The food shortages coupled with his irregular eating habits could hardly have fortified him against any diseases to which isolation, overwork, and climate may have predisposed him. In his third year in England, he embodied the distinction some physicians today make between being well and merely not being sick. He was an illness waiting to happen.
W. C. Wingfield, medical superintendent of one famous English sanatorium, would observe that the disease with which he was most familiar, tuberculosis, was brought on, or aggravated, by faulty modes of life, which he defined as “overwork, overplay, overworry, undernourishment, lack of necessary sunshine and fresh air, or chronic intemperance in any form.”
Except, perhaps, for “overplay,” Ramanujan was guilty of all of them.
6. THE DANISH PHENOMENON
Both during his life and afterward, it was a matter of some mystery just what laid Ramanujan low. But something, in the spring of 1917, did. In May, Hardy wrote the University of Madras with news that Ramanujan was sick—afflicted with, it was thought, some incurable disease.
Was this the time to send him back to India? The idea was broached. But many Indian physicians were on war duty; getting him adequate medical care, it was thought, might be impossible. Then, too, he might never reach Indian soil; the U-boats made ocean travel perilous. The future Dora Russell in August 1917 accompanied her father, a high Admiralty official, to New York. “My father had an able personal assistant,” she wrote, “but in view of the submarine menace he felt that he could not press her to accompany him.” So he asked Dora instead. “We travelled in convoy and were never allowed to be one moment without our lifebelts beside us.” The war had denied Ramanujan access to mathematicians with whom he had been brought to England to work. It had undermined his nutrition, perhaps priming him for disease. Now, sick, it helped keep him in England.
It was an anxious time. He was admitted to a “nursing home”—actually a small private hospital catering to Trinity patients—on Thompson’s Lane, overlooking the Cam across from Magdalene College, and within a stone’s throw of the Neville house. He was very ill. The prognosis was so poor that Hardy asked the master of Trinity for help in getting word to Ramachandra Rao in India by special dispatch. Later, when Ramanujan seemed a little better, he asked Subramanian to contact Ramachandra Rao and allay any fears the earlier report had raised.
By that time, Ramanujan was out of the hospital, perhaps back in Bishop’s Hostel. There is some evidence that Hardy himself nursed him for a while. But whoever did, it couldn’t have been easy. Because Hardy’s letter to Subramanian already bore the stamp of what was to complicate all efforts to restore Ramanujan’s health: “It is very difficult to get him to take proper care of himself,” Hardy wrote. Ramanujan, he was saying, was a terrible patient.
Not that this was anything new. Back about 1910, when Ramanujan got sick while living in Madras, his friend Radhakrishna Iyer put him up for a while. “As a patient,” he recalled later, “Ramanujan was not exemplary; he was obstinate and would not drink hot water and insisted on eating grapes which were sour and bad for him.” Radhakrishna called in a doctor who examined him and, mercifully, ordered that Ramanujan be sent back to his parents in Kumbakonam.
He had not changed in seven years and, all through his care, was a plague on his caregivers. “A difficult patient always inclined to revolt against medical treatment,” is the way two of his Indian biographers would describe him. “Difficult to manage,” is what Hardy had to say. “Whenever he started with a doctor he was full of confidence, faith and hope,” says Béla Bollobás, a Trinity College mathematician who was a friend of Littlewood and who has taken a special interest in Ramanujan’s life. “[But] when he realized the doctor couldn’t help him, he went to the other extreme and he saw that this doctor was no good at all. ‘I fell into his trap, how, how can I get away from him?’ ”
Ramanujan was picky about his food, wouldn’t do what he was told, forever complained about his aches and pains. Self-willed as ever, he had no faith in medicine. “There are very few doctors who would care to have Ramanujan in their nursing homes,” it would be said of him, “and fewer still who would bother with humoring Ramanujan’s palate.”
Ramanujan’s pigheadedness, along with the uncertainty surrounding his diagnosis, led him to see at least eight doctors and enter at least five English hospitals and sanatoriums over the next two years. Probably around October, he became a patient at the Mendip Hills Sanatorium at Hill Grove, near the city of Wells, in Somerset. There he came under the care of Dr. Chowry-Muthu, an Indian doctor who, as it happens, had accompanied Ramanujan on the Nevasa three years before. Dr. Muthu was a tuberculosis specialist.
