Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of about 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor.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.

Not so very long ago facial transplants would have been the stuff of science fiction, but now they are the stuff of reality. At the moment they are performed on people whose faces have been horribly injured, but in L P Hartley’s dystopian novel, Facial Justice, published in 1960, they were performed for political rather than for medical or aesthetic reasons.

Hartley (1895 – 1972) is now mainly remembered for one novel, The Go-Between, a fine evocation of traumatic sexual awakening in the upper reaches of the Edwardian society to which Hartley remained forever attached. In all, he wrote sixteen novels whose quality, says the Dictionary of National Biography, declined as their frequency of publication increased. Hartley, who was invalided out of the army by Sir Frederick Treves in 1916 without ever having seen action, died of the complications of alcoholism: by no means the first or the last author to let himself be mown down by the bottle.

Facial Justice takes place after the Third World War, when the surface of the earth has been more or less completely laid waste. Some of humanity survives, but underground; in England half the population, dissatisfied with its subterranean lot, makes the daring move to go above ground.

There the New Society is created, ruled by an otherwise nameless Dictator. It must be admitted that Hartley’s imagination was not strong enough to make his dystopia come alive, as do, say, Brave New World and Nineteen Eighty-four, for neither the details nor the history of the New Society are consistent or plausible. I suppose that is why the books remains relatively unknown and unread.

Another reason, perhaps, is that it is a satire on the notion of equality that is now so dear to us. In the New Society there is a Ministry of Facial Justice which works towards the equalisation of women’s faces by means of surgery. Divided on grounds of natural beauty into three categories, alpha, beta and gamma, plastic surgeons operate to give alphas and gammas entirely new beta faces according to a pre-ordained pattern, so that there should be no envy because of the possession of unfair natural advantages or disadvantages: for in the New Society envy is seen as the root of human evil, especially violence. Mediocrity in all things is the goal of the society, and a series of slogans – beta is best and alpha is anti-social – are inculcated into the population to drive the message home.

After an accident, the main character in the book, an alpha woman called Jael, undergoes involuntary betafication (the local equivalent of beatification) carried out by the plastic surgeon Dr Wainewright. She revolts against this and indulges in a conspiracy to bring about the downfall of the Dictator, whose identity no one knows. The result is chaos and violence, in which Dr Wainewright is killed: the message or warning of the book, in so far as any story so unconvincing and ill-constructed may be said to have a message or carry a warning, is that once democratic mediocrity is thoroughly installed in a society, there is no going back and the alternatives are worse.

Harley obviously intended the book to be a satire on what he saw as the mediocrity of the England of his time: and whether this has any meaning today for you depends crucially, I suppose, on whether you think that NICE should really be renamed NICM, the National Institute of Clinical Mediocrity.

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.

In 1960, John Havard, later secretary of the BMA, published his book The Detection of Secret Homicide, and in 1962 Anthony Burgess published his fictional depiction of gratuitous adolescent violence, The Clockwork Orange. Pamela Hansford Johnson (1912 – 1981) combined the two themes in her novel An Error of Judgement, also published in 1962.

The main character of her novel, though not the narrator, is Dr William Setter, a Harley Street specialist whom the narrator consults over simultaneous pain in his right shoulder and the back of his left knee. Setter tells him he could have a cardiograph if he wanted, but that this would be a waste of everybody’s time. Having paid his four guineas, the patient-narrator is reassured and feels better. Payment is a wonderful placebo.

Setter and the narrator become friends, or at least social acquaintances. This was in the days when middle-class women still wore hats when leaving the house and people had to behave badly, or pretend to behave badly, to get a divorce.

Setter is an odd man who starts a club in Soho where he acts in a Mephistophelean manner to bring strangely assorted people together in a discussion group. For some reason not explained, he decides to give up medicine in the middle of his successful career, which was certain to have ended in a knighthood, and do nothing much; but he continues to prescribe for selected people.

The book casts an interesting light on the prescribing habits of the time. When the narrator’s mother-in-law, who lives with the narrator and his wife, dies unexpectedly, Dr Setter prescribes Dexedrine for the narrator’s wife to help her get over her grief quicker than the Diagnostic and Statistical Manual of the American Psychiatric Association can say depression.

