Who Killed Ramesses III? Zahi Hawass and Colleagues Shed New Light on the Harem Conspiracy

YESTERDAY’S WORLD

Invention of toilet paper: something else the Romans didn’t do for us, p 41

Who killed Ramesses III? Zahi Hawass and colleagues shed new light on the harem conspiracy

Introduction sination was successful. The Judicial Papyrus The end of Ramesses III’s life has long been recounts four separate trials and lists the pun- debated among Egyptologists. A series of his- ishments meted out to those involved in the con- torical documents, of which the most impor- spiracy. Chief conspirators included a secondary tant is the Judicial Papyrus of Turin,1 2 clearly queen Tiy, and her son Prince Pentawere.1 state that in the year 1155 BC, members of his The ancient documents refer to Ramesses harem made an attempt on his life as part of a III as “the Great God,” and imply that he had palace coup. According to the documents, the died before or during the trials. However, the coup failed, but it is unclear whether the assas- texts also imply that the court received direct instructions from the king, who must therefore Fig 4 | Neck region of unknown man E. 1 have survived the original attack. The only line Arrows=skin folds and wrinkles under right specifically interpreted by Egyptologists as a mandible and neck region possible metaphor for an assassination is the “overturning of the royal bark.”2 Such circum tissue areas in the anterior side of the neck locution regarding the cause of a king’s death (fig 2). The trachea was clearly cut and its proxi- has long been considered to be part of the mal and distal ends were retracted and separated protocol of ancient Egyptian literature. by about 30 mm. A small, focal cortical interrup- Owing to the inconclusive nature of this tion at the anterior surface of vertebral body was textual evidence, and the lack of any obvious visible, at the seventh cervical vertebra (fig 2). cause of death found in previous forensic stud- Accordingly, all organs in this region (such as the ies of the king’s mummy,3 scholars have argued trachea, oesophagus, and large blood vessels) Fig 1 | Axial CT section image of the neck of Ramesses a variety of possibilities: the king was injured as were severed. The extent and depth of the wound III. Stars=wound margins. Arrow=homogeneous part of the plot and later died from his wounds, indicated that it could have caused the immediate embalming material seeping into wound and bone the plot was foiled entirely, or the attempt was death of Ramesses III. successful.4 Moreover, the mummy of Prince A flat, irregular foreign object was lodged in Pentawere has not been definitively identified. the right lower rim of the wound; it was roughly However, scholars have considered the mummy 15 mm in diameter with a high CT density (2200 of unknown man E as a possible candidate, who HU), similar to a semiprecious stone (fig 2). was found, like Ramesses III, in the royal cache Reconstruction of this foreign object showed a at Deir el Bahari. Unknown man E’s contorted wedjet (or Horus eye) amulet (fig 3). The eye of expression, unusual mummification process, Horus is a magical amulet that served as a meta- and goat skin were noted during the unwrapping phor of royal power, protection, and good health of the mummy in 1886.5 There has also been in ancient Egypt.10 much speculation about the cause of his death, We estimated unknown with poison or burial alive mentioned as possi- man E to be about 18-20 bilities, but no conclusive evidence for either.3 years old, based on the To gather more information about the harem incomplete fusion of conspiracy and the fates of Ramesses III and the epiphyseal lines in suspected conspirator involved in his assassina- the long bones, as tion, we analysed the mummies of Ramesses seen in CT scans. III and unknown man E using anthropological, Unknown man forensic, radiological, and genetic methods. E underwent an unusual process Results of mummification The CT investigation revealed a serious wound for the 20th dynasty Fig 2 | Sagittal CT section image of the neck of in the throat of Ramesses III’s mummy, directly of ancient Egypt Ramesses III. Arrow=foreign object. Stars=wound margins; embalming material has seeped into under the larynx (fig 1). The injury was roughly (1186-1070 wound and bone. Triangles=skin above and below 70 mm wide and extended to the bones (fifth BC), the wound to seventh cervical vertebrae), severing all soft

