Author Archives: Theodore Dalrymple

The Latin Grammar of Pharmacy by Joseph Ince

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Time was, not so very long ago, when medical students were expected to know Latin: indeed it was, if I may coin a phrase, a sine qua non (or what a doctor friend’s doctor father used to call a without-which-not) of becoming one.

I discovered just how much Latin medical students were once expected to know when I looked into The Latin Grammar of Pharmacy, 8th edition (and 10th thousand), 1903, by Joseph Ince, Lecturer in Pharmacy to the Pharmaceutical Society of Great Britain. The preface, written from the author’s home, Number 13, Alfred Road, Acton, takes the need for such knowledge for granted, since it does not explain it; and the author later points out that “a classical education alone will not prove sufficient to master the purely technical details involved in deciphering medical formulae.”

Here, for example, is a directive that a doctor is supposed to make to a pharmacist for a charcoal poultice:

Panem prope ignum macera in aqua horae sextam partem dein misce, lini farina gradatim addens inter agitationem ut fiat ctaplasma molle. Cataplasmate carbonis dimidium imsisce et reliquum supra consperge.

Macerate the bread in the water for ten minutes near the fire, then mix and add the linseed meal gradually, stirring the ingredients, that a soft poultice may be formed. Mix this with half the charcoal, and sprinkle the remainder on the surface of the poultice.

Or:

Ne nimis amarum sit dentifricium.

Let not the tooth powder be too bitter.

Or:

Panni linnei solutione madefacti applicanda.

Let woollen cloths moistened in the solution be laid on.

There are exercises in the book for translation into Latin, which unintentionally give us an insight into the medicine that was practised in 1903:

A blister of Spanish Fly to be placed on the region of the stomach (epigastric) for ten minutes, unless there is too much pain.

Or:

Mix, and make an ointment, of which let a piece the size of a nutmeg be rubbed on the painful forehead night and morning until pustule break forth.

(The ointment, incidentally, was to be made of tartrate of antimony and spermaceti from sperm whales).

Or again:

Mix, and make a solution to be applied to the painful part by means of a camel’s-hair pencil.

Oddly enough, the few Latin abbreviations that we still use in prescribing do not appear in the list that the book supplies. Which among us knows what V.O.S. or Donec alv. bene. respond. once meant (vitello ovi solutus, dissolved in yolk of egg, donec alvus bene responderit, until the bowels have been well opened)?

One may wonder why the use of Latin persisted so long. Perhaps in the absence of a real ability to make a difference to outcomes, impressiveness was the most important medicine of all. Certainly Sit emplastrum fuscum; vetustum recenti praeferendum is more impressive than Let the plaster be brownish-yellow; the old is to be preferred to the fresh-made.

The use of arcane language, such that all who hear may not understand, is a permanent temptation of those whose claims to special knowledge or skill are ill-founded, doubtful or insecure. Who, reading a circular emanating from management, has not wondered why the matter contained in it is not put more simply? The fact is that we must always take what management says cum grano salis.

Kipling’s Ballads of Army Life

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Rudyard Kipling (1865 – 1936), who won the seventh Nobel Prize for literature, is generally regarded as the praise singer of imperialism; and since imperialism went out of fashion, so has his poetry. But his ballads of army life seem to me considerably more nuanced than this would suggest.

For example in the poem Loot, first published in 1890, he speaks through the voice of a private soldier who is motivated in the imperial wars in which he serves by the prospect of loot; there is no suggestion that this is either laudable or glorious.

Perhaps the Tommy loots because he is so badly paid. A retiring sergeant-major who has seen action the world over is paid a pension of a Shillin’ a Day, and the poem ends ironically:

Think what ‘e’s been,
Think what ‘e’s seen,
Think of his pension an’ –
GAWD SAVE THE QUEEN!

In the most famous of all the ballads, The Road to Mandalay, the British soldier, now returned to London, has no doubts about the superiority of the East and its inhabitants:

Tho’ I walks with fifty ‘ousemaids outer Chelsea to the Strand,
An’ they talks a lot o’ lovin’, but wot do they understand…
I’ve a neater, sweeter maiden in a cleaner, greener land!

