7

HIDDEN DANGERS

THE WORLD IS a dangerous place, and unexpected threats lurk in the unlikeliest of places. Professional sportspeople seem to have a particular talent for finding them: In 1993, the Chelsea goalkeeper Dave Beasant missed the start of the soccer season after dropping a jar of salad cream on his big toe, while the England cricketer Derek Pringle once injured his back while typing a letter. But these are far from the most exotic dangers to have been recorded by medical writers: Dentures, hat pegs and even hats themselves are a few of the objects implicated in illness and injury in the pages that follow.

Nineteenth-century doctors were particularly adept at finding life-threatening situations pretty much anywhere they looked. Children’s games, organized sport, even using a pen: All were thought at one time or another to be hazardous to health. To be fair to the physicians of the past, understanding risk has always been, and remains, one of the most ferociously difficult aspects of medicine. The Victorian cardiologist who noticed that several of his patients were keen cyclists naturally assumed that there was a connection between their heart disease and their newfangled hobby—and in the framework of contemporary medicine, the theory made perfect sense.

Perhaps the most exotic threat to health was identified in the 1830s, when a worrying new disease swept through the ranks of America’s priests. Doctors everywhere from California to New Jersey reported that pulpits were falling silent as the nation’s clergymen succumbed to a “loss of tone in the vocal organs,” causing hoarseness and an inability to speak in public. Many (“a multitude of divines,” according to a contemporary report in The Boston Medical and Surgical Journal) were said to have resigned their livings after finding themselves no longer capable of addressing their flock or even leading daily worship.

What could have caused this ecclesiastical catastrophe? One sage observer observed that the priests of olden times had preached as much, if not more, than their modern counterparts, and their voices “were the last to fail.” So what had changed? Dr. Mauran, a distinguished physician from Providence, Rhode Island, thought he had the answer. The clergymen of yesteryear were all enthusiastic smokers, he pointed out, and were rarely seen without a pipe or cigar in their mouth. Chewing or smoking tobacco, he argued, “kept up a secretion in the neighborhood of the glottis, favorable to the good condition and healthy action of the voice box”—as demonstrated by the habits of another profession:

Lawyers speak hours together, and when leisure permits, many of them smoke; and, as a general rule, the leading advocates are very great smokers—and yet, who ever heard of a lawyer who had lost his voice?

Clerics, on the other hand, had largely forsworn tobacco since the rise of the temperance movement, and were now paying the price. Dr. Mauran strongly recommended that ministers who wanted to ensure a long and healthy career should resume their cigarettes and pipes without delay. And that is how a major medical journal came to warn its readers about the dangers of not smoking.

A SURFEIT OF CUCUMBERS

In 1762, a doctor from Malling in Kent, identifying himself only as “W.P.,” sent a highly unusual report to the editors of the Medical Museum in London. Malling was a small place in the eighteenth century, so it isn’t difficult to identify the author as Dr. William Perfect, son of the local vicar. He was also a prominent Freemason, a journalist and—in his own words—a minor poet.* Perfect developed a reputation as an expert on insanity, publishing books on the subject and eventually opening a small private asylum, a sort of cottage hospital for the mentally ill.

Even before he opened this institution, Dr. Perfect—known as a kind and gentle man—was in the habit of accommodating patients in his family home. Given the exceptional nature of the death he recorded in this article, it is tempting to ask whether mental illness might have played some part: His patient had apparently died as the result of eating a vast number of cucumbers.

It may be necessary to observe that this unhappy woman had all the symptoms of a bilious colic, to the most extreme degree, from the time of her being first attacked to the time of her death, which was three days after her eating the cucumbers.

Dr. Perfect suspected that the woman’s condition was caused by an excess of bile in her digestive tract.

In a few hours after she expired I opened the body, and found the stomach dilated and swelled to the size of a child’s head, but of a more oblong form, and resembling in figure and tension a large bladder filled with wind: the external or membranous coat of the stomach appeared florid and inflamed; and upon making an incision through that and the subjacent coats, a most amazing quantity of sliced cucumbers, porraceous matter . . .

Porraceous, a decidedly niche word, means “resembling leeks.”

 . . . and vesicles filled with air, issued out at the opening.

Much of the upper part of the gut was inflamed, and the small intestine was “so much inflated, as to render it impossible for anything to pass through it.”

The colon, caecum and rectum were not so much inflamed as the lesser intestines; but, what was very extraordinary, the lower part of the latter was mortified for several inches: the lungs, particularly some part of the left lobe, appeared as if they had been boiled, with several livid spots dispersed over them. The liver, spleen, and uterus were the only viscera which preserved their natural complexion. The pancreas, pleura, and mediastinum were inflamed; a very large quantity of water was found in the pericardium: the kidneys were inflamed, and the vesica* was in a very flaccid state, without containing any urine. The patient, I was informed, had had frequent motions to urine for some time before her death, but was never capable of making a drop.

These observations suggest that an excess of cucumber was not the only ailment from which the woman was suffering. In particular, the “water” found in the pericardium (the sac around the heart) was a serious finding with all sorts of possible causes. If enough fluid had accumulated there, it might even have caused the heart to stop beating.

It seems that this is a unique case: Although the recent literature contains reports of cucumber poisoning by bacteria and chemicals, there is no record of anybody else dying from a surfeit of the delicious salad vegetable.

THE PERILS OF BEING A WRITER

In an earlier chapter, we encountered the Swiss physician Samuel Auguste André David Tissot, eighteenth-century Europe’s leading expert on the dangers of masturbation. It’s a shame that he is chiefly remembered for his work on that subject, L’Onanisme (1760), because in other respects, he was an imaginative, humane and sensible clinician. He wrote an influential book about neurology, which contains a rigorous discussion of migraine regarded as a classic even today. Tissot was an early advocate of inoculation against smallpox and opposed some of the more radical measures employed to treat the disease, such as drastic bloodletting. Noted for his campaigns to improve public health among the poorest members of society, his clinic also became a fashionable destination for European aristocrats.

