THE

Glasgow Medical Journal.

No. IV. April, 1924.

ORIGINAL ARTICLES.

MEDICAL ASPECTS OF SAMUEL JOHNSON*

By Sir HUMPHRY ROLLESTON, K.C.B., M.D., D.C.L., LL.D., President, Royal College of Physicians of London.

It might naturally be thought that, apart from Napoleon, few if any famous men would have attracted more speculation about their medical ailments than Samuel Johnson, both because Boswell's Life provides such a minute and intimate account, and because "he embodies all that we most admire " in ourselves (Raleigh).1 Although this interesting subject has attracted some attention,2 it has not yet been worn threadbare. My interest was first aroused in the medical aspects of Samuel Johnson in 1891 when my colleague at St. George's Hospital, the late Lee Dickinson (1862-1904), gave me the opportunity of copying the manuscript account of the Great Lexicographer's necropsy conducted by his great-grandfather,

* An address given on 21st March, 1924, before the Royal Medico- Chirurgical Society of Glasgow. No. 4. Vol. Ui. 174 Sir Humphry Rolleston?Medical Aspects

James Wilson, F.R.S. (1725-1821). It is in a vellum folio with " " the word Dissections in written capitals on the outside and " added in writing By my Father, James Wilson, and his loving son. James Arthur . . . To be kept, and carefully by one who will know its value. J. A. W." The earliest necropsy recorded in this volume was in May, 1784, and among the accounts of many hospital and private post-mortem examinations one of the latest is that on Lieut.-General Sir Charles Napier, the conqueror of Sind (1782-1855), who wras a patient of Dr. J. A. Wilson, and died with an hepatic abscess secondary to dysentery opening through the diaphragm into the lower lobe of the right lung. James Wilson was successively a resident pupil, assistant, and partner of William Cruikshank (1745- 1800) at the Hunterian School, Windmill Street, and no doubt this was why Cruikshank, Johnson's medical attendant in his " fatal illness, asked him to do the dissection." The vellum volume descended to his son, James Arthur Wilson (1795-1882), the scholarly physician to St. George's Hospital, who in his Harveian Oration at the Royal College of Physicians in 1850 " made jokes in Latin, such as Nix noster per aethera notus," referring to John Snow (1813-1858), the early anaesthetist, and incidentally the first to establish in 1849 the transmission of cholera by water. It is on record that he was "a teetotaller when there were only a few, and also a vegetarian."3 It may also be mentioned that Wilson's sense of humour was shown by his signing some contributions to medical journals by " Maxilla" in place of his initials J. A. W. In 1851 his daughter Laura married Dr. William Howship Dickinson (1832-1913), senior physician to St. George's when I became assistant physician there, who in some respects seemed to be a medical Johnson?a writer of classical English, a humourist and lover of talking, but with an abrupt and dogmatic manner, an outspoken critic, and a fearless opponent. Wilson's account of Johnson's necropsy was in his possession when it was shown to me by his son, Lee Dickinson, by whom it was presented to the Royal College of Physicians of London in 1903. The following is the account given in James Wilson's handwriting, the only alterations being those obviously necessary " in punctuation. It is headed Asthma." "Wednesday, December 15th, 1784, opened the body of of Samuel Johnson. 175

