but others say he had no trade or occupation. Marrying late in life, he had three sons. Socrates served Athens bravely in the Peloponnesian War against Sparta. When in Athens he spent most of his time in the streets and markets discussing philosophy and ethics with anyone who would listen. Many were aristocratic young men. He taught that every man must “care for his soul”. Knowledge of what one ought to do, he said, was a step towards virtue. Conversely, ignorance led to evil. Socrates did not promote any one philosophy or creed, but encouraged his listeners to learn to know themselves. Himself feigning ignorance, he would keep questioning them. Thus he exposed their ignorance and so encouraged them to seek the truth that lay within them. Rulers, he suggested, should be those who can rule well; not necessarily those who can win elections.

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In 404 BC, after 27 years, Athens finally lost the Peloponnesian War; the greatness of Athens was gone. “Her treasury empty, farms and olive trees burned, navy destroyed, trade ruined, two-thirds of her citizen body dead from disease or war” wrote Dr Gordon Daugherty. The crushing defeat brought repression, terror and the settling of old scores. The charges that the authorities now brought against Socrates were very general: not believing in the gods of the city, introducing new gods, and corrupting the political morals of youth. The jury voted against him, but the vote was close. They asked Socrates what his punishment should be. He claimed to be Athens’ gadfly of truth, rousing its citizens from their stupidity and greed. Hence, as a public benefactor, he asked the state for free dinners and lodging for the rest of his life! Had he shown humility, the jury might have simply exiled him. As it was, they condemned him to die. Even in prison, they let him see visitors. His close friend Crito bribed the guards to let him escape, but he refused, since he believed that citizens should obey even unjust laws. What do we know of Socrates and his death? Since he himself wrote nothing, we depend on the evidence of others. We have a famous painting of the death scene, but that dates from 1787. Plato tells us of Socrates holding a long dialogue on death with 14 of his disciples. Towards sunset, the jailer brought the famous cup of hemlock. Socrates asked the gods to prosper his journey to the other world and “raising the cup to his lips, quite readily and cheerfully drank off the poison”. Presently he lay on his back. E. Hamilton and H. Cairns wrote in Plato: The Collected Dialogues, “The man [gaoler] after a while . . . pinched his foot hard and asked if he could feel it. Socrates said no . . . he was getting cold and numb.” He died peacefully. But what was actually in the cup? What did kill Socrates? By hemlock, we usually mean the plant Conium maculatum, also called “poison hemlock” or “spotted hemlock”. People sometimes

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mistake its leaves for parsnip, parsley or celery. It looks a little like a carrot but has a white root. Most accounts describe hemlock poisoning as being nothing like the peaceful death that Plato described. Nicander of Colophon (204–135 BC) wrote of the “noxious draft” which made the eyes roll, men totter and crawl on their hands: “a terrible choking blocks the lower throat and . . . windpipe; the victim draws breath like one swooning, and his spirit beholds Hades”. A later authority described an equally frightening death: “convulsions, coma, violent delirium, salivation and involuntary discharges from the bladder and bowels”. From the twentieth century, we also have experiments on animals that match these descriptions of hemlock poisoning. Did Plato, who idolised Socrates, simply omit undignified details? Perhaps, but in 1995, Dr Gordon Daugherty raised other possibilities. An extra large dose of hemlock could kill faster and with less distress. Might not Crito have bribed the poisoner to do this? Or the cup may have had hemlock laced with opium and even alcohol! Whatever the exact cause of his death, even today, over two thousand years later, we still honour Socrates. (GB)

THE

MYSTERIOUS DEATH OF EDGAR ALLAN POE Take thy beak from out my heart, And take thy form from off my door! Quoth the Raven,”Nevermore”.

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POE, THE RAVEN Edgar Allan Poe (1809–1849) was a master of writing mysterious and dark tales to embellish already morbid and macabre subjects. The Raven, a snippet of which is quoted above, is a compelling and

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chilling example. He led a dissolute, shadowy life, yet, disturbed though some of his works appear, Poe wrote with such felicity that he seems the embodiment of the cliche “genius is akin to madness”. He died in dramatic fashion at the age of 39 in 1849 when he was found alone and dishevelled in the street following what has always been presumed to have been an alcoholic blowout. But was it? Reappraising his clinical notes, Michael Benitez, professor of medicine at the University of Maryland, has recently thrown new light on the last days of this fascinating man, concluding that his death was even more extraordinary than his life. Poe was born in 1809 in Boston, USA, the son of an English actress and an alcoholic American actor. His mother died when he was two, and his sister died some years later in an institute for what was then called “mental defectives”. John Allan, his godfather, brought him up in what was an unhappy, loveless household. Despite that, he received a classical education in Greek, Latin and French, but socially young Poe was a failure. As a youth he ran up gambling debts which his guardian refused to pay, whereupon he joined the army as a cadet at West Point, but contrived to be expelled by the simple expedient of missing parades for a week. By this time he had begun to write and proceeded to marry his 13-year-old cousin. But he continued to be a troubled soul who attempted to relieve his bouts of depression with alcohol. Yet he became a well-regarded author despite often being seen drunk in public. He became dissolute and emaciated, but personable and engaging enough that, when his wife died of tuberculosis, several women promised marriage if he would stop drinking. He refused all offers, but they inspired him to write some touching essays and poems. Several editorial posts followed, but chances were squandered when he disappeared for two or three months to pursue his opium and alcohol addiction. A wild spree in Philadelphia early in 1849 was followed by a happy, drug-free summer in Richmond, Virginia, in the arms of a widow, Mrs Sheldon. However, in September he suffered forebodings of death, so departed via the railway to return

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to Philadelphia but detrained in Baltimore and disappeared, seemingly into thin air. None of his friends ever saw him alive again. So what happened? Was it alcoholic poisoning or something else that killed him? The answer theorised by Professor Benitez makes for good medical history detective work. The sequence of events was that Poe resurfaced at 7 a.m. on 3 October five days after leaving Richmond, when he was found unconscious and in an untidy and rumpled state lying across two barrels under the steps of the Baltimore Museum. On admission to the Washington College Hospital there was no sign of injury or smell of alcohol. This lack of evidence of alcohol has been disputed, but Benitez claims it is in the hospital notes. In any event, Poe died four days later, but in that brief period we now know there were produced a set of symptoms so unusual as to throw doubt on the usually accepted diagnosis of a druginduced death. Initially, the unconscious patient was unresponsive, but at 3 a.m. on 5 October he developed an irregular and thread-like pulse, sweating, tremulousness and visual hallucinations. He remained thus for 28 hours when he abruptly became tranquil, alert and orientated. He was offered alcohol as a stimulant, but vehemently refused to drink anything, water included. On the third day, clouding of his mental state returned. By late that evening he was delirious and so combative he had to be restrained. He drank water only with the greatest difficulty and under vigorous protest, foaming at the mouth in the attempt. He remained thus until he died the following day, 7 October 1849, shortly after he had murmured, “Lord, help my poor soul.” He was buried with little ado in Baltimore’s Presbyterian Cemetery. What was the cause of death? Benitez, after reviewing the various causes of delirium such as endocrine, vascular, neoplasia (tumour), central nervous system (CNS) infections, metabolic, nutritional and toxic, thinks he has the answer, and could well be right.

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Knowing the alcoholic background, he dismisses first “a nutritional cause” as in, for example, Wernicke’s syndrome, a brain degeneration consequent on long-term alcohol ingestion (because there were no ocular motor signs and the condition was progressive, not relapsing as in Wernicke’s) and Pellagra, the vitamin deficiency malady (there were no diagnostic dermatological signs and again the condition was progressive). Second, “a toxic cause” through alcohol poisoning is discounted because we know Poe had been on the wagon for six months and alcohol was not in evidence on admission. Further, and crucial to the diagnosis, he became acutely ill, briefly recovered, then relapsed, which is not the story with alcohol. Again opiate withdrawal gives a different story, including “goose flesh” or “cold turkey”, and is not recorded here. Benitez critically looked at and dismissed “relapsing fever”, yellow fever, malaria, epilepsy, eastern equine encephalitis and several other rare pathologies as the story did not fit. However, in his view one viral brain infection did fit — rabies encephalitis. This condition is marked by the acute onset of confusion, hallucinations, combativeness, sweating, salivation and spasms. These presentations are episodic and between times the victim is calm and lucid. The patient refuses to drink, indeed is terrified of any fluids, as they produce intense and involuntary laryngeal spasms resulting in frothing at the mouth. All this happened to Poe. The malady, of course, is contracted via the saliva of an infected animal, yet Poe gave no such history. The basic cause was to be discovered by Pasteur, about 40 years later, so was ill understood in Poe’s time and the bacteriology not at all. Actually, it seems that the lack of animal contact is no bar to the diagnosis as fewer than a third of cases can recall such a contact, mainly due to the fact that the virus tracks along the nerves to the CNS very slowly (up to a year from the foot) so the link is forgotten. No vaccine for rabies existed in the 1840s, and if the brain was reached, then, as now, the condition was 100% fatal.

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Benitez proposes that Edgar Allan Poe died of rabies after an initial but long-forgotten exposure, possibly from a cat, an animal of which Poe was inordinately fond. Charles Baudelaire, the French poet, on hearing of Poe’s death, somewhat portentously commented it was “almost a suicide, a suicide prepared for a long time”. But, of course, he was relating it to the commonly held belief that the American had died of alcohol poisoning. Were alcohol and/or other drugs responsible or was it rabies? We shall never know for certain, but perhaps it was prophetic that the imaginative but flawed genius had earlier written in Ulalume: The skies they were ashen and sober; The leaves they were crisped and sere — The leaves they were withering and sere; It was night in the lonesome October Of my most immemorial year.

(JL)

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Chapter

8

DISEASES

IODINE: PROTECTING OUR CHILDREN’S INTELLIGENCE Iodine deficiency has condemned millions of children to cretinism (mental and physical retardation), tens of millions to mental retardation and hundreds of millions to subtle degrees of mental and physical impairment. — James Grant, former director of UNICEF Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for that reason. — World Health Organisation, 1978

The bad news in Australia is that, unless we act now to prevent it, our children and grandchildren may become mentally deficient. We are not talking about infectious diseases like meningitis or vitamin deficiencies like scurvy, beriberi or rickets. We are talking about a simple lack of iodine. One teaspoon of iodine in a whole lifetime is all we need.

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But lack of iodine in pregnant women, their unborn babies and in young children is the world’s single most important cause of preventible mental retardation. Brain development depends on the thyroid gland which produces an essential hormone that contains iodine. To make enough hormone, the thyroid gland needs enough iodine. Professor Creswell Eastman, consultant to the World Health Organisation [WHO] says: “Very subtle hypothyroidism [caused by a thyroid gland that is not putting out quite enough thyroid hormone] in . . . pregnancy can have serious consequences when you study IQ in the offspring.” Too many affected children are still being born. Around the world, 1.5 billion people living in iodine-deficient environments are still at risk of brain damage. When we think of thyroid problems, we think of goitre, which is an enlarged thyroid gland causing swelling of the neck. Goitre is one result of the lack of iodine, but it is far less important than the effect of iodine deficiency on the brain. The general term iodine deficiency disorders (IDD) covers all effects of iodine deficiency. In early life, these include abortions, stillbirths, birth defects, infant deaths, mental deficiency, deafness and mutism. Childhood forms include mental and physical retardation. Where does our iodine come from? Iodine occurs naturally in low concentrations in our environment, mainly in soil and water. Many marine plants and animals (for example, marine fish, shellfish and seaweed) have a lot of iodine. Conversely, iodine deficiency occurs especially inland, in hilly or mountainous areas and in flooded river valleys. The world’s most iodine-deficient areas include the European Alps, the Himalayas, the Andes in South America and the vast mountains of China. Good news: for about 18 years, Australian health workers led by Professor Eastman have been working successfully on this problem in China. Artificial iodine supplements come as injections, tablets, drops, or as additives to salt, bread, water, milk, oil, soya sauce or fish sauce. The cheapest and most effective supplement for large populations is iodised salt. Chinese authorities are working towards

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universal salt iodisation. Their salt industry is being modernised so it can produce 8 000 000 tons of iodised salt each year! A survey in 1997 showed that people in all provinces of China except the autonomous region of Tibet had reached the target levels of body iodine. But in Tibet iodine-deficiency disorders are the major public health problem. Over half the people suffer from goitre and at least 30% of Tibetan children are seriously impaired intellectually. In the most iodine-deficient areas, the average IQ of children is only 85. Professor Eastman calls this “a disaster”. The Elimination of IDD in Tibet Project, in which his team is also playing a large part, includes the building of two plants to produce iodised salt for all Tibetans and their livestock. At the same time, all infants and about one million women of childbearing age (i.e. those most vulnerable to iodine deficiency) will get iodised oil once a year. AusAID is supplying $2 million for this iodised oil. What is our own situation in Australia? More good news: in a well-off country like Australia, we should be able to prevent iodine deficiency. For some decades we have believed that lack of iodine occurs only in Tasmania. This is why in other states we have not regularly monitored people’s iodine levels. When he is wearing his Australian hat, Professor Eastman runs the Australian Centre for Control of Iodine Deficiency Disorders (ACCIDD) at Westmead Hospital in Sydney. Over the last two decades, the centre has occasionally surveyed the iodine content of urine from small samples of Australians. But it’s not all good news: in the last eight years, residents of Sydney have shown a gradual fall in these levels. Other small surveys of pregnant women in Sydney and of people in Tasmania also show low iodine levels. Why are we getting short of iodine? Firstly, for over 30 years, we drank milk that had been in contact with iodine-containing solutions used to clean milk vats, but new cleaning solutions with less iodine are now coming into use. Secondly, we are using less iodine-enriched salt than we used to. What to do? Professor Eastman recommends an Australia-wide survey to confirm the low iodine levels found so far. He also advises

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publicity to stress the dangers of iodine deficiency, especially in pregnancy and early childhood. He advises all pregnant and breastfeeding women to use iodised salt and also take some other form of iodine. But above all, he is pressing for Australia to legislate for universal iodisation of salt. He wants iodine added to all salt eaten by humans and by animals. This recommendation has the strong backing of WHO. Moreover, around the world, 118 countries are now doing this. Professor Eastman can see no good reason why Australia should be among the exceptions. The cost? Less than 10 cents per person per year. The pay-off? Protecting our children and grandchildren. (GB)

THE

GENESIS OF LEGIONNAIRE’S DISEASE

Between 21 and 24 July 1976, the 58th annual convention of the Pennsylvania section of the American Legion was held in Philadelphia (City of Brotherly Love, no less). The headquarters for this jovial meeting of ex-servicemen was located in what I shall tactfully call Hotel A. At the same time, the 56th annual get-together of the local American Legion Auxiliary was being held in another hotel, Hotel B. Both affairs included family members, and there were about 1850 delegates altogether. Besides the usual speechifying sessions, there was a parade, a testimonial dinner, a dance, caucus meetings for the king makers and a breakfast. Obviously, a time of festivity and back-slapping bonhomie: no-one was to know of the approaching cataclysm. Besides the formalities, between times there could often be seen unofficial huddles of delegates in the lobby of Hotel A, or on the pavement outside for the less well-favoured. Moreover, for those

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with more voting clout, suitable refreshments were served in one or other of the 13 hospitality rooms which had been reserved by the 13 men hopeful of office. District branches and past office-bearers had similar rooms scattered throughout several hotels and in all of these beer, whisky and simple snacks were served to the faithful. All this must sound familiar to any regular conference-goer. But on this occasion to this time-honoured formula there were added one or two other seemingly unimportant details which in the end were to prove, well, fatal. For instance, the apparently trivial snippet that Hotel A had been built in 1904, though modified and renovated since, and that guests were accommodated in 700 rooms between the second and 16th floor was to become significant when bracketed with the facts that the meetings were held on the first and 16th floor, and that the out-of-date air-conditioning system consisted of two water chillers from which cool water was circulated to only 60 units in a few strategic places in these areas. At the time nobody gave it a thought. Why should they? Well, this was why: three days after the conference ended, Legionnaire Ray Brennan died of a pneumonia-like illness in Philadelphia. By the next day 117 ex-servicemen who had been at the convention were seriously ill; six were to die. Other victims with serious symptoms followed, and when, by 10 August, it was clear that no new cases were developing, it emerged that 182 persons associated with the meetings had been stricken. Of these 147 (81%) had had to be hospitalised and 29 (16%) had died. Typically, symptoms usually began seven days after the start of the four-day conference, and about three days after returning home. They comprised malaise, headaches, a rising fever with rigours and a non-productive cough. Chest pains were experienced in a third of cases and in 90% X-rays showed patchy areas of consolidation within the lungs. In most the illness progressed over two or three days and then slowly settled, with radiological evidence of improvement lagging

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behind clinical recovery. The older the victim, the greater the risk of death. This occurred at a median of ten days after onset and was associated with shock, widespread and choking consolidation and eventual collapse. No single antibiotic was clearly effective. Of the 182 cases, 142 were males and the age range was from three to 82. One hundred and forty-nine had attended as delegates to the Legion Convention, 17 were family members, one was a hotel employee, and the other 32 had attended other conventions immediately after the ex-servicemens’ assembly. Eighty-four of the sufferers had actually stayed at Hotel A, and all had visited it. Thirty-nine other people who had not attended any conference activities but who had walked down Broad Street past Hotel A at about the same time also fell ill with pneumonia. However, although five died, being non-delegates they did not meet the epidemiological criteria of what was now called Legionnaire’s Disease, so were said to be suffering from ‘Broad Street pneumonia’; a nice distinction probably lost on the grieving relatives. As epidemics go, this outbreak of Legionnaire’s Disease was pretty small beer. Nonetheless, it became an instant Roman holiday for the media and a chastening event for health professionals. Under the full glare of the public spotlight, the world’s best medical brains laboured to identify the causative agent. An intense survey of delegates’ movements, hotel staff, roommates (some soulsearching there), hospital admissions of other pneumonia sufferers, all 1002 of Pennsylvania’s Legion posts, whether sending delegates or not, weather records, workers in the streets round Hotel A and B (and C and D) was carried out. Nothing, it seems, was left to chance. Finally, two men who recovered were brought back to “walk through” their congress activities, and, crucially as it turned out, sampling of fluids and air from the physical environment and airconditioning units of the hotels was undertaken. From all this there emerged a mountain of information, consequential among which was that a significant number of victims had been in hospitality room A on the 14th floor of Hotel A; in it was located one of the air-conditioning units. No other

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room showed a difference between control and case numbers. Further, the mean number of minutes spent in Hotel A’s lobby was significantly greater in victims, as indeed it was for those who watched the parade on the pavement outside Hotel A, compared with being a spectator elsewhere. Between case and control there was no significance difference in the food eaten, alcohol (or ice) consumed, or birds, mammals or souvenirs handled. But there was in the water drunk, even though 38% of the sick said they never drank the water, and, of course, none of the Broad Street coterie had done so. Furthermore, and interestingly, serological tests on the employees of Hotel A suggested the possibility of a low-grade exposure to the malady’s causative agent had gone on for several years, thus giving immunity. In January 1977 it was announced that the pathogen was a previously unknown rod-shaped bacillus. A little later it was admitted that it seemed likely that a number of unresolved epidemics (e.g. in the District of Columbia in 1965, and in Pontiac, Michigan, in 1968) were caused by the same bacillus. Indeed, it was deduced that Legionnaire’s Disease had long been with us, but its acquired name now gave it a note of drama which hitherto had been missing. Eventually, after looking at all the computations, especially noting the implication of loitering in the lobby or the pavement outside Hotel A (over which the exhaust from a cooling unit presumably discharged), or socialising in the suspicious hospitality room, coupled with the significant finding in a special antibody blood test for infections, which for the initiated showed an indirect fluorescent-antibody titre of greater than 1/64 in 29% of the employees, it was concluded that the spread was airborne. The air-conditioning appeared to be the likely source, though it was thought to be strange that the whole grisly fandango only lasted during an exposure of about two weeks. Sporadic cases have occurred since, including in hospitals themselves, and, more recently and closer to home, at the

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Melbourne Aquarium. It would seem that fresh enemies are ever at the ramparts. (JL)

TUBERCULOSIS

CAME HERE WITH

THE CONVICTS A dread disease . . . which medicine never cured, wealth warded off, or poverty could boast exemption from — which sometimes moves in giant strides, or sometimes at a tardy, sluggish pace, but slow or quick, is ever sure and certain. — Charles Dickens, Nicholas Nickelby

Because of their geographical isolation, Australian Aborigines remained free of tuberculosis (TB) until 1770. But TB caused the first white death in Australia. Fosby Sutherland sailed with Captain James Cook on the Endeavour and died of TB (often called consumption) at Botany Bay. Cook buried him on the Kurnell Peninsula, now named Point Sutherland after him. Later Sutherland also became the name of the shire. Tuberculosis was widespread in England, and the convict transports brought many cases to the colony. Australia’s Aborigines, lacking immunity, fell victim not only to TB but also to chickenpox, measles, scarlet fever, whooping cough, diphtheria, smallpox, dysentery and venereal diseases. What effect, if any, did climate have on people with TB? This was a big question during the first two centuries of white settlement in Australia. Why? Remember that until streptomycin became available in the mid-twentieth century, doctors had no specific treatment for TB. Hence they often advised those who could afford it either to rest up or to travel. One doctor here wrote that the warm Australian climate made TB progress faster than in Europe. But many English doctors

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believed just the opposite. Mild climates, whether in Italy or Australia, they insisted, were the best treatment. Indeed, the key English medical journal, the Lancet, often carried glowing reports on the good health of our colony. I wonder what made these writers so optimistic about a distant country that most had never seen. Among hopeful people with TB who made the long trek here were several doctors. Samuel Dougan Bird probably picked up his TB while working at the Brompton Hospital for Consumption in London. First he had six months travel in Europe which did not help. But after only three months in Australia he lost all symptoms and put on six kilos. He was now well enough to set up practice in Melbourne and write a guidebook for other migrants. But Dr William Thomson who had made six voyages here and also worked in Melbourne insisted that the climate had no effect on TB. This started, wrote B. Thomas and B. Gandevia in the Medical Journal of Australia, “one of the most remarkable medical controversies of the nineteenth century . . . it involved not only leaders of the profession and the medical press at either end of the world, but also the lay public and the newspapers”. During the gold rush, migration boomed. Here was a huge reservoir of TB to infect a new generation of Australian-born whites and the even more vulnerable Aborigines. The death rate from TB rose until by the end of the nineteenth century it became the commonest cause of death. But there were also advances in what we now call public health. Eighteen eighty-two saw the setting up of the NSW Board of Health to control infectious diseases. Soon after came testing of cattle for TB. Authorities opened sanatoria for TB, laid underground sewers and improved water supplies. Next came free medical services for mothers and children; later school medical services. In 1915, the Commonwealth Serum Laboratories opened. Pasteurisation of milk started in the 1930s and TB allowances began in 1944. Our first Commonwealth Director of Tuberculosis, Dr Harry

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Wunderly, who himself had TB, persuaded Prime Minister Ben Chifley to fund a national campaign. The 1948 Act increased allowances for people with TB, offered mass chest X-rays and BCG vaccinations and funded TB clinics and hospitals. Also in the 1940s came effective drug treatment, first streptomycin, then PAS and isoniazid. As the standard of living kept rising, so death rates fell dramatically: from 27 per 100 000 per year in 1948 to 1 in 500 000 per year in 1985. In 1976, the Commonwealth stopped funding for mass chest X-rays. But then Asian refugees, among whom TB is commoner, started migrating here, and later came HIV/AIDS, which makes patients very vulnerable to TB. The result is that TB in Australia has again become a concern. Younger doctors, because they have not often seen it, may miss it. But the greatest danger is that without strong public support and government funding, measures to control TB will disappear long before TB does. (GB)

WHEN

IS COT DEATH A COVER FOR MURDER?

Five American children died Waneta and Tim Hoyt were not well off when they married in New York State in 1964, but they did want to start a family. It was a terrible shock when Waneta found her first child, threemonth-old Erik, barely breathing. She could not revive him. Their second child, James, was two years old when he also died suddenly. Julie lived only 48 days. Molly died at three months, as did their last child, Noah. Waneta adopted a son (who survived) but never forgot her own children. She kept their photos throughout the house and every Memorial Day took flowers to their graves.

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Assistant Professor Alfred Steinschneider had cared for the last two Hoyt children. He blamed the deaths on sudden infant death syndrome (SIDS). As well, he taught that all newborn children have brief periods when they stop breathing (apnoea), but that those with apnoea over about 15 seconds are at risk of SIDS. Moreover, he stated that SIDS had a strong genetic basis; this convinced poor Tim Hoyt to have a vasectomy. Many other bereaved parents wondered if they should do the same. Steinschneider also believed that home monitoring (with alarms) of the breathing and pulse of infants would reduce the risk of SIDS. He set out these views in a landmark paper which was published in the October 1972 edition of Paediatrics. The effect of this paper was “like lighting a match in a gasoline factory”. Anxious American parents flocked by the thousands and spent millions on monitors. To a lesser extent, so did Australians. But meanwhile, an English researcher, Professor David Southall of North Staffordshire Hospital, was following and monitoring over 9000 babies in a prospective study to confirm the link between brief apnoea and SIDS. In 1982, he startled a SIDS conference by reporting that he could find no such link. Nor could other workers reproduce Dr Steinschneider’s findings. Nurses at his hospital claimed that they had told him long ago that Waneta Hoyt herself was killing her own children. Psychiatrists talk about Munchausen syndrome by proxy: bizarre behaviour when disturbed people injure or even kill their own children as a way of getting attention from doctors and hospitals. Oddly enough, it was the original paper by Steinschneider that caught the eye of District Attorney William Fitzpatrick. What the paediatrician saw as a deadly genetic affliction, the DA saw as serial killing. In 1994, Waneta Hoyt faced five charges of murder. Steinschneider, now president of Atlanta’s SIDS Institute, appeared for the defence. But much of the incriminating evidence actually came from his detailed records on the Hoyt family. Time magazine asked: “When is Crib Death a Cover for Murder?” Waneta Hoyt confessed to smothering three of her

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children with pillows, one with a bath towel and one by pressing its face against her shoulder. Later she withdrew these confessions, but she was convicted and finally died in gaol in 1998. She now lies buried in an unmarked grave near the children she killed. The medical examiner of San Antonio, Texas, said parents like Waneta “usually keep killing until they’re caught or run out of children . . . Two SIDS deaths [in one family] is improbable, but three is impossible”. Time also cited the case of Marybeth Tinning, whose nine children had died of SIDS and other “natural causes” between 1972 and 1985. “Doctors and friends suspected some rare genetic defect . . . even though one of the victims was an adopted son.” (Time, 11 April 1994.) She was convicted (but not until 1986) of murdering her last child. Even before the Hoyt trial, two medical experts, Byard and Beal, queried the diagnosis of SIDS in two other American families. One family had five siblings die and the other had six; at the time, all were attributed to SIDS. Their conclusion: “Munchausen [syndrome] by proxy is worth considering in the differential diagnosis of any case that appears to defy medical logic.”