More importantly (for the plot), Dr Setter prescribes phenobarbitone three times a day for a young man called Sammy Underwood who has joined his discussion group and who, by the rather tame standards of the time, is something of a rebel. No reason is given for this prescription, but presumably it is to quieten him down, for Sammy is not epileptic. He comes from Clapham, from a respectable working class home, and his bad language would now strike us as almost ladylike in its gentility. Intelligent but badly educated, he has some slight intellectual pretensions; but Dr Setter suspects him of being responsible for the kicking to death of an old inebriate woman in Clapham, as yet unsolved by the police. Sammy is indeed guilty and confesses to Dr Setter, who comes to the conclusion that Sammy is so lacking in remorse, contrition and conscience that he is likely to do it again. And so, for the public good and also because he has always enjoyed inflicting harm (it is one of his reasons for having gone into medicine in the first place), Dr Setter decides to kill him, but subtly.

Sammy complains of insomnia and Dr Setter suggests that he ask his own doctor for some sodium amytal to help. He then suggests a small bottle of brandy to be taken with the pills just to make sure he gets a good night’s sleep, though with the stern warning that Sammy should take no more, absolutely no more, than four fifths of the bottle. Next morning, of course, Sammy is dead.

Setter is never brought to book and disappears. His secret homicide goes undetected. Was – is – this social realism?

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Could it be, I wonder, that Mr Micawber derived his great dictum about happiness and misery from having read Edwin Chadwick’s Report to Her Majesty’s Principal Secretary of State for the Home Department from the Poor Law Commissioners, on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain of 1842, only five years before the publication of David Copperfield?

Dickens, after all, read such literature, and on pages 139 and 140 would have seen a tabulated comparison of those who lived providently and improvidently:

William Haynes, of Oakamoore (wire drawer), wages £1 per week; he has a wife and five children; he is in debt, and his family is shamefully neglected.

John Hammonds, of Woodhead (collier), wages 18s. per week; has six children to support; he is a steady man and saving money.

This great book is, to me at any rate, inexhaustibly fascinating. Chadwick was a barrister, not a doctor, and though most of his information came from doctors (unpaid for their work, incidentally) he had no exaggerated respect for their wisdom or understanding. Pages 148, for example, are headed Irrelevancy of Controversy on the Generation of Fever, as against Practical Means of Prevention. Contagion or infection, it was all the same to him; he was the Deng Xiao Ping of public health, to whom it mattered not whether the cat was black or white, so long as it caught mice. A note of impatience and exasperation creeps in:

The medical controversy as to the causes of fever; as to whether it is caused by filth and vitiated atmosphere, or whether the state of the atmosphere is a predisposing cause to the reception of the fever, or the means of propagating that disease, which has really some superior, independent, or specific cause, does not appear to be one that for practical purposes needs to be considered, except that its effect is prejudicial in diverting attention from the practical means of prevention.

And he quotes from an episode from a French report about the small town of Prades (through which, as it happens, I have often passed) in the Ariège, which suffered a disastrous epidemic:

The physicians of Ariège, in order to prove that the disease was not contagious, and to re-assure the inhabitants, lay in the beds from which the invalids had been removed.

Arguing for sanitary reform, Chadwick points out the advances made in the navy. In 1779 one in eight employed on ships died in a year; from 1830 to 1836, it was one in 72. This improvement he attributed to sanitary measures, even though he quotes the case of the expedition of HMS Centurion in which, a hundred years earlier, 200 of 400 men were lost to scurvy. It is interesting to note that although in the latter years lemon juice was by Chadwick’s time in general use, it was still uncertain in 1842 as to whether it, or better conditions in general, was responsible for the prevention of scurvy.

The book contains sanitary maps of Leeds and Bethnal Green of great beauty: were it not vandalism to do so, I would tear them out and frame them. And Chadwick provides illustrations of workmen’s housing, infinitely better, aesthetically-speaking, than almost anything built for the last hundred years. If there is one thing that has not improved, it is architecture.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

In his Lettres Persanes, first published in 1721 and reprinted many times during his lifetime, Charles-Louis de Secondat, better known as Montesquieu (1689 – 1755), used the device of letters from fictional Persian visitors to Paris to examine French (and European) manners, assumptions and prejudices. Among the subjects which he treated with irony, perhaps not surprisingly, was the medicine of his time.

For example, he relates the story of a doctor who had a patient who suffered from insomnia for thirty-five days. He prescribed him opium, but the patient, reluctant to take it, asked whether he might try an idea of his own first, on the promise that if it did not work he would then take the opium.

His idea was to try some of the books in a local bookseller as a soporific. “Monsieur,” he asks him, “would you not have in your shop some book of (religious) devotion that you have not been able to sell, for often the rarest remedies are the most effective?” The bookseller replies “Monsieur, I happen to have the Holy Court of Father Caussin. I will send it to you.”

