7

So What Was Wrong with Sarah? The Physician’s View

Cans’t thou not minister to a mind diseased,

Pluck from the memory a rooted sorrow?

Shakespeare: Macbeth

Over the century and a half since Sarah Jacob died, writers, many of them qualified medical professionals, have produced theories with reference to actual physiological illness, in addition to a number of psychological interpretations. So, what was wrong with Sarah? Is it possible to find an explanation other than the ‘hysteria’ so confidently asserted by Dr Fowler after his examination of the girl?

My first enquiry is on possible physiological illness. After all there were copious notes on Sarah’s autopsy, and since the publication of these in the British Medical Journal in January, 1870, there have been many more theories and speculations as to her illness.

First, what about her condition in February, 1867 at the beginning of her illness? The family scourge then was scarlet fever, and that provides our first possibility. Here is a recap of the three interpretations of the whole case.

Theory one: Sarah really had an actual definable illness and this segued into a condition dominated by a mental state indicating some kind of hysteria. The point to grasp about this, as explained in a medical manual in the early twentieth century, is that ‘the emotions of the hysteric are for the most part artificial’ and ‘the hysteric feels because he does not act.’ That is, we are to assume that when we read of what she says and does, it is like watching a puppet in a shadow play, nothing we see being trusted as ‘real’.

Theory two: Sarah was ill from the very beginning with symptoms of glandular fever, concurrent with the scarlet fever, or with TB, as John Cule suggested in 1967. The various signs of illness during the trajectory of the fasting period can be made to align with a specified condition.

Theory three: Sarah, after recovering from scarlet fever, was still physically ill but this was secondary to her relishing the special place she had attained in the family, adding the religious and ritualistic elements later. Simply, she lapped up the situation of freedom and ‘prima donna’ specialness that she was given. What child does not like to be the centre of attention?

As an example of how easy it is to assign any one of a dozen conditions to Sarah, look at Bright’s Disease. The duration and trajectory of scarlet fever and its symptoms includes the advent of desquamation – the formation of scales on the epidermis. The risk when this occurs is the chance of the kidneys being inflamed, particularly in the cold. Sarah went back to school at the end of February 1867, with that risk definitely present. One consequence of desquamation is the onset of Bright’s Disease, which had been defined and explained in 1827 by Dr Richard Bright. Was this a possibility in Sarah’s case?

The difficulty when seeing this through modern eyes is that Sarah may have developed chronic Bright’s Disease, or equally any of the other suggested physiological ailments. Along with several other suggestions, this diagnosis fits with the post mortem comments on the digestive tract, and also, enticingly, with the examination by Dr Lewis in early 1869: ‘Occasional flatulent rumbling noises were heard in the abdomen’ but unfortunately it also aligns well with the supposed ‘globus’ of the hysteric. In such a way does the muddled and unsatisfactory theorising develop. This globus was widely accepted, even by the most pre-eminent medical men, and was everywhere in the literature of hysteria.

With this in mind, later in this chapter I will unashamedly exercise the right of the historian and biographer to suggest an explanation, though being well aware of the caveat I have ventured to explain.

For this reason, we need to start with the autopsy and look at the key findings before exploring any possible definable illness. This was done and reported by Thomas Lewis on the 30th December, 1869, and also by Mr J. Phillips (of Guy’s) printed in Medical Times and Gazette.

The more detailed report is by Lewis, who has more to say on the nature of the digestive tract, but with regard to the normal signs of starvation both agree that there was a layer of fat and also fat stored in the omentum, a fatty tissue linked to the stomach. Lewis noted, ‘On making incision from the larynx to the pubes, a considerable layer of subcutaneous fat was cut through; below the umbilicus it was an inch in thickness and above it half an inch.’ The fat in the omentum would be a pointer towards the proportion of fat across the body, as it is a kind of store, much as the spleen is to the blood supply. Phillips reported also that all the organs were healthy, corroborated the notes on fat, and added that all aspects of the brain were healthy, as were the lungs.

The most important detail was that, as Lewis put it, ‘…there was no emaciation, no appearance of bedsores ever having existed.’ Both noted the faeces, and Phillips’ expression of this is interesting: ‘Colon fairly distended with gas, and, with the rectum, contained about eight ounces of hardened faeces, not at one spot but diffused throughout its entire length.’

