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 th
e 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 disagr
eeable 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.
The Mystery of the Exploding Teeth and Other Curiosities From the History of Medicine Page 25