It duly arrived. “The dust was shaken from it and the son of the ill man, a young schoolboy, began to read it. He was the first to feel the effect; at the second page, he began to mispronounce, and everyone felt tired; a moment afterwards, everyone was snoring except the ill man who, after long resisting, finally succumbed.”

The doctor visits the next day and assumes that the patient, who has slept well, has taken the opium he prescribed. He is quickly disabused, and begins his researches into the medical effects of boring books. A footnote gives his prescriptions:

Purgative infusion: Take three pages of Aristotle’s logic in Greek; two pages of the most acute treatise of scholastic theology, as for example that of Duns Scotus; four pages of Paracelsus; one of Avicenna; six of Averroes; three of Porphyry; as many again of Plotinus. Infuse them for
twenty-four hours, and take four times a day.

In order not to make his medicines as cheap as possible, and in order not to cause his patients financial embarrassment, the doctor decides not to use rare ingredients, such as dedicatory epistles that cause no one to yawn, prefaces that are too short, Jansenist works not highly-regarded by other Jansenists and not despised by Jesuits. As for a good vomit, six funeral orations, a collection of new operas, fifty new novels and thirty new memoirs, distilled in an alembic, should be sufficient.

As for asthma:

Read all the works of the Reverend Father Maimbourg, taking care not to stop before the end of every sentence; and you will feel the ability to breathe return little by little, without the necessity to repeat the cure.

As to the medical books of the time, Montesquieu was hardly more complimentary:

The textbooks of medicine: these monuments to the fragility of nature and the power of the art; which make us tremble when they treat of even the slightest illnesses, so close to death do they make us seem; but that reassure us completely when it comes to the value of remedies, so that it is as if we had become immortal.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

It is hard to understand it now, but in 1938 five-year plans had a certain cachet, thanks to the prestige of the Soviet Union. Even the International Institute of African Languages and Cultures had one, according to the preface to a volume of anthropological papers published that year. Of course it was a success, as all five-year plans must be:

The Five Year Plan of the International Institute of African Languages and Cultures has given an immense impetus to the study of culture change in modern times…

My copy of this admittedly obscure work once belonged to Edward Joseph Lister Lowbury (1913 – 2007). Lowbury, whose father was a doctor, was named after the great surgeon, and his own work as a bacteriologist was in the control of hospital infection, an example of life imitating a name rather than art. Early in his career, though, he was a pathologist in East Africa, hence his possession of this book.

Lowbury was an extremely cultivated man, an accomplished pianist and a poet who won the Newdigate Prize for poetry at Oxford, as did Matthew Arnold and Oscar Wilde. On the inside cover of his copy of Methods of Study of Culture Contact in Africa are two sonnets in his own hand, written at Moshi in Tanganyika in October 1945, and not included in his published works. One is called From the Train to Moshi and the other Road to Kibo. (As it happens, I have been to Moshi.)

There is nothing specifically medical in the two poems. The second half of the first expresses revulsion against the colonial life in Africa, comparing the whites unfavourably with the Masai:

For laughter these are best
Value, as also for lolling at their ease,
The Masai! And again, who is so impressed,
So smiling even when shouted at as these
Whom nothing will persuade man is unblest
And sex is wicked – especially witnesses
Of the white man at his worst, drunken, depressed,
Stealing their women, catching their disease?

This is dated 30 October, 1945; the second poem (written in a surprisingly clear hand) the following day. Here Lowbury extols the children whom he sees:

The children line the road, click heels, salute,
And have the last word in every greeting.
Their eyes are deep, expressive, never mute;
They meet yours roundly, never flinch at meeting…
Their charm is so great that even their vices are forgiveable:
What matter if they lie and laze and steal?
When chances offer? – That’s reflected too.
You’ll soon forgive them when you see how real,
Under the lying and the ballyhoo,
Are the fine nerves, the touch fit like a glove
By the light fingers of the God of Love.

Either Lowbury – who wrote the poems with only a few crossings out, for he was famed for his fluency – forgot these sonnets, or did not think them good enough to be published. No doubt they resort to stereotypes, but which of us never does so, indeed goes a day without doing so?

Under the lying and the ballyhoo,
Are the fine nerves…

The feeling of the young pathologist is real enough, unmistakable I should say, and my experience of the Tanganyikans was like his. They were the best-mannered people I have ever met.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

One shouldn’t judge a book by its cover, of course, nor by its title; but when 200,000 books are published each year, this is the counsel of perfection, and you have to judge by something. Some titles are more intriguing than others; recently, for example, I came across one that seemed to sum up the human predicament pretty succinctly: Until Further Notice, I Am Alive.