There was no significant evidence of any serious condition; but the space under one arm, which had been referred to in the trial as a place where a bottle could have been hidden, was noted. This pointed to the fact that her diet, of ‘milk and flummery’ as one doctor put it could have been hidden there. Flummery (Welsh, llymru, is a jelly made from oat husks). With the constituency of a soup, such food would be easily taken, and would provide plenty of good nourishment, without the need for solid food to be somehow accessed and taken surreptitiously. The best way to think of this is that it was ‘baby food’ and would have had the effect of comforting as well as nourishing the girl.

In short, there were no clues as to any serious illness, but there was plenty of detail to back up the decision of the court that Sarah had taken food secretly and that, as she had easy access to the dairy, she could have walked across the adjoining servant’s room (he too would have been working outside for much of the day) to get food from the dairy. This hints at the suspicious silence of her siblings, who were never asked to speak in court. They perhaps would have known about any secret eating, at least some of the time. Hannah and Evan would often have been working outside too, so when Sarah was left alone, she could have filled the small bottle and kept it with her; naturally, when we note that examination by doctors was largely forbidden, suspicion grows.

Yet what actually happened is of less interest than whether or not there really was anything wrong with the girl. There was no indication of any specific disease in her corpse. From that basis, we can only logically proceed on the assumption that if she had some variety of physical complaint, then it was bacterial, and that the supposed deadness in one arm and the ‘fits’ and sensitivity to noise were part of any one of a number of ailments.

If we assume that she did eat and drink, exclusively from the dairy, and there was the flummery or even the soup frequently found in Welsh cuisine, cawl, then she would have had the sustenance required for healthy life, but cawl, a broth usually with vegetables and bacon, was not mentioned. More likely she had the bwyd llwy (spoon food) mentioned earlier, which would have included mashed potatoes. Flummery would have been an everyday food, as the oats used in that were needed to feed the horses. Oats were sometimes mixed with crushed gorse also. What I have said above about the food seems more and more interesting, and all commentators have picked up on the unusual space under Sarah’s arm.

Keeping this speculation in mind, it seems likely that she would have had a predominance of dairy food, and so she would have had fats, protein, carbohydrates and some fibre. But there is clear evidence that she was constipated, and it is highly probable from this that dehydration was a major problem – something that determined her malaise. It is not likely that she had the 15 grams of fibre needed for a child of 10, and perhaps the 24 grams of proteins were also rarely met.

Most of this points to some pathological source of her failure to eat, made even worse by dehydration as time passed. There was no evidence of any intestinal blockage, but more generally, if we survey observed symptoms across the last year of her time in bed, we can list: impaired gastrointestinal function, muscle atrophy, reduced renal function, disturbed sleep patterns and some evidence of poor thermoregulation.

John Cule supports this view, surmising kidney failure in the last days, and he does not rule out the possibility of tetanus, but his conclusion is (and this agrees with most other readings) that, ‘She was, in the end, a victim of her own personality.’ He goes along with this largely because the earlier supposition that there was TB at the heart of some symptoms found, have to be dismissed. Cule is more in favour of ‘a non-tuberculous meningitis or an encephalitis from which she never recovered and which exaggerated her fundamentally hysterical personality.’ It makes as much sense as other ideas, and Cule knew the case very well indeed.

What are we left with? As all the physiological theories relating to diseases that partly fit the known behavioural facts have their limits, we may have to look for something rather more specific to the Jacobs’ lifestyle than has previously been considered: the fact that they shared their long house with calves.

In terms of public health awareness, the great landmark of the time was Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population (1842) which had concentrated on the terrible health consequences of urban overcrowding and polluted water. Full attention had been made by authorities to this issue because it was in their interests to attend to the health of their workers. But what about health risks in the countryside? In the mid century Britain was still largely an agricultural economy. The public by the 1860s would have been aware of such matters as the cattle plague of 1866 and in Monmouthshire and Wales there had been over 7,000 reported cases of sick cattle, and 5,000 of these had died. But what about diseases of mankind that may have been transmitted from cows to people?