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Our analysis showed that Ramesses III and Table 1 | Genetic kinship analysis unknown man E shared the same paternal line- Y chromosomal data DYS DYS DYS YGATA DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS age and had identical alleles at autosomal mark- Sample 448 438 437 H4 392 635 439 391 393 385a,b 19 458 389II 390 389I 456 ers, strongly suggesting that they were father Ramesses III 20 10 14 13 17 — — 8 8 20 19 — 33 21 13 13 and son. However, based on the genetic testing, Unknown 20 10 14 13 17 — — 8 8 20 19 — 33 21 13 13 any differentiation among the several sons of man E Ramesses III was not possible. Historically, Pen- Controls* tawere was the only son who revolted against his Control 19 12 15 13 13 24 12 11 13 11,14 15 17 29 24 13 15 DNA 007 father in contrast to all his brothers. According Staff 1 19 12 15 12 13 23 12 11 12 11 14 15 29 24 13 16 to the Judicial Papyrus of Turin, Pentawere was Staff 2 19 11 14 11 11 25 12 10 12 13 13 19 27 24 11 14 involved in the harem conspiracy, was found Staff 3 19 12 15 12 13 23 12 11 12 11 14 15 29 24 13 16 guilty at trial, and then took his own life. DYS=DNA Y chromosome short tandem repeats (repeating DNA sequences of 4-5 base pairs). Data are number of repetitions of each The unusual mummification process of short sequence; overall, they represent a Y chromosomal genetic fingerprint that can be used to test the paternal relation of Ramesses III unknown man E, including the ritually impure and unknown man E and moreover predict the Y chromosomal haplogroup. *Data from control DNA (provided with chemicals for DNA analysis; refers to an unknown European sample) and male staff members also use of a goat skin to cover the body, could be supplied for comparison. interpreted as evidence for a punishment in the because there was no evidence of removal of the form of a non-royal burial procedure. Together inner organs or brain.11 The skin has a reddish with the genetically proved family relationship colour and the body was covered by a goat skin. with Ramesses III, we therefore believe that Use of goat or sheep skins in dynastic burials was unknown man E is a good candidate for Pen- rare because these materials were regarded ritu- tawere. Unknown man E’s cause of death has ally impure.12 13 The red coloration of the mum- to remain a matter of speculation. His inflated my’s skin could have been caused by a mixture of thorax and the skinfolds around his neck may natron, crushed resin, and lime, which had been point to violent actions that led to death, such as detected under a layer of bandages during the strangulation. However, the lack of further evi- unwrapping in 1886.5 dence for strangulation (such as fractures in the Unusual compressed skin folds and wrinkles Fig 5 | Axial CT image of the lower thoracic region of laryngeal skeleton)17 and the gas formation in the were seen directly under the right mandible and unknown man E. Thorax is filled with air (stars) and body caused by decomposition processes do not appears to be inflated. Residue in the diaphragm at the right and left neck regions (fig 4). CT scans allow any clear conclusions regarding the cause and organs (arrows) are present at the dorsal site confirmed residue in the brain and inner organs, of death of unknown man E. and the absence of embalming material inside rounding Ramesses III, and finally reveals its Zahi Hawass egyptologist, Supreme Council of body cavities (fig 5). The scans also revealed tragic outcome. Our CT analysis provides evi- Antiquities, Zamalek, Cairo, Egypt Somaia Ismail professor of molecular biology, taphonomical changes in the mummy, as shown dence that conspirators killed Ramesses III by cut- Department of Medical Molecular Genetics, National by gas formation in the abdominal cavity, urinary ting his throat. The large and deep cut wound in Research Center, Cairo, Egypt and Ancient DNA bladder, hip, and lower neck (fig 5). The thorax his neck must have been caused by a sharp knife Laboratory, Egyptian Museum, Cairo, Egypt also seemed to be strongly inflated with air, or other blade. Damage to the throat after death Ashraf Selim professor of radiology Sahar N Saleem professor of radiology, Department together with widened intercostal spaces and a appears to be unlikely, because the collar around of Radiology, Kasr Al Ainy Faculty of Medicine, Cairo lateral shifting of the scapulae (fig 6, bmj.com). the mummy’s neck was intact and undamaged University, Cairo, Egypt This effect could be due to postmortem processes at the unwrapping in 1886, where a thick layer Dina Fathalla molecular biologist, Ancient DNA of degradation in the mummy, but other reasons of bitumen was removed with a hammer from the Laboratory, Egyptian Museum, Cairo, Egypt 15 Sally Wasef molecular biologist, Learning Resource for the thorax widening should be considered. mummy. It is a possibility that the throat was cut Center, Kasr Al Ainy Faculty of Medicine, Cairo University, In modern cases, diseases such as emphysema during the mummification process. Embalmers Egypt or death by suffocation can lead to overinflation often restored damages during mummification, Ahmed Z Gad molecular biologist of the lungs.14 by inserting wooden sticks or replacing missing Rama Saad molecular biologist 16 Suzan Fares molecular biologist, Ancient DNA Genetic kinship analyses revealed identical body parts; however, a treatment in which the Laboratory, Egyptian Museum, Cairo, Egypt haplotypes in both mummies (table 1); using throat was cut by the embalmers has not been Hany Amer assistant professor of pharmacology, the Whit Athey’s haplogroup predictor, we described in any other Egyptian mummy. Department of Animal Reproduction, National Research Center, Egypt determined the Y chromosomal haplogroup Further evidence of an assassination comes Paul Gostner radiologist, Department of E1b1a. The testing of polymorphic autosomal from the presence of a Horus eye amulet in Radiodiagnostics, Central Hospital Bolzano, Bolzano, Italy microsatellite loci provided similar results in at the wound. The presence of the amulet deep Yehia Z Gad professor of molecular genetics, least one allele of each marker (table 2, bmj.com). in the soft tissue of the wound together with Department of Medical Molecular Genetics, National Research Center, Cairo, Egypt Although the mummy of Ramesses III’s wife Tiy the homogeneous material that penetrated the Carsten M Pusch molecular biologist, Institute of was not available for testing, the identical Y chro- wound up to the bone substantiate the supposi- Human Genetics, Division of Molecular Genetics, mosomal DNA and autosomal half allele sharing tion that the wound was already present at the University of Tübingen, Tübingen, Germany of the two male mummies strongly suggest a time of embalming. Most probably, the ancient Albert R Zink paleopathologist, Institute for Mummies father-son relationship. Egyptian embalmers tried to restore the wound and the Iceman, European Academy, 39100 Bolzano, Italy [email protected] during mummification by inserting the amulet We thank the Supreme Council of Antiquities of Egypt for Discussion (generally used for healing purposes) and by their generous support of this study. For more details of contributors, funds, competing interests, This study gives clues to the authenticity of the covering the neck with a collar of thick linen and references, see bmj.com. historically described harem conspiracy sur- layers (fig 7, bmj.com). Cite this as: BMJ 2012;345:e8268

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Toilet hygiene in the classical era Philippe Charlier and colleagues describe what the Greeks and Romans used instead of toilet paper

The first mention of toilet paper It therefore seems likely found during in the Western world comes from that Trygaeus is referring the American the 16th century, with a short to the Greek proverb: excavation description by the French novelist “Three stones are enough on the Athens (and physician) François Rabelais agora, for arguing its ineffectiveness.1 China, to wipe one’s arse” example, however, had toilet paper in the “Arms dealer (displaying a are described 2nd century BC,2 and the Japanese cuirass): And what, alack, shall as 3-10.5 cm in used chuugi (20-25 cm wooden I do with this rounded cuirass, a diameter and 0.6-2.2 sticks) during the Nara period beautiful fit, worth ten minas? cm thick and having been (8th century AD) for both external Trygaeus: Well, that one will not re-cut from old broken ceramics and internal cleaning of the anal make a loss for you, anyway. Give to give smooth angles that would 4 canal. Other cultures do not use me that at cost price. It will be very minimise anal trauma. Use of a by Horace in his 8th epode (1st toilet paper, partly because paper convenient to crap in . . . pessos can still be seen on a Greek century BC)—“an ass at the centre is often not easily available. Anal Arms dealer: Stop this impudent kylix (wine cup) conserved in the of dry and old buttocks mimicking cleaning can be carried out in mockery of my goods! Museum of Fine Arts in Boston that of a defecating cow”— refers various ways according to local Trygaeus (placing the cuirass (above). The cup, dating from 6th to complications arising from 8 customs and climate, including on the ground like a chamber pot, century BC, was found in Orvieto, such anal irritation. with water (using a bidet, for and squatting on it): Like this, if Italy, and shows a man, semi- Philippe Charlier assistant professor in example), leaves, grass, stones, you put three stones beside it. Is it squatting with his clothing raised. forensic medicine and anthropologist, corn cobs, animal furs, sticks, not clever?”5 The man is maintaining his balance Department of Forensic Medicine and Pathology, University Hospital, 104 R snow, seashells, and, lastly, hands. with a cane in his right hand and is This conversation is clearly Poincaré Boulevard, F-92380 Garches, During the Greco-Roman period, scatological (as often in clearly wiping his buttocks using a France and Laboratory of Medical Ethics, a sponge fixed to a stick (tersorium) Aristophanes), and the lines pessos with his left hand. Faculty of Medicine, Paris, France was used to clean the buttocks before and after this quote refer to Some scholars suggest that [email protected] after defecation; the sponge was wiping the buttocks. It therefore ostraka, small pieces of broken Luc Brun pathologist , Department of then replaced in a bucket filled seems likely that Trygaeus is ceramic inscribed with names Pathology, University Hospital, Parakou, with salt water or vinegar water.3 that the Greeks used to vote to Benin referring to the Greek proverb: Clarisse Prêtre researcher, HALMA-IPEL, Another technique was to use oval “Three stones are enough to wipe ostracise their enemies, could also Lille 3 University, Villeneuve d’Ascq, France THEAMBROSIOS PAINTER(KYLIX), MUSEUM FINEOFARTS, BOSTON(GIFT EDWARDOFPERRY WARREN) or circular fragments of ceramic one’s arse,” although some have have been used as pessoi, literally Isabelle Huynh-Charlier radiologist, known as “pessoi” (meaning suggested the stones were for putting faecal matter on the name Department of Radiology, University pebbles),4 a term also used to balancing the cuirass. of hated individuals. (Examples of Hospital Pitié-Salpêtrière, Paris, France denote an ancient board game. Many pessoi have been found ostraka with the names of Socrates, Competing interests: None declared Aristophanes referred to the use within the faecal filling of Greek Themisthocles, and Pericles have Contributors: PC initially conceived, headed the research, and wrote the majority of the of pessoi for sanitary purposes in and Roman latrines all around the been found in Athens and Piraeus). manuscript with critical input from LB, CP, Peace (5th century BC): Mediterranean world (fig 1).6 Pessoi The two pessoi in figure 1 and IHC. All authors had full access to all of belong to a private collection. the data and are guarantors. Their precise archaeological origin Provenance and peer review: Not commissioned; externally peer reviewed. (discovered in the filling of latrines 1 Rabelais F. Gargantua et Pantagruel, 1, 13. close to deposits of excrement) 2 Needham J. Science and civilization in China. and their morphology (rounded Vol 5. Chemistry and chemical technology. Part 1: paper and printing. Caves Books, form with the edges recut) clearly 1986:122. indicate their use for anal cleaning. 3 Seneca. Letters to Lucilius, 70, 20. Solidified and partially mineralised 4 Papadopoulos JK. A contextual approach to pessoi (gaming pieces, counters or convenient excrement can still be seen on the wipes?). Hesperia 2002;71:423-7. non-cleaned and lateral surfaces, 5 Aristophanes. Peace [Translation by A which has been confirmed by Sommerstein]. In: The birds and other plays. Penguin Classics, 1998. microscopy (fig 2, bmj.com). 6 Charlier P. Le péril fécal dans l’Antiquité : The abrasive characteristics of autopsie d’une latrine romaine de Délos. Feuillets de Biologie 2011;52(299):61-5. ceramic suggest that long term 7 Colozier E. Quelques monuments inédits use of pessoi could have resulted d’Utique. Mélanges d’Archéologie et d’Histoire Fig 1 | Examples of terracotta pessoi (probably from amphora) found in Roman in local irritation, skin or mucosal 1952;64(64):67-86. latrines dating from the 2nd century AD. The one on the left comes from Utica 8 Janicke DM, Pundt MR. Anorectal (Sicily), has a diameter of 4.7 cm and a thickness of 1.7 cm, and has been re-cut damage, or complications of disorders. Emerg Med Clin North Am as an octagon.7 The pessos on the right was found in Gortyn (Crete) and has a external haemorrhoids. Maybe 1996;14(4):757-88. diameter of 6 cm and a thickness of 1.3 cm this crude and satiric description Cite this as: BMJ 2012;345:e8287

