CONTENTS

1 Editorial introduction

2 Andrew Duncan and the health of nations M McCrae

12 Care of the mentally disabled in and around Edinburgh c 1680–c1820 RA Houston

21 David Livingstone and southern Africa’s first recorded cases of sickle- cell anaemia? GW Clendennen and J Lwanda

29 Dr William Bruce (1835–1920), the Scottish Highland spa at Strathpeffer; and a possible description of polymyalgia rheumatica WW Buchanan and WF Kean

36 Medieval hospitals in Scotland: a cure for body or soul? WJ MacLennan

42 Robert Knox and Joseph Lister: pioneers of vascular physiology DL Gardner

46 The case of Madeleine Smith: a Victorian discourse of desire and death JR Roy

56 The Royal Medical Society’s library MH Kaufman

64 Torphichen and the Knights Hospitaller WJ MacLennan EDITORIAL INTRODUCTION

EDITORIAL INTRODUCTION

M McCrae, College Historian, Royal College of Physicians of Edinburgh

From the beginning, this journal (first as Proceedings and to the secularisation of society3 For previous later as The Journal of the Royal College of Physicians of generations ‘the long march of everyman initially had Edinburgh) has published work on the history of much the quality of a pilgrimage    Membership of a medicine This contribution to historiography quickly church once located an individual within that gained recognition Articles on medical history – denomination’s account of its origins, its purposes, its medical biography, the history of medical science, the self definitions, its trajectory over time and its cosmic social history of medicine and the history of medical destiny’ In modern secular society the grand narrative institutions – appearing in The Journal were soon listed in of that trajectory no longer holds ‘Postmodernism Medline; the number of submissions for publication collapses that grand narrative into a collection of little increased, including, to our great satisfaction, work by narratives and within those little narratives the passage distinguished historians with no previous affiliation to of time, and the difference created by that passage of the College On average 12 works on medical history time, are hardly important’ Emancipated from history, have been published each year The overall success of the postmodern world becomes timeless The Journal and the resulting competition for space has made it impossible to increase that number Now, as an In the 1980s and 1990s, fashionable historians, exceptional expedient we publish, for the first time, a emancipated from history, developed a postmodern supplement entirely devoted to history analysis of the past and a rhetoric that was cynical and disparaging rather than positive and constructive That This lively and continuing interest in medical history may fashion may now be passing4 Such theoretical academic seem to run counter to a contemporary fashionable debates are in any case irrelevant to the history of shift in the appraisal and valuation of the discipline of medicine Irrespective of what may or may not remain history Fukuyama has claimed that history might now of our belief in the grand narrative of the progress of be cheerfully abandoned altogether1, 2 The Cold War mankind, the grand narrative of medicine continues and had ended with American-style economic and political the trajectory of medical progress continues to be vital liberalism triumphant, no rival ideology had survived and to the future health of nations If we are to influence the no new ideology was in sight Fukuyama assumed that future of medicine we must at least have a sound ‘the universalization of Western liberal democracy as understanding of where we are now and how we got the final form of human government’ had put an end to here; a man suffering from amnesia is liable to forget not history Many were persuaded by Fukuyama’s vision but only what he has already done but also where he means more recent events must have disturbed such to go It is therefore a very proper function of this confidence College to promote the study of medical history, not only in its own account but also by making its invaluable However, postmodern de-historicisation is still with us library and archives and the pages of its Journal open to Henry Ford was an early exponent ‘I don’t know other historians who share the College’s commitment whether Napoleon did or did not try to get across [the Channel] and I don’t care It means nothing to me REFERENCES History is more or less bunk    We want to live in the 1 Fukuyama F The end of history? The National Interest 1989; present and the only history that is worth a tinker’s 16(Summer):3–18 damn is the history we make today’ Such presentism is 2 Fukuyama F The end of history and the last man London: the very essence of postmodernism It sets aside the Penguin Books: 1993 3 Clark J Our shadowed present London: Atlantic Books; ideas of objective truth and the scientific method that 2003 underpin ‘modernism’ in favour of the evidence of 4 Caesar J Reconstructing America New Haven: Yale personal subjective experience Jonathan Clark relates University Press; 1997 the emergence of postmodernism and de-historicisation

J R Coll Physicians Edinb 2003; 33(suppl12):1 1 ANDREW DUNCAN

ANDREW DUNCAN AND THE HEALTH OF NATIONS

M McCrae, College Historian, Royal College of Physicians of Edinburgh

Since the 1970s there has been a ‘blossoming of the Duncan was among the first of the medical profession in literature’1 on the history of medicine in the years of the Britain to be convinced that the profession had a duty to Scottish Enlightenment2 Some historians have promote the health of the people For many years he examined the ‘internal’ progress of medicine during argued that, since ‘Medical Police regards not merely the these years; others have set medicine in the context of welfare of individuals but the prosperity of nations [it contemporary society A third method has been to was] of the greatest consequence both to the profession discuss the contribution of individuals, either as and to the public’5 and therefore a discipline that should physicians or as leading members of influential be taught to every medical student institutions3 Even authors adopting this third method have been strangely neglectful of the contribution of This article aims to draw attention to Andrew Duncan’s Andrew Duncan (1744–1828) (Figure 1) There are struggles to find his voice in Edinburgh, to his place in references to him in various contexts in the literature the development of medicine in the Scottish but there has been little discussion of his career, or Enlightenment, and to the lasting significance of his recognition of his greatest and most lasting achievement introduction of the discipline of public heath to medical education in Scotland

THE OUTSIDER In the last years of the eighteenth century, Andrew Duncan won a place among the great medical teachers who established Edinburgh as a world centre of medical education By the end of his life he had been honoured by the Danish Philosophical Society, the Royal Society of Medicine of Paris, the American Philosophical Society of Philadelphia, the University of Moscow and the Medical Society of London; Edinburgh had made him a Freeman of the City and the Royal College of Physicians of Edinburgh had twice elected him as its President6 Yet, until he reached middle age, to the world of John Rutherford, Alexander Munro primus, Robert Whytt, Sir John Pringle,William Cullen, Joseph Black, John Gregory, and James Gregory,Andrew Duncan was an outsider

The men who had come to make up Edinburgh’s medical establishment in the second half of the eighteenth century – the presidents of the Royal College of Physicians, the professors of the Town’s university medical school and the Town’s provost who appointed the university’s professors – were, without exception, drawn from a privileged section of society

At the Act of Union, the wealthy, powerful and politically ambitious of Scotland’s aristocracy had shifted south to join London society and political life at Westminster However, the governance of Scotland had not passed FIGURE 1 Portrait of Andrew Duncan by Sir Henry Raeburn totally to London The Act of Union had left Scotland a (Royal College of Physicians) great measure of autonomy and in Scottish affairs Westminster had chosen to keep a ‘low profile’7 As a result, the lesser aristocracy and landed gentry who still In 1790 he introduced the teaching of ‘medical police’4 looked to Edinburgh rather than London had acquired a [public health] to the medical curriculum at Edinburgh new degree of local power and influence But however

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influential, many possessed nothing but their entailed follow in the footsteps of his Edinburgh mentors land and their social position Younger sons with little or Although he had none of their social advantages, he was nothing to inherit and a need to make their own way in determined to make his own mark as a medical the world, were often ‘put to’ one of the learned philosopher, teacher and reformer professions The able among them, aided by family influence, patronage and the benefit of a good university THE ROYAL MEDICAL SOCIETY education, prospered as members of the noblesse de robe The Royal Medical Society played an important part in or the wider scholar-gentry furthering Duncan’s ambitions The Society had been founded in 1734 by Edinburgh medical students as a All but one of the great phyicians who became the centre for their social activities and to provide a forum leaders of the medical profession in Edinburgh in the for their own independent efforts to promote their middle years of the eighteenth century had, after medical education Students held their own discussions graduating from Scottish universities, been able to travel on medical matters, presented and criticised student abroad, studying for two or three years at Leiden, Paris dissertations, bought bodies for anatomical dissection or Berlin All, in launching their careers, had the support and gradually built up a library The Society allowed of influential families and, in some cases, the patronage of students to promote their own interests within great personages – the Dukes of Argyle, Hamilton or medicine and to represent their views and (when Roxburghe8 necessary) their demands and protests to the Dean and Faculty Andrew Duncan had no such social advantages He was born in 1744 in Crail, a small coastal town ten miles Duncan joined the Medical Society of Edinburgh in 1762 south of St Andrews In the fourteenth century, Crail By 1764, he had become its president for the first time; had been an important centre of herring fishing, but in he was to serve as its president a further five times the eighteenth century it was in decline, its harbour between 1769 and 1774 In 1775 he organised the ‘incommodious,’ its fishing ‘neglected’ and its population fundraising campaign that enabled the Society to equip fallen to little over 1,0009 Duncan’s father described its own premises and to go on to build its Hall in 1786 himself as former shipmaster and merchant, designations Duncan was also the prime mover in securing the that tell us little of his financial circumstances It seems Society’s royal charter in 1778 On several occasions improbable that, as a merchant trading in the small Duncan, as President, acted as spokesman for the backwater of Crail, he could have had more than a students in confrontations with Faculty ‘Ever afterwards modest income However, he did manage to send his he did not hesitate to declare his pride’ in having son to the local university, St Andrews, from which he established the Royal Medical Society as ‘an essential graduated as a Master of Arts in 1762, and on to part of the medical school of Edinburgh’10 Edinburgh University medical school, open, at that time, to any boy with a little Latin and three guineas for the In the Royal Medical Society Duncan had found a place class fee in the community of Edinburgh medicine and made his first exercises as a leader and a reformer There were many Scottish students at Edinburgh University who shared Duncan’s social circumstances BUILDING A CAREER and were content to look forward to a life as a medical By 1768, when he graduated, Duncan had established tradesman Duncan did not, however, allow his poverty himself as a prominent figure at Edinburgh By creating and humble origins to be an insuperable social barrier In a sure and lasting place for the Royal Medical Society, he the six years that he spent as a student in Edinburgh, he had made his mark as an undergraduate However, he made himself known to, and was inspired by, David was still without the powerful patronage or the family Hume, Adam Smith, Adam Ferguson and William connections that were then so critical for success in Robertson, whose new ideas on philosophy, economics, most professional careers He was also still poor, sociology and history were being promoted in without the means to survive the lean years of struggle Edinburgh and published across Europe and North before a suitable academic appointment could be found America As an undergraduate, Duncan absorbed the He at once enlisted as surgeon on the East India ‘Scotch Knowledge’ (moral philosophy and political Company’s ship Asia then engaged in the Company’s economy) that was then central to teaching at Edinburgh immensely lucrative voyages, trading with India and University and, for five of his years at Edinburgh, he was carrying opium from India to China After one voyage, taught by the great physicians of the Enlightenment – Duncan had the funds he needed In 1769, he refused an William Cullen (1710–90), John Gregory (1724–73), offer of 500 guineas to embark on a second voyage and John Hope (1725–86) and Joseph Black (1728–99) returned to Edinburgh

When Duncan completed his undergraduate years in His welcome in Edinburgh was cautious Many had Edinburgh in 1768, he had already made up his mind to found that ‘ambition    made Duncan thrust himself into

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everything [and] his talk was wearisome’11 Within I have the satisfaction of being able to retire from this months of his return he took his diploma as a Doctor of arduous task with ease in my own mind, and I hope Medicine from St Andrews and immediately applied to not without some additional credit in your that university for appointment as Professor of estimation My academic labours have not indeed in Medicine His application was rejected A few months other respects been attended with equal later, he became a Licentiate of the Royal College of advantage    I had no hesitation in offering myself as Physicians of Edinburgh, in the expectation of an a candidate for the Chair recently vacant [but] in appointment at Edinburgh University Again he was that competition I had no powerful connection, no rebuffed His confidence and ambition were, however, political interest to aid my cause    I can no longer undiminished He began to teach privately, setting up act in an equally conspicuous capacity, yet I hope I extramural courses of his own may hereafter be employed as a teacher in one not less useful It is my intention to dedicate my labours THE STRUGGLE FOR PREFERMENT to the service of students of medicine    The In 1773, John Gregory, the Professor of the Institutes of present disappointment may yet afford me the Medicine at Edinburgh, died at the age of 49 To succeed strongest instance of the favour of heaven14 him, the patrons of the University appointed Dr Alexander Monro Drummond, a relative of Edinburgh’s Duncan now resumed what he advertised as an influential provost, George Drummond, and also of ‘independent course of lectures on the theory and Professor Alexander Monro primus Drummond, being practice of medicine without the walls of the university’ abroad at the time, was not able to take up the chair at The first lecture in this new course was attended by once No doubt prompted by Duncan’s growing over 100 students and his extramural school went on to reputation as a teacher, the success of his extramural flourish for the next 15 years classes and his popularity with the Edinburgh student body, the patrons of Edinburgh University invited BUILDING REPUTATION AND STATURE Andrew Duncan to fill what was expected to be a Medical journalism temporary vacancy Duncan acted as locum professor During his career,Andrew Duncan promoted a number for the sessions 1774–5 and 1775–6, extending the of laudable causes Some of his ventures were launched course to include lectures and demonstrations on with a fair wind of general approval In the 1770s the chronic disease His innovative lecture course came to dissemination of new understanding and knowledge was an end, however,when the University decided that, in the seen as an essential feature of (what was later to be continuing absence of Dr Drummond,12 it must make a called) the Enlightenment in Western Europe15 Aspects new substantive appointment of the Scottish Enlightenment would certainly have been impossible without the efforts of printers, publishers and The competition was intense The outstanding can- booksellers such as John Murray,William Smellie,William didates were William Small and James Gregory Small Creech and Charles Elliot16 When Duncan launched the was a former protégé of John Gregory, a friend of David world’s first English-language medical journal in 1773,17 Hume, Lord Kames and Joseph Black, formerly a there was already a growing market for medical professor at the College of William and Mary at literature and he had the experienced and expert Williamsburg and a Fellow of the Royal Society; he also backing of John Murray Medical and Philosophical had the strong support of Joseph Priestly and Benjamin Commentaries was based on the model of the Leipzig Franklin13 James Gregory was still a very young man, but journal, Commentarii de Remus in Scientia Naturali et he was the son of the previous professor and the Medicina Gestis, and in it Duncan presented abstracts of favoured candidate of William Cullen and a majority of the books he thought most relevant and useful for busy the medical faculty In spite of this formidable clinicians As he explained in the introduction to the first competition, Andrew Duncan assumed that, having issue: successfully occupied the post for over two years, his appointment would be automatic No one, who wishes to practice medicine, either with safety to others or credit to himself, will incline When the Town Council elected James Gregory to to remain ignorant of any discovery which time or follow his father as Professor of the Institutes of attention has brought to light But it is well known Medicine, Duncan’s disappointment was intense He that the greatest part of those who are engaged in attributed his failure, in part to his politics (he was the actual prosecution of this art, have neither the known to be a Whig of decidedly progressive views leisure nor opportunity for very extensive reading18 while the Town Council, the patrons of the University, was already cautiously moving towards a distinctly Between 1773 and 1780 more than 1,000 copies of each reactionary, even ‘counter-Enlightenment’ stance) but quarterly issue were published simultaneously in principally to his lack of patronage or family interest To Edinburgh, London and Dublin, each in three editions his students he said: selling at one shilling and sixpence19 The journal was

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well received by all types of eighteenth century medical in the most abject and appalling wretchedness’21 He had practitioners – university-trained physicians, barber been well-known in Edinburgh, regarded as a worthy surgeons and apothecaries – and its reputation soon successor to Allan Ramsay and claimed by Robert Burns justified its translation into other languages Since the to be ‘my elder brother in misfortune and by far my journal’s contents were almost entirely clinical, in 1780 elder brother in muse’ For some years Fergusson had the name was changed to Medical Commentaries In 1795 suffered recurring bouts of manic depressive illness and, Duncan retained the format but changed the title to in 1774, both his mental and physical condition Annals of Medicine and, in 1803, when the editorship deteriorated drastically after a fall down a flight of stairs passed to his son, it became the Edinburgh Medical and After a long delay, he was carried to the workhouse Surgical Journal, a forerunner of the present Scottish where ‘thrilled with horror, his friends departed and left Medical Journal the wretched Fergusson to his fate’ The pitiful circumstance of his death became notorious in The Dispensary for the Sick Poor Edinburgh and beyond Duncan was provoked into Duncan’s espousal of the Dispensary Movement also arguing for humanity in the treatment of the mentally ill met with immediate approval and support In the later He put forward a plan for the establishment of what was part of the eighteenth century, cities and smaller towns to be Edinburgh’s first public lunatic asylum Duncan’s in Britain established charities to provide out-patient Whig friend Henry Erskine, then the Lord Advocate, care (advice and medication) and home visiting for the arranged for the necessary funds to be derived from the sick poor The first, the Dispensary for the Infant Poor Jacobite estates forfeited in the Rebellion of 1745 The established by George Armstrong in London in 1769, Royal College of Physicians of Edinburgh gave its full was a ‘one-man’ institution and came to an end when support to the scheme and after many difficulties and Armstrong died in 178920 However, the idea had been delays a petition was finally presented to King George III taken up and expanded elsewhere and dispensaries A royal charter was granted under which a lunatic caring for the poor of all ages had been established in asylum (now the Royal Edinburgh Hospital) was opened many towns; the first in London was set up in 1773 By at Morningside in 1807 then, Duncan had already demonstrated his interest NO LONGER AN OUTSIDER In his extramural classes Duncan had always given In 1790, Duncan was elected President of the Royal particular attention to chronic disease and the diseases College of Physicians His journals, his Dispensary for of poverty Patients too poor to afford medical the Sick Poor, his work to establish a public asylum and treatment were invited to attend his classes where they his popularity as a teacher of medicine had combined to were demonstrated to students and, at the same time, establish him as an important figure in Edinburgh received free treatment and advice The poor and the Perhaps even more important in opening up Duncan’s sick came in unexpectedly large numbers, revealing the prospects, William Cullen and the physicians of the old extent of what was emerging as an urgent and growing medical establishment had gone22 Seventeen years after social problem for Edinburgh – the diseases, the the post had been denied him, he was appointed as disabilities and physical deterioration of the urban poor Professor of the Institutes of Medicine (physiology, Since the Royal Infirmary made no provision for any pathology, symptomatology, hygiene and therapeutics) form of out-patient care, Duncan proposed that, as was He was now in a position to make progress in what was happening elsewhere, a public dispensary should be set to be the greatest of all his good causes, the promotion up as a public charity But unlike the dispensaries in of the health of the public other towns, Duncan’s dispensary was also to serve as a teaching clinic, giving students some insight into the A POLICY FOR THE HEALTH OF THE PEOPLE medical problems of the poor By 1777 Edinburgh’s free (MEDICAL POLICE) dispensary was well established and new courses on the The population of Scotland increased rapidly in the theory and practice of medicine and on chronic diseases course of the eighteenth century23 In part this may be were advertised in the press Students paid one guinea attributed to the control of smallpox, for long the most per lecture course plus half a guinea towards the common cause of death in Scotland and the end to the expenses of the dispensary; they also provided almost all recurring famines that, as late as the 1690s, had caused the free treatment and advice offered to the patients the death of up to one in seven of the population24 Duncan was formally installed as physician-in-charge Nevertheless, in the 1750s, the overall expectation of life with Dr Charles Webster as his assistant in Scotland was only 27 years,25 and new threats to life were emerging The care of the insane Even before the dispensary was up and running, a The commercialisation of farming that had helped to different medico-social problem had claimed Duncan’s eliminate famine from Scotland had failed to provide attention The poet, Robert Fergusson, had died at the stable well-paid employment for an increasing rural age of 24 ‘in the cells of the common charity workhouse population, certainly not enough to prevent a continuing

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migration from the country to town For many reduced equilibrium Cullen’s ideas came to be accepted by the to earning a meagre wage in an uncertain rural economy, greater part of the medial profession, and for over 50 the towns seemed to offer ‘more jobs, a wider diversity years they provided a rationale for much of the medical of social contacts and infinitely greater colour and care offered by doctors throughout the English-speaking excitement’26 But whether employed in the country or world in town, the great mass of Scotland’s working population had become wage earners in a low-wage economy and Any advance in improvement in the understanding of in periods of unemployment during depressions in trade doctors was of little use, however, to those with no or production, liable to fall into poverty Poverty, access to the services of a doctor If the decline in the whether in town or country, brought the debilitating health of the great mass of the poor, particularly the effects of poor housing and inadequate diet, and the urban poor, was to be halted or reversed, some method accumulating physical disabilities consequent on a life of had to be found that would put every advance in labour But a life of poverty in the towns and cities had medicine at the service of the poor This had never been added hazards There the pressure of constantly an objective that had attracted the attention of Cullen increasing numbers27 led to gross overcrowding, lack of or the Edinburgh medical establishment of his time living space, lack of air, lack of sunlight and mental Their interests had been in the ‘internal’ cognitive depression, all of which undermined resistance to the advance of medicine and the care of their own individual potentially lethal infections encouraged by the patients accumulation of urban filth and infection carried in a haphazard and contaminated water supply Recurring WILLIAM BUCHAN AND THE GOSPEL OF HEALTH urban crises of disease and mortality were inevitable and Cullen’s elitist concept of the practice of medicine was each was followed by a ‘replenishing migration’ of new deplored by William Buchan Buchan was a reformer urban dwellers from the country In Scotland, this urban who was in no way constrained by the views or dictates cycle of disease, physical degradation and death was of the Edinburgh medical establishment He took the perhaps at its most obvious in Edinburgh, ‘the dirtiest view that the health of the general public could best be town in Britain in the eighteenth century,’28 which had improved by enabling every literate member of the also doubled in population in one lifetime To reformers public to take charge of his own health – and the health like Duncan it had become an affront to an ‘Enlightened’ of his family and dependents – without the sanction of and humanitarian society the medical profession Buchan was an Edinburgh graduate (1761) and a Fellow of the Royal College of WILLIAM CULLEN, THE MEDICAL PROFESSION AND Physicians of Edinburgh but he did not hold a university THE HEALTH OF THE PEOPLE- appointment or practice in Edinburgh29 He deplored The most influential figure in Edinburgh medicine in the Cullen’s establishment views, denounced them in print second half of the eighteenth century was William and, on one occasion, came near to ‘calling Cullen out on Cullen His appointment as Professor of Chemistry in the field of honour’30 Buchan regarded the medical 1755 had been strongly resisted by John Rutherford, the profession as oligarchic and unhelpfully given to Professor of the Practice of Physic, and the Edinburgh mystique He wrote that medical men ‘have endeav- Faculty generally since he was known to have rejected, oured to disguise and conceal the art’31 Buchan and his at least in part, the teachings of Boerhaave, then still Edinburgh publisher, William Smellie, were intent on ‘Holy Writ’ in Edinburgh Boerhaave saw health as a ‘laying medicine open’32 Together, in 1767, they state in which the ‘blood and humours’ were in published the first edition of his Domestic Medicine ‘to hydrostatic equilibrium, and blood letting as having a shew how far it is in the power of every man to rational and important place in the treatment of ill- preserve his own health by proper conduct, or restore health Cullen had not studied under Boerhaave In his it when lost’33 concept, health was the state in which the functions of the separate organs of the body were in coordination Buchan and Smellie shared a common approach to under the regulation of the nervous system; the nervous medical practice Smellie had at first studied theology at system and the healthy coordination that it could Edinburgh but had turned to medicine because he ‘could achieve were critically influenced by the body’s not take seriously the saving of human souls while so environment and its activities In Cullen’s view the many lived in physical destitution’34 Both Buchan and principal factors that determined the balance between Smellie regarded the practice of medicine as an sound and ill-health were climate, humidity, cold, alternative ministry and for many years, their book, clothing, diet and exercise In his vast private practice, Domestic Medicine, came second only to the Bible as the much of it conducted by correspondence, the history of book most likely to be found in Scottish households In the patient’s complaint was considered in great detail all it ran to 19 editions in Britain with further additions and then, often without attempting a precise diagnosis, in North America and translations into all the main Cullen set out a regimen of activity, personal habits and languages of Europe In over 700 pages, Buchan set out circumstances, and diet intended to restore a healthy simple but sound advice on the care of infants and young

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children, on diet, on clothing, on fresh air,on exercise, on Frank advocated active intervention by states to sleep, on travel and on ‘passion’ and gave guidance on the promote the health of populations This was to be done management of the common medical and surgical by regulating those environmental and social factors conditions of the time believed to influence health He proposed that central governments should assume overall cradle-to-grave Domestic Medicine proved to be immensely popular It responsibility for the health of their people and, guided was of great comfort and assistance to many In by medical experts, legislate on such factors as nutrition, recognition of his achievements Buchan was buried at wages, housing, marriage, pregnancy and prostitution, Westminster Abbey However, his efforts to promote quarantine and vaccination The state was also to health by making medical knowledge more open to the regulate the activities of all caring services – hospitals public had little influence on the early development of and dispensaries, lying-in services, poor houses and the academic discipline of ‘public health’ or the early pharmacies – and take responsibility for medical attempts to establish a state policy In that, Andrew education and the licensing of medical practitioners Duncan was much more successful Frank’s proposals derived from the philosophy of Christian Wolff (1679–1754) who held that, as INTERVENTION BY THE STATE individuals, the people had no personal intrinsic rights in The problem of public health was not one that the relation to health but, as citizens, must accept that the reformer in Duncan could ignore and through the state had a ‘right of guardianship’ over their health as editing of his journals – medical journals had become the legitimate ‘objects of governmental care’35 In this main channels of communication between Scotland, context, the role of the medial profession in the Prussia England, the Low Countries, Germany, France, Russia, of Fredrick the Great and the Austria of Joseph II was to and North America – he had become involved in the be to serve the ruler to the benefit of the state36 international discourse on public health policy Elsewhere in Europe moral philosophers and political The perceived decline in the health of the people was a economists rejected Wolff’s concept of the proper problem in every industrialising country In Continental relationship between the state and its people In France, Europe, the changes in the economy and the structure Rousseau (1712–78), in his Du Contrat Social ou Principes of society had been less abrupt than in Scotland but had Politique, claimed that man must be free to form, within continued over a much longer period There were many the state, a society based on equality Since the physical towns in Europe larger and more crowded than any in degeneration and disease suffered by the poor was Scotland, and on the Continent concern for the health ultimately the result of the gross inequality in of urbanised populations had a much longer history The contemporary society, Rousseau proposed that the first leading medical schools in Europe were looking for a duty of the medical profession should be to rescue the more collectivist approach than that attempted by people from the ill-effects of inequality37 In the years Buchan leading up to the Revolution, French philosophes demanded that this should be done by ensuring that all In Germany and France two quite different approaches citizens had equal access to healthcare, free, as to the problem were put forward, based on two quite necessary, for those unable to pay38 Poverty, in this different philosophies In German-speaking Central context, was to be recognised as a socio-economic Europe the leading advocate of a policy for the problem with no moral or religious overtones The aid improvement of the health of the body of the population provided by religious, municipal and philanthropic was Johann Peter Frank, Professor of Medicine first at charities was to be coordinated by the state and Pavia and later at Vienna In his six-volume System Einer redefined as poor relief (bienfaisance) which the poor Vollstandigen Medicinischen Polizey (A Complete System of had a right to receive and which the state had a duty to Medical Police), published in 1779, he adopted Cullen’s deliver The French Academy of Science and the Royal ideas on the determinants of health, but in addition Society of Medicine were called on to draw up schemes stressed the importance of social factors (public for the reform of the country’s hospitals, poor houses cleanliness, proper ventilation of houses, adequate loose and dispensaries to improve their therapeutic efficiency, clothing, affectionate marriages, breastfeeding and the to make them more accessible and to relieve what had vaccination of children) Like many of his become unacceptable levels of overcrowding and contemporaries in the German-speaking world, Frank squalor The Royal Society of Medicine in Paris became believed that a nation’s ‘greatest wealth’ was its people a centre for the active promotion of new ideas on and that, in the interest of the state, the people should hygiene and the control of epidemics Practical schemes be as ‘numerous, healthy and productive as possible’ were drawn up for the improvement of public drainage While Cullen aimed only to improve the health of and water supply and for the education of the people on individuals by improving the quality of the advice given hygiene The essential characteristic of health policy by their physicians and Buchan aimed to enable proposed for France was the massive intervention by individuals to take better charge of their own health, the state in the medical care of the individual The

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system was to be demand led, responding to the preparation of food and drink) individual needs presented by every citizen • Consuetudines Salutare et Noxiae (exercise conducive or adverse to health) The schemes put forward for France and Germany did • Morbi Contagiosi (prevention of infectious diseases) not survive as models for the eighteenth century • Carceres (abuses and defects of jails) Duncan was able to observe both and concluded that • Nosocomia (regulation of hospitals) both had failed The idealistic concept of equal and • Seultura adaveum: (proper burial of the dead) universal health, tentatively put in place in Revolutionary France, soon ran into trouble As the Revolutionary In 1795 Duncan submitted a memorial to the patrons of Wars continued, the depletion of Treasury funds put an the University setting out the case for the creation of a end to expensive public health schemes and a demand- Chair of Medical Jurisprudence and Medical Police His led system providing equal healthcare for every citizen proposal was rejected on the grounds that such a chair proved to be impossibly expensive The full elaborate would not contribute to the dignity or prosperity of the bureaucratic structure required for the scheme university Undaunted, Duncan continued his campaign envisioned for Germany was found to be impractical and to reform the medical curriculum giving greater was soon abandoned for more modest schemes emphasis to the protection and welfare of the public in general and the lower orders in society in particular ANDREW DUNCAN’S MEDICAL POLICE The political climate, however, had turned against Andrew Duncan declared his interest in public health in reform These were the years of the French Revolution the 1770s In his new extramural courses, begun after and the Revolutionary Wars In Scotland, as in much of his rejection as a candidate for the Chair of the Europe, the years of Enlightenment had given way to Institutes of Medicine in 1776, Duncan began to lecture years of Counter-Enlightenment It seemed to the (in Latin) on medical jurisprudence in the winter and establishment in Britain that the ideas of ‘rational’ medical police in the summer These were disciplines progress that had flourished earlier in the century had, that had been taught for some years at leading European in the end, led to civil unrest and the threat of universities but not, until then, in Britain They revolution Edinburgh society became divided Henry concerned the medical profession’s duties to the good Dundas, Home Secretary in Pitt’s government and order and strength of the state Medical jurisprudence, supreme manipulator of political power and influence in the study of the medical profession’s obligations in the Scotland, unleashed a witch-hunt against all suspected service of the judicial system and medical police, the radicals42 His chief victim was Henry Erskine, a Foxite study of the profession’s contribution to the Whig and a former Lord Advocate, who was deprived of management of the nation’s health, Duncan held to be ‘of his office as Dean of Faculty (of Advocates) As a close considerably greater consequence both to the friend of Henry Erskine, Andrew Duncan was also profession and to the public’ than some of the tainted with radicalism; his proposals for university traditional subjects taught at the university since they reform therefore found no favour with the university’s concerned ‘not merely the welfare of individuals but the patrons (the Town Council) who were firmly of Dundas’s prosperity of nations’39 party

When at last appointed to the Chair of the Institutes of A break came in 1806 In a short-lived Whig Medicine in 1790, Duncan added these very important administration, Henry Erskine again became Lord disciplines to the number of Institutes that had been Advocate Erskine quickly arranged for the creation of a taught by his predecessors He justified his action in a Regius Chair of Jurisprudence and Medical Police within letter to the Senatus Academicus: ‘In Boerhaave’s the Faculty of Law As this was a crown appointment it Insitutes Medicae you will find it subdivided into five was impossible for the Town Council to resist and, as an inferior brands – physiologica, pathologica, semeiotica,40 appointment within the Faculty of Law, the Medical hygiene and therapeutics’ He had now ‘reclassified these Faculty could play no great part in the selection of five topics under two headings, pathological physiology candidates With Erskine’s support, Duncan was able to and general therapeutics’ and added medical secure the appointment for his son Andrew Duncan jurisprudence and medical police as Institutes of junior, continued as Professor of Medical Jurisprudence Medicine He published a list of the topics discussed in and Medical Police until February 1820, when he was his lectures His Heads of Lectures on Medical Police41 succeeded in the chair by William Pulteny Alison Since were: Alison was the grandson of John Gregory, had married a daughter of James Gregory and was a Tory, the Chair of • Insalubritas Aeris (temperature, humidity and foreign Medical Jurisprudence and Medial Police no longer impregnations of the air), required the protection of the Erskine family In 1825, it • Insalubritas Aquae (purity, smell, temperature adn was translated from the Faculty of Law, where it had suppy of water), been protected for almost 20 years, to the Faculty of • Insalubritas victus et potus (price, quality and Medicine