It was late in the nineteenth century that viruses were first discovered, the first animal virus being defined in 1899 by Loeffler and Frosch. Before that, there had been a gradual realisation that there should be more controls of live animals and of the slaughter of animals in abattoirs and knackeries. One of the few researchers in this area has been Anne Hardy, who has looked in detail at early veterinarians, and has pointed out that ‘most informed Victorians were slow to make a connection between the health and welfare of animals and the welfare of the state.’ The landmark Public Health Act of 1872, aimed at establishing measures that would reduce the incidence of diseases such as diarrhoea, scarlet fever and whooping cough. Six years later some scientists were beginning to understand that animals could transmit diseases to man, and in 1879, when there was the first outbreak of food poisoning at Welbeck, it was shown that imported ham had been the cause.

After 1878 veterinary inspectors were introduced and the first meat inspections in retail locations occurred after vetinarian George Fleming demonstrated that bovine TB was something that would be a threat to people. But all this is a long time after Sarah’s autopsy, and when the doctors performed that task, they had no knowledge of zoonotic infection: diseases passed from animals to humans. Not until 1885, after a few scares, did a medical inspector identify, as Anne Hardy puts it, ‘an infectious fever of cattle which could be transmitted directly to humans through infected milk’. It was shown that cows with an infection of the udder, defined as tubercular, could be a source of infection for people. Doctors Lewis and Phillips, however, did note one or two matters that could indicate some kind of animal-sourced infection. Phillips found ‘half an ounce of a thickened mucous exudation’ and the ‘duodenum contained a little of the same fluid, as well as the ileum, where it became slightly grumous [filmy, like a mist]’. Lewis noted that the stomach had ‘an olive-green mucous fluid, spread over the lining membrane… this fluid was slightly acid’. He added that the ‘grumous fluid’ was ‘supposed to be an exhalation of blood’. It is worth asking the question, in a chapter of theoretical notions, whether this fluid was a symptom observed in a zoonotic disease.

Few people in the 1860s gave a second thought to the possibility that animals were a source of terrible disease. In the towns the horses were present in thousands, and in the country, cattle, sheep and horses were part of a dozen everyday tasks, integral to life, as they had been for centuries. No-one even vaguely considered that they were dangerous to man, except in the case of cow-pox, and that had been understood and dealt with after Jenner’s development of vaccination.

In fact, as public health inspections had shown in Carmarthen after the horrendous outbreak of cholera a few decades before Sarah’s case, animals, along with sewage and water supplies, were inextricably mixed in with factors determining some diseases which were zoonotic in nature, and were stealthily creeping into the danger areas of daily working lives. If we add to that the lack of awareness of the importance of domestic hygiene, we have something disastrous latent among the working classes in particular.

We now have a much deeper knowledge of these things, and since 1976 an infection labelled human cryptosporidiosis has been defined and isolated. Cryptosporidium was identified in 1907 by a researcher called Tyzzer when he studied the intestines of mice; it develops in epithelial cells (those which cover the external tissues of the body and of organs) and infects the small intestines of mammals – and of people. It is a protozoa, an entity whose existence was far beyond the knowledge any medical man had in 1869.

Two important features of this condition stand out in the context of Sarah’s illness and her reported behaviour. First, it is active in those who are ‘immunocompromised’ – that is, in Sarah’s case, her condition as she came out of the scarlet fever episode. At that point, she was susceptible to further infection. Secondly, it damages the little sacs in the epithelium of the intestine and impairs digestion and the absorption of nutrients. In other words, it can be the cause of weight loss, reducing the effects of food taken, which would not be absorbed, but remain in the gut.

The symptoms which would have been observable if Sarah had contracted this shortly after the scarlet fever, would have been nausea and a lack of appetite, with diarrhoea and a watery stool; anorexia and abdominal pain can persist, and the illness may remain long after the incubation period of around two weeks. So, after going to school for a while in early 1867, following the scarlet fever, she became ill again for some weeks, then the anorexic behaviour began and intensified. A case study of an outbreak of cryptosporidium in North Humberside in 1989 found that the main symptoms were diarrhoea, loss of appetite, abdominal pain and loss of weight and nausea.

Research has shown that the disease is life-threatening in those who are immunocompromised. As to clear signs which would be apparent at an autopsy, the small bowel would have a mucous infection which, as R.L. Coop and others have found, ‘may extend throughout the intestinal tract’. Note that Lewis found the mucous fluid also in the ileum – the smallest part of the small intestine. It is certain that some kind of problem with the digestive tract was evident, yet many diseases we now know of would not have been apparent at autopsy. Both doctors said that all Sarah’s organs appeared to be healthy, but pointers towards a presence of cryptosporidium would not have been evident without modern microscopic Lewis and Davies were nonplussed by the mucous fluid, and there was no suggestion given by either as to what this grumous fluid was.