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John Collins Warren (1778-1856): An American surgeon in London David K C Cooper finds that the writings of American surgeon John Collins Warren provide an insight into medical practice in early 19th century London

ohn Collins Warren was born in merely see what is done [that is, act as mere Boston, Massachusetts, in 1778, observers]. Of course, the former have vastly into a family noted for its many the greatest opportunities: but the expense is eminent medical practitioners (web likewise double; as the walker pays £25, the appendix).1 These included Warren’s dresser £50. Though I do not like to pay so J uncle, a doctor killed in the early much money for one object, I believe I shall stages of the War of American Independence, enter as a dresser; for, as I intend to become and father, one of the founders of Harvard a surgeon, I think the acquiring [of] a facility Medical School. Although professionally and steadiness in manual operation of the PRIVATE COLLECTIONPRIVATE successful and respected (box), Warren was utmost importance.”2 John Collins Warren as a young man a reserved and disciplined man, and few in He was clearly a serious student: “It will Boston had much affection for him. be necessary . . . to give up every idea of John Collins Warren’s medical career Warren began to study medicine under amusement and company; for a student who 1778: Born 1 August 1778, in Boston, his father. In 1799, with no hospital or is tolerably disposed to be industrious will find 2 Massachusetts official medical school in Boston at that every moment of his time fully occupied.” 1797: Graduated from Harvard College time, Warren chose to continue his studies Indeed, dining out at the weekend and an in Europe, beginning in London. In the US, occasional visit to a London theatre were the 1799-1802: Continued medical studies in surgery remained fairly basic, but because of only breaks Warren allowed himself. London, Edinburgh, and Paris the recent studies of John Hunter, surgery in Warren was appointed as dresser to William 1802: Entered surgical practice in Boston London was becoming an established branch Cooper (circa 1724-1800), who Warren 1806: Adjunct professor in anatomy and surgery of scientific medicine. described as one of the best of men and most at Harvard College eminent surgeons in London. Warren was 1810: Lobbied for Harvard Medical School to Impressions of London “immediately put in charge of about forty move from the “college town” of Cambridge Of London, Warren wrote to his father: “You patients, comprising as interesting a collection over the river to Boston, which had a much have no idea sir, what a shocking place this of surgical accidents and diseases as could larger population of potential patients is in winter. No cold weather, for the grass is be desired. A large number of these patients 1815: Promoted to full professor, on the death perfectly green; but a constant drizzling, that required daily dressing, which I practiced for of his father. Also gave lectures on physiology keeps the town dirty as a kennel . . . The air is a year faithfully. During my week [on call], and midwifery thickened with smoke and vapors, so that it I slept in the hospital . . . I am pitched into a 1816-19: First dean of Harvard Medical School is scarcely respirable; and as for the sun, no surgeon. Obliged to do things of which I never 1812: A founder (and an editor) of the New one can tell you when he was seen. The days saw a case, nor had an idea of, and I think I do England Medical Journal are five hours long; or, more strictly speaking, very well.”2 1819: Honorary medical degree bestowed on there are five hours of twilight: On his living conditions, Warren wrote: “My him by Harvard University, his only medical . . . I have, within this week, been obliged to residence, while at Guy’s Hospital, was in St. qualification stop almost every day, at some part of it, so Thomas Street, close to the hospital. I lived at 2 1821: A founder of the Massachusetts General totally dark was it.” There were, however, a cork-cutter’s, and had two small rooms on Hospital, serving as its first surgeon “plenty of amusements here: in truth, there is the third story . . . I lived in the usual manner 1837: Second visit to London amusement at every step through the streets of of medical students; that is, entirely by myself. London. I constantly meet something new and Food being provided by the landlady, I took it 1845: On 20 January, performed operation interesting in this wonderful place.”2 in my room. We breakfasted at nine, dined at under unsuccessful nitrous oxide anaesthesia 2 (administered by Horace Wells) three, and drank tea irregularly.” (Presumably, Surgical training in London he returned to work after dining.) 1846: On 16 October, performed the first Warren spent his most important formative William Cooper left patients largely in the operation under successful ether anaesthesia period in surgery at Guy’s Hospital, of which care of his assistants, which suited Warren, (administered by William Morton) he considered himself an alumnus. Warren who was keen to gain as much experience as 1847: Presented his collection of anatomical wrote: “There are two kinds of students in the possible. Twice a week, Cooper “walked round and pathological specimens to Harvard hospitals . . . the one called ‘dressers’, and the with his dresser in a very quiet way, making University, forming the basis of the Warren other ‘walkers’. The first have the advantage amusing and instructive remarks. He had no Anatomical Museum of practicing on all the simple surgical cases, great respect for America, considering her 1851: Third visit to London and dressing all wounds themselves [that is, as having separated from the British Empire 1856: Died 4 May, in Boston, Massachusetts receive a hands-on experience]: the others before maturity . . . He was a very pleasant