Nine years after the appearance of his famous study of the “solitary vice,” Tissot published a book about the perils of another occupation usually performed indoors and in private. An Essay on Diseases Incident to Literary and Sedentary Persons (1769) is a catalogue of the various ailments that afflict scholars, writers and all those who spend too much time poring over a book. And the dangers are truly formidable.

Tissot’s thesis is simple:

It has long since been observed, that a close application to study is prejudicial to health.

Much of his case is hard to argue with—particularly when he suggests that a sedentary lifestyle might not be the best way to a long and healthy life.

The diseases to which the learned are particularly exposed arise from two principal causes, the perpetual labours of the mind, and the constant inaction of the body.

Tissot believed that it was not just inactivity that was damaging; overexertion of the brain could also have grievous consequences.

That we may understand the influence the workings of the mind have upon the health of the body, we need only remember in the first place, the fact that, firstly, the brain is in action during the time of thinking. Secondly, that every part of the body which is in action becomes weary; and that if the labour continues for any length of time, the functions of the part are disturbed.

Tissot points out that the brain is connected to the rest of the body by a vast network of nerves, which play a vital role in regulating all our activities. Mental fatigue therefore affects the entire organism.

These evident principles being once established, everyone must be sensible that when the brain is exhausted by the action of the soul, the nerves must of course be injured; in consequence of which, health will be endangered, and the constitution will at length be destroyed without any other apparent cause.

Dr. Tissot was above all a practical physician and, unlike some of his contemporaries, believed that a theoretical argument was worthless unless backed up by empirical evidence. He cites the baleful tale of Monsieur le Chevalier D’Épernay:

After an assiduous application for the space of four months, without any previous symptom of disease, his beard, his eyelashes, his eyebrows, and in short all the hair of his head and body fell off.

Today we would call this idiopathic alopecia: spontaneous hair loss of unknown cause.

This phenomenon was certainly brought about by the little bulbs, which are the roots of the hair, being deprived of nourishment.

The “little bulbs” alluded to are the follicles. Tissot suggests that their sudden starvation might have had three possible causes: an upset stomach; problems with the nerves; or “that kind of low fever men of letters are subject to”—an ailment that apparently throws hair follicles into “a state of consumption and decay.”

This fever is often produced by the irritation the heart receives from the too earnest application of the mind, in consequence of which its pulsations become more frequent.

I am (a) a writer and (b) almost completely bald, so on the face of it, M. Tissot’s hypothesis is self-evidently true. But far more disturbing were the psychological symptoms displayed by another scholar:

Gaspar Barloeus, an orator, poet, and physician, was sensible of these dangers, and often used to warn his friend Hughens of them; but he was, notwithstanding, regardless of himself, and weakened his brain so much by excessive study that he thought his body was made of butter.

That’s right: Reading books (and writing them) not only makes your hair fall out, it can also create the delusion that your body has turned into tasty dairy fat. In the case of Barloeus, the affliction proved terminal, after he became terrified that he would melt:

He carefully avoided coming near the fire; till at last, wearied with continual apprehensions, he threw himself into a well.

Tissot makes clear that he observed one similar case at first hand: a medical colleague of great brilliance who many expected to do great things. But this friend became so obsessed with his work that he spent all day and night in the library or performing experiments, with dreadful consequences.

He first lost his sleep, then was seized with some transitory fits of lunacy, and at length became quite mad, so that even his life was preserved with difficulty. I have seen other men of learning who have begun by being maniacs, and have at length become complete idiots.

His next example is a scholar whose name would have been familiar to many of Tissot’s original readers—a French priest well known for his strongly held views and combative manner.

I have been told by a man of veracity that Pierre Jurieu, so famous for his theological disputations, his controversial writings, and his commentary on the Apocalypse, had so far injured his brain, that although his judgment was still preserved in many instances, yet he used to affirm that his frequent colics were caused by the fighting of seven knights shut up in his bowels.

If you think that sounds a bit Monty Python, the next sentence might have been lifted from one of their scripts.

Others have imagined themselves to be lanterns; and some have been known to afflict themselves upon the supposition of their having lost their thighs.

For those just embarking on a literary career and anxious to avoid the (imaginary) loss of their own thighs, Dr. Tissot supplies some very sensible advice:

The relaxation of the mind is the first preservative; without this, all other helps are inefficacious.

After observing that scholarly persons are apt to be in denial about the state of their health, Tissot suggests that friends and family should challenge them to get out of their chair and do some exercise. His description sounds much like the contemporary idea of an intervention, when addicts are openly confronted about the destructive consequences of their addiction.

The only way is to be resolute with them, to force them away from their closets, and oblige them to indulge in recreation and rest, which will remove their disorders and restore their health. Besides, the time they pass out of their closets is not thrown away; they return to their labours with fresh eagerness; and a few moments given up every day to leisure will be amply repaid by the enjoyment of health, which will prolong the course of their studies.

Who could disagree? Exercise, writes Tissot, is

one of the most powerful preservatives and restorers of the health of the learned.

But it’s not just physical exertion that helps; being outdoors in the fresh air is important, too.

From the combination of these two salutary powers, we receive refreshment, circulation is carried on with ease, perspiration encouraged, the action of the nerves reanimated, and the limbs are strengthened. Every man who has been confined to his study for some days, feels his head heavy, his eyes inflamed, his lips and mouth dry; he complains of a certain uneasiness about his breast, a slight tension at the pit of his stomach, is more disposed to melancholy than mirth, his sleep is less refreshing, and his limbs are weighty and benumbed. A walk for two or three hours in the country dispels them entirely, and brings back serenity, freshness, and strength.

Never did a doctor write a truer word. And that’s all I have to say on the matter; for some reason, I feel an urgent need to go for a run.