In Danny Deever a soldier is hanged in front of the regiment for having killed a fellow soldier in an argument; it is as great a poem as The Ballad of Reading Gaol.

Among the hazards of soldiering in Kipling’s day was cholera. In The Young British Soldier, an older man gives advice to the recruits:

When the cholera comes – as it will past a doubt –
Keep out of the wet and don’t go on the shout,
For the sickness gets in as the liquor dies out,
An’ it crumples the young British soldier.

In Cholera Camp, a soldier describes the epidemic:

We’ve got the cholerer in camp — it’s worse than forty fights;
We’re dyin’ in the wilderness the same as Isrulites.
It’s before us, an’ be’ind us, an’ we cannot get away,
An’ the doctor’s just reported we’ve ten more to-day!

The sense of helplessness is conveyed in two lines:

We’ve got the cholerer in camp — we’ve got it ‘ot an’ sweet.
It ain’t no Christmas dinner, but it’s ‘elped an’ we must eat.

The only response is to strike camp and move on, but it is no use:

Since August, when it started, it’s been stickin’ to our tail,
Though they’ve ‘ad us out by marches an’ they’ve ‘ad us back by rail;
But it runs as fast as troop trains, and we cannot get away;
An’ the sick-list to the Colonel makes ten more to-day.

Kipling wrote the poem thirteen years after Koch discovered (or rediscovered) the cholera germ; are we to take it that the British army authorities took no notice of medical knowledge, or that Kipling was behind the times? In fact there was a lot of hostility towards Koch in India, as the scientific agent of German expansionism; attempts to disprove Koch’s theory continued in India until 1897.

One cannot help but recall Kipling’s general epitaph to those who died in the First World War (in which his own son was killed):

If any question why we died,
Tell them, because our fathers lied.

Not only in 1914, of course.

All Quiet on the Western Front by Erich Maria Remarque

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

The narrator of All Quiet on the Western Front, the famous, semi-autobiographical novel of the First World War by Erich Maria Remarque (1898 – 1970), states that by 1918 war had come to seem so perpetual, so inescapable a fact of existence, that it was just another cause of death, “like cancer or tuberculosis or influenza or dysentery.” As to the latter, the German soldiers were so accustomed to it by the end of the war that they thought it was not worth pulling up their trousers; and the shirt tails of their Russian prisoners of war were stained with blood.

There are several hospital scenes in the book. Near the beginning a soldier in the narrator’s company, called Kemmerich, has been wounded. His companions visit him in the clearing station where he suffers phantom limb pain:

“How’s it going, then Franz,” asks Kropp.

Kemmerich’s head drops back. “OK, I suppose. It’s just that my damned foot hurts so much.”

We glance at his bed-cover. His leg is under a wire frame, which makes the coverlet bulge upwards. I kick Müller on the shin, because he would be quite capable of telling Kemmerich what the orderly told us before we came in; Kemmerich no longer has a foot. His leg has been amputated.

Nevertheless, his life has not been saved; he is clearly dying. He is so close to death, in fact, that his companions have already forgotten what he looked like when he was healthy. Müller is interested in his excellent boots for which, unlike Müller, he no longer has a use. Müller is not callous or unprincipled; he would never dream of taking the boots if Kemmerich still had a use for them; but Müller is anxious that the ward orderlies will appropriate them first if he does not preempt them. The war strips away all superfluous refinement of feeling, turns everyone into a raw utilitarian and makes survival the highest good.

Towards the end of the book the narrator is wounded and is sent to a hospital run by Catholic nuns. He is so exasperated by the sound of their prayers that he throws a bottle at the wall and it smashes. One of the other patients owns up to this breach of discipline because he bears a certificate of head injury saying that his behaviour might become erratic and is therefore to be excused.