• • •
The earliest diagnosis of Ramanujan’s ailment was a gastric ulcer, support for which waxed and waned all through his treatment; at one time, exploratory surgery was considered.
One doctor held that Ramanujan’s hydrocele operation back in India had, in fact, been to remove a malignant growth, and that the cancer was now spreading; but since Ramanujan’s condition didn’t deteriorate, most doctors dismissed the idea.
Blood poisoning was another possibility; an idea heard later was that, perhaps overly impressed with their presumed sterility, Ramanujan would eat canned vegetables whose labels gave assurance of their purely vegetarian origin. Bypassing proper pots and pans, the theory went, Ramanujan would cook them right in the cans, over the gas flame in his room, perhaps contracting lead poisoning from the soldered lids.
It was tuberculosis, though, for which Ramanujan was treated at Mendip Hills and for which he would most consistently be treated in the coming years, and tuberculosis—consumption, phthisis, the White Plague—which remains the most likely candidate today.
TB accounted for as many as one in three deaths in European cities during the midnineteenth century and, by the early twentieth, after half a century of decline, still caused one in eight deaths in Britain. In 1882, Robert Koch showed that the disease stemmed from infection by a particular microorganism, the slow-reproducing bacillus Mycobacterium tuberculosis. The bacillus could infiltrate most any bodily tissue, causing lesions, little granulous pockets, in the spine, the eyes, the bones, the kidneys, or the lymph nodes, but most typically in the lungs. Fever, night sweats that left the patient drenched by morning, cough, difficulty breathing, spitting of blood, and weight loss were typical symptoms—but not invariant ones. Diagnosis was always tricky. Often, the disease followed a peculiar course. Sometimes it took an abrupt, violent turn; this was the feared “galloping consumption.” Often it lay low for years, only to recur. Sometimes seemingly advanced cases recovered spontaneously.
To get tuberculosis you must, in the first place, be infected with the tubercle bacillus. But many people, probably most, in India as well as in England, got infected, yet never came down sick; their immune systems successfully warded off the attack. Heredity clearly played a role in who got sick. But so, too, almost certainly, did what today might be called “lifestyle” factors. While consensus on their influence eludes the research community, the evidence gives strong credence to Dr. Wingfield’s impression that “overwork, overplay, overworry, undernourishment [and] lack of necessary sunshine and fresh air” help transform otherwise failed bacterial attacks into successful ones.
For one thing, a formidable body of research now points to close ties between the nervous system and the immune system, and between stress and illness. The spouses of breast cancer victims, aching with worry and despair, come down sick more than controls. Neurotransmitter receptors occupy sites on cells of the immune system, making for a natural communications link between the two systems. Stress—overwork? worry? loneliness?—the evidence powerfully suggests, can weaken the immune system and offer a ripe field for disease. One study found that Filipino sailors serving in the American navy—typically away from home for years at a time, and for much longer than other sailors—were more TB-prone than other sailors. Researchers concluded that “emotional stress associated with separ
ation from family and friends”—simple loneliness—may well have contributed.
Could Ramanujan’s vegetarianism, made harder to nutritionally maintain by chaotic eating habits and food shortages, have set him up for the disease? Here, again, evidence is suggestive, with the Danish phenomenon giving the notion a powerful boost.
In 1908, Dr. H. Timbrell Bulstrode submitted his Report on Sanatoria for Consumption and Certain Other Aspects of the Tuberculosis Question to Parliament. In it, he included a chart showing a comfortingly steady decline in the tuberculosis death rate in England and Wales, from close to 300 deaths for every 100,000 population around 1850 to 120 by 1904. Similar declines were being recorded during this period in Switzerland and Germany, in Denmark and the United States.
Then came the Great War.
With it came a wild spasmodic leap in the death rate. In Prussia, tuberculosis deaths shot up from about 150 per hundred thousand to 250. The same in Belgium, Italy, and the other belligerent countries. England recorded a less dramatic, if equally unambiguous jump, 17 percent between 1913 and 1917—erasing, in two years, twenty years of steady decline.
