Henry Connor

Lest we forget: Edith Cavell 1865-1915.

The story of Nurse Cavell has been told many times, most recently by Souhami and previously in this journal by John Ford. In 1914, at the outbreak of World War I, Cavell had spent seven years as the founding principal of the first school of nursing in Belgium. As a result of her dedication and diplomacy, the school was now providing well-trained nurses for three hospitals and three nursing homes. The school in Brussels had gained an excellent reputation and was about to move into larger premises. Then, Germany invaded Belgium and, overnight, Cavell’s world and that of those around her disintegrated into chaos and horror. It was all a far cry from her orderly and secure upbringing in the vicarage of an English village. There she had been indoctrinated with the Victorian values of duty and hard work and with the Christian ethic of alleviating suffering and of service, especially to the poor. After working as a governess, she found her vocation in nursing which provided the practical expression of her Christian duty and faith. At that time nursing made immense demands on its practitioners with long hours of work, much of it menial, and the requirement for study and examinations. The demands were all the greater on those like Cavell who spent the first 10 years of her career working in the poorest and most destitute areas of London. Her colleagues noted her unremitting attention to detail and her aspiration to excellence. She put the interests of others before her own and never spared herself. She wanted little for herself, eating and living modestly. Even as a school principal her rooms were sparsely furnished. Her manner was reserved, and a matron with whom she had worked as assistant matron for two years wrote that she never knew anyone who really got to know Edith Cavell. As she became more senior she expected obedience from those junior to her, as was customary at the time, but she was by no means a martinet. Rather, she inspired devotion among both patients and colleagues. In her lectures to students she insisted that care of the patient must be imbued with compassion and she emphasised that devotion to their vocation would bring its own rewards. There was no demarcation in her own life between her nursing and such private life as she allowed herself. Wounded soldiers who arrived at the school’s hospital were given the same care irrespective of nationality because Cavell insisted that nursing recognised no frontiers. However, the Germans soon made their own arrangements for their wounded. Cavell then moved beyond the provision of nursing care by assisting allied soldiers to cross the border into neutral Holland. She became an important part of two escape networks and helped fugitives from the Germans whether they were wounded or healthy. Before the war, Cavell had refused to tell even minor lies but now she lied to the German authorities and created fictitious medical records for healthy soldiers who she disguised as Belgian civilians. She felt justified in her deceit because she did not recognise the moral authority of the oppressive and ruthless German military regime which, according to Cardinal Mercier, had shot thousands of innocent civilians by Christmas 1914 and had ruined the lives of millions more. She avoided direct involvement of her nurses but must have known that the Germans could take reprisals against them. Perhaps even more questionable was her decision that the circumstances also took precedence over the neutrality of the Red Cross to which her hospital was affiliated; but Cavell knew of 10 British soldiers who had been shot when their hiding place was discovered. The miller who had hidden them was also shot and his family sent as prisoners to Germany. Her compassion for those in such peril merged seamlessly with patriotic duty. The scale of her involvement made discovery inevitable. In nine months, she helped several hundred people to escape and at one time there were up to 80 fugitives hiding in the school; but as long as there were people at risk she continued with her work, although she knew that the net was closing in on her. She remained calm even though she expected to be arrested. In prison, she maintained her composure. Selfless as ever, she was more concerned about her colleagues and her elderly mother than about herself. ‘I am quite well’, she wrote, ‘more worried about the school than my own fate.’ Even when sentenced to death she

Medical politician and man of Olympian vision and energy: Dr William Penny Brookes (1809–95) of Much Wenlock

William Penny Brookes lived all his life in Much Wenlock in Shropshire where he worked as a general practitioner for 60 years. He is now best remembered as the founder of the Wenlock Olympian Society, as a founding member of the first national Olympian association and for his influence on Baron Pierre de Coubertin, the founder of the modern Olympic movement. He was a tireless campaigner for the introduction of physical education and a lessening of the academic workload in elementary schools. He was also an important figure in the medical reform movement of the mid-19th century. In Much Wenlock he was a much respected philanthropist and was involved in many civic activities. He was also a notable botanist and antiquarian.