When patients in the hospital are certain to die they are taken to the Death Room which, however, is not large enough to contain them all. New wounded arrive constantly:

Our room gets two blinded soldiers. One of them is very young, a musician. The nurses never use knives when they feed him; he’s already grabbed one once out of the nurse’s hand. In spite of these precautions, something still happens. The sister who is feeding him one evening is called away, and leaves the plate and fork on the side table while she is gone. He gropes across for the fork, gets hold of it and rams it with all his force into his chest, then grabs a shoe and hammers on the shaft as hard as he can.

Doctors are not heroes to the narrator; “there may be good ones,” he says sceptically, but many of them simply do the military’s bidding and, as in George Grosz’s famous picture, declare the crippled and the skeletal to be A1, that is, “Fit for active service.”

How many of us have the strength to resist the pressure of authority?

The Red Flower by Vselevod Mikhailovic Garshin

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Only two authors, as far as I know, killed themselves by throwing themselves down a stairwell, and it is now disputed that one of them, Primo Levi, did so suicidally: rather, he fell. But there is no disputing that Vselevod Mikhailovic Garshin (1855 – 1888) did so with suicidal intent.

Garshin, known as the best Russian writer of short stories of the period before Chekhov reached his maturity, wanted to be a doctor but was not admitted to medical school. He joined the army as a private during the Russo-Turkish war of 1877 and his first story, Four Days, was a fictionalised account of the wound he received in that war. He lies, semi-delirious, for four days on the battlefield, next to the decomposing body of the Turkish soldier whom he has killed with his bayonet, and whose bottle of water saves his life. Two details remind us that this is fiction, not autobiography. The “horrible grinning skull [of the dead Turk] with its everlasting smile” reminds the narrator that, as a medical student, he has often handled such skulls; and eventually the narrator’s leg is amputated. Garshin was never an amputee or a medical student, though he might easily have been both.

Almost certainly, though, he suffered severely from manic-depression. His most famous story, The Red Flower, again semi-autobiographical, is an account of a lunatic’s admission, progress and death in an asylum. I doubt there is a better account of mania in literature. The protagonist is so manically hyperactive that he constantly loses weight despite eating gargantuan meals; he has moments of insight that something is wrong with him, but they soon depart.

When he meets the doctor, the patient says to him:

I have this idea! When I discovered it I felt reborn. My senses have become more and more acute, my brain works as it never did formerly. What was once attained by a long process of reasoning I now know intuitively. I am an illustration of the great idea that space and time – are fictions. I live in all centuries. I live outside space, everywhere and nowhere…

The patient becomes seized with the idea that the evil in the world is concentrated in three red poppies that grow in the asylum garden – “they flourished on all innocent bloodshed, which is why they were so red” – and that it was his duty and destiny to rid the world of evil by plucking and uprooting them, thus eliminating their terrible emanations. But picking the flowers in the garden is not permitted, and the patient has cunningly to evade the attendants in order to carry out his grandiose and paranoid plan to rid the world of evil.

He dies of manic exhaustion (as used sometimes to happen), but with beatific contentment on his face because he has managed to uproot the last of the poppies, and therefore believes the world to have been purified.

Garshin had an immense reputation in his day though his output was small (only 20 stories). Now regarded as a minor writer, he nevertheless provided an illuminating insight into depressive thinking in his story A Night:

He imagined he saw all his life before him. He recalled a series of ugly and sombre pictures in which he was the principal figure. He recalled all that was worst in his life, turned it all over in his mind, but failed to find one clean or bright spot in it, and was convinced that none remained. “Not only none remained, but had never existed,” he added in self-correction.

On Dr Lazarus Ludovic Zamenhof

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Dr Lazarus Ludovic Zamenhof (1859 – 1917) studied at the medical faculty of Moscow University at the same time as Anton Chekhov, but completed his studies in Warsaw because of the political situation in Russia after the assassination of Tsar Alexander II. He then went to Vienna to study ophthalmology, which he subsequently practised.

But his real passion was language. He was born in Bialystok, and the entry about him in the Jewish Encyclopaedia of 1906 says:

Four different languages are spoken there, and to this fact he attributed the constant dissensions and misunderstandings which disturbed the city.