Dr. Samuel Johnson for Mr. Cruikshank, in the presence of Drs. Heberden, Brocklesby, Butter, Mr. C., and Mr. White. He died on Monday evening preceding. About a week before his death Mr. C., by desire of his physicians, scarified his legs and scrotum, to let out the water which collected in the cellular membrane of those parts, Dr. Johnson being very impatient to have the waters entirely gone. On the morning of the day on which he died he repeated the operation himself and, cutting very deep, lost about ten ounces of blood; he used a lancet for this purpose; he was in too weak a state to survive such an apparently trifling loss. For several years past he had been troubled with asthma, for which he commonly used to take opium, and found that nothing else was of any service to him ; he had discontinued, however, this practice some years before he died." " On opening into the cavity of the chest, the lungs did not collapse as they usually do when air is admitted, but remained distended, as if they had lost the power of contraction; the air-cells on the surface of the lungs were also very much enlarged; the right lobe adhered very strongly to the diaphragm ; the internal surface of the trachea was somewhat inflamed; no water was found in the cavity of the thorax. The heart was exceedingly large and strong, the valves of the aorta were beginning to ossify; no more fluid than was common was contained in the pericardium. In the abdomen seemed to be incipient peritoneal inflammation and ascites; the liver and spleen were firm and hard; the spleen had almost the feel of cartlidge. A gall stone about the size of a pigeon's egg was taken out of the gall bladder; the omentum was exceedingly fat; nothing remarkable was found in the stomach; the folds of the jejunum adhered in several places to one another; there was also a strong adhesion by a long slip between the colon and bladder; the pancreas was remarkably enlarged; the kidney of the left side tolerably good, some hydatids beginning to form on its surface; that of the right side was almost entirely destroyed, and two large hydatids formed in its place. Dr. Johnson never complained of any pain in this part; the left testicle was perfectly sound in structure, but had also a number of hydatids on its surface, containing a fatty gelatinous fluid, the right testicle had hydatids likewise, but the spermatic vein belonging 176 Sir Humphry Rolleston?Medical Aspects to it was exceedingly enlarged and varicose. The cranium was not opened." " N.B.?Mr. White, assisting me to sew up the body, pricked his finger with the needle; next morning he had red lines running up the arm, and a slight attack of fever." In the manuscript there are queries after the words " hydatids," but they appear to have been added by a later hand, as the ink is darker. It should be remembered that the common renal cysts were not recognised as distinct from the rare hydatid cysts until 1793, when Matthew Baillie brought out his remarkable book on morbid anatomy. Squibb4 stated that the right kidney was taken away by Mr. (sub- sequently Dr.) White and so may be still preserved. In Squibb's and in some other copies of this post-mortem record the gall-stone is described as "about the size of a pigeon's head" instead of "a pigeon's egg"; Sir John Hawkins, in his Life of Johnson (1787, second edition, p. 593), says that the gall-stone was of the size of a common gooseberry, and that " the liver was schirrous," which might mean cirrhosis, and if so, " goes further than Wilson's description of firm and hard," or might perhaps refer to the thickened capsule, for hepatic cirrhosis is rarely associated with simple chronic peritonitis of an advanced degree such as the cartilaginous feel of the spleen might justifiably suggest. Birkbeck Hill (Johnsonian Miscellanies, vol. ii, p. 388) quotes from Wyndham's Diary, "Vesicles of Wind were found on the lungs (which Dr* Heberden said he had never seen, and of which Cruikshank professed to have seen only two instances)." According to John Latham the plate showing "enlargement of the cells" (emphysema *) of the lungs in the atlas (1799) supplementing Matthew Baillie's "Morbid Anatomy of some of the most important Parts of the human Body" (1793) was drawn from one of Johnson's lungs. The only illustration (Figure 1, Plate VI) of this condition in the series of plates does not present

* The word emphysema, long used for what is now known as surgical emphysema, was first extended to vesicular emphysema by Laennec (1819), who described it as "pulmonary emphysema properly so-called"; Sir Thomas Watson, criticising the possible confusion thus threatened, remarks "Now in truth this is emphysema improperly so-called" {Principles and Practice of Physic, 1871, fifth edition, vol. ii, p. 173). of Samuel Johnson. 177 any obvious bullae projecting from the pleural surface, which, however, is rather sketchily drawn, the attention of the artist, William Clift, and of the engraver, William Skelton, having been concentrated on the cut surface. The interpretation of these morbid changes would appear to be long-standing high-blood pressure with subsequent renal disease (chronic interstitial nephritis), the kidneys showing an excessive degree of cystic change. In Leslie Stephen's life of Johnson in the Dictionary of National Biography the kidneys are said to have been granular, a deduction which seems highly probable, and very likely may have been suggested by the late Sir Norman Moore, who was a friend of Leslie Stephen's, and was closely associated with the Dictionary of National Biography from its start. There is no direct evidence of the presence of arterial change which in some degree would be expected in a healthy man, and this Johnson " " was not, of seventy-five, but the commencing ossification of the aortic valves is suggestive. The exceedingly "large and strong" heart without any mention of valvular disease, except of the aortic segments, points to high blood-pressure and renal disease. The condition of the peritoneum, and especially the cartilaginous feel of the spleen, probably due to chronic capsulitis, may be regarded as the result of the simple chronic peritonitis that may accompany chronic renal disease and arterial degeneration. The enlargement of the pancreas was probably due to engorgement of cardiac origin. The description of the lungs admirably fits emphysema which would be largely explained as the result of the asthmatic attacks. The possibility that the asthma was renal in origin will be discussed presently; but whatever its nature it must have assisted in producing failure of the right side of the heart, and so the oedema of the legs. How far the gall-stone may have been responsible for dyspeptic symptoms is an interesting question; the presence of peritoneal adhesions is at least compatible with the late Sir F. Treves's5 belief that Johnson was a chronic sufferer from abdominal disturbance; indeed, there is some first-hand evidence of his dyspepsia. In 1770 Johnson complained of spasms in the stomach which he had had for many years, but for the last two years had harassed him almost to distraction, and in 1772 he confided to Mrs. Thrale that 178 Sir Humphry Rolleston?Medical Aspects