Wenlock and Mandeville

The names of Wenlock and Mandeville, the mascots for the 2012 Olympic Games, derive from the work of two doctors who are the subjects of papers in this issue of the Journal of Medical Biography. William Penny Brookes (1809 – 95) was a general practitioner who founded the Wenlock Olympian Games at Much Wenlock in Shropshire and who was one of the three founding members of the National Olympian Association in England. He was an important influence on Baron Pierre de Coubertin (1863– 1937) who is regarded as the originator of the international Olympic movement. Sir Ludwig Guttmann (1899 – 1980) was the first Director of the National Spinal Injuries Centre at Stoke Mandeville in England and the creator of the Stoke Mandeville Games which developed into the Paralympic Games. 3 Biographical information about Guttmann is more extensive than that about Brookes, but what is known about the personalities of the two men reveals some interesting similarities as well as some contrasts. Both were short in stature, Brookes lithe and Guttmann stocky, and both bustled with activity. Both had a strong social conscience which arose from their work among the agricultural labourers of Much Wenlock and the coalminers of Kö nigshú´tte. Both were intolerant of injustice. Brookes lobbied on behalf of his pauper patients, on behalf of military surgeons who were treated less fairly than their combatant brethren and on behalf of his fellow general practitioners whose status was inferior to that of specialist surgeons and physicians. Guttmann, who had personal experience of racial injustice, later exerted his enormous energies in fighting the ignorance and restrictions faced by his paraplegic patients. In lobbying on behalf of others both men exhibited their own intolerance – an intolerance of bureaucracy! Brookes and Guttmann must be considered as outsiders , at least in their earlier years. Brookes was an active liberal in an overwhelmingly conservative borough and, when he ventured into national issues, he did so as an obscure provincial doctor. Guttmann was even further outside the establishment, first as a Jew in prewar Germany and then as a German e ´migré who retained a strong foreign accent and whose surgical technique, despite extensive experience in Germany, was not considered sufficiently proficient for him to be allowed to practise as a neurosurgeon in England. 4 So far as is known, Brookess bravery was never tested. Guttmann was a man of considerable physical courage, …

Drug Discovery—A History

I must thank Dr Kamran Abbasi for inviting me to review this book because if I had seen it on the shelf in a bookshop I would almost certainly have passed it by; and, in doing so, I would have missed a book of great merit and considerable scholarship. The book deals first with those drugs from historical eras, then with those derived from naturally occurring precursors and prototypes and finally with the wholly synthetic drugs. In general this arrangement works well for a history of the discovery of drugs—which is, of course, the purpose of this book—though it does produce some rather odd bedfellows; for example, the section on oral rehydration is followed by one on disinfectants. It is less satisfactory for those who wish to read about the history of the different drugs used in the treatment of certain diseases such as asthma or diabetes because the reader must flip continually from one section and from one chapter to another, and also because it is less easy to understand the relative importance of different groups of drugs as the treatment of those diseases has evolved over time. However, as a history of the discovery of individual drugs and of categories of drugs this book is excellent. Sneader writes fluently and lucidly, his research has been scrupulous and his evaluation of the data is appropriately critical. The book abounds with pertinent original references, and not just to the drugs themselves; if you want to lay your hands on the seminal references to the work by Goldblatt and his colleagues on the role of renin in renal hypertension in 1934 or on Ahlquist’s concept of alpha and beta adrenoreceptors in 1948 you will find them here. There are also first-class vignettes on such topics as the Paracelsians, Brunonianism and pneumatic chemistry, to mention only a few. Readers will also learn, if like me they did not already know, how Horace Walpole introduced the word ‘serendipity’ (from the three princes of Serendip who had repeatedly made fortuitous discoveries) and how the discovery by Henry Salter, a London physician, that strong black coffee could relieve asthma, was later to lead to the finding that theophylline was a bronchodilator. And there are many more such anecdotes. Inevitably there are omissions though all are of a minor nature and largely a matter of personal choice. I was disappointed that the chapter on herbals mentions only those which appeared in printed formats, effectively therefore just those published after 1480. Although the earlier manuscript herbals inevitably had a more limited circulation, they did still have a substantial impact on medical practice. This was especially true of those written in the vernacular, such as the English translation in 1373 by John Lelamour, a schoolmaster in Hereford, of a Latin herbal, a work which also served as one of the earliest English texts on gardening. Those with connections to the Scottish capital city will read the comprehensive section on the use of Dakin’s solution as an antiseptic and will then ponder the omission of any mention of Edinburgh University Solution Of Lime (Eusol), until they remember that the author is based in Glasgow. For most people this will not be a book to read from cover to cover but one into which they will dip repeatedly with pleasure and profit. It will probably be used primarily as a reference book and it does have the essential accompaniment of any such work, namely an excellent index; albeit one in a font size so small as to trouble the eyes of some older readers.