A brilliant linguist himself, he set about devising a universal language that would, in effect, reverse the consequences of the destruction of the Tower of Babel (he wrote a tragedy in five acts, titled The Tower of Babel, when he was 10 years old). In 1885, he published his first pamphlet on the universal language that was to become known as Esperanto under the pseudonym Doktoro Esperanto, which hardly needs translation.

The Esperanto idea caught on – to a degree. I have before me my only Esperanto book, the Esperanto Pocket Dictionary, seventeenth edition, 1939, formerly owned by Ernest Whittler of 548 Whitworth Road, Rochdale (the north of England was apparently always keener on Esperanto than the south). According to the preface, this little book had sold 48,000 copies between the first edition in 1915 and seventeenth in 1939 – far more than any book of mine.

I know it is very wrong of me to do so, but I cannot help smiling when I learn that antraks is the Esperanto for anthrax, ezofag for oesophagus and strut for ostrich. Altogether I have derived much plezur and amuzado from this little book, which cost me £1 in a charity shop.

Many books have been translated into Esperanto and the British Esperanto Association in Stoke-on-Trent has about 15,000 of them. You can buy Esperanto books online from the Association, including Winnie-la-Pu, which again needs no translation.

There is a terrible tragedy in the history of Esperanto. Dr Zamenhof hoped by his supposedly universal language to unite humanity. He devised a doctrine that he called homaranismo, according to which peoples would become friendly by the use of the same language. At the First International Esperanto Congress held at Boulogne-sur-mer in 1905, he concluded his speech by “a Prayer under a Green Flag,” which went:

A green flag held high
Means goodness and beauty.
The secret power of the light will bless us,
And we will achieve our aim.
We will break down the walls among the nations,
And the walls will creak and groan,
And will fall down forever and love and truth will reign on earth.

I think the goodness and sincerity, if not necessarily the realism, of Dr Zamenhof are obvious. Alas, he died of heart failure in 1917 in Warsaw, which was then under German occupation in the midst of the First World War. He was said to have been very anxious about the future of humanity, and with very good reason. All three of his children were killed in the Holocaust when Warsaw was once again occupied.

Esperantists celebrate December 15, Dr Zamenhof’s birthday, as Zamenhof Day.

An Introduction to the Real Psychiatry by Dr M S Rao

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Boastfulness is not a pleasant characteristic, but it is an increasingly necessary one for getting on in the world. Not only must one not hide one’s light under a bushel, but one must pretend, and make others believe, that one’s penny candle is actually a laser of such penetration that it will illuminate the far side of the universe. Gone are the days when a world expert on a subject would claim to know a little about it; nowadays even an eighteen year-old applicant for medical school is expected to produce a list of achievements filling several pages.

The other day, though, I came across a case of boastfulness disarming in its innocence. It was in a book called An Introduction to the Real Psychiatry: The Science that Studies and Corrects the Malfunctioning of the Fine Human Brain, by Dr M S Rao, published in Jaipur in 1971. Among the author’s previous books were From Utter Weakness and Impotence to the Supreme Sexual Power, 5th revised edition, 1969, 224 pages.

Dr Rao has nothing but contempt for other psychiatric texts:

It is remarkable how, in spite [of the lack of agreed facts or principles in psychiatry], the books on psychiatry are regarded as science books, simply because they have a rich get-up, are voluminous, made of superior paper with high-class printing, more especially because they are highly priced like other medical books, and because they are taught in medical colleges and their authors have many high medical degrees after their names.

Religion is no better. Sometimes he sounds like the Richard Dawkins of his day. Not only did Darwin for him pluck out the heart of the human mystery, but belief in God is a “silly childish belief” that leads to sexual frustration and thus to mental malfunctioning.

Luckily, Dr Rao has come to put us all right. Having quoted Pope’s famous epitaph to Sir Isaac Newton:

Nature and Nature’s laws lay hid in night;
God said Let Newton be, and all was light!