SIDS strikes an Australian family: 1977 On 10 July 1977, Glenn Fitzgerald died of SIDS in Melbourne. He was the eight-month-old fourth child of Kaarene Fitzgerald. Glenn’s death changed Kaarene’s life. The pain was not all from the death itself. Many close friends who came to the funeral then faded away. Did these couples fear that they themselves might lose a child? But some others who had been only acquaintances became good friends. Kaarene was one of many parents who needed to find out what had killed her child. She set up a foundation to raise funds for research into the causes and prevention of SIDS and to provide family support and education for health workers. Since its inception in 1990, the successful “Reducing the risks of SIDS” health promotion program

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has helped to save the lives of over 3500 Australian children. Gradually researchers have eliminated many of the original hundreds of possible causes of SIDS. Such research is still continuing, but no single cause has emerged. Kaarene is sure that serial killers like Waneta Hoyt and Marybeth Tinning would be detected in Australia. The closely knit Australian community of SIDS support groups, researchers and clinicians or the coroner would pick up multiple deaths within one family.

SIDS strikes an Australian family: 1999 Melbourne couple Ryan and Kathryn Bessemer have been together since 1995. On 30 April 1998, their first child, Amy, was born. She was a chubby baby with blond hair who slept through the night from four weeks and smiled early. Her first word was ‘Dadda’. Amy was eight months old when she died of SIDS on 13 January 1999. After the morning bottle, Kathryn put Amy down. Fifteen minutes later, she found her apparently dead, tried to revive her and called an ambulance, which came within two minutes. Staff continued resuscitation attempts but without success. Ryan, a computer consultant, was at work when police called him into a side room with the news. They drove him to the Children’s Hospital, where a nurse and counsellor waited with him for the ambulance. He still could not believe Amy was dead. Then Ryan had to ring his own mother. Later, everyone in the family got to hold Amy once more. They bathed her, took photographs, footprints and a lock of her hair. But later still, after the postmortem, they could see only her swollen face and cold hands. Now Amy smelled of formaldehyde. She was no longer the child they had known. Kathryn felt angry that other members of the family expected her and Ryan to comfort them when they themselves so badly needed comfort. Similarly, they both found it hard to cope with

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each other’s grief while they were battling with their own grief. Ryan felt suicidal: “The only thing a parent wants, at any cost, is to be reunited with their child.” He found the two weeks’ leave from work far too short. If he had not had to keep paying off the mortgage on their new house, he would have quit his job. He still goes to monthly SIDS Fathers’ Nights. Eight weeks after Amy died, Ryan went to hear the final postmortem report from the pathologist. Kathryn did not feel up to going. She feels close to her GP, who came to Amy’s funeral. Both Kathryn and Ryan welcomed talking to Vivian, a counsellor from the SIDS Foundation. (GB)

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Chapter

DISASTERS

9

AND

ECCENTRICS

SUFFER

THE CHILDREN

Few doctors practising in the early 1960s .. . . could read this book [Suffer the Children] without concluding ‘There, but for the grace of God, go I.’ — Dr Francis Roe, “Medicine and books”, British Medical Journal

In the 1950s, the Distillers group sold Scotch whisky, vodka, gin and pharmaceutical drugs. If only they had stuck to spirits. At Crown Street Women’s Hospital in Sydney in 1960 obstetrician Dr William McBride first prescribed a sleeping tablet/sedative new to Australia: Distaval (thalidomide). His first patient had severe vomiting of pregnancy; with thalidomide, she settled quickly. Dr McBride started to use it not only for morning sickness but also for insomnia in pregnancy.

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Later that year, nurses at Crown Street noted more women than usual with threatened miscarriage. In May 1961, Dr McBride delivered a Mrs Wilson: her baby had a blockage of the bowel and severe defects of both arms. Despite emergency surgery, the baby died after a week. Soon Dr McBride delivered another baby with similar defects; another death. In June came a third. Since the average rate of birth defects was only about 2%, this was a remarkable sequence. All three women had taken thalidomide during their pregnancy. It was the German company Grunenthal that had first synthethised thalidomide. The Sunday Times Insight Team claim that Grunenthal had simply sent samples to doctors, asking them to try the drug and note the results. No-one reading the report of Grunenthal’s 1955 symposium on thalidomide could guess that the company was employing some of the doctors who were reporting the best results. Grunenthal also played down reported side effects: dizziness, nausea and irreversible defects of the nervous system. To minimise medical scrutiny and increase profits, it promoted thalidomide both over the counter and on prescription. When pressed, the company could not say whether the drug could cross the placenta (and hence perhaps affect the unborn child). Why not? Because Grunenthal had simply not tested the drug on pregnant animals. Sales boomed, but by 1959, there were also growing complaints from German doctors. Grunenthal hired a private detective to watch patients who complained, as well as officials and doctors who spoke against thalidomide. By 1958, under licence from Grunenthal, Distillers were selling thalidomide in Britain — the blind leading the blind. They recommended its use in medicine as well as in obstetrics, where they said it was quite safe for pregnant women and nursing mothers. In late 1960, the British Medical Journal (BMJ) printed a letter describing nerve damage from thalidomide. The next year, a BMJ advertisement assured doctors of its safety. But the same issue carried three more reports of nerve damage!

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In the USA, after two years of investigation, one drug house decided not to market thalidomide. But another drug house, Richardson-Merrell, went ahead. They also assured doctors of thalidomide’s safety, even for pregnant women, though they had not studied pregnant animals either. The American “clinical trials” were just as shonky. Salesmen found over 1200 doctors willing to be “investigators”, but told them “they need not report results if they don’t want to”. These doctors distributed over two million thalidomide tablets to 20 000 patients. There was no suggestion of informed consent, let alone any control group. When thalidomide was finally withdrawn, many of these investigating doctors had no records to allow anyone to trace the women! But the vigilance of Dr Frances Kelsey of the Food and Drug Administration (FDA) kept thalidomide off the general market in the USA. Finally, in November 1961, a German professor alerted his colleagues. The public outcry in Germany forced Grunenthal, after more than four years, to withdraw the dreadful drug. Still they denied any problems. But the English medical journal the Lancet now printed Dr McBride’s famous letter from Sydney. This reported multiple severe abnormalities in almost 20% of babies whose mothers had taken thalidomide. Finally, the companies did the animal work they should have done in the first place years before. They found that thalidomide did cross the placenta in mice. Thirteen of 18 newborn rabbits showed the characteristic deformities of thalidomide babies. But in Britain, Distillers had still not given up; they kept trying to get thalidomide back on the market. In Japan, people could buy thalidomide for another year. A Swedish company continued to sell it in Argentina for three months after withdrawing it at home! The most powerful chapter in the Sunday Times book Suffer the Children deals with families affected by thalidomide. One mother said: “When they gave [my baby] to me, his face was split, hanging apart like on a butcher’s slab. The doctor was crying and said

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my baby wouldn’t live. But he did (blind and without arms) . . . I didn’t cry outwardly, but inside I screamed.” At first, many families did not know the cause; many doctors did not tell them. Some parents blamed themselves or each other; there were suicides and broken marriages. One Belgian couple, with help from their GP, poisoned their daughter who had been born without legs. These parents were acquitted of murder. Some nurses and doctors shunned the children. But there was pressure on them to do something. So doctors operated up to 40 times on some children. Many of the operations helped, but many did not. Some blind, deaf, dumb, paralysed and retarded children are still alive. Some parents are still changing nappies on children who are now in their 30s. Just as sordid as the marketing of thalidomide was the treatment of families claiming compensation. Only in Germany did the government act on their behalf. In Britain, courtroom battles pitted shattered, isolated people with poor legal advice against the top talent hired by Distillers — a real case of David and Goliath. Publicity might have helped the claimants, but for year after year, fear of contempt of court restrained the media. Dr John Newlinds was Medical Superintendent of Sydney’s Crown Street Hospital in 1960. He believes the book Suffer the Children is essentially accurate. But was this tragedy preventible? Dr Newlinds also pointed out that in 1960 doctors had not known of any drugs causing major defects in the newborn. Moreoever, even before thalidomide, phocomelia (absence of the upper arm and/or upper leg) did occur (though rarely). He blames the companies for not looking for such effects but is unsure whether animal testing would have shown the danger to humans. The Australian Drug Evaluation Committee was set up after the thalidomide tragedy. There were at least 30 live thalidomide-affected children in Australia. Around the world, there are perhaps 10 000. But how many more unborn babies had defects which killed them? (GB)

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A

PATIENT’S REVENGE

Each December, doctors look forward to a few Christmas cards and perhaps even a present or two from grateful patients. But patients aren’t always grateful; some patients can turn on their doctors. In Brisbane, one man killed two orthopaedic surgeons who he felt had failed him. Thirty-nine-year-old Karl Kast was a naturalised Australian. At 2.50 p.m. on 1 December 1955, he walked up the stairs of Wickham House in Brisbane’s quiet tree-lined medical area and shot Dr Michael Gallagher three times. At least one shot entered the chest. It was only prolonged surgery that saved the doctor’s life. Then Kast ran downstairs, lighting a gelignite bomb, with which he dashed out into the street. A passing horse-trainer tried to put out the fuse and lost three fingers in the process. In Ballow Chambers, 100 metres away, Kast shot and killed Dr Arthur Meehan and Dr Andrew Murray. He also tried to grab Dr John Lahz, who suffered severe shock. The killer then locked himself into the consulting rooms. First came the sound of a shot; then the explosion of another gelignite bomb — two murders, a severe wounding and a suicide, all in about ten minutes. The president of the British Medical Association’s Queensland Branch called the deaths of Dr Murray and Dr Meehan “unparalleled in peacetime”. The next day Brisbane Criminal Investigation Branch got Kast’s letter, presumably mailed just before the murders. He complained of the injustice of the specialists who had refused to give him worker’s compensation for his back injury. Kast had intended to send all four doctors “into oblivion”. Enclosed was a week-old clipping from Canada about a patient there who had shot his orthopaedic surgeon. There were more explosives in Kast’s boarding house room as well as another letter: “Seeing there is no justice and life is devoid of hope, I must look for justice elsewhere . . . ” Police could find

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no relatives. His personal effects went to his landlady, whose son described Kast as considerate and fond of children. Born in Bavaria, Kast came to Australia in late 1938 and was interned when war broke out. A fellow-internee told police: He [Kast] was amazingly quiet and never had any friends .. . . he escaped once but was soon recaptured. [Once] he disappeared in the camp and we found him hiding under a hut. He was a brewer by trade, but out here he was made to do heavy work. He told me then that he had something wrong with his spine . . . After the war we were sent to Alice Springs to work for the Civil Construction Corps . . . again they tried to get him to do heavy work. Apparently specialists would not agree with him that he had a spinal injury and . . . this kept building up inside him . . . I think the authorities could have helped him, but probably, without realising, made it harder for him instead.

Only detectives, pressmen and gravediggers went to Kast’s burial. Could anyone have reached out to Kast? Could three lives have been saved? (GB)

VOYAGE OF THE DAMNED: THE SECOND FLEET The Second Fleet . . . took many unsuitable convicts from England’s overcrowded and diseased gaols and hulks, put them in unsuitable ships controlled by avaricious and unsavoury men, and deposited those few who managed to survive on an ill-prepared colony. — Cobcroft, “Medical aspects of the Second Fleet”, Australia’s Quest for Colonial Health

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Three ships left Portsmouth on 19 January 1790 to bring 1000 convicts halfway around the world to Port Jackson. By then the colony was in desperate straits. The weekly ration was down to 2.5 lb of flour, 2 lb of weevilly rice and 2 lb of shrivelled salt pork. On 3 June 1790 the colony joyously greeted not the Second Fleet, but Lady Juliana, the first convict ship to reach Australia since the First Fleet. She brought the first news for nearly three years: George III’s madness, George Washington’s inauguration, the French Revolution, and the reason why no supplies had arrived for so long: the Guardian had struck an iceberg. But the crunch was that Lady Juliana not only brought little food, but dumped on the colony an “unnecessary and unprofitable” cargo of 222 women convicts. At least they were healthy, not like the prisoners on the Second Fleet (Neptune, Surprize and Scarborough) which soon followed. The Reverend Johnson boarded the Surprize: “Went down among the convicts . . . a great number of them laying . . . unable to turn or help themselves. The smell was so offensive I could scarcely bear it. . . . Some of these unhappy people died after the ships came into the harbour . . . ” At this time, naval officials in London were submitting to the King their proposed idyllic Great Seal of New South Wales. It showed “Convicts landed at Botany-Bay; their fetters taken off and received by Industry sitting on a Bale of Goods with her attributes, the distaff, bee-hive, pickaxe and spade, pointing to oxen ploughing, the rising habitations, and a church on a hill . . . ” Primary sources on the Second Fleet disagree on the number of convicts and the death rates. But in round figures, of the 1000 prisoners transported, about one quarter died on the voyage, one half were landed sick, and one eighth died soon after. Only about one eighth were still alive and well some weeks after landing. The mortality on these three ships was the highest in the history of transportation. Fatal Shore author Robert Hughes describes: “the starving prisoners . . . chilled to the bone on soaked bedding, unexercised, crusted with salt, shit and vomit, festering with scurvy and boils”.

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What went so wrong? The Second Fleet was at sea for a shorter time than the First; the ships were well provisioned. Why then did so many die? Many convicts were already sick when they were embarked from the hulks moored on the Thames. Scurvy, dysentery, vomiting and fevers were common, possibly louse-borne typhus as well: “One man . . . had ten thousand lice swarming on his body.” Drinking water, especially that from the Thames, often went bad long before the Cape of Good Hope. The water that the Surprize took in often covered its wretched convicts to above their waists. The contractors used leg-irons from their slave-trading journeys. Captain William Hill, guard commander of the Surprize, described these as having a short bolt “. . . not more than three-quarters of a foot in length so that they could not extend either leg from the other more than an inch or two; thus fettered, it was impossible for them to move but at the risk of both legs being broken”. Many died with the chains upon them. Fear of an uprising often led masters to keep their convicts below decks. Profits lay in dead convicts. In theory, convicts received twothirds of the Royal Navy ration. This covered bread, flour, beef, pork, peas, butter and rice. But in practice, convicts were often cheated of their food and half-starved. So they concealed the deaths of their fellow convicts so that they could have their rations; they took tobacco from the mouths of the dead; they stole food from the hogs. Whereas the First Fleet had been a naval exercise, the Second was a private venture.The government chartered the ships from London merchants and paid them a flat rate of £17, 7s 6d for each convict embarked. Though contracts required merchandise to be landed safely, they said nothing about the condition of the convicts. Captain Hill railed against the “villainy, oppression and shameful peculation” of the masters of the Neptune and Scarborough: “The more they can withhold from the unhappy wretches, the more provisions they have to dispose of . . . ”. On arrival, the masters

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made huge profits selling the withheld food. News of the Second Fleet’s fate caused public outrage in England. In the face of accusations by the crew of Neptune, the master (Donald Traill) and mate fled. The merchants also escaped prosecution. Though the promised inquiry never happened, great improvements did follow. The payment system changed: contractors received £5 of their capitation fee only for those convicts who landed in good health. The navy started to appoint naval surgeons who were of a higher calibre than those available to the contractors. Death rates on convict transports fell dramatically. On the Neptune, almost one in three convicts had died. But only one year later the Salamander lost fewer than one in 30! (GB)

MAD KING LUDWIG II

OF

BAVARIA

In the introductions to Walt Disney’s offerings for children which used to feature on television several years ago, those concerned with Fantasyland showed a castle with tall, slightly askew, turreted towers set in romanticised crags and forest. Despite the fairy glitter, it was in fact a fairly accurate representation of a real-life Bavarian castle, Neuschwanstein. This imaginative place was built as recently as the 1880s by the capricious King Ludwig II of Bavaria, a monarch whose tenuous contact with reality was such that Disney had made an inspired choice to represent fantasy. While it is generally acknowledged that Ludwig was definitely odd, the question for medical historians was whether his actions amounted to true mental illness or whether he was just an eccentric who could afford to indulge his extravagant and romantic whims only to fall foul of psychiatric bungling on the grand scale. It is an extraordinary story, so let’s first recount his bizarre last few days and then look at his mental background.

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Ludwig was born in Munich in 1845, the eldest son of King Maximilian II of Bavaria and Maria of Prussia. As a boy he received the strict Teutonic upbringing thought appropriate for the children of central European royalty. At the age of 13 he became enamoured by Richard Wagner’s music and when he ascended to the throne in 1864 he sought out the composer. They formed a close relationship in which they spun fantastic plans for a new world of music until their union became a national scandal and Wagner had to leave the country. They remained friends, however, and Ludwig remains famous as being the composer’s indulgent patron. Following this estrangement, and after breaking a loveless engagement of convenience which he had undertaken with his cousin, Ludwig became concerned almost exclusively with artistic endeavours, developing a lavish passion for building castles of fantastic opulence in the Bavarian mountains. Once his whims were indulged his thought pattern changed and he became suspicious, arrogant and unpredictable towards his cabinet. He frequently managed to paralyse government by going off for long periods to one or other of his three castles. He was rarely seen by his subjects and was given to solitary brooding and long sleigh rides at night. His brother, Otto, was declared insane in 1875, and it was generally thought the King was going the same way. Continually frustrated, early in 1886 the cabinet felt enough was enough and asked the Professor of Psychiatry at Munich, Bernhard von Gudden, to assess the King’s mental health. As a personal examination was thought impossible, Gudden collected documentary evidence and the views of the staff to form an opinion. Without setting eyes on the subject he concluded that the ruler was indeed insane. This rather chancy path to diagnosis was picked up by the worldly Chancellor Bismarck who neatly dismissed the report as “tittle tattle and the rakings from the King’s waste paper basket”. With the help of three other doctors but still no personal contact, Gudden reworded the document, and stated that none of the team had any doubt about the severity of the King’s madness. All signed the report which concluded that Ludwig (1) was in an

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advanced stage of paranoia, (2) was incurable and would get worse, and (3) would forever be incapable of exercising government. Not much equivocation there, and one must marvel at their certainty, especially as the Bavarian Constitution stated that a monarch incapable for more than a year could be deposed. The report was submitted on 10 June 1886, and the immediate upshot was that the King’s uncle was declared Regent. The following day, a small medical posse headed by an assured Gudden left for Neuschwanstein with the dubious task of taking the patient, a complete stranger, into protective custody. The King had been forewarned of the situation and on their arrival had the group arrested. He then made a fatal error by ordering that they be flayed alive and then flogged to death. Such punitive excesses alerted the guard that their commander may indeed be ill, so the doctors were released. The cabal left, regrouped and reappeared at 1 a.m. on 12 June. They were met by the King’s valet who solemnly pronounced that Ludwig had been drinking heavily and wanted the keys to the castle’s Fantasyland tower in order to commit suicide. That finally did it: the King was surrounded, confronted for the first time by Gudden, told of the findings, and immediately, and not unreasonably, responded by questioning the validity of the armslength diagnosis. Gudden showed the documented proof, garnered from hearsay, and the patient was seized and taken away to Castle Berg. The next day, 13 June, Gudden walked with the King through the castle park, presumably (and hopefully) to get some symptoms at first hand. They were followed by two attendants. All went well and another ambulatory chat was arranged for later that afternoon. At 6.30 p.m. the pair set off again, but due to some confusion in the orders from Gudden the two attendants returned to the castle rather than falling in at a discreet distance to the rear. When the walkers had failed to return by 11 p.m. a search party was sent out. Both psychiatrist and monarch were found floating in the lake, dead.

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The sequence of events is conjectural, but has been explained as going probably something like this. While skirting the lake it seems likely that Ludwig had made a sudden dash for the water, which, incidentally, was quite shallow for 30 metres from the shore. Gudden must have held on to his coattails for one of his fingernails had been torn away. The King then seems to have slipped out of his jacket, turned on the luckless Gudden, and gripped him by the nape of the neck while sinking the fingers of his other hand into the psychiatrist’s throat. He then held the head under water until the doctor drowned. All this has been deduced from the postmortem report. Ludwig II, already in a suicidal frame of mind, walked a further 25 metres or so into the lake, where, still in shallow water, he managed to drown himself. His watch had stopped at 6.50 p.m. It seems on the evidence that the doctor was either trying to save the life of a patient hellbent on suicide or was stopping him from escaping across the two-kilometre-wide lake. Whatever the facts, he perished in the attempt. Gudden was 62 and Ludwig 40. Despite the dubious psychiatric practice shown in this saga, Bernhard von Gudden was regarded as a man who, by the lights of the day, ran his unit in a humane way. It was he who had introduced to Germany a “no restraint” policy which allowed disturbed patients as much freedom as possible. It may have been this liberality which in the end was his undoing, although on the day of his death he had commented to other members of his party how dangerous the likes of Ludwig could be. The misunderstanding with the attendants and their premature departure made the difference between life and death. After his presumed murder, there was little public sympathy for Gudden. Indeed, his grave was later desecrated and his widow was threatened with violence. If that is the bizarre story of the royal death, what about the mental health of Ludwig and his family? Was the king really mad or just a romantic and self-indulgent eccentric? His family, the Wittelsbachs, had ruled Bavaria for 700 years.

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Grandfather Ludwig I was a byword in both European whoredom, for maintaining the infamous Spanish dancer and adventuress, Lola Montez, as his mistress, and civic largess by dint of unrestrained spending on some splendid public buildings in Munich. Otto, Ludwig’s younger brother, was pronounced incurably insane at the age of 25. He is supposed to have been a florid schizophrenic, but in letters to his old governess Ludwig revealed that “. . . Otto makes terrible faces, barks like a dog and sometimes says the most indecent things, and then again he is perfectly normal for a while”. Gilles de la Tourette, the Parisian neurologist, was not to describe his famous syndrome until nine years later in 1884, but these royal observations sound almost better than his classic description of a malady to which he gave its eponymous title. In any event, Otto was kept confined for 30 years until his death in 1916. Their cousin, Rudolph, Crown Prince of Austria, was to shoot himself in 1889. He seems to have entered into a suicide pact with a lover, for he was found in bed with a naked 17-year-old girl also dead from gunshot wounds. Ludwig’s relatives from Hanover, then on the throne of England in the embodiment of Queen Victoria, the last of the Hanover line, are postulated to have been tainted by porphyria, a malady which can become evident as severe mental disturbance; it had already famously manifested itself in King George III. And finally a paternal aunt was once kept in an asylum while suffering under the unshakeable and remarkable delusion that she had swallowed a glass grand piano. So all in all Ludwig’s psychical background was not propitious. Ludwig grew up a shy and highly strung boy whose homosexual propensities soon became evident. He had romantic attachments to several aides, troopers and stable lads, many of whom later sold his revealing letters. Nonetheless, at the age of 22 he became engaged to his cousin, Sophia, but the arrangements were called off when his relationship with an equerry, Richard Hornig, burgeoned. It was to last for years. Following his broken engagement, Ludwig became withdrawn and remote, suffering great feelings of guilt

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about these homosexual urges. He retired to Castle Berg where he developed the wearisome habit of turning night into day. His best-known quirk was to imagine he was riding to a distant town, estimate the number of circuits of the riding school it would take to make the distance, then proceed to do it through the night, taking appropriate breathers at phantom inns. The Crown Princess of Prussia, the eminently sensible daughter of Queen Victoria, reported that he dined with a horse which was kitted out with a gold crown. Not unnaturally, people began to talk. From 1869 until his death in 1886, Ludwig kept a diary, two volumes of which were eventually published. As early as 1870 ruminations about suicide were committed to the book, such as “The waters of the Alpsee beckon to me”. But many entries centre on mastering his guilt about his homosexuality, and on unbridled feelings of majesty and preoccupation with Louis XIV, the so-called French Sun King who died in 1715, 150 years previously. He was fascinated by the mystical significance of numbers and in one of his written pieces made the nonsensical conclusion that “10 + 11 = 21, the number of terrible memory, but quite exceptionally 10 + 11 make 12”. There were many other tortuous numerical ruminations which are surely highly significant in the thought disorders of schizophrenia. Through the 1870s he became even more preoccupied with his castle building, mostly on inaccessible crags. If his ministers visited he sat behind a screen, and although unseen, it was admitted that some of his observations and questions were shrewd enough. For the last three years of his life, and after the death of his romantic idol, Wagner, he became a complete recluse. In the composer the King had found a musical genius with an imagination extravagant enough to match his own. It was thus in 1886 that Bernhard von Gudden was eventually asked to report on the King’s mental state, and, as we have seen, this was accomplished by merely the logging of depositions. Indeed, some Wagnerian scholars, music critics and other

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apologists have since called the exercise “a political conspiracy done by medical hirelings”, and the conclusion of “paranoia” used to cover what was only “a multitude of minor eccentricities”. Richard Hornig, his lover, was very reluctant to testify, but others had no such reservations. The sergeant of the Royal Stud told how when out walking Ludwig said he could hear voices, could never identify the words, but would apparently answer them. His valet testified the King imagined things and could not be dissuaded in this belief. For instance, after he ordered a knife to be removed from the dinner table, when it was obvious to all that the table was bare, he ordered an hour-long search for it to be carried out. Staff told of outbursts of rage, or hours of mute contemplation, and thirty-two servants reported maltreatment in some way. There could have been some axe–grinding here, of course, so corroboration would be needed. Although he always ate alone, all dishes had to be prepared for four people as the King imagined he was entertaining guests, a fiction he perpetuated by carrying on an imaginary four-way conversation. From various accounts it seems the first signs of illness were as early as 1865 when he was 20. Definite signs of withdrawal had appeared by 1867 when the engagement was broken off, but the florid mental symptoms did not manifest themselves until about 1883. Could he have been another right royal example of porphyria, the scourge of the Hanoverians? What about the central nervous system manifestation of tertiary syphilis, grandly styled by doctors as general paralysis of the insane or GPI; perhaps as a distant link with the exotic Lola? Did he have a toxic psychosis due to alcohol, of which it is known he was fond? Or were his extravagant quirks after all merely whimsical self-indulgences carried out by an autocrat who could afford it? I think none of these. Despite the medical bungling of the certification — not to have seen the patient would rightly be impossible now — I am sure Gudden got it right. The age of onset, the family history, the delusions and hallucinations observed by

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people whose loyalty was never in doubt, and, crucially, the selfrecorded thought disorder, all point to florid schizophrenia. And yet in the whole sorry fandango, almost as tragic a figure as Ludwig was the doctor, Bernhard von Gudden. He has been portrayed as the villain of the piece, but almost certainly he died trying to save his patient’s life. It was just one more aberrant twist in an already bizarre case. (JL)

SAUERBRUCH: THE

RISE AND FALL OF A GREAT SURGEON

In The Doctor’s Dilemma, George Bernard Shaw called medicine and other professions “conspiracies against the laity”. In The Dismissal: The Last Days of Ferdinand Sauerbruch, Surgeon, Jurgen Thorwald writes, “Doctors feel obliged to cover up professional errors on the part of fellow-physicians . . . Professional discretion shields the bungler”. On 17 April 1951, Dr Ferdinand Sauerbruch (1875–1951) operated on 41-year-old Berlin woman Irmgard Fiebig. Deep inside her throat, she had a secondary cancer the size of a hen’s egg. He had already operated in 1947 for her breast cancer. But towards the end of 1950, she had noticed a lump in her neck. Then it became painful. After ignoring it for some time, she returned to the clinic where she had first seen Sauerbruch, but the staff there turned her away. Finally, she talked her way into his house to see Sauerbruch there. Hence her second operation, one of the most bizarre catastrophes in the history of surgery. In his own home, with only local anaesthetic, Sauerbruch started with a cut of about 20 centimetres in her neck! She endured agonising pain, not only during the operation itself, but for the rest of her life. Finally, six months later, Irmgard Fiebig won release in death. Why did she suffer thus? Why did a surgeon of international renown attempt major surgery in this barbaric way?

