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Literature And Medicine

John Keats and tuberculosis

RADETSKY, MICHAEL MD, CM

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The Pediatric Infectious Disease Journal: May 2001 - Volume 20 - Issue 5 - p 535-540
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Abstract

John Keats was trained as a physician. His fatal infectious disease was the cancer of former times: occult at its inception; subtle in its early manifestations; slowly destructive and wasting to the victim and incurable. When he died, he had hardly exited his adolescent years. As a poet he was capable of describing experiences and expressing emotions in a piercing way. As a physician he was acutely aware of his illness and prognosis.

John Keats was born in London on October 31, 1795. His father, Thomas Keats, was the head ostler (one who cares for horses) at the Swan and Hoop livery stables located in Moorgate. It was there that Thomas Keats met and married Frances Jennings, the daughter of the stable owners. Frances, then a girl of 19, was a lively catch, who was described as “not averse to displaying her legs while crossing a muddy street.” John, her first born, had two brothers, George and Tom, and a sister, Frances Mary, or Fanny.

Little is known about Keats’ early life. Keats’ father died during a fall from a horse when Keats was eight years old. Frances soon remarried, but left this second husband to run off with another man. Five years later in 1809, Frances, now ill, returned. Keats nursed her personally, reading to her for hours at a time, cooking her meals and allowing none else to care for her. She died soon thereafter. People said it was consumption.

“Phthisis,” the Greek word for “consumption,” was the general term applied to this malady. Contemporary understanding of the disease sprang from the work of the 17th century physician, Richard Morton. Relying on the humoral theory of disease pathogenesis, Morton concluded that phthisis was a disease in which stagnant blood distended the lungs, became dry, hardened into a tubercle and then turned malignant because of its own intrinsic “sharpness and heat” triggered by an external stimulus. The diagnosis was made by the clinical constellation of (1) wasting of the whole body, (2) hectic fever and (3) exulceration of the lungs. Hemoptysis was a noteworthy feature. The treatment was not to use strong purges, which could throw the blood into excessive motion and make it hotter still, but rather gentle laxatives to carry off the humors by stool, phlebotomy to cool the blood, opiates to quiet the lung and fasting to calm the body. Morton was an observant clinician with good intuition, but he had limited anatomical data and labored under an outmoded Hippocratic conceptual framework of disease. Yet there was no denying that phthisis was worthy of thought and investigation; it was the dominant illness of the age, accounting for approximately one-quarter of all deaths in most urban centers. For this reason phthisis was hailed by John Bunyan as “The Captain of all the men of Death.”

The care of the three children was taken over by Keats’ grandmother, who sent John and his brother George off to a school in Enfield, a village on the northwest extremity of the city. Keats was hardly a model pupil; he was aggressive, even to the point of striking his teachers, and he initially did poorly in his course work. Although he was small for his age, he was described as having “extraordinary vivacity and personal beauty.” Keats remained at Enfield from ages 8 to 14. Midway through his stay there, a certain transformation overtook him; he developed a new motivation, took some school prizes and is said to have read through the whole school library.

At the age of 14, Keats was apprenticed to Mr. Thomas Hammond, the Apothecary-Surgeon who had attended his mother’ fatal illness and who resided two miles from the school. At this time apothecaries were permitted to see patients as well as to compound drugs. Historically apothecaries developed a monopoly in the science of herbs and all botanical products and had been members of the medieval Guild of Grocers. They were granted articles of incorporation by Henry VIII, who chose an apothecary rather than a physician to attend the ailing Princess Mary. More importantly the practitioners of the London College of Physicians were few in number and closed in rank, were usually from wealthy families and catered to the wishes and pocketbooks of the aristocracy. The average citizen had to seek care elsewhere. Apothecaries took on the role of general practitioners during the reign of James I. The final validation of their new status occurred during the Great Plague of 1664, when physicians were the first to flee London, thereby leaving the field to the apothecaries. The last of the three medical practitioners, the surgeons, whose medieval function had been blood letting, were joined with the barbers in the Guild of Barbers and Surgeons until in 1745 they separated to form the Corporation of Surgeons; in 1800 the Royal College of Surgeons of England was formed and was granted a charter. The training of both surgeons and apothecaries, unlike that of physicians, was totally practical and consisted of a lengthy apprenticeship.