"my nights are flatulent and unquiet," and again, in 1775, " I was last night almost convulsed with flatulence." Although I have not found any statement as to the side on which the hydrocele was during life, the post-mortem account makes " " it more probable that it was on the left side, as the hydatids on that side contained "a fatty gelatinous fluid." On one occasion Johnson remarked, "My diseases are an asthma, a dropsy, and what is less curable, seventy-five." This, however, was a somewhat abbreviated list of his troubles, for about 1778 he wrote to his old friend, Dr. Edmund Hector, " My health has been, from my twentieth year, such as has seldom afforded me a single day of ease." His letters to Mrs. Thrale, of which more than two hundred originals were publicly sold in January, 1917, contain many references to his bodily " discomforts, and even several to his sarcocele." This chronic ill health was regarded by Sir Frederick Treves as indigestion, in and his erratic habits takingO food and fondness for tea-drinking would quite justify such a penalty. Samuel Pepys and Samuel Johnson both suffered with their eyes. Sir D'Arcy Power6 argues that Pepys had uncorrected hypermetropia with some astigmatism, and that this obliged him to end his diary prematurely and to the loss of history, at the early age of thirty-six. According to the late Sir Frederick Treves, corneal leucomas due to tuberculous keratitis accounted for Johnson's greatly impaired vision, which no doubt was responsible for his remarkable lack of interest in pictures, sculpture, and architecture, and was said, though this sounds unlikely, to have rendered it probable that he never saw his wife's face. The corneal ulceration was treated by a seton in the neck, but in spite of this the sight of the left eye was entirely lost. The question naturally arises?Had he any uncorrected error of refraction and eye-strain, such as, according to the late G. M. Gould,' explains the mental attitude of De Quincey, Cdrlyle, Darwin, Huxley, R. Browning, George Eliot, G. H. Lewis, Parkman, Jane Welch Carlyle, Spencer Whittier, Margaret Fuller Ossoli, and Nietzsche? I am not aware that this has been seriously suggested, though it seems quite possible that in addition to a leucoma Johnson had myopia, and that with the onset of presbyopia this was mitigated, for in 1756, wheu forty-seven years of age, he said of Samuel Johnson. 179 that his sight was restored to him. Johnson, however, as shown by his dispute with the Rev. Dr. Percy, ?trongly objected to being called short-sighted by the divine, and regarded this as the acme of rudeness. In 1773 he suffered from inflammation of his sound eye, ascribed to excessive reading of small print. Mrs. Montagu, when angry with Johnson for his "compassionate contempt," in his Lives of the Poets, of her friend, the first Lord " Lyttelton, spoke of his squinting look,"* but there does not appear to be any more sober evidence that he had strabismus. Johnson was also deaf, though this seldom received much notice. As it has been suggested to me that Johnson had syphilis, congenital or acquired, this should perhaps be briefly referred to. There does not, however, appear to be any clinical or pathological proof of this. The ocular leucomas have been explained on grounds other than the result of interstitial keratitis. That he exposed himself to the risk of acquired lues there is no evidence, unless Boswell's remark that, when associated with the dissipated Richard Savage in London, " he was imperceptibly led into some indulgences which occasioned much distress to his virtuous mind" be regarded as such. Like W. E. Gladstone in a later day, he talked and behaved charitably to women of the town ; Gladstone's public position favoured prurient gossip, and, as far back as 1853, an attempt was made by a commercial traveller, William Wilson, to blackmail him (vide Sunday Times, 12th August, 1923), probably for the sake of notoriety. The possibility of endocrine disorder.?In deference to modern ideas, it would be only polite to raise the possibility that his unwieldy bulk and facial appearance was the outcome of endocrine disorder, such as some degree of thyroid insuf- ficiency or even moderate over-activity of the anterior lobe of the pituitary, which became arrested before more unmistakable features of acromegaly appeared. Louis Berman,8 who argues that Napoleon, Nietzsche, and Charles Darwin were examples of personalities due to dominance of the pituitary, does not mention Samuel Johnson in connection with the ductless glands, and it is doubtful if there is enough to justify any definite suggestion in this direction. * Mrs. Montagu, "Queen of the Blues," IIer Letters and Friendships from 1762 to 1800, edited by lie^inald Blunt, vol. ii, p. 157 (Constable & Co.). 180 Sir Humphry Rolleston?Medical Aspects

