Charity concert evening on 20th July 2016 for children’s cancer charity CLIC Sargent

St James' Church, Packington Estate

The distinguished University of Warwick Chamber Choir are to perform Spiritual and Shakespeare Song Cycles and A Child of our Time on Wednesday 20th July, 2016 at the Packington Estate in North Warwickshire in support of the children’s cancer charity CLIC Sargent.

This is the third in an annual series of charity musical evenings organised by the Worsted Weavers Guild of Coventry in support of this national charity, which supports children and their families in the Coventry and Warwickshire area.

The musical performance will be in the St James’ Church on the Packington Estate in
Warwickshire (~ 20 minutes north of Kenilworth). 

St James’ Church and Packington Hall are not normally open to the public. The event is being held on the Estate by kind permission of the Earl of Aylesbury.

The neo-classical St James’ Church was inspired by the Baths of Diocletian in Rome and has an organ designed by Handel for his librettist, who was a cousin of the Earl of Aylesbury of the time, owner of the church and the Packington Estate.

Order tickets for concert and reception

The performance will be followed by a reception in the Pompeiian Hall at Packington   with wine/soft drinks and canapés. TIckets for the concert and the reception are £35 per person.

Map of Packington Hall

The children’s cancer charity  CLIC Sargent is the UK’s leading cancer charity for children and young people, and their families. CLIC Sargent provides clinical, practical, financial and emotional support to help them cope with cancer and get the most out of life. CLIC Sargent aims to help the whole family deal with the impact of cancer and its treatment. CLIC Sargent is active nationally, and locally in the Warwickshire and Coventry area.

University of Warwick Chamber Choir performs in Warwickshire and further afield, with annual tour destinations including Spain, Germany, the Republic of Ireland, Belgium and Switzerland, as well as regular performances in London and concerts on our own. UWCC have appeared on BBC national television ...

Read more about the event

As merry as the day is long? Shakespeare on seasonal mood ...

Easy to over-interpret, however when Beatrice says in Much Ado about

Winter - North of Scotland

Nothing she is " ... As merry as the day is long", interesting to consider: was this a throw-away line, a mask for her true mood, or the mirror of "... As sad as the day is short"?  We also have young prince Mamillius saying "... a sad tale's best for winter." [Winter's Tale. II.i.25]

Hippocratic writings [On Airs, Waters, and Places: ~400 BCE] recognize the potential for seasonal variation to influence patterns of disease in general. And not a new idea that people are lower in spirits in winter months: the Roman writer Jordanes refers to winter depression in his history of the Goths [Getica: 551 AD]. Describing depression as 'the blues' dates from 1741 and 'winter blues' [la dépression hivernale] describes what many people may experience. 

However SAD syndrome (Seasonal Affective Disorder) was only formally reported as such and named in 1984 by Rosenthal and colleages at the National Institute of Mental Health in the USA. Rosenthal was initially motivated by wishing to discover the cause of his own experience of depression during the dark northern US winter. His key contribution was to suggest that reduced exposure to light is a major factor causing SAD and that exposure to more light during the day may reverse features of SAD. 
 

Of note, Much Ado (as Love's Labour's Won) is currently paired by the RSC in Stratford with the bleaker Love's Labour's Lost with its unfulfilled ending, and the poem "Winter", "When icicles hang by the wall". The only "merry note" appears to be from an owl. Chilled Dick the shepherd is "blowing his nail", greasy Joan, has "... nose, red and raw...", and the "Parson (is) drowned out by coughing flock".

Shakespeare often used winter as a metaphor for hard times and troubled characters, from the direct contrast from the opening of King Richard III

"Now is the winter of our discontent, made glorious summer ..."

to Sonnet 5

"For never-resting time leads summer on
To hideous winter and confounds him there;
Sap cheque'd with frost and lusty leaves quite gone,
Beauty o'ersnow'd and bareness every where."

There is inevitable speculation about the extent to which Shakespeare was revealing on stage aspects of his own depression, or reflecting human experience, and the influence of uncertainties of life at his time.

For the present day, there are now also biochemical hypotheses for the cause of SAD - infections are common in winter and the inflammatory chemicals (cytokines) released by the body's defence cells to fight infection may have the unwanted effect of depressing mood, through toxic actions on brain cells. This may both provide new causes for depression as well as opportunities for treatment, through blocking these harmful chemicals.