Keats’ apprenticeship lasted 5 years. His duties included cleaning the shop, ordering equipment, cleaning the surgical instruments, caring for the crowded colony of leeches and watching his master diagnose ailments, compound formulations, dress wounds, lance boils, draw teeth and, of course, let blood. He also promised to fulfill a number of negative injunctions, including not to marry, not to gamble and not to visit taverns or playhouses during his apprenticeship. Keats undoubtedly would also have been a daily witness to the human suffering, disability, fear and sometimes death that accompany diseases and accidents. It is not surprising, therefore, that he looked forward to the relief of the weekly walk back to Enfield school to read poetry with his friend Cowden Clarke, the schoolmaster’s son.

By 1815 he had completed his apprenticeship requirements and needed one year of hospital training to qualify for licensure. This he obtained at Guy’s Hospital, located across the Thames from the City of London. The hospital was one of the oldest in London and had united with St. Thomas Hospital in 1768 to form the United Hospitals, the first truly comprehensive medical school in England. Although Guy’s was already venerable, it had yet to rise to the heights it would later achieve under such luminaries as Richard Bright, Thomas Addison and Thomas Hodgkin. Nonetheless in 1815 Guy’s could boast of a faculty of wide fame. The man most responsible for making Guy’s a famous institution was the great surgeon Sir Astley Cooper, of whom some one said that next to the king he was the best known man in England. Cooper was a picturesque personage of handsome physique, graceful, dashing and always dressed in the latest fashions. One of his students describes Cooper’s appearance and method of teaching: “A few moments before two Astley Cooper came briskly through the crowd, his handsome face beaming with delight and animation. He was dressed in black, with short knee-breeches and silk stockings, which well displayed his handsome legs, of which he was not a little proud. Almost to a minute he was in the theatre, where loud and continued greetings most truly declared the affectionate regard his pupils had for him. His clear silvery voice and cheery conversational manner soon exhausted the conventional hour devoted to the lecture; and all who heard him hung with silent attention on his words, the only sounds which broke the quiet being the subdued pen-scratching of the note-takers as he only talked of which he really knew from his own experience, what he taught was to be implicitly trusted.” Cooper had great skill and originality as a surgeon, and it is to him that we owe the memorable summation of a surgeon’s attributes: “An eagle’s eye, a lady’s hand, and a lion’s heart.”

The teacher to whom Keats was attached, however, was an uninspiring man of mediocre ability. William Lucas, Jr., is described by contemporaries in the following way: “A tall, ungainly, awkward man, with stooping shoulders and a shuffling walk, as deaf as a post, not over-burdened with brains of any kind, but very good-natured and easy and liked by everyone. His surgical acquirements were very small, his operations generally very badly performed and accompanied with much bungling, if not worse. He was a poor anatomist and not a very good diagnoser.” His surgeries were inevitably bloody and usually fatal. It was to Lucas that Keats acted as a “dresser,” a hybrid composed of equal parts intern and personal secretary.

Besides his ward and emergency room duties, Keats attended lectures on medical and surgical theory, and he participated in the central activity of anatomical dissection. Human dissection has had a checkered history. Although the Egyptians performed ritual embalming, which necessarily involved evisceration of the dead, they did not express an interest in the accurate description of structures or locations. The Greeks steadfastly refused to invade the sanctity of the lifeless human body. Aristotle dissected animals of every kind, but not humans. Galen conducted extensive anatomical studies of oxen, swine, sheep, apes and even elephants. Only in Alexandria, under the rule of Ptolemy, did human dissection take place, led by the father of human anatomy, Herophilus (330 BC). During the Middle Ages, human dissection was anathema. During the Renaissance in Italy, secret dissections were performed by artists to acquire enough knowledge for realistic representations. Finally it was Andreas Vesalius, Professor of Anatomy at Padua, who created the first comprehensive atlas of human anatomy, De Humani Corporis Fabrica. (1543). By Keats’ time anatomical dissection had become the cornerstone of medical education.