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man, however, and occasionally asked me to One evening, Warren dined with a group of dine with him.”2 physicians whose conversation related to the Within a few months, William Cooper standing of the medical profession in the UK, retired and was succeeded by his nephew, which was considered not as high as law. “Mr. Astley Cooper (1768-1841), who Warren Key [probably Charles Aston Key (1793-1849) described as “one of the handsomest men of Guy’s Hospital4] complained of their being I ever saw . . . a young man of the greatest unable to attain the highest honors. Lawyers natural abilities, and almost adored at the have precedence.”1 hospitals. The obligations I am under to Mr. Cooper are infinite. He has always treated Warren and anaesthesia me with the most particular attention, and In his later career in Boston, Warren suffered no opportunity of instructing me to participated as surgeon in two pioneering pass by. I wish it were possible to return, in the efforts of anaesthesia at Massachusetts smallest degree, the favors with which he has General Hospital, both initiated by dentists loaded me.”2 (box).5 The first effort, using nitrous oxide, Warren wrote to his father: “There are was unsuccessful. But on 16 October 1846, operations almost every day . . . the stone, Warren performed an operation for a neck hydrocele, cataract, and amputations tumour under successful ether anaesthesia. NIH/NLM innumerable; but Mr. Cline’s operations (at St. Warren became an enthusiastic advocate of Warren, circa 1850 Thomas’s) for aneurism and hernia are grand. this major innovation. It is a pleasure to see him take up or turn his “It was very interesting to me to go knife. The lectures have gratified me very over the ground I trod more than London, 1851 much; they have such immense advantages fifty years ago, and to compare the In September, Warren revisited Guy’s Hospital from these (anatomical) preparations. Not a feelings of the period with those of with a student. They examined the museum, part but is elegantly prepared; some injected the present” dissecting room, library (which he noted to with quicksilver, some with wax, dried contain some of his books, but none of those and wet. Every morbid appearance is here London, 1837 on ether), and the room where he used to preserved . . . You well know how much clearer Arriving in Liverpool, accompanied by his sleep. They also found, in what was described an idea is conveyed by these specimens than wife and a daughter, Warren soon moved on as the “accident ward,” the sister or nurse— can be done by a dead, flaccid body. If I had to London. “As we came within the ten miles, the only surviving person who was at the time, I should make many [specimens] myself; and witnessed the bustling of carriages, hospital when he was a dresser. but I despair of doing a quarter of what I the continuous line of houses, and saw the Describing the experience in his diary, wish, here. Dissection is carried on in style: black smoke rising at a distance—although I Warren also wrote: “Finally, I visited what twelve or fifteen bodies in a room; the young had been formerly a resident, I was in some I never did when there—the chapel of the men at work on them in different ways . . . measure oppressed by the idea of entering hospital, and the splendid monument of Guy, The people called resurrection-men [that is, this world with my family.”2 who founded it . . . It was very interesting to body snatchers] supply us abundantly . . . The One of the first things Warren did was call me to go over the ground I trod more than fifty surgeons here, considering themselves at the on Astley Cooper, now knighted, who had years ago, and to compare the feelings of the head of their profession, dare to differ from written: “My old friend Dr. Warren carries in period with those of the present; but, though everybody else, if they think they have truth his excellent head all the knowledge of the no doubt the balance would be in favor of with them.”2 Old and New World. I shall be delighted to the first, it was very fascinating, from the In late 1800, after more than a year at Guy’s see him.”2 Warren presented Cooper with a uncertainty of success, and the predominant Hospital, Warren left London for Edinburgh copy of his book on tumours. Warren noted feeling that my life would be short.”2 and, six months later, continued his studies in that, at this late stage of Cooper’s career, John Collins Warren—a “Guy’s man”—died Paris. He returned to Boston in 1802, where “having acquired an ample fortune, he has in Boston, aged 77. he joined his father in practice. no occasion to submit to the laborious and David K C Cooper professor of surgery, University of responsible duties of the profession; but Pittsburgh, Thomas E Starzl Transplantation Institute, Surgical practice in Boston he is ready at stated hours to give advice to Pittsburgh, PA 15261, USA [email protected] In 1837, Warren published Surgical those who apply, both at his own house and Competing interests: None declared. Observations on Tumors, an illustrated volume in the town. He rises early, and employs two Provenance and peer review: Not commissioned; not of over 600 pages. The British and Foreign or three hours in anatomical and surgical externally peer reviewed. Medical Review remarked in the book’s review investigations before breakfast; afterwards 1 Truax R. The Doctors Warren of Boston. Houghton Mifflin, 1968. that “the author proves himself to be a worthy he receives patients at his house till two; then 2 Warren E, ed. The life of John Collins Warren, MD, compiled chiefly from his autobiography and journals. Volumes 1 and 2. disciple of the school in which he received his visits till six or seven—the common hour of Ticknor and Fields, 1860. early instruction [Guy’s Hospital]; and which, dinner . . . He does not regularly attend any 3 Anonymous. Memoir of John Collins Warren, MD. New England Historical and Genealogical Register, 1865:XIX,1-12. connected as it is with the names and celebrity hospital; though, as consulting surgeon of 4 Wilks S, Bettany GT. A biographical history of Guy’s Hospital. of Cooper, Bright, and others of hardly less Guy’s he is ready to visit when he can be Ward, Lock, Bowden, 1892. 5 Fenster JM. Ether day—the strange tale of America’s greatest eminence, he seems proud to acknowledge as useful; and his attendance is hailed with medical discovery and the haunted men who made it. Harper his alma mater. And surely that school need be pleasure by the surgeons, as a gratifying Collins, 2001. 3 2 no less proud to claim him as a pupil.” occurrence.” Cite this as: BMJ 2012;345:e8251

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Placebos in 19th century medicine Jacqueline E Raicek and colleagues mine the BMJ’s online archive to chart the diverse uses of the placebo effect