In a more everyday context, it would make obvious sense that Sarah would not want to eat, when the result was horrendous diarrhoea and nausea. The ‘fits’ and the supposed pain down one side may well have been centred in the abdomen, where the ‘rumblings’ were heard by doctors, most vividly expressed by Dr Fowler.

We can imagine Sarah stealing through the servant’s room next door, and into the dairy for some milk or flummery, which may or may not have been kept in a bottle that went beneath her arm. If it did, then that would make it possible to take food at almost any time, rather than a quick raid as a night feeder, as Fowler surmised.

If this was the case, and Sarah had an infection of this zoonotic illness, then after the initial weight loss (which would not be much, and only for a short period) she would eat and drink, but sparingly. Given that she was bed-ridden, with very few calories burned, she would have maintained that fleshy, healthy appearance all through the period in question, with the real illness being down inside her digestive tract, something that would have made the idea of solid food most unattractive. For that reason, the spoon food referred to – something that could be bottled – seems to be the most likely nourishment.

We know that Evan’s 120 acres of land included cattle, and that these were stalled at one end of the long house, with the main bedroom at the other end; we also know that she was taking small quantities of milk, rice and flummery until August, 1867. It is reasonable to assume that this diet was continued as she night-fed, and that she contracted some disease in that early phase; there is a possibility that the disease in question was zoonotic, and perhaps specifically cryptosporidium parvum.

This was a time when human communities were living day to day in extreme proximity to their animals. In the case of a dairy farmer, it is obvious that, Welsh social history being a story of men and animals under the roofs of various types of houses and cottages, there would be maximum opportunity for disease to transfer from beast to man. In fact, the circumstances at Lletherneuadd strongly suggest that of all the family members, the night-feeder Sarah was the one who would have most access to dairy produce, eating as she surely did, secretly and as often as she liked, either while the household slept, or as they were all in the fields or busily engaged in chores.

My reading of the facts of the case makes this the most persuasive explanation of the mystery illness that afflicted her; and I feel confident that Dr Fowler, the first hard-headed medical man to look closely at Sarah, was correct in his suggestion that she could and did feed when she wanted, within the time frame of opportunities she had. Another perspective on this is that, with the idea of family collusion in mind, the eating would be part of the game, subsequently eclipsed by the more appealing business of the display, the bright girl on the bed, reading aloud and defying nature. Undoubtedly, there was a pride in the parents in seeing their girl, well-read and articulate, talking to strangers, alert and vibrant at least some of the time, while all the while the strangers and visitors from far and wide must have been assessing her condition, noting the fact that she had flesh and was certainly not emaciated, as perhaps their reading about the old saints and hermits suggested she should look. Some of the visitors must have chatted excitedly, on their long train journey to Carmarthenshire, about what they were going to see – and many would have described a ‘freak of nature’ rather than the person they saw, waiting for them bedecked and ritualised.

Of course, we will never know for sure, and there remains the question of Sarah’s hysteria or other related mental illness. We must explore her sickness in relation to the family, as well as to what can easily be labelled hysteria but may well be something far more familiar. Surely it is less vague and undefined to accept that the calves under the roof at the long house were more of an immediate threat to health – on a serious level – than the usual reference to the established diseases of childhood, most of which were dealt with by rest, food and drink, and some cosseting.

It is a speculation, but one in which there are modern parallels which compel our attention: a tiny invader of the small intestine would evince all the symptoms the doctors heard and guessed at. Yet, looking at the way the illness invaded those who were already afflicted by a sickness, it would account for the prolonged digestive troubles the little girl suffered.

Sometimes, the detective work done on the past has to pay attention to influences and possibilities which provide an answer, and leave the spaces for obvious objections there for future writers and readers to deal with. I find the potential for the zoonotic illness in Sarah to be very hard to resist in the face of so many dead ends in the thinking about the known diseases of her time which ravaged the Victorian children. We have to ask: what was the basis of her staple diet? The answer is dairy products, at a time when diseases carried in such foods were not identified nor understood.