To supply the growing demand that developed for corpses in hospitals and medical schools and because the use of bodies for teaching anatomy was still forbidden by law, the bodies for dissection were bought, for three or four guineas apiece, from body-snatchers, or “resurrection men,” who robbed local graves. As this was the only means of securing specimens, the ghoulish practice was supported by the hospital staff, especially Astley Cooper, who paid the body-snatchers’ fines when they were caught and supported their families when they were sent to prison. The rough and ready men who engaged in this business boasted that they could get the body of any person, given the right price. Naturally rumors got abroad with regard to what might happen to relatives and friends recently interred. Thomas Hood’s poem “Mary’s Ghost” epitomized the popular alarm. T’was in the middle of the night, To sleep young William tried, When Mary’s Ghost came stealing in, And stood at his bedside. “O William dear! O William dear! My rest eternal ceases: Alas my everlasting peace Is broken into pieces. The body-snatchers, they have come, And made a snatch at me. It’s very hard them kind of men Won’t let a body be! The arm that used to take your arm Is took to Dr. Vyse; And both my legs are going to walk The Hospital at Guy’s I vowed you would have my hand, But fate gives me denial; You’ll find it there, at Dr. Bell’s In spirits and a vial. “The cock it crows; I must be gone. My William, we must part; Though I’ll be yours in death, Sir Astley has my heart!”

Students treated the dissecting room as a common room, with much drinking, cooking and horseplay. A contemporary account of the dissecting room, given by the uncle of the great William Osler, sets the scene: “On entering the room, the stink was most abominable. About 20 chaps were at work, carving limbs and bodies, in all stages of putrefaction and of all colors, black, green, yellow, blue, while the pupils carved them apparently with as much pleasure as they would carve their dinners. One student amused himself with striking with his scalpel at the maggots as they issued from their retreats.”

Keats was not the most attentive of students. Keats’ friend and roommate remembered him this way: “He attended lectures and went through the usual routine, but he had no desire to excel in that pursuit. In a room, he was always at the window, peering into space, so that the window-seat was spoken on by his comrades as ‘Keats’ place.’ In the lecture room he seemed to sit apart and to be absorbed in something else, as if the subject suggested thoughts to him which were not practically connected with it.” During this time, Keats began to have reservations about surgery as a career. The horrors of surgery without anesthesia must have been profound. A contemporary of Keats writes: “I began to attend the operations in the hospital theater; this was for some time a very hard trial for me. I was always very anxious to see all I could and soon got over the blood-shedding which necessarily ensued; and so long as the patient did not make much noise, I got on very well; but if the cries were great, or if the patient was a child, I was quickly upset and had to leave the theater, and not infrequently fainted.”

Yet his disenchantment with medicine was not just the result of the physical repugnance of hospital conditions at the time. Rather it appears that he himself realized that he was unfit to be a surgeon. As his friend Armitage Brown remarked, “Keats assured me the muse had no influence over him in his determination, he being compelled by conscientious motives alone, to quit the profession. He ascribed his inability to an overwrought apprehension of every possible chance of doing evil in the wrong direction of the instrument. ‘My last operation,’ he told me, ‘was the opening of a man’s temporal artery. I did it with the utmost nicety; but reflecting on what passed through my mind at the time, my dexterity seemed a miracle, and I never took up the lancet again.’ ”

This fear of doing harm with the scalpel apparently robbed him of his self-possession, and he became unwilling to face a lifetime of worry and personal recriminations. In July of 1816, at the age of 20, he took and passed the difficult licensing examinations before the Society of Apothecaries at Apothecary Hall, Blackfriar. He then left medicine forever and joined the Romantic Age.

The Romantics felt that the conscious mind had been overvalued, and they recoiled from what was merely rational, general, abstract, public. The darker side of man and nature attracted these minds. There sprang up a desire for a dream world, with drama, mystery, ecstasy and symbolic trappings. Tableaux of times past became the idiom, and there was renewed interest in the Middle Ages, Ancient Greece and the Arabian Nights. In this new world the poet became an exile, a rebel, a prophet; nothing had value for him except that which was found in the depths of the mind and soul. The Romantic sought solitude and reverie through mystic communion with nature.

By early 1817 Keats was living south of the Thames, in Cheapside. He lodged with fellow students in rooms that formed part of the warren of streets and alleys near the hospital. It was an extremely rank portion of the metropolis, full of beggars, homeless waifs, poor working people, open sewers and rats running free. It was at this time that his friend, Joseph Severn, made his first charcoal drawing of Keats, showing the characteristic intensity and the noticeable projection of the upper lip. “Nothing seemed to escape him,” wrote Severn, “the song of a bird and the undernote of response from covert or hedge, the rustle of some animal, the changing of the green and brown lights and furtive shadows, the motions of the wind, and the wayfaring of the clouds; even the features and gestures of passing tramps, the color of one woman’s hair, the smile on one child’s face seemed to make his nature tremble.” In this year also, Keats published his first, slim volume of early poetry, a venture that turned into a publishing failure.

