Time to finally abandon a false trail

SMJ 2003 48(4): 125-126

Roy Humble (FFARCS, FRCP(C))

12407-39 Ave, Edmonton, Alberta T6J0N1, Canada  rmackh@shaw,ca

based on a presentation to the Canadian Association for the History of Medicine

"All surgical roads lead to John Hunter"

Sir James Learmonth

My road to John Hunter began at the age of eleven or twelve when I limped into the san at Cambusdoon Preparatory School in Alloway. The enthusiastic manner in which the school doctor examined my swollen and tender thigh indicated this might not be a run of the mill case and he did not take long to reach the diagnosis of a thrombosis of the vein in Hunter’s Canal. Three weeks bed rest with antiphlogistine poulticing was the recommended treatment, and although it obviously held no significance for me at the time I still recall his use of the eponym. Even better remembered, however, is the scalding and revolting looking concoction which had to be applied at regular intervals. Few parts of the anatomy of our generation escaped such assaults, for the poultice was a favourite remedy of all mothers and grandmothers. 

Eight years later, by now in second year medicine at Glasgow and loathing the dissecting room, I found myself exploring that very same canal, and when some of our clinical teachers began to enthuse over aspects of medical history the names of John and William Hunter were occasionally mentioned. For most of us, however, and certainly for me, there were other things to think about, and although I was stimulated for a while by John Hilton’s classic “On Rest and Pain”, spending spare hours on the past seemed pretty much like a waste of time. Another chance connection to the brothers came after graduation, during our pre-registration year at Hairmyres Hospital in Lanarkshire, for Hairmyres isn’t far from Long Calderwood, the birthplace of the brothers. But this association failed to ignite a spark of interest and although I knew of the Hunterian Museum in Glasgow I never could remember which of them had bequeathed its famous coin collection to the University.

Ten years passed, and more, before I walked up the broad steps of the Royal College of Surgeons at Lincoln’s Inn Fields and began at last to discover the man who is regarded as the founder of scientific surgery. John Hunter’s statue dominates the entrance, a further bust keeping guard over the remarkable Museum and the collection referred to as his great unwritten book[1]. I wandered through the three main sections that very first day, totally fascinated. Why on earth had I not paid more attention to the name and the associated history? I could only make brief lunch-time visits to the museum during my basic sciences course for the primary Fellowship in anaesthesia, but by the end of the three months at least a seed had been sown. Resolving to read more about the great man, one easy choice seemed to be Roger’s novel, “Brother Surgeons”[2]. Its pages gave me something of a shock.

Jesse[3] was the first to agree that the gossip he had heard concerning Hunter had aided him in reaching his conclusions. The sudden rages, the equally unannounced spurts of gross laughter, the fantastical splurging while the bills snowed the front door - ah, yes, quite clear to Jesse now. Clear also was the cause, Jesse alone knew ….

John Hunter staggered in, the slap, slap of his feet causing stares .... his feet wide apart, his gaze wild, one eye wide with fear or pain, and the other a pin-point of suspicion .… the pupils of a divided man.

I could scarcely believe what I was reading, for here was the individual Sir William Osler described as ‘the most remarkable observer of Nature since Aristotle’ reduced to a caricature of a man, a man branded by the classical indications of tabes dorsalis and the beginnings of general paralysis of the insane. Not only that, but these conditions had apparently been caused by an earlier and deliberate self-inoculation with contaminated venereal matter. While the face in the wonderful portrait by Sir Joshua Reynolds didn’t seem to fit this representation, I had little time to give the matter much further thought, finishing Rogers’ novel instead and returning to the grind on anatomy and physiology.

Not giving the subject much further thought is something of an understatement, for another 14 years passed before I came across an article in the Journal of the Royal College of Surgeons in which the London surgeon George Qvist challenged the allegation that Hunter had ever suffered from syphilis and presented clear evidence that the supposed self-inoculation experiment could equally well have been conducted on another individual, possibly a destitute outcast from the London streets, a practice not considered unethical at that time. Qvist concluded by urging that the stigma of venereal disease should be expunged from Hunter’s image, expanding these themes further as part of his 1979 Hunterian Oration, “Some controversial aspects of John Hunter’s life and work.”[4]

By now I was well and truly hooked, following the trail by delving into as many of the biographies and Hunterian Orations that I could get my hands on, including the Oration which started all the trouble, “John Hunter as a man”[5], given by one of the most respected British medical historians of the 1920s, Sir d’Arcy Power. Since I had another interest in Power related to some of his writings on the surgery of medieval times, I corresponded with George Qvist. He told me that after giving his own Hunterian oration he had received comments from two very senior Fellows of the Royal College of Surgeons who had both known Sir d’Arcy, to the effect that while he might have been a great chap his research into history was not always accurate in relation to detail[6].

In the closing sentence of “John Hunter as a man” Power stated that ‘it is one of the lessons of history that each age steps on the shoulders of the ages that have gone before’. Such a maxim has implications, however, which Sir d’Arcy appears to have overlooked, and in letting his imagination run riot along a false trail he set history back immeasurably, parlaying an obscure and non-contemporary footnote[7] into a slanderous myth regarding Hunter’s health. The interested reader can explore the whole issue through Qvist’s writings[8] [9] [10], and the work of Dempster[11], but Power’s Oration is so error laden that only a few brief examples are required to expose the quality of his arguments. Compare his conclusion with a modern re-assessment of Hunter’s symptoms:

(D’Arcy Power)….it seems to me that John Hunter died of syphilitic disease of his arterial system and that in addition to the angina pectoris due to this cause, he suffered for many years from cerebral syphilis. Both conditions were due to the action of the spirochaetes with which he deliberately innoculated himself in May 1767. He may be looked upon therefore as one of the great martyrs to science.