WHY CHILDREN SHOULD NEVER WEAR HATS

Most of the articles included in this book were written by doctors, for doctors, and are couched in the professional jargon of medics. But here’s a rare example of an eighteenth-century physician writing for children, taken from an engaging but eccentric book published in Germany in 1792. Its author, Bernhard Christoph Faust, was personal physician to Countess Juliane of Hesse-Philippsthal, the aristocratic ruler of a minor principality in Lower Saxony. Faust was a tireless campaigner for public hygiene and did a great deal to promote vaccination against smallpox, but his greatest success was the Catechism of Health, a short work that uses the question-and-answer form of the Christian catechism to teach children about their bodies and how to keep them healthy. He was evangelical in his beliefs (some of them rather odd) and was clearly hoping that his book would eventually be used in every school in Germany. He begins with a preface addressed to schoolmasters:

This book teaches how man from his infancy ought to live, in order to enjoy a perfect state of health, which, as Sirach* says, is better than gold. You will, therefore, with pleasure, I hope, instruct your dear little pupils in its principles; and as able and experienced men, convinced that the mere learning of the answers by heart can be of no advantage to children, you will have no objection to instruct them after the following method. The chapter which is chosen for instruction ought first to be read by the master, and then by two children that read perfectly well and distinct; one of them reading the questions, the other the answers regularly and in order to the end of the chapter; the master, understanding thoroughly what has been read, explains its general import.

The master was also expected to quiz the children at regular intervals to test their understanding of what had been learned.

An hour, at least, twice a week, ought to be devoted to such instruction, in order that the whole Catechism of Health may be gone through twice a year, and the minds of the children impressed with the true spirit of its doctrine.

Two hours a week seems optimistic; but Dr. Faust cannot be faulted for his ambition. And it paid off: The book sold eighty thousand copies in the first two years, and was soon translated into several other languages. Faust even sent a copy to George Washington, with an obsequious cover letter recommending its use in the schools of the newly founded United States:

I deemed these books worthy of being laid before you, and through you before the United States of America.

An American edition duly appeared, complete with a foreword by the founding father Benjamin Rush, one of the country’s leading physicians. The Catechism in fact contains a good deal of sensible advice, and you can see why the architects of the USA might have been attracted to it: It encourages self-reliance, virtue and abstinence—just the sort of values a young nation might want to inculcate in its children. Some of Faust’s views are decidedly progressive: He is emphatically in favor of equal education for both sexes, and condemns corsets and other forms of female dress that constrict the internal organs.

That said, Faust obviously had a few hobbyhorses, and sections of the book make amusing reading today. Perhaps the clearest example of his idiosyncratic views is the chapter on clothing:

Q.   By what means does man preserve, particularly in his infancy, the genial warmth of his body?

A.   By good wholesome food and bodily exercise.

Q.   Is it necessary to keep children warm, and protect them against the inclemency of the weather, by many garments?

A.   No.

Q.   Why so?

A.   That the body may grow healthy and strong, and be less liable to disease.

Q.   How ought the heads of children to be kept?

A.   Clean and cool.

Q.   Is it good to cover children’s heads with caps and hats to keep them warm?

A.   No; it is very bad; the hair is a sufficient protection against cold.

Q.   Are those artificial coverings dangerous and hurtful?

A.   Yes; children are thereby rendered simple and stupid, breed vermin, become scurfy, full of humours, and troubled with aches in their heads, ears, and teeth.

Q.   What kind of caps are, therefore, the most dangerous?

A.   The woollen, cotton, and fur caps.

Q.   How, then, ought the heads of children to be kept?

A.   Boys, as well as girls, ought to remain uncovered, winter or summer, by day and by night.

Lower Saxony has a mild climate and the temperature rarely drops much below freezing in winter; one wonders how the children of colder parts of Europe and the US felt about this advice.

Q.   How ought children, male as well as female, to be dressed from the beginning of the third to the end of the seventh or eighth year?

A.   Their heads and necks must be free and bare, the body clothed with a wide shirt and frock, with short sleeves; the feet covered only with a pair of socks to be worn in the shoes; the shoes ought to be made without heels, and to fit well.

Q.   What benefit will be derived from this kind of dress?

A.   The body will become healthier, stronger, taller, and more beautiful; children will learn the best and most graceful attitudes; and will feel themselves very well and happy in this simple and free garment.

It was Dr. Faust’s passionate belief that a smock was the best form of dress for both boys and girls; but his subsequent campaign to outlaw trousers was sadly unsuccessful. While his views on clothing were often peculiar, there was one aspect of the subject on which he was unambiguously correct:

Stays and stiff jackets are inventions of the most pernicious nature; they disfigure the beautiful and upright shape of a woman, and, instead of rendering her straight, as was formerly supposed, they make her crook-backed; they injure the breasts and bowels; obstruct the breathing and digestion; hurt the breasts and nipples so much that many mothers are prevented by their use from suckling their children; many hence get cancers, and, at last, lose both health and life; they in general destroy health, and render the delivery of women very difficult and dangerous, both to mother and child. It is, therefore, the duty of parents, and especially of mothers, to banish from their houses and families both stays and jackets.

Wise advice; if only those corset-loving Victorian parents had taken note!

KILLED BY HIS FALSE TEETH

William Guest Carpenter was not a famous surgeon, nor a particularly successful one. He spent many years as surgeon to Pentonville, Clerkenwell and Millbank prisons before suffering the humiliation of himself becoming an inmate. He was locked up in 1861 after being unable to pay his debts—bad timing, since legal reforms a few years later would vastly reduce the number of people incarcerated for the offense.

It would be sad if Mr. Carpenter were remembered only for his time as a guest of Her Majesty. Fortunately, an otherwise unremarkable career was distinguished by one case of a truly exceptional nature. Though not attached to any hospital, he was a member of the oldest medical society in London, Guy’s Hospital Physical Society, and at one of its meetings in 1842, he told a strange tale about a missing set of dentures:

Mr H., aged 35, the subject of the present case, was an assistant to Mr Watts, an extensive chemist in the Edgware Road, with whom he had resided for upwards of eight years. Mr H. was afflicted from childhood with asthmatic bronchitis; and it appears that several branches of his family have fallen victims to pleuritic, pulmonic, or tracheal affections.

Broadly speaking, Mr. H. and his relatives suffered from respiratory disorders: those affecting the windpipe, the lungs or the membrane surrounding them.