This was a quotation from an e-mail that Tom Lubbock, the author of the book and former art critic of a major newspaper, sent to a friend on learning, in 2008, that he had a neuroblastoma multiforme and that his expectation of life, with treatment, was only two years. Prognosis is an imperfect art, but in this case proved accurate. Diagnosed in October 2008, he died in January 2011.

Dr Johnson said that when a man knew that he was to be hanged in a fortnight it concentrated his mind wonderfully. But what about when he knew that he would die in two years, with the possibility of the dissolution of his mind before that of his body? The site and growth of the author’s tumour gave him increasing difficulties with language; the last entries in the diary of his illness, three months before he died, are short and fragmentary.

Lubbock quotes the French writer, Charles Péguy: “A word is not the same with one writer as with another. One tears it from his guts. The other pulls it out of his overcoat pocket.” Although the mystery of where our words and thoughts come from is perennial, we seldom think about it; but for Lubbock the problem became an almost physical one, as he struggled to pull words from, and form thoughts, somewhere in his mind.

He is complimentary on the whole about the medical profession, but he meets an arrogant neurosurgical registrar who, mistaking him for someone else, asks him whether he still experiences strange smells (he never experienced strange smells). There is nothing like being mistaken for another patient to make you feel small and insignificant; and the registrar also tells him he is lucky to have any speech left at all.

Lucky? What does the word “luck” mean here? Naturally the author asks himself why he should have a rare fatal disease, and the only answer he can find is that, if the disease exists, someone must have it. But was he lucky that it was initially operable, that it gave him no pain, that it preserved his intellect nearly until the end? Perhaps what the registrar meant was “Most people with a tumour such as yours in the same position in their brain would not be able to speak, therefore you are lucky.” This is a very restricted and inhuman notion of luck. How easy it is for a doctor to wound with a few thoughtless words! Let us all read, mark and inwardly digest.

Lubbock had a son eighteen months before he was diagnosed, the child of his heart; the author’s knowledge that this much-loved boy would remember nothing of him in his later life is poignantly expressed, and is all the more poignant because it is obvious to the reader that he would have been a very good father.

On the whole, I do not like memoirs of illness as a genre; I had a surfeit of them when a magazine once sent me seven of them for review. But at the end of this slender book, I felt a real sense of loss, almost of grief, as if I had known the author personally.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

There was a time when I should have despised the sermons of seventeenth and eighteenth century divines, but perhaps it is a sign of advancing age that I no longer do. The sermons are often exceedingly well written and full of sense, even if one does not necessarily share the underlying religious standpoint. If one read only that with which one was in complete agreement, one would read very little.

Joseph Butler (1692 – 1752), Lord Bishop of Durham, was considerable as a philosopher (his most famous dictum being “Everything is what it is, and not another thing,” which is actually more metaphysically profound than might at first appear), and he also wrote memorable sermons. He was a deeply charitable man, and believed in hospitals for the poor: he was the most generous contributor to the founding of an infirmary in Newcastle.

The preface to his Fifteen Sermons opens with words that could hardly be less congenial to the spirit of our age:

…it is scarce possible to avoid judging, in some way or other, of almost everything which offers itself to one’s thoughts…

Personally, I am with Butler there, and against the spirit of the age.

The other sermons are subtle explorations of human psychology, still well worth the reading; while the sixth of his Six Sermons Preached upon Public Occasions, before the Duke of Richmond and the Governors of the London Infirmary for the Relief of Sick and Diseased Persons, Especially Manufacturers and Seamen in Merchant-Service, of 1748, is of surprising contemporary relevance.

For example, he treats of the question of whether those whose illnesses are self-inflicted should be treated on the same basis as those whose illnesses are not. Butler believes that they should be; not surprisingly as a bishop, he uses the argument that “we have divine example for relieving those distresses which are brought upon persons by their own faults.”

But he goes further:

Though the natural miseries which are foreseen to be annexed to a vicious course of life are providentially intended to prevent it… yet those miseries, those natural penalties admit of and receive natural reliefs, no less than any other miseries, which could not have been seen or prevented. Charitable providence then… leads us to relieve, not only such distresses as were unavoidable, but also such as people by their own faults have brought upon themselves.