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Way back in 1904, as a young doctor, Sauerbruch had made a huge breakthrough by finding a means by which surgeons could open the chest. Thus he “put an end to a centuries-old medical doctrine that chest diseases could not be treated surgically”. His methods allowed surgeons to operate on the lungs and heart and led to great advances in the treatment of tuberculosis and cancers. He lectured in America and worked in the leading hospitals of various European capitals. At the Charité Hospital in Berlin, his surgical unit brought great renown to German medicine. But Sauerbruch was a heavy drinker and a philanderer. According to Robert Youngson and Ian Schott, his behaviour was “a bewildering hotchpotch of kindness and harshness, wisdom and thoughtlessness, great compassion and explosive temper, irresistible charm and cold hauteur . . . unaffected modesty and extraordinary conceit”. Such erratic behaviour “made it difficult to contend with Sauerbruch when he lost his faculties and began to kill patients”. After the Second World War, Berlin was divided. Sauerbruch, though in his 70s, still headed surgery at the Charité hospital, which belonged to the Soviet-controlled sector. To Soviet doctors, he was a hero. Dr Friedrich Hall, who was in charge of medicine in East Berlin, first met Sauerbruch in 1948. It struck Hall that Sauerbruch, despite his reputation for mental vigour, repeated himself, forgot names and talked of dead people as though they still lived. Then Hall came across tapes of Sauerbruch’s lectures given before the war. The contrast convinced him that the old man now had dementia. That made him “as dangerous with the knife as a drunken man”. Indeed, by now Sauerbruch had already caused at least one needless death. In 1946, he operated for a hernia on a private patient of 39 years. That night, the man bled to death. Hoping that the old man could not keep working much longer, Hall just waited. But soon after that Hall heard that a respected surgeon, Karl Stompfe, had suddenly resigned after Sauerbruch, his chief, had hit him. Then, in Hall’s presence, another assistant

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reported to Sauerbruch that he had found an inoperable brain tumour. Sauerbruch rushed into the operating theatre. A few minutes later, he held out his bare unwashed hand to show Hall the tumour: “Look at that . . . I went right in and pulled it out. The finger is still the best instrument”. So another patient died. Hall now asked the professor of pathology about unexpected deaths at the Charité. Though the pathologist was an old friend of Sauerbruch, he admitted that Sauerbruch was dangerous. Still the authorities insisted on retaining him to lend status to the now communist-controlled Charité! The party line was: “In the coming struggle of the proletariat, in the clash between socialism and capitalism, millions will lose their lives . . . it is a trivial matter whether Sauerbruch kills a few dozen people on his operating table. We need the name of Sauerbruch.” Late in 1949, Sauerbruch operated on a boy with stomach cancer and closed the bowel and the stomach without rejoining the two — another death. Finally, two of his superiors invited Sauerbruch to supper. Over three agonising hours, they appealed to his pride and finally persuaded him to resign rather than be dismissed. On 3 December 1949, Sauerbruch did officially resign from the Charité. But then he still kept coming each day to work, until they had to lock him out of his office. Sauerbruch was flattered to receive speaking invitations from colleagues who felt he had been unjustly treated. The medicos of Hanover turned out to hear him speak on the philosophy of medicine. But the demented old man lost his thread; soon he could not string a sensible sentence together. He himself was happy with his speech, but his shocked colleagues begged the reporters to hush up the fiasco. Next Sauerbruch started to work at a private clinic, until his employer realised his error. Each day he would tell Sauerbruch that there were no patients for him, or that the theatre was booked out. This farce continued for months. Then, in 1950 came the most tragic phase: the old man trying to operate in his own home, where some devoted old patients tracked him down.

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Time and again, the authorities avoided their responsibilities by asking his wife, Margot, herself a doctor, to stop her husband. Margot disconnected the doorbell, since she had to work and could not afford to stay at home to watch over the demented old man. That was how, in 1951, Sauerbruch operated on poor Irmgard Fiebig. Finally, the authorities banned him from seeing any patients at all. The tragedy did not end until Sauerbruch himself died a pauper on 2 July 1951. His ghosted memoirs, That Was My Life, finally published after his death, were remarkably successful, selling almost a million copies. (GB)

MEDICAL

BOARD CRUCIFIED

GP

Doctors who received an orthodox medical education did not look kindly on unqualified practitioners, especially those who cured the medical profession’s failures. — Maltby and Lee, “The medical establishment and association with unqualified practitioners: The sad case of Doctor Axham”, Journal of Medical Biography

About a hundred years ago, Herbert Barker was at London’s Paddington station bound for a holiday on Jersey Island. Without ceremony, a total stranger limped up to him: “I’ve come all the way from Sydney. I’ve been chasing you from pillar to post.” Barker pointed out that his train was about to leave. “You could at least examine me on the train,” the Australian persisted. By the time they were out of London, Barker had offered to manipulate the visitor’s displaced joint (we don’t know which joint) as soon as he returned from his holiday. The man said, “Do it now, I don’t mind pain.” Swaying with the speeding train, Barker braced himself and manipulated the joint. Later he wrote: “This man . . . had to travel half the globe’s circumference . . . all just to get put

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right an injury that any man properly instructed in manipulative surgery should have been able to handle.” Born in 1869, Herbert Barker first served as apprentice to his cousin, a well-known but medically unqualified bonesetter. Later, he inherited the practice and ended up in Park Lane, where his patients included H. G. Wells, the Duke of Kent and George Bernard Shaw. Barker’s manipulation often relieved dodgy necks and knee joints, back strain or painful feet. Dr Frederick Axham, a Soho GP, found that Barker could help some of his (Axham’s) patients when he (Axham) could not. To spare patients the pain of manipulation, Axham gave anaesthetics for Barker from 1906 to 1911. No problem. But in 1911, a patient had a complication after Barker manipulated his knee. When Axham testified for Barker, the Medical Defence Union complained to the General Medical Council (GMC) about Axham giving anaesthetics for Barker. The GMC charged Axham: “That you have knowingly and willingly . . . assisted . . . an unregistered person in a department of surgery, in carrying on such practice . . . and [are] guilty of infamous professional conduct.” After Axham refused to cut his ties with Barker, the GMC ignored his unblemished 49 years of practice and deregistered him. No appeal was possible, but his letter appeared in The Times: My professional status is stripped from me for an association which was and is desirable . . . It is undesirable that Mr Barker should operate without an anaesthetic . . . the alternative to a qualified man is an unqualified man. Convinced . . . that Mr Barker’s methods are both sane and sound . . . I had no hesitation in associating myself with him in a work which has resulted in unspeakable relief to thousands of patients whom surgeons by orthodox methods absolutely failed to relieve.

Though now unregistered, Axham continued to give anaesthetics for Barker but could no longer practise in any other way. Over the

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years, Axham’s friends, as well as Barker and his friends, all tried to get Axham reregistered. So did the press: “The . . . profession has a habit of crucifying its most gifted members on the cross of conservative prejudice.” All in vain. After Axham retired altogether in 1921, many younger doctors offered to give Barker’s anaesthetics. The chosen one was Dr Frank Collie, from an eminent medical family. He wondered if he would also be struck off. But the GMC’s silence was deafening. As Barker wrote, “the law had a Nelson eye”. Sir William Arbuthnot Lane was among the prominent surgeons whom Barker won over. Lane told his students at Guy’s: “The bonesetter . . . has profited by the inexperience of the profession and by the tendency . . . of adhering blindly to creeds whose only claim to consideration is their antiquity.” As Barker’s star rose, so did Axham’s fall; he lived in genteel poverty and professional disgrace. In 1922, Barker won a knighthood for his services to manipulative surgery. Four years later, Axham died at the age of 86. His last words were: “I forgive as I hope to be forgiven.” Herbert Barker paid tribute: “All who knew the man and know the facts hold my old friend and colleague in the highest esteem.” Professor Roger Maltby remembers hearing that in the 1920s his own mother, a physical education student, had a locked knee. After a surgeon put it in a plaster cast for six weeks, her parents took her to Barker, who not only unlocked the knee, but showed her how to do it herself. He charged her only 30 guineas (the same fee he charged footballers), whereas most patients paid 100 guineas. In 1936, the British Orthopaedic Association invited Barker to show his skills at St Thomas’s Hospital. The president-elect of the Association of Anaesthetists won thanks for anaesthetising! But Barker, still thinking of his old friend Axham, challenged the doctors: “Gentlemen, are you not now guilty of unprofessional conduct?” Dr Rowley Bristow was among the 100 surgeons there. He wrote in the British Medical Journal: “Had [Barker’s] offers to demonstrate . . . been accepted twenty-five years ago, the general

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utilisation of this branch of therapeutics (manipulation) would not have been so long delayed.” Drs Maltby and Lee sum up: “The GMC could have reviewed its earlier disciplinary action against Axham before he died; in view of its omission to take similar action against his successors, its failure to do so appears both hypocritical and unjust.” A comment from Dr Peter Arnold, veteran of Australian medical politics: “A latter-day Dr Axham who gave anaesthetics for manipulative (as opposed to operative) surgery would have no problem with today’s NSW Medical Board.” (GB)

T HE

FREEZING OF

FRANKLIN

In a 12-day voyage during September 1969 the 151 000-ton oiltanker Manhattan traversed the 1000-kilometre Northwest Passage off northern Canada. The task was accomplished with contemptuous ease and the Manhattan became the first ship to make its way through the five-metre thick ice of the passage and be back at the fleshpots of New York within the month. This was not, however, the first vessel to make the transit. That single honour belongs to the ship of the Norwegian explorer Roald Amundsen who, setting off in 1903, took three years over it, navigating only in summer to eventually finish in 1906. He did it in a 47-ton herring boat and dallied, it is said, to escape his creditors. The first single-season voyage was in 1944 by Sergeant Larsen of the Royal Canadian Mounted Police. The original object of this seemingly foolhardy mission was to find a quick way to the Orient from Europe, a desirable and timesparing objective of the pre-flying days and which had first been mooted to the well-regarded navigator John Cabot, by King Henry VII of England. That was in 1497, and between then and 1906 there were many disastrous, albeit gallant, attempts.

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But in all that time there were none more disastrous or more gallant than the expedition mounted in 1845 by a former Governor of Van Diemen’s Land, Sir John Franklin. Van Diemen’s Land is, of course, now called Tasmania, and Franklin is probably better known to the locals as having lent his name to their most famous river. But to the world at large, his exploratory zeal in the Canadian Arctic has become a byword in courage. And it is not without considerable interest in the annals of medical history. The facts surrounding the start of this voyage of discovery are well documented. Of how on 19 May 1845 the naval ships HMS Erebus and HMS Terror sailed out of the Thames carrying 134 officers and men on the best-equipped expedition ever to leave for polar regions. The ships were the most technologically sophisticated vessels afloat and were built to go where no ships had gone before. There were provisions for five years, which at a pinch could have been stretched to seven, and they had retractable propellers, desalinaters, an internal heating system and some of the world’s first cameras to record the epic event. They even had on board a wardrobe of costumes for amateur dramatics which had been planned to amuse the men during the long nights. And of the expedition’s leaders, the President of the Royal Geographical Society, catching the mood of the day, proudly stated, “The name of Franklin alone is, indeed, a national guarantee.” Freshly painted in yellow and black, the ships departed from Greenwich and were given a spirited farewell by 10 000 people, brass bands and the good wishes of a clutch of civic dignitaries. Five men were dropped off in Greenland and the ships with 129 souls on board were seen to enter Baffin Bay at the end of July. But then . . . silence. Not one of them was ever seen alive again. By 1847 the Admiralty began to wonder aloud about their fate. But not until 1850 did any urgency creep into plans for sending out a search party. During the subsequent hunt traces of huts were found, and also, most excitingly, three graves. A chiselled headstone put the earliest death at 1 January 1846. It was speculated that scurvy was the cause, but the inferior quality of the

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tinned food was considered a factor. It was not until May 1859, fourteen years after their dazzling departure, that, together with a lifeboat, two skeletons and some abandoned equipment, the first and only written record was found. With agonising brevity it stated that Sir John Franklin had died on 11 June 1847 and the ships were abandoned on 22 April 1848, by which date nine officers and 15 men had perished. What it did not say was how they had perished and where the rest had gone. The observation of the search party leader, Captain M’Clintock, could not have been bettered when he wrote at the time, “So sad a tale was never found in fewer words.” Parts of skulls and other fragments of cloth and rope were found over the years, but interest languished until in 1981, 133 years on, Owen Beattie, an anthropologist from the University of Alberta, thought that King William Island, site of the known landing, might still hold some secrets of the Franklin disaster. The distillation of his findings over the following four or five years, which have been written up mainly by his co-explorer, John Geiger, have produced a unique scientific record of quite remarkable fascination. The visits Beattie paid to the area and the sometimes grisly finds he chanced upon are not only documented with punctilious detail and literary grace, but are enlivened by a set of the most brilliant photographs; no petrified grin is avoided, no femur is left unturned. The account, however, is not for the squeamish or fainthearted. Several exploratory trips were made to the area of the disaster, and it eventually became evident that to get some sense into the mystery of the deaths, three main questions needed to be answered. First, why was it that when a dismembered skeleton was found the skull fragments were near the campsite and the limb bones farther afield? Second, was it not strange that quite a few of the crew died fairly early on in the expedition, and, more than that, there was a disproportionate number of officers to men, including the leader? And lastly, and crucially, why was it that lead levels in

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the bones of crew members were ten times the levels of those found in Inuit from the same area? Beattie originally thought these heavy metal readings were a chance finding, as, along with everyone else, he considered that the sailors had died of a combination of starvation and scurvy due to vitamin C deficiency. But to ensure completeness of any postmortem examinations, he requested that the laboratory do a blanket scan of all elements. This was unusual and timeconsuming, but the unexpected results demanded a rethink of the situation. The conclusion regarding the scatter of bones was the unsavoury one that during the last days cannibalism had taken place. While strength lasted, and perhaps to avoid the haunting gaze of your fellow sufferers, the more meaty limbs could be picked up and carried off to be eaten away from the tents. To crack open and eat a face and brains, it was reasoned, you would have to have been pretty hungry, insensate or getting to the end of your tether, probably all three. Therefore, you were more likely to be lying in the campsite, too weak to move far. It was concluded that the answers to the second and third questions were related and opened up completely fresh theories from those put forward over the years. The reasoning went that the contractor for the supply of the huge order of 8000 of the then relatively new-fangled tinned foods (remember this was in the mid-nineteenth century) had difficulty meeting the sailing deadline. He was Stephen Goldner, a victualler from London. To expedite delivery he employed unskilled labour, paid scant attention to hygiene and packed poor meat together with animal hair and bones. The most generous comment is that quality control suffered, but, furthermore and tragically, records were to show that a significant proportion of the food went bad due to indifferent sealing. But there was even more to it than that. At the time the tins were made from a wrought iron sheet which was bent into a cylinder and then soldered with lead both

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inside and out. Beattie collected a number of the cans which had been dumped on the shore and were still scattered about, and came to the conclusion that lead contamination from the soft solder, known to contain 90% lead, would have been quite considerable. The average amount of lead in the ordinary urban population is 5–14 parts per million, and symptoms of poisoning begin to develop after the absorption of about 40–50 parts per million. In recovered hair from exhumed bodies and other tissue, the figures ranged from 138–657 parts per million. It was concluded that lead poisoning and not just starvation was the prime cause of death. Why more officers? Well, they would have had a preferred diet of more tinned food and less blubber, pemmican and the like garnered from the surrounding terrain. They also ate off leadenriched pewter plates. For once class distinction worked to a disadvantage. Three of the sailors were exhumed, a task not without its difficulties in view of the fact that the ground was frozen solid with permafrost. In the unlikely event that you are ever called upon to do the same, the trick is to pour boiling water on the soil and be prepared for a prolonged operation of tedious, unrewarding digging. The drama was heightened by the fact that a distant relative of one of the men answered an advertisement the organisers had placed in a British newspaper to assist the expedition, sailed with the scientists and in the end came face to face with an ancestor whose likeness was in almost mint condition, preserved by the ice. It must have been an emotional moment for him. As well as the excess lead, tuberculosis was a feature in those exhumed. This was a common disease back then and would not be the result of any privations suffered. So I think it can be concluded that the long-held belief that vitamin deficiency was the prime cause of death is not true. It was more likely to have been lead poisoning and starvation, complicated by the then common and debilitating disease of tuberculosis. However, whatever the cause, slow death in such a solitary place, in bitter weather and knowing there was no way out, must have been

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particularly pitiable. Franklin’s nephew, Alfred Lord Tennyson, wrote the explorer’s touching epitaph for his Westminster Abbey plaque. It goes: Not here: the white North hath thy bones, and thou Heroic Sailor Soul Art passing on thy happier voyage now Towards no earthly pole

But for these two remarkable and doggedly persistent Canadian researchers another quotation from the same orotund author could well apply. It is from his poem Ulysses and appears on the memorial of the gallant South Polar explorer Robert Falcon Scott. It goes, you will recall: To strive, to seek, to find and not to yield.

(JL)

AUSTRALIAN

DOCTORS’ BATTLE WITH LEAD POISONING

Medical researchers often criticise the delay between a key discovery and its widespread application: the gap between knowledge and action. One striking example is the prevention of lead poisoning. In this field, Australian research ranks with the best in the world, but we have been slow to apply this knowledge. Hippocrates, Galen and Celsus were among early authors who described lead poisoning in adults. But only much later did doctors studying the families of leadworkers recognise the very different picture in children. In the 1890s, there was an epidemic, mainly in Queensland and northern New South Wales, of children with anaemia, wasting, poor vision and stomach pain. Brisbane doctors studied 79 children, of whom many died. They showed that these children had

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lead poisoning. But how were the children exposed to lead? The intense search covered roofs, water tanks, pipes, guttering, cooking pots, home canning and even the silver paper wrapping of sweets. (This was before the days of leaded petrol.) Then one hot Sunday an idea came to Dr Lockhart Gibson while he was relaxing on his verandah. He saw that the paint on his railings was powdery. After he wiped this powder onto a clean rag, the government analyst confirmed its high lead content! On the woodwork in the homes of the sick children, he found the same white dust. Thus doctors confirmed that peeling and flaking household paint was the source of the lead. This tied in with the higher frequency of lead poisoning during the Queensland summer, when paint became dry and powdery. But why were only some children poisoned when whole families lived in painted houses? One mother told Dr Gibson that of her four children, the only ones to get lead poisoning were the two “nailbiters and fingersuckers”. The doctors warned the government of the dangers of white lead paint and pressed for legislation: “. . . recurrent attacks of lead poisoning could be prevented by getting them (parents) to replace lead paint by zinc paint on verandah railings and outside surfaces within the reach of children”. In 1929 doctors noted that chronic kidney disease was very common among young adults in Queensland and linked this condition with lead exposure during childhood. A special report in the Medical Journal of Australia pressed for “Legislation against lead paint . . . on any articles available to children — furniture, toys, pencils and so forth, as well as on external surfaces such as verandahs.” But still nothing changed. Further reports hammered home the same message. Finally in 1955, the government banned lead from all paint made, sold or used in Queensland. But that was not the end of the problem, either in Queensland or elsewhere. Even now many people live in houses containing old, lead-based paint. It will still be a long time before we see the end of poisoning by lead in paints in Australia. (GB)

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THE

MURKY HISTORY OF TOBACCO

Have you heard of the man who got so worried when he read all the articles linking smoking to cancer that he gave up reading? Most authorities agree that the use of tobacco started in South America. For many centuries before white exploration, indigenous Americans grew and smoked tobacco. They used it in ceremonies, for its intoxicating effects and to ease aches and pains, snakebite, chills, fatigue, hunger and thirst. They smoked it in cigars, pipes and cigarettes (wrapped in cornhusks); they made tobacco syrup to swallow or apply to the gums. They chewed it or snuffed it. The Maya of Yucatan (now in Mexico) regarded tobacco smoke as divine incense to bring rain. Perhaps the oldest representation of a smoker is a stone carving from a Mayan temple showing a priest puffing on a ceremonial pipe. Christopher Columbus was the first known white man to meet the weed on the island of Cuba, or perhaps San Salvador. One of his crew brought the habit home. But back in Portugal, his friends, seeing smoke pouring out of his mouth, were sure he was possessed by the devil. He languished in jail for several years. By the early sixteenth century, Spaniards in the West Indies and Portuguese in Brazil were smoking more and more. Most could not stop. In 1559, Jean Nicot, French ambassador to Lisbon, used tobacco leaves to cure his cook’s cut finger. Then he sent seeds as medicine to the French Queen Catherine di Medici, who grew medicinal herbs. Nicotiana tabacum is named after him. It is related to potatoes, belladonna and henbane. In the 1580s, Walter Raleigh set up a colony in Virginia; Francis Drake brought back the tobacco habit. It is reported that Sir Walter Raleigh’s servant, on first seeing smoke drifting from his master’s mouth, poured a bucket of water over him! Many of the large tobacco plantations around the world got their start from the Portuguese. By 1600, all the maritime nations

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of Europe were using tobacco. But in England, King James I, who succeeded Elizabeth I, challenged its popularity. He had his Counterblast to Tobacco published anonymously: A custome lothesome to the eye, hateful to the nose, harmfull to the braine, dangerous to the lungs, and in the black stinking fume thereof neerest resembling the horrible stigian smoke of the pit that is bottomless.

James decreed that people who were caught smoking would have the pipe rammed down their throat — an early example of health education. Next James organised at Oxford the first public debate on tobacco, at which he showed black brains and innards said to come from deceased smokers. He increased the tobacco tax 40-fold, but this just made smuggling boom. In the 1600s, Turkey, Russia and China imposed (and enforced) the death penalty for smoking. Yet the Chinese became the heaviest smokers of tobacco in Asia; later this led them to smoking opium. In his 1653 work English Physician the herbalist Nicholas Culpeper listed the many benefits of homegrown tobacco. People used it in cigars or pipes or as snuff; some used tobacco as an enema to revive the drowned. With special bellows, fans could even have smoke enemas. One enthusiast pushed it as an infallible cure for 36 different ailments. Some people smoked to cure asthma, while others took infusions of tobacco. Some used tobacco as a stimulant, while others liked it as a sedative. Others swore by finely powdered tobacco as a disinfectant. When plague broke out in London, doctors said smokers were less likely than others to catch it. During epidemics, scholars at Eton were thrashed if they did not smoke! Doctors used tobacco as well as mercury in sweating baths for syphilis. London had 7000 tobacco shops. While the poor mostly used pipes, the upper crust also snuffed or sniffed tobacco dust. Though various popes forbade its use, not even priests could stop. It was over two centuries ago that some doctors warned patients of the link between tobacco and cancer. In 1761, the English

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physician John Hill described perhaps the first case of tobaccoinduced cancer: his patient had cancer of the nose. In 1851, the eminent surgeon James Paget warned a man with a white patch (“smoker’s patch”) of the tongue where he rested the end of his pipe: “he certainly would have cancer of the tongue if he kept smoking”. Soon after, a French doctor reported 68 cases of cancer of the mouth; 66 of these patients smoked tobacco, while the other two used to chew it. How did cigarettes come into existence? Beggars in Seville picked up discarded cigar butts, shredded them and rolled them in scraps of paper. Cigar makers, fearing the competition, spread rumours that cigarettes contained opium, and were made with tobacco from discarded cigar butts and paper made by Chinese lepers! Warfare and smoking have often gone together. During the American War of Independence, George Washington begged: “If you can’t send money, send tobacco.” The French used to buy tobacco from the colonists, so General Cornwallis did his best to destroy the Virginia tobacco plantations. As long as chewing tobacco (usually a mixture of molasses and tobacco) was popular in the USA, all public buildings had to have spittoons. The advent of cigarette-making machines and safety matches around the late 1800s set the stage for smoking to boom. Soon after the First World War, doctors in Britain noted that lung cancer was becoming much more common. During the next half century, the annual death rate from lung cancer shot up. Scientists suspected an environmental cause: suspects included occupational exposure, urban pollution, tarred roads, exhaust fumes from internal combustion engines, and tobacco smoke. Cigarette smoking among men boomed during the Second World War. In Britain after the war, Dr Richard Doll asked 600 patients with lung cancer about their smoking habits. Almost all were cigarette smokers, whereas there were fewer smokers among the control subjects (people without lung cancer). At this time, the male smoking rate in Britain was still about 85%; many people smoked to clear their lungs! Dr Doll was himself a smoker but now the evidence

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induced him to stop. To nail down the connection, he needed to follow people in a prospective study. He sent questionnaires to the 60 000 doctors then practising in Britain. After five years he found “a marked and steady increase in the death rate from lung cancer as the amount smoked increases”. The good news: those who stopped smoking cigarettes reduced their risk. One eminent chest physician advised colleagues to follow his example. To keep his hands occupied after he stopped smoking, he took up knitting! Sir Macfarlane Burnet, an icon of Australian medicine, also used to smoke. But by 1955, he gave up, saying, “The evidence [against it] is too strong.” Moreover, he kept speaking up in public, urging Australians to do the same and the television stations to stop cigarette advertising. In 1971, he appeared in an advertisement for the Anti-Cancer Council of Victoria. Channel 7 showed the advertisement for a week, but then pulled the plug. The publicity following on from this censorship greatly advanced the goals of the anti-smoking lobby. In 1962 the Royal College of Physicians in the United Kingdom stated clearly that smoking caused lung cancer. Two years later, the American Surgeon-General said the same thing. Was it this report that led activists in New York to carry scissors and cut cigarettes out of the mouths of passers-by smoking in the streets? Long-term results of Doll’s study on doctors showed that about half of all regular cigarette smokers would eventually die from a smoking-related cause. (Tobacco causes many diseases apart from lung cancer.) In 1979 came a second report from the US Surgeon-General with further alarming findings: pregnant mothers who smoke may harm their babies; as smoking levels among women rise, so do disease and death rates (“Women who smoke like men die like men who smoke”); and more children were smoking. The Medical Journal of Australia asked doctors to set an example

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by not smoking. Indeed, by 1982–83, only about 11% of Australian doctors were smoking cigarettes, compared with over 30% of the Australian population. It is now hard to deny the devastating effects of cigarette smoking on health. But as anti-smoking movements have hobbled promotion in wealthier countries, tobacco companies have turned to other markets. While visiting Australia in 1998, Sir Richard Doll, then an active 85-year-old, said, “Exposing the hazards of tobacco smoke is the thing for which I would like to be remembered.” He reserved his harshest scorn not for tobacco companies, but for governments that have failed to restrict tobacco promotion. Even though the NSW government has just banned smoking in indoor restaurants, cafes, shopping centres and casinos, and governments in Australia have been among the global pioneers in tobacco control, we are still a long way from achieving a smoke-free generation in Australia. The epidemic of death and disease caused by tobacco is still mounting all over the world. Tens of millions who smoke today are doomed to be killed before their time unless they give up the habit. (GB)

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Chapter

QUIRKS

10

AND

ODDITIES

IT’S

NEVER TOO LATE TO CHANGE

Does life feel like one big drag? Do you want to do something quite different? One middle-aged doctor left his practice to sell hot dogs. His therapist had similar feelings of rebellion. This story struck a chord with me too. I was over 50 before I realised my teenage dream of writing. Back to the discontented doctor and his family. When seven-year-old Charlie was referred to Dr Herbert Strean, a psychoanalyst in New York, his parents were not hopeful. Charlie was unruly and aggressive. He would flare up whenever he could not get his own way. His mother and father saw themselves as model parents and felt that his bad behaviour reflected on them. The father, Saul, turned out to be a physician. Once when they were alone together, Dr Strean asked Saul how Charlie’s behaviour affected him. Saul sprouted a long

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speech, saying that children should obey their parents: “When I was a boy, my parents’ rules were like law. I was always good.” Over the next few months, Saul talked about his own childhood. Finally, he told Dr Strean a secret: “Sometimes I feel like giggling when Charlie is naughty.” With a lot of prodding from the therapist, he went on: “I would have loved to be a rebel too, but I always did the right thing. I really never wanted to be doctor at all, but that was my parents’ dream. I’ve never enjoyed my work.” “So what did you want to do?” “I’ve always wanted to run a hot-dog stand.” This confession reminded Dr Strean of one of his own happiest memories. At 19, he had escaped briefly from the academic grind and worked outdoors selling ice cream. At college, he had written a composition about the happiest man he knew: it was the local garbage man. This had triggered Herbert Strean’s own fantasies of doing his own thing and also being a garbage man. Just like Saul, the young Herbert had resented his parents and other authority figures. So the rebel in him wanted to encourage Saul’s dream. But since he believed that therapists should not tell clients what to do, he tried to remain neutral. Gradually Saul came to accept Dr Strean’s view that Charlie represented the little boy in Saul who secretly resented his parents’ wishes, even though he felt obliged to follow them. At night Saul often dreamed that he was selling hot dogs at Disneyland. But then someone would destroy his stand, or he somehow lost it, and he would wake up depressed. After nine months of therapy, Dr Strean suggested: “You want to give up medicine and sell hot dogs but you also want something to stop you.” Saul agreed: “If I gave up medicine, I’d be rejecting my parents.” After a year, Saul told Charlie about his dreams. Charlie surprised him by saying: “Daddy, you should do what makes you happy.” Saul finally resolved to make his move. His wife thought he was crazy, but she was happy to escape the dreadful winters in New York.