8 J R Coll Physicians Edinb 2003; 33(suppl12):2–11 ANDREW DUNCAN

For half a century, Andrew Duncan senior had worked Cambridge48 and the private medical schools in London to establish the study of public health as an essential part and elsewhere in England prepared their students for of medical education He had also made certain that, private clinical practice, rather than for public service when Edinburgh University should see fit to appoint a The first lectures on public health were given at St professor of this new discipline, there would be a Thomas’s by Edward Greehow, an Aberdeen graduate, in suitable candidate When Andrew Duncan junior 1856, and it was not until 1878 that training and graduated MD for Edinburgh in 1791, he was examination in public health were required for students immediately sent ‘at his father’s direction’ to continue at English medical schools his medical education at the major medical centres of Continental Europe43 From 1793 until 1796, and again When the nineteenth-century public health movement in 1797, he spent time at Gottingen Vienna, Pavia and began, English-trained doctors did not have the Padua reporting and receiving directions in frequent expertise,49 or perhaps any inclination, to take the lead long letters to and from his father44 An important The medical evidence presented in the Report from His objective of Duncan junior’s tour was to equip him for Majesty’s Commissioners for Inquiring into the Administration the preparation of an annotated translation of JP Frank’s and Practical Operation of the Poor Law (1834) and the System Einer Vollstandigen Medicinischen Polizey (Complete Report to Her Majesty’s Principal Secretary of State for the System of Medical Police) When he was appointed to the Home Department on an Inquiry into the Sanitary Condition new chair of Medical Jurisprudence and Medical Police of the Labouring Population of Great Britain (1842) was he had been well prepared by his father provided by Scottish graduates – Southwood Smith (Edinburgh), James Kay (Edinburgh) and Neil Arnott In their teaching, Andrew Duncan senior and his son (Aberdeen) When the government created a General discussed but did not endorse the philosophy behind the Board of Health in London in 1842, its leading members public health reforms that had been proposed in were George Milroy, John Sutherland and Hector Gavin, Germany or the philosophy that drove the radical again all Scottish graduates Remarkably when WP proposals for France45 As products of the Scottish Alison, the Professor of Medical Police at Edinburgh, and Enlightenment and as Whigs,they were convinced of the Robert Cowan, Professor of Medical Police at Glasgow ineluctable progress of human society and believed that disputed the recommendations of the Report from Her progress could best be achieved with the minimum Majesty’s Commissioners for Inquiring into the Administration interference by the state In providing for the future of the Poor Law in Scotland, the medical experts on both health of the people they preferred to look to sides of the debate were Scottish graduates philanthropy and to the efforts of local communities, all acting with the professional guidance of suitably trained CONCLUSION doctors Their aim was to encourage medical students Andrew Duncan came to be regarded as one of the to give attention to the health of the poor, to study of most ‘eminent Scotsmen    as much an ornament to the causes of their ill-health and to give thought to the private as to public life    his contributions to medical role that the medical profession should play in advising science deserving especial notice’50 magistrates on sanitary schemes and the role of doctors in the philanthropic provision of hospitals and He began his career at a disadvantage His manners and dispensaries personality were not impressive Socially he appeared amiable but dull, given to weak jokes and bad poetry ‘He Medical police was not at once included in the number was one of a class which seems to get liked, by its mere of disciplines that Edinburgh medical students were absurdities’51 He had not been born into the landed required to study before being accorded the degree of scholar-gentry that dominated the Edinburgh medical Doctor of Medicine46 Nevertheless, it was a subject in scene in the second half of the eighteenth century He which most Edinburgh students took an active interest was without wealth or patronage He was a man of the In the 1820s, when some 120 students were graduating Enlightenment when the years of the Enlightenment from Edinburgh each year, up to 100 had attended the were giving way to years of anti-Enlightenment He was classes in public health47 At the same time the a progressive Whig at a time of growing conservative Universities of Glasgow and Aberdeen had also begun to supremacy introduce instruction in medical jurisprudence and medical police and, in the 1830s, these subjects became Duncan overcame his disadvantages, however He mandatory for all licentiates of the Scottish Royal circumvented social exclusion by founding and becoming Medical Corporations and the Scottish Universities president of his own clubs – the Aesculapian Club, the Harveian Society, the Caledonian Horticultural Society, a This was Andrew Duncan’s greatest achievement His golf club and an athletic club – and by getting up his own widening of the scope of the training of Scottish medical parties to climb Arthur’s Seat on May Mornings and to students to include public health took place at a time bathe in the sea at Leith He gained the respect and when ‘medicine was moribund’ at Oxford and support of the student body at Edinburgh by his efforts

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on behalf of the Royal Medical Society He won the Edinburgh’s College of Physicians during the Scottish thanks and admiration of the Edinburgh public by Enlightenment Edinburgh: Royal College of Physicians of establishing a dispensary for the city’s sick poor and by Edinburgh 2001 responding constructively to the notorious and shameful 4 In the seventeenth and eighteenth centuries, the word death of its favourite poet, Robert Fergusson By ‘police’ was often used in the sense of ‘policy’ Duncan, taking his first ideas on health policy (medicinischen polizey) establishing so successfully the first English-language from Germany, used what was then a convenient direct medical journal he became an important figure in translation, ie‘medical police’ It is in that sense that the medicine across Europe and North America word ‘police’ is used here In the nineteenth century that meaning of the word became obsolete In the end, he was accepted in Edinburgh and appointed 5 Duncan A A short view of the extent and importance of to a position that allowed him to make his great and medical jurisprudence considered as a branch of medicine lasting contribution to medicine in Scotland and in Edinburgh: 1798 Britain He introduced the study of public health to the 6 Biographical dictionary of eminent Scotsmen Edinburgh: R medical curriculum at Edinburgh University, an example Chambers; 1855;Vol II; 170 7 Devine TM The Scottish nation London:Allen Lane Penguin quickly followed by other Scottish universities This Press; 1999; 24 advance in medical education was achieved at a time 8 Alexander Monro primus and William Cullen are notable when the great majority of British medical graduates examples in this respect were trained in Scotland; in the century to 1850, Oxford 9 The topographical, statistical and historical gazetteer of and Cambridge produced only 500 medical doctors Scotland Glasgow:A Fulerton & Co; 1842 while 10,000 had been educated in Scotland52 It was 10 Op- cit- ref 6 therefore due to Duncan’s persistent campaigning that 11 Cockburn H Memorials of his time, 1779–1830 when, in the middle of the nineteenth century, Edinburgh: TN Foulis; 1856; 273 Parliament introduced the first British legislation on 12 Drummond never did turn up 13 Uglow J The lunar men London: Faber and Faber; 2002 53 public health measures, the medical profession had 247 received some relevant instruction The full justification 14 Duncan A Medical and philosophical commentaries, 1776 of Duncan’s campaigning did not, however, come for a Edinburgh:Vol IV; 103 further century For many years the phenomenal rise in 15 Brown SW William Smellie and natural history: dissent and the discipline of bacteriology encouraged the belief that dissemination In:Withers and Wood op- cit ref 1, 190–214 the complete and final conquest of disease had become 16 Ibid- 192 a possibility and ‘as bacteriology waxed Public Health 17 An earlier English-language journal, Medicina Curiosa, established in 1684, ceased publication after two issues waned’54 It was not until the second half of the twentieth century, when medicine began to develop as a Medical Essays and Observations first produced in Edinburgh in 1733 and Medical Observations and Inquiries in London in 55 social science, that medical students in Britain were 1757 both appeared erratically and failed to survive again taught to recognise, as Andrew Duncan had done, 18 Duncan A Medical and philosophical commentaries that the ultimate causes of the physical and mental Edinburgh: 1773;Vol I disabilities and degeneration suffered by so many in 19 Chalmers I, Tröhler U Helping physicians to keep Britain included not only an unsanitary environment but abreast of the medical literature: medical and philosophical also poverty, ignorance and destructive lifestyle commentaries Ann Intern Med 2000; 133:238 20 Walker-Smith JA Children in hospital In: Louden I, editor Western Medicine Oxford: Oxford University Press; 1997; REFERENCES 1 Withers CWJ and Wood P Historical overview In: 221 Withers CWJ and Wood P, editors Science and medicine 21 Op- cit- ref 6,172 in the Scottish Enlightenment- East Linton: Tuckwell Press; 22 Only Joseph Black was still alive and in office 2002; 3 23 Webster's census of 1755, the first useful estimate, 2 Donovan AL Philosophical chemistry in the Scottish indicated a population of 1·27 million At the census of Enlightenment; the doctrines and discoveries of William 1801 that figure had risen to 1·6 million Cullen and Joseph Black Edinburgh: Edinburgh University 24 Houston RA The demographic regime In: Devine TM and Press; 1975 Anderson RD and Simpson ADC, editors The Mitchison R, editors People and society in Scotland early years of the Edinburgh Medical School- Edinburgh: Royal Edinburgh: John Donald; 1988; 15 Scottish Museum; 1976 Lawrence C The nervous system 25 Ibid 13 and society in the Scottish Enlightenment- In: Barnes B and 26 Wohl AS, quoted by DevineTM Exploring Scotland’s past Shapin S Natural order: historical studies of scientific culture East Linton;Tuckwell Press; 1995; 126 London: Sage Publications; 1979 Philipson NT The 27 Lord Cockburn recorded that in his lifetime the population Scottish Enlightenment In: Porter R and Teich M, editors of Edinburgh doubled The Enlightenment in a national context Cambridge: 28 Houston op- cit ref 24,16 Cambridge University Press; 1981 A useful guide to the 29 He practiced first in Yorkshire, but for most of his career, literature is given in Withers and Wood op- cit ref 1, 9–12 in London 3 Lawrence op- cit- ref 2 Doig A, Ferguson JPS, Milne IA et al 30 Emerson RL Medical men, politicians and the medical William Cullen and the eighteenth-century world Edinburgh: schools In: Doig A, Ferguson JPS, Milne IA et al op- cit ref Edinburgh University Press; 1993 Passmore R Fellows of 3, 203

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31 Buchan W Domestic medicine Edinburgh: William 44 Ibid 90 Smellie; 1767; Introduction 45 Lecture notes taken by James Keir RCPE M57 32 The phrase, and perhaps the idea, was borrowed from 46 Duncan believed that any student going forward for John Gregory Brown op- cit- ref 15, 195 the MD should already be, a man of wide education, 33 Buchan W Edinburgh Weekly Journal 3 June 1767 fluent in Latin and with some understanding of moral 34 Brown op- cit ref 15, 195 philosophy and political economy 35 Martin SMK William P Alison: active philanthropist and 47 Duncan A A proposal for new regulations in granting pioneer of social medicine (PhD thesis, St Andrews the degree of Doctor of Medicine (1824) RCPE University, 1997) 35 M57 36 Porter R The greatest gift to mankind London: 48 Porter op- cit ref 36, 291 Fontana Press; 1999; 293 49 Poynter FNL The evolution of medical practice in 37 Rousseau JJ Du contrat social ou procipes politique Lesky E Britain London: Pitman; 1961; 3 A system of medical police Boston: 1976; x 50 Chambers op- cit ref 6; 179 38 Martin op- cit ref 35, 37 51 Cockburn op- cit ref 11 39 Duncan op- cit ref 5 52 Dow DA The influence of Scottish medicine 40 Signs and symptoms Carnforth: Parthenon; 1988; 39 41 RCPE M57 53 Public Health Act (1848) 42 Devine TM The Scottish nation London: Penguin 54 Crew FAE Measurements of the public health; Press; 1999; 209 essays on social medicine- Edinburgh: Oliver & Boyd; 43 Nicolson M The continental journies of Andrew 1947; viii Duncan junior In: Wrigley R and Revill G Pathologies 55 Ibid viii of travel Amsterdam: Clio Medica; 2000; 90

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CARE OF THE MENTALLY DISABLED IN AND AROUND EDINBURGH c1680–c18201

RA Houston, Department of Modern History, University of St Andrews

INTRODUCTION Scotland,but it also has certain distinctive features It Individuals with mental problems which made them did not have the first public asylum – that was Montrose, wholly or partly unable to look after themselves could where the institution opened in 1782 However,in the be cared for in a number of ways in eighteenth-century shape of the Bristo Bedlam from the 1740s,it did have Scotland They could be housed with and cared for by the first separate repository exclusively for the insane; their family of origin; looked after individually in their that was nevertheless ‘public’,because it was an adjunct own home by one or more temporary or permanent of the Charity Workhouse opened in 1743 A second minders or ‘keepers’; boarded out with another family distinguishing feature of the Edinburgh area is the sheer on an individual basis; placed in the custody of men and variety of provision in a small area,involving multiple women who took in numbers of such people possible locations for sufferers and various funding simultaneously or consecutively; or incarcerated in an solutions infirmary,poor relief institution,asylum or prison2 Edinburgh in the eighteenth and early nineteenth A third distinctive aspect is the overwhelming centuries offers examples of all of these forms of concentration of Scotland’s licensed private madhouses provision for those whom contemporaries described in in the Lothians (principally Midlothian,but with some in legal terms as incapax or incompos mentis and,in what East Lothian) Responses to an 1816 House of seems to modern ears the harsh language of everyday Commons enquiry revealed that there were 25 licensed life,as mad,lunatic and furious,or fatuous,idiotic and madhouses in Edinburgh Sheriffdom Of these,nine imbecilic This article focuses principally on the former contained a single patient and four contained two The group four largest contained 76 people compared with 17 in the smallest 136 The 1857 Royal Commissioners For much of the nineteenth and twentieth centuries investigating provision for the mentally incapable could formal institutions were the most prominent means of only trace 23 private madhouses in Scotland,12 of which care for the mentally disabled people of Scotland had admitted fewer than 20 patients during the previous Sufferers were best documented (and are thus most year; nine of them had fewer than ten patients7 The historically visible) in asylums This paper deals with the Commissioners believed that it was easier to get origins,development,and extent of institutional care up licenses for private madhouses in Midlothian (where to 1820,and also looks briefly at its alternatives – whatnearly all were located),but this has to be set against the is now cautiously referred to as ‘care in the community’3 background of extensive provision in that shire long In-relief was unusual for any kind of poor person in before the nineteenth century The concentration of eighteenth and early-nineteenth-century Scotland,and private madhouses in the capitals characterised all three throughout the nineteenth century the boarding out of nations In 1819 provincial England had 49 licensed idiots and imbeciles in particular remained more madhouses though the ‘trade’ was concentrated in important than in England4 Workhouses and prisons London,which had 40 at that date; Ireland had only 14 are considered,as well as private madhouses and thelicensed private madhouses in 1844,half of them in the public-chartered asylums5 Dublin area8

This paper briefly discusses sources and sets out the SOURCES numbers of sufferers involved,before chronicling theA House of Commons Committee began an development of institutional care It ranges over a investigation into the care of the mentally afflicted number of issues,including the cost of care,the types of throughout the British Isles in 1815 This was an people who ran asylums,and the experience of payers,important landmark in official thinking about the role of carers and patients The concluding remarks include a asylums in the care of the insane and about state case study which highlights the human dimensions of concern with madness ‘An act to regulate madhouses helping the mentally incapable,focusing on the choicesin Scotland (7 June 1815)’ (55 George III cap 69) people had to make in a world before extensive welfare required annual licensing of private asylums,and twice- provision and before there were many asylum places yearly inspections by the Sheriff-Depute and medical available practitioners9 An inspectorate of eight was elected from the members of the Royal College of Physicians Edinburgh is a microcosm of developments across (Edinburgh) and the Faculty of Physicians and Surgeons

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(Glasgow) Sheriffs,who had ultimate responsibility for confined with private individuals,principally with overseeing enforcement,could also appoint medical small farmers and cottagers,and 21 are in gaols – inspectors and were required to send in reports to the making the number of persons actually in a state of president of the Royal College of Physicians and the confinement,1,861;while upwards of 1,600 are clerk of the High Court of Justiciary The inspectors allowed to be at large,most of them wandering over were to check that all who were confined should be the country,and subsisting by begging11 there and the Sheriff was empowered to release those improperly detained The act specified heavy penalties Another survey for 1818 (based on approximately 850 for any keeper who received a lunatic without a parishes) showed 2,304 males and 2,324 females of reception order from the Sheriff,who for his part waswhom 416 were in asylums or madhouses,1,357 with to ‘satisfy himself as to the propriety of granting such an ‘friends’ (relations),and 2,855 were at large (of whom order,by the certificate or report of medical persons,2,419 were maintained wholly or partly by the parish)12 and otherwise,as the circumstances of the case mayAbsolute numbers were small (one quarter of 1% of the seem to require’ The Parliamentary Select Committee population) and the proportion in any sort of institution of 1815–16,which investigated the condition of private no more than a sixth madhouses in Scotland,also generated information on public asylums LOCATIONS Edinburgh and its hinterland were well-endowed with The investigations and the new legal structures places for the mentally disabled in the early nineteenth subsequently imposed generated quantitative and century,and seem to have been so for over a century qualitative information that provides an anchoring point before The first recorded public institutional provision for earlier material derived principally from original came in the mid-seventeenth century In 1658 manuscript sources,rather from the literary and printed representatives of the General Sessions (comprising all secondary accounts which dominate existing literature the city’s Kirk Sessions) met the city magistrates ‘that a on the care of the mentally disabled The sources used course may be taken for curing the mad people’ They are civil court ‘cognitions’ of mental incapacity (involving agreed that ‘a man may be provided to cure them,and proof by witnesses before a judge and jury),and criminal that a house and other accommodations may be court records involving an insanity defence Family provided for them’14 This initiative was begun in the papers supplement these sources,as do further civilCromwellian era and under English occupation; it is court documents about marital break-up and disputed unclear if anything came of it in the short term A inheritance,newspapers,and the records of Kirk further proposal ‘to build some little houses for keeping Sessions Town or ‘burgh’ council minutes and poor mad people’ beside the House of Correction appears in relief records contain decisions about buildings Edinburgh burgh council minutes for October 167515 (workhouse,prison,House of Correction) and the people who occupied them or who received doles These early initiatives concerned paupers Before 1743, These documents allow investigation of other forms of poor relief across the city of Edinburgh was organised by support and,crucially,the changing types of care,which the ‘Kirk Treasurer’ In his accounts for 1684 there is a individuals might experience in the course of their lives payment ‘to Robert Stansfield from the 29th of or illnesses December 1683 to the 2nd of February 1684 for prisoners,his own wages,whoors [prostitutes] & mad NUMBERS people’ £36 8s 0d16 Stansfield,an Englishman,was the How many people needed or deserved or were entitled keeper of the House of Correction,one of only two to care in eighteenth and early-nineteenth-century such institutions documented in Scotland at this date17 Scotland? In his General view of the present state of It is likely that this type of reformatory played a very lunatics, and lunatic asylums,Andrew Halliday calculated limited role in care of the insane (or any other that ‘in 1826,there were six hundred and forty-eight‘troublesome’ poor),despite the passing of an Act of the individuals in the public and private asylums in Scotland, Scottish Parliament in 1672 ‘for establishing Correction and ten in public gaols; but this bears no proportion to Houses for idle beggars and vagabonds’18 Until the the actual number of insane persons in that kingdom’10 building of the new workhouse and Bedlam during the Using returns provided by clergy from 800 of 900 1740s,Edinburgh lunatics who required locking up were parishes,Halliday claimed that there were some 3,700 generally placed there,though some were briefly insane persons and idiots in Scotland Of these,146incarcerated in one of the tolbooths or jails located in were in private asylums or madhouses,50 in the publicthe royal burghs of Edinburgh and the Canongate asylum and 60 in Bedlam – all in or close to the city of respectively One inmate of the House of Correction Edinburgh Other public asylums and workhouses was Elizabeth Row,daughter to Mr John Row,minister at accommodated 387 people: Dalgety She married John Thomson,writer in Edinburgh: ‘by him she had several children,who died One thousand,one hundred and ninety-two areyoung,and she herself turning wrang [wrong] in the

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head,was committed to Paul’s Work in Edinburgh,where somewhat troubled in mind’31 There was here an early she died in June 1727,and lies buried in the Greyfriars’19 provision specifically for lunatics,which was continued into the nineteenth century32 In contrast,Canongate The search to establish a dedicated asylum continued in Charity Workhouse (opened 1762) never accepted the late seventeenth century A small madhouse was people of unsound mind,and periodically reiterated this built in 1698 in the New Greyfriars churchyard (to policy become the site of the new Charity Workhouse in the 1740s) and a piece of ground to the north was leased to Further developments at St Cuthbert’s illustrate a the incorporation of surgeons who said it ‘was so common thread in the development of care,for they proper for nothing as to be a flower garden for planting were financially driven In July 1781,George Dick, evergreens and other pleasant herbs and flowers for plasterer in Nicholson Street,Edinburgh,was committed ornament’20 Whether this facility was much used is to Bedlam by magistrates:‘he being so much disordered doubtful since the king’s printer in Scotland asked for a in his judgement that both his family and the public were lease of the building in 1715,as it ‘had stood so longin danger’33 A committee of St Cuthbert’s Charity waste and no benefit made to the town thereby and the Workhouse management visited its cells and found that roof was entirely ruinous’21 Ye t by c1730,furious ‘this unhappy man’ could not be accommodated there, people were certainly being held in this early Bedlam as they were insecure and the floors were ‘very damp When Lieutenant George Graham was brought back and consequently hurtful to the health of those who from his deranged wanderings in Fife,he was first lodged were confined in them’ One of the cells was to be lined in the Cowgate then ‘carried    in a [sedan] chair to a with bricks ‘being reckoned warmer than stone’ At a room in Bristo’22 meeting a year later the management committee recalled that ‘a man disordered in his senses’ from St A ‘Charity Workhouse’ was opened in Edinburgh in 1743 Cuthbert’s (the said George Dick) had been sent to and was soon to house more than 500 people In August Bedlam because there were no cells fitted up for such 1745 the keeper of the workhouse received funds ‘for people One member balked at the cost to the buying blankets to lunatics’23 Earlier that summer,a sub- workhouse of £8 10s 0d sterling a year – double what committee of the Charity Workhouse board,the purely they themselves would expend on his care Edinburgh local body which administered the institution,was set up Bedlam was indeed regarded as an expensive asylum to investigate building cells and doing other repairs to Instead of paying the Bedlam rates,it was proposed to the Bedlam The project proceeded during the following equip a cell of St Cuthbert’s Charity Workhouse where three years A new Bedlam was completed in 1748 with Dick ‘or any other unhappy person in his situation might 21 cells,leaving the old madhouse to be used as be an confined with safety’34 infirmary24 The insane are not mentioned in the annual report of Edinburgh Charity Workhouse until year The point about costs is important because asylums or ending June 1748 At that date the facilities housed five madhouses are sometimes portrayed as dumping men and eight women,‘and there has been taken in since grounds for the unwanted That might be true of the opening of the Bedlam 10 men,16 women whereofVictorian public asylums,but not of eighteenth-century have died one man,one woman and five men and institutions six In reality,placing someone in an asylum was women so well recovered that they have the liberty of not a cheap option,for sponsors had to provide entrants the house or have gone out’25 Numbers remained tiny with clothes,bedding,and other necessaries in addition There were 19 lunatics at the time of the annual report to their considerable board and lodging costs35 Indeed, in summer 1749,17 for 1750,13 in 1751 and 18 all in specialist institutional care was expensive The sum 175226 There were said to be about 40 inmates in early required of friends who wished a relative placed in 176327 Edinburgh Royal Infirmary was initially (1742) £5 a quarter,reduced to £3 following complaints The former The new Bedlam was the only purpose-built madhouse meant a charge of just over a shilling a day,the latter 8d in Edinburgh until the nineteenth century,though other a day36 As shown above in the case of George Dick, institutions accommodated the insane Edinburgh Royal Bedlam charged 5½d a day for paupers a generation Infirmary – a hospital in the modern sense28 – was later For comparison,the crown allowed 4d a day for completed in 1748 with 12 vaulted cells for lunatics the aliment of prisoners in the tolbooth of mid- However,it ceased to take in such people towards theeighteenth-century Edinburgh37 end of the eighteenth century29 In June 1768 the newly opened St Cuthbert’s Charity Workhouse asked for That is one end of the paying spectrum At the other,a donations ‘towards the building of a house for people pound sterling a week seems to have been the base for deprived of their reason’30 It received disturbed keeping ‘a person of quality’: £50 sterling was the annual patients on a temporary basis until 1781 In its first year, fee deemed necessary to ‘insure attention and careful for example,Elizabeth Gillespie was admitted ‘till sheusage’ for Alexander Clark at the Stonedykehead private recovers of her present illness as she appears to be madhouse in 179938 Stonedykehead was one of the new

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upmarket private madhouses of the late eighteenth asylums built by taxation While the funds for building century One of the few private madhouses to receive public asylums were certainly voluntary in late unqualified praise from the Sheriff-Depute of Edinburgh eighteenth and early nineteenth-century Scotland,those in 1816 was newly opened at Inveresk and run by for running them were as varied as we find south of the Thomas Hughes He had seven patients paying £50–200 border Three broad categories of patient existed,even a year: unsurprisingly (for that was 30 times what St in ‘public’ asylums: private patients whose families paid Cuthbert’s wanted to pay),‘nothing could surpass the for their whole maintenance; paupers paid for by their good order,cleanliness and comfort that was observable parish; and gratis patients paid for from civic or asylum in this asylum’39 In contrast,Mrs Munro near Edinburgh funds Bedlam took paying patients In 1757 Mr Thomas housed five people,four of whom were paupers boarded Carlyle paid the managers more than £113 sterling at £16 yearly40 Not surprisingly,rich and poor had very ‘contained in the contract for receiving Miss Corbet into different lifestyles During David Cross’s time at the up- Bedlam’45 Edinburgh Morningside was the city’s first market private Saughtonhall Asylum near Edinburgh, true public asylum,opened in 1813,later to become the patients had access to the newspapers three times a Royal Edinburgh Hospital There,a majority of paying week and were always dressed in their best clothes on patients were supposed to subsidise free places,but, Sundays41 Cross ate until he was sick and started eating initially at least,funds were insufficient to allow anygratis again Within the same shire,there were hungry inmates patients to be admitted46 with hardly any clothes to wear Examples given above have already indicated the variety This distinction in provision is also clear for criminal of experience among the inmates of public and private lunatics It is sometimes thought that the mad and bad institutions Both categories contained a spectrum of were lumped together indiscriminately in this period social classes,and there was a wide variation in The reformer Sir Andrew Halliday held up prisons as an standards and treatment in both47 The larger private example of this alleged lack of discrimination Accused madhouses of Midlothian seem to have been most criminals were generally kept in jails both before trial criticised by the Sheriff-Depute of Edinburgh in his and immediately after conviction42 Sometimes judges twice-yearly visitations48 Mrs Veitch’s at Newbigging had ordered the criminally insane to be confined in jail until 27 patients in 1816 and was closely investigated The relatives found surety to restrain them,for it was to kinSheriff recorded ‘the alarm exhibited by the keeper lest that responsibility devolved in the first and last the patients should communicate with the [Sheriff’s] instances43 In the 1800s and beyond,the criminallyReporter not in her hearing,together with her general insane might be sent straight to the Edinburgh Bedlam demeanour,satisfied the reporter that she is by no or one of the asylums which took paupers (for such means of a temper suited for such a charge’49 Mrs convicted felons often were),subject to guarantees toVeitch was not alone in being criticised In the fourth the owners or managers of such institutions about largest private house in the shire the reporters found funding The alternative was languishing in a jail44 excessive restraint,including a woman with chilblains on Sending the criminally insane to an institution to be her feet who had been chained for many years,into cared for in loco amicorum (so to speak) later became the whose room snow was drifting through broken panes, norm,but in the 1800s and 1810s there and was who was kept warm by just two thin blankets and a considerable debate and litigation about the source of thin mattress50 For those historians seeking examples funding for the pauper criminal lunatic of asylums as sinks of humanity,the largest houses seem to have attracted the most adverse comment It may In sharp contrast,people whose families were prepared also be telling that most of the mistreatment uncovered to look after them had a very different fate if found by the visitors involved women Mrs Anderson from irresponsible for their criminal acts on the grounds of Leith complained of being both starved and force-fed at insanity Wealthy murderers like Sir Archibald Gordon different times in the house of Mrs Munro51 Kinloch,convicted in 1795 of shooting his brother,were allowed to live out their days in their own home, We can trace back the tradition of private care for guarded 24 hours a day by keepers paid for by the family individuals and small groups of sufferers to at least the – who had also to deposit a bond for the astronomical start of the eighteenth century James Watt in sum of £50,000 sterling with the authorities Kinloch’s Drumsheugh was a long-standing acquaintance of the home was at Athelstaneford family of Porteous of Craiglockhart When Robert became ill during the 1720s he lodged him in a separate Thus far we have looked at adjuncts of welfare or room in his house and provided a keeper Moved by reformatory institutions,while making mention ofwarrant of the Justices of the Peace to his sister’s house, private madhouses Scotland’s early nineteenth-century Robert was visited there and at Inveresk by Watt After public asylum provision depended more on voluntary escaping from Inveresk he was moved to Slipperfield subscription than was the case in England,which (by thenear West Linton,Peeblesshire,‘at the desire of his middle of the nineteenth century) had more county friends and in company with his two brothers’ Robert

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Porteous beat his landlady’s mother while there,and was This contrasts with England The late eighteenth and therefore returned to Inveresk soon after and was early nineteenth century saw the gradual replacement of housed at William Lindsay’s while the court case to non-medical by medical proprietors in England By 1800 judge his sanity was being conducted On his own two-thirds of English private asylums had medical account,Lindsay,not a physician or surgeon,but a proprietors To a degree,comparisons depend on what gardener in Inveresk,told how Porteous came to stayone describes as an asylum,but there were apparently with him At first he lodged in another house,Lindsaymany more run by doctors in England than in Scotland58 ‘several times coming and going,paying him visits in theScottish lunatics might be visited occasionally by medical way of his trade as a doctor to people in the distemper men,but they were only rarely entrusted to their that Robert Porteous was under’52 Other evidence constant care from this and other court cases shows that even in the early eighteenth century,Edinburgh and its hinterlandIn fact,mad and idiotic Scots were almost always cared had a national reputation both for deciding cases of for by lay men and women who had no professional mental incapacity and for providing specialist private qualification (or pretension) Where medical care for sufferers practitioners learned from their formal training and from consultations,most keepers and under-keepers Most readers would probably assume that the word were essentially amateurs,who learned on the job – ‘specialist’ should be closely associated with the thus ‘empirics’ They blended the abilities of school adjective ‘medical’ Yet most private madhouse teachers,jailers,lodging-house managers and sometimes proprietors in eighteenth and early nineteenth-century healers Those who ran asylums or worked in Lothian were ‘empirics’: lay people with a real or madhouses came from a wide range of backgrounds imagined aptitude for dealing with the fatuous and David Veitch,the allegedly spendthrift husband of the furious Medical practitioners were not prominent in woman who kept the largest private madhouse in running madhouses J Clerk Rattray,a former Sheriff-Midlothian in 1816,said that he was ‘bred a farmer’ Depute of Edinburgh,wrote to the current incumbentOthers came to running madhouses via that route William Rae on 5 April 1817 He claimed to have Warrick Smith at Stonedykehead (an upmarket private ‘promoted to the utmost of my power the madhouse) was one example,as was the gardener, establishment at Morningside which however has not William Lindsay,whom we encountered above The met so much of the public favour as I expected – owing keeper of the Edinburgh Bedlam in 1750 was another very much to the jealousy of the medical men’53 The gardener called Robert Dickie The predominance of background to Rattray’s aside about jealousy is that this group may be attributable to the tradition of physic Thomas Wood,a surgeon,and Andrew Duncan,a gardening or the cultivation of medicinal plants,though physician,both had ideas about opening asylums in thethe physical strength of a man accustomed to manual 1790s Wood withdrew his proposals to the surgeons in labour was also an asset One plank of Mrs Veitch’s claim favour of Duncan’s and in 1800 Wood attended a for separation was that her husband was always drunk meeting of medical advisors to the Morningside Asylum and thus of no use to her in physically managing patients Later he renewed his own scheme54 Ancillary workers were similarly non-specialist Those with sufficient funds could employ one or more keepers In this case it was not the unanimity within medicine,but to attend them at home or even out walking Keepers the tension between elements of the profession which were not ‘nurses’ in the modern sense of the word,but was productive,since two establishments were set upwere there to attend to and contain the potentially The Sheriff-Depute at the time Rattray wrote dangerous rather than to administer medicine The post pronounced that Morningside’s medical care was the provided work for sedan chairmen and the soldiers of best available,but the accommodation was not ideal –Edinburgh city guard,the qualification in this case being not when compared with Wood and Bryce’s exemplary purely strength of arm and broadness of back rather private asylum at Saughtonhall,which ‘also possesses the than medical knowledge or an engaging bedside manner peculiar advantage of being under the care of gentlemen of the medical profession’55 That was true,but only up Except in the case of the larger private madhouses, to a point Saughtonhall was unusually well-staffed by those who took in the mentally incapable seem to have the standards of Lothian private madhouses in 1816, practised lodging or supervising them as a by- with a ‘superintendent’ or ‘principal keeper’ and at least employment They only occasionally gave their two ‘under-keepers’56 However,Bryce himself admitted occupation as ‘keeper’,preferring a more conventional to an 1818 inquest that his partner Dr Wood ‘takes no agricultural or artisanal label Females too may have charge of the patients’ and that the only other medical regarded caring for non-family members as either a full- person who ever saw them was Dr Spence on the or part-time job,providing all or just some of their twice-yearly Sheriff’s visits required by Act of income Women ran ten of the 25 private Midlothian Parliament57 madhouses in 181659 Most of these had only one or two inmates,but the largest two were owned and