With the exception of an occasional attack of increased difficulty of breathing, nothing which attracted particular notice seems to have occurred during the early part of his residence with his last employer; although, from the curious facts that were brought to light in the post-mortem examination, I think he must have suffered more or less for some years past; but his high flow of spirits, and his devoted attachment to business, were perhaps the means of diverting his attention from his own state of health. I first became acquainted with him in the early part of last winter. I never found him free from fever: his pulse was always above 100, skin hot, with other symptoms of inflammatory action.

The patient asked for medicine, but Dr. Carpenter refused. This was a matter of professional courtesy, as it transpired that another physician had already been consulted. Whatever the other medic prescribed was no use, since the symptoms persisted throughout the winter. A few months later, the patient took a turn for the worse:

On Friday the 13th of April I received a note from him requesting me to call, as he had been attacked with pain in the side and chest, which had that evening become so acute as to render coughing, speaking and breathing almost impossible. I immediately visited him. He complained of an acute pain in the right side of the chest shooting up to the clavicle, increased upon deep inspiration: respiration short, and hurried; pulse 140, rather wiry; skin hot and dry; tongue furred at the base and margin, red in the centre; bowels confined; cough troublesome.

After listening to his chest, the doctor concluded that there was an infection of the right lung: Breathing sounds on that side were inaudible.

Considering the case one of active inflammation, I bled him from the arm to eight ounces, without inducing syncope:* this relieved him of pain: he could then breathe with more freedom, and said that bloodletting was always of service to him. I ordered him some calomel, antimony, and compound extract of colocynth, to be taken at bedtime.

The trio of drugs prescribed for the unfortunate patient made up a cocktail of highly unpleasant laxatives. Colocynth, also known as the bitter cucumber or bitter apple, was particularly nasty, described by one contemporary writer as a “drastic cathartic, exciting inflammation of the mucous membranes of the intestines, causing severe griping, vomiting and bloody discharges.”

After three days, and despite a variety of treatments and medicines, there was no improvement in the patient’s condition. Dr. Carpenter sought a second opinion from a colleague. The upshot was a new therapeutic regime—the complete opposite of what had preceded it. Instead of violently emptying his gut, they were filling it up again:

An enema of gruel and olive oil to be administered immediately. Diet to be more generous: some port wine to be given occasionally throughout the day, with good beef-tea.

A few days later, matters came to a head.

I had prepared the requisites for administering an enema, to relieve the abdomen and allow its muscles more freedom of action; and had left him for a few seconds, to get some wine which he might take as a support through the operation, when I was summoned up to his room, as he had become very restless. I went immediately, but only to see him breathe his last.

The following day, Dr. Carpenter and another colleague performed a postmortem. They opened the man’s chest to look at the lungs.

As soon as I passed the scalpel into the right pleura, a gush of very offensive gas escaped. The pleural cavity on this side contained five pints of sero-purulent fluid.

Thin yellow pus, in other words. Just try to imagine what five pints of the stuff would look (and smell) like. Both lungs showed clear signs of disease, but there was one other obvious anomaly, a hole on the surface of the right lung “large enough to admit the tip of my little finger.” A little later, Dr. Carpenter discovered what had made it:

After I had completed the examination, I was removing the remaining fluid and coagula of blood that had escaped from the pulmonary vessels to replace the lung, when I came to an irregular substance, which when examined turned out to be, to our great astonishment, a piece of ivory worked into four artificial front teeth, covered with a brownish crust, with a pointed piece of silver riveted into the upper part of the teeth, which had evidently assisted in fixing them to the upper jaw.

These false teeth were not in the stomach or intestines, but in the chest cavity! How on earth had they got there? The surgeon asked the dead man’s father if he knew:

He immediately exclaimed that his son swallowed them thirteen years ago, in a fit of coughing, during his apprenticeship. I again examined the oesophagus; and we were satisfied that there was neither a recent wound nor a cicatrix to be found; and the only opening through which it could have escaped into the pleura of the right thoracic cavity, where I found it, must have been the fistulous* one in the corresponding lung.

The doctor realized that a set of false teeth lodged in the lung was likely to be intensely painful, so asked whether the patient had been in serious distress at the time, but apparently not.

The morning after it happened, he mentioned the circumstance to Mr Champley, his master, who advised him to take an aperient,* supposing the teeth had passed into the stomach: it was thought that the teeth had passed away by the bowels, unnoticed; and then the circumstance gradually became forgotten.

Dr. Carpenter surmised that the patient had somehow managed to inhale the denture, that it had entered the lung and then worked its way through the wall of the organ before lodging inside the pleura, the sac around it. He noted that one of the false teeth was still quite sharp: enough, he thought, to have created the opening he observed. It all seems rather unlikely (you’d expect such a major injury to have caused serious bleeding and altogether more dramatic symptoms), but it’s difficult to explain the case any other way. What is particularly remarkable about it is that the teeth remained in situ for thirteen years before the patient’s death.

The report ends with a postscript for the morbidly curious:

The teeth are now in the possession of Mr Carpenter, West Street, Finsbury Circus.

Where I’m sure he received a steady stream of visitors eager to see them.

PEGGED OUT

In 1864, a surgeon from Gloucester, Robert Brudenell Carter, sent a series of case reports for publication in The Ophthalmic Review. By his own admission the thirty-six-year-old Carter was “a conspicuously unsuccessful general practitioner in the country,” but within a few years, his career had blossomed, providing some justification for the old chestnut that for some, at least, life begins at forty. Carter was an unusually accomplished individual whose achievements went far beyond surgery. He performed with distinction as an army surgeon in the Crimea, and his dispatches from the front were published in The Times.

Carter founded ophthalmic hospitals in Nottingham and Gloucester, but eventually became disillusioned with medical life in the provinces. When he decided to move back to London in 1868, it was the newspapers, rather than hospitals, to which he applied for a job. The Times made him a staff member, as did The Lancet; and the following year, Carter resumed his surgical career at the Royal Eye Hospital in Southwark. For the rest of his life, he pursued this unconventional double life as an eminent surgeon and a prominent member of Fleet Street. At The Times he was celebrated as the first journalist to use a typewriter, and for doing so while wearing two pairs of glasses simultaneously.