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Tearfully, Saul thanked Dr Strean: “You’re the kind of parent I always wanted but never had.” From California, Saul wrote about his happy days outdoors selling hot dogs. Charlie was also doing well. The famous psychoanalyst Sigmund Freud wrote: “No psychoanalyst goes further than his own complexes and internal resistances permit.” Dr Strean feels that he was able to help Saul only because he himself had dealt with similar conflicts during his own analysis. But sceptics would say that this analyst actually encouraged his patient to do what he himself dared not do. Did Saul really jump or was he pushed? (GB)

TRUTH

STRANGER THAN SOAP OPERA

It all started in 1974. He was Professor of Neurology at Rush University, Chicago. She came into hospital to have a small ulcer removed from one ear. She was a widow aged 64, a heavy smoker of 40 years who admitted she had smoker’s cough. The intern confirmed that she had chronic bronchitis. The anaesthetist ordered premedication, which included morphine. They gave her the morphine injection at 9.20 a.m. the next morning. When the porter came for her at 9.30 a.m., she was covered in a blanket and was half-asleep. The lift was as slow as usual, so she didn’t reach the theatre suite until 9.45 a.m.. At 9.50 a.m., the theatre nurse came to check her in. Red alarm. Her lips were blue; she wasn’t breathing. Then her heart stopped as well. After the staff revived her, she got good heartbeats, but when they tried to stop ventilating her (pumping oxygen into her

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lungs), she could no longer breathe for herself. Again, they ventilated her, but once again they dare not stop. So they cancelled the surgery, kept her on a ventilator and settled her in the intensive care unit. Then they asked the neurologist to assess whether she had suffered any brain damage. For half an hour, he talked to her. Because of the breathing tube in her windpipe, she had to write her answers. But her mind was very sharp; she told him all about her children and grandchildren, and even her favourite soap operas. He concluded that she had no brain damage. Still, her own doctors just couldn’t get her off the ventilator. Week after week, month after month, she stayed in hospital, reading, listening to music or knitting. She could do anything except talk or breathe for herself. Then the hospital started buzzing with rumours of a court case. People said she was suing; that with her bronchitis, the anaesthetist shouldn’t have ordered morphine (which depresses breathing) for her. Once more they asked the neurologist to see her. When he walked in, she was still on her ventilator but no longer sitting up, no longer reading. She was in a coma; no brainwaves; she was brain dead! The notes told him only that two days before she had suffered a cardiac arrest; they didn’t say why or how. When finally they had to take her off the ventilator, that was the end of her life, but not the end of the lawsuit. She had filed it, and her heirs kept it going. About two years after she died, the neurologist got a subpoena. The heirs were suing everyone. The hospital blamed the anaesthetist for ordering the morphine. He in turn blamed the hospital, especially the porter who had taken her to theatre in the beginning, for not seeing that she was not breathing. After six months, the case was settled for around US$1 million; one-third from the anaesthetist (or his insurer) and two-thirds from the hospital. Only much later did the neurologist get the story from a defense lawyer. The hospital administrators knew what had caused her fatal

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second episode. After her first episode, they had decided to teach all the porters resuscitation. But there was one porter who just wouldn’t learn; he wouldn’t even go to the classes. It was the same one who had taken her to theatre when she first arrested. The hospital felt they couldn’t fire him — at least until the case was settled. Instead, they changed his job. They wouldn’t let him move patients anymore; now he’d just deliver flowers, presents and television sets. One day, the 64-year-old woman felt bored; she’d read too many books, listened to too much music. She asked for a television so she could watch her beloved soapies again. The porter came to the bed; she was snoozing, so he didn’t need to wake her. He’d just make sure the set was working, leave it for her and go off to lunch. All the power points were in use, so he unplugged one. The bedside light went out, so he plugged it back in and unplugged another. He tuned the television, turned it to General Hospital, and went on his way. Except of course that it was the ventilator he had disconnected. It was only on the day before the porter was due to give evidence that the hospital settled. (GB)

A

GREAT WAY TO KEEP YOUR DATA SAFE

This story takes me back over ten years now. My wife Kitty started the whole computer thing. It was during what she lovingly called my “second midlife crisis”, or when I was trying to start a writing career. I was thinking of an electric typewriter, but Kitty could see further ahead and suggested a word processor instead. Our friend Phil took pity on my ignorance and helped me find a secondhand PC with the various extra bits. But now I needed a study large enough for all these bits with their cords and connections. It wasn’t easy, but by juggling the kids’ bedrooms, I finally managed.

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Only thing was, Kitty seemed quite tense by now. At dinner parties, we no longer talked politics and cappuccino machines but RAM and bytes. Even now Kitty still says I went overboard, I was neurotic, I was obsessional . . . how wrong she was. I was simply being careful. How would you feel if a week’s work vanished in a flash? At least she didn’t argue about the surge board, but that’s useless in a blackout. Obviously, an emergency generator was the way to go. I joined Neighbourhood Watch. Etching my licence number on the computer, keyboard, monitor and printer was fine, but the floppy discs were harder. Kitty visits her parents each week, so I asked them to look after my third set of back-up floppies. They were fine about that, but Kitty got stroppy when I asked her to just update the floppies when she went over. Then one day, we were planning to go out for dinner for my birthday. I worked extra hard, finished an article about 4.30 p.m. and sent it from our post office (the poor man’s fax machine). On my return, I was surprised to see a delivery truck in our drive. Two burly men, breathing heavily, were battling with a huge steel-plate safe. Our daughter Jackie stood firmly barring the doorway. Her face was crimson and she kept shouting: “Take that thing back; it’s all a mistake.” To add to the uproar, her ghettoblaster was blaring out “We shall overcome” at 100 decibels. “There’s no mistake,” one of them snapped at me. “Just look at the docket.” Sure enough, it had our name and address; it was all prepaid. “Just give me a minute. I’ll ring your office and sort it out.” But by now the office people had all knocked off. What could I do? Without high explosives there was no way I could budge this monstrosity. Until we could talk to the office, we were stuck with it. Jackie and I were trying to settle our frayed nerves with a strong coffee when Kitty bounced home from work. She edged her way past the safe in the hallway, jumped onto my lap and gave me a big hug: “It’s come today, just as I asked them. I’m so glad for you. Happy birthday darling”.

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“Kitty, what on earth is going on? Did you order this thing?” “Of course I did. You’ve been so worried about losing things from the computer, I had to help you. Don’t you like your birthday present?” “Just tell me one thing! Why do I need a safe three feet by three feet by three feet for floppies that are only five inches wide?” “Don’t be silly. It’s not just for the floppies. This is your very own, very special safe. It’s for the whole computer!” (GB)

DOCTOR OSLER,

THE JOKER

As you battle with the daily grind, do you ever yearn to do something childish just for the hell of it? Perhaps play a practical joke? In 1884, the prestigious American journal Medical News carried a doctor’s report of a house call: I was sent for about 11 p.m., by a gentleman . . . in a state of great perturbation . . . At bedtime . . . a noise in the coachman’s room attracted his attention . . . he discovered that the man was in bed with one of the maids. She screamed, he struggled, and they rolled out of bed together and made frantic efforts to get apart . . . He was a big burly man . . . and she was a small woman . . . She was moaning and screaming, and seemed in great agony . . . I found the man standing up and supporting the woman in his arms . . . it was quite evident that his penis was tightly locked in her vagina, and any attempt to dislodge it was accompanied by much pain on the part of both . . . I applied water, and then ice, but ineffectually, and at last sent for chloroform, a few whiffs of which sent the woman to sleep, relaxed the spasm, and relieved the captive penis, which was swollen, livid and in a state of semi-erection, which did not go down for several hours, and for days the organ was extremely sore. The

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woman recovered rapidly . . . Yours Truly, Egerton Y. Davis Ex–US Army

Over the years, journals and textbooks cited this case as a complication of vaginismus (contraction of the muscles around the vagina). But the account was pure fiction, written under an alias by Sir William Osler (1849–1919). Osler was a physician who became eminent in three countries, first at McGill University in Canada, later as founding professor of medicine at the Johns Hopkins University, and finally as Regius professor at Oxford. His reputation, according to albert Lyons and Joseph Petrucell; in Medicine: An Illustrated History, is still secure as “a pragmatic, practicing physician who made outstanding contributions to medicine . . . a writer of an encyclopaedic medical text which was a standard for generations . . . the model of a cultured, articulate, insatiably curious, highly principled physician.” Does this sound like a man addicted to practical jokes? But the letter above was not Osler’s only offbeat case report. Four years later, in 1888, in the Canada Medical Record, he described: An interesting experience which I had [while on vacation by train] in the Northwest [of Canada] in 1886 . . . [A friend] mentioned [that] two days before, a woman while in the water closet on the train, had given birth to a child which had dropped to the track and had been found alive some time after. I was so incredulous that he [the friend] ordered the conductor to stop the train at the station to which the woman had been taken . . . I found mother and child in charge of the stationmaster’s wife and obtained the following history: “She was aged about 28, well developed, of medium size and had had two previous labours which were not difficult. She had expected her confinement in a week or ten days, and had got on the train to go and see her husband, who was

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working down the track. Having a slight diarrhoea she went to the water-closet, and while on the seat, labour pains came on and the child dropped from her. Hearing a noise and groaning, the conductor forced open the door and found the woman on the floor . . . with just strength enough to tell him that the baby was somewhere on the track, and to ask him to stop the train, which was running at . . . about 20 miles an hour. The baby was found alive off the side of the track a mile or more away, and with the mother was left at the station where I saw her. She lost a great deal of blood, and the placenta was not delivered for some hours [Osler made no mention of the umbilical cord]. I saw no reason to doubt the truthfulness of the woman’s story, and the baby presented its own evidence in the form of a large bruise on the side of the head, another on the shoulder and a third on the right knee. It had probably fallen between the ties on the sand and clear of the rail, which I found, on examination of the hole in the closet was quite possible.”

This time the report bore, not an alias, but William Osler’s own name. Moreover, Osler held affidavits from the train conductor and other witnesses. Not only did the baby survive, he lived for 74 years. But Osler was like the boy who cried wolf. How could his colleagues know that this time he was for real? The editor of Anomalies and Curiosities of Medicine hedged his bets. All he would print was: There was recently a rumour, probably a newspaper fabrication, that a woman while at stool in a railway car gave birth to a child which was found alive on the track afterward.

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Chapter

11

DISCOVERIES

WHEN

LESS IS MORE: THE LEGACY OF SAMUEL HAHNEMANN Let’s face it, the principles of homoeopathy do sound odd. Here’s a satirist’s directions for homoeopathic resuscitation: “Lay one finger on the chest while blowing very gently in the general direction of the mouth.” But many present-day practitioners of homoeopathy are mainstream medicos. Moreover, some controlled trials suggest homoeopathy does work. Should we honour its founder, Dr Samuel Hahnemann (1755–1843) as an inspired trailblazer? Or did he just delude impressionable people with the power of suggestion? Hahnemann was born into a poor family but was so gifted that supporters paid for him to study medicine in Leipzig and Vienna. He wrote on the treatment of venereal disease with mercurous oxide, translated many scientific works into German and researched the effects and detection of various poisons. In his day, the mainstream medical treatments were bleeding, enemas, purging and induced vomiting. Many

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common medicines contained poisons like mercury or antimony. All in all, doctors may have killed more patients than their diseases did. But Samuel Hahnemann was a rebel. He advocated good food, clean air and exercise and was among the few doctors to follow Pinel’s enlightened treatment of mad people. Above all, he opposed the complex blunderbuss mixtures and medicines that doctors kept prescribing and chemists kept dispensing. The death of two of his own children from childhood illnesses made Hahnemann give up conventional practice and look for a better way. For the next few years, he supported himself by translating scientific works into German. One day, Hahnemann read about the remarkable benefits of Peruvian bark (later shown to contain quinine) for malaria. When he tried a little on himself, it produced symptoms like those of malaria. That surprised him at first. Then he thought: instead of regarding fever as the effect of malaria, could not fever be the body’s response to malaria? In that case, the bark’s ability both to produce fever and to relieve malaria made sense. Did Hahnemann know that Hippocrates had said “like cures like [similia similibus curantur]”? Over several years, Hahnemann tested many simple substances (derived from herbs, minerals or snake venom). First, he gave small amounts to healthy volunteers and noted their reactions. Later, when his own family or patients showed symptoms like those reactions, he treated them with a tiny amount of that same substance. Onions made healthy people’s eyes water and noses run, so Hahnemann found onions good for the common cold. Arsenic produced the stomach pains, vomiting and diarrhoea of dysentery, so he decided arsenic was good for dysentery. But Hahnemann used the smallest possible doses of drugs. According to his theory of “potentisation”, medicines gain in potency by being diluted, as long as vigorous rhythmic shaking or pounding accompanies the dilution. How did he come to use such dilute mixtures? How did he convince himself, his followers and his patients (surely they were not all his relatives!) that umpteen dilutions were not only safer,

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but also more effective? By the time Hahnemann was through with his endless diluting, his mixtures might not have even contained one atom of his original active drug. On this issue, his critics have had a ball. One doctor said that a dose which an English practitioner would give to a suckling baby would, in the hands of Hahnemann’s disciples, cure everyone in the whole solar system! He taught that all diseases resulted either from conventional medical treatment or from one of three conditions: psora (the itch), the skin disease sycosis (papillomatous warts) or syphilis. Indeed, most chronic diseases were caused by psora being driven inward. Hahnemann called all other (non-homoeopathic) systems of medicine fraudulent. He had the fanaticism and arrogance of many crusaders: “He who does not walk on exactly the same line with me, who diverges, if it be but the breath of a straw to the right or left, is an apostate and a traitor . . . ” But he did seem to get results. Chemists denounced him for using only one drug at a time and, even worse, for dispensing all his own medicines. Unable to handle his popularity with patients, jealous physicians had Hahnemann run out of Germany. In 1835, he remarried and set up in Paris, where his practice flourished and he became a millionaire. He remained active until his death at the then remarkable age of 88. Since then, homoeopathy has spread widely, and Hahnemann’s name and teachings still live on in some of the world’s most prominent medical schools and hospitals. To return to our original question: was he a quack or a genius? It all depends on whom we ask. The famous American medico Oliver Wendell Holmes (1809–1894) called homoeopathy “a mingled mass of perverse ingenuity, of tinsel erudition, of imbecile credulity and of artful misrepresentation”. Holmes may be too harsh. Even without necessarily believing that Hahnemann did any objective good, we could accept that he did get better results than those practising orthodox polypharmacy, bleeding, puking and purging. Even critics agree that homoeopathy must at least have been pretty harmless; and medical schools still teach students that, above all, they must do no harm.

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But there is evidence that Hahnemann and homoeopathy have done better than this. In 1813, when an epidemic of typhoid (or perhaps typhus) swept through Leipzig, Hahnemann treated 180 patients, of whom only one died! Later, during London’s cholera epidemic of 1854, the death rate at the Homoeopathic Hospital was said to be only 16%, compared to 52% elsewhere. Moreover, Geoffrey Watts wrote “a review of the literature in 1991 identified over 100 published controlled trials of homoeopathy, and found that while its case could not be taken as proved, the balance of evidence lay in favour of accepting that it works.”

Homoeopathy alive and well in 1999 Dr Eric Asher and Dr Nick Goodman are associates in a busy general practice in the Sydney suburb of Lindfield. Both graduated from Sydney University in the 1970s and have postgraduate medical qualifications. Both also have British experience and qualifications in homoeopathy. Both integrate homoeopathy with their mainstream medical training and use the former as a cheap, simple approach, especially for their less ill patients. Dr Asher’s examples: “Viral illnesses, coughs, colds, sore throat, childhood fevers, bee stings and hangovers. The herbal remedy Arnica is strikingly effective for sprains and bruises, even those following surgery or childbirth. A homoeopathic treatment often works within minutes, while the patient is still with me. But if the response is not so clear, I may also write a conventional script to be filled later if necessary. Only about one-third of patients actually use these scripts.” Dr Goodman works similarly. “Homoeopathy does not work all the time, but neither do antibiotics. When homoeopathy does work in infection, it stimulates the immune system, is cheaper than an antibiotic and does not stimulate germs to become resistant to drugs.”

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The million-dollar question: can we explain why a super-diluted mixture should work? American researchers have photographed homoeopathic solutions. They found that the original active ingredient or solute changes the water or solvent. As one dilutes and redilutes the solution, even at room temperature, specific water crystals (visible under the electron microscope) form and these crystals carry the specific code of the active solute. Different solutes trigger different crystals, and these crystals may be therapeutic even when the solute itself is too diluted to be effective. This fundamental research is still in progress. Clinical trials of homoeopathy appear in the Lancet, the British Medical Journal and the British Journal of Homoeopathy. Drs Asher and Goodman run courses on homoeopathy and general health care for their patients. These aim to inform people and so make them feel more self-reliant and in control. (GB)

MEDICINAL

PLANTS: A KEY LINK WITH OUR PAST

Medicinal drugs all come from chemists working in factories. Right? Wrong. About three-quarters of the world’s population depend on traditional medicine, which in turn depends largely on drugs from plants. The use of medicinal plants is as old as humanity itself. Our ancestors were not just hunter-gatherers; they were also practical botanists. Juice from the opium poppy was popular at least 6000 years ago. Chinese records of medicinal plants go back at least 4000 years. Egyptians used ergot and about 800 other drugs. The RigVeda, the oldest sacred book of Hinduism, lists 700 medicinal plants. Even in “advanced” countries, medicinal plants are of far more than historical interest. In Australia, though we use many synthetic drugs, we still depend on the plant world as well.

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How come? Our range of synthetic drugs is far from complete. We still lack effective drugs for many diseases and some germs become resistant to our antibiotics. Plants make far more chemicals than we humans have ever devised. So we turn to plants to find new drugs, less toxic drugs or cheaper drugs. Perhaps one quarter of our synthetic drugs were first isolated from plants. In the 1950s, researchers studied the Madagascar periwinkle, a folk-remedy for diabetes. They derived vincristine and vinblastine, now used for Hodgkin’s disease and childhood leukaemia. The Second World War stimulated Australians to use the Australian native Duboisia to extract hyoscine to prevent motion sickness in our armed forces. We still extract some hyoscine in this way, but most of the leaves go overseas for processing. We used to make digoxin (for heart failure) from our own foxglove, but South African plants have replaced this. Manufacturers still derive morphine and codeine from the Tasmanian opium poppy. A potent drug for cancer of the uterus and ovary is taxol, which is derived from the yew tree. Plants, especially those in rainforests (including our own in North Queensland), offer the world an enormous, still largely untapped laboratory. Of about 250 000 known flowering plants, we have analysed the medical potential of only 5000. So the forests still contain many useful plants that we should check out. That’s great news for us, our children and grandchildren. But the bad news is we have already lost about half of the world’s tropical rainforests. What to do? Perhaps go green. (GB)

FRENCH

FREEZE OUT FOREIGN FEMINIST PHYSICIST

At least she is in Paris. But not the Paris of anyone’s dreams! An abandoned shed: just a few boards thrown together; bitumen floor; a cracked skylight that lets in the rain. It was a dissecting room

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but is no longer fit even for corpses, stifling in summer and freezing in winter. Outside in the courtyard, the woman battles with a huge, heavy iron rod, stirring a large cauldron brimming with a boiling, volatile liquid. Occasionally she stops to pour the liquid into a jar, which she drags into the shack. When all the jars are full, she joins the man inside. Marie and Pierre Curie toiled like this for years on end. Born in 1867, Marie (Manya) Sklodovska was the youngest daughter of welleducated Polish patriots. Marie’s mother was dying of tuberculosis. Only much later did Marie understand why her mother never kissed her. Russia ruled their part of Poland. Her father, a physics professor, was demoted when the Russians found him teaching his Polish students their own language. He lost his life savings just when Marie was about to enrol at the Sorbonne in Paris. So Marie first worked for five years to support her elder sister, Bronya, while the latter studied medicine. After graduating, Bronya in turn helped Marie. In 1893, living on tea, bread and butter, Marie topped her class and got her master’s degree. For her wedding to another physicist, Pierre Curie, she chose a dark suit that would not show the stains of lab work. It was an exciting time to be working in physics. Soon after Roentgen’s discovery of X-rays, Antoine Becquerel found that uranium emitted mysterious rays that penetrated solids. For her doctorate, Marie explored other sources of this radiation, which she herself named radioactivity. She found that the radiation from pitchblende (the main ore of uranium, mined in Bohemia) far exceeded that expected from its content of uranium. Hence, she concluded, pitchblende must also contain another very radioactive, but still unknown, element. In fact, the Curies discovered not one but two new radioactive elements (both breakdown products of uranium): polonium (named after Poland) and radium. Radium was one million times more radioactive than its parent uranium! It took several years to realise that the Curies’ gamma rays were identical to Roentgen’s X-rays.

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But to isolate radium was another matter. So poisoned was the atmosphere in the derelict dissecting room that the Curies’ notebooks are even now still dangerously radioactive. Pierre’s hands became so scarred that he could not even knot his tie. Later he developed cancer. In 1901, the Curies lent their friend Becquerel a tube containing radium. After carrying it in his pocket for only six hours, Becquerel found it had burned his skin, just like a burn from X-rays. This triggered interest in radium’s possible medical effects. Finally, in 1902, after four years of toil, from eight tonnes of pitchblende, the Curies isolated one tenth of a gram of radium! Marie and Pierre shared the 1903 Nobel Prize in physics with Becquerel. The world cheered. A farmer wanted to put radium into his chicken-feed so his hens would lay hard-boiled eggs. An academic at Columbia said radiumfertilised soil would yield more and tastier crops. Reportedly the Shah of Persia came all the way to France to see radium. When he saw the jar of crystals glowing in the dark, he got so excited that he jumped up, knocked over the table and broke the jar. Marie kept cool: she dissolved the carpet in acid and recovered her radium. Pierre and Marie could have taken out patents and got rich, but instead made public their findings for others to apply. Life was looking up when, in 1906, Pierre died after being run over by a lumber wagon. Marie worked on despite this bereavement, the first symptoms of radiation sickness and the insults of the French. As a foreigner and as a woman, she never won over the French authorities. Very reluctantly, they awarded her Pierre’s professorship and asked her to give his lectures at the Sorbonne. Marie was the first woman to do so. She found that the luminous substance she and Pierre had called radium was actually a salt of radium. But Marie finally did isolate radium itself. She produced the first international standard of radium. The curie became a unit of measurement of radioactivity. In 1911, she won her second Nobel Prize (this time for chemistry), but still the French Academy of Science would not admit the “foreign woman”.

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When the First World War came, she invented mobile X-ray vans (“little Curies”) to locate pieces of shrapnel in wounded troops. She trained 150 people as X-ray technicians, raised money to equip the vans, and she herself drove one. By the end of the war, her 20 vans and 200 X-ray posts had examined over a million men. In 1921, Marie went to the USA, where President Warren G. Harding presented her with one whole gram of radium (worth $100 000) for medical use in Europe. Her older daughter, Irene, worked with Marie on the medical applications of radioactivity. Warsaw set up a Radium Institute, with Marie’s sister Bronia as director. It was radium, the element to which she had devoted her life, that killed Marie. When she died in 1934 of leukaemia, her body joined Pierre’s at a cemetery. But over 60 years later, in 1995, the French finally moved her remains to the pantheon. She is the first woman to be so honoured. Finally now, Marie Curie rests with the foremost sons of France. (GB)

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Chapter

MAYHEM

THE

12

AND MURDER

BLOODING OF GENETIC FINGERPRINTING

Six miles from the county seat of Leicester, England, is the village of Narborough. It was here that a passer-by found the body of Lynda Mann in November 1983. Her scarf was wrapped around her neck and knotted at the back. The autopsy showed that she had been strangled. There had been attempted intercourse and premature ejaculation. On antigen testing the semen showed group A secretor substance. “Village of fear” was how one paper described Narborough that winter. A murder squad of 150 started the investigation. They had plenty of leads. Over 100 potential suspects took blood tests, but by August 1984 there were no suspects left. In desperation, Lynda’s parents went to a medium who predicted that the murderer would strike again. At nearby Leicester University, a young geneticist, Dr Alec Jeffreys, was developing the technique to be known as genetic fingerprinting.

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In August 1986, Dawn Ashworth, another 15-year-old schoolgirl, was found strangled. She had also suffered a brutal sex attack. A businessman offered £15 000 for information leading to a conviction. Police soon arrested a 17-year-old porter at the local psychiatric hospital. He was known to molest girls and had talked of Dawn’s body being found before it had become common knowledge. His story changed with every questioning, but he did confess, though only to the second murder. Dr Jeffreys found that the porter’s blood did not match the three-year-old semen sample from Lynda’s body. It took another week to test Dawn Ashworth’s sample. The tests showed that the porter had not committed either murder, but that the same man had murdered both girls. Many of the 1800 leads came anonymously. One tip was about a baker, Colin Pitchfork, who had no alibi and had a record for flashing. Perhaps because Colin had not moved to the village until after the second death, police did not follow this up. Nor did Colin’s wife tell anyone what really turned him on: he liked her to wear long white socks, like a schoolgirl. Now police set up voluntary blood and saliva testing. They targeted males who had been between 13 and 30 when Lynda Mann was killed. Why they excluded older men is not clear. Colin felt worried when he saw the headline “Blood tests for 2000 in killer hunt”. After he got the second letter, his wife pushed him to go, but he said that his old record of flashing would get him into trouble. Quietly he asked several workmates to take the test in his name. No luck. His last chance was young Ian Kelly. At a bakery Christmas party, Colin had propositioned Ian’s wife, who did not tell Ian. Later she wished she had. Finally, Ian agreed to Colin’s ruse. Colin stuck Ian’s photo in his own passport and drove him to the blooding. Ian carried it off. By May 1987, over 3000 males (98% of those invited) had given samples but the laboratories were way behind. On the anniversary of Dawn’s death, a plainclothes man with a video camera was watching the murder site, but saw nothing.