Objective To provide the first quantitative data on war with the development and adoption of the on our hypochondriacal and fanciful patients.”7 the use of the term “placebo” in the 19th century. randomised controlled trial.3 4 It is thought that The idea of an ineffective placebo was also Design Computer search of BMJ’s archival in earlier periods placebos were deceptively and emphasised in pejorative descriptions of unor- database from January 1840 (the first issue) routinely used in clinical practice and considered thodox practitioners. “It is not an uncommon through December 1899 for uses of the words an innocuous “pious fraud” to placate “igno- occurrence for a sick person to go to the near- “placebo(s).” Grounded theory was used to rant . . . disappointed . . . and incurable cases.”5 est apothecary, and get one of the assistants to categorise the implications of uses of the term. Patients reporting improvements from placebo prescribe some placebo for the more trivial com- Results 71 citations contained the term were experiencing “imaginary” symptoms.3 This plaints.”8 Homeopathic medicine gives “globules “placebo(s).” Of these, 22 (31%) used the term understanding of placebo history is based on as placebos.”9 We decided to combine “no effect” to mean “no effect” or as a general pejorative non-systematic archival evidence and qualitative and “pejorative” because it was often difficult to term, 18 (25%) portrayed placebo treatment as descriptions. We sought to provide quantitative decide whether any distinction we might perceive permitting the unfolding of the natural history (the historical data on placebo use in the 19th century. was the intent of the authors. normal waxing and waning of illness), 14 (20%) Natural history—In this category placebo described placebo as important to satisfy patients, Methods treatment was equated with the opportunity for 7 (10%) described it as fulfilling a physician’s We included all BMJ articles, reports, and let- allowing patients to use their own ability to get performance role, 3 (4%) described its use to buy ters between the dates of January 1840, the first well, often within the context of getting good time, 3 (4%) described its use for financial gain, year of the journal’s publication, and December sleep, eating a healthy diet, and proper care. For 2 (3%) used it in a manner similar to a placebo 1899. We chose the BMJ for the availability of example, physicians wrote that giving placebos control, and only one implied that placebo could its online historical database, its prominence, provided an opportunity “to place the patient have a clinical effect. Only one citation mentioned and the likelihood that it represented the medi- in circumstances as favorable as possible to the telling the patient about his placebo treatment. cal profession’s practices and attitudes. We sanative operations of nature.”10 Another physi- Conclusion Nineteenth century physicians had searched the BMJ database with the terms “pla- cian reports on a visit to Persia, where a tradi- diverse a priori assumptions about placebos. cebo” “placebos” and “placebo effect.” We used tional healer, or hakim, “leaves his patient very These findings remind us that contemporary methods from grounded theory to categorise much to nature, prescribing merely placebos.”11 medicine needs to use rigorous science to citations according to theme.6 (See supplemen- Satisfy patient—We put an article into this cat- separate fact from its own beliefs concerning the tary material on bmj.com for list of of full meth- egory when there was some indication that the “provision of care.” As in previous generations, ods, all citations found, and types of article) desire for a treatment came from the patient. For ethical issues concerning placebos continue to example, a fever was treated with “a saline mix- challenge medicine. Results ture, with nitric aether, (more as a placebo than We found 71 citations for “placebo.” All queries because he really seemed in want of medicine).”12 Introduction for “placebos” yielded the same 71 articles, and A bandage was applied to a man’s arm “as a pla- Currently, placebos are integral to the methodol- we found no articles that mentioned “placebo cebo to satisfy the patient.”13 Included in this cat- ogy of scientific research. Additionally, placebo effect.” Forty seven of the citations (66%) were egory are cases where the physician dispenses a treatments are generally thought to affect health in specific sections of theBMJ (such as “Corre- placebo to calm the patient. A physician described outcomes, especially those based on subjec- spondence” (10%), “Original communications” other physicians treating patients with diarrhoea tive self appraisal.1 Furthermore, administering (10%), and “Reports of societies” (4%), with the from the “fear only” of cholera, “who upon dis- placebos deceptively, outside of the concealed remaining 42% distributed among 23 other cat- covering this, gave mere placebos to their patients, context of clinical trials with informed consent, egories). Twenty four of the citations (34%) were who flocked to them in shoals during the panic.”14 is considered unethical.2 Historians have noted in non-specified sections. Performance—In these citations physicians that such contemporary notions of placebo Using grounded theory, we distinguished nine described their use of placebo as fulfilling the gained acceptance only after the second world categories for the use of “placebo” in the 71 arti- requirements of their professional role. There cles (although there were 75 individual mentions was no contextual implication of patient request; Primary categories of use of the term “placebo” in of “placebo” in all): no effect or pejorative (31%), the behaviour seemed self generated. When “the 71 citations in BMJ 1840–99 natural history (25%), satisfy patient (20%), patient suffered from disease in which the organs Category No (%) of citations medical performance (10%), buy time (4%), were so profoundly altered that it was little use No effect or pejorative 22 (31%) financial gain (4%), placebo control (3%), has attempting to prescribe anything more than a Natural history 18 (25%) clinical effect (1%), and unclear (1%) (see table). series of placebos.”15 Another physician reports Satisfy patient 14 (20%) These categories are further explained and con- “while examining her she passed a watery evacu- Performance 7 (10%) nected with illustrative examples below. ation involuntarily on her bed. I had to do some- Buy time 3 (4%) No effect or pejorative—The commonest use of thing, so I resorted to the blister over the vagus, Financial gain 3 (4%) “placebo” was in a derogatory manner to denote and left a lavender water placebo to be given.”16 Placebo control 2 (3%) therapy that was ineffective or harmless or valu- Buy time—Three citations described situa- Has an effect 1 (1%) able only for imaginary therapies. A typical com- tions where placebo was given to patients for Unclear 1 (1%) ment was placebos are an “innocent deception extended periods of time or to extend the time

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Discussion Limitations Our sample is limited to a single journal, the BMJ. We selected it because it is one of the old- est continuous medical journals in the world with an electronically searchable database, and because of its affiliation with the British Medical Association (BMA). We could have expanded our numbers by using the databases of other journals, but we decided that limiting our search to a single journal would provide a valuable proof of principle that quantitative methods could illuminate the history of placebos. Verification in other electronically acces- sible journals is warranted.

Conclusions A priori beliefs concerning dummy treatments have been rampant throughout history. In the 19th century, physicians considered placebos to have no impact on clinical outcomes. The idea of what Stuart Wolf first called, in 1950, “the placebo effect” did not exist.26 27 Recently, there has been interest in the effects of placebo treatment and the ritual that surrounds all active or inactive medical interventions. Given the recent interest in placebo studies,1 there is hope that rigorous scientific research will correct our own contemporary a priori beliefs concerning placebos and the “provision of care.” Discovering

“PORTRAITWASHINGTONDROF EPPS, DOCTOR”LAWRENCE MYBY ALMA-TADEMA, BAL/GETTY IMAGES exactly what effect the ritual of medicine has is Buying time important for a full understanding of clinical practice and healthcare policy. An expanded for the physician to make a diagnosis. One phy- equally good results.”21 Another experiment, per- understanding of the underlying neuroscience sician describes how he used a placebo for three formed in 1889, tested whether mercuric iodide of placebo effects should also help to make years while he experimented to make lax tym- had value for scarlet fever. The physician “treated vague beliefs more precise.28 Furthermore the panic membranes tense.17 In order to determine three series of eight cases each simultaneously, absence of an ethical discussion on placebo use a patient’s “type of appendicitis,” another doctor with iron, mercuric chloride, and a placebo, and, in the 19th century and our own hidden use of advocated “a carminative placebo” and making on the whole, the latter series did best.”22 placebos in clinical practice29 should remind us a second visit four hours later.18 Has an effect or unclear—Only one citation that an ethical examination of placebo remains Financial gain—Three articles clearly sug- was categorised as having an effect on clinical a critical challenge for medicine. gested that placebos concerned financial incen- outcomes. It was mentioned that in cases of sleep Jacqueline E Raicek researcher, Program in Placebo tives. One physician described how “some anxiety, “a placebo administered with the assur- Studies and Therapeutic Encounter, Beth Israel Deaconess medical men” with “starving families” would ance that it is a powerful hypnotic” was “often Medical Center, Harvard Medical School, Boston, MA 19 23 02215, USA and University of New England College of “give globules as placebos.” While the author successful.” The implication of placebo in one Osteopathic Medicine, Biddeford, ME 04005, USA 24 expressed compassion for his peers, he stressed citation could not be ascertained. Bradley H Stone researcher drawing a “broad line between medicine and Ted J Kaptchuk director, Program in Placebo Studies and homeopathy” and reminded his peers to not bar- Ethical considerations Therapeutic Encounter, Beth Israel Deaconess Medical ter “principle for pelf [wealth].” Another article Ethical issues (such as administering ineffective Center, Harvard Medical School, Boston, MA 02215, USA described the opportunity of some physicians to medicine, quackery, earning extra money) were We thank Iain Chalmers for advice. “swell up the bill” and prescribe an “aqua col. or an overlapping underlying theme in many of the Contributors: TJK and JER designed the study, analysed the 20 data, and prepared the manuscript. BHS analysed the data placebo prescription.” articles. Our impression is that placebos were and contributed to the manuscript. TJK is the guarantor. Placebo control—Two articles used placebo as largely administered deceptively, and patients Funding: The paper is supported in part from NIH NCCAM a research tool, probably to ensure blind assess- were never told of the “pious fraud.” Only one grants K24 AT004095, R01 AT004662, R01AT005280, R01 AT006364, and P01 AT006663. ment. Both took place in the late 19th century case reported disclosure. A placebo disguised as Competing interests: None declared. when orthodox medicine began to have interest morphine was given to a patient with morphine References are in the version on bmj.com. 4 in blind assessment. In one experiment, con- addiction. Three months later, during the follow- Accepted: 27 November 2012 cerning amblyopia (n=20), performed in 1886, up visit, the physician reported having “a good Correspondence to: T J Kaptchuk a physician gave “half the cases strychnine” and laugh [with the patient] over the pious fraud of [email protected] 25 “in the other half a placebo, with apparently the water hypodermic injection.” Cite this as: BMJ 2012;345:e8326