Folk wisdom and health

Shakespeare and the history of heartbreak  The Lancet
 

Sadness and the four humours in Shakespeare

Shakespeare and depression

Shakespeare's Medicine Cabinet discussed at the Dana Centre

@HealthMed: Shakespeare’s Medicine Cabinet was the theme of a packed evening session at the Dana Centre on 8^th November. The Dana Centre is funded as joint venture with the Science Museum and Imperial College London, with the aim of bringing together the public with academics and other experts to discuss a wide range of themes.

This evening explored, with the help of the excellent Dana Actors (directed by Silvia Ayguade), facts and fantasy underlying effects of plants as medicines, poisons and aphrodisiacs in Shakespeare’s plays.

Professor Rod Flower FRS selected examples from Macbeth, Midsummer Night’s Dream and Romeo and Juliet, asking the question whether botanical references were ‘merely dramatic license, or was there a scientific basis for the use of drugs in his plays?’ For example Juliet imploring the Friar:

“… Let me have a dram of poison, such soon-speeding gear 

As will disperse itself through all the veins 

That the life-weary taker may fall dead …”

And the Friar’s offer of a specific death-mimicking toxin to last ‘… two and forty hours …’

Love-in-idleness

The interval was spiced with the opportunity provided by the British Pharmacological Society organisers to sample some of the healthier plants mentioned, including an interesting Heartsease floral tea – the plant referred to as ‘love-in-idleness' by King Oberon in Midsummer Night’s Dream.

Dr Randolph Arroo, Head of Research at the School of Pharmacy in Leicester, went on to discuss the interface between plants and medicines in the second Elizebethan Age.

His comments on reliability of plant sources and earlier issues raised by Professor Flower were echoed in the discussion points raised by a very engaged and informed audience.

For more see the Dana Centre website

and the website of co-organiser the British Pharmacological Society.

Tuberculosis, Bel Ami and the Belle Epoque

Guy de Maupassant

@HealthMed Maupassant's 1885 book Bel Ami concerns the rise to wealth and influence of ex-soldier Georges Duroy, son of a poor rural family. Themes which still have a topical international resonance include the power of the press, foreign wars, corruption in business and government, and stock market insider trading. The anti-hero's success is largely due to the power of the wives of the rich, through their husbands, or direct involvement in political intrigue. A major subplot in Bel Ami is the impact of tuberculosis - estimated to cause the death of between 1 in 4, and 1 in 7 of the population in the mid 19th Century. In Bel Ami, Forestier, a wealthy publisher, develops rapid serious lung involvement, coughing blood, becoming breathless, and fevered. His early death provides a key opportunity for Duroy to enter formally into society.

Belle Epoque France was the outcome of cultural and economic flourishing during the latter part of 19th Century. An obvious question is what people at that time thought about tuberculosis. They knew that is was a serious and often deadly disease: Forestier's rapid death is anticipated as a matter of fact by Clothilde, a faithful companion of Duroy. An important academic view was that the 'soil'' - individual susceptibility - played a major role in the likelihood of developing consumption. There are several apparent similarities between those perceptions and public reaction to the epidemic of HIV-AIDS which emerged in the early 1980s. Tuberculosis was known as consumption because of its wasting effect. The term in translation dates back at least to Hippocrates in 460BCE: the Ancient Greeks used the term phthisis (wasting away) to describe the commonest disease of their time.  This was echoed by the description 'slim disease' for a wasting disorder which emerged in rural Uganda in the early 1980s, strongly associated with infection with the HTLV-III, and thus recognized to be a feature of HIV-AIDS. A major cause of weight loss in HIV-AIDS is associated opportunistic infections such as tuberculosis - a clear illustration of the importance of the impact of impaired host defence on development of a disease.

 

At the time of publishing Bel Ami, Maupassant was ill with syphilis. Not a socially acceptable disease to reflect in a literary work - although ample opportunity for this to be acquired by Maupassant's  anti-hero Duroy and passed on to his high society conquests. The concept of the risk of progressing from a 'night with Venus to a lifetime with Mercury' emerged shortly after the 1494 siege of Naples. In an epic poem of 1530, the Veronese doctor poet Girolamo Fracastoro refers to use of mercury as a possible cure for the disease. And its late effects were well known to Shakespeare, with examples in his play 'Timon of Athens'. One of Fracastoro's many contributions to science and medicine was the idea that certain diseases are spread by particles. In the 1600s, early inventors of microscopy went on to confirm the existence of minute particles. Antoni van Leewenhoek was the first to report single-cell micro-organisms, in 1676 correspondence to the Royal Society, which, after initial scepticism, then confirming his findings, made him a member in 1680. 