This unusual case report gives some hint of his literary abilities:

G.W., a hale, vigorous old man turned 73 years of age, fell down stairs in the dark, being drunk, some time in the last few days of May. He did not lose consciousness from the fall. He injured the nasal side of the right eye, and bled very freely from the wound; but he did not seek medical aid till June 1st, when he went to Mr Clarke, who found a ragged conjunctival wound and much swelling of the lids, and ordered a simple dressing.

Nothing very remarkable, or so it appeared at first. It seemed that the old man had fallen on a sharp object, which had grazed the surface of his right eyeball and made a small wound between the eye socket and the nose.

The patient presented himself at intervals until the 6th of June, when Mr Clarke discovered the presence of a foreign body in the wound, but deferred its removal until the following day, when he visited the man at his home. He then felt the extremity of a piece of iron, which he seized with forceps and attempted to withdraw. By using considerable force, and after much time, he removed the entire shaft of a cast iron hat-peg, measuring three inches and three-tenths in length, and weighing twenty-five scruples.

An amazing item to find completely hidden in an eye wound. A scruple was a unit of weight used by apothecaries and pharmacists, equal to one twenty-fourth of an ounce. This hat peg was a substantial object, more than eight centimeters long and weighing thirty-two grams.

On further inquiry, Mr Clarke found that this hat-peg had been one of a row, screwed to the wall near the bottom of the staircase; so that the man must have fallen upon the end of the peg, and must have broken it by his momentum after it had become completely buried in his orbit.

I’ll be honest, I winced a little at this point.

The base of the hat-peg was still in its place in the row, and presented a recently fractured surface fitting accurately to that of the portion removed from the patient.

Nobody had noticed the broken hat peg—understandable, perhaps. What is more surprising is that the patient had failed to notice three inches of metal inside his eye socket.

When the question arose with regard to the exact period of impaction, no one could answer it. There were the seven days during which the patient had been under medical observation; but he could not remember on what day of the week he fell down, and could only say that it was four or five days before he went to the doctor. Four or five, with an illiterate old man, means simply x; but it may be presumed that the actual period of impaction was between ten and twenty days. The patient recovered without a single unfavourable symptom.

The lucky man. One final question arose: How was it possible for a three-inch metal spike to enter his eye socket without causing blindness, brain injury or death?

Mr Clarke was compelled to use very considerable force to remove the hat-peg, and had to loosen it by lateral movements as well as by direct pulling. Partly from this reason, and partly from his natural astonishment at its bulk and length, he can scarcely be certain of its direction; but he thinks that its point must have been received in the antrum of the opposite side.

The theory that the peg had entered the patient’s sinus (antrum) seems reasonable enough, but as Robert Brudenell Carter points out, the possibility that it actually penetrated the brain cannot be ruled out. Forty years later, the surgeons could have taken an X-ray and put the matter beyond doubt; but in 1864, it was still a guessing game.

THE CAST-IRON STOVE PANIC

In the late 1860s, a fashionable new phrase began to proliferate in the medical literature like bacteria in a petri dish: “germ theory.” For decades, scientists had been arguing about the means by which diseases were able to spread. In the first half of the nineteenth century, the orthodox view was that epidemics of such illnesses as typhoid and cholera were caused by foul air, known as miasma, which was either emitted by rotting organic matter or generated spontaneously in a badly ventilated or dirty environment. A few mavericks believed that tiny particles, invisible to the naked eye, were in fact responsible—but this “germ theory” did not become respectable until Louis Pasteur’s investigation of the process of fermentation in the early 1860s led him ineluctably to the conclusion that it was microorganisms that caused disease.

The phrase “germ theory” was first used in a British medical journal in 1863, but the hypothesis was not generally accepted until long afterward. Many researchers continued to insist that epidemics had other causes—one suggested that particles of dust acted as “rafts” ferrying “atmospheric poisons” between their victims. Other theories were stranger still, such as this one aired in The Lancet in 1868:

When the attention of the Academy of Sciences of Paris was drawn some time since by M. Carret, one of the physicians of the Hotel Dieu of Chambery, to the possible evil consequences of the use of cast iron stoves, little interest was excited in the matter.

It may not immediately be apparent what possible connection there could be between cast-iron stoves and infectious disease. But Dr. Carret was determined to make one.

M. Carret does not hesitate to assert most positively that cast iron stoves are sources of danger to those who habitually employ them. During an epidemic which recently prevailed in Savoy, but upon which M. Carret does not furnish us with any detailed information, he observed that all the inhabitants who were affected with it made use of cast iron stoves, which had lately been imported into the country, whereas all those who employed other modes of firing, or other sorts of stoves, were left untouched by the disease. An epidemic of typhoid fever, which broke out some time after at the Lyceum of Chambery, was regarded by the same author as being influenced by a large cast iron stove in the children’s dormitory.

This looks at first sight like the classic error of mistaking correlation for causation. So what’s the evidence? Well, Dr. Carret cites the experiments of two of his colleagues, Messieurs Trorst and Deville:

These able investigators have established that iron and cast iron when heated to a certain degree become pervious to the passage of gas. They have been enabled to state the quantity of oxide of carbon which may, as they suppose, transude* from a given surface of metal, and have shown that the air which surrounds a stove of cast iron is saturated with hydrogen and oxide of carbon. They conclude that cast iron stoves when sufficiently heated absorb oxygen, and give issue to carbonic acid.

A dubious assertion. It’s not clear what the connection between carbonic acid (carbon dioxide) and typhoid might be, but no matter.

General Morin related some comparative experiments which had been performed by M. Carret, and which, he said, corroborate this theory. Thus, after having remained during one full hour in a room heated to 40°C by means of a sheet iron stove, M. Carret perspired abundantly, got a good appetite, but felt no sickness whatever; he had obtained the same result with an earthenware stove; but the experiment when performed during only one-half hour with a cast iron stove, had brought on intense headache and sickness.