The example he gives is of the diseases brought on by drunkenness, and not so long ago I was asked by a newspaper to write an article denouncing (which I declined to do) the second liver transplant given to a late drunken footballer.

Butler even deals with the economic problems of health care. The infirmary’s rules stated that “none who are judged to be in an asthmatic, consumptive, or dying condition be admitted on any account whatsoever.” Harsh as these words sound, says Butler, they proceed out of the mouth of Charity itself, for:

Charity pronounces it to be better, that poor creatures, who might receive much ease and relief, should be denied it, if their case does not admit of recovery, rather than that others, whose case does admit of it, be left to perish.

The need to ration is nothing new.

My edition of Butler’s works, incidentally, was edited by W E Gladstone in retirement: hard to imagine a recent Prime Minister on such a task in retirement.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Patrick McGrath (born 1950), the distinguished novelist, is the son of Dr Patrick McGrath (1916 – 1994), Physician Superintendent of Broadmoor Hospital between 1957 and 1981. Alas the latter, though he led a dramatic and varied life, committed very little to paper: not more, he said, than a few occasional medical papers and some letters to The Times. His life story would have been the stuff of legend.

In the first third of his novel Asylum, McGrath gives a lyrical picture of what it was like to grow up in the precincts of an institution for the criminally insane as the son of the superintendent, an upbringing half-prelapsarian and half-sinister. There may be better contemporary prose than this account, but if so I do not know it.

Though not a doctor himself, McGrath junior was clearly marked by the medical environment in which he grew up and absorbed the medical atmosphere for later use in his work. The protagonist of his novel Dr Haggard’s Death is a young registrar in surgery at a London teaching hospital just before the outbreak of the war (when McGrath’s father qualified) who fails to make the grade. His irascible boss, Vincent Cushing, does not think much of him; on one occasion he, Haggard, makes a hash of an appendectomy.

Dr Haggard has a passionate affair with the beautiful wife of the chief pathologist, the arrogant and unsimpático Dr Ratcliff Vaughan, who never manages – or even tries – to rid himself of the smell of cadavers and formalin. When Vaughan discovers the affair, he strikes Haggard across the face at the head of the hospital stairs, down which Vaughan falls and breaks his hip. He cannot reveal what Vaughan has done because to do so would harm his lover. In those days, neither adultery nor divorce were as lightly-regarded as they are now.

Dr Haggard remains in traction for three months: a Smith-Petersen nail is inserted into his femur by his boss, Cushing, who then dismisses him from his service. At the same time Mrs Vaughan brings the affair, the one great love-affair of Haggard’s life, to an end. He has lost everything, and knows that he will never recover from it. Nothing remains to him but general practice in a dispiriting seaside town on the South Coast, where senior civil servants and retired professionals go to die.

Haggard gives a name to the metal rod in his femur: Spike. Spike gives him trouble when the weather is damp and cold, or when disagreeable emotions and memories come to the fore in Haggard’s mind. He then injects himself with morphine; investigated by the Home Office for the practice’s high usage of narcotics, he succeeds in persuading the inspector that it is because of the nature of his patients, who are mostly decrepit or close to death.

On one occasion Haggard tries to defeat the habit by abstention, and there follows the usual exaggerated literary depiction of withdrawal effects from morphine; yet it is only too plausible that Haggard should himself be a victim of the mythology of withdrawal. Altogether, the novel is a sensitive depiction of loss and failure, so much more interesting than that of unbroken success: and more frequently encountered, too.

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Xavier de Maistre (1763 – 1852) was the younger brother of the brilliant reactionary philosopher, Joseph de Maistre (1753 – 1821). Both wrote in French, but were actually Piedmontese: Joseph was Sardinian ambassador to St Petersburg while Xavier served the Tsar and died there.

Xavier is now mainly remembered for his amusing Voyage autour de ma chambre (Voyage Round My Bedroom) in which he describes with wit and irony a circumnavigation of his room in forty-two days, stopping off at various points to reflect philosophically on the condition of mankind. For example, he calls his looking-glass the greatest masterpiece of human art because it reflects, and can reflect, nothing but the truth; the only problem is that the prism of amour-propre is the most powerful distorting prism known, far more distorting than that used by Sir Isaac Newton. In other words, we are ready to receive anything except the truth about ourselves.

Xavier wrote little; one of his works was The Leper of the City of Aosta. The protagonist of the story – the leper – is made to live in an abandoned castle in a depopulated area south of the city, where he is provided for by the municipality but is cut off from all human contact for fear of contagion. His sister lived with him for a time, also a leper, but she dies of the disease, leaving him entirely alone – apart, that is, from a dog.