A dramatic change in medical thinking and knowledge about tuberculosis occurred in the early 1880s. In 1881, French doctor Louis Landouzy gave a series of influentual lectures on causes of consumption, including speculation that routes of transmission could included infected dust, milk and meat. And in 1882, the Prussian pathologist Robert Koch was the first to describe the causative tubercle bacillus, supported by his formulation in 1884 with Friedrich Loeffler of 4 postulates about the evidence needed to confirm disease causation by microbes. This direct work on the germ theory of disease had been anticipated 350 years before by Frascatoro. Koch's investigations and discoveries in relation to tuberculosis lead to his receipt of the 1905 Nobel Prize in Physiology and Medicine.

The timing of publication in 1885 of Maupassant's novel Bel Ami is therefore of special interest, following 3 years after Koch's discovery. There is no explicit recognition in Bel Ami of the resulting logic for isolating patients with what later became called 'open' tuberculosis - when the TB germs are free to travel from the lungs through the air to nearby contacts. However the move of Forestier to a remote house may have served both to give him a quiet place to convalesce or die, and tacitly to isolate him from at risk friends.

Modern parallels to the public response to tuberculosis in the Belle Epoque range from reactions such as fear, concern and denial for mystery illnesses with no cause known (e.g. pre-HIV 'slim disease'), the response of the public to those affected by HIV-AIDS, before the emergence of effective treatment; and responses to the many types of cancer without known cause, and other  reasons for premature illness and mortality, for example - sudden cardiac death syndromes in young athletes and older adults, despite many advances in diagnosis and treatment.

Romeo's 'Sick health'

@HealthMed One of Romeo's string of oxymorons [Romeo and Juliet Act 1, Scene 1: reflecting on his heart sickness for fair Rosalind], 'sick health' illustrates the challenge of preventing more conventional heart disease - with its long prodrome of apparent health masking the development of sub-clinical disease from unrecognized risk factors, which may however be reversible if identified and addressed.

Why don't more people engage? Many reasons, including fear of finding a problem if tested, difficulty accessing advice/health checks, lack of interest or knowledge of outcomes of 'treatment', lack of confidence in self-efficacy to achieve supporting or first-line life-style changes, in diet, exercise, weight, smoking cessation, alcohol intake ...

To find out more on challenges and solutions for success in behaviour change, look for sources on Theory of Planned Behaviour e.g. this referenced link from the University of Twente.

See my previous blogs on smoking and alcohol.

Stopping smoking: why and how?

Hip fracture risk and smoking

Smoking: literary warnings

Alcohol: literary warnings

Alcohol and the French paradox

The Tempest and Prospero's curse - magic, pleurisy, and other thoughts

@HealthMed In response to Caliban's cursing in 'The Tempest', Prospero rewards him with a threatening prophecy: 

'... tonight thou shalt have cramps, 

Side-stitches that shall pen thy breath up ...'

This is a plausible symptomatic description of the intermittent, breath-restricting pain caused by pleurisy [earlier known as pleuritis], a suggestion at least as early as 1886. In contrast, as used by Shakespeare, the word pleurisy denoted a plethora, or excess of blood. This use is thought to have arisen from the idea that the word pleurisy was derived from plus pluris. 
e.g  in Hamlet Act IV, Scene 7:  

"For goodness, growing to a plurisy
 Dies in his own too much."

Pleurisy, local pain and difficulty in breathing, usually arises from inflammation of the pleura - the membranes that lines the lungs and inner walls of the thoracic cage. These inflammatory processes lead to adhesion of the visceral to the parietal pleura.  

Dr Charles Buckmill, writing in 1860, was sceptical of the medical nature of Prospero's curse, seeing it as a blend, half health, half magical in character.

How could Prospero have predicted this would happen to Caliban? Were there poisons at the time [1610-11] that Prospero could have given to Caliban to cause reversible pleurisy? And how did doctors of Shakespeare’s day diagnose pleurisy? The pain of pleurisy is often knife like or cramp-like pain, and worse on inspiration. Pleuritic pain is typically altered by posture, eased in some positions, made worse in others.

These symptoms we now recognize as pleurisy were well-established in Tudor and early Jacobean times; and post-mortem examination was then in European medical centres a route to understanding (or misunderstanding) the nature of disease in retrospect.  The Hippocratic writers were already diagnosing pleuritis from a cluster of symptoms: pain in the side, fever, shivering, rapid breathing, difficulty in breathing when lying flat [orthopnoea] and cough productive of pomegranate-peel coloured or blood-stained sputum. From 300BC, discussion moved to the pathology of pleurisy, with a distinction between disease in the lung (e.g. Herophilus: modern pneumonia) and pleuritis as a disease of the membrane that lines the inner part of the ribs [membrana hypezocota] and resulting in increased pain on lying on the unaffected side [because lung movements than are greater at the site of pleural inflammation], or in some greater when lying on the affected part. 