Johnson had scrofula early in life, which Dr. Samuel Swinfen, his godfather, and probably the first of his numerous medical advisers, explained by infection from a wet nurse; but it might well be regarded as due to tuberculous milk. He was one of the last in this country to be touched for the King's Evil; for on the advice of Sir John Floyer he was one of the two hundred touched by Queen Anne at St. James's Palace, where her public healings were commonly held, on 30th March, 1712, when he was thirty months old. There has been some dispute 9 about the year when Johnson was touched; E. L. Hussey gives it as 1714, and thus renders Johnson's recollection of the pro- ceedings more intelligible. But in his autobiography, from his birth to his eleventh year, which was published in 1805 from the manuscript preserved in Wright's Museum, Lichfield, John- son gives the year as 1712, and mentions that he had a bad cough on his journey home. The scars of the tuberculous " abscesses disfigured a countenance naturally well formed, and hurt his visual nerves so much that he did not see at all with one of his eyes, though its appearance was little different from that of the other" (Boswell), and in Raymond Crawfurd's10 words, "Johnson carried with him to the grave abiding testi- mony of Anne's ineffectual handiwork." His step-daughter, Miss Lucy Porter, described Johnson as " often having seemingly convulsive starts and odd gesticulations which tended to one's surprise and ridicule." At a much later date (1777), Fanny Burney writes in her diary, "His mouth is almost constantly opening and shutting as if he were chewing. He has a strange method of frequently twirling his lingers and twisting his hands. His body is in constant agitation, see- sawing up and down; his feet are never a moment quiet, and, in short, his whole person is in perpetual motion." According to Boswell, "Such was the heat and irritability of his blood, that not only did he pare his nails to the quick, but scraped the joints of his fingers with a pen-knife, till they seemed quite red and raw." There is thus perhaps some excuse for Hogarth, who, meeting him accidentally for the tirst time, concluded that he was an idiot, and when he was carried away by argument into eloquence, imagined "that this idiot had been at the moment inspired." Boswell, fortified by his study of Syden- ham's writings, regarded the condition as St. Vitus's dance, of Samuel Johnson. 181 and, in a later day, Cahall suggested that the cardiac disorder was a sequel of chorea and rheumatism. Sir Joshua Reynolds, however, thought that Johnson indulged in "a habit of accom- panying his thoughts with certain untoward actions." And Johnson himself, when asked by a very young girl, Miss Hunter, more inquisitive than considerate, why he made such strange gestures, replied, "From bad habit, my dear; do you take care to avoid bad habits." It seems not improbable that his words were more technically correct than he knew, and that he was the subject of a habit spasm or physical tic, and that this may be correlated with the psychical tic, which obliged him to touch certain posts, to count his steps carefully as he walked along the streets, and even to retrace his steps for this duty. The vile fiend melancholy laid a heavy hand on Johnson throughout his life, and tightened this firm grip at certain periods. Thus, in 1729, when twenty years of age, he was over- whelmed with depression; in 1764, when fifty-five years old, he suffered severely, and for some years this continued on and off; after a bout in 1766 he was left with obscure arthritis of one knee, though the connection is not very obvious, which caused him trouble on occasions when he walked much, as on his tours in Scotland. Special notes as to depression are to be found in the years 1768, 1773, 1776, and 1777. This he believed to be inherited from his father, who was a similar sufferer. He had dreadful tits of depression, said to be caused or accompanied by remorse for venial or fancied sins, or by fear of madness or of death. He fought his cross vigorously by walking, work, and other forms of distraction, especially by con- versation, which he characteristically distinguished from mere talk. Thus, in 1729, when submerged in morbid melancholy, he often walked the thirty-two miles from Lichfield to Birmingham and back in hope of relief. It may safely be assumed that there was a trace of autobiography in his description of Mr. Sober in The Idler (No. 31), whose "chief pleasure is conversa- tion . . . and is free for the time from his own reproaches." To others his advice was constant occupation of mind, much exercise, moderation in eating and drinking, and especially the avoidance of alcohol at night. Sometimes Johnson was ex- tremely abstemious, but when he did eat and drink he did so 182 Sir Humphry Rolleston?Medical Aspects

voraciously and copiously, like a half-famished man; and when " not altogether a teetotaller acted on the maxim, claret for boys, port for men, brandy for heroes," preferring the last, as it did its work (intoxication) most rapidly; in his own words, "abstinence is as easy to me as temperance would be difficult." It is remarkable what strength of mind he showed in breaking off habits which are prone to get the dominion over their addicts; thus, having been advised after illness to give up wine, he did so; from 1736 to 1757, and for the last twenty years of his life, except on special occasions, he only took water and lemonade; his hero-worshipper, the Rev. J. Hay,11 described him as the first total abstainer, a rather startling statement. On more than one occasion he advised the convivial Boswell to confine his drinks to water, and to his old college friend, " Edwards, who said, I am grown old ; I am sixty-five," re- joined, "I shall be sixty-eight next birthday. Come, sir, drink water, and put in for a hundred." " According to Sir Joshua Reynolds, Solitude to him was a horror; nor would he ever trust himself alone but when em- ployed in writing or reading," and quoted Johnson's dictum that " the great business of life was to escape from himself." This sentiment was expressed by him in Rasselas (Chapter XVI), described by Walter Raleigh12 as "that most melancholy of fables," "I live in the crowd of jollity, not so much to enjoy myself as to shun myself "; and he said elsewhere that he often " took wine to get rid of myself ; to send myself away." When at Brighton, in 1782, with Mrs. Thrale and Fanny Burney, he explained why he accompanied them to a ball by the doleful " remark, It cannot be wrorse than being alone." This mental attitude throws light on Johnson's essentially clubbable nature, which led him to found three dining clubs?the Ivy Lane Club, the Essex Head Club, and (with Sir Joshua Reynolds) the famous Literary Club.13 Swinfen's injudicious remark to Johnson, at the usually imaginative age of twenty, that the " melancholia would probably terminate in madness," seems to have left a lasting impression, and, by auto-suggestion, to have been responsible for Johnson's fear of insanity. In 1766, when this fear was accentuated, he lived for more than three months in the Thrales' hospitable home at Streatham. He suffered much from what he called indolence, but this may in reality of Samuel Johnson. 183