By early 1818 Keats’ brother Tom had fallen ill, with the ominous coughing up of blood. Forgetting everything else Keats became his brother’s sole nurse, such as he had nursed his mother, but to no avail: Tom died in late 1818. Keats was understandably depressed. Yet the death of his brother was to begin a year of inspired creativity.

After Tom’s death a friend of Keats, Charles Armitage Brown, a 30-year-old bachelor and trader in bristles with Russia, invited him to move into Wentworth Place, near Hampstead. At this point Fanny Brawne came into his life. Mrs. Brawne and her daughter Fanny had moved into a house in the neighborhood. Keats and Fanny probably first met in November of 1818. Keats was drawn to this lively and flirtatious 18-year-old girl. In April Fanny moved next door to him at Wentworth Place, which must certainly have been a distraction for the poet-recluse. But the moment was propitious, and from his pen glorious poetry poured forth. From September 20, 1818, to September 20, 1819, Keats was to write almost all of the poems for which he is best known, including “Ode to a Nightingale,” considered by Swinburne to be “one of the masterpieces of human work of all time:” My heart aches, and a drowsy numbness pains My sense, as though of hemlock I had drunk, Or emptied some dull opiate to the drains One minute past, and Lethe-ward had sunk: ’Tis not through envy of thy happy lot, But being too happy in thine happiness, That Thou, light-winged Dryad of the trees In some melodious plot Of beechen green, and shadows numberless, Singest of summer in full-throated ease.

Such a period of calm and fruitful peace as that in which the Odes were conceived was never to come to Keats again. Fanny was coy and evasive, and desperate finances began to taint his life. He was forced to complete poems rapidly to appease his publisher and redeem the monetary advances made to him. His throat began to bother him more and more, and as an exceptionally bleak winter came on, he began to worry about his health. He became easily fatigued, and the winter’s cold chilled him deeply. His friend, Armitage Brown, gives this account of the events of February 3, 1820: “He arrived at 11:00 in the night, in a state that looked like a fierce intoxication. As such a state in him I knew was impossible, it therefore was the more fearful. I asked hurriedly, ‘What is the matter? You are fevered.’ ‘Yes, yes,’ he answered. ‘Fevered, of course, a little.’ I followed with the best immediate remedy in my power. I entered his chamber as he leapt into bed. On entering the cold sheets, before his head was on the pillow, he slightly coughed, and I heard him say, ‘That is blood from my mouth.’ I went toward him; he was examining a single drop on the sheet. ‘Bring me the candle, Brown; let me see this blood,’ and after regarding it steadfastly, he looked up in my face, with a calmness of countenance that I can never forget, and said, ’I know the color of that blood; it is arterial blood. I cannot be deceived in that color; that drop of blood is my death warrant; I must die.’ ”

Keats was treated by local surgeons, using the prescribed therapy of the time. Morton’s theoretical construct still held sway. Over the course of the century, this was to change. In Paris in 1816, Rene Theophile Hyacinthe Laennec (1781–1826) utilized a roll of paper to hear the heart sounds of a young woman, instead of applying his ear directly to her chest. This first stethoscope was followed by a wooden model and then other, improved versions. It was the stethoscope that allowed the multitude of dramatic and subtle auscultatory findings to be used in the diagnosis of lung diseases. It was then Laennec’s genius that he pursued the truth of his clinical impression by correlating what he heard with what he saw at autopsy. The Age of the Clinical-Pathological Correlation was beginning, which would eventually demonstrate that the tubercle was the dispositive pathologic lesion which defined the disease. The stethoscope remained the technologic advance of the century until the fortuitous discovery of x-rays in 1895 by Professor Karl Wilhelm Röntgen (1845–1923). The x-ray picture he had made of his wife’s hand was reproduced in publications all over the world. While the general public became very enthusiastic about this new wonder (and avidly bought and framed x-ray images of their own loved one’s hands), physicians immediately applied x-rays to the diagnosis of disease, in particular pulmonary tuberculosis.