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administered by females Yet the role of women who spouse to William Watson,weaver in Edinburgh,lodged specialised in lodging the insane,or who ran madhouses James Arbuthnot in her house for a year and a half with their husbands is under-researched Christian Once he was so delirious he had to be bound ‘to Thomson,wife of Thomas Henderson at Stonedykehead, prevent doing mischief to himself and others’ That was told how John Cunningham had been confined ‘on a standard justification for restraining lunatics,but there account of mental derangement,and that he was at firstwas specific meaning to what she had to say In February somewhat violent particularly when restrained from 1751 she recalled how she ‘came into his room and saw going out’ but had quietened down while becoming a part of his cravat fixed upon the top of the closet door more ‘stupid’ Speaking with a matter-of-fact and by a knot and two pieces of it lying upon the tea table competent air,she described how she managed himThat at that time he told the deponent if his cravat had ‘without necessity of putting on the strait waistcoat by been strong enough he would have been hanging where putting on an iron upon his leg in the night time which the knot was’65 On another occasion she and her prevents him getting out’60 Henderson’s name rather servant accidentally came in and found James was than his wife’s is attached to this private madhouse For bleeding a great deal A surgeon had just bled him,but example,‘The character of Mr Henderson,for attention he had torn off the dressing and re-opened the wound and humanity to the unhappy objects committed to his Refusing to allow Margaret or her servant to bind up his care,has for many years been well known’61 This does arm,he ‘begged of them to let him bleed to death for he not mean he ran it alone Beatrix Smith ran the was dying easily’66 Stonedykehead madhouse with her husband Warrick Smith before Henderson took it over,and she wasCONCLUSION AND CASE STUDY similarly able to give evidence about inmates on her During the ‘long eighteenth century’ there developed an own62 The quasi-professional standing of female increasing variety of locations for the restraint and care madhouse keepers gave them an authority,whichof people with mental problems Those of low transcended the normal limitations of their sex and intelligence (idiots and imbeciles) continued to be cared social status in a profoundly gendered society63 for overwhelmingly in the home,but for lunatics more options became available Infirmary,Bedlam and private Providers of such facilities began to advertise in and public madhouses all opened their doors in our newspapers in the age of George III,as in the case of thisperiod to complement existing private madhouses, Edinburgh woman in 1785: prisons and (for a time) the House of Correction Motives for providing care have not been analysed in Mrs Stoddart,near the foot of Leith Walk,north side: detail here,but the development of care cannot simply Begs leave to acquaint the public that,for thesebe seen as a result of medical professionalisation or a sixteen years past,she has been in the practice desire of to shut away those who had once been (in keeping persons troubled in their minds From her Halliday’s words) ‘at large’ Indeed,there was a strong experience,she hopes she may say that such as arehumanitarian emphasis in the changing provision of in this unhappy state can be no where better institutional care,notably the willingness of Edinburgh’s attended to than with her The friends of those who moneyed classes to subscribe towards the building of a have been entrusted to her care bear ample public asylum testimony in her favours Her house being at present fully occupied,she has been induced to take the one The story of care of the mentally disabled in the long immediately contiguous and therefore has it in her eighteenth century is a profoundly human one with power to accommodate a greater number than particular interest to the medical profession But it also formerly,and from her unremitting assiduity,she touches on many other areas of life Among these we hopes she will continue to deserve the public favour should consider economics At the micro level of the The terms,which are moderate,and otherfamily,choices for care were often driven by financial particulars,may be learnt by applying at her house64 considerations In discussing the motives of private madhouse keepers for taking in individuals or small Court cases are peppered with examples of Edinburgh groups of the mentally disabled we should consider the women who looked after both fatuous and furious men importance of commercial imperatives Economics was and women on a commercial basis important at a macro level too,because Scotland in the late-eighteenth century was beginning to generate Most mad people were cared for individually in their enough wealth to allow funding of institutional care own or someone else’s home Yet this is the most shadowy aspect of care,and one where we Finally,there only is an important political dimension occasionally get glimpses of what life was like for Edinburgh’s first public asylum at Morningside is usually sufferer and carer The best we can do is to multiply associated with Andrew Duncan junior Duncan was a examples and provide detail Those who took on such Whig,which explains why he had to campaign during 15 ‘lodgers’ certainly had a tough job Margaret Wilkie, years of Tory administrations to get his asylum project

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off the ground Nor is it accidental that the Whigs had expense of keeping her decent in clothes’ would cost a brief period in power at the time Morningside received more than her annuity would bear69 For this reason,the its royal charter and the chair of ‘Medical Jurisprudence petitioners rented a house for her at £6 a year with ‘a and Medical Police’ (forensic medicine and public health) servant who had been 14 years with her mother and was established at Edinburgh The initiative to build the her’,and another woman This too did not prove a asylum was conceived and prosecuted by Duncan and permanent solution At the end of two years the woman the Royal College of Physicians,early meetings of the‘wearied of her charge’ and refused to continue on any projectors often being held in its hall However,theterms,with the result that Jean was taken into the active support of the town council and the country’s petitioners’ house in the country Jean was not a principal legal officers was essential,and subscriptionscandidate for Bedlam because she was,in contemporary would never have been raised without the tireless parlance,fatuous rather than furious efforts of all the managers,including £2,000 raised from Parliament by Henry Erskine,the Lord Advocate (andBy the early 1750s Jean was in a dreadful state,racked by Duncan’s friend),and Sir John Sinclair67 It is hard to convulsive fits which left her in ‘a state of absolute avoid the conclusion that,in one way or another,care of idiotry’ and ‘devoid of all sense and understanding’ She the mentally disabled has always been a political matter was also covered in ‘loathsome ulcers’ The main reason and that,while at root a deeply personal issue,it hasfor the ulcers was bed-sores since Jean was too weak to always had a very public face turn herself where she lay When helped from bed,she also tended to sit too close to the fire if left unattended This article ends with a case study,which illustrates theand her clothes caught alight Once,she had fallen into problems and possibilities for those with a mentally the fire and the resulting burns had turned septic,adding disabled dependent The case of Jean Marshall illustrates to her bodily discomfort Her sores had to be dressed the difficult choices and limited facilities available to regularly and,to cap it all,she was incontinent:‘her bodily carers in mid-eighteenth-century Scotland Jean’s infirmity was at all times so great that she constantly relations squabbled over her inheritance before the spoiled her bedclothes,which,besides a perpetual Court of Session from 1756 until just after her merciful attendance and trouble that no servant cared to submit death in the spring of 1758 Those who cared for her to,occasioned a great waste and consumption of until her demise were her maternal niece,Marybedding’70 While Lawrie was a surgeon and could Gillespie,and Mary’s husband,Gilbert Lawrie of provide medicines and advice,it was his wife who did Crossrig,surgeon in Edinburgh Their interest was inmost of the day-to-day caring and ‘it has been great part retaining control of an annuity,left to Jean by of herthe work of the whole family to look after and wait mother,against the efforts of her cousin,who was heron her’ However exaggerated their claims,it would be legal curator or guardian hard to deny their argument that such a person made ‘a disagreeable boarder’,and that care of her ‘is not simple Never very bright (‘originally but of mediocre boarding’71 Those who seek to criticise modern understanding’),Jean Marshall’s physical and mentalinstitutional care for the mentally incapable may wish to health had been declining for years before her plight was consider the plight of Jean Marshall’s relatives recorded in the court papers In particular,convulsive fits,which Jean began to experience,left her very poorly REFERENCES in the mid-1740s Her predicament worsened when her 1 This article was first delivered as a paper to the Old mother died in 1746 Gilbert and Mary,faced with the Edinburgh Club in November 2000 The research on problem of who was to look after Jean: which it is based was made possible by funds provided by the Trustees of the Leverhulme Foundation with much importunity,prevailed upon a good 2 Houston RA ‘Not simple boarding’: care of the mentally friend of her mother’s,one Mrs White,to take her incapacitated in Scotland during the long eighteenth into house and board her at a rate of £5 sterling per century In: Bartlett P and Wright D,editorsOutside the quarter; but at the end of one quarter she grew so walls of the asylum: the history of care in the community, 1750–2000 London:Athlone; 1999; 19–44 Houston RA wearied of her that no arguments could prevail upon Madness and society in eighteenth-century Scotland Oxford: her to keep her any longer,though the petitioners Oxford University Press; 2000 Houston RA Therapies for were willing to give any addition to her board that mental ailments in eighteenth-century Scotland Proc R Coll she could demand68 Physicians Edinb 1998; 28(4):555–68 Houston RA Institutional care for the insane and idiots in Scotland However financial the reason for their petition,and before 1820 Part 1 Hist Psychiatry 2001; 12:1,3–31 Part however overstated their submission,Mary and her 2 Ibid+ 2001; 12:2,177–97 husband seem genuinely to have cared about Jean 3 For an example of how communities could help families in Indeed,nobody else would take her The Royal Infirmary caring for the mentally disabled see Houston RA and Frith U Autism in history+ The case of Hugh Blair Oxford: wanted £20 sterling a year plus another £12 a year for Blackwell; 2000 For the fuller context of Scotland's constant attendance by a servant,‘which with the

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history in the eighteenth century see Houston RA and relief in Scotland+ An outline of the growth and Knox WWJ,editors The new Penguin history of Scotland administration of the poor laws in Scotland, from the middle London: Penguin; 2001 ages to the present day Aberdeen: D Wyllie & Son; 1923; 4 Sturdy H and Parry-Jones W Boarding-out insane patients: 76–80 Ibid,56,quotes authorities who state (variously) the significance of the Scottish system,1857–1913 In: that no such institutions were built (Monypenny D Bartlett P and Wright D,editorsOutside the walls of the Remarks on the poor laws, and on the method of providing for asylum: the history of care in the community, 1750–2000 the poor+ Edinburgh:Thomas Clark; 1834; 28) and that three London:Athlone; 1999; 86–114 were erected 5 On lunatics in prison see Cameron J Prisons and 8 Mitchison R North and south: the development of the gulf punishment in Scotland from the middle ages to the present+ in poor law practice In: Houston RA and Whyte ID, Edinburgh: Canongate; 1983; 158–81 editors Scottish society, 1500–1800 Cambridge: 6 Third report of the Committee on Madhouses in England, Cambridge University Press; 1989; 208 The act was etc (June 1816) Parliamentary Papers (PP) 1816; modelled on the English statute of 1601 VI:353–400 Forfarshire was the only other county 19 Maidment J Memorials of the family of Row Edinburgh: np; returning licensed private madhouses,having four singleton 1828; 5 establishments National Archives of Scotland (hereafter 20 Armet H,editor Extracts from the records of the burgh of NAS) JC54/1 Edinburgh, 1689–1701 Edinburgh: Oliver & Boyd; 1962; 7 Rice F Madness and industrial society A study of the 232–3,235 origins and early growth of the organisation of insanity in 21 Armet H,editor Extracts from the burgh records of nineteenth-century Scotland, c+ 1830–1870 University of Edinburgh, 1701–18 Edinburgh: Oliver & Boyd;1967; Strathclyde: unpublished PhD thesis; 1981; 268–70 xxxiii–iv 8 Parry-Jones WL The trade in lunacy: a study of private 22 NAS SC39/36/2,George Graham (1732) madhouses in England and Wales in the eighteenth and 23 ECA Edinburgh Charity Workhouse,vol 1,7 August 1745 nineteenth centuries London: Routledge & Kegan Paul; 24 Birnie A The Edinburgh charity workhouse,1740–1845 1971; 30 Robins J Fools and mad+ A history of the insane in Book of the Old Edinburgh Club 1938; 22:40,45 Houston Ireland Dublin: Institute of Public Administration; 1986; 82 RA Fraud in the Scottish linen industry: Edinburgh’s 9 Andrews J ‘They’re in the trade of lunacy+ They “cannot charity workhouse,1745–58 Archives 21 1994; 91:43–56 interfere” – they say’+ The Scottish Lunacy Commissioners and 25 ECA Edinburgh Charity Workhouse,vol 2,4–5 lunacy reform in nineteenth-century Scotland London: 26 ECA Edinburgh Charity Workhouse,vol 2,25,38,47,54–5 Wellcome Institute for the History of Medicine; 27 NAS SC39/36/6,John Rutherford (1763) Occasional Publications no 8; 1998; 2 Pages 2–6 deal with 28 The word ‘hospital’ was usually applied to a place of ‘inspecting and overseeing the insane pre-1857’ Beveridge retirement Gairdner A An historical account of the old A On the origins of psychiatric thought: the contribution people’s hospital, commonly called the Trinity Hospital in of Edinburgh,1730–1850 In: Freeman H and Berrios GE, Edinburgh+ Edinburgh: np; 1728 editors 150 years of British psychiatry Vol+ 2: the aftermath 29 Risse GB Hospital life in Enlightenment Scotland London:Athlone; 1996; 339–66 Includes some information Cambridge: Cambridge University Press; 1986; 31,107 The on early Edinburgh asylums,but is based solely onchange in policy can be dated from 1789 though it may be secondary sources that those who could pay fees were still admitted 10 Halliday A A general view of the present state of lunatics, and 30 ECA St Cuthbert’s Charity Workhouse Minutes,vol 1 lunatic asylums, in Great Britain and Ireland, and in some other 31 ECA St Cuthbert’s Charity Workhouse Minutes,vol 1,27 kingdoms London: Thomas & George Underwood; 1828; October 1767 27 32 This was also true of eighteenth-century Dublin,where 11 Ibid+ 28 lunatic paupers were cared for in a hospital attached to the 12 Tuke DH History of the insane in the British Isles 1882; 330 ‘house of industry’ Nicholls G A history of the Irish poor Quoted in Easterbrook CC The chronicle of Crichton Royal law London: John Murray; 1856; 103 (1833–1936) Dumfries: Courier Press; 1940; 14 See also 33 ECA St Cuthbert’s Charity Workhouse Minutes,vol 3,17 Summary,showing,according to the returns from the July 1781 The same thing had happened to the poet parochial clergy in Scotland the number of lunatics in each Fergusson a few years earlier Houston RA Madness, presbytery (House of Commons,9 July 1817)NAS morality,and creativity: Robert Fergusson and the social SC9/21/1 context of insanity in eighteenth-century Scotland Br J 13 Scotland’s capital has recently been the subject of a 18th Cent Stud 1999; 22:133–54 substantial new social history Houston RA Social change 34 ECA St Cuthbert’s Charity Workhouse Minutes,vol 3,2 in the age of Enlightenment+ Edinburgh, 1660–1760+ Oxford: July 1782 Oxford University Press; 1994 35 Walsh L ‘The property of the whole community’ Charity 14 NAS CH2/131/1,ff12–12v and insanity in urban Scotland: the Dundee Royal Lunatic 15 Wood M,editor Extracts from the records of the burgh of Asylum,1805–1850 In: Melling J and Forsythe W,editors Edinburgh, 1665–80 Edinburgh: Oliver & Boyd; 1950; 240 Insanity, institutions and society, 1800–1914 A social history of 16 Edinburgh City Archives (hereafter ECA),Kirk Treasurer’s madness in comparative perspective London: Routledge; Accounts 1999; 183–4 17 Wood M St Paul’s work Book of the Old Edinburgh Club 36 Turner AL Story of a great hospital+ The royal infirmary of 1930; 17:49–75 Aberdeen had a House of Correction, Edinburgh, 1729–1929 Edinburgh: Oliver & Boyd; 1937; though only for a few years in the mid-seventeenth 97–8 Edinburgh: Lothian Health Board [Edinburgh century This was emphatically a workhouse,to which University Library] (LHB) 1/72/14 lunatics and idiots were not admitted Cormack AA Poor 37 See the case of Robert Spence (1750): NAS JC7/27,334–8

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38 Signet Library (SL) Session Papers,vol 400,case 22, [Tyninghame Estate Office,Dunbar:TD73/130/ bundle 21, ‘Answers for James Whyte    ’,2 unnumbered] 39 PP 1816,VI, 368 54 Craig WS History of the Royal College of Physicians of 40 NAS JC54/1,report for Edinburgh (1816),25 Edinburgh Oxford: Blackwell; 1976; 196 LHB HB7/1/1,10 41 NAS SC39/47/9,David Cross (1818) 55 PP 1816,VI, 370 See also 372 42 See,for example,the case of John Philip analysed 56 in SC39/47/7,David Balfour Hay,1807 SC39/47/8,John Hay Houston RA A stalker in Georgian Edinburgh History (1811) NAS SC39/47/9,David Cross (1818) Scotland 2001; I:51–6 57 NAS SC39/47/9,David Cross (1818) The Spence referred 43 NAS JC3/47,29 June–15 July 1795 to was presumably Dr Thomas Spens,one of two visiting 44 As happened to Robert Spence (NAS JC7/25,29 June 1747 physicians to the Morningside Asylum Smith CJ Historic JC26/135/D2362 JC7/27,334-8) and Jean Blair (NAS south Edinburgh+ Edinburgh: 1978; 195 JC3/41,13 March 1781) Spence’s case is analysed in detail 58 Parry-Jones Trade in lunacy+ op+ cit ref 8 284 in Houston RA New light on Anson’s voyage,1740–1744: 59 PP 1816,VI, 367–71 a mad sailor on land and sea Mariner’s Mirror 2002; 60 NAS SC39/47/6,John Cunningham (1801) Andrews J 88:260–70 Identifying and providing for the mentally disabled in early 45 ECA Edinburgh Charity Workhouse,vol 2,101 modern London In:Wright D and Digby A,editorsFrom 46 LHB HB7/1/1 See the minutes of 1806 and 1811 for idiocy to mental deficiency: historical perspectives on people examples Checkland O Philanthropy in Victorian Scotland: with learning disabilities+ London: 1996; 82–4 Finds a social welfare and the voluntary principle Edinburgh: John number of women nursing idiots in early modern London, Donald,1980; 175 The same aspiration characterised though this may be because the objects of their care were Glasgow and Dundee Andrews J Raising the tone of usually young children There is some evidence for this in asylumdom: maintaining and expelling pauper lunatics at a document relating to Renfrewshire,but the licensed the Glasgow Asylum in the nineteenth century In: Melling madhouses of Lothian dealt exclusively with adults,as did J and Forsythe W,editorsInsanity, institutions and society, the public asylums of the early nineteenth century PP 1800–1914+ A social history of madness in comparative 1816,VI, 399–400 perspective London: Routledge; 1999; 206–7 Walsh, Charity 61 SL Session Papers,vol 400,case 22,‘Answers for James and insanity op +cit ref 35 189–90 Walsh also highlights the Whyte    ’,2 (1799) importance of income from paupers to the finances of 62 For example NAS SC39/36/13,Agnes Wright (1795) asylums like Dundee in the first half of the nineteenth 63 Houston RA Madness and gender in the long eighteenth century century Soc Hist 2002; 27:309–26 47 Rice FJ Class and the treatment of the insane in mid- 64 Edinburgh Evening Courant,no 10,473,2 March 1785 nineteenth century Scotland Journal of the Scottish Labour 65 NAS SC39/36/4,James Arbuthnot (1752) History Society 1985; 20:43–58 Demonstrates the class- 66 Bleeding was a standard treatment for maniacal and based differences in care for a later period See also melancholic conditions,along with purging Cullen WFirst Andrews J Case notes,case histories,and the patient’s lines of the practice of physic 1778–84 4th ed Edinburgh: experience of insanity at Gartnavel Royal Asylum,Glasgow, 1784; vol 4;156–60,173,184–6 in the nineteenth century Soc Hist Med 1998; 11:255–81 67 Report by William Scott,W+ S+, treasurer of the Lunatic Asylum 48 The larger houses did not always specialise in paupers as at Morningside, to the managers of that institution; detailing its Scull suggests for England Scull AT The most solitary of rise, progress, and present condition, with regard both to its afflictions+ Madness and society in Britain, 1700–1900 funds and inmates [since 1792] Edinburgh: Andrew London:Yale University Press; 1993; 81 Shortrede; 1836; 3–12 49 PP 1816,VI, 368 68 SL Session Papers,vol 120,case 17,‘Petition of Gilbert 50 PP 1816,VI, 368–9 Lawrie    ’,3 51 NAS JC54/1,report on Edinburgh (1816),26 69 Ibid4 52 NAS SC39/36/1,Robert Porteous (1728) 70 Ibid7 53 National Register of Archives for Scotland 3503/1/21/1–15 71 Ibid+ vol 58,case 30,‘Petition of Gilbert Lawrie    ’,7–8

20 J R Coll Physicians Edinb 2003; 33(suppl12):12–20 DAVID LIVINGSTONE

DAVID LIVINGSTONE AND SOUTHERN AFRICA’S FIRST RECORDED CASES OF SICKLE-CELL ANAEMIA?

GW Clendennen, Lecturer, Kyoto University, Japan, and J Lwanda, GP and Honorary Senior Lecturer, Department of General Practice, University of Glasgow

INTRODUCTION: THE DISEASE AND LIVINGSTONE EARLY CASES OF SICKLE-CELL DISEASE Sickle-cell anaemia is an inherited (non-gender linked Although a genetic disease of considerable antiquity, the Mendelian dominant) disease that, in the homozygous modern medical history of sickle-cell anaemia is state, in the presence of certain adverse conditions can relatively short; written reports date only from the mid- lead to severe haemolytic anaemia accompanied by nineteenth century! However, malaria, against which the painful ‘crises’, due to its abnormal haemoglobin HbS! heterozygous (sickle-cell) trait confers an advantage The genetic abnormality is caused by a substitution of (particularly in infancy),4 is recorded in Egyptian papyri!5 valine for glutamic acid at position six in the beta chain of the normal haemoglobin A! Haemoglobin S changes In sub-Saharan Africa, little work has been done on the shape as it de-oxygenates! Sickling causes red cells to history of sickle-cell disease except within a few centres, become more fragile, rigid and easy to aggregate, thus such as the Korle Bu Hospital in Accra, Ghana! facilitating stasis, small-artery blockage and tissue Nevertheless, the disease has been known for infarction!1 centuries!6 In West Africa the syndrome that caused ‘cold-season rheumatism; pallor of nails, tongue, palms of Sickling disorders include the heterozygous state for hands and soles of feet; yellow colouring of eyes; and a haemoglobin S or the sickle-cell trait (AS), the homo- general low state of health’ was from ancient times zygous or sickle-cell disease (SS), and the compound called chwechweechwe by the Ga people, and nuidudui by heterozygous states formed by HbS with other the Ewe,7 with the onomatopoeic forms reflecting the haemoglobinopathies, like haemoglobins C, D and E, and repetitive, relentless and gnawing experience of the with the thalassaemias!2 sufferer!

When on a journey into the high hinterlands west of In Malawi (the setting for the present study) the most Lake Malawi (then Nyassa) in 1863, David Livingstone troublesome aspect and commonest manifestation of and almost two dozen African companions of varying the disease, pain,8 was given the specific diagnosis of ethnicity and birthplace encountered a strange and, to rheumatism (nyamakazi); with chronic leg ulcers (zilonda Livingstone, unprecedented disease! The symptoms zosapola), and jaundice (matenda achikasu), among the appeared soon after the men had climbed from the other commoner symptoms! The Chewa language lakeshore to a plateau of over 3,000 feet, and were describes the several types of pain caused by the exhibited by almost half of the Africans! One case was disease: kupweteka pweteka (persistent or repeated to prove fatal! Livingstone took notes on the spot, pain), kuwawa (a biting pain), and kulasa lasa (stabbing mentioned the problem in letters after a few months, pain)! The concepts of ‘repeated’, ‘biting’, and ‘stabbing’ and commented for the last time in a book published pains are similar to those found in West Africa, and in two years later, but he was never able to satisfy himself modern sickle-cell narratives!9 concerning the true nature and identity of the disease! Livingstone’s own map is reproduced in Figure 1! The known severe form of the disease arrived in the Subsequent developments in medical science strongly Americas via the slave trade,10 yet black Africans were suggest that the disease was sickle-cell anaemia!3 present in Europe even before the heyday of Rome! The first recorded case in Western medical literature This paper examines a historical incident, recorded long suggestive of sickle-cell disease, reported by R Lebby, ago on the spot, which seems to have relevance today to came much later, during the era of abolition of slavery! one such ‘new’ disease! The authors suggest – from the In 1846, a runaway slave in the US, of unrecorded name, limited available written narrative evidence and in the was captured, executed and subjected to an autopsy light of present knowledge – but do not seek or claim to which revealed that the ‘spleen [was] wanting’! The prove conclusively, that Livingstone was the first to man’s known medical history (‘bilious intermittent and describe a sickle-cell crisis in southern Africa! Without remittent fevers’) and phenotype (‘full chest, narrow corroborative data, such as testable archaeological hips, very spare build’) are all suggestive of sickle-cell remains, proving conclusively that these were cases of disease!11 sickle-cell anaemia, at that time in this geographical area, would be impossible! The first recognised written description of the sickle- cell ‘syndrome’ in Africa, by the Sierra Leonean graduate

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13° South latitude

21st 4 pm Line of 1,000 metres above sea level 18/21

17/18

Slave trade route to Katanga Masses of hills

Civil headman 16/17

14/15

Village of a civil headman 13/14 34° East longitude

Kasamba River

13th 6 am North

FIGURE 1 The journey from Kotakota to Muasi’s village

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of Edinburgh University, Africanus Horton, appeared 28 in 1971! As this survey was carried out at the central years later! Horton described ‘the fever of crises, the referral facility (Queen Elizabeth Hospital, in Blantyre), shifting joint pains, the exacerbations during the rainy this percentage was considered a fair average for the season, and the constant abnormality of the blood’!12 entire country, given the nature of sickle-cell disease!25 This published description came, as is suggested below, Sickle cell remains a major cause of anaemia in Malawian 11 years after Livingstone’s apparent encounter with the children!26 Another major study gives an average disease in the uplands west of Lake Malawi! Another frequency of 3–9% for the entire Zambia–Malawi– early case report, by E Hodenpyl, appeared in 1898: a 32- Mozambique area, which is consistent with the above year-old black male exhibited generalised body pains, information!27 pleuritic symptoms, jaundice, and an absent spleen!13 Hodenpyl’s description came after Felix Hoppe-Seyler’s The combination of a sickle-cell trait with beta discovery, in 1862, of haemoglobin and its role in oxygen thalassaemia can give rise to sickling! The frequency of transport!14 Twelve years later the first formal report of beta thalassaemia (also thought to confer some sickle cell came, also from the US! JB Herrick, with advantage against malaria in the carrier state) in the significant input from his internist Ernest Irons, southern African area, at approximately 1%, is therefore described the case of a young Grenadian studying at the an added mathematical factor increasing the possibility Chicago College of Dentistry named Walter Clement of a sickle-cell carrier marrying another sickling-state Noel, who had sickle-cell disease!15 Finally, in 1922 VR carrier partner!28 Mason summarised the first four cases, and used for the first time the term ‘sickle-cell anaemia’!16 LIVINGSTONE’S PREPARATION David Livingstone began the formal study of medicine at After Mason’s work, early speculations that it was either age 23, when in 1836 he enrolled in Glasgow’s a ‘latent disease’, or that carriers bore ‘lethal genes’ that Andersonian College (now Strathclyde University)! In could be spread to the general populace via inter-racial 1838 he moved to London in connection with his mixing, were eventually broken down with the missionary plans, and continued studying medicine at the demonstration by the Nobel Laureate Linus Pauling of British and Foreign School of Medicine, the General the molecular basis of the sickle-cell problem!17 During Dispensary at Aldersgate, the Charing Cross and those decades, progress on the disease was Moorfields Hospitals, and perhaps also the Ophthalmic compounded by – and indeed mirrored clearly – the Hospital in Moorfields! wider suppositions and debates about race and eugenics in the US and Europe! Initially sickle-cell anaemia was As the young Livingstone suffered from both lack of thought to be an exclusively African disease, but knowledge and money, he was probably admitted gratis subsequently the gene has been found to occur (in to most of these places in London by elders who varying frequencies) in all racial groups,18 and in fact the recognised both his promise and his seriousness! Unable highest gene frequencies occur among non-African racial to meet the fee of a final medical examination in groups, in Saudi Arabia and India!19 However,the diseases London, in November 1840 Livingstone sat for the produced elsewhere are much milder than the ‘African’ diploma of the Faculty of Physicians and Surgeons in type! Glasgow, passed his test, and three weeks later was outward bound for Africa!29 INCIDENCE OF SICKLE-CELL DISEASE In the southern African region the sickle-cell gene is From early 1841 to late 1856 Livingstone was at first a found in all Bantu-speaking groups to differing extent, settled and later an itinerant missionary in the remotest with a 5–9% frequency in southeast Mozambique, the parts of southern and south-central Africa! He had homeland of Livingstone’s ‘Shupanga’ men!20 Botswana ample time to study African people, their languages and (2%), Zambia (5%) and Zimbabwe (0·8–6·3%) comprise customs, behavioral patterns and diseases, and his the land of the Kololo!21 Within Zimbabwe, a much journals and notebooks from these and later days are a higher incidence occurs along the Chobe River system, rich and untapped source of information about African which runs through the Kololo heartland, than in the customs and culture, especially medicine! Livingstone remainder of this mostly arid country! The sickle-cell also accumulated plenty of experience of the great gene is found at a 3% frequency in the Comoro Islands, continent itself, becoming intimate with its climate, from which up to a dozen men accompanied Livingstone geology, history, drainage systems, and wildlife! Evidence on this trip!22 This island group, so important to suggests that he received medical journals sporadically Livingstone during this phase of his career in Africa,23 from friends in Great Britain and his brother Charles, was ‘mainly settled by migrants from the Mozambique first from Ohio and later from the northeastern US, but Coast and the Arabian Peninsula; both are regions of as Livingstone was usually far from population and sickle-cell disease with allelic frequencies of 6–8% and medical centres and quite bereft of regular 2–4% respectively’!24 Within Malawi the sickle-cell trait communications, it seems unlikely bordering on was found to be 5·4% in the only major survey to date impossible that he read Lebby’s diagnosis of 1846!

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In 1858 Livingstone began his second tour of Africa, this ascended past the 1,300-foot (396-metre) level above time as the leader of the government-sponsored the rapids! There they turned west and northwest up Zambezi Expedition in the continent’s southeast, and it the Rivirivi River, and marched north across the seems certain that at that time, he witnessed firsthand watershed (elevation 2,524 feet, 769 metres) and down the ravages of sickle-cell disease among his African near the southwestern shore of Lake Malawi! The men companions! proceeded normally on this leg of the journey, although a Comoro man with the unlikely name of Zachariah34 LIVINGSTONE’S OBSERVATIONS often rested when on the march, which Livingstone, who The austral winter of mid-1863 caught David Livingstone usually knew, attributed to laziness! facing an untoward period of inaction! The explorative and scientific (read ‘colonising’) expedition he had led Livingstone’s route next led northwest away from the for over five years into south-central Africa had just lake, then back northeast, and followed the shore to been recalled by HM Government, in failure! Few, if any, Nkhota Kota, just under 13º south latitude and the of its anticipated results had been realised, and the eastern point of the main slave trade route from Katanga undertaking had illustrated more the Sisyphean strivings in the interior! Having heard two years previously of two of man, both European and African, against the elements unmapped lakes in that direction, and wanting to study of that great continent, than the progress and syntheses the slave trade closer to its source, Livingstone turned one usually associates with geographical revelation and and led his men inland! They left Nkhota Kota on 13 the application thereto of science! The timely order of September,35 and after crossing a small fruited plain recall surprised almost no-one, and in fact six weeks began ascending the tableland west of the lake! The way previously Livingstone had begun sending his was steep and undulating: each ‘up’ had a downside that companions of both continents to their homes! Chief added significantly to the toil! The day after departure, among the departees was Livingstone’s right-hand man, Livingstone wrote: ‘! ! ! up steep inclines & down others John Kirk, MD, who two years earlier had described the gives the lungs many a blow – roads rough & hard for world’s first case of blackwater fever!30 Livingstone, feet’! A third day of the same followed, and high up on however, had to remain: two ships in his charge (one his the scarp that night Livingstone noted a temperature of own) were stranded far up a shallow river, immobile 74ºF (23ºC) at an altitude of 3,440 feet (1,049 metres) until the spring rains of November at the earliest! above the sea!36 On the 16th at dawn, usually the coldest part of the day then and there, the temperature had With time on his hands, anathema for Livingstone, he dropped to 62ºF (17ºC), and Livingstone wrote: ‘Four decided to proceed with work begun in 1859 and Shupanga men said to have headache fell behind ! ! !’ continued in 1861: the exploration of Lake Malawi, its Later that day Livingstone added:‘! ! ! five men sick from outlets, inlets, and hinterlands, and the precise sitting in the cool draught of the air of the highlands relationship of it all to the slave trade! Along with the when heated’! curing of malaria, the elimination of the east African Arab-Swahili-dominated slave trade had become the Next day the march resumed over ‘gently undulating’ goal of Livingstone’s life, and thus he and his companions country, accompanied by a ‘heavy drift of clouds to set out northward on 15 July 1863! Livingstone was north, with a few drops of rain & cold high wind,’ and accompanied by about 20 Africans,31 including at least ‘men were sick from stoppage of perspiration on hills, four Kololo from the region upriver of Victoria Falls; ten the wind being very cold & the men sit in it without or 12 Comoro Islanders from Nzwani (his ‘Johanna’ clothes’!37 Friday, 18 September saw the temperature men, one of whom had died on the Tchiri River in the drop to 46ºF (less than 8ºC), and ‘2 Shupanga men previous March); and at least five ‘Shupanga’ men [Arimasau, and probably Mandzu] remained behind, & (Kanyai, Peoso, Ropa, Arimasau, and Mandzu) from the we had to stop at a village a mile ahead – others sick or lower Zambezi valley!32 One additional and somewhat beginning to be’! Later that day, perhaps after camping shadowy figure was Royal Navy sailor Thomas Ward, and when getting ready to turn in, Livingstone wrote the Steward of HMS Pioneer, who made the journey to tragic sentence:‘Arimasau died at village behind!’ At that improve his health and act as Livingstone’s cook, and time, Livingstone was at Undi’s, about a mile ahead of the whom Livingstone never mentioned by name, except in sick men, who were at Chimponda’s! the odd list here and there! There were also an unspecified number of Mang’anja and Yao men, most (but Saturday’s temperature rose to a low of 54ºF (12ºC) at apparently not all) of whom turned back after only a few sun up, but:‘Eight are down ill – headache, pain in chest days!33 & back & joints! It is cold and they will sit naked so medicines determining to the skin are rendered Starting from an altitude of about 100 feet (30·5 metres) useless’!38 The men were ‘somewhat better but still above sea level (below which all of Livingstone’s down’ on the following day, and a passing Babisa man companions except the Kololo had been raised) at the suggested that they all might have been poisoned by foot of the Tchiri River Cataracts in Malawi, the party drinking water, perhaps treatment meted out to