have been the result of prodigious bouts of intense application to work. The great George Cheyne's book, "The English Malady, or a Treatise of Nervous Diseases of all kinds as Spleen, Vapours, Lowness of Spirits, Hypochondriasis, and Hysterical Dis- tempers" (1733), appealed to him, and he recommended it in 1776 to Boswell, who also complained of depression, with the warning against "a foolish notion that melancholy is a proof of acuteness," evidently suspecting that these lamentations were the sincerest form of flattery and unreal. Although he rather spoke up for the much lampooned Sir Richard Blackmore, " possibly because they had both begun life in the whipping trade" (that of schoolmaster), he is very guarded in the remarks14 " on this poet-physician's Treatise on the Spleen and Vapours, or Hypochondriacal and Hysterical Affections: with three Dis- courses on the Nature and Cure of the Cholic, Melancholy, and Palsy" (1725), and gives the impression that he had not had the patience to do more than glance at its contents. In 1854 Vieillard and Dumont15 appropriately dedicated a brief memoir on this subject to Samuel Johnson, as a life-long sufferer from nervous disturbance, and in 1857 Dumont contributed a " feuilleton, sur l'etat pathologique de Samuel Johnson,"16 dealing in rather fantastic language with the morbid psycho- logical aspects which he discovered in Johnson, and explaining them by his early struggles with depressing conditions of disease, poverty, and disappointments. Dumont, it may be noted, was the sympathetic author of a remarkable volume17 of 600 pages on his own lengthy sufferings from Nevrose cerebrale, which has been compared with J. J. Rousseau's Confessions. While freely admitting his dread of death, Johnson pointed out that this was a natural emotion, and that "the whole of life is but keeping away the thoughts of death." But with Walter Raleigh and Parkes Weber,18 it may be argued that his feelings in this respect have probably been over-estimated, and that his courage in speaking freely may, from his downright manner, have led to a somewhat exaggerated impression of his mental attitude. In his last year he canvassed in varying moods the lease of life before him. Thus, on 11th February, 1784, he writes to Boswell, "If my life is prolonged to autumn," and on " 27th March is more optimistic, and says that the asthma does 184 Sir Humphry Rolleston?Medical Aspects

" not lay very close siege to life "; for Sir John Floyer, whom the physical race consider an author of one of the best books upon it, panted on to ninety as was supposed "; but on 20th July " he writes to Brocklesby that the asthma has no abatement," and expressed his fear that it was not of the same kind as F1 oyer's. It is therefore natural that he was always pleased to be told that he was looking well. His fear of death and the hereafter was naturally associated with a dislike of growing old, and even of the mention of his birthday, probably because he was thus reminded that he wTas " passing into the sere, the yellow leaf." On meeting, after forty-nine years' interval, Oliver Edwards, who had been at Pembroke with him and was guilty of the rather natural" commonplace, "Ah, sir, we are old men now," Johnson hinted " that this was wanting in taste by the remark, Don't let us discourage one another." This recalls Filson Young's dictum in " The Pall Mall Gazette before the war to the effect that every man flatters himself that he looks ten years younger than his real age," and it is perhaps a little comforting to find that the great Samuel Johnson shared this* weakness with us. Though difficult, it is an interesting question how far John- son's infirmities influenced his views of matters and men, and the style and temper of his work. It is inevitable that his rough manner, constitutional irritability of temper, and occasional rudeness should be thus, at any rate in part, explained. Having suffered much, he saw little reason to sympathize with the com- plaints of others unless they appealed to him as really serious, and then he was monstrous kind. With sentimental grievances and valetudinarians he had scanty patience, and his reproof to " the Rev. Dr. Delap, Do not be like the spider, man, and spin conversation incessantly out of thine own bowels," appears to be the victim's chief claim to remembrance. But he made his house an asylum for poor, unattractive, and quarrelsome dependents, was kindly to servants, and thoughtfully generous to children, putting pennies in their hands so that on waking they might be able to get food. According to Fanny Burney, of whom as the youthful authoress of Evelina, it is true, he made much?" He wras always indulgent to the young, he never attacked the unassuming, nor meant to terrify the diffident." Goldsmith, who owed him much also, may be quoted?"Johnson, of Samuel Johnson. 185 to be sure, has a roughness in his manner; but no man alive has a more tender heart. He has nothing of the bear but his skin." Constant bodily discomfort, and the need for disguising or silently bearing pain, may possibly have made him modify his thoughts and spoken words when deliberately written out for public consumption. His conversation was forcible and to the point; but when he put pen to paper he adopted a different dialect, and translated his English thoughts into what Macaulay, a somewhat antagonistic critic, called Johnsonese, with its learned words and uneasy mannerisms. Gout first attacked him in 1773, but in 1770 and 1771 he wrote to Mrs. Thrale that he had rheumatism ; and it is assumed by Cahall19 that this caused mitral disease which remained latent for years, its first evidence appearing in 1776 in the form of dyspnoea when at Bristol. In this last year he was the victim of an acute gouty paroxysm, which recurred after his aphasic seizure. Attack of aphasia.?At 3 a.m., on 17th June, 1783, Johnson woke up, and after a preliminary feeling of confusion and indistinctness in his head, lasting about half a minute, experi- enced the severe shock of finding himself aphasic. In his alarm that his mind would go he prayed to be spared this, and, to test his mental processes, turned his prayer into Latin, which he did easily, though recognising that it was not very good; this assured him that his faculties were unimpaired. Sir Walter Scott, it may be mentioned, who for years before his death had a foreboding of intellectual failure, employed a similar test with satisfaction. Subsequently, with the view of bringing back his speech, Johnson took two drams of wine, on the ground that alcohol was famous for the production of eloquence, and slept. When Heberden and Brocklesby arrived there was weakness of the right side of the face, but apparently the " hemiplegia was slight, for the next day he wrote, Though God stopped my speech, he left me my hand." There, however, was " evidently some agraphia, for he adds, In penning this note I had some difficulty; my hand, I know not why, made wrong letters." Within twenty-four hours he regained his speech fairly well. Whether this attack was due to a small haemor- rhage or was uryemic is an interesting speculation, but there is no positive evidence to settle this point, as the skull was not 186 Sir Humphry Rolleston? Medical Aspects