But did he go down with typhoid? Dr. Carret remains silent on this matter.

Deville, at the same sitting of the Academy, supported these views with considerable warmth.

Which is hardly surprising, if he’d spent as much time as M. Carret sitting next to a hot stove.

The danger which attended the use of cast iron stoves, he said, was enormous and truly formidable. In his lecture room at the Sorbonne he had placed two electric bells, which were set in motion as soon as hydrogen or oxide of carbon was diffused in the room. Well, during his last lecture the two cast iron stoves had scarcely been lit when the bells began to ring.

And did anybody contract typhoid? This crucial point remains unresolved.

These facts are certainly startling, if we consider the reputation of comparative harmlessness which these articles of domestic use had hitherto enjoyed. In France, particularly, the lodgings of the poorer classes, the barrack rooms of the soldiery, the artists’ studios, the classrooms of large schools, etc., are commonly heated by this means.

I cannot be alone in thinking that Dr. Carret had failed to make an absolutely compelling case for a causal relationship between cast-iron stoves and typhoid. Nevertheless, his findings were deemed so alarming that the French Academy of Sciences decided to investigate further, appointing a heavyweight committee headed by the physiologist Claude Bernard, one of the country’s greatest scientists, to do so. Its report, which took five years to produce, is marked by Bernard’s characteristic rigor. After an exhaustive series of experiments, the committee concluded . . . that cast-iron stoves were indeed extremely dangerous—though not for the reasons originally suggested. Bernard found that they emitted hazardous amounts of carbon monoxide, a gas that he had already shown to be highly toxic. It was an important finding that led manufacturers to make significant changes to the design and installation of their stoves.

But did they cause typhoid? The report is almost fifty pages long, but the authors dismiss Dr. Carret’s claim in a single sentence:

The facts this doctor cites in support of his opinion do not appear to us sufficiently settled to justify the conclusions that he has drawn.

Which, in the world of science, is about as brutal a putdown as you can imagine.

BROLLY PAINFUL

When I was at school, one of my contemporaries suffered an unfortunate injury. As he was bending over to pick something up, a friend thought it would be amusing to prod him in the bottom with a golf umbrella. The joker sadly misjudged the degree of force used, causing an injury that necessitated a trip to the school doctor. The damaged derrière was diagnosed as an anal fissure, a small tear in the muscular wall of the anus: not serious, but it made sitting down painful for a few days. Somehow this piece of school gossip was picked up by one of the tabloids—presumably after a tip-off from an entrepreneurial student—which printed the story under the headline “BROLLY PAINFUL.”*

That was a relatively trivial incident, but I was reminded of it when I came across this rather more serious case recorded in 1873 by an Irish surgeon called H. G. Croly:

A boy named Patrick Donohoe, aged eight, was admitted to the City of Dublin Hospital on the 12th of February, under Mr Croly’s care. Three days before admission to hospital the child was playing with the steel rib of an umbrella, one end of which he had put in his mouth. He was on a bed, and fell off it on to the floor. The end of the umbrella rib went deeply in through the back of the pharynx, and the child pulled it out himself.

The rib (one of the metal spikes that stiffens the fabric of the umbrella when in use) had not gone down toward the boy’s stomach but punctured the back of his throat.

His mother came home two or three hours afterwards, and found the child with his head resting against the chimney-piece. He had been sick in his stomach, and bled from his mouth and nose. She thought the child had been smoking, and beat him without inquiring into the cause of his illness.

Oh, the injustice! Still, the fact that she immediately suspected him of the crime suggests that he may have been a serial offender.

She was told, however, by a sister of the boy what had occurred, and on looking into his mouth found a wound in the back of the throat. The child raved that night, and on the following morning, finding that he was not getting better, she brought the child to Mr Croly. She stated that, in addition to the feverish symptoms, the child had double vision. There was a dress of one of the children hanging on a line across the room, and he said he saw two dresses.

It must have been a shock for the poor woman, especially since the first treatment she had offered her child was a thorough flogging. When the surgeon examined young Patrick, he could see an obvious puncture wound at the back of his throat. The boy had also developed a squint and could not cope with bright light. Most worryingly, he could not stand upright without staggering.

Mr Croly concluded from these symptoms that the rib of the umbrella had penetrated to the spinal cord between the first and second cervical vertebrae, and he came to that conclusion from the history of the case and the paralytic symptoms. He had the child’s head shaved, leeched him on each side of the spine, and treated him with calomel and James’s powder.

Calomel was a strong laxative made from mercury, while James’s fever powder, invented in 1746 by the physician Robert James, was a patent medicine with a loyal following. Goodness knows why it was so popular, since its ingredients included the highly toxic element antimony, which provokes vomiting.

There was a difficulty of swallowing. The temperature was taken and it was found that it ran up from 98°F, which it was on the 14th of February, to 102 and 105. He whistled, he screeched, he had the knitted brow, and he threw back his head. These symptoms became very alarming, and he had to be kept in a room with a subdued light. The treatment with mercury and James’s powder was persevered in, and ice was applied to the head; all the symptoms had now disappeared, and the child had in fact recovered.

The boy’s recovery was as abrupt as it was comprehensive. The surgeon was still unsure what exactly had happened to the boy; hoping to test his hypothesis that his spine had been injured, he took himself to the hospital morgue. There he chose a suitable cadaver and pushed a sharp wire through the back of its throat in the same place where the boy had injured himself:

He found the wire went in between the first and second cervical vertebrae and wounded the spinal cord. The case was, he believed, unique.

Assuming Mr. Croly’s analysis was correct, it certainly was unique. Injuries between the first two vertebrae of the neck (known as C1 and C2) are potentially the most serious of all spinal injuries. If the spinal cord is completely severed, the likely outcome is death, or at least complete paralysis (including cessation of breathing). This obviously didn’t happen, so the spike can only have grazed the cord at worst. Either way, it’s a novel way to fall foul of an umbrella.