First use of ether anaesthesia under combat conditions.

thesia. Philadelphia: Lippincott Williams & Wilkins, 2013. 22. Miller RM, Ericksson LI, Fleisher LA, et al. Miller’s anesthesia. Philadelphia: Saunders, 2015. 23. Singler R. Pediatric regional anesthesia. In: Gregory G (ed.) Pediatric anesthesia. New York: Churchill Livingstone, 1983, pp.481–506. 24. Small GA. Brachial plexus block anesthesia in children. JAMA 1951; 147: 1648–1651. 25. Farr RE. The role of local anesthesia in office practice. Am J Surg 1930; 8: 340–344. 26. Labat G. Regional anesthesia: its technique and clinical application. Philadelphia: W.B. Saunders Company, 1922. 27. Bacon DR, Reddy V and Murphy OT. Regional anesthesia and chronic pain management in the 1920s and 1930s. The influence of the American Society of Regional Anesthesia. Reg Anesth 1995; 20: 185–192. 28. Blalock A. Principles of surgical care: shock and other problems. St. Louis, Missouri: C.V. Mosby Company, 1940. 29. La Vake RT. Robert Emmett Farr, M.D., F.A.C.S. (1875–1932). Trans Am Assoc Obstet Gynecol Abd Surgeons 1932; 45: 240–242. 30. Anonymous. Death notice of Robert Emmett Farr. JAMA 1932; 98: 406. 31. Anonymous. Certificate of Death Robert Emmett Farr (Dr.). State of Minnesota: Division of Vital Statistics, 1932. 32. Anonymous. Former Montello Boy Recommended for Nobel Prize. Oshkosh: Daily Northwestern, 1930.

Lest we forget: Dr John McCrae – Physician, soldier, poet

John McCrae (1872–1915) was born in Ontario into a farming and military family with a strong Scottish Presbyterian faith which formed the bedrock of McCrae’s own character. He graduated in medicine with the gold medal from Toronto before holding internships there and then at the John Hopkins Hospital under William Osler (1849–1919) with whom his elder brother Thomas (1870–1935) was already associated.

Pental was not sodium thiopental

In his paper on Thomas James Walker, the author equates Walker’s publication on the use of pental as an anaesthetic in 1896 with sodium thiopental. However, sodium thiopental was not introduced as an anaesthetic until 1934. Pental, which had been introduced in Germany in 1892, was the trade name of b-isoamylene which was alleged to be a purer form of amylene which John Snow had stopped using as an anaesthetic in 1857 because he considered it more dangerous than chloroform. Pental proved just as hazardous as the amylene used by Snow and others.

Siegle's Steam Spray Inhaler.

Serendipitously, the photograph of Siegle’s Steam Spray Inhaler (Figure 1) was taken one day before this author read Kirkup’s paper on Lister’s antiseptic steam spray. When Lister first introduced a carbolic spray in 1871, he used the hand spray devised by Benjamin Ward Richardson (1828-1896) for local anaesthesia. By this time Richardson was using a version of Siegle’s spray powered by the handball invented by Dr (later Sir) Andrew Clark (1826-1893), PRCP although Dr (later Sir) Morell Mackenzie (1837-1892) had already used a steam-powered version to deliver atomised liquids to the bronchi of patients with chronic bronchitis. Emil Siegle (1833-1900) was born in Stuttgart and studied medicine in Pisa, Tübingen, Vienna and Paris. He is best remembered for his pneumatic ear speculum which he introduced in 1864, the same year in which he described his Steam Spray Inhaler in a book on the treatment of throat and lung disease by inhalations. His spray used the Venturi principle to atomise liquid medications and, as such, it represents the earliest form of nebuliser. The steam-powered model of the design shown here was introduced by the London instrument maker Krohne and Sesemann in 1871 and marketed by S Maw and Company. In 1876 the same model was also marketed by Arnold and Sons of London at a cost of 7s 6d when made from tin and 12s 6d from brass. A deluxe brass model with safety valve, water gauge and barometer cost 2 7s 6d. In 1875 Lister wrote that he now found it ‘more convenient to use highpressure steam as the motive power, on the principle of Siegel’s steam inhaler. . . modified to adapt it for our purpose’. Dr Andrew Clark had already used Siegle’s steam inhaler at the London Hospital in 1869 to administer intra-bronchial carbolic acid to bronchitic patients. This model was discovered during renovations to a house in Harlech that belonged to Dr Richard Thomas Jones (1854-1920), JP, LRFPS (Glasgow), LSA (London) and the first County Councillor for Harlech. Incidentally, as a radical Liberal he had been a close friend of David Lloyd George (1863-1945) in whose nomination as Parliamentary Candidate for Caernarfon Jones was instrumental.