opened at the necropsy. The rapid recovery is quite compatible with the view that it was uraemic, and is on the same lines as the suggestion that his asthma was of renal origin. Although the aphasia passed off, so that in July he wrote to Rev. Dr. Taylor that he was in better health than he had been before the attack, it was not long before other ills began to compass him about, which he bore in a philosophic manner, for he wrote to Dr. Mudge, of Plymouth," By representing the gout as an antagonist to the palsy, you have said enough to make it welcome." But this was not all; he had what with little con- cern he regarded as a hydrocele, a condition from which his contemporary, John Wesley (1703-1791), also suffered ; but when a puncture drew blank, a diagnosis of a solid tumour of the testis or sarcocele was made in September, 1783, and Percivall Pott, who attended him in consultation with W. Cruikshank, urged excision or "amputation," as Johnson, who now prepared himself for this ordeal, called it. There was, however, delay, as Cruikshank was more afraid of the shock than was Johnson.

" While waiting for the formidable operation of excision, the sarcocele ran off at an orifice made for mere experiment" (Johnson, Letter to Rev. Dr. Taylor). Asthma.?In discussing the asthma which played such an important part in his later years, it may be well to run rapidly over his medical history in this respect. Except that he had a bad cough when returning in 1712 from being touched for the King's Evil by Queen Anne in London, there is no record of any respiratory distress until 1755, when, at the age of forty-six, he had a cough and hoarseness of voice (laryngitis), and was bled three times to thirty-six ounces. Then, in 1772, he had a winter cough; two years later, in 1774, he was very ill with "cough and cold," and in February, 1777, his breathing was so distressed that he was bled to thirty-six ounces in three days, and, indeed, repeated this himself by opening the venesection wound. After similar attacks in 1778 he improved, and on 18th June, 1779, wrote that he was free of "convulsions" in the chest which had troubled him for more than twenty years; he was said to have a fresher complexion, and to be happier as well as gentler in his manners. On 23rd October, 1781, he wrote to Mrs. Thrale, 4< The gravedo [catarrh] is not removed nor does it increase," and in February, 1782, the asthma was so harassing that he was of Samuel Johnson. 187 bled three times; and Hannah More,20 after seeing him in April, " wrote, Poor Johnson is in a bad state of health ; I fear his constitution is breaking up." In June he still had a "catarrhous cough," and in 1783 it was extremely severe, and in October was complicated by much oedema of the lower extremities. From now to the end of his life he suffered much from these attacks, having a bad attack which kept him in the house for eight or nine weeks at the end of 1783 and beginning of 1784. In 1783, on medical advice, he took opium, and at one time the daily dose reached 3 grains. He, however, entirely gave it up a few days before his death, when he extracted from Dr. Brocklesby the truth that his end was near. As he almost certainly had granular kidneys, the question arises if his asthma, at any rate within a year or so of his death, was renal in nature. In 1889 the late Sir Stephen Mackenzie21 showed that renal asthma could be safely and successfully treated by hypodermic injection of morphine, thus confirming Loomis's22 advocacy of morphine in the treatment of uraemic manifestations more than a quarter of a century before. This at the time was a very bold statement, for it was then most widely and emphatically held in this country that opium and morphine should never be given in granular kidney. It was, indeed, regarded as one of the most serious mistakes that could be made. When I was house physician at St. Bartholomew's Hospital a night nurse, by mistake, gave a man with renal disease ten minims of tincture of opium, with the result that he slept very well, whereas I did not. Since then I have often given morphine in uraemic conditions in granular kidney, and never with any untoward results. It would be interesting to know how this bogey originated. Sir Thomas Barlow, who was Sir William Jenner's last house physician, tells me that Jenner's teaching was definite about the danger of morphine in granular kidney. As he was an impressive and dogmatic teacher at that time, it is possible that his influence was largely responsible for this once widespread belief. But to return to the question of the renal nature of Johnson's asthma. That it was asthma in a patient with renal disease seems fairly certain, but it is difficult to believe that he had renal asthma?which is a late event in the course of chronic nephritis?for twelve years. It might, however, be argued that in 1772 he had bronchitis, and that this 188 Sir Humphry Rolleston?Medical Aspects