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strangers travelling on this major highway of slave raised in a lowland malarious district, unlike the Kololo drivers! Although Livingstone himself had been suffering men and the rest of the party! At this time Livingstone, the week from ‘dysenteric affection’, he had no stoppage and apparently everyone else, believed that malaria was of perspiration, and believed, as he had after living and caused by some unidentified substance airborne in the walking over 20 years in various African climes, that effluvia of tropical swamps, although he had frequently continued activity (‘marching’ or walking) improved noted malaria and mosquitoes in the same sentence, and almost any illness! Finally, on 21 September the party his brother Charles had suggested that the bite of the reached Muasi’s village, where they rested two days, as female mosquito was much more ‘poisonous’ than that some of the men were still ill! of the male!42 Just at this time, however, Livingstone was beginning to doubt the ‘mal-air’ theory, for while on this This concludes the notes written by Livingstone ‘on the trip he noted: ‘! ! ! malaria and offensive effluvia are not spot’! At that time his mind was filled to overflowing always companions’!43 with the strange disease; the recall of his expedition; the future of his friends in the Universities’ Mission to What appears to have been Livingstone’s final words on Central Africa and the Africans they had together freed the subject of the ‘new disease’ he wrote early in 1865, from slavery, now near his ships; the slave route he was in his book about the Zambezi Expedition! Much of on; the rivers and lakes ahead; and most of all, his what appears above was included, but Livingstone added determination to be back to his ships and men by 1 a few more pieces to the puzzle! In recording November (he was to arrive there on that very day)!39 temperature, Livingstone wrote that it was only 10º F During that month he rested and recovered from his higher down at lakeside but he gave an upland figure of own fatigue and dysentery, and in December, when the 52ºF (when his notebook recorded a low of 46ºF on the annual rains had still not appeared (indicating that morning that Arimasau died)! The men scarified44 ‘almost Livingstone’s haste might have been mitigated by better every part of their bodies as a remedial measure, [and] perception), he began a period of intense letter-writing! medicines administered on the supposition that their In at least two of his letters that month, Livingstone malady was the effect of a sudden chill had no effect’! mentioned the tragedy which had been played out high The unfortunate Shupanga man died due to a ‘change on the faraway tableland! from a malarious to a purer and more rarefied atmosphere’!45 One he wrote to Dr Kirk, now safely home in England, on 9 December: ‘The Shupanga men, who are malaria- Almost two weeks after Arimasau died,‘The effect of the proof in the Delta, succumbed on the heights – and one piercing winds upon the men had never been got rid of! of them actually died from change of air! The Several had been unable to carry a load ever since we temperature was not low! They complained of pains all ascended to the highlands; we had lost one, and another over, cut themselves everywhere, I never saw anything poor lad was so ill as to cause us great anxiety! By like it! They were useless [for work]!’40 There is no waiting in this village [Chinanga’s, on the banks of a known evidence suggesting that Kirk responded to this feeder of the Loangwa River] ! ! ! all became worse!’ Also, in writing, or that the two men subsequently discussed ‘The Makololo too were becoming dispirited by sickness the case together when they met often during the and want of food ! ! !’46 Thus the men continued to suffer following two years! for two weeks after they clambered up onto the plateau, and likely did so until they returned to the lowlands over Three days later there was additional information for a week later! The earliest published reference to this the Foreign Secretary, Lord John Russell, on the plateau: tragedy was by Blaikie:‘Some of the natives had been ill, and indeed one had died in the comparatively cold !!!we witnessed a strange phenomenon in five climate of the highlands!’47 As during his trip up the west Shupanga men, accustomed from infancy to the shore of the great lake in 1861, Livingstone and his men malarious air of the Zambesi delta! The atmosphere were unable to ‘live off the land’, and on top of that, both of the heights quite overcame them! The times they were confronted by the Mazitu, Zulu- temperature differed but little from that of the lands descended Africans who ravaged the area and killed below but the wind seemed to pierce through one! thousands of the local Maravi inhabitants! There was They complained of pains all over and scarified large danger in the land, and careful return was prudent! portions of their bodies & limbs, and in two days one actually died apparently from change of air alone! DISCUSSION They have the advantage of us in the malarious With hindsight it is easy to recognise the many districts but we had it in the pure air which similarities between the clinical signs recorded for the exhilarated mind & body!41 Shupanga men, the Comoro Islanders, and the Kololo, and a number of medical conditions now known! Clearly, with time to reflect, the only clue that Possibilities range from simple tiredness and muscle Livingstone could find was that these men had been fatigue caused by over-exertion to more serious

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conditions like sickle-cell anaemia!48 The latter is more seems a later echo of Livingstone’s few drops of rain and likely to be the case with the Comorian Zachariah, very cold high wind, with the men sitting exposed to the whose frequent rests, even in the earlier part of the elements without clothing! journey, suggest the fatigue and shortness of breath characteristic of sickle-cell disease!49 The pace of their One wonders if the men explained their pain to march and the high terrain also make it possible that Livingstone! He had a high regard for African some of the carriers had the sickle trait and suffered medicine,54and we may justly assume that he did enquire exertional heat illnesses!50 Certainly malaria, which is of the men about the condition! Livingstone’s men, like often accompanied by bodily pain, would have been Konotey-Ahulu’s Ghanaian patients, applied ‘limb girdle’ obvious to both Livingstone and the Shupanga men, and tattoos,55 or as Livingstone recorded, scarification of this was certainly on his mind when he wrote to Kirk in large portions of the limbs! December! Further, the time sequence of the men’s illness is clearly However, in that same letter, Livingstone mentioned characteristic of sickle-cell disease: the ‘rheumatism’ having never seen anything like it, reiterating his either proceeding over several days to death, or suspicion that this was a disease new to him! Altitude persisting until the men returned to the lowland! sickness would have been a possibility for the men Consider the suddenness of the crises: ‘[men] who are raised at sea level, although the maximum elevation here well one moment are gravely ill the next, due to sudden of 1,100 metres is significantly less than the textbook- in vivo sickling of the red cells or a sudden suppression mandated 3,300+ metres!51 Cold exposure, in the wind- of bone marrow activity’!56 chill conditions Livingstone described, could also have been considered! Although Livingstone was with men of diverse origins, all came from areas where both sickle-cell and thalassaemia That these environmental diseases formed a complex genes occur in significant levels! The frequency of these unsolved picture in Livingstone’s mind emerges from in these areas is between 3 and 40%! Given these several clues! Livingstone had previously travelled in frequency figures, it is fair to ask: why were as many as Africa for over 21 years, knew well the physical at least nine out of approximately 20 Africans on this limitations of his African carriers, and as a physician, at trek afflicted in one way or another by the symptoms first would likely have diagnosed simple fatigue or over- discussed? The answer may be related to the exertion! Finally, ‘medicines determining to the skin’ recruitment practices of the day: when labour was suggest that he had tried some embrocations! required, word of mouth spread quickly among kith and kin! Thus consanguinity, thalassaemia, and sickle-cell The symptoms he described, however, are uncannily factors may have combined to afflict about half of the similar to those noted by Konotey-Ahulu in his report men! on one of 1,550 patients he studied in Ghana: The factors commonly associated with precipitating ! ! ! he has just been caught in the rain, or has suddenly sickle-cell crises are all present in these men: woken up in the middle of the night, and found geographical areas of origin, consanguinity, the ‘steep’ himself very ill with excruciating pain ‘all over the exertion, the altitude, the decline in temperature, and body’! Asked to be more specific, the patient points the cold high wind producing a chill effect, all to the larger joints (knees and/or shoulders) and complicated by ‘the men sitting without clothes,’ after rubs his palm over the lumbosacral region, groaning walking rough roads with sore feet! The ‘stoppage of and gyrating all the while! The patient rolls from side perspiration’ suggests dehydration, another of the major to side, twists, arches his back and ‘screams the ward precipitating factors for the sickling disorders! As down’! The pain is so severe that even grown-ups dehydration sets in, despite exercise the body will stop shed tears and young adults beg to be put to sleep sweating in an attempt to conserve fluid! In fact, ‘because I have not slept all night’!52 dehydration was the major precipitating factor in such cases in the US Army, until steps were taken to prevent There is also similarity of these symptoms to those exertional heat illness among the affected troops by recorded by Horton in the language of his day: such measures as better hydration!

! ! ! the fever of crises, the shifting joint pains, the Livingstone also noted: ‘the effect of the piercing winds exacerbations during the rainy season, and the upon the men had never been got rid of’, even almost constant abnormality of the blood!53 two weeks after Arimasau’s death! This may further confirm the diagnosis of sickle cell, whose crises can last The pain is relentless and continuous, and has a from hours to several weeks before full recovery! throbbing character! As for one of the precipitating Livingstone underscored the men’s debility: ‘they were causes, Konotey-Ahulu’s ‘just been caught in the rain’ useless [for work]’! Further, the characteristic quartet

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of ‘headache, pain in chest, back, and joints,’ which usually Postgraduate haematology! Oxford: Butterworth; 1999; accompany a sickling crisis were not explicable within 111! Livingstone’s experience! His subsequent letters 2 Sergeant GR! Sickle cell disease! Oxford: Oxford indicate that he puzzled over the problem for some time University Press; 1985; 25–8! afterwards! 3 In his excellent medical biography of Livingstone, Dr Gelfand omits this episode! Gelfand M! Livingstone the doctor: his life and travels! Oxford: Blackwell; 1957! Finally, in conditions of extreme travail, the sickle-cell 4 Reflected in the ‘close geographical association between trait can be associated with exertional rhabdomyolysis the distribution of malaria and of the sickle-cell gene’! (muscle necrosis), exertional heat illness, and exercise- Konotey-Ahulu FID! The sickle cell disease patient! related sudden unexplained cardiac arrythmia! If only Watford: T-A’D Company; 1991: 94! Sergeant op cit! ref! 2, Livingstone had noted one of the local names for the 17! tragic clinical episode he otherwise recorded so well, 5 Karlen A! Plague’s progress: a social history of man and disease! London: Gollancz; 1995; 40! our task would be easier!57 6 Konotey-Ahulu op cit! ref! 4, 4–5! 7 Ibid! 4–5! CONCLUSION 8 Phillips JA, Kazembe PN, Nelson EAS et al! A paediatric Thus from all of the above we conclude that the strange handbook for Malawi! Lilongwe: Lilongwe Central Hospital; disease which so severely inflicted his men and puzzled 1998; 177–8! Livingstone may in fact have been a sickling crisis, due 9 Cf! Anionwu E! Politics of sickle cell and thalassaemia! either to sickle-cell anaemia or one of the sickling states, London: Open University; 2001! most likely a combined sickle-cell trait with beta 10 Konotey-Ahulu op cit ref! 4, 75; Sergeant op cit! ref! 2, 18! thalassaemia! 11 Lebby R! A case of absence of the spleen! Southern J Med Pharm 1846; 1:481–3! 12 Horton JAB! The diseases of tropical climates and their ACKNOWLEDGEMENTS treatment! London: Churchill; 1874! In: Sergeant, op cit! ref! The authors extend warmest thanks to Dr David 2, 61! Livingstone Wilson, of Perthshire, for permission to 13 Hodenpyl E! A case of apparent absence of the spleen, with quote freely from his great-grandfather’s writings; the general compensatory lymphatic hyperplasia! Med Record Trustees and Mr Iain MacIver,Keeper of Manuscripts, the 1898; 54:695–6! National Library of Scotland, for cooperation and 14 Sergeant op cit ref 2, 61! permission to use manuscripts in their care; Dr Kenneth 15 See Savitt TL! The first two sickle-cell anaemia patients in King, African Studies Centre, Edinburgh University for the medical literature: a study in contrasts! Accessed at bringing the authors together; Ms Elizabeth Lwanda for http://www!ecu!edu/medhum/issue1_2!HTM and also providing firsthand further insights into the nature of Herrick JB! Peculiar elongated and sickle-shaped red blood corpuscles in a case of severe anaemia! Arch Intern Med sickle-cell anaemia; Mr Angus Macindoe of London and 1910; 6:517–21! Aichi University for his telling comments on an early 16 Mason VR! Sickle cell anaemia! J Am Med Assoc 1922; draft of the manuscript; and Dr Bernard Susser of New 79:1318–20! York and Doshisha Women’s College of the Liberal Arts 17 Pauling L, Itano HA, Singer SJ et al! Sickle cell anaemia: a for crucial advice and aid on computer conversion! molecular disease! Science 1949; 110:543–8! 18 Cf! Conley CL! Sickle cell anaemia – the first molecular All written items in Figure 1 are Livingstone’s own disease! In:Winthrobe M, editor! Blood, pure and eloquent! script; printed information has been added, usually from New York:McGraw–Hill; 1980: 319! Livingstone’s notes, by GW Clendennen! Some words 19 Sergeant op cit! ref! 2, 19! 20 Konotey-Ahulu op cit! ref! 4, 75! written by Livingstone are illegible, and thus omitted, and 21 Ibid!, 77; Sergeant op cit! ref! 2, 20! others have been moved slightly for reasons of clarity 22 Cf! Lehman H and Huntsman RG! Man’s haemoglobins! and aesthetics! Abbreviated dates indicate Livingstone’s Amsterdam: North Holland Publishing Company; 1974! approximate progress: for example, 16/17 indicates that The specific figures are from Konotey-Ahulu op cit! ref! 4, Livingstone spent the night of 16 September and the 76–8! early morning of the 17th in the village of a ‘civil 23 Clendennen GW and Nottingham PM! William Sunley and headman’ (most on this route were not, hence the David Livingstone: a tale of two consuls! University of noting) near the place indicated! Movement of Wisconsin-Madison;African Studies Program; 2000! Livingstone’s African companions would have varied only 24 Badens C, Di Montemuros FM, Thuret I et al! Molecular basis of haemoglobinopathies and G6PD deficiency in the slightly from his own! The party’s route over the 1,000- Comorian population! Hematol J 2000; 1(4):264–8! metre contour line and the many rivers crossed from 25 Simbeye AGA! An analysis of some haemoglobin and the 13th to the 15th clearly indicates the difficulty of the haploglobin phenotypes in Blantyre, Malawi! Am J Hum terrain! Genet 1971; 23:510–12! 26 Phillips JA, Kazembe PN, Nelson EAS et al op cit! ref! 8, 61! REFERENCES 27 Cavalli-Sforza L, Menozzi P and Piazza A! History and 1 Weatherall DJ! Genetic disorders of haemoglobin! In: geography of human genes! Princeton: Princeton University Hoffbrand AV, Lewis SM, and Tuddenham EGD, editors! Press; 1996; 60!

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28 See at http://www!thalassemia!com/genetics/inherit3!shtml! 40 Foskett op cit ref! 32, 75! 29 Gelfand op cit ref! 3, 17! See also Shepperson G! David 41 Clendennen op cit ref! 32, 83! Livingstone’s mention at this Livingstone, 1813–1873! Br Med J 1973; 2:232! latter date of only five Zambezi men as being ill, when 30 Foskett R, editor! The Zambesi journal and letters of Dr John contrasted with his mention of eight as being ‘down’ on 19 Kirk! Edinburgh: Oliver & Boyd; 1965; vol! 2: 401! Cf! September (the day after Arimasu died), suggests that while Gelfand op cit! ref! 3, 3, 113 and 178! At this time nine in all were ill, four may have recovered so quickly that Livingstone was in personal communication with Kirk and they were not to be included later in the same category as it is likely that the men discussed the case! the other five! Earlier, Livingstone had noted: ‘When Dr 31 Livingstone D and Livingstone C! Narrative of an expedition Kirk comes down into the lower lands he feels cold, to the Zambezi and its tributaries! London: John Murray; though the temperature may be 250 higher! On the 1865; 477! A major weakness of this work is that both the heights he feels comfortable at lower temperatures! He names and the numbers of the European and African men has intermittents frequently!’ Wallis op cit ref! 32, 174! with Livingstone are often erroneous when compared to Written 6 June 1860, when on the plateau just west of the contemporaneous notes! Kaora Basa rapids! 32 When making a brief foray over the Tchiri Cataracts from 42 Letter,David Livingstone to Richard Owen, Superintendent 15 June to 3 July 1863, immediately preceding this major of the British Museum (Natural History), 18 November trip, Livingstone was accompanied by six Zambezi men: see 1864; original in the National Archives of Zimbabwe, Clendennen GW, editor! David Livingstone’s Shire Journal, Harare, LI 2/1/1! 1861–1864! Aberwrystwyth: The National Library of 43 Livingstone D and Livingstone C op cit ref! 31, 575; and ‘In Wales (privately printed); 1992; 139; and Wallis JPR, editor! a number of instances, effluvia and fever seem to have no The Zambesi expedition of David Livingstone! London: Chatto connexion’, ibid , 53! & Windus; 1956; vol! 2: 239! It is remotely possible that all 44 In addition to scarification being used locally in Malawi and six Zambezi men accompanied Livingstone on the trip with elsewhere for individual and tribal identification, it was which this paper is concerned! Their names are from a employed as a method of introducing medicines directly letter of Livingstone to John Kirk, 8 August 1863: Foskett into the bloodstream, and is thus analogous to modern R, editor! The Zambesi doctors: David Livingstone’s letters to subcutaneous and intramuscular injections! Africans also John Kirk, 1858–1872! Edinburgh: Edinburgh University used herbal medicines to lessen pain! Cf! Johnston HH! Press; 1964; 72! A note on the number of Kololo to make British Central Africa! London: Methuen; 1897; 440! this trek is in David Livingstone’s Shire Journal, 143! Gwilym S, Linnard S and Lavy C! Mphini – a safe local 33 One who continued on was Karizela, who may have been treatment for chronic pain? Malawi Med J 2000! 1:17! Yao or the sixth (and usually unmentioned) ‘Shupanga’ 45 Livingstone D and Livingstone C op cit ref! 31, 519! man! 46 Ibid!, 539, 540! 34 Of the 32 known names of Livingstone’s Comorian 47 Blaikie WG! The personal life of David Livingstone London: companions, Zachariah is the only one with a non-Islamic John Murray; 1880; 318! name! Clendennen and Nottingham op cit ref! 23, 141! 48 Konotey-Ahulu op cit! ref! 4, 292; and Sergeant, op cit! ref! 35 All quotations (13–20 September) are from Livingstone’s 2, 142! Field Diary 12, in the National Library of Scotland, Acc! 49 Mitchell BL! Morbidity associated with the sickle cell trait! 9844, no! 12! Accessed at http://www!dcmsonline!org/! 36 Livingstone’s usual practice was to take three readings and 50 Kumar P and Clark M! Clinical medicine! London: Bailliere average them; here this was not done and this must be an & Tindall; 1994; 763! estimate! 51 Ibid , 116! 37 One additional factor noted earlier by Livingstone 52 Konotey-Ahulu op cit ref! 4, 116! certainly contributed: ‘The dew makes the legs and feet 53 Sergeant op cit! ref! 2, 61! sore! It provides a stoppage of perspiration in the limbs 54 King M and King E! The story of medicine and disease in wetted and an uneasy feeling which does not leave till the Malawi! Blantyre: Montfort Press; 1992! Young ED! Nyasa, sweat bursts out again! The Makololo speak of it tiring the a journal of adventure! London: John Murray; 1877; 23! legs as a thing well known!’ Field Diary 2, 12 April 1859, 55 Konotey-Ahulu op cit! ref! 4, 117! Konotey-Ahulu notes written in the highlands east of the Tchiri River south of that such tattoos were ‘pathognomonic of sickle cell Mt Dzomba (In the National Library of Scotland, MS! disease’ among the Gaadangbe tribes! 20315)! John Lwanda adds that until the sun evaporates 56 Ibid 122; and Sergeant op cit ref! 2, 196! the dew, it is very cold and humid, and when going up the 57 Few of Europe’s great explorers, if any, could have been so mountain, for example to fetch bamboo or firewood, one’s indefatigable as Livingstone about adding local words to his shirt becomes very wet! vocabulary! Given this habit, coupled with the condition 38 In none of the four accounts presented herein does and relative inacessibility of the two notebooks (FDs 12 Livingstone name the medicines given! and 13) he kept on this trip, it is quite possible that a key 39 On the return half of the journey, Livingstone and his men word or two was recorded at this time! covered approximately the same distance in less than half the time, suggesting that the outward leg was not extraordinarily strenuous!

28 J R Coll Physicians Edinb 2003; 33(suppl12):21–28 DR BRUCE AND THE SPA AT STRATHPEFFER

DR WILLIAM BRUCE (1835–1920), THE SCOTTISH HIGHLAND SPA AT STRATHPEFFER; AND A POSSIBLE DESCRIPTION OF POLYMYALGIA RHEUMATICA

WW Buchanan, Emeritus Professor of Medicine, and WF Kean, Clinical Professor of Medicine (Rheumatology), McMaster University, Canada

Hold a glass of pure water to the eye of the sun! immunoregulatory effects16–21 Hot mineral water baths It is difficult to tell one from another were shown to improve many different forms of Save by the tiny hardly visible trembling of the water arthritis, of both degenerative and inflammatory type, in This is the nearest analogy to the essence of human life double-blind controlled trials22–8 Further research in spa Which is even more difficult to see treatment of such conditions as fibromyalgia is required29 Hugh MacDiarmid (Christopher Murray Grieve) (1892–1978)1 When the National Health Service was introduced in Britain in 1948, spa therapy was not included among the Water is essential for life and man has found many uses benefits The lack of interest in spa therapy may stem for it Among these are its healing properties, in part from two sources The first was the unsanitary evidenced by the numerous mineral-water spas in condition of the communal baths, which the Scottish Britain, elsewhere in Europe and the Middle East Spas novelist Dr Tobias Smollett (1721–71) described in his flourished under the Romans, and in Britain are mostly novel The Expedition of Humphrey Clinker after a visit to found in England Only two, at Leamington and Buxton, the Bath spa: remain operative today2 In Scotland, despite the numerous ‘healing’ wells,3 there is only one spa, situated The first object that saluted my eye, was a child full in the village of Strathpeffer, near Inverness Dr William of scrophulous ulcers, carried    under the very Bruce (1835–1920) helped to develop the facilities of noses of the bathers    Suppose the matter of those the spa between the years 1870 and 1919,4 and there ulcers, floating upon the water,comes in contact with described the arcane but very real syndrome of my skin    Good Heaven, the very thought makes polymyalgia rheumatica5 my blood run cold30

SPA THERAPY The second reason was that spas were associated with Most British and North American rheumatologists entertainment and recreational activities, which remain sceptical regarding spa treatment, but interest in attracted rich valetudinarians31 The puritan sensibilities the potential benefit of such treatment has rekindled6, 7 of Sir James Paget (1814–99) were shocked when he Head-out immersion in hot water has been shown to visited the spa at Baden-Baden in Germany, and: result in salt and water diuresis and hypercalciuria;8 pressure exeted by the water on the lower part of the saw a wider and more complete reign of folly, body increases fluid return to the right atrium, and fashion, and extravagance, and vice than I ever saw increased plasma atrial natriuretic peptide9 Plasma before, or than, I suppose, can be seen anywhere in noradrenaline decreases, which may explain the the world The gaming-tables were crowded and the relaxation patients experience, and also the ‘spa-fatigue’ stakes were often very high: the women were syndrome from too-frequent treatments10, 11 dressed at the highest cost: the men looked like fools or rogues; the defiance of virtue was complete32 In spas, patients drink the water as well as bathing in it Heywood and Mackenzie12 have recently investigated the Paget was, of course, the quintessential Victorian puritan, ancient claim that treatment with mineral waters at the who considered a holiday a time for contemplation and spa in Bath, England, led to curing of lead poisoning in study, and walks with the family for appreciating the 45% of patients and improvement in 93% The mineral scenery, flowers and bird song33 waters contain calcium and iron, both of which are known to reduce lead absorption13, 14 Imbibing Bath Smollett, however, was a follower of Aphrodite the mineral waters led to increased excretion of urinary Greek goddess of beauty and love, but only in so far that lead and urate,12, 15 which lends some credence to the she emerged from the sea foam! In 1752 Smollett claim that spa water improves both plumbism and gouty published a book on the external use of water, with arthritis especial emphasis on sea-bathing34 The latter had been originally recommended by Asclepiades of Bithynia Mineral waters also have endocrinological and (124–56 BC), a Greek physician, and remained popular

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both in the eighteenth35 and nineteenth centuries36 Like, changing figures in a dream, Robert Burns (1759–96), the Scottish national poet, was To Muttonhole or Pittenweem! prescribed sea-bathing for his ‘flying gout’ by his As, by some harmony divine physician Dr William Maxwell (1760–1834) In a letter The devils quartered in the swine, to his father-in-law, James Armour (d 1798), Burns If any baser place exist expressed doubts as to the benefit: In God's great registration list – Some den with wallow and a trough – I returned from sea-bathing    and my medical Find it, ye Ogres, and be off!40 friends would almost persuade me that I am better; but I think and feel that my strength has so gone that (The sentiments expressed are reminiscent of the the disorder will prove fatal to me37 horror he expressed on meeting the lepers of Moloka'i)41 THE STRATHPEFFER SPA The Strathpeffer spa is situated in the strath of that Strathpeffer in Easter Ross was originally inhabited by name, sheltered from the prevailing west winds by the the Picts, as evidenced by the many Pictish carvings on 3,500-foot Ben Wyvis The village where the spa is stones,42–5 such as the famous Clach an Tiompain, known located is some four miles west of Dingwall and in English as the Eagle Stone (Figure 1) Coinneach approximately 25 miles northwest of Inverness as the Odhar (Sallow Kenneth), the Braham Seer (fl mid- crow flies The village has always been known locally as sixteenth century) was a local fiosaiche (seer) who An Srath, the Strath38 Robert Louis Stevenson prophesied: (1850–94) spent some weeks at the spa after his return from California in 1880, when he praised the scenery: If ever that stone was taken out of place, Loch Ussie would ooze up through the well and flood the valley Near here is a valley, birchwoods, heather and a below to such an extent that ships could sail up to stream    No country, no place was ever for a Dingwall and be moored to the Eagle stone46 moment so delightful to my soul The stone has fallen twice, but the inhabitants of He goes on to comment that the spa itself is: Strathpeffer have considered it prudent to have it propped up and cemented in place! A heathenish place near delightful places, but inhabited, alas! by a wholly beastly crowd39

Stevenson, indeed, wrote a poem ‘On Some Ghastly Companions at a Spa’:

That was an evil day when I To Strathpeffer drew anigh, For there I found no human soul But Ogres occupied the whole

They had at first a human air In coats and flannel underwear They rose and walked upon their feet And filled their bellies full of meat FIGURE 1 The Eagle Stone at Strathpeffer They wiped their lips when they had done, But they were Ogres every one Coinneach Odhar made one other prophecy which was Each issuing from his secret bower, to prove correct in terms of the establishment of a spa I marked them in the morning hour in Strathpeffer: By limp and totter, lisp and droop, I singled each one from the group One day, unseemly as it is, the day will come when it I knew them all as they went by – will be under lock, and many people will come I knew them by their blasted eye! seeking a drink of its waters47

Detested Ogres, from my sight DEVELOPMENT OF THE STRATHPEFFER SPA Depart to your congenial night! By the end of the seventeenth century, people were From these fair vales, form this fair day, frequenting the sulphur well in Strathpeffer in Fleet, spectres, on your downward way, considerable numbers48 The first reference to the

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springs was not made, however, until 1772 by a Dr sources of amusement and recreation, including an Donald Munro49 Five years later the local parish excellent 18-hole golf course Members of several minister, who was also factor to the Cromartie estates, European royal houses are recorded as taking the cure wrote a memorial drawing attention to the apparent at the Strathpeffer Spa Ernest Henry Shackleton healing properties of the water50 It was an arthritic (1874–1922) gave a lecture on his travels to Antarctica, sufferer, who received immediate pain relief by taking and Mrs Emmeline Pankhurst the militant suffragette the waters, who drew attention to the benefits of the also visited In addition to Robert Louis Stevenson, spa to a wider public: he was Dr Thomas Morrison from other writers who spent time at the Spa included Elsick,Aberdeen The result of the doctor’s proselytizing George Bernard Shaw (1856–1950), Neil Miller Gunn was the erection of a wooden pump room (Figure 2) (1891–1973) and the blind, deaf-mute American Helen some 40 feet long, in 1819 Hotels quickly followed and Adams Keller (1880–1961) The German Jew, Oscar provided facilities up to the highest standards to be Slater (c 1871–1948), after his release from prison having found in England (Figure 3 and Figure 4) A hospital was been wrongly convicted on a charge of murder, was a built to meet the needs of arthritic patients by a Mrs guest at one of the Spa hotels (it was Sir Arthur Conan Morrison Duncan of Naughton, Fife, in memory of a Doyle (1859–1930) who championed the innocence of relative Dr Nicholson Mackenzie who had perished Oscar Slater)56, 57 However, after the First World War when the ship Pictou was lost at sea in 185351 Critical the popularity of the Spa began to wane and had to the growth of the spa was the coming of the railway vanished altogether by 1948:58 Strathpeffer became in 1855, making it possible for patients to travel in a what Oliver Goldsmith might have called ‘The Deserted sleeper overnight from London, arriving at the spa the Village’ next morning52 From this date the spa rapidly grew, and more imposing hotels were built, although the Highland Hotel was not built until the first decade of the nineteenth century

FIGURE 3 The gardens of the Spa Hotel, one of the first to be built in Strathpeffer in the early nineteenth century

FIGURE 2 One of the pump rooms now standing in the village square at Strathpefffer

The waters were served steaming hot and being sulphurous gave forth a most obnoxious stench It was expected that patients consume at least one full glass before breakfast, and to ensure this a piper walked about the town beginning playing at 7 am to ensure everyone awoke in sufficient time53 The ‘cure’ covered a period of FIGURE 4 three weeks, the course of treatment varying according The Ben Wyvis Hotel, erected in 1879, where Robert Louis to the disease There were four wells providing sulphur Stevenson stayed and made his comments about waters, and one chalybeate or iron well54 The pièce de Strathpeffer and the patients attending the spa résistance of the baths was the peat bath, a variation on the continental mud bath, which was the first to be DR WILLIAM BRUCE introduced in the United Kingdom55 Dr William Bruce was born at Keig in the Vale of Alford, Aberdeenshire, in 1835 He graduated MA at King’s The climate of Strathpeffer is uncommonly dry for the College, Aberdeen, in 1855, and MD in 1858 After Highlands, with an average annual rainfall of only 30 graduation he practised at Crimond, on the cold, inches Days at the spa passed pleasantly with endless windswept northeast coast of Aberdeenshire, where he

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established the second cottage hospital in Scotland, and publishing, though without ever doing so, they would be helped found the Northern Medical Society, including the happiest of men’64 In 1883 he wrote a paper, in the Aberdeen Medical and Surgical, the Buchan, the which he described for the first time, the occurrence of Garroch, and the Morayshire and Banff Medical contagious pneumonia based on his observations of Societies In 1870 he removed to Dingwall, where he clustering of patients65 This was one year after the opened the Ross Memorial Hospital in 1873, and isolation of Klebsiella pneumoniae by Carl Friedländer consulted at the nearby Spa in Strathpeffer He was also (1847–87) from the lung tissues in acute pneumonia66 chairman of the school board; member of the County Friedländer wrongly regarded this the causal organism in Secondary Education Committee; Governor of the Trust all cases of pneumonia Up until this time the consensus for Education in the Highlands and Islands for Ross and of opinion was that pneumonia was not contagious, and Cromarty, and chairman of its finance committee; was characteristic of the aged67 Bruce also published an external examiner in medicine at the University of article on sciatica in 1903,68 which was followed by a Aberdeen; and Justice of the Peace Dr Bruce was a 175-page book on the same subject in 191369 He strong proponent of preventative medicine, and in 1889 maintained that sciatica was not a primary neuritis, but became medical officer of health for Ross and Cromarty, was pain referred from disease of the hip joint, as Sir which included the Island of Lewis59 William Osler (1849–1919) had suggested already in his landmark textbook, The Principles and Practice of Dr Bruce, in concert with the prevalent views of the Medicine, published sometime earlier in 1892 time, was convinced that poverty and disease were commented the same, ‘occasionally lesions of the hip- closely interconnected, and that curing poverty would joint induce a secondary sciatica’70 Bruce’s paper lead to better health He was able to impart the merited a leading article in The Lancet which gave little importance of cleanliness to school children through the credence to his views,71 but was followed by a not education authorities, ensuring proper lavatories were particularly convincing, if spirited, riposte by the author72 installed in all schools and strict regulations enforced In his paper Bruce did not consider the possibility that regarding hand-washing Although a general practitioner sciatica might arise as a consequence of disease of the he was a strong advocate of scientific and technical lumbar spine, although he acknowledged the fact that education However, he believed that the medical pelvic disease, such as tumors could lead to sciatica73 student required a sound general education, with a curriculum not overcrowded with specialisation In The publication that Bruce is remembered for is his 1886 he was chosen by the Scottish medical profession possible description of polymyalgia rheumatica, which he to be their first Direct Representative of the newly termed ‘senile rheumatic gout’74 It seems strange that established General Medical Council, on which he Bruce should use the term ‘gout’, as he must have been served for three terms in office, a position he held for aware that Sir Arthur Baring Garrod (1819–1907) had 20 years He was selected by Queen Victoria clearly stated that,‘the disposition of urate of soda    is (1819–1901) to accompany her consort Prince Francis at once pathognomonic and separates gout from every Albert (1819–61), Duke of Saxe-Coburg-Gotha, to Egypt other disease which at first sight might appear allied to as private physician In 1891 his alma mater, the it’75 and had described a ‘thread test’ to detect University of Aberdeen conferred on him the honorary hyperuricaemia76 The absence of Garrod’s ‘thread test’ degree of LLD and the use of the term ‘gout’ by Bruce can be justifiably criticised His paper begins with a review of rheumatic Dr Bruce was an extremely popular physician at the disease where he clearly differentiated acute rheumatic Strathpeffer Spa, and undoubtably was responsible for fever, which he considered of ‘germ origin’, acute gouty much improvement in its facilities and its reputation He arthritis which may be polyarticular, rheumatoid was described as having a ‘hardy physique, disdainful of arthritis, and ‘muscular rheumatism’ which today might fatigue    His mental energy and power were not less be labeled fibromyalgia He refers to lumbago and remarkable    Such men not only seize opportunities, ‘deltoid rheumatism’, and also to ‘acute gout’ which was but make them’60 Although his obituary ran only half a ‘very common in the knees’, especially in men, and may column in the British Medical Journal61 there were nearly represent pseudogout from chondrocalcinosis He two pages in The Lancet,62 and no less than four pages in considered in such cases that,‘the hand placed over the the local Ross-Shire Journal63 His funeral took place at knee outside the clothes will in flexion and extension the cemetery at Fothraididh, Fodderty, where a large readily detect the roughness of gout, and affords the number of prominent members of the local society practitioner a simple and very ready means of diagnosis’ attended Here Bruce may be referring to osteoarthritis, which, strangely, he otherwise does not mention MEDICAL WRITINGS Dr Bruce appears to have followed the views expressed Bruce then goes on to describe five patients, all of whom by William Heberden Senior (1710–1801) that,‘If men of were men in their seventh or eighth decade Their letters could be obliged to write always with a view of salient clinical features are summarised in Table I Bruce