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Surgical thimbles William H Isbister discusses the usefulness of the humble thimble and its derivatives in a variety of surgical situations 1

As a child, Christmas meant good pushing a finger through the valve to food, especially nuts and chocolate, break down the adhesions or by sharp lots of presents, and party games. We dissection, although this may result in often played “hunt the thimble,” and valvular insufficiency postoperatively. sometimes the thimble was hidden Glenn described how a thimble, worn behind my father’s pile of brown paper on the first finger of the operator’s wrapped, unopened BMJs. hand, can facilitate and standardise By 1975 I was married with three this process. To prevent the thimble children. Our Christmases still involved becoming stuck in or below the valve, 5 fine food and presents but my wife tapes were looped around the thimble had become a thimble collector and under the surgeon’s glove (fig 1). If it instead of hunting the thimble I was was difficult to extract the thimble or the ends of the fingernails and Fig 1 | System used to dilate the “gifting the thimble.” Over the next finger, an assistant pulled on the tapes. underneath the vein. The finger was heart valves during open heart surgery2 years, as I travelled to meetings and In his first series, Glenn reported 250 protected from the pin by a thimble. Fig 2 | Finger protector conferences, I had the opportunity patients in whom this system had been A ligature was wound around the pin Fig 3 | Metal thimbles for the left to seek thimbles out from all over the used with good results. and drawn tight. This process was forefinger and thumb to facilitate world, and over time I too became repeated for every dilated vein, so making cotton wool mops3 Ear, nose, and throat surgery interested in them. I have devoted my from eight to 15 pins may have been Fig 4 | Millard surgical hook retractor retirement to the hobby of thimble Finger protectors (fig 2) can prevent needed between the ankle and the Fig 5 | Different types of retractor collecting and thought that, as a accidental biting injury during intraoral knee. The ligatures and pins were not based on the tailor’s type open surgeon, close to Christmas, it might procedures. They might also have removed until the vein had become thimble be interesting to review the use of the been used by staff trying to secure an necrotic (around 12 days). If the Fig 6 | Device for introducing a pelvic humble thimble in surgical practice. oral airway during a fit in patients with eschar had not detached by this time drain5 6 epilepsy. it was removed. Velpeau claimed Fig 7 | Thimble for protecting against Searching for thimbles In 1906, Cresswell Baber developed to have used this method in private finger injury I searched the BMJ archive for the word metal thimbles for the left forefinger and public practice and that only one Fig 8 | Thimble and wire saw for use “thimble” and searched on Google and thumb to facilitate making cotton patient died after the procedure. in obstructed labour with a dead for “surgical thimble.” I excluded wool mops for use in ear, nose, and In 1921 De C Wheeler, vice fetus thimbles mentioned as foreign bodies throat surgery (fig 3).3 The thimbles president of the Royal College of and it is troublesome to separate one in the oesophagus or trachea and were flattened and had several Surgeons, Ireland, reported that a from the other.” Surgeons must avoid non-surgical uses of thimbles. Of 113 shallow and one deeper groove on thimble was “of great assistance cutting too boldly on an unguarded finger articles identified in the BMJ archive, 11 the opposing surfaces, where the in making a suprapubic opening in the presence of septic peritonitis. detailed the use of surgical thimbles or metal was dull rather than polished. for drainage in cases of septic A similar technique has been thimble shaped instruments. According to Baber, “with a little peritonitis.”5 He said that “Before used for draining axillary abscesses practice mops of any size can be rapidly the primary wound is closed, the after mastectomy. In 1938 the same The many uses of thimbles made.” The thimbles fitted on to a metal finger guarded with the thimble is technique was described using an Although surgeons used thimbles for stand and could be boiled before use to introduced into the abdomen and ordinary sewing thimble.7 sewing in the past,1 with the advent reduce the risk of infection. The handles seeks the interval between the recti Surgeons operating in deep cavities of needle holders this is no longer the were for lifting them off the stand. muscles just above the pubes. With sometimes use the index finger of the case. Thimbles or thimble derivatives, The Millard surgical hook retractor is the thimble as a guide a stab wound is non-dominant hand to guide the tip of a however, are used in other surgical used in fine work such as rhinoplasty. rapidly made, dividing all the tissues needle into the correct position. During situations. The thimble may be worn on the thumb down to the peritoneum. The latter is this process the guiding finger may be (fig 4) or other finger. Small hooks have pushed forward and is opened by a injured. Accidental finger stick injuries Cardiac surgery been attached to a tailor’s type open nick of a sharp pointed knife between can occur during normal suturing, as can In the 1950s, a cardiac surgeon, thimble (fig 5) to create a retractor; the bars carrying the round knob. A scalpel cuts during dissection. Because William Glenn,2 described the use of several versions are available. drainage tube (Keith’s glass tube for of the risk of HIV infection and hepatitis, a tailor’s thimble to dilate or split the preference) is fitted to the top of the surgeons usually wear two pairs of gloves mitral valve during open heart surgery. General surgery thimble and is guided with great ease and some also wear a thimble on the In patients with severe mitral valve In 1842 Velpeau lectured on his to the bottom of Douglas’s pouch [fig index finger under the glove. A more stenosis needing surgery, the cusps of method of ligating varicose veins.4 6].” He adds: “If the unguarded finger complex type of thimble, which is worn the valve are sometimes tightly stuck The trunk of the vein was raised with is used as a guide, the peritoneum outside of the glove and held in place together. They can be separated by the fingers and a pin passed below stretches itself over the rubber glove with a malleable handle, has recently