A FLAMING NUISANCE

In western Scotland, the name Sir George Beatson is virtually synonymous with cancer care. Glasgow’s major cancer hospital, as well as a research institute and medical charity dedicated to the disease, are named in honor of a Victorian surgeon who devised one of the first effective treatments for advanced breast cancer. He deduced that the progress of the disease could be slowed if the patient’s ovaries were removed; the operation, known as oophorectomy, remained a standard therapy for over a century.

In 1886, this pioneer of oncology made a startling discovery about the dangers of smoking. Nothing to do with lung cancer—it was not until the 1950s that the link between the two was established beyond doubt. No, the article Beatson submitted to The British Medical Journal that February addressed the important subject of exploding belches:

I have thought it right to put on record the following case, as it seems to me to be one of some rarity, and to have some importance from a medico-legal point of view. I cannot do better than give the facts in the words of the patient himself, who communicated them to me by letter. He writes as follows:

“A rather strange thing happened to myself about a week ago. For a month or so I was troubled very much with foul eructations.”

The polite medical term for belching.

“I had no pain, but the smell of the gas which came from my stomach was disagreeable to myself, and to all who happened to be in the room. About a week ago I got up in the morning, and lighted a match to see the time, and when I put the match near my mouth, to blow it out, my breath caught fire, and gave a loud crack like the report of a pistol. It burnt my lips, and they are still a little sore. I got a terrible surprise and so did my wife, for the report awakened her.”

I don’t know what would be more alarming: being woken up by an explosion or seeing your husband belching fire like a dyspeptic dragon. Mr. Beatson concluded that halitosis, normally a mere inconvenience to the sufferer and those around them, could also “become a condition of danger.”

In the present instance, the gaseous results of the imperfectly digested food had their atoms of carbon and hydrogen so arranged as to give rise to the presence of carburetted hydrogen . . .

An antiquated term for methane. The verb carburet means “to react or mix with carbon.” The carburetor of a car engine is the part that mixes hydrocarbons (i.e., petrol) with air to render them more explosive.

 . . . the inflammable and explosive qualities of which came into play when mixed with a due proportion of atmospheric air in presence of the unguarded light of the burning match.

This is quite plausible, although the explosion may well have involved hydrogen as well as methane. Both gases are generated in relatively large volumes (around two hundred milliliters per day) in the human digestive tract. Most is produced in the large intestine, however, which makes it difficult to explain why it should have exited via the mouth.

Dr. Beatson’s short article prompted a rather lively correspondence. A couple of weeks later, a Birmingham physician, Robert Saundby, wrote a scholarly letter that included chemical analyses of the flammable gases belched by other patients. But his thunder was stolen by another Glaswegian, Dr. R. Scott Orr, who shared an anecdote sent to him by an “old gentleman aged about 70, who has since died of apoplexy”:

“Some five or six years ago I had great acidity and indigestion, and then found relief from Gregory’s mixture and bismuth, and, for a good time, found comfort by using these.”

Gregory’s powder was a mixture of rhubarb, ginger, and magnesium carbonate, a patent medicine commonly used to treat digestive disorders.

“But within the last year or two, indeed longer, I have been much troubled by great flatulency, general puffiness after dinner and during the night, with considerable pain at the pit of the stomach. Not troubled with heartburn or acidity so much, but with eructations of wind or gas, and this of such an offensive smell as to render me most uncomfortable, indeed unhappy, in any one’s company or proximity, and latterly the pain so severe, or rather oppressive, as to prevent my sleeping.”

As if it weren’t bad enough smelling like a tannery, the poor chap now developed an even more antisocial habit.

“About four or five months ago, while lighting my pipe of an evening, it so happened that one of these involuntary eructations took place while the match was at my pipe, and the gas then took fire, and burned my moustache and lips, and frightened me a good deal. It was just such an explosion or puff as would occur on your putting a pinch of gunpowder to a light.”

BOOM, as they say.

“My son H. was sitting by me, reading, and immediately looked up in astonishment. He has witnessed the same thing occur either two or three times, and it has occurred in all five or six times. I have tried all sorts of changes of diet, but to no purpose.”

Readers hoping for an explanation of the fire-breathing antics of the two patients were disappointed: The appearance of flammable gas was dismissed as the side effect of an unusual species of indigestion. But four years later, all became clear when Dr. James McNaught recorded another case of the phenomenon. His patient was a twenty-four-year-old factory worker:

His work requires him to rise early, and on one occasion after striking a match to see the time, and when holding it near his mouth, an eructation of gas from the stomach took place. To his consternation the gas took fire, burned his face and lips considerably, and set fire to his moustache.

Dr. McNaught noticed that his patient’s abdomen was bloated and unusually taut. Out of curiosity, he passed a tube down into the man’s stomach and removed some of the contents for inspection. These consisted of

soupy matter smelling exactly like sour yeast, and when it was allowed to stand, a layer of frothy stuff half an inch thick, like dirty yeast, formed on the top. This was full of bubbles of gas which could be seen forming and bursting as it stood in the vessel.

The gas was flammable, and Dr. McNaught realized that it was produced by fermentation, a process normally confined to the lower part of the gut. His patient had an obstruction in his digestive tract that made it difficult for stomach contents to pass into the small intestine. Confined in the stomach for far longer than usual, they were fermenting and giving off large amounts of hydrogen and methane that could be vented only through the mouth.

The association between flammable belches and gastric obstruction was confirmed by a number of similar cases in the early years of the twentieth century. They include this peach of a party trick, performed by a sufferer who tried to light a cigarette while playing a quiet game of bridge:

As he leaned forward he felt an undeniable necessity to belch but, being in the presence of company, he attempted to do this discreetly through his nose; he electrified his associates by producing two fan-shaped flames from his nostrils.

And what could be more discreet than that?

CYCLING WILL GIVE YOU HEART DISEASE

In September 1894, many of the world’s most eminent scientists descended on Budapest for the Eighth International Congress of Hygiene and Demography. It was an enormous gathering: more than seven hundred research papers were presented over the course of nine days, with 2,500 delegates taking part. The Hungarians’ hospitality was lavish, so much so that one journal described the whole affair as “a pleasant outing for which scientific work serves mainly as a pretext.”