Pleurisy results in abnormal lung sounds, which, if loud, would have been audible by a physician placing an ear against the chest [auscultation]. This medical diagnostic method is thought to have been used by Ancient Egyptian physicans. However the key early method of diagnosing pleurisy was ‘hardening of the pulse’.

On listening with a stethoscope, a pleural friction rub is heard. Laennec, the inventor in 1816 of the stethoscope, called this friction sound ‘frottement ascendant et descendant’ and ascribed it to emphysematous change in the lungs. Descriptions of the rub include - a scratchy sound similar to that of a door opening on a rusty hinge; or similar to the sound or two pieces of sandpaper rubbed together.  Laennec also used described ‘aegophony’ in pleurisy - a sound like the bleating cry of a goat. Laennec considered that pleurisy was typically associated with modest accumulation of fluid in the pleural cavity (pleural effusion). However with too much pleural fluid, lung sounds disappear, including pleural rubs.

Recognition of pleural effusion goes back to early Babylonian medicine.  Small lead tubes discovered in ancient Babylonian sites are considered to have been trochars – implements inserted through the chest wall to drain pleural fluid. With the benefit of modern imaging, it is now easy to be clear in life that both ‘wet’ and ‘dry’ forms of pleurisy may develop.

Contributors to the germ theory of disease range from Varro in 36BC, to microscope inventor Van Leeuwenhoek’s reports in the 17^th Century, and Semmelweiss and Pasteur in the 19^th Century. Modern medicine recognizes pleurisy, pleuritic pain and its other symptoms as part of a syndrome. Investigations aim to identify the cause of the pleurisy, which might include viral or bacterial infection, pulmonary embolism, immune-mediated disease, kidney failure and tumours. In addition pneumothorax may present wth pleuritic pain. Of note as early as the early 17^th Century, the Paduan Vincent Baronius recognized that patients with pneumonia can also develop pleurisy [pleuripneumony], a concept more widely disseminated by Morgagni a century later.

Back to Prospero’s curse. If not just author’s invention, here are some possible recurrent disorders symptoms of which Prospero could be predicting.

- Pleurisy is typical worse at night, when during attempts at sleep the sufferer may turn to adopt a posture likely to make pleurisy worse and thus awake in pain and breathless.

- Tuberculosis may not be fatal but may leave a patient with pleurisy.

- Malaria was endemic in Shakespeare’s day, including in Mediterranean islands such as Sicily. Attacks of malaria are known sometimes to present with cramping chest pains – and the anaemia of malaria could have made Caliban breathless, especially if were already anaemic. For example his inherited deformed appearance could have had a physical rather than imaginary basis. Thalassaemia – common in the Eastern Mediterranean setting of ‘The Tempest’ - may cause of chronic severe anaemia and is associated with facial deformity.  

- And familial Mediterranean fever (FMF), a genetic disorder common in the Mediterranean,  is a recurrent painful disorder of membranes, including the pleura. And FMF induced joint disease could contribute to a deformed appearance.

Prospero may thus simply have been reminding Caliban of previous or likely medical afflictions. Clearly the scientific details are modern, however these conditions were endemic at the time and present in the right geographical setting for the play.

More on history of pleurisy, stethoscopes and older treatments:

1. Hippocrates. Index of symptoms and diseases. vi. 33. Loeb edition. Translated by P. Potter. London, 1988. 

2. Shakespeare's doctor son-in-law John Hall describes use of scabious as a herbal remedy for ‘pains and stitches in the side’.

3. Laennec, R. T. H. (1819) De l’Auscultation Médiate ou Traité du Diagnostic des Maladies des Poumons et du Coeur. Paris: Brosson & Chaudé.

4. The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases ... Volume 1 Edited by Sir John Forbes, Alexander Tweedie, John Conolly. Publishers Whitaker et al, Paternoster Row, London 1833.

5. The medical knowledge of Shakespeare by Sir John Charles Buckmill MD, Longman, 1860.

6. TCM. Notes from a physician's notebook.  The Cincinnati Lancet. p75, January 16th, 1886.

7. Wilson, A. (2000) On the history of disease concepts: the case of pleurisy, History of Science, Volume 38 (3), 271 – 319. 
 

© DRJ Singer