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2 3 4

6 7 8

been described (fig 7). Thimbles Ophthalmology Thimble splints have been used to testes in the scrotum after surgery for modified with a “pushing rod” can be Ophthalmologists have used a immobilise fractures that are confined undescended testis. Usually a loop used to facilitate knot tying in deep thimble with an extension to facilitate to the distal phalanx.11 A plaster of suture is placed in tissue adjoining cavities with not enough room to tie the eversion of the upper eye lid Paris thimble enclosing the whole digit the testis and brought out through the a normal knot. The first throw of the (fig 9). This technique was not widely provides adequate immobilisation. scrotal skin. To prevent the tied suture knot is tied outside the cavity and then used and these thimbles are rare. Aluminium thimbles have also been from cutting through the scrotal skin, slid down one of the suture ends until used for this purpose (fig 10). the suture is tied over something more tight using a pusher. The next throw is Orthopaedic surgery substantial. Special buttons, pieces of similarly tied and then pushed down In the 1930s Nordenbos used fibular Plastic surgery rolled gauze, and even thimbles have to tighten. Many other simple pushing bone to stabilise femoral neck fractures Breast plastic surgery often involves been used. devices are also in use, so the thimble in much the same way as Küntscher extensive finger dissection to separate pusher is not very popular. nails were used later.10 A thimble was breast tissue from surrounding Dental applications placed over the end to prevent the graft structures, and a thimble has been In 1971, a pair of thimbles was Obstetrics from shattering as it was hammered devised to facilitate this process. patented that facilitated the use of In 1875 Gordon described an into the drilled out track between the dental floss (fig 11). The thimbles “obstetric thimble” for rupturing the greater trochanter and the femoral Urology clamped the floss to the fingers by amniotic membranes.8 The thimble, head. Thimbles have been used to fix the friction, thus avoiding the need to which fits on the index finger, had a wrap the floss around the fingertips. sharp point that curved over the free Floss was held in a container and fed edge of the nail and which facilitated between the finger and thimble and the rupture of the membranes. out through an aperture in the top of In obstructed labour with a the thimble. dead fetus, it may be necessary to decapitate the fetus to facilitate Concluding remarks vaginal delivery. A special thimble has Thimbles have been part of my 10 been devised that allows the fetal neck life at Christmas for many years, to be encircled with a wire saw (Blond but surprisingly I have never used Haidler saw). The saw has ball ends a thimble in a surgical procedure and the thimble has a small opening in myself. The BMJ archive is testimony one side with a hole at its end to the many uses of thimbles in (fig 8). The saw ball is inserted into this surgery over the years, and this opening and the thimble is worn by article attempts to illustrate many the obstetrician. The thimble bearing of them. finger is introduced into the vagina and William H Isbister retired professor passed around the fetal neck. The saw of surgery, Hangstrasse 4, Feucht- handles are attached after removal of Moosbach 90537, Germany [email protected] the thimble. 9 11 Competing interests: None declared. In 1903 a cocoa butter and cocaine Provenance and peer review: Not thimble was used to rapidly dilate the Fig 9 | Thimble with an extension to facilitate the eversion of the upper eye lid commissioned; externally peer reviewed. cervical os during the first stage of Fig 10 | Thimble splint References are in the version on bmj.com. 9 labour. Fig 11 | Pair of thimbles for facilitating the use of dental floss Cite this as: BMJ 2012;345:e8447

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Barbara Hepworth’s hospital drawings Richard Cork shows that artistic inspiration can come from the most unlikely places

obody could have guessed that clear that observing “any element of catastrophe Barbara Hepworth’s contact with a would be impossible for me,” Hepworth decided surgeon would suddenly produce, to push aside her misgivings, take up Capener’s after the second world war, an offer, and scrutinise an operation in Exeter. outstanding series of drawings The experience was so compelling that Hep- Ninspired by hospital operations.1 She was, worth went on to observe further operations at after all, renowned for her controversial the National Orthopaedic Hospital in London achievements as an abstract sculptor. So why and the London Clinic. Having produced her first did she start work on these powerful images hospital drawing in November 1947, Hepworth of surgeons, while tirelessly visiting operating devoted a prodigious amount of her energy and theatres in Exeter and London as her fascination imagination to make nearly 80 drawings over the with the subject deepened? next couple of years. By that time, the National Hepworth’s involvement with surgery began Health Service had been created, and her strong in 1944, when her young daughter Sarah had support for this crucial postwar initiative must osteomyelitis. After Sarah was bandaged “in plas- have added to the extraordinary intensity of her ter of Paris from head to toe,” Hepworth’s anxiety hospital images. became intense. But even then she was fascinated Over two decades earlier, the young Hepworth enough to notice that “the moulding of plaster had made her first contribution to art in a medical jackets . . . was very near to my own profession.” context, while still a student at the Royal College As Sarah’s illness became protracted, Hepworth of Art in London. As an entry for a scholarship to and her husband, Ben Nicholson, found the study in Rome, she made a proposal for a “panel

medical bills ever more daunting. Yet she received sculpture” above the main entrance of a hospital. BOWNESS,HEPWORTH ESTATE heartwarming sympathy and support from the The traditional style she adopted bore no relation Fig 1 | Prelude II surgeon Norman Capener. Unlike so many British to her subsequent work as a highly audacious art- art lovers of that period, he relished modern art at ist, who shared Henry Moore’s determination to its most adventurous. Capener was an amateur revitalise British sculpture. Hepworth became All these drawings show Hepworth’s will- painter and was particularly fascinated by the one of few women to achieve a prominent posi- ingness to simplify the surgeons and patients mutually rewarding relation between avant-garde tion as a modernist during the interwar period. alike. Their bodies are purged of all unnecessary art and music. He told Nicholson that Hepworth’s And now, in the late 1940s, her involvement with detail and reduced to essential forms. But this sculpture had “a very striking similarity to Bach’s surgical operations proved that drawing could search for minimal reduction does not mean more abstract work.” Capener began purchasing have a major role in her mature output. that Hepworth lost sight of communicating the her art, and he also backed up their friendship by Hepworth visited hospitals armed with a pen, fundamental meaning inherent in the medical waiving his surgeon’s fee. pencil, and sterilised pad. They enabled her to scenes she had studied at first hand. In her exhi- make swift sketches and notes while scrutinising bition at The Hepworth Wakefield, Wakefield, Seeing surgeons in action the surgeons as they went through the various the expertise and dedication of the surgeons is In the summer of 1947, Capener sensed that stages of intricate bone operations. All her ini- clearly evident. Hepworth’s central involvement with the struc- tial misgivings disappeared, and she grew capti- ture of the human body might mean that she vated by the spectacle unfolding in front of her. Long and distinguished tradition would find stimulus in observing an operation. “From the moment when I entered the operating Hepworth takes her place in a long and distin- He had transferred the ailing Sarah from a mod- theatre,” she remembered, “I became completely guished tradition of great artists who became est Cornish hospital, near Hepworth’s home absorbed by two things.” The first thing was “the enthralled by the skill and commitment of in St Ives, to the far larger Princess Elizabeth extraordinary beauty of purpose and coordina- medical practitioners. In my book, The Healing Orthopaedic Hospital in Exeter. Capener seized tion between human beings all dedicated to the Presence of Art, I single out doctors’ portraits his moment when he stayed in St Ives to recover saving of life, and the way that unity of idea and by painters as eminent as Francisco de Goya, from jaundice. Visiting Hepworth, he asked her purpose dictated a perfection of concentration, Vincent Van Gogh, Henri de Toulouse-Lautrec, if she would like to attend an operation in Exeter movement, and gesture.” Secondly, she was and Frida Kahlo.2 In 1820, Goya painted a mov- and “see directly the work of surgeons in action.” awed “by the way this special grace (grace of ing Self Portrait with Doctor Arrieta.3 4 Here the At first, Hepworth reacted with horror and mind and body) induced a spontaneous space stricken, 73 year old Goya is supported by a phy- denounced his suggestion as “a grim idea.” composition, an articulated and animated kind sician who clasps him while offering a lifesaving Sarah’s illness still haunted her, and she turned of abstract sculpture very close to what I had glass of medicine. A similar respect distinguishes down Capener’s proposal. But then, after making been seeking in my own work.” Van Gogh’s Portrait of Trabuc, the head attendant