But why did Denmark also show a precipitous 30 percent rise? Denmark was neutral, untouched by war or civil strife. Moreover, why did the Danish figures resume their downward course beginning in 1917, two years before the other countries?
As it happens, Denmark shipped large quantities of meat and dairy products to England and other belligerents during the first two years of the war. Prices rose dramatically at home, but wages failed to keep pace. Danish per capita consumption plummeted. But with the resumption of unrestricted submarine warfare around 1917, Danish food piled up in Denmark. Consumption on the home front rose—and with it, apparently, TB resistance. “There is ample evidence, accepted by virtually all authorities,” wrote the English physician R. Y. Keers in explaining the war’s impact on tuberculosis deaths, “that the main factor in the production of this increased mortality was malnutrition—a view supported by the figures from Denmark.”
What was the crucial missing nutrient that meat or dairy products supplied? Quite possibly vitamin D—a deficiency of which may have left Ramanujan, among thousands of others, more vulnerable to the tubercle bacillus.
It was not until 1920 that vitamin D’s role in the prevention of rickets, a bone disease, was discovered. Much recent research, however, links it also to the immune system. And in what has been called a piece of “admirable epidemiological detective work,” Welsh physician P. D. O. Davies in 1985 showed how vitamin D deficiency could explain, through its immune system effects, the much higher TB rate among immigrants to Britain from the Indian subcontinent.
Davies noted that the disease was thirty times higher in this group than among native Britons; that studies showed more than a third of them had vitamin D deficiency; that vitamin D clearly played a role in marshaling monocytes and macrophages—key immune system players. “A Possible Link Between Vitamin D Deficiency and Impaired Host Defence to Mycobacterium Tuberculosis,” Davies titled his paper in Tubercle, the British tuberculosis journal. “Can this complex [biochemical] pathway really explain the incidence of tuberculosis in dark-skinned immigrants to the United Kingdom and the cure of skin tuberculosis by vitamin D treatment?” asked another medical researcher, Graham A. W. Rook, in evaluating the logic of Davies’s argument. He concluded: “It probably can.”
Prime sources of vitamin D include egg yolks, organ meats, and fatty fishes. Indeed, cod liver oil was used as early as the eighteenth century to treat tuberculosis. With the possible exception of egg—the evidence here is contradictory—Ramanujan ate none of them.
Another source of vitamin D today is milk specifically fortified with it. But fortified milk wasn’t available in Ramanujan’s day.
There is another prime source of vitamin D, one that explains why Indians back in India, for example, unlike those in Britain, have normal levels of the vitamin: the sun. The sun gives off not just visible light but ultraviolet radiation, and ultraviolet rays activate cholesterol in the skin to make vitamin D.
Ramanujan got little sun. In Cambridge, high up near the Arctic Circle, there wasn’t much to begin with. And the English cloud cover blocked most of the rest. Then, too, Ramanujan didn’t leave his rooms much, often working at night and sleeping by day. Even working by a sunny window would have done no good: ordinary window glass absorbs the ultraviolet rays that make vitamin D.
In the fifth edition of his classic Principles and Practice of Medicine, published in 1902, the great physician William Osler, referring to the sheer capriciousness with which infection by the tubercle bacillus ended in disease, observed:
There are tissue-soils in which the bacilli are, in all probability, killed at once—the seed has fallen by the way-side. There are others in which a lodgment is gained and more or less damage done, but finally the day is with the conservative protecting force—the seed has fallen upon stony ground. There are tissue-soils in which the bacilli grow luxuriantly; caseation and softening, not limitation and sclerosis prevail and the day is with the invader—the seed has fallen upon good ground.
Both the common medical wisdom of his own day and scientific evidence from our own suggest that Ramanujan, during his first three years in England, had become fertile ground indeed for the growth of M. tuberculosis.
• • •
In the years between 1899 and 1913, Mendip Hills Sanatorium claimed hundreds of “cures.” And five other sanatoriums within a twenty-mile radius apparently also found the country just across Bristol Channel and the Severn River from Wales conducive to recovery. Still, geography and cure rate notwithstanding, something didn’t take for Ramanujan at Mendip Hills; he was there but briefly, and soon, in about November, he was transferred to Matlock House Sanatorium in Derbyshire. There, off and on for the best part of a year, he was treated by at least three doctors and ran up bills of at least £240, the equivalent today of perhaps $20,000.