Dr Rao continues:

Mother Nature got busy in creating a new brain which was destined to illuminate schizophrenia, etc., etc.; and I was then ushered into the world, rather silently… Mother Nature urged me to show up, and I was declared the topmost student of my class in my state, getting by far the highest marks and winning the highest merit scholarship…

Mother Nature was not yet finished with Dr Rao:

Mother Nature later on seemed to say in my ears, “The brain (cerebrum) constructed by me is a purely mechanical brain. It is as prone to work in a wrong way as in the right way… and the wrong ways are innumerable, and the humanity has been using this brain mainly in the wrong ways… ever since I gave this brain to humanity, some 10,000 generations ago, – simply because I forgot to enclose the operating instructions with this mechanism I constructed (as is now usually done by the thoughtful engineers who construct various sorts of machines – they tell people in a leaflet how to operate their particular machine).

Fortunately, Dr Rao has discovered the operating instructions of the human brain, and:

…thus I could make Newton’s genius flourish far far more fruitfully if that unfortunate and psychologically ignorant boy could somehow come in contact with me…

For some reason, this boastfulness is endearing (perhaps because it is so eccentric) rather than off-putting, unlike our own which is merely crude and grasping.

Suicide in Antiquity and in Modern Times by Gaston Garrisson

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Suicide remains an elusive problem, both clinically and philosophically. Indeed, Camus said that suicide was the only philosophical problem of any real importance; but that is an exaggeration, if an excellent opening line to the philosophical treatise in which he makes the claim.

French writing on suicide is extensive; Émile Durkheim’s study on suicide is still a standard work. Twelve years earlier, in 1885, a lawyer called Gaston Garrisson published a book entitled Suicide in Antiquity and in Modern Times, full of the most fascinating and recondite information on the subject: for example, that under the Justinian code, it was permissible for a debtor to commit suicide if he could not pay his debts. This was because if he did not pay his debts he could be enslaved to his creditor; to avoid the shame of this was deemed a good reason for him to kill himself. It is perhaps as well that the Justinian code no longer applies.

Garrisson also mentions the Suicides’ Club that existed in Paris and Berlin at the beginning of the nineteenth century, and which probably inspired Robert Louis Stevenson’s novella, The Suicide Club. The rule of the Paris and Berlin clubs was that every member should be willing to kill himself if chosen by lot to do so. Membership of the clubs, unsurprisingly perhaps, was never very extensive, twelve in Paris and six in Berlin. The last member to kill himself did so in 1819.

Garrison was an early supporter of assisted suicide, though mainly for legal reasons; for if suicide was not a crime (as it was not in post-revolutionary France), how could assisting it be a crime? Before the Revolution suicide was a crime, the corpse was punished, and a man’s property was forfeit; there was a long historical struggle between the king and the nobles over which of them got the suicide’s belongings.

Britain is referred to throughout the book as the classic land of spleen and suicide. The fact that the statistics showed that the French were more prone to suicide was explained by the hypocrisy of the British coronial system, which rarely found that a man had killed himself, thus preventing the forfeiture of his goods to the crown, a regulation that was then still nominally in force though in effect a dead letter. Garrisson quotes Henry Maudsley, the founder of the hospital.

My copy of Garrison’s book serves as a memento mori. One is inclined to suppose that, when one possesses an old book, it has found its final resting place, its true owner. But in fact, one is only ever its temporary guardian.

The first identifiable owner of the volume was a Dr Revertégat, who owned a psychiatric clinic in the town of Sannois, where he several times treated the painter, Maurice Utrillo, for his alcoholism. The second was Dr Gregory Zilboorg (1890 – 1959), the Russian born psychoanalyst and historian of medicine among whose patients were the writer Lillian Hellman and the composer George Gershwin. When Zilboorg emigrated from Russia to the United States in 1919, he lived by means of translation while pursuing a medical degree at Columbia University, among the books he translated being Yevgeny Zamyatin’s early dystopia, We, which is said to have inspired George Orwell’s Nineteen Eighty-Four.