The idea that tuberculosis was a contagious disease was advocated by William Budd (1811–1880) and Jean Antoine Villemin (1827–1892). However, it was Robert Koch (1843–1910) who established the infectious nature of the disease. On April 10, 1882, Robert Koch announced the identification of the causative agent, Mycobacterium tuberculosis, and revealed the validating animal experiments that satisfied his exacting “postulates” that this tubercle bacillus was the specific cause of the disease. Finally, in 1944 the soil microbiologist Selman Waxman isolated from the soil Streptomyces, which would yield the first effective antimycobacterial agent and for which he would receive the Nobel Prize.

Consumed with chest pain and growing weakness, it seems likely that Keats produced no more poetry, except, perhaps, for these last verses penned onto a manuscript of his poems: This living hand, now warm and capable Of earnest grasping, would if it were cold And in the icy silence of the tomb, So haunt thy days and chill thy dreaming nights That thou wouldst wish thine own heart dry of blood So in my veins red life might stream again And thou be conscience-calmed. See, here it is, I hold it towards you.

He wrote letters, however; in particular to his beloved Fanny. On February 24, 1820: “Indeed I will not deceive you with respect to my health. This is the fact as far as I know. I have been confined three weeks and am not yet well―this proves that there is something wrong about me which my constitution will either conquer or give way to.” And later: “You know our situation. What hope is there? My very health will not suffer me to make any great exertion. I am recommended not even to read poetry much less to write it; I wish I had even a little hope.” On August 14: “My chest is in so nervous a state that anything extra such as speaking to an unaccustomed person or writing a note half suffocates me. I have more to say but must desist for every line I write increases the tightness of the chest.” Later that month: “I am sickened at the brute world which you are smiling with. I see nothing but thorns for the future. I see no prospect of any rest. I wish you could infuse a little confidence in human nature into my heart. I cannot muster any―the world is too brutal for me―I am glad there is such a thing as the grave―I am sure I shall never have any rest until I get there.”

His doctors recommended that he winter in Italy. Accompanied by his friend, Joseph Severn, he set sail from England on September 17, 1820. They landed at Naples on October 31, after the unbelievably long time at sea of 43 days, and thence on to Rome, where they settled at once in lodgings on the Piazza di Spagna. His Doctor, James Clark, proceeded to bleed him and put him on a restricted diet amounting to starvation. His condition slowly worsened. Severn writes of the experience: “Little did I think what a task of affliction and danger I had undertaken, for I thought only of the beautiful mind of Keats, [and] my attachment to him. He remains quiet and submissive under his heavy fate. For three weeks I have never left him. I have nothing to break this dreadful solitude but letters. Day after day, night after night, here I am by our poor dying friend. My spirits, my intellect and my health are breaking down. I can get no one to change with me―no one to relieve me. All run away, and even if they did not Keats would not do without me.”

His illness now entered its terminal phase and Severn sat by him continuously. In the early morning of January 28, to keep himself awake, he drew a sketch of Keats, on which he wrote: “Drawn to keep me awake―a deadly sweat was on him all this night.” In one of his lucid moments Keats asked Severn: “Did you ever see anyone die? Well, then I pity you, poor Severn. Now you must be firm for it will not last long.” Keats had finally given up all wish for recovery. As the time approached, he became more quiet and calm and seemed to go to sleep. Then: “Severn, lift me up. I am dying. I shall die easy. Don’t be frightened, be firm and thank God it has come.”

He died on Friday, February 23, 1821 at the age of 25. Fade far away, dissolve, and quite forget What thou among the leaves hast never known. The weariness, the fever, and the fret Here, where men sit and hear each other groan; Where palsy shakes a few, sad, last gray hairs, Where youth grows pale, and spectre-thin, and dies; Where but to think is to be full of sorrow And leaden-eyed despairs, Where Beauty cannot keep her lustrous eyes, Or new love pine at them beyond tomorrow. Darkling I listen; and, for many a time I have been half in love with easeful Death, Call’d him soft names in many mused rhyme, To take into the air my quiet breath; Now more than ever seems it rich to die, To cease upon the midnight with no pain, While thou art pouring forth thy soul abroad In such an ecstasy!

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              Keywords:

              Tuberculosis; John Keats.

              © 2001 Lippincott Williams & Wilkins, Inc.