The dog is not a handsome one, but he is affectionate and the leper loves him. From time to time, however, the dog roams and is thought by the nearest inhabitants to be a potential spreader of his master’s disease, so that one day they come to the castle and demand that he deliver the dog up to them so that they can kill him. Initially they want to drown him but finally decide on lapidation. The leper hears the pathetic cries of the dog as he is done to death, and despises himself for not having protected him better as it was his impossible duty to do.

De Maistre here demonstrates his sympathetic understanding of the intense and loving relationship that the lonely and disabled develop with their dogs; his story is strongly reminiscent of Turgenev’s short masterpiece, Mumu, in which a deaf and dumb serf called Gerasim is forced to drown the little dog upon which he pours all the love of his heart for lack of any other object upon which to pour it because his mistress, a capricious and thoroughly spoilt woman, says that the dog’s barking (not very much) has given her a headache. Carlyle wrote that Mumu was the most powerful denunciation of arbitrary power that he had ever read; and if there is a more powerful one, I certainly do not know it.

After the dog dies, the leper thinks of suicide, but even the thought seems to him a terrible crime.

In de Maistre’s story, a sympathetic soldier visits the leper and extends his hand to him, which the leper refuses to take. He does not even agree to epistolary contact between them, for fear of infecting the soldier. Instead he says to him as he takes his leave that he needs no other friend than God, in whom they will eventually be united. ‘Stranger,’ he says, ‘when sorrow or discouragement attack you, think of the hermit of Aosta. You will not then have visited in vain.’

Ah, if only the thought of those who are worse off than ourselves could truly console us as it should!

Note: When Dalrymple’s long-running BMJ column ended in 2012, he had a backlog of around 50 or 60 unpublished pieces, and he kindly gave them to us to post here at Skeptical Doctor. We are posting one each Wednesday to coincide with the schedule of his old BMJ column. We hope you enjoy them.

Publishers, in my experience, speak as if they had some special insight into the book market; but they are always surprised when a book sells either well or badly. The market is incalculable: who would have guessed that books with titles such as Does Anything Eat Wasps? Or Why Don’t Penguins’ Feet Freeze? would sell so well?

Yet there has long been a taste for arcane and miscellaneous knowledge. John Timbs (1801 – 1875), who once worked as a druggist, spent most of his life catering to the Victorian public’s thirst for facts, or supposed facts, compiling compendia about everything from ghosts to frescoes to electric telegraph cables. One of his most successful works was Things not Generally Known, my copy (1857) being a new edition that claimed to be one of the sixteen thousandth printed.

Among the things not generally known were some of medical interest, for example that epidemic cholera did not add to the overall mortality:

It appears that the total number of deaths in the cholera-year (1849), for all England and Wales, was 440,839; but in 1850 the number of deaths fell to 368,995, being not only 71,844 less than in the cholera-year, but even less than the number of deaths in the year preceding that of cholera, by as many as 30,838.

Averaging the number of deaths in the two pre-cholera years and that of the cholera year and the year following, we find “that no greater number of people died in those years because of the cholera intervening than if the cholera had not visited us.”

Is the moral of this that there was no need to panic, and that those victims of cholera should take consolation from the fact that they would have died anyway without it? Doctors, at any rate, could draw no such happy conclusion: Timbs mentions the fact that during “cholera visitations” between 12 and 20 per cent of “the medical men employed” died. True officers lead from the front.

Published only two years before On the Origin of Species by Means of Natural Selection, Timbs informed his readers that:

The new and brilliant science of geology attests that man was the last of created beings in this planet… she affords conclusive evidence that, as we are told in Scripture, he cannot have occupied the earth longer than six thousand years.

But as for individual humans, their time is short:

The average of Human Life is about 33 years. One quarter die previous to the age of seven years; one half before reaching 17. To every hundred persons, only six reach the age of sixty-five.

For the enlightenment of those lucky six, Timbs turns his attention to the important question of human hair turning grey, and tells the following story of a doctor:

A medical man in London, less than twenty years ago, under the fear of bankruptcy, had his dark hair so changed in the same period that his friends failed to recognise him; but the colour in this instance returned, as his worldly prospects revived.

There is hope for me yet, then; unlike Lady Harbury’s hair, that turned quite gold from grief, mine might (if my investments do well) turn quite brown from prosperity. The colour of my hair depends, then, on the outcome of the crisis.