Who will own the book after me?

The Surgeon by Alan Thomas

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Even bad or mediocre novels are not without interest, especially when they have aged a little and so tell us something about times gone by. They are like symptoms.

But symptoms of what, exactly? Do such novels tell us about the past as it actually was, as the author wanted or believed it to be, or as he thought it ought to have been? Do such novels tell us the truth of the age or the illusions of the age, or some combination of the two?

Recently I picked up a novel titled The Surgeon. It was the medical title that drew me to it; it was by Alan Thomas and published in 1964. Although 48 years is not exactly an historical epoch ago, and is well within the memory of people now living, the world depicted would be almost as remote to a young person as that of, say, the court of Frederick the Great.

The author, Alan Ernest Wentworth Thomas, was born in 1896 and died in 1969. He had a varied career, as classical scholar, army captain (wounded four times in the First World War), barrister, crime novelist, employee of the League of Nations, editor for nineteen years, between 1939 and 1957, of The Listener, and finally as a reasonably successful novelist. His first book was published in 1928 and his last, posthumously, in 1970.

The surgeon of the title is Larry Balneath, young, accomplished, handsome, successful and flawed. One day he is called to the hospital because a minor Conservative politician, Sir Humphry Halland, Bart., has had a car crash and fractured his lumbar vertebrae, on which Balneath operates with his customary brilliance. In those days, if the novel is to be believed, titles still inspired awe; when Halland’s young wife asks to be called Gloria instead of my lady it is a sign of her broadminded and democratising informality.

Balneath and Lady Halland fall in love while Halland is flat on his back in hospital. They do so very chastely, I must say, despite Lady Halland being twenty years younger than her husband. He is referred to throughout the book as if he were an old man, though in fact he is only 53, and the marriage was never a successful one.

Unfortunately, when Halland recovers he has a further accident, falling off a podium and injuring his back so badly that he suffers paraplegia (despite Balneath’s second brilliant operation on him). Lady Halland asks Balneath to kill Halland, partly for his own sake because he will be so miserable as a paraplegic, but partly so that Balneath and she can marry. Balneath refuses, and she thereafter discovers an affection and duty towards her husband. It is Lady Chatterley in reverse. Balneath, in the meantime, marries his utterly devoted Harley Street receptionist and secretary.

The world that Thomas portrays is one in which hospital consultants are gods, nurses are ministering angels, divorce is an utter scandal, porters and butlers are deferential, Daimlers are chauffer driven, sex occurs only at the end of an elaborate pas de deux, if even then, and the rich smoke as a matter of course. Did this world ever really exist? Fled is that music: do I wake or dream?

Two Plays by Augy Hayter

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Augy Hayter (1940 -2004) was an actor, translator, poet and playwright who lived on the fringes of the avant-garde. His father, Stanley William Hayter, was a famous artist who lived in Paris and knew such painters as Picasso and Miró. In 2002 Augy Hayter published five one act plays; by then he had given up “voiced-based activities” after an operation on his throat, presumably for cancer, for he died two years later.

In two of the plays, not connected in any other way, a children suffers from a cerebral haemorrhage, which not surprisingly has a profound effect on the father of each, though each child survives without sequelae. Since such haemorrhages are not very common, one might surmise an autobiographical element. One of the fathers describes the experience:

I never had a religious education, I didn’t even know the Lord’s Prayer. And then I said, Oh God, and the words came, Oh God, if you need a brain, take mine.

Electro-convulsive therapy plays a large part in two of the other plays, and again I surmised a personal connection. In the first play, Fit to Be Tied, a patient who has escaped from an asylum returns to his former office, where he was the boss, and advertises for an employee. A young man applies for the job, but in the middle of his interview a doctor (described as having “the arrogance of insecurity”) and a nurse arrive to haul him back to the asylum.