led to asthma due to bacterial sensitisation. The interval of comparatively good health in 1780, followed in 1782 by severe asthma, might conceivably mean that the nature of the asthma had changed, and that it was now renal or mixed in character. The relief obtained from opium does not, of course, bear on the discussion as to the nature of the asthma, for all forms may be so alleviated. But if the asthma at the later period of his life was renal, the adoption of opium is an interesting and uncon- scious anticipation of comparatively modern therapeusis. Dropsy.?In October, 1783, oedema of the legs, which had been noticed in the previous June by Sir Lucas Pepys, who did " not find him a very tractable patient," spread up to the thighs, and in February, 1784, its farther increase after a severe attack of asthma so much alarmed Johnson that in March he obtained, through Boswell, the advice of five Edinburgh physicians?Sir Alexander Dick, Drs. Gillespie, William Cullen, John Hope, and Alexander Monro secundus, the most famous of these three Professors of Anatomy and perpetuated in the foramen of Monro. These physicians, though without the opportunity of seeing the patient's actual condition, were naturally constrained by the circumstances to give advice and prescriptions which may have rather embarrassed Johnson's advisers in London. The only recorded prescription is that of the octogenarian, Sir Alexander Dick, for rhubarb grown in his garden at Prestonfield, which Boswell was to bring south, but whether or no Johnson ever took it does not appear. Soon after this, about 16th March, after a day of solitary prayer, humiliation, and fasting, he suddenly had a urinary crisis, passing twenty pints of urine with temporary relief, and the dropsy which had confined him to the house for 129 days disappeared. Both he and Boswell regarded this as a special answer to his prayers; but as he was taking various diuretics and fasted, it would not be fair to put aside the influence of this form of treatment. Johnson had squills, which is, of course, a member of the digitalis group, but not " foxglove, for William Withering's An account of Foxglove and of its Medicinal uses, with practical Remarks on Dropsy and other Diseases" was not, published until 1785. For a time he was much improved, and in June went to Oxford and travelled about in the summer time to Ashbourne and Lichfield, of Samuel Johnson. 189 but the exertion led to threatenings of dropsy, which, however, were controlled by medicine and rest, until November, when the oedema progressively advanced and he was obviously near the end. On 11th December, Cruikshank incised his legs so as to obtain relief, and Johnson, always eager to suffer pain if thereby he could benefit, urged him to cut deeper, and upbraided his medical friends, among them William Heberden, the elder, whom on a former occasion he had summoned as " Ultimum Romanorum the last of the learned physicians," for anxiety about their professional reputation, calling Heberden "timidorum timidissimus." On 13th December, the day of his death, he indeed, carried his precept into practice, and getting a lancet from his servant, cut deeper into his legs and thereby lost some ten ounces of blood, but either in spite of, or because of, this he sank and died at 7 p.m. From his catholic interest in everything touching human " nature Johnson was a great dabbler in physic." Comparison of his own extensive reading with that of many doctors, and his authorship of some small parts in Robert James's Medicinal Dictionary (1743), which Bos well, though unable to identify himself, suggests might be successfully recognised by medical some excuse for that men, may have given Johnson thinking he was no mean authority. At any rate, he gave directions to Mrs. Thrale as to the treatment of her husband in 1780, and recommended her to take St. George's Spa water. When in his own attack of aphasia blisters were ordered to the back and neck, he "compelled the apothecary to make his salve according to the Edinburgh dispensatory, that it might adhere better. I have now two on my own prescription." Fanny Burney said that he severely disciplined himself by starvation, mercury, and opium, and that he appeared to suffer more from his remedies than from the disease. Although he strongly disapproved of periodical bleeding, because it established the habit of an evacuation which, he said, nature could not perform when it was discontinued and so sudden suffocation might supervene, he was often bled for asthma, and, as mentioned elsewhere, both bled himself and incised his cedematous legs. When his friend, Thomas Lawrence, President of the Royal College of Physicians (1767-1775), after an attack of right hemiplegia and aphasia in 1782, got oedema of the paralysed hand, Johnson recommended No. 4. M Vol. CI. 190 Sir Humphry Rolleston?Medical Aspects