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Dawn’s parents were at the time visiting relatives in Australia; they timed the dateline crossing so as to make the anniversary disappear: an extreme case of denial. In August 1987, Ian Kelly was drinking at a pub with a bakery manager and other workers. When the talk turned to Colin Pitchfork, Ian let slip that he had taken the blood test for Colin. The manager wanted to go to the police, but the others didn’t want to make waves. The publican’s son was a constable, but he was on holiday. It was six weeks before the manager finally talked to him. Police compared Colin’s own signature with Ian’s forgery from the blooding; they were quite different. The police arrested Ian, who admitted to the impersonation. Colin told police his whole life story, the flashings as well as the murders and rapes. After killing Dawn, he had gone home and baked a cake: he showed no remorse. A psychiatrist called him a psychosexual psychopath. He got a double life sentence for the murders, 10 years for each rape, three years each for earlier assaults and three years for the impersonation. But this sentence means little, since he would serve the terms concurrently and there was no minimum term. The police were outraged; the parents of Lynda and Dawn wanted hanging brought back; 96% of locals who took a poll agreed. The superintendent in charge of the second case said God must have had a hand in this DNA business, which had not only led to the release of the porter but also to the conviction of Colin Pitchfork. (GB)

MEDICAL

PATRIOT OR AGENT OF DEATH?

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By 1942, the Nazis had invaded France and installed the collaborationist Vichy Government. Jews in France had every reason to fear persecution from both the occupying Germans and Marshal Petain’s puppet government. Why wait for the noose

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around their necks to tighten? Why not try to escape? Many Jews turned to the Resistance for help. A Mr and Mrs Wolff consulted a Dr Eugéne who ran his own underground escape system (Fly Tox). He told them to take as much money as they wanted, but to remove all labels from their clothes. While they were in a safe house waiting for their new papers, he would give them inoculations for the journey. The Knellers paid Dr Eugéne 1 500 000 francs. Dr Braunberger paid 1 000 000 francs to escape via Spain. There were other clients as well: Paulette la Chinoise planned to open a brothel the minute she reached South America. Dr Eugéne kept his word — his clients all disappeared from France. But one family pulled out at the last minute; the wife was a doctor. No problem; he just refunded their money. By now the Germans were closing in; soon they arrested “Dr Eugéne” as Dr Marcel Petiot, a Paris GP. Though it is reported that they interrogated and tortured him for eight months, the patriotic Dr Petiot would not name his Resistance friends in the escape network. Finally, in December 1943, Petiot was released and was soon practising again. A few months later, neighbours complained about the foul, greasy smoke billowing from the chimney of a large house belonging to Petiot. There was no answer to their knocking, and all the doors were locked. By now the chimney was alight! They called the police, who forced their way in. The first man to enter the house came out vomiting. In the basement, a huge furnace was blazing; from the open door, there drooped a human hand. On the stairs were skulls, limbs, hands, feet, other bones and masses of flesh. A man came forth, saying he was the owner’s brother, head of a Resistance group. Moreover, he said, the bodies belonged to Germans and to French collaborators. Petiot always told people what they wanted to hear; the patriotic French officials advised him to vanish.

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Only then did they find the tiny triangular room without windows; the single door was soundproofed and opened only from the outside; it had a spyhole. On one wall were eight iron rings. In the garage, from a huge pile of quicklime, they sifted many human parts. A manure pit in a stable held more bodies. Medical experts spent months sorting the human parts. But they could piece together only ten bodies, none of which they could identify. Petiot vanished for eight months. The Police Commissionaire leaked a story to the papers accusing Petiot of having worn a German uniform and having worked against the French Resistance. The super-patriot Petiot took the bait and wrote a furious denial. This letter suggested that he was still in Paris, serving with the French forces. Soon the police tracked Petiot down and arrested him. Finally, in March 1946, he faced 27 counts of murder. Though the Nuremberg war trials were on, in Paris it was Petiot who got the headlines. Details of his past came out. In the First World War, he had dealt in stolen drugs. He avoided the front by shooting himself in the foot and by throwing convulsions. About 1918, he got a disability pension and entered a mental hospital. But somehow he became a medical student and even graduated in 1921. Later a pregnant mistress disappeared very conveniently. In 1930, there were rumours of robbery and murder, perhaps even a second murder to cover up the first; also fraud, illegal abortions and supplying narcotics to addicts. Remarkably, no medical authorities had ever questioned his fitness to practise medicine! But Petiot was amazingly popular. Many patients told police the good doctor would often cycle miles to see a sick child and would not charge poor patients. Locals had twice elected him mayor. Still the accusations of murder remained. But no-one had seen any victims enter his house; none of the corpses had been positively named, and pathologists could not show the cause of death. Petiot admitted to killing 63 people, but insisted it was all in the name of the Resistance and for “the glory of France”. The courtroom clapped when his lawyer proudly declared: “He brought down his

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enemies, our enemies.” Had Petiot not resisted torture at the hands of the Gestapo? But the prosecution called over 80 witnesses: Resistance heroes had never heard of Fly Tox or of Petiot. If his clients had escaped, why had none of them ever contacted their relatives in France? How could the jurors ignore the immense pile of victims’ suitcases in the courtroom? After midnight on the 16th day came the verdict: Petiot was guilty of 24 murders and would face the guillotine. Only then did Doctor Death’s mask fall as he screamed, “I must be avenged!” Had he not chosen the path of murder and fraud, Dr Marcel Petiot might well have been a hero. (GB)

THE RISE AND FALL OF DR RODERIGO LOPEZ Doctors should stick to medicine. Political intrigue is dangerous; even to be accused of intrigue . . . Nineteen ninety-four saw the 400th anniversary of the execution in London of Dr Roderigo Lopez, physician to Queen Elizabeth I. Lopez was born around 1520 in Portugal. The Inquisition there forced him, like many other Jews, to convert to Christianity and to leave Portugal. He probably studied medicine in Spain. Finally, Lopez settled in England. Soon he became senior doctor at St Bartholomew’s Hospital. By 1586, he was physician, companion and confidant to the Queen herself. Being fluent in Portuguese, Spanish, Dutch, Latin, Hebrew and English, he often translated documents of state. When she granted him the monopoly to import the herbs aniseed and sumach from America, many Englishmen were jealous. To understand his life and especially his death, we must remember the prolonged conflict between the Protestant Queen of England, Elizabeth I, and the Catholic King of Spain, Philip II.

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In 1588, Sir Francis Drake defeated the Spanish Armada which had been sent to conquer England. Thereafter, some, but not all, English politicians wanted to make peace with Spain. Much of the intrigue at both the English and the Spanish courts surrounded Don Antonio, the illegitimate son of the heir to the Portuguese throne. Philip of Spain forced him to flee to England, where the hawkish Robert Devereux, Earl of Essex, supported him as a tool against Spain. Among the prominent patients who flocked to Lopez was Secretary of State Sir Francis Walsingham, who also recruited Lopez to spy for England. In 1593, a Spanish agent tried to bribe Lopez with a diamond and ruby ring to poison Don Antonio. Lopez reported the plot to Elizabeth who pooh-poohed the story. Later, Spanish agents offered Lopez 50 000 crowns, which he refused. Essex got wind of this and also suspected (or claimed to suspect) a plot to poison Elizabeth herself. Under torture, the Spanish agents tried to save themselves by implicating Lopez in such a plot. In January 1594, Essex arrested Lopez himself and threatened to torture him as well. Eventually, the terrified old man made a so-called “confession”. Now the Spaniards and Lopez faced a harrowing crossexamination at London’s Guildhall by a commission that included Essex. Lopez again proclaimed his innocence but was convicted. Essex declared: “I have discovered a most dangerous and desperate treason. The point of conspiracy was Her Majesty’s death. The executioner should have been Dr Lopez; the manner poison.” By now Walsingham, who would have protected him, was dead. Both anti-Spanish and anti-Semitic feelings were directed against Lopez; Englishmen published drawings of him mixing poisons. The penalty for conspiring to poison the Queen was death, but Elizabeth, still convinced that Lopez was innocent, refused to sign his death warrant. Essex had Lopez moved from the Tower to Southwark Prison, where death warrants did not need her signature. On 7 June 1594, Lopez and the Spanish agents were dragged

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through the streets to Tyburn (now the site of Speaker’s Corner in Hyde Park). There he declared: “[I love] the Queen as much as Jesus Christ.” The mob jeered. The men were hanged, drawn and quartered: first hung from the scaffold, next cut down while still alive, then castrated, disembowelled and chopped into quarters. No-one emerged with credit from this brutal story. Political intrigue and religious persecution are to blame for these deaths. Elizabeth restored Lopez’s property to his widow. The ring that Lopez had offered her she wore in her belt for the rest of her life. It is reported that documents found much later in Spain cleared Lopez. Essex’s accusation that Lopez planned to poison his patron, Queen Elizabeth, seems absurd. Having been forced by the Inquisition to flee from his native Portugal, why would he want to kill his patron and protector? Lopez never knew that the stubbornness and ambition of Essex finally lost him Elizabeth’s favour and led Essex himself to be executed for treason in 1601. A revival of Christopher Marlowe’s anti-Semitic play The Jew of Malta at the time of the trial may have fanned English hatred of Jews. Was there also a link between Lopez and the character of the Jew Shylock in Shakespeare’s Merchant of Venice, which played in London two years after Lopez died? Even today, visitors to the Guildhall may still notice a sign headed “Famous Trials Held in This Hall”. The names include Lady Jane Grey and Archbishop Thomas Cranmer and the sign notes: “Dr Roderigo Lopez, physician to Queen Elizabeth, was tried for High Treason, and was executed at Tyburn in 1594”. (GB)

ADDICTS

M A K E D E A D LY D O C T O R S

The son of an Anglican clergyman, Dr George Henry Lamson was born in 1849. He won decorations as a volunteer army-surgeon in Serbia and Romania. Yet only a few years later, he was convicted of

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perhaps the most diabolical murder of the century. How could a man fall so far so quickly? In the Balkans, Lamson suffered war wounds and become addicted to morphine and perhaps also to aconitine, the active principle of the wolfsbane plant. Mainstream doctors used aconitine in liniments, though Lamson prescribed it indiscriminately for most ailments. Back in England, the young doctor married Miss Kate John. On marrying, she came into a small fortune, but before the Married Woman’s Property Act, her money passed into the control of her husband. Kate was as devoted and submissive as “a feudal Japanese wife”. She had two brothers, Herbert and Percy, and one sister. When Herbert died suddenly, Kate inherited £700, with which Lamson bought a practice in Bournemouth. But he passed too many dud cheques and bailiffs called more often than patients. He also had paranoid delusions. Why else would he fire a revolver from his bedroom window, swearing that Turks were about to attack him? The local medical society expelled him. He had to sell their home and pawn his watch and even his surgical instruments. But if his remaining brother-in-law, Percy, were to die unmarried before turning 21, Kate would inherit £1500. Percy was a boarder at Blenheim School, Wimbledon. Despite the paraplegia that bound him to a wheelchair, he was a cheerful boy. In mid-1881, when Percy came to spend his holidays with his sister, Lamson probably slipped him a dose of aconitine. This gave Percy nasty heartburn, but he recovered. On the evening of 3 December, gaunt and excitable, Lamson called at the school to see Percy. With him he brought sweets and a currant-studded, almond-topped Dundee fruit and nut cake, probably already sliced. Percy, the headmaster and Lamson himself all had cake and sweets. Soon Lamson left, caught the boat train from Victoria and crossed to France. Within 20 minutes, Percy complained of heartburn. Between frequent, copious vomits, he suffered such agonies that he had to be held down. Two doctors came, but nothing helped. After four hours of agony, poor Percy died. The doctors collected a sample of his

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vomitus. Though the autopsy report was pretty normal, everything pointed to poisoning and to Lamson as the poisoner. On 8 December, Lamson, bold as brass, returned to London and went straight to Scotland Yard to “clear his name”. In his luggage, police found a book on vegetable poisons. The Home Secretary ordered a further autopsy. Pathologist Dr Stevenson found gross irritation of the stomach, but also a little aconitine in a raisin from Percy’s gut. The Old Bailey was packed as the trial started on 9 March 1882. Lamson pleaded not guilty. Dr Stevenson believed that Percy had been poisoned. Lamson could have somehow marked Percy’s slice of cake, pulled out a few raisins, filled them with aconitine and replaced them. The crown had a strong case, except that there was then no chemical test to detect vegetable poisons. Forensic experts had to taste extracts from various organs after death! Dr Stevenson said he had learned to identify 50 substances by taste! He testified that Percy’s bowel contents had yielded a distinct substance. Moreover, injecting mice with extracts from Percy’s organs had produced effects identical to aconitine. The jury took only half an hour to find Lamson guilty. But fashionable women bombarded him with flowers and gifts. His defenders claimed that morphine addiction had destroyed Lamson’s sense of ethics. Even the American President, Chester Alan Arthur, intervened on his behalf. All in vain. Waiting in Wandsworth Prison, Lamson found the cold-turkey withdrawal from morphine devastating. Finally, he confessed to Percy’s murder, hoping that his career would give “an awful warning to others, similarly tempted and assailed, seeing to what fearful consequences morphine addiction has led”. Even as the hangman was pulling the lever, Lamson begged for time to hear just one more prayer. (GB)

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Chapter

MIDWIVES,

13

WOMEN

AND BABIES

A

HISTORY OF MIDWIFERY

Of the three main streams within the discipline of medicine, namely pure medicine, surgery and obstetrics, that of obstetrics is very much a Johnny-come-lately. Physicians look back on their lineage as being an intrinsic, essential and perhaps glorious part on life’s grand plan for society, with clinical medicine at the forefront. Surgeons take bogus pride in their humble beginnings and early association with barbers but are quick to point out that Henry VIII was their first mentor. But obstetricians have not completely thrown off the ignoble feeling of being male midwives and a poor relation of the other disciplines. Only in this century have they been formed into a Royal College, although their battle to wrest power from the neighbourhood handy woman took place about 200 years ago. At this safe distance the battle makes salutary reading, so let’s look at it.

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The doctor whose name is the first to be associated with the rationalisation of childbirth is William Smellie, born in 1697 in Lanark, Scotland, and a graduate of Glasgow University. There had, of course, been many male accoucheurs before him, but it was Smellie who published the original primer on the subject. It was called A Treatise on the Theory and Practice of Midwifery and appeared in 1752. Smellie had a stroke of luck right at the beginning, for he was assisted in this literary task by one of the foremost writers of the day, Tobias Smollet, himself a doctor and author of Roderick Random. Doubtless, the partnership made the textbook more readable, so gaining it a wider audience. At the time of publication, Smellie was 55 years old, and, by dint of much practice in the Scottish countryside, as well as in Paris and in Wardour Street in Soho, London, his knowledge on the subject was encyclopaedic. Thus armed he proceeded to correct many of the fallacies which had been passed down over the years from one dubious practitioner to another. For instance, it had always been maintained that the foetus lay with its head uppermost in the uterus until the seventh month, when, due to it becoming top heavy, the baby turned turtle, ready to escape by, so to speak, crawling out on its hands and knees. True enough it often has the head high in the womb early in pregnancy, but crawling out was surely a bit fanciful. He also noted that the head did not come straight down through the pelvis like a diver from the high board, but took the line of least resistance and progressed with a kind of slow screwing motion through the passages. He worked out his theories by observation and careful measurements of the female pelvis. Of course, Smellie had centuries of prejudice and misinformation to overcome, starting with Hippocrates (460–357 BC), the Father of Medicine, who, amongst other gems, thought that labour was started by the efforts of the baby struggling to get out when it had gathered enough strength to do so. This picture of the infant clawing its way to the outside world persisted for almost 2000 years. It was even shared by the great William Harvey a hundred years

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before Smellie, and who wrote, “the foetus promotes his own delivery by his efforts, like a butterfly emerging from a chrysalis”. Maybe a poetic appraisal, but, in passing, note the parsing of “foetus”. I wonder if he considered that female infants had such a kinetically charged arrival. But let us go back to Hippocrates in the fourth century BC. He thought, not unreasonably for the era, that any presentation other than head first was dangerous. After this good start he fluffed it by recommending that to ensure cephalic, or head, presentation the unfortunate lady should be strapped to a board which was then put upright and repeatedly struck on the ground. The next great name to emerge in the field of obstetrics was that of the Greek Soranus, from Ephesus. This is now a splendid ruined town in modern Turkey. Soranus lived in the second century AD and like many of his countrymen sought his fortune by setting up practice in Rome. He was a sound clinician and acute observer, relying on simple rules to explain disease, and attributing illness to an adverse state in the “internal pores”. His monumental work, On Midwifery and the Diseases of Women, contains descriptions of contraceptive methods and delivery of babies feet first. He distinguished between contraceptives and abortifacients, considering the former more desirable. Unfortunately, his advice as to how to avoid conception would seem to lack the ingredients for success, for he advocates holding the breath, coughing, jumping and sneezing after coitus in order to expel the semen. Regrettably, he does not give success rates, and I suppose that with the advent of more reliable methods such as the Pill, the moment to carry out clinical trials has passed. But there is no doubt that if assiduously followed the method would at least add a new dimension to a couple’s sex life. Although Soranus wrote a great deal on the subject of obstetrics and gynaecology, incredibly his chief manuscript was not found until 1838 when it turned up in the Vatican library. This is a pity because the skill he taught in podalic version, or delivery feet first, was forgotten for 1400 years until Ambrose Pare (1510–1590) in

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Paris redescribed it, thinking he had discovered it for the first time. Soranus advocated embryotomy, or sacrificing the child by dismembering the body, in a case of difficult labour. This barbaric practice survived until comparatively modern times when anaesthetics thankfully changed the outlook. The Middle Ages were a thin time for all medical progress, including obstetrics. But at least one odd piece of apparatus was devised then and came into constant use — the birthing stool. Such an item of furniture formed part of the dowry of every bride in many countries until the seventeenth century. It was a wooden affair with a straight high back and a seat constructed in the shape of a horseshoe to leave a large hole in the middle. Only in the following century was delivery in bed regarded as the norm. This preferred lying position is still disputed by some today. Eventually, medicine in general emerged from the old GrecoRoman ideas of Galen and others with the groundbreaking discovery by William Harvey in the seventeenth century of the circulatory system. As well as this fundamental work in physiology, Harvey was also a distinguished obstetrician. Towards the end of his life he wrote De Generatione, about 30 pages of which deal with his experience in the delivery room. He was a great believer in the “power of Nature”, and deplored the meddlesome efforts of some midwives to hasten the birth process. “Nature herself must be our adviser,” he wrote. “The path she chalks must be our walk.” In another section he was more pointed in his remarks when he expostulated, “the young, giddy and officious midwives do persuade poor women to use their birth stool before the time and do bring them in danger of their lives”. This kind of gratuitous talk did not endear him or his fellow doctors to the midwives of the day. I am sure that they did not consider themselves officious, nor probably young in the sense of inexperienced, and most certainly not giddy. I suppose what Harvey lacked in tact, he made up in courage. Other medical men added their weight to the castigations. Peter Willoughby from Derby wrote of the “incessant and violent interferences of ignorant midwives” — fighting talk to an ancient

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and well-entrenched profession. Of course, many of the patients refused to be attended by a man. Decorum was at stake. Willoughby instructed his daughter in the art and she would call him in if she felt complications were at hand. So as not to affront the patient by his masculine presence, it was his practice to creep unseen into the delivery room on his hands and knees. The Royal College of Physicians would have no part in the training of midwives, especially in this deteriorating obstetrically political climate. But at least the Church of England accepted responsibility for their control, and in a fit of ecclesiastical whimsy the Archbishop of Canterbury, no less, granted them licences. Perhaps rather prudently, the Church did not dabble in training or education, just a licence. The appropriate piece of paper given to one Eleanor Pead giving her permission to ply her trade reads in part: “I promise I will be ready to help poor as well as rich women in labour; I will not suffer any other body’s child to be brought to the place of a natural child; I will not use sorcery or incantations; I will not destroy, cut or pull off the head of any child, and I will, in time of necessity, baptise the child with the accustomed words, using pure and clean water.” That clause about substituting another child may have been included following the remarkable incident concerning Mary of Modena, wife of James II. She delivered a male child on 9 June 1688, but her jealous stepdaughters, Mary and Anne, both of whom were destined to become Queens of England, doubted the authenticity of the pregnancy. They claimed that a baby boy had been smuggled into the delivery suite in a warming pan, then touted as the royal issue. There is no question that a male child was produced. He became James Francis Edward Stuart, better known later as the Old Pretender. On account of his Catholic background he was disinherited by Anne so he never became king. Although the handy women undertook not to pull off children’s heads, the medical profession was not convinced that such instructions would be followed. Perhaps they feared the pious incantations had merely become sotte voce and were being turned

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onto them. Feelings were running high, as illustrated in 1769 when William Buchan, an obstetrician distinguished enough to be buried in Westminster Abbey, wrote, “Few women think of following the employment of midwife unless they are reduced to the necessity of doing it for bread. Not one in a hundred of them has any education or proper knowledge of her business.” It must have taken a brave man to write such things, and there is no doubt there was a great deal of rivalry between midwives and obstetricians over several hundred years and that it was at its most astringent in the eighteenth century. Indeed, in England it was only as recently as 1902 that the Midwives Act actually defined “midwife”. The animosity generated was not calmed by the use of two operative procedures to which the doctors had access but the midwives did not — obstetrical forceps and Caesarean section. Fact and fiction are hopelessly entangled in the early history of Caesarean section. Macbeth believed he could not be killed by “one of woman born”, only to have his confidence undermined by Macduff’s revelation that he was, “from his mother’s womb untimely ript”. Perhaps from the word “untimely” we can infer that this was a postmortem operation, as I am sure all early such procedures took place after the death of the mother, a not altogether uncommon happening. Popular belief is that the operation is so-called because Julius Caesar was delivered this way. We know that his mother, Aurelia, was alive when he invaded Britain, so it was certainly not a postmortem operation in his case. Even if at the time it had been possible to do it in life, it is still unlikely as, by contemporary custom, the doctor would have been a Greek slave, and he would hardly have dared to even suggest such a risky procedure on the Emperor’s wife. A more likely explanation for the name is that in 715 BC a law was passed in Rome forbidding the burial of a women who died during pregnancy until the infant had been surgically removed. The two were then given separate burials. Under the Caesars, the code of laws was called Lex Caesarea, and, since the law ordered it,

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the operation was called the Caesarean operation. Be that as it may, it has always been regarded as a major surgical bravura which is brought to a dramatic conclusion with the presence of two individuals where previously there had been only one. One of the earliest accepted instances of a successful outcome was an operation carried out by an Austrian sow gelder, Jacob Nufer, in 1500. The story goes that after 13 midwives had struggled in vain to deliver his wife’s baby, Jacob thrust them aside and did the job himself with the aid of a few judicious slashes to the abdomen with a razor. Not only did Mrs Nufer survive, but she went on to have five more children per via naturalis. About this time case studies and opinions regarding its desirability began to appear in the medical literature. The obstetrical heavies of the time opposed it on the grounds that the mother would not survive the operation. Mr Nufer was apparently not consulted. In the contemporary journals abuse of one’s opponent was a common way of denigrating his worth, and the hurled insult was used as logical argument. An obstetrician called Rousset tells of a successful case of a colleague, John Lucas, who was apparently drunk at the time of surgery, and he writes, “if the operation succeeds with him when drunk, what may not he expect who perform it when sober, according to the justest rules of his art”. A specialist called Osiander said at the time that before undertaking the procedure “one should allow the patient to draw up her will and grant her time to prepare herself for death”, which is hardly the frame of mind to engender when about to embark on what was supposed to be a joyous occasion. The redoubtable William Smellie took the middle view that it would be better to operate if in the perceived parlous state of the labour, mother and child are going to die anyway. In the early days, if done at all, the uterus was not sewn up, although the abdominal wall was brought together. There were, of course, no anaesthetics then and I suppose speed of operation was important. What is more there was no thought of sterilising equipment, and intra-abdominal sutures of string or silver wire

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which had merely been cleaned on the lapel of the obstetrician’s frock coat caused massive and often fatal infection. In fact, it was not until 1882 that the womb was sutured as a matter of course. The first successful Caesarian operation in Britain was carried out in 1738 by midwife Mary Donally. She was an illiterate Irishwomen whose decision was untrammelled by having read the contemporary medical literature. After having had a patient 12 days in labour she felt, and rightly so, that enough was enough. So she took a razor and simply put an end to the proceedings with a few well-directed slashes. Her decision was so precipitous that she had to hold the skin edges together while someone ran to fetch needle and thread from the local tailor. At the end of the nineteenth century Caesarean section became an elective procedure rather than one done as a last resort in heroic circumstances. As a result patients were better prepared, the operation was more leisurely and the results were quite acceptable by the lights of the day. Since then it has become a common, some say too common, and safe procedure. In fact, it is quite some time since I saw anyone running to the local tailor for thread. One of the most important events in the history of obstetrical practice was the invention of the obstetrical forceps. It is a most remarkable story. It started in 1569 when a William Chamberlen and his wife left France to flee to England as Huguenot refugees. They brought with them their small son, Peter, and shortly after their arrival another boy was born. With singular lack of imagination, they also called him Peter. Ever after they were known as Peter the Elder and Peter the Younger. By the early 1600s Peter the Elder prospered as a doctor due mainly to the fact that he had devised an instrument which, when placed round the baby’s head in delayed delivery, could pull it out of the pelvic cavity with hitherto undreamt of ease. This apparent trick, like all good tricks, was blindingly simple; he merely made two separate blades appropriate curved to fit at once both the baby’s head and the mother’s pelvis. These were applied separately and then locked together when in position. Single blades had been

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thought of before, but not two together as it was thought they could not be opposed to act as a single unit. Chamberlen’s secret was the locking device which allowed this to happen. It has not changed in principle in over 300 years. Because it was unique, he kept the secret to himself, a state of affairs continued by other family members through four generations. Eventually this involved seven medical relatives over 125 years. It was known at the time, of course, that they had some secret weapon, and as a result over many decades several family members were in demand at some top-drawer confinements. These included being the accoucheur to Henrietta Maria, wife of Charles I, some of the mistresses of Charles II, and James II’s wife. It was this last lady, you will recall, whose delivery was clouded by rumours that a male child had not appeared in the usual way, but via the back stairs, having been smuggled into the lying-in room in a warming pan. The Chamberlen mystery itself was maintained by the simple expedient of, during delivery and supposedly in order to preserve modesty, placing a large sheet over the recumbent woman and tying the ends round the obstetrician’s neck, rather like a spaghetti eater’s serviette. The doctor then worked by touch, while gazing into the patient’s eyes. If the instrument was needed, he reached behind into the tails of his long jacket, a sartorial trim which was fortunately fashionable at the time, where was constructed a capacious pocket in which the forceps were hidden. The unsterile instruments were withdrawn, like a rabbit out of a hat, and dexterously applied. To make sure no-one knew he was using the contentious aid, especially the rather hostile midwives ranged around, the blades were either made of wood or covered in leather so no clinking would be heard. Both Peter the Elder and Peter the Younger used obstetrical forceps with great success. The Younger later had a son whom he also called Peter, known eventually as Peter III. This Peter in turn became a doctor, and party to the secret. In the 1650s he bought a house called Woodham Mortimer Hall near Malden in Essex. Just store that name away in your memory for it featured in the saga