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“A particularly beautiful example of the difference between physical and spiritual animation can be observed in a delicate operation on the human hand by a great surgeon”

The longer we look at Hepworth’s images, the more we realise just how appropriate the phrase “hospital theatre” really is. All the participants seem to be caught up in a life-or-death drama, and we gaze at them as avidly as an audience watching a mesmeric play being performed on a stage. But Hepworth also makes us aware of what Stanley Spencer described as the “stillness in the theatre.” After serving at Beaufort War Hospital in Bristol, a former lunatic asylum taken over by the army for war casualties, Spencer announced in 1916 that he wanted to paint “a fresco of an operation” catching the “classical” quality of the scene. He never achieved his aim, and yet Hep- worth’s finest drawings have the aura of ancient frescoes discovered on the walls of a temple dedicated to healing. She was particularly fascinated by the ear fenestration operations carried out by the prominent London Clinic surgeon ER Garnett Passe, accompanied by his assistant Dr John Seymour and the theatre sister Margaret Moir. The surgeon uses a hammer to gain access to the inner ear, and Hepworth must have been especially intrigued by this connection with the sculptor’s

at the Saint-Remy mental home where the dis- the surgeon have a piercing probity as he gazes traught artist was cared for in 1889-90. Trabuc down at the prone, vulnerable body we cannot looks stern, and yet Van Gogh explained that “he see. But the focus of the drawing rests on his two is a man who has seen an enormous amount of immense hands, one of which is precisely adjust- suffering and death, and there is a sort of contem- ing the sleeve of his garment. The elongated fin- plative calm in his face.” gers and thumbs are at once strong and delicate. Only one year later, in Paris, Toulouse-Lautrec Hepworth almost seems to carve them in space. became obsessed by the virtuoso operations carried out in the Hopital Saint-Louis by the Nervous energy celebrated Dr Jules-Emile Pean. “If I were not a Sometimes, she even used a razor blade to painter, I would like to be a doctor,” Toulouse- scratch the surface of the drawings, thereby giv- Lautrec often declared. And he made many inci- ing them an even greater sense of etched urgency. sive portraits of Pean who, like Norman Capener, The scratching also conveys the nervous energy harboured dreams of becoming a painter. Then, experienced by the surgeon, as he braces himself in 1951, Frida Kahlo painted an iconic portrait for taking on the full, burdensome responsibil- of herself in a wheelchair with Dr Juan Farill, an ity involved in wielding the knife. In a drawing outstanding Mexican surgeon who operated on called Prelude II (fig 1), which includes as many her severely damaged spinal column.5 She called as seven figures, Hepworth might be the masked him “cutie,” but his face has a god-like character woman who stands on the far left of the scene, in Kahlo’s reverential painting. her clasped hands possibly hiding a sketchpad. Although Barbara Hepworth had a similar She could easily be praying, and the other figures affection for Capener as Kahlo did for Farill, in gather round the patient’s bed, like priests enact- most of her hospital drawings, the surgeons are ing a religious ritual. The surgeon at the centre masked and difficult to identify. Fascinated by stares at his own upraised hand, as if apprais- every stage of the surgical process, she used a ing its readiness for the task ahead. And another mixture of pastel, gesso, pencil, and oil paint masked participant holds a large oval light,

to define the moment of preparation in a mas- directing it carefully down towards the crucial BOWNESS,HEPWORTH ESTATE terly drawing called Prevision. Here, the eyes of place where its brightness will be needed. Fig 2 | Tibia Graft

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hammer, which she deployed to chisel into stone. and attentive atmosphere in the operating “basic tenderness.” For Hepworth was able to Moir, who later became Hepworth’s secretary, theatre. She brought a seasoned carver’s know- invest the finest of these images with a heartfelt described how Hepworth “came to the London ledge to the task of conveying surgical finesse, belief in the profound significance of compas- Clinic on several occasions in the space of two or and Hepworth was awed by the activities she sionate and delicate surgeons, as they devote three weeks, each time a fenestration operation observed. “A particularly beautiful example of themselves to the challenge of life saving in the was being performed . . . She did brief sketches the difference between physical and spiritual luminous hospital chamber. during these visits, at all stages of the operation.” animation can be observed in a delicate opera- Richard Cork is an art critic, historian, broadcaster, The only surviving sketchbook with Hepworth’s tion on the human hand by a great surgeon,” she and curator [email protected] hospital drawings relates to the “fenestration of explained. “The anatomy of the unconscious Competing interests: None declared. the ear” operations that she witnessed between hand exposed and manipulated by the conscious An exhibition of Hepworth’s hospital drawings continues April and May 1948. The sketches are labelled hand with the scalpel, expresses vividly the crea- at The Hepworth Wakefield, Wakefield, until 3 February 2013, before travelling to the Pallant House Gallery, with colour references to help Hepworth embark tive inspiration of superb coordination in contrast Chichester (16 February to 2 June 2013), and the on her elaborate drawings back in the studio, to the unconscious mechanism. The basic tender- Mascalls Gallery, Kent (14 June to 24 August 2013). and she also jotted down notes like “magnifying ness of the large and small form, or mother and Provenance and peer review: Commissioned; not externally glasses” to help her identify the crucial optical child, proclaims a rhythm of composition which peer reviewed. 1 Hepburn N. Barbara Hepworth: the hospital drawings. Tate devices employed during surgery. is in contrast to the slapping and pushing of tired Publishing, 2012. mother and frustrated child through faults in our 2 Cork R. The healing presence of art: a history of western art Basic tenderness way of living and unresolved social conditions.” in hospitals. Yale University Press, 2012. 3 Park MP, Park RHR. The fine art of patient-doctor No such notes are permitted to interfere with the Hepworth’s revealing account, with its empha- relationships. BMJ 2004;329:1475-80. eloquent effect of the figures in Hepworth’s large, sis on the relationship between a mother and 4 Curran J. Medical Classics: Self Portrait with Dr Arrieta. BMJ 2008;337:a1121. finished compositions. Drawings as powerful as child, suggests that she was guided throughout 5 Lomas D, Howell R. Medical imagery in the art of Frida Tibia Graft (fig 2), orConcentration of Hands II the hospital drawings by the strength of her love Kahlo. BMJ 1989;299:1584-7. (fig 3), take us right to the centre of the hushed for her own daughter Sarah. The key words are Cite this as: BMJ 2012;345:e8529

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