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considered that these ‘acute senile cases belong to a features of temporal arteritis, which was only first different category from gout or rheumatism on the one described by Schmidt in 193082 and by Horton et altwo hand and rheumatoid arthritis on the other;    years later,83 despite the fact that the disease was clearly remarkable in its severity and complete curability’ Four depicted in paintings in the fifteenth and sixteenth of the five patients had severe constitutional symptoms centuries84, 85 (Cases 1–4) and one (Case 3) was so severely ill that he developed what appears to have been a septic parotitis ACKNOWLEDGMENTS The red sediment in this patient’s urine (Case 3) might The authors wish to thank Mrs Margaret E Spark MR have been urobilin, although this is usually a brown Pharm S of the Spa Pharmacy, Strathpeffer, and also Mr colour Several patients developed severe polyarthritis David Watt, Editor of the Ross-shire Journal for providing (Cases 1–4) which is uncommon in polymyalgia information and illustrations Mr James Beaton, Librarian rheumatica, and when present is usually mild77 The fifth of the Royal College of Physicians and Surgeons of patient had pain and stiffness of his shoulders, but no Glasgow provided invaluable help in obtaining historical constitutional symptoms, and may have had bilateral references supraspinatus tendonitis The erythrocyte sed- imentation rate was not available until the 1920s and REFERENCES 30s,78, 79 nor until 1948 was corticosteroid therapy, which 1 The glass of pure water In: Hugh MacDiarmid complete results in dramatic improvement with a few days, and is poems Grieve M, Aitken WR, eds London: Martin Brian almost diagnostic80 The fact that all of the patients and O’Keeffe Ltd; 1978: 1041–3 recovered within one to two years (Cases 1, 2 and 3) is 2 Clarke AK Spa therapy in Britain – a historical memory Rheumatology in Europe 1995; 24:134–5 consistent with the diagnosis The condition was only 3 Hamilton D The healers' A history of medicine in Scotland 81 named – polymyalgia rheumatica – by Barber in 1957 Edinburgh: Canongate Publishing Ltd; 1981 None of the patients described by Bruce had any clinical 4 Obituary Death of Dr William Bruce, Dingwall End of a

TABLE 1 Clinical features of five male patients treated at the Strathpeffer Spa

Case Age Clinical features Outcome

1 70 Rheumatic pains for a day or two, which became Remained completely helpless much worse after exposure to cold and wet after three months, but made Completely crippled with rheumatic gout, affecting complete recovery after a year his hands and feet, as well as wrists and ankles Symptoms were relieved with salicylates

2 70 Developed ‘rheumatism’ after a chill, which was Recovered completely after two sufficiently severe to prevent him working for six months years Became almost helpless from pain and stiffness in his joints General health extremely poor and very depressed

3 60 Developed painful shoulders and limbs and felt generally After two years and three months unwell after a chill Pains attacked feet and ankles, which condition improved, with a gain in were relieved by salicin Developed a ‘swelling behind the weight and strength Still had ear’ associated with a sensation of choking The swelling stiffness especially in his finger was extremely painful and required morphine for its joints alleviation General health poor, continuation of rheumatic pains, and marked weakness Had several ‘fainting fits’, as his condition improved developed swelling of the finger joints, which persisted Urine was of a dark colour, with a sediment like ‘red sand’

4 74 Developed pain in the left leg, followed by the same on the Condition improved, but duration right, which extended down to the foot Developed swelling of illness not recorded Could in the legs, and was unable to walk or stand Arms, shoulders walk, but remained weak and hands became stiff and swollen, and associated with marked weakness Marked loss of weight

5 71 Developed severe pain in arms, after being chilled Improvement but duration of Shoulders particularly affected Gradually improved, but illness not recorded shoulders remained still

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great career The Ross-shire Journal, Friday 29 October 28 Sulenik S Spa treatment of rheumatic diseases in the area 1920; 3–4 of the Dead Sea Rheumatology in Europe 1995; 24:127–48 5 Bruce W Senile rheumatic gout Br Med J 1888; 2:811–13 29 Schmidt op' cit ref 20 6 Helliwell PS An appraisal of medicinal spa therapy for 30 Smollett T The expedition of Humphrey Clinker London: rheumatological disorders R Soc Hlth J 1989; 109:3–7 The English Library Ltd; 1960: 54–7 7 Fam AG Spa treatment in arthritis: a rheumatologist’s 31 Corfield PJ Spas and resorts In: The impact of English towns view Editorial J Rheumatol 1991;18:1775–7 1700–1800 Oxford: Oxford University Press; 1982; 4: 8 Epstein M Renal effects of head-out immersion in man 51–65 Physiol Rev 1978; 58:529–41 32 Paget S, editor Memoires and letters of Sir James Paget 9 Anderson JV,Millar N, O’Hare JP et al Do circulating levels London: Longmans; Green and Co; 1901 of atrial natriuretic peptide (ANP) mediate the natriuretic 33 Buchanan WW Sir James Paget (1814–1899): surgical response to water immersion in man? Clin Sci 1985; 69:2 Osler? Proc R Coll Physicians Edinb 1996; 26:91–114 10 O’Hare P and Heywood A Observations on the effects of 34 Smollett T An essay on the external use of water 1752 immersion in Bath Spa water Br Med J 1985; 291:1747–9 Reprinted by Jones GE Bull Inst Hist Med 1935; 32:31–82 11 Hall J, Bisson D, O’Hare P The physiology of immersion 35 Russell R Dissertation on the use of sea-water in the diseases Physiotherapy 1990; 76:517–21 of the glands 2nd ed London: W Owen and R Goadby; 12 Heywood A and Mackenzie C Spas can cure A modern 1753 study of the 18th century ‘Trial of the waters in Bath’ New 36 Priessnitz V The coldwater cure, its principles, theory and Eur Rheumatol 1994; 2:59–65 practice London:W Strange; 1843 13 Mahaffey K, Boyer R, Haseman JK Dose response to lead 37 Buchanan WW and Kean WF Robert Burns’ illness ingestion in rats fed low dietary calcium J Lab Am Med revisited Scott Med J 1982; 27:75–88 1973; 82:92–100 38 Finlayson C The Strath' The biography of Strathpeffer' 14 Barton JC, Marcel E, Conrad SN et al Effects of iron on the Edinburgh: St Andrews Press; 1979 absorption and retention of lead J Lab Clin Med 39 Hennessy JP Robert Louis Stevenson London: Jonathan 1978; 92:536–47 Cape Ltd; 1974; 144–5 15 Heywood A, Wadron HA, O’Hare P et al Effect of 40 Smith JA, editor Robert Louis Stevenson collected poems' 2nd immersion on urinary lead excretion Br J Indust Med ed London: Rupert Hart-Davis; 1971; 337–8 1986; 43:713–15 41 Buchanan WW Robert Louis Stevenson, Father Damien, 16 Okada Y, Miyai K, Iwatsubo H et al Human growth and the lepers of Moloka’i Proc Roy Coll Phys Edinb 2000; hormone secretion in normal adult subjects during and 30:69–74 after exposure to cold J Clin Endocr 1970; 30:393–5 42 Wainwright FT, editor The problem of the Picts Perth:The 17 Okada Y, Matsuoka T, Kumanara Y Human growth Melven Press; 1980 hormone secretion during exercise to hot air in normal 43 Ritchie A Picts' An introduction to the life of the Picts and the adult male subjects J Clin Endoc 1972; 34:759–63 carved stones in the care of the Secretary of State for Scotland 18 Lammintaustra R, Synalahti E, Pekkarinen A Change in Edinburgh: Her Majesty’s Stationery Office; 1989 hormones reflecting sympathetic activity in the Finnish 44 Cummings WA The age of the Picts Gloucestershire: Alan sauna Ann Clin Res 1976; 8:266–71 Sutton Publishing Ltd; 1995 19 Günther R, Spath P, Egg D et al Behavior of the 45 Foster SM Picts, Gaels and Scots' Early Historic Scotland complement components C3 and C4, CRP and blood London: BT Batsford Ltd; 1996 sedimentation rate for activity control in arthritis patients 46 Mackenzie A The prophecies of the Brahan Seer (Coinneach during thermo-hydrotherapy Z Rheumatol 1978; 37:33–9 Odhar Fiosaiche) Stirling Eneas MacKay, 1899 Golspie: 20 Schmidt KL Scientific basis of spa treatment in rheumatic Sutherland Press 1970; 24 The prophecies in Gaelic have diseases Rheumatology in Europe 1995; 24:136–40 been recorded in: MacIomhair, DI Coinneach Odhar 21 Rovensky J, Ferencikova J,Vigas M et al Endocrinological Glasgow: Gairm Publishers; 1990 and immunoregulatory effects of the hyperthermic bath in 47 Finlayson op' cit ref 38 Piest’any Rheumatology in Europe 1995; 24:141–3 48 Ibid 22 Szücs L, Ratko I, Genti G et al Double-blind trial of 49 Munro D An account of the sulphureous mineral waters effectiveness of the Püspökladany thermal water on of Castle Leod and Fairburn, in the County of Ross; and the arthrosis of the knee pain R Soc Hlth J 1989; 109:7–9 salt purging water of Pitkeathly, in the County of Perth, in 23 Sukenik S, Buskila D, Neumann L et al Sulphur bath and Scotland Philos Trans R Soc Lond 1772; 62:15–32 mud pack treatment for rheumatoid arthritis at the Dead 50 Finlayson op' cit ref 38 Sea area Ann Rheum Dis 1990; 49:99–102 51 Ibid 24 Elkayam O,Wigler I,Tishler M et al Effect of spa therapy in 52 Ibid Tiberius on patients with rheumatoid arthritis and 53 Mowat AG Strathpeffer Spa: Dr William Bruce and osteoarthritis J Rheumatol 1991; 18:1799–803 polymyalgia rheumatica Ann Rheum Dis 1981; 40:503–6 25 Konrad K, Tatrai, Hunka A et al' Controlled trial of 54 Chalybeate or chalybite is natural ferrous carbonate, balneotherapy in treatment of low back pain Ann Rheum FeCO3 Dis 1992; 51:820–2 55 Mowat op' cit ref 53 26 Bálint G and Szebenyi B Research and training at spa 56 Roughead W The Slater case – a retrospect In: Classic resorts in Europe Rheumatology in Europe 1995; Crimes London: Cassell; 1951; 369–412 Cited by 24:149–52 Cunnison J and Gilfillan JBS (eds) The third statistical 27 Kolarz G Critical approach to spa treatment in rheumatic account of Scotland Glasgow Glasgow:William Collins Sons diseases Rheumatology in Europe 1995; 24:144–6 and Co Ltd; 1958: 644

34 J R Coll Physicians Edinb 2003; 33(suppl12):29–35 DR BRUCE AND THE SPA AT STRATHPEFFER

57 Finlayson op' cit ref 38 72 Bruce W What is sciatica? Correspondence Lancet 1903; 58 Coren M Conan Doyle Toronto: Stoddart Publishing Co ii:785 Ltd; 1995; 127–30 73 Ibid 59 Macdonald D Lewis' A History of the Island Edinburgh: 74 Ibid Gordon Wright Publishers; 1990 75 Garrod AB Sir A treatise on gout and rheumatic gout' 60 Anonymous William Bruce MA, MD, LLD Aberdeen London:Walton and Maberly; 1876 Dingwall (obituary) Br Med J 1920; 2:723 76 Garrod AB Observations on certain pathological 61 Ibid conditions of the blood and urine in gout, rheumatism and 62 Anonymous William Bruce MA, MD, Hon LLD Aberd, Bright’s disease Med Chir Trans Soc Edinburgh 1848; LRCS Edin (obituary) Lancet 1920; ii:1113–5 31:83–7 and 1854; 37:49–59 63 Buchanan WW, Kean WF William Heberden the Elder 77 Ryle V, Tudor J, Wraight EP et al Rarity of synovitis – (1710–1801) The compleat physician and sometime polymyalgia rheumatica Ann Rheum Dis 1990; 49:155–7 rheumatologist Clin Rheumatol 1987; 6:251–63 78 Westergren AV Studies on the suspension stability of the 64 Bruce W Contagious pneumonia Br Med J 1883; ii:268–9 blood in pulmonary tuberculosis Acta Med Scand 65 Friedländer C Ueber die Schizomyceten bei der acuten 1921; 54:247–82 fibrösen Pneumonie Virchows Arch Path Anat 1882; 79 Wintrobe MM and Landsberg JW A standardized 87:319–24 technique for the blood sedimentation rate Am J Med Sci 66 Mettler CC and Mettler FA History of medicine' A 1935; 189:102–15 correlative text, arranged according to subjects' 80 Kyle V and Hazleman BL Treatment of polymyalgia Philadelphia: The Blakiston Co; 1947; 396 Reprinted by rheuamtica and giant cell arteritis I Steroid regimes in the the Classics of Medicine Library New York: Gryphon first two months Ann Rheum Dis 1989; 48:658–61 Editions; 1986 81 Barber HS Myalgic syndrome with constitutional effects 67 Buchanan and Kean op' cit ref 63 Polymyalgia rheumatica Ann Rheum Dis 1957; 16:230–7 68 Bruce W An address on sciatica; an enquiry as to its real 82 Schmidt M Intracranial aneurysms Brain 1930; nature and rational treatment founded on the 53:498–540 (case 24; 532) observations of upwards 400 cases Lancet 1903; 83 Horton BT,Magath TB,Brown GE An undescribed form of ii:511–14 arteritis of the temporal vessels Proc Mayo Clin 1932; 69 Bruce W Sciatica: a fresh study with notes of nearly 700 cases 7:700–1 London: Ballière,Tindall and Cox; 1913 84 Roth WG Arteritis temporalis, dargestellt an einem 70 Osler W The principles and practice of medicine New York: Gemälde des Reichmuseums in Amsterdam Hautartz D Appleton and Co; 1892; 818 Reprinted by The Classics 1969; 20:330–2 of Medicine Library Birmingham Alabama: Gryphon 85 Dequeker J Polymyalgia rheumatica with temporal Editions Ltd; 1978 arteritis, as painted by Jan Van Eyck in 1436 Can Med Assoc J 71 Anonymous What is sciatica? Leading article Lancet 1981;124:1597–8 1903; ii:614–15

J R Coll Physicians Edinb 2003; 33(suppl12):29–35 35 MEDIEVAL HOSPITALS IN SCOTLAND

MEDIEVAL HOSPITALS IN SCOTLAND: A CURE FOR BODY OR SOUL?

WJ MacLennan, Professor Emeritus of Geriatric Medicine, the University of Edinburgh

INTRODUCTION One of many contributions the Church made to life in the Middle Ages was to establish hospitals for the poor, infirm and chronically sick1 It is important, however, to distinguish medieval aims and systems of care from those of hospitals today Direct medical intervention was uncommon and treatment involved providing a wholesome diet, rest, cleanliness and a pleasant environment Physical health apart, the main purpose of the hospital was to prepare the souls of the inmates for the life to come; in a cynical vein, this attitude was reflected in the founders who erected and paid for the maintenance of hospitals to ease their own way to Heaven rather than help the needy

Several excellent reviews of medieval hospitals in England have been published, but the topic has received little more than a mention north of the border2–7 The intention of this paper is to at least make a start in correcting the imbalance

MEDIEVAL HOSPITALS IN SCOTLAND FIGURE 1 For the purpose of this paper, hospitals were identified Distribution of medieval hospitals in Scotland by scanning through the records of the Royal Out of 105 hospitals for which appropriate Commission on Historical and Ancient Monuments, and documentation could be found, 26 were founded in the reading the relevant sections of a book on religious twelfth, 33 in the thirteenth, 15 in the fourteenth, 27 in 8 houses in Scotland Few of the buildings survive, so the fifteenth, and four in the sixteenth century There information for these sources was collected by was a particularly high level of activity in the late twelfth unearthing charters or documents which at least and thirteenth centuries as in England, but there was a mention a hospital Other sources have been place reduction of new foundations in the fourteenth century names or local inhabitants with information about the related to the Wars of Independence and subsequent site of a hospital in a particular area It is thus likely that visitations by the plague There then was a substantial the lists contain many omissions and inaccuracies increase in foundations during the fifteenth century, a period associated with a decline in England9 This With such limitations in mind, it would appear that 179 historical aspect is rather paradoxical given that an hospitals were founded between 1144 and the middle of ecclesiastical building programme was still in progress in sixteenth century (Figure 1) in Scotland These Scotland right up to recurrent invasions by Henry VIII establishments were more frequently found around such and the collapse of Catholicism during the sixteenth administrative centres as Edinburgh (15), Perth (seven), century10, 11 Stirling (six) and Dundee (five) Hospitals also were common where a large number of monasteries had been HOSPITAL CAPACITY established Examples are Roxburgh and Berwickshire The records of only 18 of the hospitals have information (32), Fife (14), Glasgow (eight) and Haddington (four) A on the numbers of inmates There were from two to puzzling exception is the small number of hospitals in St four in three, six to eight in 11, 12–13 in three, and 24 in Andrews (two) It is clear from this that the number and one hospital, giving a mean of seven per hospital Most geographical location of hospitals bore little relationship hospitals in England at the same period also catered for to the population of an area, but, with the exception of small numbers, but a few housed up to 200 individuals12 St Andrews, was related to places where there was most likely to be an interaction between potential founders On the basis that hospitals accommodated an average of and the clergy

36 J R Coll Physicians Edinb 2003; 33(suppl12):36–41 MEDIEVAL HOSPITALS IN SCOTLAND

eight in-patients, and that between 1150 and 1550 the FOUNDATION AND MAINTENANCE population of Scotland was 400,000, 1,250 (0·31%) out One of the reasons that so many medieval hospitals of 400,000 might have received hospital care at any one existed is that the Church guaranteed the founder a time13 Highly speculative though this figure is, it bears minimum time in Purgatory through the acquisition of reasonable comparison with the current situation in indulgences This was achieved by conducting frequent Scotland where around 0·75% of a much older services, including the Eight Daily Hours and a daily population receive care in nursing or residential homes, Mass Residents were expected to contribute to the or in continuing-care geriatric or psychogeriatric units well-being of their benefactor by religious observances such as attending Mass daily, and repeating the Hospitals provided accommodation for several Paternoster,Ave Maria and Creed15 categories of patients14 The most common were those who were poor, old and feeble There were special units Maintaining a medieval hospital was at least as difficult as for lepers Others, sited on the routes of pilgrimages, obtaining funding and grants for a modem university were for poor or frail travellers; most pilgrims either department, and many such establishments went out of stayed in monastic guest houses (Figure 2), or shifted for business16 Donors were encouraged to supply money, themselves Finally, there were places for impoverished land, property, grazing rights, and charters for fairs In and frail secular clergymen who had none of the security return, after their deaths, they received a ‘sliding scale’ of of their monastic colleagues or priests with a permanent religious services conducted by their establishments for livelihood the salvation of their souls17

STAFFING The master of a hospital was a cleric whose responsibilities were the administration of the hospital and the organisation of divine services with the support of one or more priests Facilities for care varied but often nuns or lay brothers (monks) provided care Lay brothers along with lay servants also performed the manual work required within the hospital

Information on staffing is only available for 22 hospitals These refer solely to clergy and rarely specify whether such others were in addition to or instead of a master FIGURE 2 In two instances it seems appropriate that only one Hospitium (guest house) for distinguished visitors to chaplain was responsible for two paupers At the other Grayfriars’ monastery, Inverkeithing This was more extreme, six minor canons had the care of six paupers, comfortable than the hospitals for poor pilgrims and in another instance a preceptor and four canons looked after an unknown number of residents Several The vague and inaccurate data for hospitals in Scotland hospitals were run by the established monastic orders indicate that 49 (60%) out of 81 provided care for the In one this was the Bethlehemite Order, and, in three, poor and infirm; ten (12%) cared specifically for poor or the Trimontian Order In Aberdeen, for an obscure infirm pilgrims; one (1%) cared for poor and infirm lay reason, a hospital was run by the Knights Templar clergy; and 21 (26%) cared for lepers These figures indicate that few hospitals provided specialised care, the RESIDENTS only exception perhaps being those for lepers The fact In most hospitals applicants were assessed prior to that only one hospital mentions the specific care of admission18 ‘Undesirables’ such as those with epilepsy, clergy suggests that they were also usually admitted with psychiatric disorders or acute illnesses were turned all other categories Only four entries describe the care away The other requirement was that before admission of women, but there is circumstantial evidence that most the applicant should make a formal confession hospitals admitted both sexes where there were in- house facilities for maintaining acceptable standards of Care was based upon the regimen sanitas and varied with separation and decorum needs, but all residents received a bed with clean sheets Each bed was often shared with one or even two others Although patients could be admitted for the acute Other nursing duties included washing patients, helping management of conditions such as hunger or them in visits to the latrine, supervising the ward at exhaustion, this was unusual and they were discharged night, and washing clothes as quickly as possible The staff were neither trained nor equipped to manage medical emergencies The diet varied between a loaf per day with pottage three times per week in parsimonious establishments, to

J R Coll Physicians Edinb 2003; 33(suppl12):36–41 37 MEDIEVAL HOSPITALS IN SCOTLAND

bread and drink each day along with a varied amount of MONASTERIES AND PRIORIES meat, fish, eggs, and cheese in more affluent ones19 Sick monks in religious houses enjoyed a higher standard Exceptions to the routine were feast days or the of medical care Their health was the responsibility of anniversary of the founder when much more lavish and the infirmarian who often had access to copies of the imaginative meals were served classical pharmacopoeias, and was adept in the preparation of medicines from plants in the kitchen It is unlikely that residents ever saw a physician A garden29 The monastery may even have paid for medical doctor was often attached to larger English hospitals, visits but he was retained more for the needs of the staff, and rarely had contact with residents20 The master and KNIGHTS TEMPLAR AND KNIGHTS OF ST JOHN priests did not provide medical care; indeed an edict (HOSPITALLERS) from the Council of Lateran of 1215 prohibited clergy These orders were founded to provide care for pilgrims from doing so21 Patients may have received herbal in the Middle East Both soon became formidable medicines, but there is no information on this If they religious warrior castes, but continued their did, it is likely that this was based on the knowledge commitment to the sick In Scotland the headquarters nursing staff had of folk medicine of the Hospitallers was at Torphichen, West Lothian (Figure 3)30 This was a monastery and did not provide If residents received no medical treatment, they were a hospital service It is on record, however, that in 1296 given a great deal of spiritual support from the religious Edward I was treated in Torphichen for a fall from his services and daily rituals already described The hospital horse at the Battle of Falkirk The headquarters of the usually had its own chapel, which was often an integral Templars was at Temple in Midlothian (Figure 4) With part of the ward so that even bedfast patients could be their suppression throughout Europe in 1309, the present during the celebration of the Mass22 monastic site was transferred to the Hospitallers

Most hospitals also provided a community service by distributing alms to a small and fixed number of poor people from the neighbourhood23

LEPER HOSPITALS Leprosy was imported from the Middle East during the Crusades24 It reached a peak in the thirteenth and fourteenth centuries, and subsequently became less common, eventually disappearing by the sixteenth century25 A possible explanation for this is that urbanisation increased the incidence of tuberculosis which produced a cross-resistance to leprosy26

Misinterpretation of the Old Testament suggested that leprosy was a mark of sin, so that its diagnosis and FIGURE 3 The tower and tall aisles of the preceptory of the Knights management was an ecclesiastical responsibility27 The sufferer was segregated from the community, and, prior of St John, Torphichen, West Lothian The outline of the chancel is on the front of the tower, while the foundations to hospital admission, was clad in a shroud, had a of the monastic buildings are in the church yard Requiem celebrated on his behalf and had earth thrown over him He then was dead in the eyes of the law

The reality was less severe than the theory and ritual Once registered, lepers were still allowed to do farm work, and to visit town to seek alms They had to avoid direct contact with the townsfolk by covering their faces with a cloth and using a clapper to signal their presence They might even be discharged if the hospital was overcrowded or if they consistently misbehaved

Given the rapid decline of the condition, leper hospitals had a short lifespan, and were then demolished or used FIGURE 4 for other purposes28 Surprisingly simple chapel in the monastic site of the Knights Templar at Temple Midlothian Excavation has revealed the remains of monastic buildings

38 J R Coll Physicians Edinb 2003; 33(suppl12):36–41 MEDIEVAL HOSPITALS IN SCOTLAND

Pilgrimage hospitals were placed at strategic sites along extension at one end appears to have been a bake- the routes of many pilgrimages An example is that there house was one at North Berwick and another at Earlsferry in Fife for pilgrims sailing across the Forth on their way to Maison Dieu, Brechin St Andrews31 The remains of the chapel attached to the There only are a few fragments of a thirteenth-century hospital still can be seen at Earlsferry (Figure 5) chapel These include an arched doorway with moulded jambs, and four lancet windows along one wall

St Magnus, Highland region Only the foundations of a rectangular hospital building remain Several transverse walls divide this into a number of rooms A chapel to the south of the hospital has ruined side walls and gables between 2 m and 5 m tall

DECLINE AND FALL The fifteenth and sixteenth centuries witnessed a deterioration in the institutional care provided by the Church for the sick and poor A factor in this is that recurrent episodes of famine and plague created financial instability so that the viability of hospitals was compromised33 One approach was to devote more FIGURE 5 Chapel at Earlsferry, Fife This was linked to the hospital space and staff to conducting lucrative services and which received poor and frail pilgrims who had sailed here Masses for the dead The institution changed, often from North Berwick en route to St Andrews imperceptibly, from a hospital to a chantry

ARCHAEOLOGY Hospitals instituted choirs to accompany services, and Few medieval hospitals survive intact, but some often enlisted boy choristers as poor scholars34 Since foundations of walls remain above ground, and there many eventually took Holy Orders, the standard of have been several excavations education of priests was improved In St Andrews the change eventually led to the establishment of Scotland’s Soutra first university (Figure 6) The hospital stood close to Roman Dere Street at the border between Bewickshire and East Lothian, the principal invasion route from England to Edinburgh It was designed to care for poor or sick travellers and pilgrims All that remains above ground is a seventeenth century burial vault Excavation revealed the foundations of a chapel surrounded by a large enclosure32 Three cellars abutted the precinct wall Analysis of material from drains revealed that there were seeds from henbane, opium, poppy and hemlock This suggests that, unlike those attached to most hospitals, the monks were involved in the preparation of FIGURE 6 herbal medicines This may relate to the fact that they St Leonard’s Church, St Andrews The Culdees founded a were frequently involved in the treatment of troops Church of St Andrews in twelfth century This later was suffering from a contagion or wounded in battle transferred to the Priory of St Andrews when it became the Hospital of St Andrews and, later, St Leonard’s It was Kincase, Prestwick rebuilt in 1512 when it became a College of Poor Clerks The leper hospital is reputed to have been founded by King Robert the Bruce All that remains are fragments Another explanation for the decline of hospitals is that of the chapel This is 11 m by 5 m with a maximum many became rich benefices with absentee masters35 height of 2 m Hospitals also became more selective in their admission policies36 Less frail and more educated paupers were St Nicholas, St Andrews more useful participants in religious services, and Excavation of another leper hospital uncovered a helpers in with domestic work The most needy also fourteenth or fifteenth-century rectangular building were displaced when descendants of founders or against the western boundary wall A semicircular donors admitted their own nominees, often elderly

J R Coll Physicians Edinb 2003; 33(suppl12):36–41 39 MEDIEVAL HOSPITALS IN SCOTLAND

servants37 Life in many hospitals was so comfortable were all that stood between them and the tortures of that ‘private patients’ gave a single large donation, which Purgatory or Hell The strength residents obtained from allowed them to remain in hospital for life religious observance may also have had a beneficial effect on their mental and physical well-being: whether the A series of Acts against such abuses was approved at a process did anything to speed founders and donors Parliament in 154138 Enactment was delayed by the through Purgatory is more problematic death of James V, and became irrelevant when ecclesiastical property was appropriated during the A major cause for the demise of medieval hospitals was Reformation Corruption remained within the new the diversion of funds from the care of residents to system so that many resources were transferred to the expand liturgical activities This could be justified in that nobility payment for these services could help cover the cost of caring for residents, but the policy could become a CONCLUSION reductio ad absurdum Some hospitals only survived by A striking feature of most medieval hospitals in Scotland changing their role and getting rid of patients altogether is the lack of involvement of medical practitioners Part These abuses had already been recognised by both of the explanation is that, apart from leper hospitals, Church and State, but steps taken to rectify them were they were designed to provide care for the poor, aged swallowed up in the upheaval of the Reformation and chronically disabled rather than patients with an acute illness The other factor was that there were few One of the few changes in the role of hospitals which physicians in Scotland, and that the only medical schools were of benefit was the provision of board and were those recently established on the continent;39 even education for poor scholars (Figure 6) This helped in there the theoretical basis of medicine was ill conceived the foundation of Scottish universities Reformers Although the innovative writings of Arab physicians such hoped that reallocation of resources could be used to as Avicenna had percolated through, teaching was mainly expand primary and secondary education Before this based on the tenets of Galen Astrology also had an happened, however, the nobility diverted the bulk of important influence on medical practice, and was used in Church funds to their own private use, an early warning deciding such issues as which vein should be chosen for that the Reformation did not herald an end to phlebotomy40 In these circumstances, the residents of corruption hospitals perhaps were fortunate in not having access to such experts The only medicines they were likely to Despite their many faults, medieval hospitals provided a receive were concoctions prepared by a nun or lay system of care for vulnerable members of society This, brother with practical experience of herbal remedies at its best, produced hospitals which compare favourably with the nursing and residential homes of today Even No records have survivied to tell of the response of after their demise they provided a model and inspiration recipients to hospital care, but if the hospital statutes for the present healthcare system were followed, they should have lived in reasonable comfort and have received competent and kindly nursing REFERENCES care41 Their diet also should have been adequate, if 1 Rawcliffe C Medicine for the soul Stroud: Sutton and rather dull Such provision contrasts with the official Sutton; 1999 policy regarding workhouse care in the nineteenth 2 Ibid century designed to make conditions so unpleasant that 3 Carlin M Medieval English hospitals In: The hospital in history Cranshaw L and Porter R, editors London: none but the most destitute and disabled would want to Routledge; 1989; 21–39 42 stay therein As at present, there must have been some 4 Comrie JD History of Scottish medicine 2nd ed London: medieval hospitals where the standard of care was poor, Wellcome Historical Medical Museum; 1932 where residents were abused, and where funds for food 5 Ewart G and Moffat B Soutra Hospital (Fala and Soutra went into the pocket of the master In most hospitals, Parish), medieval monastic hospital Discovery and however, the environment was better than the squalid, Excavation in Scotland 1987; 32 crowded and semi-starved state in which many lived at 6 Furniss DA The monastic contribution to medieval home medical care J Roy Coll Gen Pract 1968; 15:244–50 7 Hamilton D The healers: history of medicine in Scotland Edinburgh: Canongate; 1981 The overwhelming aura of sanctity and religious 8 Cowan IB and Easson D Medieval religious houses 2nd ed observance in most hospitals conjures up the image of London; Sheed and Ward; 1976 down-and-outs at an evangelical mission singing hymns 9 Orme N and Webster M The English hospital 1070–1570 for their supper In the Middle Ages, however, the London: Yale University Press; 1995 populace in general had a different frame of mind, in 10 Fawcett R Scottish abbeys and priories London: Batsford; which religion was all-pervasive Life was unpredictable 1994 and short so that most people believed that prayers, 11 Fawcett R Scottish cathedrals London: Batsford: 1997 relics and participation in the Mass and the sacraments 12 Carlin op cit ref 3

40 J R Coll Physicians Edinb 2003; 33(suppl12):36–41 MEDIEVAL HOSPITALS IN SCOTLAND

13 Whyte ID Scotland before the Industrial Revolution London; England and Ireland J Roy Army Med Cor 1925; 45:410–22 Longman; 1995 28 Ibid 14 Hamilton op cit ref 7 29 Fawcett op cit ref 10 15 Orme and Webster op cit ref 9 30 Maclennan WJ Torphichen and the Knights Hospitaller JR 16 Ibid Coll Physicians Edinb 2003 33(supp12):58–65 17 Furniss op cit ref 6 31 Yeoman P Pilgrimage in Medieval Scotland London: Batsford; 18 Carlin op cit ref 3 1999 19 Orme and Webster op cit ref 9 32 Moffat B Exploring Scotland’s medical past Scot Med 20 Ibid 1999; 18:12–13 21 Talbot CH Medicine in medieval England London: 33 Orme and Webster op cit ref 9 Olboume; 1967 34 Rawcliffe op cit ref 1 22 Carlin op cit ref 3 35 Hamilton op cit ref 7 23 Rawcliffe op cit ref 1 36 Rawcliffe op cit ref 1 24 Mitchell PD Leprosy and the case of King Baldwin IV of 37 Ibid Jerusalem: mycobacterial disease in the crusader states of 38 Burleigh JH A Church history of Scotland Edinburgh: Hope the 12th and 13th centuries Int J Lepr Other Mycobact Dis Trust; 1983 1993; 61:283–91 39 Porter R The greatest benefit to mankind London: Fontana, 25 Richards P Leprosy: myth, melodrama and medievalism 1997 J R Coll Physicians Lond 1990; 24:55–62 40 Talbot op cit ref 21 26 Lietman T, Porco T and Blower S Leprosy and tuberculosis: 41 Rawcliffe op cit ref 1 the epidemiological consequences of cross immunity Am J 42 Mackay L A culture of poverty – the St Martin in the Fields Pub Health 1997; 87:1923–7 workhouse 1817 J Interdisc Hist 1995; 26:209–13 27 MacArthur WP Some notes on old-time leprosy in