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years later. Peter III had a son whom in a moment of mental aberration he called Hugh. It was this man who became accoucheur to several mistresses of Charles II and Mary of Modena, the wife of that monarch’s brother, James II. As Charles admitted to siring 15 illegitimate children, despite the new contraceptive invention of the royal physician, Dr Condom, Hugh must have done quite well out of coming and going into regal bedrooms. He also wrote a book on obstetrics which refers to the fact that he and his relatives had long practised “a better way” of delivery, but carefully omitted to say what this was. But Hugh became involved in politics and had to flee to the Continent. While in Holland, and in order to raise money, he sold the family secret. Cunningly, or so he thought, he only parted with one blade of the forceps, knowing that the key of the mystery was in the way in which the two blades locked together. But the purchaser, van Roonhuysen, was a bright chap and soon worked out the rest, thus letting the cat out of the bag forever. Modifications were made over the years and forceps gradually came into general use, as indeed they are to this day. But just cast your mind back to Woodham Mortimer Hall, property of Peter III. It was in the family from about 1650 to 1715 and then sold. Almost a hundred years later in 1813, a Mrs Kemball was visiting the place and quite by chance came across a secret hatch in an unused closet. When the door was opened inside was found a small treasure trove. There was a medallion showing the image of Charles II, a tooth wrapped in paper on which was written “my husband’s last tooth”, a pair of kid gloves and a box. When the box was opened there was found three pairs of the famous secret forceps in mint condition. They must have been there for 150 years or so and hidden so that no casual medical visitor would see them. They are priceless antiques now. Some odd modifications of forceps were devised in the eighteenth century. John Burton of York constructed a set where the blades opened and closed by screwing the handle. Burton was

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portrayed as the grotesque Dr Slop in Laurence Sterne’s Tristram Shandy. He brought Tristram into the world using his fiendish apparatus, thereby causing the lad to have a permanent deformity of the nose. In the tale Slop himself lacked three front teeth, which had been knocked out by his forceps when they slipped through his bloodied hands during a particularly vigorous joust he had had with the new-fangled bits of metal. But by now the benign influence of Dr William Smellie was being felt, at least in England, and a more compassionate approach towards labouring women was taking over. The first maternity wards in the country were established in the Parish Hospital at St James’s, London, in 1739 by Sir Richard Manningham. In passing, Manningham’s other claim to fame was the fact that in 1726 he was sent by King George I to Godalming in Surrey to investigate the case of Mary Toft who was reputed to have given birth to 17 rabbits. He exposed the hoax, but not before Mrs Toft had become the sensation of the London season for that year, as I am sure she would have been of any other year if rumour of such a feat had got about. The first professor of obstetrics was appointed the same year as the Rabbit-Woman sensation, and worked in Edinburgh. Mystifyingly, he had no maternity beds; they did not arrive until 1756. It was in the same city that in 1847 Sir James Young Simpson first discovered the value of chloroform as an anaesthetic in childbirth. His first heroic patient was the wife of a medical colleague. Mercifully, all went well, and the child, Wilhelmina Carstairs, was forever after called Saint Anaesthesia. Queen Victoria popularised the use of chloroform during labour when she used it during the birth of Prince Leopold, the eighth of her nine children, in 1854. Not all obstetricians have had such felicitous results. Sir Richard Croft attended as accoucheur to Princess Charlotte. She was the only child of the Prince Regent, later George IV, and so presumptive heir to the throne. Tragically, the poor women died in labour as did the infant, whereupon Croft shot himself. That, of

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course, is how Victoria came to be on the throne, for she was the daughter of a younger brother of George and became heir by default. Maternal and infant mortality have fallen dramatically in the last century, and the hazards of embarking on a pregnancy now are minuscule compared with the dangers of as recently as the preantibiotic days of 60 years ago. The techniques available to the accoucheur have progressed from the masterly inactivity of ancient times, through the use of jealously guarded secret instruments, to a vast array of glittering diagnostic tools available today. But the joy of a successful outcome to the obstetrician’s manipulations is the same whether you were delivered by Hippocrates, Chamberlen, Smellie or the most recent graduate from medical school. (JL)

DOCTORS

AND MIDWIVES AT EACH OTHERS’ THROATS

Ever since the First Fleet, midwives, or women acting as midwives, have been prominent in Australia. Phoebe Norton was transported for stealing spoons and bed linen. On the way out, she fell overboard into the Indian Ocean, was fished out, and flourished to become a busy midwife in Parramatta. Despite their lack of status, convict women (called ‘finger smiths’) delivered many, perhaps most, babies. One observer wrote: “The majority of women . . . were attended by women with the title midwife, but none of the associated expertise.” Of course, VIPs got VIP treatment. When Elizabeth Macquarie, wife of the Governor, went into labour in 1814, midwife Ann Reynolds was with her all afternoon. The icing on the cake was that William Redfern arrived in time for the delivery. Both of Mrs Macquarie’s helpers were ex-convicts. Ann Reynolds had been transported for stealing, while the upwardly mobile Redfern was

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our first obstetrician, charging up to 20 guineas per delivery. Redfern’s high reputation stands in stark contrast to that of Dr John Savage, who refused to attend a woman with obstructed labour in Parramatta in 1805, allegedly because there were no instruments available. (He probably meant forceps, designed to fit around the baby’s head and speed delivery.) The woman died. Savage was found guilty of neglect of duty and sent to England, where the authorities pardoned him! Our colonial history has seen many tensions between midwives and the few available doctors (who were male).* Doctors often invoked Charles Dickens’s portrait of midwife Sairey Gamp (from Martin Chuzzlewit): The face of Mrs Gamp — the nose in particular — was somewhat red and swollen and it was difficult to enjoy her society without becoming conscious of a smell of spirits . . . she went to a lying-in or a laying-out with equal zest and relish.

While condemning midwives as untrained, ignorant and dangerous, doctors for many years would not help to train them. The law also favoured doctors. In 1864, a midwife was convicted of manslaughter; she said she had sent for a surgeon, who had refused to come because his fee was not guaranteed. The mother died, but it was the midwife who was blamed. In another case near Port Fairy in Victoria, the doctor did attend as requested, but both mother and child died. On the doctor’s evidence, the midwife, Charlotte Ward, was tried for manslaughter. The local paper asked “why Mrs Ward . . . of much experience and irreproachable character, should be dragged before a jury and judge . . . The only reasonable inference . . . is that the poor woman belongs to a class which is not in favour with doctors . . . ” The “not guilty” verdict was very popular. *My account draws on the description by sociologist Evan Willis of the long-standing competition between Australian midwives, nurses, pharmacists and doctors. At times, these groups competed, not only for confinements, but also for abortions. I use the word midwife to mean female midwife.

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It is easy to see why people liked midwives so much. Mrs Mary Howlett attended 10–12 cases a year, and usually charged three guineas, though she was often not fully paid. She would stay and look after mother and child, as well as doing all housework for about nine days. Some midwives also used their homes as private hospitals, for confinements and sometimes for abortions. This ad appeared in the Bathurst Times in 1886: “Accouchements: Mrs Moir is prepared to accomodate Ladies at her residence, Pedrotta Terrace.” With blatant sexism, an editorial in the Medical Journal of Australia (MJA) of 1879 opposed regulation and registration of midwives, and questioned whether “the practice of obstetrics should be permitted to women at all”. Yet others who were not doctors delivered babies. Thomas Sheridan, a pharmacist, delivered babies and did abortions. Within about one week, four of his aborted patients died, whereupon Sheridan went to prison for ten years. On his release, his first aborted patient died, and in 1895 Sheridan was hanged. At least in Victoria, midwives pushing for autonomy had to fight both the doctors and the nurses. Between about 1880 and 1910, as the profession of nursing evolved, its leaders tried to include midwifery as one of its branches. Similarly, doctors wanted maternity nurses whom they could control. Just as occurred overseas, it took decades for the findings of Ignaz Semmelweis on childbed fever to filter through into hospital practice. Devastating epidemics continued even into the twentieth century. Quite unfairly, doctors made midwives the scapegoat for childbed fever. It was the hospital doctors who could still move freely between the maternity and other sections, unwittingly spreading fever as they went, long after nurses lost this freedom. In 1912, to boost the low birthrate, the Commonwealth Government legislated for a “baby bonus” of £5. But this generosity was very selective. It excluded not only Aboriginal and Asian women but also mothers of stillborn children, and of those who died within 12 hours.

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An MJA editorial claimed that the lavish bonus would lead to midwives attending more births and so cause more childbed fever. The editor could not have been more wrong! Many women used the bonus to engage doctors instead: from 1913 to 1923, the proportion of births attended by midwives alone was halved. But there was little improvement in the high death rates of either mothers or babies. One reason may have been the poor training of medical students in obstetrics and the enthusiasm of some doctors for using forceps and anaesthetics, which midwives could not use. As late as 1929, one NSW doctor boasted that, to prevent complications, he had used forceps in every one of his 768 deliveries. In 1929, a Victorian Bill put the Nurses Registration Board in charge of midwifery. This marked (at least officially) the end of independent midwives in Victoria. Making nurses out of midwives also put them under the control of doctors. But in the country, untrained, unregistered midwives (“rabbitsnatchers”) carried on. It is reported that the main qualification of these midwives was that they had themselves delivered at least ten children who had all survived. Their cheapness was an attraction. In the Victorian town of Colac, the midwife was said to cost only twoand-a-half guineas. This compared with four guineas for the doctor, plus five guineas a week for the local private hospital. Now in the new millennium the wheel may be coming full circle, with many doctors avoiding obstetrics, and midwives coming into their own again. (GB)

WET

NURSES

And Naomi took the child, and laid it in her bosom, and became nurse unto it. — Ruth 4:16

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Each year swarms of tourists flock to the island of Capri to admire the famous Blue Grotto. Few give a thought to Tiberius, the infamous Emperor of Rome, who held unspeakable orgies there. The outraged historian Tacitus wrote: “He seized young men of ingenuous birth and forced them to yield to his brutal gratifications . . . New modes of sensuality . . . scandalous refinements in lascivious pleasure . . . ” But what made Tiberius so depraved? Many observers blamed the alcoholic wet nurse who used to suckle him as a baby. Tiberius’s successor Caligula was notorious for insanity, perversion, sadism and incest. Sure enough, his bloodthirsty wet nurse used to daub blood on her nipples before feeding baby Caligula. The legends, prejudices and controversies about breast-feeding are as old as history. We have used breast milk to treat sore eyes, blockage of urine, cataracts, burns and eczema. Direct suckling of infants by animals (such as goats, asses and ewes) is an ancient and widespread practice thought to make the baby resemble that animal. Hence goat’s milk makes children swift and nimble. It was nursing by she-wolves that had made the mythical founders of Rome, Romulus and Remus, so cruel. Kings often claimed that the gods had suckled them. In ancient Egypt, the royals themselves seldom suckled their own infants. Royal wet nurses enjoyed high status, their daughters calling themselves “milk-sister” to the king. But if the wet nurse herself delivered a daughter, so the story went, the male whom she nursed would become effeminate. In the second century, the Greek physician Soranus set out the ideal qualities of a wet nurse. (These ideals changed little until the nineteenth century.) She must be cheerful, active and healthy. Her breasts and even the blue veins on them must be not too large or too small. Her teeth must be strong and white, since bad teeth and bad breath would affect the baby’s lungs. She should speak well and not stammer. The teacher Sir Thomas Elyot (1544) even wanted nurses who could speak good Latin to the infant. She should have had (and hence be immune to) smallpox and measles. But she must not have gout, leprosy, falling-sickness

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(epilepsy), consumption, squint or bladder stones. Also taboo were red hair, freckles, vaginal discharge, drinking or smoking, and above all menstruation and pregnancy. Many accounts forbade a menstruating woman to wet nurse, because they believed that periods meant poor, scanty milk. The story went that during pregnancy and lactation, all the blood normally lost during menstruation went via a duct to the breasts, where it changed into milk. Indeed, old anatomy texts used to show a duct leading from the uterus to the breasts. Many also insisted that a nurse who became pregnant must stop suckling at once. Between about 1500 and 1800, many medical and religious writers gave wet nurses a bad press. Walter Harris (1689) wrote: “The passing bell hardly ever ceases ringing out the death of infants which have died for the neglect, nastiness, barbarity, or intemperance of their nurses.” Sir John Floyer (1706) said bluntly: “No child has the rickets unless he has a dirty slut for his nurse.” Why make scapegoats of wet nurses? Before about 1800, people believed that the wet nurse (like the breastfeeding mother) could transmit to the baby her own diet, ideas, beliefs, intellect, speech and all other physical and emotional qualities. What affected the nurse affected the child. Anything bad that happened to the child was the nurse’s fault. Nor was it only the ignorant who held such beliefs. Throughout his long life, Samuel Johnson blamed his tuberculosis and poor eyesight on his wet nurse. So what did you do for a sick nurse or a sick baby? First give the nurse a purge, then look at her diet. If all else failed, sack the nurse and find another, or else wean the baby. But occasionally a nurse got another chance. In 1727, when the son of the Earl of Cardigan was six months old, his nurse fell and broke her forearm. “I sent immediately for Dr Foyer who came and set it. We do not suffer Master Robert to suck for these five or six days, for these things are always attended with a fever.” After a few days: “The nurse is entirely free from pain and has not been at all feverish — so that in a day or two the child may suck without any manner of danger.” In the seventeenth and eighteenth centuries, a major cause of

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death among infants was “overlaying”, where a seemingly healthy baby was found dead in the morning. People blamed these deaths on nurses falling asleep on top of the babies and so suffocating them. Overlaying occurred not just in Britain but wherever wet nurses were common. In Florence, wet nurses had to use a wooden frame — the arcutio — to protect babies. Wrote Valerie Fildes: “Every nurse . . . is obliged to lay the child in it, under pain of excommunication. The arcutio, with the child in it, may be safely laid entirely under the bed cloaths in the winter, without the danger of smothering.” But the British knew better. Though the arcutio was widely advertised in European journals, it never caught on in Britain. Modern research suggests that unless the nurse or mother is drunk, drugged or unconscious, even without a protective frame, it is very hard to overlay or suffocate a healthy baby. So did some of these babies die of what we now call SIDS or cot death? (GB)

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A

FINAL WORD:

LOUIS PASTEUR — THE GREATEST

If you look back on the panorama of the history of medicine stretching over six or seven thousand years, there has emerged a pantheon of men and women who stand out above the others; their contributions have been outstanding and far-reaching. They have appeared in all eras and, although in many cases their worth was not recognised until years later, they set the tone. I suppose many have been rather like medical Van Goghs, appreciated when safely out of the way. For this distinguished role a very few are regarded by common consent to be ahead of the other greats, the crème de la crème. To attain this enviable position the laureates have had to make a contribution that has significantly changed the course of medical history, or indeed history itself. Who are these few? Rather as when picking an alltime great Olympic team, opinions vary as to the worth of individual excellence, so my choice for the award of

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bronze and silver medals in these lofty stakes could be reasonably questioned. But my gold goes to someone who has few detractors. I would award the bronze to Claudius Galen (c.130–c.210). I give it not because he was correct in his thinking (on the contrary he was often wrong) but because his influence was such that it lasted almost unquestioned for almost 1500 years. In casting about for answers he laboured under the disadvantage that he was not permitted to dissect humans, only animals, so often his conclusions were inaccurate in detail. Despite this he was an acute observer, voluminous writer and powerful advocate of his ideas. His influence on medical thinking was without parallel in history, both in its diversity and certainly in the length of time it held sway. My silver would go to William Harvey (1578–1657). As we have seen, by dissection and careful use of the so-called “scientific method” of proving all his observations by repeating and crosschecking their accuracy, he exploded the old theories of Galen. By so doing he opened up for the first time ever the logical process of medical thought as we know it today. His most famous contribution, of course, was the discovery of the circulation of the blood in the mid-1600s. After him came the deluge. But the gold belongs, in my opinion, to the man who discovered the basic cause of those infections which had from the beginning of recorded time decimated the population of the world — Louis Pasteur. Pasteur (1822–1895) was neither medically qualified nor trained — he was a chemist — but for my part I believe he was the greatest benefactor to medical welfare in human history. Pasteur was born in the village of Dole in the Jura district of eastern France on 27 December 1822. His father was a retired sergeant major from Napoleon’s grande armèe and at the time of the birth was working as a tanner. At school Louis was regarded as an average student but a very good drawer. He went to the Royal College of Franche Comte in Besancon and graduated as a Bachelor of Letters (Arts) in 1840 and as a Bachelor of Science in 1842. From there he went to Paris, where for the first time his academic ability began to be recognised. He wrote theses in

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chemistry and physics, but his real interest lay in crystallography, and in 1848 he read a paper in this subject to the Academy of Science. Shortly afterwards he became Professor of Physics at Dijon, and in 1849 he was elevated to the Chair of Chemistry at Strasbourg where he was able to pursue his interest in crystals. At the time he was 26 years old. In 1853 Pasteur succeeded in transforming tartaric acid into racemic acid, a piece of fundamental chemistry which showed for the first time that the biological properties of substances depend not only on the nature of the atoms, but also on the manner they are arranged in space. For this work he was awarded the red ribbon and rosette of a Knight of the Legion of Honour. The following year he was made Professor and Dean of the Faculty of Science at Lille where he became a sought-after lecturer who was able to display clarity of thought yet lose none of the polished and well-modulated delivery which made him a favourite among the students. He also introduced a new teaching aid whereby he summarised his notes and had them bound together to give to the students. He also introduced evening classes for the first time ever so that undergraduates could attend after doing a day’s work elsewhere. About 300 students were attracted to his sessions. It was during these lectures at Lille that his famous aphorism first saw the light of day — “In the field of observation, chance only favours the mind which is prepared.” Or as it is usually put, “Opportunity presents to the prepared mind.” In 1862, while still at Lille, he was elected a member of the Academy of Science, mainly as a result of his fundamental work on the fermentation of alcohol, that arcane path of winemaking never far from a Frenchman’s heart. He felt that diseases of wine might be caused by “microscopic vegetations which would develop in certain circumstances of temperature . . . the alterations of wine are coexistent with the multiplication of microscopic vegetations”. These conclusions became known as the “Pasteur effect” and were to stand him in good stead later in his medical experiments. At that time they were used to overcome the wine problem by the use of

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heat, or “pasteurisation” as the locals had it. It was applied to milk as well and the word, of course, has passed into common usage. As can be imagined, some old diehards thought the vintage would be ruined by heat. Ageing, it was claimed, required dark, cool cellaring and time. Pasteur replied, “The ageing of wines is due, not to the fermentation, but to a slow oxidisation which is favoured by heat.” Rather foolhardily he elected to test his theory on the navy. Two barrels of wine were sent to sea, one with wine which had been previously heated, and one unheated. Perhaps rather surprisingly, after ten months at sea, both barrels arrived back intact. The heated one was found to be “limpid and mellow” and the other “limpid but astringent”. The discovery was implemented commercially and the export of French wines increased enormously. The scientist then applied himself to the question of how these micro-organisms which caused fermentation arose. Was it spontaneous generation, the contemporary popular favourite explanation, or were they present in the air all the time, just waiting to settle? By means of simple experiments involving filtered air and exposure of unfermented liquids to pure air high in the Alps, Pasteur proved that food decomposes when placed in contact with germs in the atmosphere and does not spontaneously generate new organisms within itself. Proving the existence of these “germs” in the air led Joseph Lister (1827–1912), a surgeon working in Scotland, to apply the same principle to surgically infected wounds. The results were dramatic. This single discovery of attempting to eliminate the germs transformed surgical operations with their terrible risks and appalling side effects due to infection into procedures with an acceptable degree of danger; not good, but distinctly better. Thus much misery was relieved and countless lives were saved. If Pasteur had thrown light on no other problem during his life, this single event itself would have put him in the running for the gold. But there was much more to come. At the time the lucrative business of silkworm cultivation, centred in Alais in southern

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France, was threatened by a disease which was killing off the worms. Pasteur was called in, and again with the aid of his microscope and keen observation detected the cause to be in the micro-organisms in the gut of the silkworm. He saved the industry and the honour of France. By now, in 1868, the scientist was at the top of his form, or so everyone thought. He was in great demand and became the Professor of Chemistry at the Sorbonne University in Paris. Then disaster struck. On 19 October that year and when he was 45, he felt a strange tingling sensation on the left-hand side of his body but insisted on reading a paper he had promised to give to the Academy of Science. That night the threatening cerebral haemorrhage occurred and the master became paralysed down the left side. Fear was expressed for his life, and 16 leeches were prudently applied behind the ear to relieve the pressure. Obviously, some areas of medicine had not received his searching attention. It’s a pity he did not have some surgical problem so some of his newfangled ideas could be tried out. In any event, the attack was regarded as being so serious that the French Emperor daily sent a footman to enquire after his progress. Fortunately, the great mind remained lucid, but officialdom was not so sanguine as regards the ultimate outcome, for work was ordered to be stopped on the laboratory which the government was currently building specifically for him. It now seemed that the trouble and expense might turn out to be unnecessary. Slowly and painfully, Pasteur recovered and at length he returned to the silk-growing region to continue his investigations. He finished them with, as I say, complete success. In the following years he looked at the fermentation of yeast within the brewing industry, both in France and in London. His work led him to modify the brewing of beer so that it would not deteriorate with time and hence could travel to distant countries for sale. In 1877 he investigated so-called “splenic fever” in sheep; there was no stopping the man. This is known now as anthrax and at the time was threatening to wipe out the pastoral industry as cattle and

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horses were also affected. Modifying the guidelines of Edward Jenner (1749–1823) with his treatment of smallpox initiated a hundred years before, Pasteur prepared a dilute form of the causative germ which he then injected into the animal thereby causing a mild attack and thence immunity. As we have seen, his method was actually more in line with the ideas of Lady Mary Wortley Montagu rather than Jenner. Chicken cholera was approached in the same way with equally gratifying results. It almost seemed he could do no wrong and the accolades kept coming. By now he was more a bacteriologist than chemist, and indeed in 1873 was elected to the Academy of Medicine despite his lack of formal medical training. As a product of this honour, Pasteur started to look at the diseases of man, and the hospital began to assume as great an importance in his life as did the laboratory. So it was at this comparitive late stage in his professional life, at the age of 51, that he approached for the first time those problems for which he is best remembered. He looked at pus under the microscope and identified bacteria, recognising its key role in infection. One day at the Academy when the discussion turned to puerperal fever, the deadly infection of recently delivered women, his colleagues were ventilating their various theories when Louis Pasteur suddenly rose and said, “None of those things cause the epidemic; it is the nursing and medical staff who carry the microbes from an infected woman to a healthy one”. If that was so, someone remarked, it would never be found. Whereupon Pasteur went to the board, drew a diagram of a chainlike organism and said, “There, that’s what it is like”. Nobody had seen such a thing before. Nonetheless, their collective professional feathers were ruffled after being told by a man who had never even been into a lying-in ward that they should be sterilising the linen and washing their hands between cases. Others had no such doubts about his genius, however, and honours were heaped upon him by a grateful government and indebted industry. He represented his country at international conferences; he had dinner with the Prince of Wales; a

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commemorative plate was placed on the house where he was born; the daughter of the famous missionary Dr David Livingstone sought him out to present a book on her father’s life, and in 1882 he was accorded what was regarded as his country’s greatest honour, membership of the Académie Française. From all over the world came appeals and requests for consultations. Many thought him a physician with almost mystical powers, but as a scientist of the time said, “He does not cure individuals; he only tries to cure humanity”. Pasteur himself regarded his laboratory as “the temple of the future”. Despite all this hullabaloo and advancing years, the scientist’s most famous work was still in front of him. It was to be a piece of research which in the end Pasteur himself placed above all others, for it was concerned with a mystery which had constantly haunted him for many years — that of hydrophobia, as he called it, or rabies. It was known that the frightening condition was caught from affected dogs, and in 1880 the researcher was presented with two such “mad dogs” by an Army veterinary surgeon who was trying to find a cure for the puzzle of hydrophobia. Incredibly, the contemporary method of prevention was to file down the teeth of the dog so its bite would not penetrate the skin. The only clinical certainties known then were that the rabies virus was present in the saliva of “mad” animals, that it was passed on by bites and that incubation could be from a few days to several months. The animals were regarded as “mad” on account of the bizarre behaviour which overtook them when infected. The symptoms of the condition were restlessness, muscle spasms, a fierce thirst accompanied by an inability to swallow (hence “hydrophobia”, fear of water), convulsions and fits of rage. The victims often died by drowning in their own saliva. The whole presented as a very distressing picture. Pasteur set to work on dogs. By observing the troubled behaviour in an infected canine he felt the virus must be lodged in the brain, and by microscopic examination set out to prove this.