The male nurse returns to the office to reassure the applicant who asks “Is it true he is being given shock treatment?” The nurse replies that it is and it isn’t; he goes through the motions of having it, but the apparatus has been deliberately disabled so that no electricity goes through his brain. The doctor doesn’t know this, but is nevertheless satisfied with the result. The play seems to have been inspired by the commonly repeated story of the ECT clinic in which the machine had broken down but nobody noticed: to which one can only say they cannot have been very observant.

In the second play, called Sheherazade, a man gets into a train compartment with a young girl and tells her that he is going to rape her, cut her throat and throw her from the carriage before they reach Clapham Junction. However, they start talking, and he relates his experience of ECT, seeing other people have it while waiting for his own:

The eyeballs turn up, the teeth snap together, the eyelids are trembling, the eyes are white and while the body is convulsing they’re holding your arms and legs so you don’t knock over the equipment. You see, the hospital Bursar gets very shitty about that sort of expense. If they kill you on the operating table, no problem, but if they lose an electrode, the doctor won’t be let go of for months.

The dedication of the play is at the end. “The play is dedicated to… the memory of my mother, who received such treatment.”

Hayter translated Jean-Luc Lagarce’s play It’s Only the End of the World, written in 1990 five years before Lagarce died of AIDS, about a man long estranged from his family who returns with a fatal disease, and exposes the family’s secrets and mutual hostilities. In literature, one is never more than a degree or two of separation from medicine.

Not Guilty by Llewelyn Powys

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting them on Wednesdays to coincide with the schedule of his old BMJ column. We hope you enjoy them.

The life of Llewelyn Powys (1884 – 1939) was considerably shaped by tuberculosis. He had his first pulmonary haemorrhage in 1909 and went to a sanatorium in Davos and then to Kenya as a plantation manager in an unavailing attempt at a cure. Life in the sanatorium and in Kenya were the background of some of the stories in his first book, Ebony and Ivory, published in 1923.

Powys detested the Kenyan colonists, whom he saw as greedy philistine brutes. In one of the stories, a farm labourer is so badly treated by his employer, but has so little chance of escape, that he decides not to kill himself but simply to lie down and die – and he does, his corpse being burned as “Rubbish,” the title of the story. In another story, a young man just out to the colony starts out better and more refined than the other colonists but is gradually coarsened by them. He takes a local girl as a lover but contracts syphilis from her, so virulent that the doctor tells him that even salvarsan cannot help him. He takes a pistol and shoots himself in the head.

The story Not Guilty starts “No, I have never deceived a living man but, by Jove! I came near to doing so once.” As might be surmised, this turns out to be ironic.

The narrator is in a Swiss sanatorium for a cure of his relatively mild tuberculosis. There he meets a prosperous, slightly vulgar but very rich British boot manufacturer, whom he befriends, and whose beautiful young wife comes out to visit him. The manufacturer is very ill and close to death. The narrator and the wife are attracted to one another, and on one occasion find themselves alone, as they think, in the manufacturer’s bedroom, where they take the opportunity to make love. Suddenly, however, they realise they are not alone:

The doors leading on to the balcony were ajar and through the narrow open space I could see the end of my friend’s couch. Judge then of my horror on catching sight of one of the well-known brown boots! He had been there all the time and had doubtless been a witness of our illicit love! What were we to do?

The man’s wife decides to brazen it out; but on reaching the balcony realises that her husband is dead.

All the stories in the book are short and powerful, written with the greatest economy. Powys’ philosophy of life (his father was a clergyman, but he had no faith himself) is summarised in one of the stories and is clearly that of a man who had looked mortality in the face:

If, if our days in the garden of the earth are in reality so uncertain, if indeed as was made clear to me then, death cannot be gainsaid, then surely the secret of so sorry and insecure an existence must lie in detachment, for he who would lose his heart to a life so beset with tragedy had best have a care for his wits.

I suppose, when you come to think of it, that this is a little analogous to the doctor’s attitude to the human suffering with which he inevitably comes into contact. The introduction to this volume, which was written by Edward Shanks, says:

From these stories sensitive reader is not to expect anything but pain. But there is a pain in the realisation of truth which is a sort of ecstasy.