J R Coll Physicians Edinb 2003; 33(suppl12):36–41 41 KNOX AND LISTER

ROBERT KNOX AND JOSEPH LISTER: PIONEERS OF VASCULAR PHYSIOLOGY

DL Gardner, Emeritus Conservator, Royal College of Surgeons of Edinburgh

SUMMARY be necessary to determine whether contemporary This paper describes poorly-remembered but shared views on the rapidity of the pulse were correct aspects of the lives and work of two Victorian medical men of conspicuously different character, Robert Knox In a footnote to his report, Knox describes himself and Joseph Lister Both undertook little-knownfrankly but ‘The subject of these experiments is about 22 fundamental experiments on the cardiovascular system years of age, of a moderate height, and somewhat At a very early age, Knox made important observations muscular His constitution may be called irritable – by on diurnal variations in the pulse rate Hewhich may is meant be only that it is easily excited by stimulants regarded as an early exponent of the importance of of almost every kind He has not laboured under any Circadian rhythms in the regulation of human physiology kind of serious indisposition for a great number of years, Lister employed clinical and animal experiments that nor is he conscious of any hereditary or acquired related the diameter of limb arteries, and thus arterial tendency to disease in any organ ’ blood flow, to posture The pulse at rest The investigations of cardiovascular function by Knox Cullen7 had claimed that a natural acceleration of the and Lister have been overshadowed by the attention pulse took place twice each day, the first at noon, and directed to their other, better-known activities Knoxthat the acceleration resembled a ‘febrile paroxysm’ achieved notoriety on account of his association with Knox could not confirm this opinion He was equally the Burke and Hare murders Joseph Lister dismissive became of the views of Fodéré8 who stated that a famous because of his discovery of the means for slow morning pulse accelerated towards the end of the preventing infection at the sites of injuries and wounds day before reverting to the slow morning rate as the night passed Fundamental observations on the function of the cardiovascular system can be traced not only to the In a first experiment, Knox found that his own pulse was unique studies of Harvey,1 Hales2 and Poiseuille3 but to 72 beats per minute at 11 a m , 71 at noon, 65 at 1 p m their Arabian and European antecedents 4 In addition to and 64 at 1·30 p m Later recorded figures, taken at the work of these early investigators, however, hourly intervals and beginning at 3 p m , were 68, 66, 64 innumerable, less well-known clinical and experimental and 62 His pulse continued to decrease and was no observations have combined to lay the foundations of more than 58 at 8 p m modern cardiovascular understanding Two such pioneers are Robert Knox and Joseph Lister In a second series of observations, the mean of ten measurements of the pulse rate was 68·5 at 9 a m and ROBERT KNOX 64·38 at 12 p m Knox was careful to explain that it was The life and exploits of Robert Knox (1791–1862) have summer time, and that his morning records were made been very fully recorded 5 However, it is not generally in the sitting position, immediately after rising from bed, remembered that Knox made important, early and before breakfast observations on vascular Circadian biorhythms These experiments, conducted upon himself, were performed The pulse during digestion in 1813 when he was still a student The resultsThe were digestion of food, Knox claimed, went on more published two years later 6 His writings, not unex- easily in the morning than in the evening Animal food, pectedly, reveal an immaturity of style Knox’s wordshe believed, excited the pulse more than vegetable but were often repetitive and occasionally inaccurate to a lesser extent than wine and to a much lesser degree Nevertheless, his thoughts were clearly those of a young than ‘spirituous liquor’ One consequence was the great mind of unusual talent and originality attention given to food and the time of day at which it was taken, by those training men ‘to the performance of Knox’s studies started when he found it necessary to great muscular feats’ Knox’s subsequent records were question prevailing opinions on the actions of foxglove made in the evening after a light supper, and a small (digitalis) The drug was said to be at the samequantity, time much diluted, of ‘spirituous liquor’ He sedative and stimulating He realised that, in orderconfirmed to not only that the morning pulse rate was analyse the properties of foxglove further, it would first higher than the evening, but that the excitability of the

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pulse in response to comparable amounts of food or Some years later, while demonstrating the procedure to drink was greater in the morning than in the evening a class of students, he noticed that his own raised hand The time of day at which his own pulse began to became unusually cold He sought for a reason and, in diminish appeared to be at or about 3 p m It must be the course of his Harveian lecture,10 gave a practical noted that the figures quoted by Knox in his fourth table demonstration of how he had arrived at an explanation do not entirely substantiate his argument since the mean for this phenomenon of 18 pulse recordings made after breakfast but before 10 a m was 72 whereas the mean of 18 records made Blood flow through the raised arm after dinner, at 5 p m , was 74·22 The mean of a similar Beginning with a volunteer, Lister showed how the fully number of records taken between 10 and 12 p m was raised right arm paled and came to have the colour 64·39 ‘almost that of a limb of a corpse’ He commented that the minute arteries of the hand ‘must surely have the The pulse after exercise same state of extreme constriction as in syncope’ What Since exercise was one of the most obvious stimulants was the explanation? An elastic bandage was applied to to rapidity of the pulse, Knox began to examine the the volunteer’s raised arm, quickly and firmly The man degree of this reaction After ‘moderate was exercise’ now asked to lower his arm; the limb remained consisting of a walk of three miles before breakfast, the lowered for eight minutes The arm retained its corpse- pulse after breakfast was 79·33, after dinner the same like pallor The volunteer was then asked to raise his day 76, and after supper 63·3 Dinner was taken beforearm again, as high as possible The elastic tourniquet was 5 p m , supper at a later but unstated time At this point removed The skin of the right hand now rapidly showed in his long paper,Knox interpolates a detailed account of patches of redness Within a few seconds the limb, a four-year-old child with cyanotic congenital heart including the finger tips, was ‘of a florid red hue’ The disease who was found to have a patent foramen ovale, veins remained collapsed but the arteries were patent interventricular septum and transposition of the distended throughout their length The longer the arrest aorta but no sign of a ductus arteriosus Knox’shad initialbeen, the greater the subsequent ‘after blush’ observations demanded elaboration On ‘August 30th 1813, the day being moderately warm,’ he revealed that Lister argued that, since neither the sensory nor the ‘I walked between 1 and 11 p m , a distance of nearly 40 motor function were affected by the application to a miles ’ Not having slept well, he found that about 7 a m raised limb of an elastic bandage, sufficiently tight to the next morning his pulse was ‘80 and rather feeble’ prevent arterial blood flow, it was highly unlikely that the He took a small glass of spirits before his breakfast, vasomotor nerves of the limb were directly affected In recorded his pulse as 104, and set out to walk a further the language of the day, Lister then deduced that a 27 miles ‘at a tolerable pace’ Curiously, his long demandpaper for a ‘vital fluid’ had been created by the ‘want’ gave no further details of the pulse after this second of this fluid from a part deprived of its arterial period of prolonged exercise circulation In turn, this ‘want’ had acted upon the vasomotor nerves of the limb, inducing arterial JOSEPH LISTER relaxation The deficiency overpowered the stimulus to Joseph Lister’s life (1827–1912) and achievements have vascular contraction that had resulted from the found many apologists 9 A striking example of Lister’s diminution of [blood] pressure upon the vessels in the capacity for inspired, logical thought combined with elevated position practical experiment was described in an invited address which he gave to the Harveian Society 10 Lister then suggested that the phenomena that he had demonstrated might be exaggerated if the circulation In 1864, prior to his epoch-making investigations of was brought ‘into full effect’ He therefore tested the wound infection, Lister11 devised a new operation for the influence of exercise on the responses of his own hands treatment of the then common condition of caries The experiment was made, as he says, ‘just after I had (tuberculosis) of the wrist joint Until that time,been walking the with great haste to catch a train, when my customary treatment for this condition had been heart was beating with unusual vigour, and my hands amputation In the course of the were conservative of florid colour’ The left hand that he had raised procedure it became clear that a drawback to wrist for half a minute, perhaps on the railway platform, excision was bleeding from numerous small arteries became of a much deeper ‘arterially red’ colour than the Lister therefore began to examine the value of the right After one and three quarters minutes, the hands application of a tourniquet, a procedure used previously were once more of the same hue Repeating the only in amputation The experiment was successful Byobservation, after two minutes, he elevated the left hand raising the patient’s arm to the maximum possible height for two minutes Lowering it, he observed that in ten before applying ‘a common tourniquet’, he secured a seconds it had become much redder than the right, bloodless field which had been suspended the whole time The longer period of elevation resulted in a prolonged period of

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redness Even after two minutes and 20 seconds, whenLister believed that the large differences in arterial as Lister says, ‘I was obliged to start for the train’, the diameter and in the cross-sectional area of the calibre previously elevated left hand was still redder than the right could not be accounted for simply by the differences in blood pressure between systole and diastole Hales2 had Blood flow in the animal limb famously described how blood rose to a height of nine Characteristically, Lister now turned to animal feet and eight inches above the level of the heart, in a experiment On 29 November 1873, he anaesthetised brassa tube inserted into an equine carotid artery Lister horse with chloroform A contrivance of slings, ropesdeduced that the blood pressure within the smaller and pulleys allowed the animal to be inverted arteriesAt the of the limb was not significantly different from lower part of a foreleg, Lister exposed a metacarpal that in the large vessels Since the elevated limb of the artery Callipers were used to measure the horse, external in his studies, extended no more than four to five diameter of the artery in each of three positions: with feet above the heart, it followed that raising the limb the feet dependent; in a horizontal position; or with the vertically could not diminish the pressure of the blood feet raised vertically into the air He found thatupon when the internal surface of the vessel wall by more than the limbs were elevated, the artery was in a state of one half extreme constriction The external diameter of the artery increased when the animal became horizontal DISCUSSION and, to a greater degree, when it was vertical The arteryIt is an axiom of biographical history that many of the was then excised, the cross-sectional area of the most famous and, by analogy, most infamous, men and muscular wall measured Assuming that the area of womenthe possess diverse talents Although Alexandre arterial muscle coat remained constant no matter Dumas (fils) said:‘All generalisations are dangerous, even whether the vessel was contracted or dilated, he this one,’ it appears reasonable to speculate that those demonstrated that the cross-sectional areas of the who have achieved fame or infamy in one field of calibre (the lumen) in the upright position was more endeavour,are likely to show originality in others In this than three times greater than when the limbs were paper,I suggest that this is true both of Robert Knox and horizontal, and sevenfold greater than when the limbs of Joseph Lister were elevated The results are shown in his diagram (Figure 1) By 1815, young Robert Knox had displayed great promise He was a youth of exceptional, natural ability He came from a modest family background but enjoyed a good education Knox5 left the Edinburgh High School in 1810 He was a fine classicist He graduated MD Edinburgh in 1814 before moving to London, assisted John Abernethy at St Bartholomew’s Hospital Medical School, Smithfield, London, and came to know Charles Bell with whom he travelled to the battlefield of Waterloo in early July 1815

Although remembered for his notorious association with the Burke and Hare scandal, the published evidence confirms that Knox possessed a highly original mind He was thoughtful but contentious, persuasive but argumentative, a brilliant anatomist and much admired FIGURE 1 lecturer He taught and wrote on ethnology, anthro- Drawing from Joseph Lister’s 1879 paper The first part pology and philosophy Surprisingly, he also published (from left to right) of the diagram illustrates the diameter one of the most attractive of all books on fishing 12 Knox and cross-sectional dimensions of the metacarpal artery of inherited Barclay’s School of Anatomy, and became the a horse after the artery had been excised The second, first Conservator of the Royal College of Surgeons of third and fourth parts illustrate the external diameters of Edinburgh The investigations of the pulse described in the artery measured with the living animal supported in his 1815 paper6 were made when he was a medical the erect, the horizontal and the inverted positions The cross-sectional area of the vessel in these three positions, student By twenty-first-century standards, Knox’s and the area of the lumen (the calibre), were derived from experiments seem simplistic and naïve Set against the the measurements of these components made on the views of early nineteenth century authorities, however, excised vessel In Lister’s words: ‘The numbers in the they were informed, critical and imaginative There is no diagram are hundredths of an inch, and the drawings are evidence that Knox had access to special instruments or accurate to scale, though magnified for convenience of apparatus In his experiments, he therefore used only representation Lister was an able artist and it may be practical common sense His conclusion that the pulse supposed that he drew this figure himself declined in frequency from morning to evening ran

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counter to the textbook dogma of his time and must be paper10 reveals with great clarity the modus operandi of accepted as a valid opinion of considerable originality one of the greatest intellects of his time

The later enquiries of a mature, older (and wiser) Joseph ACKNOWLEDGEMENTS Lister9 are in an entirely different category ListerI amnot grateful to Mr Steven Kerr of the Library of the only grew up in a wealthy and privileged society but Royal College of Surgeons of Edinburgh for his expert enjoyed the constant support of a father who was assistance himself a noted scientist By the time Lister gave his Harveian Society address,10 he was a revered figure of REFERENCES the Establishment, Surgeon to Queen Victoria and an 1 Harvey W Exercitatio anatomica de motu cordis et sanguinis authority respected throughout the Western world He in animalibus Frankfurt: Guilielmi Fitzeri; 1628 had revolutionised surgery through a system of wound 2 Hales S Statical essays, containing haemostaticks Vol 2 dressings that prevented putrefaction, invented the London: W Innys and R Manby; 1733 3 Poiseuille JLM Recherches sur la force du coeur aortique absorbable, antiseptic suture, studied the life of micro- Paris: These No 166; 1828 organisms in liquid culture, and analysed the mechanisms 4 Dalton JC Doctrines of the Circulation Philadelphia: HC of inflammation and coagulation He had introducedLea’s Son and Company; 1884 new instruments and designed operations such as those 5 Lonsdale H The life of Robert Knox London: Macmillan & for excision of the knee meniscus and the tuberculous Co ; 1870 wrist Lister’s studies of the response of the peripheral6 Knox R On the relation between the time of the day, and circulation to the application of tourniquets were begun various functions of the human body; and on the manner after he had become Professor of Clinical Surgery in in which the pulsations of the heart and arteries are Glasgow, in 1860 Continued in 1873, they were notaffected by muscular exertion Edin Med Surg J 1815; XI:52–65; 164–7 published until 1879, nine years after he had left 7 Cullen W Synopsis nosologiae methodicae 6th edition Edinburgh to assume the Chair of Surgery at King’s Edinburgh: William Creech; 1795 College Hospital Medical School 8 Fodéré FM Essai de Physiologie Positive, apliquée spécialement à la médecine pratique Avignon: Tom I; 1806; The exact external diameter of arteries in different 190 postures must seem to present-day physiologists a trivial 9 Godlee R Lord Lister 3rd ed Oxford: Clarendon Press; matter But the attempted calculation of the 1924 cross- sectional area of the lumen of these limb vessels in 1873, 10 Lister J Effects of the position of a part on the circulation and the derivation of the areas of the transected arterial through it Br Med J 1879; II:923–42 11 Lister J On excision of the wrist for caries Lancet smooth muscular walls, show that Lister was closely 1865; I:308–12; 335–8; 362–4 engaged with the problem of blood flow and its influence 12 Knox R Fish and fishing in the lone glens of Scotland on the vitality of the parts on which he operatedLondon: His Routledge & Co; 1854

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THE CASE OF MADELEINE SMITH: A VICTORIAN DISCOURSE OF DESIRE AND DEATH

JR Roy, Professor Emeritus, Psychiatry, McMaster University, Canada

THE LOVE AFFAIR At the age of 20, Madeleine led a carefree, indulged life On 1 April 1855, Madeleine Smith (Figure 1) wrote the as the eldest and favourite of her wealthy father’s five first of approximately 300 letters1 of a fateful corres- children)2 In her letters we come to know a strong, pondence, which began: impulsive, duplicitous personality and a capable, daring young woman who differed greatly from the stereotype My Dear Emile, I do not feel as if I were writing you of the Victorian ‘young lady’) Already in the first letter, for the first time) Though our intercourse has been she controls the correspondence and decides when and very short yet we have become as familiar friends, where she and her lover should meet, waiting for a time may we long continue so and ere long may you be a when her parents will be absent: friend of Papa’s is my most earnest desire) Papa & Mama are not going to Town next Sunday) So of course you do not come to Row ) ) ) Write on Wednesday or Thursday)

A few weeks earlier, while walking with her sister Bessie in the streets of Glasgow, then in the heyday of the Industrial Revolution and of its Victorian splendour as the Second City of the British Empire, Madeleine had exchanged fervent glances with a handsome, dapper man of exotic appearance:‘The way we used to look at you; I feel ashamed of it now,’ she wrote later)

Useful here is French psychoanalyst Jacques Lacan’s theory of ‘the gaze’ of the Other (the consoling sense of being safe under the mother’s look) crucial in the structuring of the infantile moi or self) The gaze here is not the Other’s gaze as such, but an imagined gaze and how it seems to concern and affect the subject’s desire) According to Lacan, following Sartre, ‘this double gaze whereby I see that the Other sees me, and that any intervening third party sees me being seen’ can arouse an intersubjective desire that has more to do with a primordial lack in the subject than with any qualities of the human object before her)3–5

The young man,‘Dear Emile’, was Pierre Emile L’Angelier (Figure 2), born to an exiled French family in the Channel Islands) Seeking to make his fortune by an advantageous marriage, he had learned that Madeleine’s father was wealthy and influential, and in mid-March contrived an introduction to her on the street through a mutual acquaintance) On Valentine’s Day he sent her a flower) FIGURE 1 Madeleine Smith In the months that followed, Madeleine declared that she She was sitting by a window of Rowaleyn, the mansion was in love and a passionate affair began) She arranged designed and built in the Scottish Baronial style by James assignations to coincide with her trips back to the city) Smith, her father, as the family’s summer home in Rhu They also met surreptitiously in the family’s rented town (then Row), looking out on the Clyde Estuary) home during the ensuing winter and in the grounds of Rowaleyn in the summer of 1856) She did not show the

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self-restraint, calculation or series of deceptions Reflecting the turbulent contradictions of her nature advocated in Victorian courtship manuals) At the ‘top of and her journey of self-discovery, Madeleine’s letters, in the garden’ of Rowaleyn, on Tuesday evening, 6 May their tiny envelopes, took on the character of romantic 1856, Madeleine and Emile had their first sexual amorous epistolary discourse; which: intercourse) Her ecstatic reaction, in a letter the next day, horrified the presiding judge at her trial: ) ) ) simultaneously dramatizes [the] silence [of the absent beloved], the [writer’s] alienation, and the It is the letter of a girl rejoicing in what had passed, metonymic displacement of desire ) ) ) Since every and alluding to it ) ) ) in terms which I will not read, letter to the beloved is also a self-address ) ) ) [the for perhaps they were never previously committed writer’s] project – aided by her reading and her to paper as having passed between a man and a writing – also involves self-creation, self invention)9 woman) What passed must have passed out of doors and she talks of the act as hers as much as his)6 Written rapidly in a large flowing script with a quill pen, late at night, by the light of a candle, they are free- Emile, characteristically, blamed Madeleine: ‘You had no associated, intertextual patchworks of half-remembered resolution) We should indeed have waited till we were songs, sermons, and romantic novels, interspersed with married ) ) ) It was very bad indeed)’7 quotes from letters, vehement denials, ardent protestations of undying love, arrangements for meetings, for exchanging letters, accounts of dances, excursions and trivial, random, everyday happenings) ‘There is nothing I am so fond of as writing,’ she claimed) Large sheets of paper were folded to make eight small pages, and then cross-written) Many still exude an odour of musk from a perfumed ink that lingers on the twenty- first-century reader’s fingers)

Adopting a childhood pet name of Emile’s, she began to sign herself: ‘Your own dear little wife, Mimi L’Angelier’ and wrote:

Oh Emile, my heart burns with love for you) I adore you with the ardour of a woman’s love) I wish I could be with you this night) I would love you, pet you, fondle you)

She joked that when they were married: ‘I suppose I must not be too hard [in sexual demands] upon my little husband or I would kill him in no time)’

Madeleine was ready,she declared, to share a life of poverty with Emile, who earned only ten shillings a week; the approximate cost of a ‘modest lodging’ in Glasgow according to the newspaper of the time) Emile rejected her frequent offers to elope with him, hoping for the FIGURE 2 Pierre Emile L’Angelier acceptance and patronage of an influential father-in-law)

During the ensuing months, Madeleine (like Inanna the But initially, Madeleine acted against her true nature, Sumerian goddess of love in a myth at least 4,000 years portraying herself as an inferior who needed teaching, old) descended into an underworld of dark passionate reprimand and control by Emile who was perfection) love and hate) Gradually her defensive layers were She thus exemplified the role of the slave in a stripped away just as Inanna successively shed clothing and Master/Slave or Lordship/Bondage relationship which, earthly possessions at each of the gates of the according to Hegel is ‘simply to live or to be [or to underworld) Madeleine would encounter the unconscious work] for another’)10 William R Schroeder explains, depths of her nature and come to terms with her dark ‘[Though] the vision according to which [the slave] ruthless self) Both Madeleine (in reality) and Inanna (in the transforms the world is not [her] own ) ) ) [she] does myth), after their experiences in the underworld, brought transform the world; [she] can see [herself] reflected in about the death of ‘him to whom she had been ecstatically the products of [her] work’ – in Madeleine’s case the linked as lover, bridegroom and husband’)8 letters she wrote and the complex organisation of the

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affair)11 In so-doing, the slave (as Madeleine did) develops level of the plan, sleeping in a bed in the corner furthest an identity becoming ‘conscious of what [she] truly is ) ) )’12 from the door and the windows (Figure 4))

THE MURDER Through the window (seen from the outside in Figure 3) On 17 November 1856 the Smith family returned to Madeleine received letters from Emile and would hand Glasgow to take possession for the winter of a rented out to him cups of coffee or cocoa) The kitchen, also on town house at No) 7 Blythswood Square in the new West the basement level, was convenient for preparing End of the City (Figure 3)) The Smiths occupied the beverages) Her parents’ bedroom was upstairs) While ground floor and the basement) The partly sunken the household slept, she would sometimes take Emile window nearest the side-steps is of particular significance) into the laundry or even the drawing room)

The separate upper part of the house, reached by the On Sunday 1 February 1857 Madeleine wrote that she side entrance on Mains Street, was the residence of Mr wished to end the relationship as she no longer loved Minnoch, a banker friend of Madeleine’s father who had Emile) She asked him to return her portrait, adding been proposing Minnoch as a suitable match for his coyly, that she trusted to his honour not to reveal daughter ever since he became aware of Madeleine’s ‘anything that may have passed between us’) involvement with the socially unsuitable Emile) During the winter of 1856–7, Madeleine began to look Emile responded that he would ensure that she would favourably on William Minnoch and contemplated a never be the wife of anyone but him and threatened to return to respectability and an assured, though send Madeleine’s revealing letters (which she thought he conventional future) Rumours of her prospective had destroyed long ago at her request) to her father) marriage came to Emile’s ears) Alarmed, she begged him:‘Do not bring your once loved Mimi to an open shame ) ) ) For God’s sake do not send Madeleine and her sister Janet (who was a heavy my letters to Papa ) ) ) Emile do not drive me to death’ sleeper) occupied the room indicated on the basement – did she mean hers or his?

FIGURE 3 No 7 Blythswood Square

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determinate mode of life) The slave thus recovers [her] own abstract self-identity, which is distinct from [her] life-processes and particularity)’15

Madeleine, prevaricating and feigning a continuance of love, quickly decided on drastic intervention) Some of her actions were coolly calculated, but concealment was not the main object as she staked her life in the Hegelian life-and-death struggle) Christina Haggart, the maid who had been an accomplice in the affair and a sardonic observer of Madeleine’s behaviour, recalled a convers- ation with her about this time:

I remember asking her if she had got back Mr) L’Angelier’s letters, her letters to him) She smiled and said, ‘I haven’t got them back but I don’t care,’ and then left me)16

In Lacan’s theory and other intersubjective models, when the substitute for the primordial Other (Emile in this case) ceases to provide the required self-enhancing reflection, the self’s created unity is unravelled and the subject or lover falls back to the primal stage of ‘disembodied fragmentation’ and insecurity) Then the narcissistic rage of the thwarted infant can return to be visited aggressively and cathartically on the denying and threatening Other)17, 18

Sometime during the second week of February 1857, Madeleine sent the servant-boy William to a neighbouring dispensing physician with a shilling and a note that politely requested a ‘small phial of Prussic Acid’)19 Given that this poison induces death rapidly, it is as well that the doctor refused this request) Even Madeleine Smith’s resourcefulness would have been severely taxed if faced with an instant corpse in the family drawing room at one o’clock in the morning!

However, Madeleine persisted in her purpose by other FIGURE 4 Plan of basement at No 7 Blythswood Square means) Late in the night of Thursday, 19 February 1857, Emile L’Angelier was afflicted with the first of three The situation was serious) According to Scottish law of separate episodes of illness characterised by diarrhoea, the time, Madeleine was bindingly married to Emile) An vomiting, abdominal pain and weakness)20 Earlier on that irregular, but perfectly legal and indissoluble marriage, Thursday evening, Madeleine Smith (in possession of a was constituted by the promise of marriage (which little white folded paper package of poison) spent a occurs frequently in her letters) followed by sexual pleasant evening at the opera with her new fiancé, Mr intercourse (copula carnalis in legal terminology))13 Again William Minnoch, respectable banker, and his sister) In a Hegel understands the situation) Madeleine has: remarkable coincidence, the performance that night by the touring Italian opera company, was Lucrezia Borgia, )))trembled in every fibre of [her] being, and Donizetti’s renaissance drama of love and poisoning) everything solid and stable has been shaken to its foundations) But this pure universal movement, the That Madeleine saw Emile after her return home is absolute melting-away of everything stable, is the indicated by an entry in a little leather-bound simple, essential nature of self-consciousness, pocketbook in which Emile began at this time to write absolute negativity, pure being-for-self ) ) )14 short cryptic notes)21 The entry for 19 February reads: ‘Saw Mimi a few moments, was very ill during the night)’ The fear induced by the master eliminates ‘the slave’s Only a Verdi quartet could do justice to the emotions attachment to anything worldly, to any role, or any and interactions of these four people that night)

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Probably Madeleine did not take Emile inside on this required by the relevant Act of Parliament)25, 26 occasion) When he tapped at her window, he gave her a Madeleine charged this purchase to her father’s account) letter and she handed out to him, between the bars At the time of the trial it had not been paid) protecting the window to her bedroom, a poisoned beverage while her little sister Janet slept in the bed six George Murdoch added the fascinating information that, paces away) ‘I saw her again some three days after; she called to enquire if arsenic should not be white)’ It is probable I accept that Emile’s illness on 19 February was due to that Madeleine had recently read, in Dickens’ new irritant poison; the symptoms were considered by his magazine, Household Words, the story of a famous landlady and himself to be identical to those both of his eighteenth-century poisoning case in which it is second episode and of his third, fatal, illness) But no one emphasised that arsenic is a white powder)27 This belief was able to prove that Madeleine Smith had purchased would have been confirmed if she had received white arsenic or other irritant toxic substance in Glasgow tartar emetic from Mr Spence believing it to be arsenic) prior to 19 February) Mr Murdoch explained to Miss Smith the current legal obligation to add colouring matter to the white arsenic John Spence, an apothecary at West Bay, Helensburgh powder) (near Rhu), who knew Madeleine from her frequent visits to his shop during the summers, could not rule out The results of this purchase quickly became evident) the possibility that he had been Madeleine’s source of Emile had a second (less severe and more slowly poison in the period prior to the death of Emile developing) attack of gastrointestinal irritation during L’Angelier: ‘) ) ) it is quite possible it may have occurred the night of Sunday, 22 February) He ‘knocked through and that it may have flitted out of my memory’) When the wall’ to summon Mrs Jenkins about four o’clock on young ladies asked him for arsenic to kill rats, Mr the Monday morning, and that paragon of landladies got Spence’s policy was to give them tartar emetic: out of bed to tend Emile) Emile’s memorandum note for that day stated:‘Saw Mimi in drawing room, promised me )))marking the paper in which it was wrapped with French bible, taken very ill)’ the word Poison and of course they have gone away with it under the impression that it was arsenic I had Probably when she attempted to use Murdoch’s arsenic given them)22 Madeleine found it impossible to administer sufficient to be lethal) As the Act of Parliament that mandated the Tartar emetic (antimony-potassium tartrate) is, like addition of colouring matter intended, the colour and arsenic, a white powder and when taken by mouth it taste of soot in a high dose would betray the presence induces similar, but perhaps more rapid and severe, of a noxious foreign substance in any beverage) symptoms)23, 24 This poison (thought by Madeleine to be arsenic) may have been the cause of Emile’s first set of On 5 March, Emile recorded that he:‘Saw Mimi gave her symptoms) a note and rec’d one)’ In this threatening note, recklessly hastening to his doom, he accused her of being engaged At this stage she may not have determined on actually to marry another and insisted on a satisfactory answer) killing Emile but was merely trying to make him ill enough to decide to leave town) She wrote to him with The following day, Madeleine, accompanied by her the authority of secret knowledge: school friend Mary Jane Buchanan, bought an ounce of arsenic (this time mixed with indigo) from John Currie, If you would take my advice, you would go to the a druggist on Sauchiehall Street) As they walked along south of England for ten days; it would do you much the street, Madeleine exclaimed,‘Oh just stop a moment, good) In fact, sweet pet, it would make you feel quite I want to go into this shop; will you go in with me?’ well) Do try and do this) Mary Jane recalled: His absence would allow her to make a public announcement of her engagement to Minnoch and )))I heard her ask for arsenic) She was told by the perhaps she thought Emile would accept a fait accompli) shopman that she must sign her name to a book) She But he received her advice with suspicion and refused to said, ‘Oh, I’ll sign anything you like)’ He did not ask leave the city) her what she wanted with it) I asked her that in the hearing of the shopman and she said it was to kill It is known that Madeleine did buy sixpence worth of rats ) ) ) I think she asked the shopman something arsenic (one ounce) from Murdoch the chemist, in [like]; how was arsenic sold and ‘would sixpence Sauchiehall Street, on Saturday, 21 February) She was worth be a large quantity?’ ) ) ) and he said such a given ‘common white arsenic’ (arsenious oxide or quantity as she named would kill a great many arsenic trioxide) mixed with soot in the proportion people) She turned to me and said she only wanted

50 J R Coll Physicians Edinb 2003; 33(suppl12):46–55 THE CASE OF MADELEINE SMITH

it for rats ) ) ) Everything was done very openly, she Adieu with tender embraces, ever believe me to be paid for it) On leaving the shop I laughed at the idea your own ever dear fond, Mimi) of a young lady buying arsenic; she said nothing but laughed too)28

Madeleine then left Glasgow with her family to enjoy a holiday at their favourite resort, Bridge of Allan in Stirlingshire, where they were joined on 12 March by William Minnoch) They chose 18 June as their marriage date) Madeleine, appearing happy and relaxed to family members,29 continued to write loving letters to Emile, promising to meet him soon when everything would be explained)

On 18 March, the day after her return to Glasgow, Madeleine again visited Currie’s shop and bought a further ounce of arsenic mixed with indigo, ‘the last having proved so effectual – she having found eight or nine large rats lying dead)’30 She now had in her possession two apothecary ounces or 960 grains of arsenic) According to a forensic chemist, four or six grains are generally regarded as sufficient to destroy life; ‘two grains have been known to kill)’31

Why would Madeleine purchase such an enormous amount of arsenic? I suggest that she needed to make some amateur chemical experiments in preparation for administering the final fatal dose) For example, she may have found a way to eliminate most of the added dye)

No characteristic blue indigo coloration was noted in FIGURE 5 Emile’s stomach or intestine at autopsy)32 Yet when a dog Portrait of Dr Christison was given a fatal dose of arsenic coloured with indigo by Dr Penny, professor of chemistry at the Andersonian University Glasgow, he had no difficulty in detecting Thanks to the enviable promptitude of the Victorian indigo in the gastro-intestinal tract)33 Dr Robert postal system, Emile received this fateful letter the Christison, Scotland’s foremost forensic toxicologist following morning, Sunday 22 March, and immediately (Figure 5), stated that the arsenic mixture that returned to Glasgow, where he left his lodgings at about Madeleine purchased from Currie ‘was not coloured by 9·00 p)m) true indigo; it appears to be waste indigo)’34 Dr Penny declared that most of the indigo colouring matter in Mrs Jenkins was certain that ‘he had an appointment with Currie’s arsenic could be removed by repeatedly his lady-love but he did not say and I did not ask him’)36 agitating the powder in water and decanting the supernatant liquid after settling)35 Further trials by Before going on his recent holiday Emile had talked to a Madeleine could have focused on strategies of friend, Miss Perry, about Madeleine, saying: ‘My suspending arsenic in coffee or chocolate as will be attachment to that girl is a perfect infatuation – if she discussed later) were to poison me I would forgive her)’ He mused further: ‘I cannot think why I felt so unwell after that Madeleine had been setting her trap and now was ready coffee and chocolate from Mimi)’ Miss Perry could not to entice her victim within) On Saturday 21 March 1857 take these remarks seriously and told him that ‘his she sent her last letter to Emile, who was away from suspicions were groundless)’ To this Emile replied, ‘I Glasgow on convalescent leave) This short letter, found don’t know that – perhaps she would not be sorry if she after his death in his jacket pocket, appointed a time of were rid of me)’37 meeting at her home and ended: Yet despite these suspicions he went eagerly to a further Do come, sweet love, my own dear love of a meeting with Madeleine who probably took him into the sweetheart) Come beloved and clasp me to your drawing room late on the night of 22 March while the heart) Come and we shall be happy) A kiss fond love) family and servants slept) She found a way to pacify his

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suspicions and persuaded him to take a cup of poisoned left to suspend in the beverage) Taste was not a chocolate from her hand) problem) Dr Christison testified that from personal experiment he knew that ‘the taste [of arsenic] was very A very large quantity of arsenic must have been slight indeed – if anything, sweetish, but all but administered to Emile L’Angelier, as 88 grains remained imperceptible ) ) )’41 in his body after death despite all that he had vomited: ‘as much would be vomited as remained; it might, On his way back to his lodgings through the silent city early without any extravagant supposition, be taken at four or on the morning of Monday 23 March 1857,Emile L’Angelier five times as much’, declared Dr Christison, the author became very ill and was again tended by Mrs Jenkins who of a text book on toxicology, who reported that he had called a doctor) No treatment was of any avail and at 10·30 never had a case ‘with eighty grains in the stomach of a a)m), he died with his face to the wall) Surprisingly, he said person who had been poisoned with arsenic’)38 nothing to Mrs Jenkins or the doctor of any suspicions he may have had as to the cause of his symptoms)42 Experiments demonstrated that if arsenic is simply added to a prepared cup of warm chocolate or coffee, Events then moved quickly) Madeleine’s incriminating most of it is neither dissolved nor suspended but falls to letters to Emile were found in his room and in his desk at the bottom)39 If, however, arsenic and coffee or work) An autopsy confirmed the clinical diagnosis of death chocolate powder are boiled together in a pan with milk by irritant poison; the stomach and its contents were sent or water, more than 200 grains of arsenic can be held in for analysis) On 31 March Madeleine was charged with free suspension at the temperature at which these murder and, as she later put it,‘cast into prison’) beverages are usually served)40 Madeleine may have discovered this in her own experiments) An exhibit at THE TRIAL the trial was Madeleine’s packet of chocolate, the label The trial of Madeleine Smith in the High Court of of which advises just this method of boiling powdered Edinburgh, began on Tuesday, 30 June 1857, and lasted for chocolate and milk in the pan, without of course the nine sensational days amid scenes of tumult inside and arsenic! Sixpence worth of arsenic (one ounce outside the courtroom (Figure 6)) apothecary measure) would contain 480 grains) Even assuming that she had used one whole packet in Throughout her trial Madeleine exemplified Paul Valéry’s experimenting she would have a large quantity of arsenic saying that ‘in all criminal cases the essential thing for the