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It did not take a researcher of this man’s quality long to find that his supposition was right. He then cut up a dog brain and cultured the organism within the specimens in rabbits, concentrating it through several generations. Brain tissue was taken from these infected smaller animals and dried to attenuate the germ. The nowinactive tissue was crushed, mixed with water and injected under the skin of a healthy dog. Attenuated viruses of more and more virulent strains were injected over several days. The animals were then exposed to the bite of an infected dog, or they were injected with the deadly virus, while the experimenter anxiously waited to see what happened. In fact nothing happened; the disease was resisted. Another day, another triumph. The thought following on from this was to inoculate all the dogs of France to give them immunity. As there were an estimated 2 500 000 such animals, Gallic enthusiasm took on a new meaning. Indeed, the only thing which seemed to dampen this zeal was not the enormity of the task but the non-availability of sufficient rabbits to provide the vaccine emulsion. But the real problem lay with the disease in humans. Celsus, the first century Roman physician, writing at about the time of Christ, described the symptoms, saying, “The patient is tortured at the same time by thirst and by an invincible revulsion towards water.” He went on to recommend cauterisation of the bite with a red hot iron and the application of various corrosives. In passing it should be noted that this fear of water is characteristic of the infected human and is not replicated in the dog. Pliny the Elder (23–79 AD) recommended eating the livers of mad dogs as a cure, and Galen, for reasons best known to himself, suggested crayfish eyes. Such remarks put his bronze medal in jeopardy. In the eighteenth century sea-bathing held sway, especially at Dieppe. In some less squeamish quarters the ultimate solution of suffocating the victim, presumably as a perceived act of kindness, was advanced as a treatment. In the time of Pasteur’s childhood the turn of cautery had come round again, and hot

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needles were even thrust into the face while nitric acid was used elsewhere. No wonder the sight of a salivating, disturbed dog held great terror in a population where the treatment was patently worse than the complaint. So after 2000 years treatment had come full circle. Then Louis Pasteur appeared and all was soon to be light. By mid-1885, when he was 62, the experimenter was ready to try his theories on the human state, and on 6 July that year opportunity literally knocked at the door in the form of nine-year-old Joseph Meister and his mother. They were from Meissengott in the Alsace region where the boy had been bitten two days previously by a rabid dog. The animal in question had promptly been shot by the owner and when the stomach was opened hay, straw and pieces of wood were found. When the lad’s parents heard this they feared the worst and consulted their doctor. He cauterised the wounds with carbolic and suggested that Joseph should be taken to Paris to see Pasteur, which the parents promptly did. As he opened the door and took a look at the frightened boy, Pasteur knew he had reached his rubicon. The scientist was touched, for although he had seen people seeking his advice many times before, here was a forlorn victim with 14 wounds and in so much pain he could hardly walk. Could he risk a form of treatment which thus far had only been tried on dogs? Doubtless, he sucked his teeth and absentmindedly examined his cuticles as he pondered the dilemma. He sent the pair away so he could agonise without the emotional pressure of being fixed with the appealing gaze of a sick child. Two colleagues were consulted. What was there to lose, they asked. If, they continued, the certain danger which threatened the lad was weighed against the chances of snatching him from death, then the experimenter should see it was more than a right, it was a duty — high-sounding and facile sentiments if you do not have to take responsibility. Another look at the child decided him. It was now or never. A 14-day-old vaccine was chosen, ensuring that no living virus was

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within. It was injected into the site of one of the bites. The prick was slight and young Joseph did not move. A few days later on 11 July the boy was sleeping and eating well. The virulent strength of the continuing daily inoculations increased, and Pasteur suffered from mounting anxiety, knowing there was no drawing back now. He stopped all other work and had difficulty sleeping, and when he did drop off had nightmares of children dying from suffocation. The serum grew stronger over a ten-day period. On the last day the strength was of a degree that would have killed a rabbit in experimental circumstances. But as Louis Pasteur tossed all night, Joseph Meister slept the sleep of the innocent. The treatment was completed and mother and son went home, while the therapist went to a deserted country house with his daughter in order to settle his jangled nerves. The feared telegram from the local GP never came, and 31 days after the bite, Joseph was declared out of danger. Pasteur returned to Paris to resume his life of experimentation, doubtless going about his task with a warm feeling of a job well done. With justification, he was now regarded as “The Oracle” and a steady stream of visitors beat a path to his door. Bottles of wine were brought to study and “cure” of acidity. Silkworms, cases of swine fever and anthrax and chicken cholera all showed up. Inevitably, another case of human rabies presented. Although lacking the uniqueness of being first, the fearlessness and audacity of this second victim, together with the success of the subsequent treatment, so caught the public imagination it is commemorated to this day by a statue set in the grounds of the Pasteur Institute in Paris. The story is this. On 24 October 1885 the mayor of VillersFarley in the Jura district wrote to Pasteur with the information that a shepherd boy had been bitten the previous day by a mad dog. It seems six young shepherds were guarding their sheep when a large dog approached. Five ran for safety, but the eldest, 14-yearold Jupille, turned to protect his fellows and wrestle with the

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animal. It seized his left hand but he managed to disengage himself by forcing the jaws open with the right hand. Consequently, both hands were severely bitten and covered in the deadly saliva. However, the dog was eventually overpowered and clubbed to death. A necropsy was done the next day and rabies was confirmed. It was at this point that the mayor wrote to Paris. Pasteur replied immediately to say he had treated only one human case, and, although that one had been successful, the dangers were great. The family decided to give it a go, but in the inevitable and agonising delay, six whole days had elapsed before Jupille arrived in the laboratory. With young Meister it had been two-and-a-half days, which had been stressful enough, but following the spectacular success of that case, the master had a newfound confidence and plunged straight into treatment. A few days later he went to speak at the Academy of Science and recounted the Meister case, his original brief for speaking. But while on his feet Pasteur also seized the opportunity to tell of the current problem. He spoke of the courage of the young shepherd protecting his companions and almost sacrificing his life in the process. Other speakers took up the theme and the upshot was that for his courage and devotion 14-year-old Jupille received the Montyon prize of France’s highest national institution, the Académie Française. The boy recovered and later, as I say, a statue was erected to the shepherd in the grounds of the Pasteur Institute. It shows the boy fighting off the rabid dog and is still there for all to see and marvel at. For Pasteur’s part he was lionised wherever he went. Prizes and praise continued to be heaped upon him. The President of the Academy of Science said of the scientist’s efforts with rabies, “it is one of the greatest steps ever accomplished in the medical order of things . . . treatment for a disease the incurable nature of which was a legacy handed down from one century to another. It is to M. Pasteur that we owe this, and we could not feel too much admiration or too much gratitude for the efforts on his part which

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have lead to such a magnificent result.” The speech contains much more of this kind of hyperbole. When news of Pasteur’s paper regarding the two cases became common knowledge he was besieged by victims from all sides. He prepared vaccine from the spinal marrow of rabid dogs. The specimen hung in a flask to be gradually dried out by the action of caustic potash lying in the bottom of the glass. The marrow was then cut up and placed on a glass plate, and veal broth was added and the mixture was ground up. The vaccinal fluid was now ready. It was left for 14 days, and each patient had a series of little glasses with different strengths. The hour for inoculation was 11 a.m. and Pasteur himself was always present. It was the master himself who called the patients in. One child, Louise Pelletier, was brought along 37 days after being bitten. Pasteur hesitated to treat her in case the almost certain failure after so long an incubation period would put off other suffers. In the end, common humanity prevailed, and he sat at the girl’s bedside as, despite all his efforts, she began to fit. Louise died and when Pasteur came downstairs he burst into tears. Her death was the only one in his first 350 cases. The contemporary untreated death rate was 16 per 100. Four children came from New York to be treated, having been financed by public subscription via the good offices of The New York Herald. They all returned in triumph. Master Jupille kept up a correspondence with Pasteur and he wrote back with political correctness encouraging the young shepherd always to take advice from his father and mother and not waste time with other boys! The Academy of Science established a unit for the prevention and treatment of hydrophobia. This was the previously mentioned Pasteur Institute, and it was built in 1888 in what had been a market garden in the middle of Paris. Where young lettuces and spring onions had grown there arose a solid stone building with a suitably opulent Louis XIII façade, grand enough to go with its irreproachable international reputation. It is still there and functioning as a research laboratory but with a greatly enlarged

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brief, its current prime research being into AIDS. It can be visited, along with the reconstruction of Pasteur’s living quarters and his tomb in the basement. It was to this institute that the Duchess of Windsor deemed that the proceeds of the posthumous sale of her jewellery should go. Pasteur had a few detractors who thought that his failures were not being published. These upset him and his health began to suffer. Despite being cheered by resounding support from English workers, he had two minor strokes in 1887, and although he recovered, his pale face and gaunt frame testified to the stresses of the previous few years. But he lived on, a legend in his own lifetime. On 27 December 1892 a distinguished academic gathering was held at the Sorbonne University in Paris to celebrate the maestro’s 70th birthday. The place was packed with the most illustrious men and women of the era, both from France and from overseas. A medal was struck showing, on one side, Pasteur in profile wearing his skull cap, and on the other an inscription which read, “To Pasteur on his seventieth birthday. France and Humanity grateful.” Louis Pasteur mounted the podium leaning on the arm of the President of the Republic of France, no less. The speeches were grand, sonorous and numerous. “Who can now say how much human life owes to you and how much it will owe to you in the future.” “The day will come when another Lucretius will sing, in a new poem of nature, of the immortal Master whose genius engendered such benefits.” “Pasteur’s works shine with such dazzling light, that, in looking, one is inclined to think that it eclipses all others.” And so on, and so on, and so on. Pasteur was too weak and emotional to speak, so his reply was read by his son. It was a fairly short presentation by the standards of the occasion, but during it there occurred one magical instant which not only made a great impact then but has remained to be remembered as one of science’s most deathless moments. Among those present was Joseph Lister, Lord Lister, who, as we have seen, years before had applied the germ theories of Pasteur in his surgical practice and had thereby saved countless lives. As

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Pasteur spoke of the overseas visitors he said, “You bring me the deepest joy that can be felt by a man whose invincible belief is that Science and Peace will triumph over Ignorance and War . . . that the future will belong to those who will have done most for suffering humanity. I refer to you, my dear Lister . . .” Spontaneous applause and shouts of “Vive Pasteur!” broke out, and as the crowd rose cheering, Lister and Pasteur embraced. This electrifying moment marked the sealing of the new era in medicine and surgery. Louis Pasteur lived for another three years, becoming gradually weaker but remaining mentally very active. Work in his laboratory was carried on by his assistants, many of whom became famous in their own right. It was from them that antitoxins for diphtheria and plague were discovered. Indeed, the tomb of Pasteur’s successor, Dr Emile Roux, inventor of the diptheria serum injection, is in the garden of the institute, and the road on which the building stands is now called Rue du Docteur Roux. Pasteur took a critical interest in all their efforts, but the fire had gone and on 28 September 1895 he died. We may smirk at the grand and fulsome praise that was heaped upon him, but there is no doubt of his greatness. The fundamental discoveries of Louis Pasteur transformed modern medicine, surgery, obstetrics and public health and made possible the control of infectious disease. He brought about a revolution in scientific investigation by studying the agents of disease in their natural environment and almost always provided a solution. He had insatiable curiosity, an analytical and mercurial mind, a remarkable gift of observation, and immense and persistent enthusiasm. While gracious in his dealings with his colleagues, he was not immodest and did not refuse the honours heaped upon him, and for good reason. For, of course, he knew what we now know — he was simply the greatest. (JL)

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BIBLIOGRAPHY

Chapter 1: Pioneers Appleby, L., A Medical Tour Through the Whole Island of Great Britain, Faber & Faber, London, 1994. Birch, C. A., Names We Remember, Ravenswood, Beckenham, 1979. Gethyn-Jones, J. E., The Jenner Museum, Jenner Trust, Bristol, 1986. Gordon, R., The Alarming History of Medicine, Sinclair Stevenson, London, 1993. Guthrie, D., A History of Medicine, Thomas Nelson & Sons, Edinburgh, 1945. Haggard, H. W., Devils, Drugs and Doctors, Blue Ribbon Books, New York, 1929. Karlen, A., Plague’s Progress, Indigo, London, 1995. Keynes, G., The Personality of William Harvey: The Linacre Lecture, Cambridge University Press, Cambridge, 1949. Leavesley, J. H., Medical Byways, ABC/Collins, Sydney, 1984. Perry, C. B., Edward Jenner, Jenner Trust, Bristol. Porter, R., The Greatest Benefit to Mankind, HarperCollins, London, 1997.

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Roberts, S., “Constance Stone — Australia’s first woman doctor”, Journal of Medical Biography, vol. 3, 1995, pp. 1–7.

Chapter 2: Frauds Broad, W. & Wade, N., Betrayers of the Truth, Simon & Schuster, New York, 1982. Hixson, J., The Patchwork Mouse, Doubleday, New York, 1976. Youngson, R. & Schott, I., Medical Blunders, Robinson, London, 1996.

Chapter 3: Versatile doctors Encyclopaedia Britannica: Micropaedia, “Buccaneers”, vol. II, 1975. Encyclopaedia Britannica: Macropaedia, “David Livingstone”, vol. 11, 1975. Gelfand, M., Livingstone the Doctor: His Life and Times, Basil Blackwood, Oxford, 1957. Longfield-Jones, G. M., “Buccaneering doctors”, Medical History, vol. 36, 1992, pp. 187–206. Ma, K., “Sun Yat-sen (1866–1925)”, Journal of Medical Biography, vol. 4, 1996, pp. 161–170. Manne, R., The Petrov Affair: Politics and Espionage, Pergammon Press, Sydney, 1987. Osler, W., Michael Servetus, Oxford University Press, Oxford, 1909. Roland, C., Introduction to S. Squire Sprigge, The Life and Times of Thomas Wakley, Krieger, Huntington, NY, 1974 (1899). Sheridan, R., “The doctor and the buccaneer”, Journal of History of Medicine and Allied Sciences, vol. 41, 1986, pp. 76–87. Sun Yat-sen, Kidnapped in London, Arrowsmith, Bristol, 1897.

Chapter 4: Medicine and the arts Beighton, P. & Beighton, G., The Man Behind the Syndrome,

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Springer-Verlag, London, 1986. Boswell, J., Boswell’s London Journal 1762–1763, William Heinemann, London, 1950. Boswell, J., Life of Johnson, Oxford University Press, Oxford, 1980. Burgess, A., Ernest Hemingway and His World, Thames & Hudson, London, 1978. Gibbon, E., The Decline and Fall of the Roman Empire, Penguin, London, 1981. Gordon, R., The Literary Companion to Medicine, Sinclair Stevenson, London, 1993. Haggard, H. W., Devils, Drugs and Doctors, Blue Ribbon Books, New York, 1929. Keynes, M., “The personality and illnesses of Wolfgang Amadeus Mozart”, Journal of Medical Biography, vol. 2, 1994, pp. 217–32. Landon, H. C. R., 1791: Mozart’s Last Year, Flamingo, London, 1989. Leavesley, J. H., Medical Byways, ABC/Collins, Sydney, 1984. MacLaurin, C., “Gibbon’s hydrocoele”, Medical Journal of Australia, 20 April 1920, pp. 385–7. McLeish, K. & McLeish, V., Composers and Their World: Mozart, Heinemann, London, 1978. Meyers, J., Hemingway: A Biography, Macmillan, London, 1985. Morton, R. S., Gonorrhoea, W. B. Saunders, London, 1977. Murray, T. J., “Dr Samuel Johnson’s movement disorders”, British Medical Journal, vol. 1, 1979, pp. 1610–14. Page, P. M., Medical Biographies, University of Oklahoma Press, Norman, 1952. Porritt, A. E., “Some historical surgical operations”, General Practitioner of Australia and New Zealand, 16 December 1937, pp. 288–94. Porter, R., “The dark side of Samuel Johnson”, History Today, vol. 34, December 1984, pp. 43–6. Porter, R., The Greatest Benefit to Mankind, HarperCollins, London, 1997.

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Power, D., “Some bygone operations in surgery: A historical lithotomy: Samuel Pepys”, British Journal of Surgery, vol. XVIII, no. 72, April 1931, pp. 541–5. Schultz, M. G., “The strange case of Robert Louis Stevenson”, Journal of the American Medical Association, vol. 216, no. 1, 1971, pp. 90–4. Vincent, E. H., “And so to bed”, Surgery, Obstetrics and Gynaecology, vol. 87, no. 3, September 1948, pp. 353–7.

Chapter 5: Opium Inglis, B., The Opium War, Hodder & Stoughton, London, 1976.

Chapter 6: Famous and infamous people Brander, M., The Victorian Gentleman, Gordon Cremonesi, London, 1975. Fuentes, C., The Buried Mirror: Reflections on Spain and the New World, Andre Deutsch, London, 1992. Green, V., The Madness of Kings: Personal Trauma and the Fate of Nations, Alan Sutton, Phoenix Mill, England, 1993. Innes, H., The Conquistadors, Fontana/Collins, London, 1969. King, G., The Murder of Rasputin, Century, London, 1966. Leavesley, J. H., A Mixed Medical Bag, ABC/Collins, Sydney, 1985. L’Etang, H., The Pathology of Leadership, Heinemann, London, 1969. Magnus, P., King Edward the Seventh, John Murray, London, 1964. Maples, W., Dead Men Do Tell Tales: The Strange Cases of a Forensic Anthropologist, Doubleday, New York, 1994. Palmer, A. (ed.), Age of Optimism, Weidenfeld & Nicolson, London, 1970. Winton, R., From the Sidelines of Medicine, Australasian Medical Publishing Company, Sydney, 1988.

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Chapter 7: Death Benitez, M. B., “A 39-year-old man with mental changes”, Maryland Medical Journal, vol. 45, 1996, pp. 765–9. Cavendish, R. “Death of Edgar Allen Poe”, History Today, vol. 49, no. 10, October 1999, p. 52. Daugherty, C. G., “The death of Socrates and the toxicology of hemlock”, Journal of Medical Biography, vol. 3, 1995, pp. 178–82. Day, D., John Curtin: A Life, HarperCollins, Sydney, 1999. Fabricant N., 13 Famous Patients, Pyramid, New York, 1960. Hamilton. E. & Cairns. H. (eds), Plato: The Collected Dialogues, Princeton University Press, Princeton, 1961. L’Etang., H., Ailing Leaders in Power 1914–1994, Royal Society of Medicine Press, London, 1995. MacGregor Burns, J., Roosevelt, Soldier of Freedom 1940–45, Weidenfeld and Nicolson, London, 1971. Ross, L., John Curtin: A Biography, Melbourne University Press, Melbourne, 1977. Serle, G., For Australia and Labor: Prime Minister John Curtin, Prime Ministerial Library, Perth, 1998. Wilkins, R., The Fireside Book of Death, Robert Hale, London, 1990.

Chapter 8: Diseases Fraser, D. W. et al., “Legionnaire’s Disease”, New England Journal of Medicine, vol. 297, no. 22, 1977, pp. 1189–96. Hudson, R. P., “Lessons from Legionnaire’s Disease”, Annals of Internal Medicine, vol. 90, 1979, pp. 704–7. Steinschneider, A., “Prolonged apnoea and sudden death syndrome: Clinical and laboratory observations”, Pediatrics, vol. 50, 1972, pp. 646–54. Thomas, B. & Gandevia, B., “R. Francis Workman and the history of taking the cure—consumption in the Australian colonies”, Medical Journal of Australia, 4 July 1959, vol. II, pp. 1–10.

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Chapter 9: Disasters and eccentrics Alexander, L., “The commitment and suicide of King Ludwig II of Bavaria”, American Journal of Psychiatry, vol. III, 1954, pp. 100–7. Bateson, C., The Convict Ships, 1787–1868, 2nd edn, Brown, Son & Ferguson, Glasgow, 1969. Beattie, O. & Greiger, J., Frozen in Time: The Fate of the Franklin Expedition, Bloomsbury, London, 1987. Blunt, W., The Dream King, Hamish Hamilton, London, 1970. Cobcroft, M., “Medical aspects of the Second Fleet”, in Australia’s Quest for Colonial Health, eds J. Pearn & C. O’Carrigan, Department of Child Health, Royal Childrens Hospital, Brisbane, 1983. Cookman, S., Ice Blink, Wiley, London, 2000. Dods, L., “Early paediatrics in the Antipodes”, Medical Journal of Australia, 10 June 1961. Gregg, C., A Virus of Love and Other Tales of Medical Detection, Scribner’s, New York, 1983. Hay, G. G., “The illness of Ludwig II of Bavaria”, Psychological Medicine, vol. 7, 1977, pp. 189–96. Hughes, R., The Fatal Shore, Pan, London, 1987. Maltby, J. R. & Lee, J. A., “The medical establishment and association with unqualified practitioners: The sad case of Doctor Axham”, Journal of Medical Biography, vol. 3, 1955, pp. 119–23. Newman, E., “The strange case of King Ludwig II of Bavaria”, The Saturday Book, No. 4, Hutchinson, London, 1944. Nicol, B., Behind the Myth, ABC Enterprises, Sydney, 1989. Pearn, J. (ed.), Milestones of Australian Medicine, Amphion Press, Brisbane, 1994. Roe, Francis, “Medicine and books”, British Medical Journal, 9 June 1979, pp. 1553–4. Sexton, C., The Seeds of Time: The Life of Sir Macfarlane Burnet, Oxford University Press, Melbourne, 1991. Sauerbruch, F., A Surgeon’s Life, translated by Fernand G. Renier

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and Anne Cliff, Deutsch, London, 1953. Sunday Times, Suffer the Children: The Story of Thalidomide, Andre Deutsch, London, 1979. Thorwald, J., The Dismissal: The Last Days of Ferdinand Sauerbruch, Surgeon, Thames & Hudson, London, 1961. Youngson, R. & Schott, I., Medical Blunders, Robinson, London, 1996.

Chapter 10: Quirks and oddities Klawans, H. L., Trials of an Expert Witness: Tales of Clinical Neurology and the Law, Bodley Head, London, 1991. Klawans, H., The Medicine of History, Raven, New York, 1982. Lyons, A. & Petrucelli, J., Medicine: An Illustrated History, Macmillan, Melbourne, 1979. Strean, H. S., Behind the Couch: Revelations of a Psychoanalyst, Wiley, New York, 1988.

Chapter 11: Discoveries Pflaum, R., Grand Obsession: Madame Curie and Her World, Doubleday, New York, 1989. Watts, G., Pleasing the Patient, Faber & Faber, London, 1992.

Chapter 12: Mayhem and murder Wambaugh, J., The Blooding, Bantam, London, 1989. Sakula, A. “Roderigo Lopez: Executed 1594”, Journal of Medical Biography, vol. 3, 1952, pp. 114–18.

Chapter 13: Midwives, women and babies

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Fildes, V., Breasts, Bottles and Babies, Edinburgh University Press, Edinburgh, 1986. Guthrie, D., A History of Medicine, Thomas Nelson & Sons, London, 1945.

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Haggard, H. W., Devils, Drugs and Doctors, Blue Ribbon Books, New York, 1929. Jeffcoate, T. N. A., Principles of Gynaecology, Butterworth, London, 1957. Willis, E., Medical Dominance: The Division of Labour in Australian Health Care, Allen & Unwin, Sydney, 1989.

A final word: Louis Pasteur — the greatest Guthrie, D., A History of Medicine, Thomas Nelson & Sons, London, 1945. Porter, R., The Greatest Benefit to Mankind, HarperCollins, London, 1997. Vallery-Radot, R., The Life of Pasteur, vols I & II, Archibald Constable, London, 1902.

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Bonus

TB

Stories

AND SOME OF

ITS FAMOUS VICTIMS

Deaths from tuberculosis today number between 1 and 2 million a year. In the mid 1990s the World Health Organization declared TB a global emergency and predicted that without radical funding to eliminate it, by 2005 the annual death toll could be 4 million. At any one time, 20 million people round the world have the active disease, and it has been estimated that 1.9 billion are infected but not actually ill. TB accounts for a quarter of all adult deaths in developing countries, but their governments spend on average 2 cents on TB out of every $10 (note, not $1) they spend on health. The rich countries spend 0.1% of their foreign aid on TB control. So you can see it is an infinitely bigger problem than, for instance, AIDS, which globally has a quarter the number of deaths but 18 times the funding. AIDS, of course, has a much more powerful lobby and has caught the public imagination. On the other hand, the disease which has always been there, niggling away at the morale and sapping the vigour of the population, has, by dint of

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this characteristic insidious and arcane nature, received a less than sparkling press. As it has a considerably greater mortality rate than any other microbe, to say nothing of the morbidity it occasions, it is no mean disease. So let us look at the eponymously named “white plague”, Bunyon’s “captain of the men of death” — tuberculosis. And at some of its famous victims, to see if we can, in part at least, redress the balance away from its status as the poor relation of medicine. The long-winded death of some opera stars on stage from TB is well known. If terminally stricken with a chronic lung disease, how they have the breath to warble on defeats me. But at least it renders heroines pale and interesting. Literary people of various sorts have also been well-known sufferers, from Cicero, Robert Louis Stevenson and Chopin, to Shelley and Keats. Keats was 26 when he died, and had no hope of curing himself, despite his medical qualifications. It was 13 months from his first spitting of blood, or haemoptosis, to his death. During that time he was starved and had repeated letting of his blood. In the years before he died he wrote Hyperion, in which he had this to say of Saturn: . . . Upon the sodden ground His old right hand lay nerveless, listless, dead, Unsceptred; and his realmless eyes were closed

Pretty cheerless and probably prophetic regarding his own parlous state. The odd thing is that tuberculous writers were often prolific in their output, as though trying to get it all down before coughing their last. For instance, D. H. Lawrence wrote his last novel, Lady Chatterley’s Lover, between 1926 and 1928 while he was suffering from the rapidly advancing pulmonary tuberculosis that finally killed him in 1930 at the age of 45. It has been suggested that it was written in a mood of anger and frustration at the impotence of the medical fraternity to heal him.

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If of significance at all, I suppose such frenetic activity may have been because of the low, persistent fever and consequent slight quickening of the body metabolism that sufferers had — the fire that wastes the body also makes the mind shine with brighter light. The more cynical may say it was due to the contemporary medical treatment for TB: opiates, to quell the cough, ease the anguish and relax the body. On this drug, the imagination was then able to run riot. Indeed it was said of Victor Hugo at the time when he displayed rude health, good vitality and a legendary bedroom athleticism that he would have been an even greater writer had he not been in such robust health. Artists themselves sometimes thought the condition had an effect on them. The essayist John Addington Symonds wrote that TB had given him a wonderful Indian summer of experience, and that the colours of life had been richer, personal emotions more glowing, perceptions more vivid and he had grown in youth and versatility inversely to his physical decay. Sounds more desirable than good health — but he knew his number was up, for he then added, “I may rave, but I shall never rend the heavens. I may sit and sing, but I will never make the earth listen.” There is no evidence that tuberculosis breeds genius. It was just a common disease, affecting the intellectually gifted and the mentally impoverished indiscriminately. Indeed, languorous singing young women or poets wheezing their last were actually uncommon; they just got a generous press. The vast majority of sufferers were anonymous people of all ages living out their lives in quite desperation, as Thoreau had it. To them it was not a source of romantic inspiration, but a prelude to destitution and consequently a breeder of crime, and also an inexorable killer of youth. So what is it all about? Medically, tuberculosis is a disease caused by several species of mycobacterium collectively called tubercle bacilli, and in man it usually follows infection by the human or bovine variety. The bacillus was discovered by the German bacteriologist Robert Koch in 1882 during that great surge of discovery of the causes of all the

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infectious diseases starting with anthrax in 1872 and finishing with plague in 1896. Up until that moment TB was thought to be due to an inherited disposition, unfavourable climate, sedentary life and depressed emotions. It was not regarded as communicable, and if you could afford it, wintering in Egypt was as good a cure as any. Well, you might as well go down in style. The word “tuberculosis” first appeared in print in 1840 and has come into common usage only in the last 50 years. Due to its wasting nature it was called consumption, asthenia, phthisis or, if in the neck, scrofula. The latter was supposed to be cured by a touch of the monarch, hence its name “King’s Evil”. The treatment started with Edward the Confessor in 900 AD, but Charles II in the seventeenth century was its greatest exponent, touching over 90,000 during his 25-year reign. Samuel Johnson was touched by Queen Anne in 1712 when he was aged two and a half, it being thought worth the three-day journey from Lichfield to have this done. It did no good in his case. His glands were later incised, and he bore the scars for life, as can be seen in a number of his many portraits. This bogus method of treatment went out of fashion forever in 1714, but the medallion given to Johnson by the Queen is now in the British Museum for us all to see and marvel at. Although “tuberculosis” is a comparatively modern word, the disease itself is as old as mankind. Evidence has been found in Neolithic burial grounds at Heidelberg, Germany, where a skeleton of a young man was unearthed showing fusion of the fourth and fifth vertebrae characteristic of the disease. The bones were 6000 years old, considerably more ancient that many examples dug up at Ammon in Egypt from 1000 or so BC. Greek and Roman physicians recognised night sweats, spitting up blood, pleurisy, dry cough and chest pain to be a chronic disease entity. What impressed them most, however, was the wasting of the body and accompanying fatigue. “Phthis” or “phthoe” was the name given by the Greeks to someone shrivelled under intense heat, and so eventually came to denote wasting or consumption of the body.