him to try electrical treatment. In 1783 he wrote to his companion in sickness, Rev. Dr. J. Taylor, "It does not appear from your doctor's prescriptions that he sees to the bottom of your distemper," and proceeds to dictate that regimen, and especially milk, were more likely to do good than medicine. When in need of physic at Montrose in 1773 he wrote out the prescription in technical characters. He insisted that a medical man should always tell his patient the truth, and that it was wrong to lie to a sick man for fear of alarming him. In 1775 Boswell obtained from him a somewhat lengthy opinion on the relation of the titles " " " " Physician and Doctor of Medicine when defending in the Court of Sessions the Managers of the Royal Infirmary, Aberdeen, against Dr. John Memis. This St. Andrews graduate " " objected that instead of being termed Physician he had been " dubbed Doctor of Medicine," which he contended was applicable only to the recently qualified before they entered on practice. Johnson, fortified by the opinion of Thomas Lawrence, upheld the title of Doctor as the highest that a practitioner of physic can have, and as implying not only physician but teacher of physic. His acquaintance with doctors of various degrees was extensive, and he was always fond of their society. When corresponding with them on the subject of his ailments he did so in Latin; the scholarly style of his account of his mental depression in 1729 struck Dr. Samuel Swinfen as so remarkable that he thought- lessly showed it to others, thus arousing Johnson's indignation at his breach of professional conduct. From 6th July to 8th November, 1784, Johnson kept a journal in Latin of the " state of his health under the title Aegri Ephemeris."

REFERENCES.

1 Raleigh, W., Six Essays on Johnson, Oxford, 1910, p. 32. 2 Besides the references in the text, attention may be drawn to the following articles:? Chaplin, Arnold, Medicine in England (1760-1829), FitzPatrick Lectures, Royal College of Physicians of London (1917-1918), London, 1919, pp. 120-126. Ogle, J. W., Brit. Med. Journ., 1874, vol. ii, p. 163 (Aphasia). of Samuel Johnson. 191

Packard, F. R., "Medical History of Samuel Johnson," New York Med. Journ., 1902, vol. lxxv, pp. 441-445. 4 Rogers, B. M. H., "The Medical Aspects of Bos well's Life of Johnson' with some account of the Medical Men mentioned in that Book," Bristol Med.-Chir. Journ., 1911, vol. xxix, pp. 125-148. Warbasse, J. P., "Doctors of Samuel Johnson and his Court," Med. Libr. and Histor. Journ., Brooklyn, New York, 1907, vol. v, pp. 65, 194, 260. 3 Embleton, D., History of the Medical School of Newcastle-on-Tyne, 1890, p. 10. (Snow was one of the original students of this school.) 4 Squibb, S. J., London Journ. Med., 1849, vol. i, pp. 615-623. 6 Treves, F., CasselVs Magazine, February, 1924, pp. 38-44. 6 Power, D'Arcy, Lancet, 1911, vol. i, p. 1687. 7 Gould, G. M., Biographical Clinics, 1903, vol. i; 1904, vol. ii. 8 Berman, L., The Glands Regulating Personality, New York, 1921. 9 Hussey, E. L., Archaeological Journ., 1853, vol. ix, p. 106. 10 Crawfurd, R., The King's Evil, Oxford, 1911, p. 145. 11 Hay, J., Johnson: His Characteristics and Aphorisms, London, 1884, second edition, p. 96. 12 Raleigh, W., loc. cit., p. 33. 13 Vide Timbs, John, Clubs and Club Life in London, London, 1872, pp. 171-187. 14 Johnson's Works?Vol. v : Lives of the Poets, London edition, 1818, p. 99. 15 6tude de psychologie m^dicale, contenant lettre Sur les souffrances auxquelles sont soumises les organisations n^vros^es, par le Docteur Dumont (M&lecin de la Maison Central du Mont Saint-Michel) de l'id^e fixe par P. A. Vieillard (Conservateur de la Bibliothkque du Senate). A la m^moire de Samuel Johnson. Baillikre, Paris, 1854. 16 Dumont, Union m^d., Paris, 1857, tome xi, pp. 296-7, 521-3. 17 Dumont, Testament medical, philosophique et litteraire, Paris, 1865, pp. xxx and 604. 18 Weber, F. P., Aspects of Death and Correlated Aspects of Life, London, fourth edition, 1922, p. 408. 19 Cahall, W. C., Amer. Med., Phila., 1901, vol. ii, p. 338. 20 More, H., Memoirs, 1834, vol. i, p. 249. 21 Mackenzie, S., Lancet, 1889, vol. ii, pp. 208, 263. 22 Loomis, A. L., Med. Rec., New York, 1873, vol. viii, p. 361.