FIGURE 6 Scene outside the court, Edinburgh

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accused is to make himself appear infinitely more book excluded and the xenophobia that portrayed Emile interesting than his victims’)43 as the foul French seducer of the flower of Scottish maidenhood) At 10·35 a)m): The jury found Madeleine ‘Not guilty’ of the first charge )))a very young lady of short stature and slight form, and ‘Not proven’ on the second and third charges, by a with features sharp and prominent, and restless majority of 13 to two) Many were reminded of the sparkling eye, was seen to ascend the trap-stair, and common witticism that the Scottish verdict of ‘Not step into the dock with all the buoyance with which proven’ means:‘Not guilty, but don’t do it again)’ she might have entered the box of a theatre ) ) ) THE AFTERMATH She was elegantly but simply attired in a white straw In a letter written from Rowaleyn four days after the bonnet, trimmed with white ribbon and mounted verdict of Not Proven was received in the court with with a figured black veil) She had on a visite trimmed wild enthusiasm, Madeleine informed the matron of with lace; her gown was of brown silk) She held in Edinburgh prison, who had sat beside her during the trial her gloved hands a cambric handkerchief and a bottle that ‘mama [was] in a bad state of health’ and that ‘The of smelling salts)44 feeling in the West is not so good towards me as you kind Edinburgh people showed me)’ She added that she All were aware that a finding of guilty of murder would was: lead to Madeleine’s public execution) Many in the Court ) ) ) not at all pleased with the verdict [but was] would have read of, or even witnessed a few years delighted with the loud cheer the court gave) I did previously, the public hanging in Glasgow of 25-year-old not feel in the least put about when the jury went Margaret Lennox for the murder by arsenic of her out considering whether they should send me home sister-in-law) Demoralised and physically helpless, in a or keep me) I think I must have had several hundred state of stupor, she was carried to the scaffold and held letters, all from gentlemen, some offering me upright on the trap door until the executioner released consolation, and some their hearths and homes)47 the bolt in the presence of an estimated 30,000 people who showed no sympathy for her plight)45 As Fryn Tennyson Jesse, one of the most insightful writers on Madeleine, says of this letter, ‘Whatever we Madeleine, on being formally presented with the three may think of Madeleine Smith, it is impossible not to charges against her: two of attempted murder by admire the excellent state of her nervous system)’48 To poisoning and the capital charge of murder by poison on Tennyson Jesse, Madeleine was a woman who had been the dates already mentioned, stood up and was born before her time) addressed by the Lord Justice-Clerk as follows: ‘You, Madeleine Smith, or Madeleine Hamilton Smith, are The Smith family never recovered from the disgrace of charged with intent to murder, as also murder) Are you 1857) None of her siblings married, her father effectively guilty or not guilty?’ withdrew from business and died relatively young) Madeleine, in contrast, had a long and varied life) To this Madeleine replied ‘in a clear sweet treble – no trace of huskiness or emotion perceptible in the voice, On 4 July 1861, Madeleine married an artist, George no trembling on her tongue,“Not guilty”’) Wardle, in the fashionable London church of St Paul’s Knightsbridge,49 and thereby, like John Fowles’s French As the trial proceeded, one journalist waxed ecstatic: Lieutenant’s Woman, entered the fringes of the Pre- Raphaelite Movement when her husband became Others may be thirsty amid the hot excitement, but, William Morris’s manager) The details of her crime were when the female attendant offers her a glass of well-known to the artistic community, occasioning only water, she will not have it) There she sits, refusing some jokes about whether it was safe to eat dinner in meat and drink, or a moment’s retirement in her cell, her home and a skit or satirical playlet by Dante Gabriel with a smelling bottle in her dainty little hand, which Rossetti about Morris, the Wardles, arsenic and tea)50 she never uses – a splendid specimen of physical power, and of such endurance as only a will of Possibly through William Morris, Madeleine became terrible strength could attain)46 involved in radical socialist politics, becoming a member of the Council of the Socialist League and treasurer and co- John Inglis, Dean of Faculty and counsel for the defence, librarian of the Bloomsbury branch on 26 February 1887)51 arose on the eighth day of the trial (Wednesday 8 July) to give a passionate and eloquent defence) Equally George Bernard Shaw dined occasionally at Mrs important in determining the verdict were the defence’s Wardle’s home and sought her advice when he had a ability to have the evidence of Emile’s damning pocket- problem scheduling a lecture and when he needed a

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copy of the Socialist League Manifesto)52 To Shaw: ‘She Jesse’s comments on the judge’s remarks) seemed an ordinary good-humoured capable woman 7 Pierre Emile L’Angelier, letter to Madeleine Smith, SRO,AD with nothing sinister about her)’53 Madeleine, or Lena 14/57/255/8, No) 16) Wardle, as she now chose to be called, worked closely 8 Wolkstein D, Kramer SK) Inanna Queen of Heaven and with Karl Marx’s daughter Eleanor on socialist projects) Earth: her stories and hymns from Sumer) New York:Harper & Row; 1983; 51–90) After her husband’s death (certified as from ‘cancer of 9 Kauffman LS) Discourses of desire: gender, genre, and the caecum and colon’ on 11 September 1910)54 epistolary fictions) Ithaca: Cornell UP; 1986; 25; 56–7) Madeleine emigrated to New York where her son had 10 Hegel GWF) Phenomenology of spirit) Oxford and New preceded her) York:Oxford University Press;1977; 115; paragraph 189) 11 Schroeder WR) Sartre and his predecessors: the self and the She spent her final years in the Bronx in the age of the other) London: Routledge & Kegan Paul; 1984; 61–74) flapper and the Charleston, within earshot of Babe 12 Hegel op cit) ref) 10, 118, paragraph 195) Ruth’s triumphs at Yankee Stadium, and there she died of 13Chisholm J, editor) Green’s Encyclopedia of the Law of Scotland Vol VIII Edinburgh: William Green & Sons; 1898; ‘uraemic poisoning’55 at the age of 93 on 12 April 1928, 261–5) the year in which Bessie Smith recorded her sexually 14 Hegel op cit ref) 10, 117, paragraph 194) explicit Empty Bed Blues and people in the streets 15 Schroeder op cit) ref) 11, 73) whistled Bye, Bye Blackbird She is buried in Mount Hope 16 Haggart C) Precognition SRO, AD14/57/255/3, No) 29, Cemetery in Hastings-on-the-Hudson) 31 March 1857) For all witnesses the precognitions, when available, give accounts that are nearer in time to the Not a shrinking Victorian heroine, Madeleine Smith was, events witnessed and thus, presumably, more accurate than rather, the hero of her own life, and as awesome in her statements made at the trial) The latter, of course have the mythic qualities as those female protagonists of French correcting effect of cross-examination) novelist Stendhal of whom Julia Kristeva declares: 17 Lacan J) Écrits: a selection) New York:Norton; 1977; 16–25) 18 Kohut H) Thoughts on narcissism and narcissistic rage) Psychoanal Study Child 1972; 27:360–400) They have the strength of destiny, the power of 19 Murray W) Precognition) SRO, AD14/57/255/3, No) 31, ancient divinities) Through their secular side, they 6 April 1857) Murray estimated that this event occurred secure or destroy the social power of their lovers, ‘about six weeks’ before Madeleine ‘was taken into followers of Don Juan, while through their nocturnal custody’) side they bring about the madness and death of their 20 Vivid accounts of Emile’s three episodes of ‘illness’ and of Werthers)56 his death are found in the precognition of his landlady Mrs Ann Duthie or Jenkins of 11 Franklin Place) SRO, AD 14/57/255,Vol) 3, No) 6) ACKNOWLEDGEMENTS 21 In the Mitchell Library, Glasgow) I would like to thank Alexander Aiken of Giffnock; the 22 Spence J) Precognition) SRO AD14/57/755/5, 8 June 1857) directors and staff of the Mitchell Library, Glasgow; the 23Glaister J) Medical jurisprudence and toxicology) Edinburgh: Scottish Record Office, Edinburgh; and Stephen and Gay Livingstone; 1947; 506–9) Newell of Rowaleyn, Rhu) 24 Christison R) A treatise on poisons) 4th ed) Edinburgh: Black;1845; 472–87) REFERENCES 25 Dickie J) Precognition) SRO, No) 6, 3 April 1857) 1 All quotations from Madeleine Smith’s letters are from an 26 Murdoch G) Precognition) SRO, AD14/57/255/4, No) 35, unpublished collection of 290 of her letters by JR Roy) 3 April 1857 and evidence in TRIAL, 106–8) This is based on all known holograph letters in the Mitchell 27 Dickens C) Two difficult cases: case the second [Miss Mary Library, edited, dated and collated with the Procurator Blandy]) Household Words) November 29, 1856; 473–5) Fiscal’s clerks’ handwritten copies provided for the trial 28 Mary Jane Buchanan) Precognition) SRO, No) 66, 6 April which are in the Scottish Record Office (SRO)) 1857; re-examined 29 May 1857) The quotation is from 2 She was probably christened Magdalene Marshall Smith, TRIAL, examination-in-chief and cross-examination, 101–3) later adopting Hamilton in preference to her given middle Re-arranged for coherence as marked by ellipsis points) name because of the social prominence of her grandfather, 29 Smith Bessie, Madeleine’s sister) Precognition) SRO, architect David Hamilton) ‘Madeleine’, while avoiding the No) 48, 10 April 1957) Victorian association of ‘Magdalene’ with fallen women, 30 Haliburton GC, Currie J) TRIAL,108, 109; SRO added a romantic foreign and poetic touch) Precognitions) No) 37 and No) 38) 3Lacan J) Jacques Lacan Book I: Freud’s papers on technique 31 Dr Frederick Penny, Professor of Chemistry, Andersonian 1953–1954) New York:Norton; 1988; 218) University, Glasgow in monthly J Med Science, March,1850) 4 Sartre J-P) Being and nothingness: a phenomenological essay 32 Christison R) Evidence) TRIAL, 88–9) on ontology) New York: Washington Square; 1956; 340–400) 33 Penny F) Evidence) TRIAL, 130–1) 5 Lacan J) The four fundamental concepts of psychoanalysis 34 Christison R) Evidence) TRIAL, 88–9 and Letter to Crown (seminaire XI)) New York and London: Norton; 1981; agent 27 May 1857, SRO,AD 14/57/255/10) 67–78) 35 Penny F) Evidence) TRIAL, 83) 6 John Hope, The Lord Justice-Clerk) In: Tennyson Jesse F, 36 Jenkins AD op cit) ref) 20) editor) The trial of Madeleine Smith) (TRIAL) London: 37 Perry MA) Precognition) SRO,AD14/57/255,Vol) 3, No) 53) William Hodge; 1927 (1949); 295) See p)14 for Tennyson 38 Christison R op cit) ref) 34, 90)

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39 Penny op cit) ref) 33, 84) 49 Marriage Certificate) B186195, General Register Office, 40 Unattributed) The Story of Minie [sic] L’Angelier or Madeleine London and Registry Book, St Paul’s Church) Smith) Edinburgh: Myles MacPhail; 1857;34–5) 50 Lindsay J) William Morris: His life and Work) London: 41 Christison op cit) ref) 34, 144–5) Constable;1975; 227–30) 42 Steven J) Evidence) TRIAL, 75) 51 Unattributed) The Commonweal) 26 February 1887; 71) 43Valéry P) Masters and friends) Princeton: Bollingen and 52 Weintraub S) Bernard Shaw: The Diaries, 1885–1897 Princeton UP; 1968; 195) Volume 1) London: Pennsylvania State University; 1986; 44 Unattributed) Glasgow Poisoning Case: Unabridged Report of 262, 324) the Evidence in this Extraordinary Trial etc) London: George 53Hunt P) The Madeleine Smith Affair) London: Carroll & Vickers; 1857; 6–7) Nicholson; 1950; 196) 45 Unattributed) Execution of Margaret Hamilton or Lennox 54 George Young Wardle) Death Certificate #B219380, 11 for forgery and murder) Glasgow Courier) Saturday 2 September 1910, North Friary Nursing Home) February 1850; 4; column a) 55 Death certificate is signed ‘Edward N Roeser’ and states he 46 Unattributed) op cit) ref) 44, 26) attended the deceased from 13 March, 1928) 47 Letter from Madeleine Smith to prison matron) Glasgow 55 Kristeva J) Tales of Love) New York: Columbia UP; 1987; Examiner) Saturday 29 August 1857; 2; column d) 362–3) 48 Tennyson Jesse F) TRIAL, Introduction; 7, 37–8)

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THE ROYAL MEDICAL SOCIETY'S LIBRARY

MH Kaufman, School of Biomedical and Clinical Laboratory Sciences, University of Edinburgh

INTRODUCTION – EARLY ACTIVITIES OF THE leaden case( The bottle was found to contain the silver SOCIETY, INCLUDING THE ESTABLISHMENT OF ITS medal that is now worn by the Society’s Senior LIBRARY President (Figure 2)(4 In 1776, very shortly after the hall According to Stroud, writing in 1820, toward the end of was first occupied by the Society, its library was 1734 a group of six medical students had spent three transferred there from its earlier accommodation in the weeks dissecting a body in the Anatomical Theatre of the Royal Infirmary( University of Edinburgh with the permission of Professor Alexander Monro primus(1 They decided to celebrate the completion of their dissection by spending a social evening together in a tavern( After supper it was proposed by one of their number that they should meet once a fortnight in their respective lodgings, and that one of them would present a dissertation, either in Latin or English, on a medical topic as a basis for subsequent discussion( The first dissertation was prepared by ‘Dr’ FIGURE 1 Cuming,‘On the Signs, Causes, and Methods of Cure, of Foundation stone that was originally incorporated into the the Rabies Canina’, and was read to the others present Society’s first hall in Surgeons’ Square Courtesy of the on 20 December 1734( The presentations continued Royal Medical Society until the summer of 1735 when most of the members of the group dispersed( Those that remained in Edinburgh continued to meet and present dissertations during the subsequent winter months(2

Their successors maintained the momentum established by their predecessors, and this laid the foundations for what later became the Medical Society of Edinburgh( This was first formally constituted in 1737, in the presence of ten students( Initially, the Society met in a tavern close to the university( Soon after 1741, the Society was given permission to hold its meetings in one FIGURE 2 of the rooms in the newly established Royal Infirmary, Two views of the Society’s silver medal This dates from 1775 Courtesy of the Royal Medical Society Photographs and the funds that had previously been spent on hiring courtesy of Dr GS Findlater rooms in a tavern were deflected towards the accumulation of a library( While the Senior President of the Society during the By 1771 the space available in the Infirmary was already 38th (1774–5) and 39th (1775–6) sessions was Mr John too small to accommodate the increasing number of Aitken,5 it is curious that the address given before an members of the Society and their library, and a assembled company at an extraordinary meeting of the committee was then set up to investigate the possibility Society held in the hall of the College of Surgeons to of building the Society’s own hall( In 1775, Dr William celebrate the laying of the foundation stone of the Cullen, then President of the Royal College of Physicians Society’s new hall was given by Gilbert Blane of Edinburgh, who had suggested both the site and the (1749–1834)(6 Gray, in his History of the Royal Medical plan of the building, laid the foundation stone of the Society, published an abbreviated version of Blane’s Society’s first hall( That stone, which bears the legend: address(7 Blane was the acting First Junior President and ‘Sacred to Medicine( Founded April 21st 1775( By Thos( had replaced Robert Freer (1745–1827) who had McInnes Mason’, was formerly incorporated into the recently resigned office( During the 1775–6 session Society’s hall in Surgeons’ Square (Figure 1)(3 In 1852 it Robert Freer was again elected First Junior President was transferred into the stairway leading to the Society’s while Aitken remained the Senior President of the new hall in Melbourne Place( This stone is of note in that Society( The first meeting in the Society’s hall was held it contained a glass bottle within a hermetically sealed on 26 April 1776 with Robert Freer in the chair although

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Aitken was still the Society’s Senior President(8 they instanced in the second paragraph of their petition:

The external appearance of the Society’s first hall, at That the Society, by contributions of the Members Number 11 Surgeons’ Square, is well known from have gradually made a collection of Medical Books, Thomas Shepherd’s engraving of the southwest corner which is daily increasing, and of the Chemical and of Surgeons’ Square in 1829 (Figure 3)(9 This shows the Philosophical Instruments, and the like, to a Old Hall of the Royal Medical Society, located next to considerable value( They likewise have purchased Barclay’s House (Number 10), and close to Old ground within the City of Edinburgh, and thereupon Surgeons’ Hall (Number 8), with Gordon’s classroom erected a building in which their Hall or place of (Number 9) in the background(10 It stood until 1853 Meeting, and their Library(11 (Figure 4) when it was demolished on the instructions of the managers of the Royal Infirmary who wished to use A Royal Charter of Incorporation was granted by the the land on which it was built to extend the surgical King on 14 December 1778,12 and is now displayed in hospital of the Infirmary( The Society’s hall had been the Society’s present hall in Bristo Square( built on land feued to the Society by the College of Surgeons, and close to their own hall( THE EARLY MEMBERS OF THE SOCIETY The students who probably gained most from membership of the Society during the period considered here were principally those with ambitions towards careers as physicians rather than as surgeons or those who at that time became country practitioners, and constituted one of the more lowly groups within the medical profession( Those that joined the Society usually came from a fairly well-off background( This was because the annual subscriptions were considerable( Indeed, such sums were probably more than the majority of those that attended either the university or the extra-academical schools could reasonably afford(

FIGURE 3 Some of the Annual Presidents of the Society, of which Shepherd’s engraving of the southwest corner of Surgeons’ there was a Senior President and First, Second and Third Square The Society’s first hall, at Number 11 Surgeons’ Junior Presidents, were elected from recent medical Square, is to the right of this engraving graduates during the late eighteenth and early nineteenth centuries(13 A few were even elected from those who had been qualified for a number of years( John Aitken, for example, who was Senior President of the Society in their 38th and 39th sessions (see above), had signed the Society’s Obligation when he first became a member of the Society five years before he was first elected Senior President( He had obtained the FRCS Edin diploma in 1770, although he appears not to have possessed either a licentiate diploma from the College of Surgeons or the MD degree before he obtained his College Fellowship(14 When he was awarded the FRCS Edin diploma, in the Minutes of the College of Surgeons,he was referred to as ‘Mr John Aitken Surgeon’(15

All of the above was summarised by Arnot,writing about the Royal Medical Society and their hall in 1779:

Since [1737] ( ( ( the greater part of the medical FIGURE 4 students at the University, who have distinguished Painting by Mr Dallas of the Society’s hall in Surgeons’ themselves by their ingenuity or diligence, have been Square as it appeared shortly before its demolition in members of this society; nor is anyone admitted into 1853 Courtesy of the Royal Medical Society it till he has been of some standing in the study of physick( ( ( ( In 1778, the Society petitioned King George III for a Royal Charter, and among their reasons for so doing, Regarding the reading of dissertations before the

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society, he continued: books in the Society’s library, it gradually encroached on other parts of the building, and a committee was Thus, emulation and industry are excited, genius is established, which included several professors from the called forth, and the judgement exercised and university, to seriously consider how the Society’s improved ( ( ( And it is acknowledged by all who are premises might be enlarged( In 1818–19, the acquainted with the University of Edinburgh, that the membership rose to 84, and it was decided that the only Medical Society has contributed much to the way forward was either to reduce the annual prosperity and reputation of this school of physick( membership, a suggestion that was not generally ( ( ( Besides small apartments, it contains three rooms acceptable, or expand the Society’s premises by the of thirty feet by twenty each( One of these serves as building of an extension, rather than completely a hall for their weekly meetings, another as a rebuilding the Society’s premises( It was also suggested repository for their valuable collection of medical that expansion could only occur to the north side of the books, of natural curiosities, and anatomical hall( An architect was accordingly procured, and various preparations; and the third is to be fitted up for plans prepared( In 1819, the cost of the proposed wing chemical experiments( When the different was believed to be in the region of £1,000, and that of a apartments are furnished with a proper apparatus, new hall in the region of £4,000(18 The latter was well the students at this university will enjoy advantages beyond the means of the Society at that time( which are not to be obtained at any other seminary of medical education ( ( ( The building has a plain When the plans for building an extension to the hall handsome front; and the roof terminates in a cupola, were presented to the Town Council they were rejected intended for an observatory, and adorned with the on the grounds that ‘its admission would occasion an ensigns of the Aesculapian art(16 injurious encroachment on the limits of a neighbouring Institution, already sufficiently circumscribed’(19 As a It is appropriate at this stage to make some brief consequence, attempts were made at that time to observations on the Society’s hall in Surgeons’ Square( purchase Barclay’s property (Number 10 Surgeons’ Square) that adjoined the Society’s hall, but this proved THE SOCIETY’S FIRST HALL, AND PROBLEMS unsuccessful( A later attempt to purchase one of the ENCOUNTERED WITH SPACE IN IT WHEN THE houses on the opposite side of the Square as a MEMBERSHIP INCREASED DURING THE SECOND temporary measure was considered, but the idea was DECADE OF THE NINETEENTH CENTURY subsequently rejected( When Barclay died in 1826, As noted previously, the first hall of the Society was built another attempt was made to purchase his property in 1775–6 on land feued to the Society by the College of but, as Dr Knox wished to continue his teaching Surgeons, and located near to their own hall( It was built activities there, this idea was not proceeded with( on the west side of Surgeons’ Square, and backed onto ground that was shortly afterwards to be occupied by In 1837 another architect was employed, and a variety of the old High School at the bottom of Infirmary Street(17 plans proposed at that time to enlarge their premises, The Society’s hall was the meeting place for the including the addition of a third storey( No decision was members of the Society, and this is where they had their made at that time, and eventually, in 1851 and after much private and public business meetings, and where their debate, the Society was encouraged to sell its premises more senior members read and defended their to the managers of the Royal Infirmary for £1,700, in dissertations( It was also within the Society’s meeting order to allow the Infirmary to expand( This was hall that the more senior members, if they were not probably a fairly generous sum, as the south gable of the already medical graduates, gained the skills that would be Society’s hall had been damaged when Barclay’s former of value to them when they sat the MD examinations, house was demolished in 1850 to provide space for the and the social skills expected of them when they proposed extension to the surgical hospital( For various eventually entered medical practice( reasons, the surgical hospital never expanded in this direction( It was also apparent to the Society that the In addition to the establishment of a laboratory in one money they received from the managers of the Royal of its apartments, the Society’s library flourished( By the Infirmary for their hall was insufficient to cover the cost end of the eighteenth century, it contained over 6,500 of building a new hall( Active measures were then taken selected volumes (see later), many donated to the to find premises into which the Society could move both Society by their authors( In the spring of 1819 the at relatively short notice and with minimal disruption to Society established a general museum at the suggestion their activities( and under the guidance of the Professor of Natural History at the university( A sum was also set aside to Before considering the Society’s move from Surgeons’ allow for the purchase of additional preparations for the Square to Melbourne Place, it is appropriate to briefly museum, and for the maintenance of these specimens( note the extent and range of books contained in the Principally because of the increase in the number of Society’s library towards the end of the eighteenth

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century, as detailed in their 1799 catalogue (Figure 5)( printer cited; 1796( Observations will also be made on the extent of the 4( Anon( Catalogus Librorum in Bibliotheca: Society’s collection towards the middle of the Societatis Medicae Edinburgenae, Secundum Auctorum nineteenth century, at about the time of the Society’s Nomina Dispositus( Edinburgh: T( Ross & Son; 1799( move to Melbourne Place( (Figure 5) 5( Anon( Appendix Catalogi Librorum in Bibliotheca Societatis Medicae Edinburgenae( Edinburgh: James Pillans & Sons; 1801( 6( Anon( Appendix Catalogi Librorum in Bibliotheca Societatis Medicae Edinburgenae( Edinburgh: James Pillans & Sons; 1802(

Parts 1, 3 and 4 indicated above were each signed as follows: ‘J( Kirby( Edinburgh 1800’( This refers to Jer( Kirby who signed the Society’s Obligation Book on 28 November 1800 (Session 64, 1800–1)( What is of particular interest is that inside the front cover of this volume the following inscription is found:‘To be kept in the Iron Chest( March 18th 1851( John Wolley, Pres(’20 Note that the ‘iron chest’ was kept in the Secretary’s room in the Society’s rooms in Surgeons’ Square(

Despite the fact that the 1799 catalogue of the Society’s library is the earliest so far located, reference to the 1775 edition of the Laws of the Society21 would appear to indicate that earlier library catalogues were prepared( According to Section IV,entitled ‘Of the Catalogue,’ page 36, the following appears: ‘Law 122( The Librarian shall insert in the alphabetical and press catalogue, the title of every book added to the library; and he shall keep a separate list of the additions of each section(’ While it is unclear whether such lists were ever formally published, they appear to have been prepared in one form or another by the Librarian on an annual basis( The other Law that is particularly relevant to the purchase of books is Law 118(22 This states: ‘At the end of every Session, a committee shall be appointed by the FIGURE 5 president, with power to purchase books, to such an Title page of the 1799 copy of the Society’s library extent as the Society shall think proper; and, when their catalogue Courtesy of the University of Edinburgh Library office expires, they shall bring in a report of their transactions(’ LIBRARY CATALOGUES The earliest catalogue of the Society’s library so far A number of other copies of the Society’s printed located dates from 1799, and is in the Special library catalogue are located in the reference section of Collections section of Edinburgh University Library( This Edinburgh University Library( These catalogues date volume consists of six separate items that have been from 1823,23 with lists of donations to the library since bound together( They consist of the following individual the year 1812, listed annually to and including 1823, with items: appendices for the periods 1823–6 and 1826–7( Other volumes date from 1832,24 184525 and 1896(26 It appears 1( Anon( Laws of the Medical Society of Edinburgh, that the latter volume represents the most up-to-date Instituted 1737, Incorporated by Royal Charter 1778( printed catalogue prepared by the Society( All of the Edinburgh: no publisher or printer cited; 1796( volumes listed in these various catalogues bear a shelf 2( Anon( Appendix to the Laws of the Medical mark so that they may be readily located, while some Society of Edinburgh( Edinburgh: no publisher or bear asterisks or other signs to indicate that the printer cited; 1799( corresponding works were not permitted to circulate( 3( Anon( List of the Members of the Medical Society of Edinburgh, Instituted 1737, Incorporated by According to the 1796 edition of The Laws of the Society, Royal Charter 1778( Edinburgh: no publisher or ‘the same person shall act both as Secretary and

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Librarian, and shall receive £25 sterling per annum’(27 The add to your library, by sending presents of their own information in this volume would seem to indicate that publications, not only from every quarter of Europe, only the Presidents were elected from members of the but even from the continent of America( It is indeed Society, and that by 1796 the other posts were salaried true, that at this place [i(e( in Edinburgh] there is no and held by non-members of the Society( It is also scarcity of medical books, either in public or private evident that the members treated the salaried staff as libraries( But the limitation of this collection to the little better than servants who could be hired and fired members of the Medical Society, the facility with almost at will( which they can at all times obtain books from thence, and the unlimited command which they have It should not be altogether surprising that the members of these books, are circumstances which render this of the Society appeared to be prepared to take such a library no inconsiderable advantage, at a place where high-handed attitude towards the salaried staff of the the concourse of medical students is very great(28 Society( The majority of the members during the eighteenth and early nineteenth centuries would have The 1845 catalogue is divided into two sections, Parts I been financially far better-off than most of their and II( The volumes associated with named authors are contemporaries who would neither have wished or listed in Part I, and the lists of journals in Part II( While indeed have been able to afford to join the Society( This there are only about 600 items listed in Part II, the is clearly seen with reference to the current values of majority of the entries in this section refer to substantial both the election fee and the annual retention fee runs of journals( The total number of volumes of required of members (see previously)( journals held in the library at the time that the 1845 catalogue was prepared would therefore have been FUNDING AVAILABLE EACH YEAR AT THE END OF considerable( If it is assumed that each volume by a THE EIGHTEENTH AND EARLY NINETEENTH named author purchased and listed in the two CENTURIES TO SPEND ON PURCHASING NEW BOOKS appendices cost in modern terms somewhere between FOR THE SOCIETY’S LIBRARY £20 and £30, this suggests that the funds available to An analysis of the information in the 1799 catalogue of purchase new books would have been in the region of the books in the Society’s library and the two about £4,000 per annum( Clearly a proportion of these appendices to this document (Appendix 1801 and volumes may have cost considerably more than this, Appendix 1802) are particularly informative( The 1799 while others might have been donated to the Society catalogue indicates that at the time of its preparation, either by their authors or by a member of the Society the Society possessed about 2,500 titles associated with and were acquired at no cost to the Society( It has not named authors( This contrasts with the position in 1845, been possible to estimate the cost of journals( when this component of the library catalogue indicated that the collection then contained about 6,500 titles THE SOCIETY’S INCOME FROM THE MEMBERSHIP associated with named authors( The appendix for 1801 AND AN ATTEMPT TO ASSESS ITS FINANCIAL indicates that over the two-year period between 1801 OUTGOINGS DURING THE LATE EIGHTEENTH AND and the previous printed catalogue, the Society acquired EARLY NINETEENTH CENTURIES about 240 books associated with named authors, while Reference to the 1850 General List of the Members of the during the period between 1800 and 1801, the library Medical Society of Edinburgh29 indicates that during the acquired a further 250 books of this type( six-year period between 1795 and 1800, about 30 new members signed the Obligation each year( Information An analysis of the books listed in these two appendices from published lists of new members,30 and an analysis of indicates that the majority of these books were recently lists of students who graduated with the Edinburgh MD published volumes( Those in the 1801 appendix mostly degree, suggests that of these about half [i(e( about 15 dated from 1797–1800, while those listed in the 1802 members] remained in the Society for at least three appendix mostly dated from 1800–1( While the 1799 years and graduated with the Edinburgh MD degree(31 If catalogue did not distinguish between books associated this figure is correct, with a consistent fall-off rate, it with named authors and runs of journals, the latter are might be expected that about 23 members joined the not included in the figures indicated above( This is Society during their second session( This would suggest consistent with the observation made by Andrew that the total number of members in the Society might Duncan many years earlier( He stated: therefore be about 68 each year during this period( To this should be added their annual subscriptions( In 1796, You are now, as a Society, the proprietors of a the first year subscription was four guineas, the fee for medical library, by no means inconsiderable( From the second session was one guinea, and that for the third the present state of your funds you are able to session was half a guinea( The income from this source purchase every new medical production which would therefore be 30 x 4, plus 23 x 1 plus 15 x a half deserves a place in any well chosen collection( Some guineas, that is, 150 and a half guineas( In 1796, each of your absent members have not been unmindful to member paid one guinea as their annual subscription to

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the library, and the income from this source alone would Society’s meeting hall( This extended the full length of be about 68 guineas( Thus the funds available from these the building( Several detailed descriptions of these two sources would have amounted to about 218 and a premises are available, and much of the area was a half guineas per annum, or £229·43 sterling( This progressively taken over by the Society’s enormous would be equivalent to about £13,000 at current rates( library(34 When it was necessary to make the transfer Reference to the 1796 Laws of the Society indicates that from the old to the new hall, the move was extremely the members covered the entire cost of preparing their smooth, because all of the internal modifications were diplomas( so speedily achieved(

The financial outgoings during this period would have THE EVENTS IN 1965, WITH THE COMPULSORY been as follows: stipend for the Secretary/Librarian – PURCHASE OF THE SOCIETY’S PREMISES IN £25 per annum, and the cost of the Annual Prize MELBOURNE PLACE competition( The latter would have cost the Society 20 The entire block of buildings in Melbourne Place, the guineas in 1784, the year of its introduction, but its value central part of which was occupied by the Society was had been reduced to five guineas in 1801( The cost of compulsorily purchased by the Edinburgh City Council purchasing books for the library, based on the in 1965, and the Society was given relatively little time to calculations provided in the previous section, would have vacate the premises that they had occupied for over 110 been about £4,000, and possibly a similar amount for years( The block was rapidly demolished and replaced by journal subscriptions( The total output would have council offices of minimal architectural merit( The amounted to about £8,000 plus the Secretary/Librarian’s Society then moved into temporary accommodation stipend and the cost of the Prize Essay of about £2,000( generously offered by the Royal College of Surgeons of Even if the total outlays in 1800 were about £10,000, the Edinburgh in the basement of Number 3 Hill Square, fact that the input was close to £13,000 would mean although the space available here was only a fraction of that the Society would probably have had sufficient funds that available at Melbourne Place(35 Relatively little of to cover the cost of maintaining its building and its other the hall could be rescued apart from the original incidental expenses( While it is clear that the foundation stone and the eagle, with spread wings, that calculations indicated here are extremely approximate, surmounted the gable on the fourth storey(36 The they suggest that during the period under consideration foundation stone of the Society’s original hall had been the Society gained sufficient funds from its members incorporated into the wall below the staircase facing the each year from membership and related fees to cover its entrance door in Melbourne Place( These two items and financial outgoings( a few other mementoes are now displayed in the Society’s present hall in Bristo Square( It should be THE SOCIETY’S MOVE TO MELBOURNE PLACE noted that the ground floor of Melbourne Place only To facilitate the purchase of its new premises, a consisted of the entrance passage, as the two shops, one subscription fund was established, and £600 of their located on either side of the Society’s door, were shares were cashed in when the decision to move was independently owned( eventually made, in March 1852(32 It was at that time that suitable accommodation in Number 7 Melbourne With the demolition of the Society’s premises in Place, on George IV Bridge, was found, and was within Melbourne Place, and their transfer to temporary the funds then available to the Society( This property accommodation in Hill Square, there was little room for was sufficiently large, when appropriately adapted, to more than a few of the Society’s enormous collection of accommodate all the needs of the Society( The New Hall historic and valuable books( The greater part of the Committee quickly realised the potential of the latter collection was sold at a sale organised by Sotheby premises, and the upper four storeys of this property and Company, carried out over a period of six days in were purchased by the Society( The last meeting of the 1969( Because of the very high quality and uniqueness Society in their old Hall in Surgeons’ Square took place of many of these volumes, despite the relatively poor on 12 November 1852, and the first meeting in their condition of most of them, the sale attracted a great deal new Hall took place one week later(33 It is interesting to of international attention, and realised at that time a note that the architect who supervised the internal total of £145,000, equivalent in modern terms to about modifications to the new hall was Mr David Bryce, who £1,480,450(37 The Society only retained the bound also designed the various extensions to the Royal volumes of the dissertations and a few hundred of the Infirmary( volumes that related to the early history of the Society and its membership( The group of buildings along Melbourne Place had been erected in 1835, and the Society purchased Number 7 THE MOVE TO BRISTO SQUARE from its first and only occupants Messrs( James and John The Society occupied the temporary premises in Hill Gray( Substantial alterations needed to be made to the Square for about ten years gratis( Much of this time was second and third storeys to convert them into the occupied in negotiating with the University of Edinburgh