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In 1679 the famous physician Franciscus Sylvius found that the lungs of sufferers had characteristic nodules which he labelled tubercles. It was also noted that if the subject died quickly these tubercles were disseminated throughout the body and were so small as to resemble millet seeds, hence the term “miliary tuberculosis”, still in use today. Diagnosis in the living was speculative, until in 1761 a great leap forward took place with the publication of a paper by an Austrian, Leopold von Auenbrugger, in which he observed that the chest, when tapped, yields up different notes in different diseased areas. “A healthy chest,” he said, “resembles the stifled sound of a drum covered with a thick woollen cloth.” Cavities had a hollow ring, solid areas sounded dull and so on. You wonder why it had not been noted before, but 55 years later in 1816 members of the medical profession kicked themselves again when another very simple aid was devised: the stethoscope. The exploratory ear had been applied to the chest on and off for centuries; Hippocrates mentions the gurgling sound of a death rattle, which he describes as “a slight noise like boiling vinegar”. But on the whole there had been medical resistance to applying the shell-like to an unwashed and verminous chest wall. And then Theophile Hyacinthe Laennec from Brittany enters the story. In the early nineteenth century he was the first man to advance the theory that the various cavities, tubercles and bone deformities of phthisis were in fact due to a single disease entity. But he needed to get a more careful listen to the chest to marry what could be heard in life with the lesions he found later at postmortem . . . Strolling one day through the gardens of the Louvre in Paris he saw children listening at one end of a log to the noise created by another child scratching at the other end. He hot-footed it back to the hospital, rolled up a card, placed it decorously on the chest of a nameless patient, said to be a young lady to add flavour to the story, and, surprise, surprise, heard heart sounds of a heretofore undreamtof clarity. It was his burning bush moment. He combined the Greek

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words for “chest” and “to examine” and came up with “stethoscope”, resisting the grave temptation, I have no doubt, to call it a “Laennecascope”. His original cylinder has, of course, now developed into the familiar tubes and metal bits, some of which are now goldplated, the better to match a black waistcoat and pinstriped trousers. This was the greatest advance until X-rays came along in the 1890s. But by then Robert Koch had found the basic cause of the disease, and with it the beginning of the end for the commonest of scourge of all time, one which had laid waste to humankind since it had begun to form communities. As I said at the beginning, many well-known characters from history suffered from the condition. One of the most interesting was probably Joan of Arc. She was a country girl, as you know, and as such may have contracted bovine TB. The fascinating thing is that it has been conjectured that the auditory hallucinations that she heard and that drove her on to become the highest in the land may have been from the effect of a tuberculous mass, or tuberculoma, in the temporal lobe of the brain. She was only 19 when she was executed, but to add credence to the story it was reported that her entrails would not burn — possibly as a result of calcification of the glands surrounding the gut due to quiescent tuberculosis. Vivien Leigh was described by a reviewer, who in turn was quoting Wordsworth, as . . . Phantom of delight, When first she gleamed upon my sight, A lovely Apparition, sent To be a moment’s ornament . . . A dancing shape, an image gay, To haunt, to startle, and waylay

She was mentally disturbed too, suffering from a bipolar disorder alternating between hypomania and depression. Sufferers F. Scott Fitzgerald, Pandit Nehru, Laurence Sterne and Cecil Rhodes lived a good few years, whereas Chopin and Keats

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died at a very young age from the condition, as did several members of perhaps British history’s most famous tubercular family, the Brontes. And it is at them I wish to look in a little more detail. The Reverend Patrick Bronte and his wife Maria were married for only eight and a half years before she died of cancer. In that time they had six children. The father was left with a salary of £200 per year, a draughty parsonage at Haworth, a village adjacent to the Yorkshire moors, and five girls and one boy to look after. He was a withdrawn and reclusive man and discouraged his children from mixing with village children. (In passing, if you are ever in the north of England take time out to visit Haworth, with its steep cobbled street and the original vicarage, now open as a museum, and church. It is all very evocative, and you will come away a lifelong Brontephile.) Anyway, in 1824 the two eldest, Maria and Elizabeth, were sent to board at the Clergy Daughters’ School, a Dickensian institution calculated to mortify the flesh rather than enlarge the mind. Added to that, due to little exposure to other children, the immunity of the girls was low and they were easy prey to any infection. So in February 1825 Maria became ill, was sent home, rapidly went downhill and among tear-jerking entreaties from the little girl for the others not to grieve, died aged 11, probably of the miliary TB. On her tomb were chiselled the words “Be Ye Also Ready”. A bit morbid for an 11-year-old, but it must have been some kind of portent, for six weeks later Elizabeth joined her in the family vault. She was 10. Many years later sister Charlotte described her symptoms as shortness of breath, pain in the chest and frequent flushings. Sounds like the true bill, all right. The remaining four stayed at home and amused themselves by writing stories in a minute hand in the form of minuscule letters that were bound together, some of which can be seen in the parsonage now. At least they reached adulthood. The next victim was the only son, Patrick Branwell (known as Branwell). He was a different personality from his sisters. Whereas

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they were introverted, he was sociable and expansive, spending much time in the local tavern, the Black Bull, which is only about 100 metres from the house. At the pub he was regarded as a talented if somewhat moody raconteur. Being the only boy, much store was put on his success, probably too much, and he was not up to it. He failed as a painter, writer, schoolmaster and tutor. He took to alcohol and opium until he became quite unbalanced, and with his tattered clothes and unshaven appearance became an object of fun in the village. He developed a cough and died in 1848 at the age of 31. That left three children, and they became the most famous: Charlotte, Emily and Anne. Emily wrote the powerful novel Wuthering Heights and was at her happiest when wandering on the wild moors beyond the village. Though of an introspective nature, she could be quick-tempered. She caught a chill attending her brother’s funeral and rapidly went downhill, to be described by Charlotte thus: A more hollow eyed, wasted and pallid aspect I have not beheld. The deep, tight cough continues; the breathing after the least exertion is a rapid pant accompanied by pains in the chest. Her pulse, when allowed to take it, is 115 per minute. She resolutely refuses to see a doctor; she will not give an explanation of her feelings, and will scarcely allow her illness to be alluded to.

Emily stated, apparently, that she would have no poisoning doctor near her. Sounds as though she lived before her time. Anyway, on 19 December 1848 she attempted to do some sewing, but by noon was so weak she could only whisper and finally agreed to see the doctor. She was moribund by the time he arrived and died at 2 o’clock. She was 30. She only wrote the one book, a remarkable offering of repressed sexuality, and the heartrending outpourings from one who led a cloistered life. Within six months Anne Bronte, author of Agnes Grey and The Tenant of Wildfell Hall, was also dead. In March 1849 she was

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diagnosed as having “consumption” and Charlotte wrote that her arms were no thicker than a child’s and she would creep rather than walk. Unlike Emily, Anne welcomed medical advice, though goodness knows why, for her treatment consisted of cod-liver oil, vegetable balsam, carbonate of iron, blistering and “hydrotherapy”, a euphemism for a bath. She was taken to Scarborough for the bracing air, but succumbed within four days. She was 29. By embracing all the then known therapies, she in fact died at a younger age than her sister who eschewed such fol-de-rols. This left Charlotte, author of Jane Eyre, Villette and The Professor. She suffered from a variety of ills including short-sightedness, migraines, insomnia, dyspepsia and depression. Added to that she was small in stature and said to be unprepossessing to look at. A dress of hers now in the Bronte Museum would scarcely fit a 10year-old of today. She had an introspective nature, and visited the doctor fairly frequently. In 1852 she was given some pills for a sick headache. After taking these for a week her mouth became sore, her teeth loose and her tongue swollen, and water welled into her mouth. She wrote about this and gives a very good description of mercury poisoning. It cleared when the pills were stopped. Two years later, at the age of 37, she married her father’s curate, and this allowed her to be the one member of the family who probably died of something other than TB. True enough, she had occasional bouts of chest pain and coughing, but managed to throw them off. But then something else happened: she fell pregnant. Early in her marriage her headaches and indigestion cleared up, but after six months the nausea returned. Early in 1855 pregnancy was confirmed, and it was thought the morning sickness would clear. However, it persisted, and became day-long and was accompanied by fainting. She could not eat and slowly acquired a skeleton-like emaciation. Vomiting of blood occurred, and by mid March a muttering delirium manifested itself. She then seemed to rally and feebly asked for food, but it was too late and on 31 March 1855 she succumbed. She was 38.

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Now, her death certificate said the cause of death was phthisis, but she did not present like the others at all, and it seems to me the most likely cause of death was quite unrelated, and was hyperemesis gravidarum, or the excessive vomiting of pregnancy. Not common, even then, and with modern treatment very rare now, but we know how she presented. She became emaciated, partly from starvation, partly dehydration. The skin was dry and muddy in appearance, the eyes were sunken, the tongue brown and cracked, and the breath smelled of acetone (the “odour of sanctity”) due to the metabolism of her own body fat in the absence of food. Characteristic of the condition, the symptoms improved two days before death, when she asked for nourishment. The illness was said, even when I was a student 50 years ago, to be of a neurotic origin, and the treatment was to take the vomit bowl away, or to get the most overbearing and vulturine sister to sweep in and talk some sense into the poor unfortunate. It was never any good. That cleaned up the family except for the father. He survived them all and lived to the age of 84, having sired the most remarkable family in literary history. They were made even more exceptional on account of the early age at which their genius manifested itself, plus the fact that it was sustained during the pall of chronic ill health that hung over them all. At the time of the Brontes there were 17 times as many deaths from TB as there are now. But, as it happens, by macabre chance we know of the low health rate of Haworth itself at that time. The reason is that the frequency of outbreaks of cholera, typhoid, dysentery and smallpox in the area was such, and the death rate so high, that in 1850 the General Board of Health for Yorkshire instituted an inquiry. The report stated that because of bad sanitation and polluted drinking water the average age of death then was 25.8 years, and that 41.6% of the population died before reaching the age of six. Haworth was then a self-contained village and had been so since the Middle Ages, until, in fact, the coming of the railway in the

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1840s. Every house had its obvious and odious dunghill and pigs roamed the streets, but at the time of the Brontes a new economy had made its presence felt, for many of the houses had hand looms used for the expanding worsted industry. Today the cottages at the top of the hill near the church can still be seen to have a third storey to accommodate two or more hand looms, thus allowing a true cottage industry to flourish. It brought more wealth, but at the expense of diminished physical wellbeing, with a fetid indoor existence involving long hours in an ambient atmosphere full of floating fibres. The only source of social life was the public house. Although they were not weavers, all in all it is a wonder that the Bronte family survived as long as it in fact did. In the 19th century tuberculosis killed the young; more recently, if it occurs at all, it has been more common in the elderly. But, as already mentioned, there has been a worldwide resurgence since the advent of AIDS, which has lowered body resistance and allowed infections such as TB to ravage the body again. Today there is a small reservoir of infection in Australia. The public health measure that we in the West have undertaken to control TB started comparatively recently, and I can recall being warned as a young graduate that if a tubercular patient gave you a present, to accept it with good grace, take it home and burn it. The mass X-raying of the Australian population for TB was regarded as redundant 20 years ago and abandoned in 1976. Three hundred years ago TB caused 20% of all deaths in England and John Bunyan wrote, “The captain of death that came against him to take him away was the consumption, for it was that which brought him down to the grave.” That certainly happened to the great Bronte family, and all the preventive measures and modern drugs came too late for them. So we only got a glimpse of their collective genius. Whether that precocity would have been sustained if they had lived out a full life is a tantalising imponderable. Is it reasonable to postulate that TB inflamed this genius? Well, Samuel Butler felt that although God cannot alter the past, historians can, and that’s why He tolerates them. Perhaps

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because of this, I doubt very much whether the effect of the acidfast bacillus of tuberculosis on the human intellect is all that it purports to be; the source of this brilliance was something rare, secret, brittle and above all innate, a set of circumstances that is at complete variance with the story of the mycobacterium itself which, as we have seen, shows it to have been common, overt, durable and, above all, dramatically ostentatious. The wonder is not the possible complementing of one with the other, of TB with genius, but that their dissimilarities allowed them to hang together at all. (JL)

Bibliography: Karlen, A., Plague’s Progress: A Social History of Man and Disease, Indigo, London, 1996. Guthrie, D., A History of Medicine, Thomas Nelson & Sons, Edinburgh, 1945. Leavesley, J. H., Medical Byways, ABC Enterprises, Sydney, 1984.

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Bonus

Stories

ABRAHAM LINCOLN: A CASE OF MARFAN’S SYNDROME

So highly thought of is Abraham Lincoln, 16th President of the United States, that 35 American towns are named after him, together with 125 statues, from one in Newark of him sitting on a park bench to his colossal face on Mount Rushmore, and numerous bronze engravings of his speeches exist. His birthplace in Sinking Spring Farm near Hodgenville, Kentucky, is a national shrine, and it is said if America had been an older country, fragments of his phalanes, shrivelled fingernails and locks of his hair would have been preserved as relics credited with miraculous cures. Born on 12 February 1809 to a shiftless part-farmer, part-carpenter father and semi-literate mother, Lincoln grew up to be a gaunt, gangly, awkwardly built man with joints, it was said, that seemed to need oiling. Though he had only one year of primary school learning, he became a great reader and was largely self-taught. He was an excellent axeman and later in life adoring constituents would point out wooden rails he had split.

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His left shoulder was higher than the right and he had a slight upward-turning cast in his left eye resulting from a kick from a horse as a youth. He stood 194 centimetres tall, wore size 14 shoes and a size 71⁄2 hat, had elongated fingers and spoke in a highpitched voice. From a pair of spectacles he bought for 371⁄2 cents in 1857, now a museum exhibit, we know he had defective vision, probably from dislocated lenses. Like many people in public prominence he suffered recurrent bouts of depression, a state not improved by the stresses of office, the eccentric and nagging behaviour of his wife, Mary Todd, the death of two of his four sons from cholera, one at age four and one at 12, and the failure of his eldest son, Robert, in 15 out of 16 subjects in the Harvard entrance examination. Thomas (Tad), the youngest, was intellectually impaired, but was his favourite. Being a backwoods man, Lincoln was never a snappy dresser, but the frequent mismatching of his socks may have been at least partly due to colour blindness. His wife failed to teach him the difference between pink and blue. This little eccentricity was made more obvious to everyone by his habit of propping his feet up on the backs of chairs when at his most expansive. A master of folksy humour, he himself was his best audience, as he was always amused by his own often-told stories. Sociable, affable and slow to anger, when President he would welcome anyone who dropped into the White House. A great man with the common touch; little wonder he has all those memorials. If that was the beloved public figure of Lincoln the man, what about his secretive side, his health? It is no less interesting. In 1959 Dr Harold Schwartz, a physician from California, diagnosed the fairly rare autosomal dominant inherited condition Marfan’s syndrome in a seven-year-old patient of his. On going into the child’s history, Schwartz established that the boy shared a common ancestor with Lincoln, Mordecai Lincoln, born in 1686. Now by happy chance it so happened that the doctor was a Lincoln buff, and looking at the lad’s features in a new light, it suddenly dawned on him that his patient and the Great Emancipator could well have shared the same malady.

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Bernard Marfan was a French paediatrician who in 1896 presented a five-year-old girl to the Medical Society of Paris. He especially drew attention to her disproportionately long limbs and asthenic build. Later other cases surfaced, and it was found that they characteristically showed long fingers (called arachnodactyly because the fingers look like the legs of a spider, or an arachnid), dislocation of the lens of the eye, a high palate, thoracic asymmetry and cardiac value incompetence. The incidence is said to be 1.5 per 100,000 people, and it occurs equally in each sex. So how does President Lincoln fit into all this? As well as going by his well-known rangy appearance, Dr Schwartz knew of a photograph taken in 1863 that showed Lincoln with his legs crossed, and in which, in an otherwise sharp picture, the suspended left foot was blurred. He cleverly deduced that this seeming flaw in the picture might not be due to camera tremble, but could be due to pulsations caused by the aortic valvular incompetence characteristic of Marfan’s. Fired up, the physician then examined the Lincoln lineage going back 11 generations. He found what he considered to be 12 cases of the syndrome, of whom 10 had a physical resemblance to the President. He also came across a professional actor whose uncanny resemblance to his hero had allowed him to take the part of Honest Abe in various plays and films. In the end it turned out they were not related. We know the presidential legs, arms and digits were disproportionately long, as was his face; it is recorded his speech was squeaky and high-pitched, probably due to an arched palate; he has a visual defect which, looking at his existent spectacles, could well be dislocated lenses; two months before his assassination he displayed early congestive cardiac failure with breathlessness, ankle oedema and fatigue, probably due to a valvular cardiac condition. All were characteristics of Marfan’s. It is always chancy diagnosing disease in people long dead and before proper examinations were the norm, but Abraham Lincoln seems to fit the picture of Marfan’s syndrome. He had no hope of

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being diagnosed in his lifetime, of course, for as we have seen, the malady was not recognised and described until nearly 30 years after his death. If he had not been shot by John Wilkes Booth on April 14 1865 while watching the play Our American Cousin in Ford’s Theatre, Washington, Lincoln may have died anyway in the near future, due to the cardiac effects of his presumed disease. After being hit, the President was taken to a house across the road from the theatre, where it took him almost 12 hours to die. When the customary silver dollars were placed on his closed eyes the Secretary of State uttered the immortal words, ‘Now he belongs to the ages.’ A postmortem was done and the lead bullet which caused death was found to be etched ‘A.L.’. It had entered the left side of the head and finished up behind the right eye. Abraham Lincoln was a master orator, but an indifferent impromptu speaker. His most pellucid and ringing sentences were assiduously honed and chosen with infinite care; he was at his best when his own emotions were genuinely involved. His Gettysburg Address was 265 words long (less than a quarter of the length of this essay) and is regarded as one of literature’s masterpieces. Tad died of TB in 1871. Wife Mary died in 1882. Son Robert lived until 1926, having fathered two daughters who between them produced two daughters and a son. None of these greatgrandchildren of the 16th President had any issue, so with the death in 1985 of the only boy, Robert Todd Lincoln Beckwith, the direct Lincoln line came to an end. But the memory of Abraham Lincoln lives on as ‘everyone grows a little taller’. (JL)

Bibliography: Leavesley, J. H., The Common Touch, ABC Enterprises, Sydney, 1983. Morris, J., Lincoln: A Foreigner’s Quest, Penguin, London, 1999.

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Bonus

Stories

HOWARD FLOREY: ONE OF AUSTRALIA’S GREATEST

As an Australian, let me celebrate the story of one of Australia’s most famous medical sons, Howard Florey. Born in Adelaide on 24 September 1898, and forever commemorated there by his sculptured likeness, set outside Government House and on the city’s main thoroughfare, his name will always be associated with the commercial development of penicillin. This epoch-making medical advance gained for him the Nobel Prize, a knighthood, Presidency of the British Royal Society, a life peerage and deserved international fame. Howard Walter Florey was the youngest of five children and the only boy. He grew up in the Adelaide suburb of Fullarton and attended St Peter’s Collegiate School, where he acquired the nickname “Floss”, a sobriquet that stuck with him throughout his life. The portents for brilliance were evident early and at school he was a regular prize-winner in most subjects

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except mathematics. He went on to Adelaide University Medical School in 1917 and a Rhodes Scholarship at Oxford in 1921. To take this up, Florey made his way to England as a ship’s doctor; he never came back to live in Australia. His main interest at Oxford was pathology and after completing his studies he held several posts in America, Cambridge and London. Between 1931 and 1935 he held the Chair of Pathology at Sheffield University. In 1935 he returned to Oxford to take up the prestigious post of Professor of Pathology. It was at Oxford, due to his forthright way of cutting red tape, that he was called “the bushranger of research”. During the late 1920s, while investigating naturally occurring antibacterial agents, Florey came across a paper written in 1929 by Alexander Fleming, the Scottish-born bacteriologist of St Mary’s Medical School, Paddington, London. It was concerned with the antibacterial effects of a mould called penicillium and had received little heed from his medical colleagues. The story goes that in 1928 Fleming was experimenting with pathological bacteria of the staphylococcus group. As was his habit, in July he travelled to his native Scotland to indulge in his favourite pastime of fly-fishing and had left some culture plates exposed near his window. He returned on 3 September and found that while he was away by chance a mould, later identified as penicillium notatum, had wafted in through an open window and landed on the petri plate. Where the mould had grown Fleming noted that the adjacent colonies of stapholococcal bacteria had been killed. The bacteriologist extracted the juice of the mould (which he called penicillin) and proceeded to show that this penicillin was capable of inhibiting the growth of a whole range of micro-organisms. Fleming’s old and very small laboratory, situated several floors up in the Clarence Wing of St Mary’s Hospital and overlooking the very busy Praed Street, is now a museum. It is set up exactly as it was on that fateful day of discovery in 1928, in typical disarray and including a copy of the Times newspaper for 3 September! In fact, the effect of penicillium had first been noticed by

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Richard Westling in Stockholm in 1911, but was not followed up. Oddly, after Fleming’s discovery other experimenters could not replicate the observation, nor get the mould into a pure form, so abandoned the attempt, thereby missing out on a place in history. It was not until 1964 that Fleming’s former assistant, Ronald Hare, worked out that the petri dish had not only not been contaminated, but, on looking up the records, found that the climate in London in July to August 1928 was cool and just the right temperature to encourage the growth of the mould. Other researchers just did not have the right conditions. Fleming himself did not pursue his observations and they were regarded by him and others as of no great practical importance. The accolade for pursuing the life-saving antibiotic was to belong to Howard Florey and his associates, including his wife, Ethel Florey, and Dr Ernest Chain, a chemist, when they took a second look ten years later in 1939. Though Florey was prodigiously industrious, it was slow and difficult work to extract the active factor in the primitive working conditions that were his lot. Ingenuity had to be exercised and the mould was grown in bedpans and other unlikely recepticles and stored in milk bottles. It took 18 months to produce 100 milligrams of the pure compound. Controlled experiments were carried out on mice infected with streptococci and it was shown that even very diluted penicillin was able to destroy the bacteria. Further, it was non-toxic and effective in the presence of blood or pus. As it was destroyed by digestive juices, it had to be injected. Florey published his experimental findings on animals in the medical journal, The Lancet, of 24 August 1940. Then came the denouement: trying it on humans. This took place for the first time on 12 February 1941, when a 43-year-old Oxford policeman, Albert Alexander, became the first person to receive the drug. He had a nasty infected rose scratch on his face. Initially there was a marked improvement, but on 17 February the supply of penicillin ran out. The septic condition worsened dramatically and the patient died a month later.

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Four more people were treated in the next few weeks with the precious drug. The results were published in August 1941, when it was reported that the effects were promising, but lack of material had caused the premature termination of treatment in a number of cases. But the far-reaching ramifications of the concept, especially in infected war wounds, attracted government interest in the United States, then entering World War II, and after a visit by Florey to the USA, money and other intangible largess, such as enthusiasm and encouragement, were poured into the project, allowing for swift development. It would be ungenerous to think that the prime motives were not so much altruistic as directed towards getting soldiers back on the frontline. But for once a government agency had got it right and we all benefited. With the increased supply of the drug, many cases were treated, including large numbers of patients so severely infected that up until that time they had been considered doomed. These infections included cases of septicaemia, meningitis, gas gangrene and syphilis. The effects seemed to be miraculous. On the other hand the negative effect of the drug on diseases such as tuberculosis, poliomyelitis and typhoid sounded a cautionary note. The rest, as they say, is history. In 1945 Florey, together with Fleming and Chain, received the Nobel Prize for Physiology and Medicine. The citation pointed out that their work “has shown us the fundamental importance of basic research” and “affords a splendid example of different scientific methods cooperating for a common purpose”. After the war Florey continued to receive acclaim from his scientific colleagues and honours from various grateful governments. He received honorary degrees from 17 universities and was approached to help plan the establishment of a medical research school in Canberra. Though he applauded the idea and applied himself to the task with ideas, motivation and encouragement, when offered a Chair he found it too difficult to make a break from Oxford and declined.

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He had been knighted during World War II, and in 1965, such was the regard in which he was held by the British Establishment, it was felt that his analytical mind should be used in the House of Lords and he was created a Life Peer. He styled himself Baron Florey of Adelaide. In 1960 he was elected the first Australian President of the illustrious Royal Society of London (a predecessor had been Sir Isaac Newton) and was known as “the Bushranger President”. He was Chancellor of the Australian National University from 1964 to 1966, although he remained in England. As regards the man himself, it is said that he was regarded by his colleagues as uncompromising, blunt, prickly, tense, remote and driven by burning ambition. Though displaying great personal integrity, he did not suffer fools gladly, was scathing of pretence and could be destructive with criticism. But there is no doubt he was a peerless research worker. Regrettably, Florey had an unhappy relationship with his wife, Ethel, but they never parted. They had two children, Paquita and Charles. Lady Florey died in 1966 and in June 1967 Lord Florey married Dr Margaret Jennings, his long-time research colleague. Howard Walter Florey died suddenly eight months later on February 21 1968. He was 69. The heights by great men reached and kept Were not attained by sudden flight, But they, while their companions slept, Were toiling upwards in the night. — Longfellow

(JL)

Bibliography:

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Le Fanu, J., The Rise and Fall of Modern Medicine, Little Brown, London, 1999. Porter, R., The Greatest Benefit to Mankind, HarperCollins, London, 1997.

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I am glad to acknowledge the help of Dr David Leavesley of the Queensland University of Technology, and formerly of the Renal Medicine Unit, Royal Adelaide Hospital.

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CREDITS Illustrations by Greg Smith and Adam Yazxhi Book covers and text design by Melanie Calabretta, HarperCollins Design Studio, Australia eOmnibus cover by Jon Foye, HarperCollins Design Studio, Australia

ABOUT

THE AUTHORS

To help satisfy a natural curiosity that many people seem to have about “things medical”, Jim Leavesley and George Biro have once again exposed their vanities, prejudices and morbid curiosity to bring together this collection of essays on clinical oversights and underestimates, pathological vagaries and oddities, and medical bungles and botches. Some of the stories are well known, some more obscure, but all record a rather offbeat side of medicine — that aspect which appeals to our sense of fascinated disapproval. Most of the pieces have appeared in the medical magazines Australian Doctor or Medical Observer, or, in Jim Leavesley’s case, on ABC radio. Jim Leavesley has frequently been allowed free range to his natural verbosity, so his pieces are longer but fewer than those of George Biro’s more succinct and disciplined offerings. Rather surprisingly, they both passed the post together with about the same number of words. Jim Leavesley was born and educated in the northern English seaside holiday resort of Blackpool. He graduated in medicine in Liverpool in 1953 and emigrated to Western Australia in 1957. After over 30 years in general practice he retired to Margaret River to take up the much more chancy occupation of writing about medical history, which for the past 10 years he has done on a fortnightly basis for the medical newspaper Australian Doctor. He is also a weekly presenter of the subject on ABC radio in WA, and an irregular guest on ABC Radio National’s “Ockham’s Razor”. Before his partnership with George Biro, he had published five books on the subject.

George Biro was born in Budapest to an Italian mother and Hungarian father. The family migrated to Australia in 1947. He was nine when he arrived and could speak no English, but his application to study knew no closed season and he went on to graduate in medicine at Sydney University in 1963. George started his professional life as a GP/anaesthetist, but since 1990 he has been a freelance medical writer. The Medical Mysteries eOmnibus is Leavesley and Biro’s first venture into electronic publishing. Their three previous books, What Killed Jane Austen?, How Isaac Newton Lost His Marbles and Flies in the Ointment, collected for the first time in this e-book, were published between 1998 and 2001.

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THE PUBLISHER

Australia HarperCollins Publishers (Australia) Pty. Ltd. 25 Ryde Road (PO Box 321) Pymble, NSW 2073, Australia http://www.harpercollins.com.au Canada HarperCollins Publishers Ltd. 55 Avenue Road, Suite 2900 Toronto, ON, M5R, 3L2, Canada http://www.harpercanada.com New Zealand HarperCollins Publishers (New Zealand) Limited P.O. Box 1 Auckland, New Zealand http://www.harpercollins.co.nz United Kingdom HarperCollins Publishers Ltd. 77-85 Fulham Palace Road London, W6 8JB, UK http://www.fireandwater.com United States HarperCollins Publishers Inc. 10 East 53rd Street New York, NY 10022 http://www.perfectbound.com