The Keats-Shelley house by the Spanish Steps in Rome

Keats spent his last months in Rome, before succumbing in February 1821 at the age of 25 to consumption - tuberculosis. He had earlier nursed his brother Tom until the latter's demise from consumption at the age of 19. Keats had trained as an apothecary and had studied medicine at St Thomas' Hospital: surviving records mention treatment given by a "Mr Keats".

As a remarkable example of individual differences in susceptibility to the disease, the artist

Photo © Donald Singer: Keats-Shelley House and Spanish Steps, Rome

Joseph Severn survived until the age of 85, despite living with Keats for 3 months in Rome and nursing Keats' during this final illness. Severn painted Keats on his deathbed.

Shelley travelled to Rome after Keats' death and wrote the poem Adonaïs: An Elegy on the Death of John Keats. Whether for effect or real belief, Shelley is reported to have attributed the major cause of this final illness to bleeding from ruptured lungs in response to poor critical reception of Keats' poetry. Keats was more sanguine. He was confident in future recognition, writing to his brother George in 1819: "‘I have no doubt of success in a course of years if I persevere ..."

The Vatican authorities were pragmatic,  aware in 1821 of consumption as a potentially transmissable disease. They gave instructions that all contents of Keats' rooms at Piazza di Spagna were to be removed and destroyed by burning - including his boat bed and the wallpaper.  

This was in the tradition of the germ theory of disease, which dated at least from Varro in 36BC, to microscope inventor Van Leeuwenhoek’s reports in the 17^th Century, with firm evidence reported later in the 19th Century by Semmelweiss in Vienna, Koch in Berlin and Pasteur in Paris. 

Robert Koch was the first to describe the causative tubercle bacillus, supported by his formulation of postulates about evidence to confirm disease causation. Koch's investigations and discoveries in relation to tuberculosis lead to his receipt of the 1905 Nobel Prize in Physiology and Medicine. 

Read further historical notes about tuberculosis

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

Tuberculosis, Bel Ami and the Belle Epoque

More on the Keats-Shelley House: 26 Piazza de Spagna in Rome

 
 
 

90 years for the Postgraduate Medical Journal

A Symposium is being organised by the Fellowship of Postgraduate Medicine to mark the 90th Anniversary of its first official journal, the Postgraduate Medical Journal. The Symposium will be held at the Medical Society of London on on 1st October 2015.
Speakers on the day will comment on what medicine was like in the 1920s, current progress in their field, and what is in prospect over the next 90 years.
Other speakers will include FPM Fellow Professor Peter Barnes FRS, London, who will speak on advances in respiratory medicine, Professor Dame Carol Black, Principal of Newnham College, Cambridge and Past-President of the Royal College of Physicians who will discuss opportunities to improve public health through a focus on health in the workplace, Professor Melanie Davies (Leicester) on progress in managing diabetes, vascular surgeon Professor Alison Halliday (Oxford) on carotid surgery to prevent stroke, FPM Fellow chemical biologist Andrew Marsh (Warwick) who will discuss advances in drug discovery, FPM Fellow cardiac surgeon Wade Dimitri (Coventry) who will discuss early development of heart surgery  Dr Paul Nunn (London), former Director of the WHO Tuberculosis Programme, on advances in managing tuberculosis, FPM Fellow Professor Munir Pirmohamed (Liverpool) who will discuss Progress in Personalised Medicine, Emeritus Professor Terence Ryan (Oxford) on Sir William Osler and Professor Karol Sikora (London) on cancer - a disease of our time.

The Postgraduate Medical Journal publishes topical reviews, commentaries and original papers on themes across the medical spectrum. It provides continuing professional development for all doctors, from those in training, to their teachers, and active clinicians, by publishing papers on a wide range of topics relevant to clinical practice.
Papers published in the PMJ describe current practice and new developments in all branches of medicine; describe relevance and impact of translational research on clinical practice; provide background relevant to examinations; and papers on medical education and medical education research.  The FPM is a British non-profit organisation founded in the autumn of 1919 as a merger of the Fellowship of Medicine and the Postgraduate Medical Association, with Sir William Osler as its first president. Its initial aims were the development of educational programmes in all branches of postgraduate medicine. 
The FPM organises clinical and research meetings and publishes two journals. The FPM has since 1925 published the international journal, the Postgraduate Medical Journal. In 2012 the Fellowship launched a new international journal, Health Policy and Technology, published on the Fellowship's behalf by Elsevier.

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.

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