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authorities for space in their new student centre in 9 Shepherd TH( Modern Athens! Displayed in a series of views: Bristo Square( While the university retained ownership or Edinburgh in the nineteenth century: exhibiting the whole of these premises, the Society was required to cover the of the new buildings, modern improvements, antiquities, and proportionate cost of the rooms to be occupied by the picturesque scenery of the Scottish metropolis and its environs, Society, the architect’s fees, and the full cost of from original drawings0 London: Jones & Company; 1829 [the pages on which the engravings are displayed are furnishing, decorating, heating and lighting these unpaginated]( premises( What little funds remained were invested for 10 Shepherd's engraving is based on the almost identical view the future use of the Society( of Surgeons' Square of ten years earlier, published by Storer( See: Storer J & Storer HS( Views in Edinburgh and REFERENCES its vicinity; drawn and engraved by J & HS Storer, exhibiting 1 Horn DB( The anatomy classrooms in the present Old remains of antiquity, public buildings, and picturesque scenery( College, 1725–1880( Univ Edinb J 1965; 22:65–71( In two volumes( Edinburgh:A Constable & Co(; London: JM 2 Out of the six ‘medical students’ who were present at the Richardson, Chapell & Son; Nornaville & Fell; Smith & first meeting, five were referred to as ‘doctors’ by Stroud, Elder; Cowie & Co(; Taylor & Hessey; T Wilson & namely Cleghorn, Cuming, Russel, Hamilton and James Sherwood; Neely & Jones; 1820 [the section in Volume 1 Kennedy, while the sixth member present was said to have with the engravings is unpaginated, as is all of Volume 2]( been ‘Mr’ Archibald Taylor( See: Stroud W( History of the 11 Gray op0 cit( ref( 2, 54–5( Medical Society of Edinburgh( Edinburgh: printed for the 12 Ibid( 55( Society by William Aitken; 1820; xvii–xviii( In a fuller 13 While no presidents of the Society are recorded as having version of this episode published by Gray, no mention is graduated with the MD degree, out of a total of 203 made that five of the six individuals present were styled elected before the 1813–14 session, a total of 59 ‘doctor’( Nor do their names appear on the list of those presidents possessed the MD degree out of 191 that had graduated with the Edinburgh MD degree( See: presidents elected during the period between 1813–14 Stroud op0 cit( Anon( List of the Graduates in Medicine in the and 1854–5( This represents 31% of the presidents elected University of Edinburgh, from MDCCV to MDCCCLXVI0 between the latter two dates, although a number of them Edinburgh: Neill & Co(; 1867( Gray J( History of the Royal served for more than one Session( According to the 1845 Medical Society 1737–1937( Edinburgh: Edinburgh Laws of the Society, the first presidents were elected University Press; 1952; 15–20( For additional observations during the 1764–5 Session( See:Anon( Laws of the Medical on the early history of the Society, see: Holmes JD( Early Society of Edinburgh( Edinburgh: printed for the Society, by years of the Medical Society of Edinburgh( Univ Edinb J James Gall & Son; 1845( 1968; 23:333–40( 14 An analysis of the University's Matriculation Albums 3 Gray, op0 cit( ref( 2, figure opposite page 40( revealed that Aitken matriculated in 1763 and 1769, and 4 The medal bears the following inscription: ‘Medicinae probably also in 1765( During these three years, he Sacrum April 20’, and on the reverse, ‘Societate Medica attended most of the obligatory courses required by a Conditum A(P(C(N( 1775’( student who wished to graduate with the MD degree( 5 Kaufman MH( John Aitken (d( 1790) – grinder or scholar? From the early 1780s, he styled himself ‘MD’, and was then J Med Biogr 2003 (in press)( referred to as ‘Dr’ Aitken in the Minutes of the College of 6 Gilbert (later Sir Gilbert) Blane was appointed in 1780 Surgeons, but there is no evidence that he graduated with Physician to the Fleet under Admiral Rodney, and saw the Edinburgh MD degree( See: Minutes of the Royal service in Gibraltar and in the West Indies( In his College of Surgeons of Edinburgh, 1771–93( eg( 255; see also Observations on the Diseases of Seamen, he emphasised that Anon, op0 cit( ref( 2( most troops and seamen died of conditions unrelated to 15 After he had been duly examined, he was required to pay enemy action and later he was instrumental in introducing the Treasurer ‘one thousand pounds Scots,’ or £83-33 the use of lemon juice in the navy, particularly in 1795 sterling, as his ‘upsett, as twelve pounds Scots was when he was appointed Commissioner for Sick and Hurt equivalent to one pound sterling’( See: Minutes of the Seamen( This had the immediate effect of banishing scurvy College of Surgeons, 1738–70, 514( According to the OED, from the navy( In 1793 he was appointed Physician to St the ‘upset’ was a term used in both the North of England Thomas's Hospital and was created a baronet in 1812( See: and in Scotland( It was the fee paid upon setting up in Blane G( Observations on the Diseases of Seamen( 3rd ed( business as a master or becoming a freeman in a trade, the London: Murray & Highley; 1799 [the first edition was term being first used in 1687( His ‘upsett’ would therefore published in 1785, the second in 1789, and the 3rd edition have been equivalent to £5,208, as £1 sterling in 1770 was is the much enlarged version]( Kaufman MH( The Regius equivalent in October 2002 to £62·50; information from Chair of Military Surgery in the University of Edinburgh – Enquiries Office, Bank of England( This was clearly a very 1806–55( Amsterdam: Rodopi BV (Wellcome Trust Centre considerable amount of money, and it should not be for the History of Medicine at UCL); 2003; Chapter 1, surprising that the number of individuals who submitted 9–46( themselves for examination by the College, leading to their 7 Gray op0 cit( ref( 2, 40–2( The full version of the Address was Fellowship diploma, was quite small( The total number of published at that time( See: Blane G( Address to the Medical Fellows elected during each decade between 1760–1859 Society of Students at Edinburgh, upon laying the foundation of are given in brackets: 1760–9 [6]; 1770–9 [16]; 1780–9 their Hall, 21st April 17750 No publisher cited; 1775 [17]; 1790–9 [18]; 1800–9 [19]; 1810–19 [29]; 1820–9 [41]; [Anonymous pamphlet, but Address delivered by Gilbert 1830–9 [23]; 1840–9 [19]; 1850–9 [88]( For information, Blane]( see: Anon( List of Fellows of the Royal College of Surgeons of 8 Gray op0 cit0 ref( 2, 43( Edinburgh from the year 1581 to 31st December 18730

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Edinburgh: George Robb; 1874( Part II, 273–306]( 16 Arnot H( The History of Edinburgh( Edinburgh:W Creech; 26 Anon( Catalogue of the Library of the Royal Medical Society( London: J Murray; 1779; 428–30( Edinburgh: printed for the Society by Darien Press; 1896 17 The foundation stone of the High School was laid on 24 [Author list, 1–118; periodical publications, 119–26; June 1777( See: Grant J( Cassell’s Old and new Edinburgh: its reports, 127–9]( history, its people, and its places( Three volumes( London: 27 Equivalent in modern terms to £1,416( £1 in 1796 Cassell,Petter, Galpin & Co(; 1880–3( Volume 2; 293( This equivalent to approximately £56·64 as of October 2002( close proximity of the High school was to cause the Information from Enquiries Office, Bank of England( Society considerable concern over the years, as on 28 Duncan A( Introductory Address to the Medical Society of numerous occasions the Society's windows were broken Students at Edinburgh( Edinburgh: no details of publisher by the boys when they were at play in the School grounds( provided; 1771; 9–10( The Society complained on numerous occasions to the 29 Anon( General List of the Members of the Medical Society of Town Council, as Patrons of the School, but no Edinburgh( Edinburgh: printed for the Society, by Thomas compensation was ever received( In desperation in 1816, Constable, printer to Her Majesty; 1850; 67; and the headmaster was approached, and the janitor eventually Supplement 1850–51 to 1854–55, 6] persuaded the boys to direct their energies elsewhere( 30 Ibid( See: Gray op0 cit( ref( 2, 118( 31 Anon op0 cit( ref( 2( 18 Stroud op0 cit( ref( 2, xcviii( 32 While no information is available relating to the cost the 19 This is most likely to have referred to the Infirmary but Society paid for Melbourne Place, and the various may have referred to the High School onto which the modifications made to it, it is likely that this was in the Society’s premises backed( See: Stroud op0 cit( ref( 2, xcix( region of £2,300( This would have been the £1,700 that 20 This was John Wolley, Senior President 1850–1 (114th they received from the Managers of the Royal Infirmary for Session)( He took part in the sale of the old, and purchase their premises in Surgeons’ Square and the £600 of their of the new Hall( See: Gray op0 cit( ref( 2, 190–2, 194, 199, shares that they cashed in at that time for this purpose( 200( This would be about £122,590 in October 2002, as £1 21 Anon( Regulations of the Medical Society, instituted at sterling in 1852 is equivalent to about £53·30( Information Edinburgh in the year M,DCC,XXXVII( Edinburgh: no details from Enquiries Office, Bank of England( of publisher provided; 1775( 33 Gray op0 cit( ref( 2, Chapter 12, 189–208( 22 Ibid( 34( 34 Gray op0 cit( ref( 2, 204–8( For additional observations on 23 Anon( Catalogue of the Library of the Medical Society of the early years of the Society's Library, see: Cormack JJC( Edinburgh, distributed in two parts0 Part I0 Consisting of works The Society's Library( Bulletin of the Medical library of known authors, alphabetically arranged in the order of their Association 1960; 48:125–41; see also: Kaufman MH( The names0 Part II0 Consisting of anonymous, collective, periodical, first and second Halls of the Royal Medical Society( Book and miscellaneous works; alphabetically arranged in the order of the Old Edinburgh Club (New Series)( 1997; 4:119–29( of their titles( Edinburgh: printed for the Society by Hay, 35 This was in reciprocation for the fact that in 1828–9 the Gall & Co(; 1823( College of Surgeons were offered temporary 24 Anon( Catalogue of the Library of the Medical Society of accommodation in the Society's original hall when their Edinburgh( Edinburgh: printed for the Society by A Balfour new building in Nicolson Street was being erected( & Co(; 1832 [this is printed in two parts, and follows the 36 For appropriate images, see: Kaufman op0 cit( ref( 34, Figures arrangement of the earlier Catalogues]( 3 and 6( 25 Anon( Catalogue of the Library of the Medical Society of 37 £1 in 1969 equivalent to approximately £10·21 as of Edinburgh( Edinburgh: printed for the Society by James Gall October 2002( Information from Enquiries Office, Bank of & Son; 1845 [this is printed in two parts, and follows the England( arrangement of the earlier Catalogues, with Part I, 3–272,

J R Coll Physicians Edinb 2003; 33(suppl12):56–63 63 TORPHICHEN

TORPHICHEN AND THE KNIGHTS HOSPITALLER

WJ MacLennan, Professor Emeritus of Geriatric Medicine, the University of Edinburgh

At Torphichen,a small village to the west of the Bathgate sanction of the master Hills in West Lothian, about a mile from the Stone Age • Brothers should not wear furs or brightly coloured relic Cairnpapple Henge, there is a massive tower with clothes unusually high transepts on either side This is all• thatA brother committing fornication should be flogged remains of the church and monastery that was the and then expelled If he repents, he should be administrative centre of the Knights Hospitaller, the allowed to return but made to a wait a full year order that owned vast tracts of land in Scotland and before becoming a full member of the community recruited knights and men to fight against the Saracens • A brother quarrelling with another should fast for and to organise care for those who were wounded or seven days, and if he strikes him should fast for 40 fell ill during their many campaigns days One leaving the house without permission should eat sitting on the floor and fast twice a week FOUNDATION • Brethren should be silent at meals and in bed During the Crusades, Italian merchants from Amalfi • If a brother dies 30 masses should be said for his established a hospital at Jerusalem to care for sick soul pilgrims 1 This was placed under papal protection in • Prior to admission, a patient should confess his sins 1113 and, under the charge of Gerard, adopted the He should then be given a bed and fed regularly Benedictine Rule In 1120 the next superior• A calledbrother finding another misbehaving should leave himself Grand Master of the Order of St John of him to chastise himself If he fails to do so, two or Jerusalem and changed the order to the Rule of St three brothers should discipline him, and if this does Augustine, as this more accurately reflected the practical not work the master should be informed nature of its work The Order was granted considerable• Brothers should wear a cross on their cassocks and autonomy falling under the authority of the Pope alone, mantles and had sole responsibility for the appointment of its master and was free from payment of tithes to secular HOSPITAL AT JERUSALEM authorities The hospital could accommodate 2,000 patients 1 Each ward was the responsibility of a brother who organised Many knights, inspired by their treatment at the hospital, the admission of each patient He took confessions and provided it with estates, while others went as far as to gave communion to them on admission There were 12 join the order so that they could participate in the direct servants on each ward to make beds, give nursing care care of the sick and wounded 2 As a result the Order and provide food and drink The food was of high quality accumulated a lot of land in both Asia Minor and Europe and served from silver plates White bread and meat were available at least three times a week Two servants CONSTITUTION on night duty kept lights burning, called priests and took The religious discipline and practical objectives of the bodies to the church Order are reflected in this summary of its constitution:3 Two female servants looked after women in a separate • Brothers should profess their acceptance of chastity, ward There also was a labour ward in which particular obedience and lack of personal property care was given to new-born infants Care also was • None should accept more than their due in material organised for foundlings Staff went out of the hospital things to provide succour to impoverished women and • They should behave decorously in church and assist children priests in conducting services • When outside they should be with others of the Physicians visited each patient once a day to check their order and behave with propriety pulse and examine their urine The duties of surgeons • They should seek alms for the poor, and, when in extended beyond the care of the wounded in hospital to need of lodging, should arrange this through a church dealing with soldiers brought to a treatment tent on the or a person of recognised propriety battlefield • The brothers should keep records of all alms obtained for the poor MILITARY ACTIVITY • A brother should only go out to preach with the Although the knights were primarily involved in

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providing care for pilgrims, they also perceived it as their patients twice daily A surgeon could only be appointed duty to guard them as they travelled through the Holy if he had the approval of one of the physicians Though Land 4 From this it was a short step to adopting a more drugs were initially purchased from apothecaries, a proactive role in fighting with other Crusadershospital This pharmacy was eventually established The resulted in the brothers being categorised as knight pharmacists were kept under close supervision with brothers, sergeant brothers and priest brothers Therephysicians assessing their proficiency and supervising also was a variable number of mercenaries hired to their work, and a hospitaller or physician paying augment their force unannounced visits on the pharmacy

LATER HISTORY Apart from members of the Order, the hospital was After initial success the Crusaders suffered a series of open to male civilians and pilgrims, but wounded disasters due to poor coordination and internal feuds soldiers, sailors and knights were given special beds As a result, the Hospitallers moved from Acre in the Places also were provided for orphans and foundlings, Holy Land to Cyprus in 1291 and thence to Rhodes in and six poor girls each year were given marriage 1310 1 dowries

Rhodes occupied a narrow strait between Europe and Despite the construction of extra wards the demand Africa For this reason the knights had to buildcontinued up a to exceed resources In 1560 an epidemic powerful fleet to control the movement of Saracen craft resulted in double the number of patients sharing the in the area In response, the Egyptian Mamelukessame number of beds Houses and bedding were attacked Rhodes without success in 1440 and 1444, and requisitioned from the surrounding area in 1480 the Turks besieged the island Though the knights put up a gallant and successful resistance, the Valletta balance of power swung in favour of the Turks, and the Work started on a new hospital in Valletta in 1574 6 A Hospitallers were driven off the island in 1523 description of the hospital, known as the Sacra Infirmeria, in the second half of the seventeenth century There is little information on hospital activity in Rhodes indicated that it had two main wards the largest of which other than that a small one was built in 1314 1 Each bed was 155 m long by 11 m wide by 9·5 m high This was was placed in a cubicle recessed into the main wall of divided in two by an altar half-way along A section of a the ward, and there was a chapel half way along the hall the same length below the main ward was walled off ward Nobles received care in small private rooms to provide a ward 115 m long for civilians and slaves A smaller section accommodated foundlings while the MALTA remaining space was used for a kitchen Construction Birgu was piecemeal so that contact between different After several years during which the knights sought a sections was by tortuous corridors Some rooms were suitable base, the Holy Roman Emperor Charles V built next to other buildings so that lighting was poor granted them one in Malta in 1530 5 Their first hospital and, despite high ceilings, there was a damp fetid on the island was at Birgu, a promontory close to the atmosphere Grand Harbour This hospital consisted of a rectangle around a cloister with four wards, a pharmacy, a chapel, The principal officials were a commander and two administrative office, medical staff quarters, a refectory knights appointed as a treasurer and a commissary and a kitchen around three sides Underneath Although was a there were detailed rules, adherence was smaller quadrangle with store rooms, a laundry room variable The knights saw day-to-day supervision of the and accommodation for servants hospital as an onerous and unpleasant task and usually entrusted it to the youngest and most callow of their A Grand Hospitaller was in charge, but an Infirmarian Order The days in which all members of the Order had day-to-day responsibility for patient caretook This part in the care of patients were long past One of included visiting the patients daily, providing them with the few relics from the past was that patients still nutrition, monitoring their behaviour, and recruiting received food from silver plates enough servants to provide care and arrange burials Two comptrollers obtained food and equipment, Medical treatment was carried out by three senior and maintained an inventory of furniture, kept accounts and three junior doctors supported by six final-year medical ensured that wills were completed and enforcedstudents A The standard of medical care was such that chaplain said mass daily, heard confessions, administered patients were often referred from the mainland Staff sacraments and conducted funeral services had particular expertise in cataract extraction and the removal of bladder calculi A master of physic ran the Physicians were laymen selected on the basis of their pharmacy while 38 lay nurses provided personal care experience and medical knowledge They had to Patients visit received high quality food

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There was an out-patient clinic for patients with syphilis Foundlings were placed in a basket that rang a bell at the entrance Once they were admitted, attempts were made to find foster homes Beggars were given food, poor women given clothes and sheets and the lame given crutches and splints Those with blindness, scofula and leprosy received money Needy old people were accommodated in small houses

Free prescriptions were available to slaves, poor people, members of religious orders, pages and students Lists were drawn up of sick patients requiring home visits from physicians

Over the next century lack of funds, deterioration in commitment and the disruption of the French Revolution caused a serious deterioration in standards of care Howard, noted for his work on hospital and prison reform, reported in 1789 that pewter plates had replaced silver ones 7 The wards were dark with the ceilings black with soot from braziers Commodes at the bedside lay unemptied The commander was a young man with no experience and was unable to control the staff and the Grand Master rarely if ever visited the wards Nurses were reported as being dirty, ragged and uncaring The ignominious decline continued until Malta surrendered to Napoleon in 1798 and the Order, in its original form, came to an end The Valletta hospital building still stands, as do the Order’s headquarters in Rome FIGURE 1 Tower and north transept of preceptory TORPHICHEN Both transepts are exceptionally tall and the north one The Order of the Knights of St John obtained its recruits has a large window with particularly fine tracery Two from ecclesiastical centres throughout Europe It wasdoors a in the west wall provide access to the ground bone of contention that the Preceptory of Torphichen floor of the tower and the upper tower chamber The was subordinate to the Priory in England 8 This in return south transept also has a large traceried window was responsible to the Grand Master in Jerusalem, Rhodes or Malta and was part of a general chapter that The ceilings of the transepts are vaulted and ribbed with usually met at Torphichen once every few years 1 It central bosses, while the tower is supported by thick appointed priors and preceptors, but the master made shafts with piers and capitals carved as foliage There is all other major policy decisions so long as they lay within access to a bell chamber by a spiral staircase Doorways the rules of the chapter Under the Grand Master there connect the chamber to rooms over the transepts was a Grand Preceptor responsible for administration of These may have been added when the upper tower was the Order, a Marshall and an Admiral in charge of the used as a court of barony after the Reformation army and navy, and a Hospitaller in control of the hospital and services to the communityThe At only evidence the of the old nave and southern aisle are headquarters the knights were divided into several the marks of their roofing on the west wall of the tower langues (tongues) and allocated to separate auberges A map from the eighteenth century shows that the nave (inns) In this arrangement, the Scots were part ofwas thesimilar in size to the pre-Reformation church and English langue that along the south side was an aisle supported by columns (Figure 2) 11 There was a cloister to the north The priory at Torphichen, West Lothian received a of this but the only fragments of the ranges around it charter in 1153 9 There is a central tower with the remain foundations of a choir to the east and traces of the roof marked on the tower wall (Figure 1) 10 There also is a FUNCTION blocked fifteenth-century crossing arch through the Spiritual life and recruitment same wall Although the Grand Master of Rhodes selected the Preceptor, the King of Scotland formally appointed him 8

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Cloister

North Transept

Nave Crossing Choir

South Transept

FIGURE 2 Plan of medieval church and cloister

In addition to providing spiritual guidance to the Order he was responsible for the administration of its ecclesiastical and secular property Other brothers in the Preceptory supported him in running the Order’s estates and identifying and negotiating with potential recruits There also were novices receiving religious training, but, by the thirteenth century, such were the military needs of the Middle East that many recruits missed out on this At this stage it only was the priest brothers who spent most time in training There also were elderly or disabled brothers living out their remaining years in the monastery While there was a small hospice for sick residents, this did not provide care for the surrounding populace

ADMINISTRATION Popularity of the war against infidels and concern for souls in the afterlife ensured that the Order received generous land donations from both the king and his nobility 8 By the early sixteenth century these amounted to over 700 separate properties in Scotland (Figure 3) Most were in the Borders, the Central Belt or along the east coast with the greatest concentrations in Angus (58), Ayrshire (67), Fife (48), Lanarkshire (50) and West Lothian (60)

There were three common types of property A barony was a site in which a baron was expected to establish a mill, run a home farm and rent the rest of the land to FIGURE 3 tenants He also administered justice, supervisedSites of property granted to Order of St John in Scotland standards of husbandry and cared for the needs of

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FIGURE 4 Much-modified toft of the Order of St John in St Andrews cottars In return, tenants provided defined services andBaillies assisted in administering justice A toft was a propertyBaillies were laymen with day-to-day responsibility for in a burgh There is no record of how the Preceptorythe collection of rent 8 Each bailly covered an area such managed them They could have been as used Angus, Ayr, as Berwick, Fife, Gowrie, Haddington or temporary accommodation for knights with business in Lennox Other duties included transfers of tenancy, the burgh, developed as a hospice or almshouse or presiding over land disputes and enforcing evictions rented out to raise funds Crofts, small plots of land, were often given to monasteries in return for prayers HISTORY for the souls of a proprietor and his family The history of the Preceptory in Scotland reads rather like that of a modern university constantly trying to Two tofts survive in St Andrews 12 One is on the balance its books, to meet research selectivity standards southern side of North Street It contained a stable withand to ward off attempts at compromising its inde- three stone vaults (Figure 4) The first floor was a singlependence 8 Little mention is made of deeds of chivalry, hall with a direct entrance to it At right angles to itmanifestations was of the miraculous or acts of charity an extension with a ground floor vault It is likelyPreceptors that were selected for their hard-headedness and the site also had a courtyard and curtain wall The otherbusiness acumen rather than their sanctity toft has its front on the southern side of North Street There have been so many modifications that little of the In the thirteenth and fourteenth centuries, by virtue of original building is apparent their ties with the English Priory, Hospitallers were unpopular in Scotland The fact that the Preceptor It would have been impossible for a monastery to run fought and died supporting Edward I in the Battle of such a large number of properties with its own staff Falkirk did nothing to improve their image Neither did Most was let to individuals as a lease or a feuferm 8 The the information that Edward was taken to the most common was to lease it to a tenant, often for a Preceptory after the battle to recover from a kick from period of 19 years Some individuals were given feufermhis horse tenure In return for a large down payment and a fixed annual payment the individual gained possession of the In 1312 a sister order,the Knights Templar,was dissolved land in perpetuity The church initially disapprovedby the of Pope 13 Members were accused of a bizarre list monasteries making such an arrangement, but had of blasphemies and irregular sexual practices, but the become much less rigid by the fifteenth century underlying concern was that their extreme wealth had made them a threat to the stability of states throughout

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FIGURE 5 Centre of Knights Templar at Temple, Midlothian Christendom In Scotland the lion’s share of confiscatedtenants in general and Erskine in particular Templar property, including the Order’s centre at Temple,Midlothian,was given to the Hospitallers (Figure 5) Just when the issue had been resolved there was a papal There were some shady deals associated with the schism with one Pope settling in Avignon and the other redistribution of property Some of it ended up remainingin the in Rome Scotland and the Grand Master of hands of Reginald More, a lay adminstrator at Rhodes supported the one at Avignon and England the Torphichen 8 In 1345, some time after his death, the sub- one at Rome This resulted in two successive Torphichen prior of the English Priory visited Torphichen with Papal preceptors being deposed by Benedict VIII of Rome Bulls demanding that his son William make restitution for the Templar lands William was excommunicated butIn the fifteenth century there were fewer administrative whether the money was returned is not recorded complications Most preceptors and many recruits went through the Preceptory to fight in the sea-battles The Pope continued his involvement in the affairs of involving the Hospitallers at Rhodes In 1508 there was Torphichen and in 1356 recommended the appointment a dispute over the right of the London Priory to appoint as Preceptor of David de Mar, procurator to the the Scottish preceptor James IV supported the claim Hospital of St John of Rhodes This did not resolvebut the was killed at Flodden in 1513 along with James financial irregularities and indeed de Mar gave extensive Panniter, his favoured candidate The Regent, the Duke lands to a Sir Robert Erskine, and conspired with him to of Albany pursued the case but his position was halt payment to the Grand Master of Rhodesweakened The when England and France called a truce from Master's successor attempted to resolve the issue in their most recent conflict 1375 by mandating the land to Robert Mercer, a member of James II’s household for an annual payment Subsequent to the Order moving to Malta there was an of 400 florins Robert de Hales the London Priorimproved then relationship between the Scottish and English became involved and, with the backing of Edward III, centres The last Preceptor, James Sandilands was objected to the dues bypassing the London Priory appointed in 1550 During the evolution of the (Figure 6) Since a new Crusade was being Reformation mooted, he supported the Lords of Congregation there was pressure for an early agreement and the and passed the property and lands of the Order over to decision was taken to pass the money through the the Crown in 1664 London priory after all It also was agreed that Mercer be replaced by Robert Grant, a more effective REVIVAL administrator who succeeded in obtaining dues from An effort was made to revive the order in England in the

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FIGURE 6 Gatehouse of Priory of St John, London nineteenth century At this stage, a Catholic Order haddeveloping a military role A compelling argument can already been established in Malta, but differences in be made for defending pilgrims from attack It also is religion made it impossible for English Protestants to true that the hospital would not have succeeded if it had join this 14 In view of this, an independent Order was not defended itself With time, however, the activity of established in England in 1831 and given a Royal Charter the Order became focused on aggressive warfare This in 1888 14 A similar Order, the Order of St John in diverted the energy and enthusiasm of individuals from Scotland, was established in 1879 Recent activities havethe more mundane tasks involved in hospital care included setting up a hospital, establishing a nursing home and organising 20 nursing supply centres ItAll alsohospitals, those in Malta in particular, demonstrate a set up a home for the elderly, a home for working high level of administrative ability, skill and compassion in mothers and children, and two holiday homesproviding The care and sophisticated methods of monitoring Order makes regular contributions to the St John this The hospitals looked impressive but, as in the Ophthalmic Hospital of Jerusalem 15 Some of these present, there were unforeseen design defects and a services have been discontinued or remodelled with chronic shortage of beds It is unlikely that our changing needs, but the Order continues with energetic managers would be allowed to accommodate two and dynamic planning for the requirements of the needy patients to a bed, but even outside hospital, this was the norm in medieval society Indeed many were lucky to CONCLUSIONS even have a bed Though patients did not receive the The practical idealism of Raymond de Puy and his equality of treatment written into the Rules, civilians and dedicated brothers produced a system of hospital care slaves at least received a high standard of care that was centuries ahead of its time It also is clear that the Order also applied rigorous monastic disciplineIn contrastIn to the pervasive misogyny often associated its work it was trying to imitate the work of Chist who with this period, much thought went into the provision considered the sick to be blessed and entitled to a of care for women, infants and children, even extending maximum of care and compassion This sometimesto the provision of dowries for needy young girls It is reached ridiculous extremes, as when the Order served interesting to read of measures taken to extend the food on silver plates Unlike many European hospitalswork of the hospital into the community Current ideas there was access to both physicians and surgeons on community care clearly are not as innovative as they seem There must be mixed feelings about the Order

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The later picture of the hospital, as portrayed by recruits for work overseas Towards the end of its life, Howard,7 is depressing With a decline in the Turkishcorruption and inefficiency led to disillusionment, threat and unrest in France fewer resources were scepticism and resentment, features common in many directed to the Order and few young men saw retrieval aspects of the late medieval Church The tragedy is that, of the Holy Land as a cause worth fighting withfor theGiven collapse of the Church, its funds and lands were lack of interest, disillusion and more exciting causes, it is not used to build a new Jerusalem in Scotland They no surprise that lack of leadership in the Order led to went into pockets of the aristocracy who all too often indiscipline, inadequate care and negligence supportedIt is the Reformation for reasons of greed rather possible of course that Howard had a hidden agenda and than altruism may have exaggerated adverse conditions in the hospital ACKNOWLEDGEMENT It is a matter of regret that this courageous and I am grateful to Joan Blair,Administrator of the Priory of successful experiment in hospital and community care Scotland of the Order of St John for taking time to talk remained so firmly linked to the Crusades long after to me and provide references to the history of the their objectives had become unattainable HadOrder theand its present-day work lessons of the Hospitallers been applied to countries throughout Europe the healthcare of the populace may REFERENCES have been advanced by several centuries 1 Nicholson H The Knights Hospitaller Woodbridge: Boydell Press; 2001 Another matter of regret is that, although the Order had 2 Ridley-Smith J Hospitallers The history of the Order of St monastic rules and the Torphichen Preceptory was John London: Hambledon Press; 1999 3 Laglader GT Statutes of Fr Roger de Moulins South Africa: designed as a monastery, there is little evidence that Brotherhood of the Blessed Gerard; 1966 religious observance figured highly in its agenda4 The Barber M The military orders – fighting for the faith and Preceptor was preoccupied in administering his vast caring for the sick Aldershot: Asgak; 1966 estates and providing the Crown with political advice 5 Cassar P Medical history of Malta London: Wellcome; 1964 There is the further problem that the Preceptory 6 Critien A Holy Infirmary Sketches Malta: Lux Press; 1946 functioned as a house of transit where the priority was 7 Calviero R The last of the Crusaders; the Knights of St to get out to the Mediterranean and fight rather than John and Malta in the eighteenth century Philadelphia: spend time on spiritual development Dufour Editions; 1960 8 Cowan IB, Mackay PH, Macquarrie A The Knights of St John of Jerusalem in Scotland Edinburgh: Scottish Historical A lot of energy also was spent raising funds for the Society; 1983 Grand Master How much of this went 9 to Smith military J Torphichen Torphichen: Smith; 1997 equipment and obtaining mercenaries and how much to 10 Baldwin J Exploring Scotland's heritage: Edinburgh, Lothians increasing hospital staff and expanding hospitals is and Borders Edinburgh: Stationery Office; 1997 unclear Detailed accounts suggest, however, that11 Gough R Plans of the old and new kirk lodged by Lord wherever else it went, much stuck to the fingers of Torphicen Catalogue of Templar or Torphichen Writs corrupt administrators and clerics Corruption apartEdinburgh; Keeper of Records; 1762; 74 the system of landholding was inefficient Unlike12 McCall the HB The Knights Templars and the Knights Templars clergy of Melrose Abbey and other early monasteries, and their Possessions in St Andrews In: The history and antiquities of the parish of Mid-Calder: with some account of the Order did not work or supervise work on their land the religious house of Torphichen 1912; Edinburgh: Cameron; but merely rented it out to tenants The prime job1912; of 13–25 baillies was to collect rent rather than improve the 13 Forey AJ The military orders: from the 12th to early 14th quality of husbandry centuries Basingstoke: MacMillan Education Ltd; 1992 14 Burnett CJ, Tilling H The Order of St John in Scotland At their best, the Knights Hospitaller made an important Edinburgh: The Priory of Scotland of the Order of St John; contribution to the health of their fellows1997 The Torphichen Preceptory, with its immense land holdings, 15 O'Shea JG A history of the St John Ophthalmic Hospital, provided badly needed funds and enthusiastic young Jerusalem Proc R Coll Physicians Edinburgh 1997; 27:603–10

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