Topics dealt with at the congress ranged from the management of diphtheria outbreaks to the health benefits of cold-water bathing. On Wednesday, September 5, a brief session was devoted to the “hygiene of sport.” The Paris doctor E. P. Léon-Petit gave a talk entitled “Women and the Bicycle,” addressing himself to the vexed question of whether the newfangled contraption was safe for the poor delicate creatures. The dangers had been exaggerated, he suggested, and the potential health benefits significant, adding that in women with anemia or constipation, he had even found that a bike ride brought some improvement.*

Dr. Léon-Petit was himself an accomplished club cyclist, as was the delegate who spoke after him. But George Herschell, a specialist from London, had an altogether less sunny message to impart:

Cycling, rationally pursued, is one of the most health-giving forms of amusement; but when indulged in to excess, or under improper conditions, one of the most pernicious. I have been led to choose this subject for my paper from the fact that my position on the staff of a special hospital devoted to the treatment of diseases of the heart has given me unusual opportunities of studying the subject. Moreover it is of great interest to me, as I am myself a practical cyclist. I am sorry to say that during the last few years a considerable number of cases of heart disease, undoubtedly caused by cycling, have come under my observation.

But cycling is physical exercise, and the Victorians were all in favor of that. So what’s the problem? Dr. Herschell explains:

The chief danger of cycling, or rather the reason why it is more injurious than some other forms of exercise, is the probability when riding alone of being led into an injurious excess of exertion, and the almost certainty of the same thing happening when riding in company, especially with a club.

“Injurious excess of exertion” is a good phrase, and one that I intend to use next time I am feeling too lazy to go out for a run.

In the first place we will take the solitary rider. He is extremely likely to take much more exercise than he is aware of before he recognises the fact that he has done so.

It does not apparently cross Dr. Herschell’s mind that the “solitary rider” might be a she.

He starts off in the morning for a ride, fresh and vigorous, having previously mapped out his course. It not unfrequently happens that when the time arrives for his midday meal some unforeseen delay may have caused him to have some few miles yet to go. He has perhaps overrated his capacity; or the condition of the roads render travelling at the rate upon which he had based his calculations impossible. But he is hungry, and so he redoubles his efforts to reach the place. When he arrives there he is utterly fagged out and has lost his appetite.

“That cycle ride has left me so exhausted that I could not possibly manage a hearty lunch”—a sentence I have never uttered, nor ever expect to.

Again—the roads are good, the wind is at one’s back, and the rider is fresh. The machine runs easily. Having ridden out for half a day or so the rider starts to return. But everything is now reversed. The rider is tired, and the wind is against him. Moreover he has been led by the easiness of the outward journey to go much further than he had intended; so that by the time he reaches home he is in the vernacular of the cyclist ‘baked’.

In 1890s cycling slang, baked meant “extremely tired” rather than the modern surfer-dude sense of “intoxicated by drugs.” That said, given recent scandals in the world of cycling, perhaps the latter isn’t so far off the mark.

The commonest way however in which the cyclist does himself harm is in climbing hills. He is nearing the top of the hill, the heart is dilated with the strain put upon it by the increased arterial tension. If the rider were now to stop to recover himself no harm would be done. But in too many cases he does not do so. Only a few more revolutions of the wheel will be required to carry him to the top. So he redoubles his exertions, and puts further strain upon a heart already taxed to the utmost limit of its capacity. But in those few moments, damage has been done to the heart from which it perhaps cannot recover.

Dr. Herschell adds that his concern is mainly for recreational cyclists rather than serious road racers. But the experts are not exempt from such danger, since they are “deliberately sacrificing their future health for the sake of winning a few prizes.”

Another very wicked thing is what is known as a “hill-climbing contest”. If people were to deliberately set themselves to devise a method of riding which should be as injurious as possible they could not hit upon a better one. Hills of the steepest gradient are deliberately selected, and the competitors ride up them against time. Nothing more suicidal, or more certain to produce heart disease, can possibly be imagined.

What on earth would he have made of the Tour de France, with its regular ascents of mountain peaks? On a single day of the 2017 Tour (Stage 9), competitors rode 180 kilometers through the Jura Mountains, during which they climbed 4,600 meters. In climbing the Grand Colombier, exactly halfway through the stage, they had to propel themselves up an eye-watering gradient of 22 percent for over 3 kilometers.

Dr. Herschell then lists a number of precautions that he suggests the leisure cyclist should take “to prevent this fascinating sport from injuring us”:

1. The use of a low gear.

2. The upright position in riding. The stooping posture so affected by the modern cyclist, by contracting the chest, prevents the proper expansion of the lungs, and by interfering with the aeration of the blood, causes the condition of breathlessness to come on quicker.

3. Adequate food when riding, and the avoidance of muscle poisons such as beef-tea.

4. The cyclist must avoid the advertised preparations of kola and coca. These by numbing the sense of weariness, enable injuriously excessive work to be done, almost without the knowledge of the rider.

Kola nut contains caffeine and is relatively innocuous, but coca leaves are used to make cocaine, the consumption of which is generally frowned upon in competitive sport.*

5. On no account should the cyclist continue riding after he has commenced to feel short of breath, or when there is the slightest sensation of uneasiness in the chest.

Duly noted. Any club cyclists who followed Dr. Herschell’s advice to the letter would have been denying themselves much of the benefit they could otherwise expect from their hobby. Raising the heart rate, and getting out of breath, is the whole point of aerobic exercise: It helps to strengthen the heart muscle and improve the circulation and (within reason) is unambiguously a Good Thing. These days, cycling is even recommended to some patients in chronic heart failure to improve their cardiac function.

Despite his position at a specialist heart hospital, Dr. Herschell published very little on cardiac disease. He was highly regarded as an expert on disorders of the digestive tract, and his textbook on the subject ran to several editions. He thoughtfully included a short chapter of recipes for those with delicate stomachs, and a few years after his death, these were excerpted and published as a slim volume called Cookery for Dyspeptics. I don’t know if any recipe book has ever had a better title, but somehow I doubt it.