Thomas Paytherus (1752–1828): Entrepreneurial surgeon-apothecary and ardent Jennerian

Thomas Paytherus was born in Fownhope and apprenticed in Gloucester. He practised there and in Ross-on-Wye where he and Edward Jenner undertook an autopsy on a patient with angina that they linked causally to coronary artery ossification. In 1794 Paytherus moved to London and opened a highly successful pharmacy that he later sold to his partners Savory and Moore. Paytherus was among those who advised Jenner on the publication of his work on vaccination. Then he acted as an intermediary in the dispute between Jenner and Ingen-Housz and also alerted Jenner to Pearson’s claims as a pioneer of vaccination. In 1800 he published a detailed analysis of the dispute between Jenner and Woodville whose patients had developed variola-like lesions following vaccination. Their correspondence shows that Paytherus, Jenner and their families remained firm friends. Paytherus and his family moved to Abergavenny where he died in 1828.

Poison ArrowsFeldmanS244pp Price £14.99 ISBN 1-84358-137-X London: Metro Publishing

Professor Feldman describes how our understanding of the mechanism of action of curare has developed, from the early demonstrations by Squire Waterton and Benjamin Brodie that it kills by poisoning the muscles of respiration, leading on to the work of Bernard who showed that it poisoned the motor but not the sensory nerves, and of his pupil Vulpian who concluded that its site of action was at the muscle end-plate. The reader is led through the elegant work of Loewi and Dale, who used curare to prove that acetylcholine came from the nerves and was not a product of muscular activity, to the theory of competitive inhibition (and the limits and deficiencies of that theory) and on into the era of molecular biology with studies on single acetylcholine receptors. The author can be forgiven for devoting a disproportionate amount of space to his own research but it is less easy to condone the over-enthusiasm for his subject which leads him to claim that it was the knowledge derived from the study of neuromuscular blockade which has brought about the development of drugs for asthma, hypertension, depression, mania, Parkinson’s disease and many other illnesses—though he does eventually concede, on the final page of the book, that ‘it would be foolish to pretend that these discoveries would not have been made had curare not been available’. It is easy for us to forget that our predecessors had to learn how to use these drugs safely, and there is an interesting account of the introduction of curare into clinical practice, from the earliest employment of crude extracts in the nineteenth century to the use of purified preparations in the 1940s and of other neuromuscular blockers in subsequent decades. However, the reader is required to extract these facts from a morass of incidental information. The ten-page Introduction which explains how the contents of our cells are derived from primordial seawater would, in abbreviated form, be relevant to the discussion on chemical transmission which comes five chapters later, but here it is bereft of all context; and, while we do indeed need to know something of the academic milieu in which Claude Bernard worked if we are to appreciate the significance of his studies of curare, Feldman does not achieve this aim in the nine pages which he devotes to the subject. The absence of an index is always an irritation but an even greater annoyance is caused by Feldman’s decision to dispense with an orthodox system of referencing in favour of a lengthy list of citations which are not linked to statements in the text, so that the reader cannot readily pursue some of the issues which are raised. Moreover, the relevance of many of the citations is not readily apparent, and readers will have difficulty pursuing those from scientific journals because page numbers are never given and even the volume number is sometimes omitted. If Feldman had submitted himself to the discipline of constructing a proper list of references he might have avoided several errors, which include statements that the Poor Law Reform Act was enacted in 1828 (it was 1834) and that Lister introduced antisepsis in 1845 (it was 1867); and, if he had checked the existing references more carefully, then the name of the author of a paper on Spencer Wells might have been given correctly (Shepherd not Shepard), as might the year of publication (1970 not 1907). How can an author who is presumably meticulous when writing papers in his professional discipline (in this case, clinical science) think it acceptable to be any less diligent when he moves into another (history of medicine)? It may well be that the facts and opinions which relate to the author’s area of specialist interest are all correctly stated but, inevitably, the reader is left wondering.