Early in his stay, he wrote Hardy:
I have been here a month and I have not been allowed fire even for a single day. I have been shivering from cold many a time and have not been to take my meals sometimes. In the beginning I was told that I could not possibly have any except the welcome fire I had for an hour or two when I entered this place. After a fortnight of stay they told me that they received a letter from you about one and promised me fire on those days in which I do some serious mathematical work. That day hasn’t come yet and I am left in this dreadfully cold open room.
The Matlock staff wasn’t being flinty eyed or cruel in denying Ramanujan the warmth of a fire; it was just that cold open rooms like the one Ramanujan endured were, during this period, the most accepted treatment for tuberculosis.
Physicians facing TB today take their pick from a variety of drug regimens to suit considerations of cost and possible side effects. In developed countries at least, the disease has been largely wiped out. But it wasn’t until the 1950s that the first effective drug, streptomycin, came along. Until then, tuberculosis remained the great White Plague, resistant to all that medical science could throw at it. Koch, discoverer of the bacillus, had trumpeted a vaccine—which didn’t work. There was surgery, involving the opening, treatment, and draining of tubercle abscesses. There was the artificial pneumothorax vogue, in which the tuberculous lung was collapsed, by injecting it with a gas, and allowed to “rest,” presumably leading to healing; one of Ramanujan’s doctors, the prominent London chest disease specialist Harold Batty Shaw of Brompton Hospital, would a few years later be among those to remark on this treatment’s rise to popularity. Gold salt injection had its proponents. So did patent medicines like “Tuberculozyne,” taken with milk three times a day, and “Crimson Cross Fever and Influenza Powder for the Cure of Consumption.”
But most widely accepted of all during Ramanujan’s time was the open-air treatment pioneered in the late nineteenth century, and calling for bed rest, typically in open lodges exposed to the fresh air, lots of food, and
measured amounts of light exercise.
“Open-air treatment for tuberculosis had preceded the bacteriological revolution in origin and was little influenced by it,” Linda Bryder has observed in Below the Magic Mountain, her study of tuberculosis treatment in England. Tuberculosis was bred in urban slums? The great outdoors were linked to health? Then open air, far out in the countryside, was what the lungs of the hapless consumptive needed. Such, anyway, was the treatment rationale.
Launched in Germany, the open-air strategy heavily influenced British practice, especially in the years around the turn of the century. Indeed, one of the most influential of the early German sanatoriums, at Nordrach, in the Black Forest, lent the weight of its name to one of those near Mendip Hills. It was known as Nordrach-upon-Mendip. There was a Nordrach-on-Dee, too.
It was no longer possible, Bulstrode observed in his 1908 report, to meaningfully distinguish sanatoriums from ordinary hospitals, “seeing that practically all hospitals for consumption have now made some attempt towards carrying out the ‘open air’ treatment.” And by 1913, there were at least fifty-two British sanatoriums embracing it. Mendip Hills was one of them. So was Matlock, though as a more recent convert; it had earlier served as a hydropathic establishment specializing in heat therapy.
By Ramanujan’s time, being left to the mercies of the cold was the treatment of choice. “Wide-open windows and cure on outside balconies were the order, bleak and cold as the night or day might be,” Rene and Jean Dubos wrote in The White Plague. “The art of wrapping oneself in blankets became an essential part of the cure, almost a ritual.” Architects competed to find new ways of bringing fresh, cold air to patients. Some sanatoriums had open-air chapels. More typically, patients lay on beds lined up in long, wide open corridors; Liegehallen, the Germans called them. Sometimes, sanatoriums were wholly unheated. Even children were not exempt; one school for consumptive children in Northumberland recorded a temperature of thirty degrees Fahrenheit in November 1915. At another sanatorium, just after the war, a girl described what amounted to a hut on top of a hill in which her consumptive sister stayed. “There was no door, no glass in the windows; the window and the rain blowed [sic] through.”
The Man Who Knew Infinity Page 34