(Livesley)….His symptoms were classical of long standing angina pectoris, including  attacks of severe upper epigastric pain brought on by exertion and emotion, dyspnoea on exertion, attacks of dizziness sometimes associated with disorientation and memory loss, and accompanied by what was described as an absent pulse. It has been suggested that in addition to the angina he most likely had what is termed ‘sick sinus syndrome’. He clearly suffered from transient ischaemic attacks (minor strokes of brief duration), while his brother William experienced similar symptoms of cardiovascular degeneration, dying from a major stroke.[12]

Compare it also to a modern re-assessment the autopsy findings:

(Turk)….The (autopsy) findings show no evidence of any pathological change that might have been caused by syphilis .… there is no doubt that Hunter died as a result of coronary artery disease of atheromatous origin …. I can find no evidence for a syphilitic aetiology in the contemporary descriptions of his illnesses when alive, or of his death.[13]

Power stated quite bluntly that Hunter inoculated himself with venereal matter. What did the best witness of the day say? Jesse Foot, a vehement opponent of Hunter’s views on venereal disease, wrote a commentary on Hunter’s treatise on that subject immediately it appeared, and later published ‘A Life of Hunter’[14] which vilified his character and reputation. He was totally familiar with all of his adversary’s writings, and with his lectures, yet in 12 pages describing the crucial experiment he makes absolutely no suggestion that Hunter was its subject. Indeed he discusses the possibility or probability of his arch-rival being wrong had ‘the subject of the case’ (Foot’s actual words) ‘previously suffered from venereal disease.’ Now if Hunter openly told his students that he experimented on himself, as we have been led to believe by apocryphal stories to this effect, Foot must have known, and the malicious tone of his book leaves little doubt that he would not have missed the opportunity for further denigration. When combined with the lack of any other contemporary account, the silence of this best witness speaks volumes.

In refuting the entire story we can introduce perhaps the best evidence of all in Sir d’Arcy’s own words. Describing one period of extended ill health, he states that:

…. finding no improvement Hunter travelled to Bath in September, and in December was again in London where he performed his first operation for cure of an aneurysm by ligaturing the artery in its continuity.

Not bad work, that cure of an aneurysm, for a man he claimed was suffering from ‘syphilitic inflammation of the smaller cerebral arteries, perhaps in the nature of a syphilitic periarteritis, and …. from syphilis of the heart and aorta’, reinforcing such conclusions in remarkable fashion by the comment …. ‘I am not a neurologist, but so far as a surgeon can guess the lesions may have been situated in the immediate neighbourhood of the basal ganglia’[15]. Not bad work, either, since this operation was preceded by one of the most beautiful experiments in the whole history of surgery.

From the times of Charles I herds of deer had occupied Richmond Park, at that time outside of the city of London. After catching and wrestling a young stag to the ground with the help of several attendants, Hunter incised its neck and ligatured the external carotid artey. Laying his hands on the half-grown July antlers, he found that the pulsations in the velvet-like covering had stopped, and that the surface soon became cold. The buck was then released.

Two weeks later he again drove to the park and caused the buck to be caught and thrown. The wound had healed, but to his surprise the warmth had returned and the channels of supply to the velvety formative covering of the antlers were pulsating. The buck was killed and sent to Leicester Square. After injecting the arterial system, Hunter confirmed that the external carotid had been duly tied off. But small branches from the proximal (heart) side of the ligature had enlarged, and on tracing these he found that they had anastamosed with other branches from the distal continuation of the carotid artery. These new channels had restored the supply to the growing antler.

This recognition of the significance of the collateral circulation under what he termed ‘the stimulus of necessity’ helped lead him to a simpler and safer operation for politeal aneurysm, a relatively common condition at that time. Rather than the usual dangerous direct exposure of the diseased vessel, he ligatured the superficial femoral artery in the upper part of the adductor canal. His first patient returned to work as a hackney carriage driver and survived for 15 months, whilst his fourth patient lived for 50 years after a complete cure.[16] This man’s leg can still be seen on a visit to the Hunterian Museum in Lincoln’s Inn Fields, testimony to a brilliant piece of innovative thought, experimentation and surgery.

Consider finally one last sentence by Power:

We can only be thankful that the stress of the disease fell upon the deeper parts of the brain, and that his intellectual powers were so little impaired that he could give sound judgements in consultation, invent new methods of operating and retain those powers of collecting which enabled him to form his magnificent museum.’

That incredible summation requires little further comment, and those who failed to challenge the 1925 Hunterian Oration - the leaders of the medical establishment of the day in particular - must share in the blame of its acceptance. Not one single eyebrow was raised through the correspondence columns of the British Medical Journal or Lancet, an editorial in the former postulating mildly that if Sir d’Arcy’s view became established, the writings of Hunter might come to be regarded as the products of a sick brain. Read the above sentence once more. How on earth were these words not called into question? Instead, sixty three more years were allowed to pass before another editorial marked the 250^th anniversary of John Hunter’s birth by carrying this sentence:

The belief that Hunter innoculated himself is almost certainly mistaken[17].

While researchers on both sides of the Atlantic have contributed to the renewed modern judgement of Hunter, with Dempster bluntly stating that the whole story is beyond belief[18], most of the credit belongs to George Qvist. Sadly he became seriously ill during the penultimate stage of his biography, the final proofs being delivered to his house just three hours before he died in July 1981. Even more sadly, however, the calumny persists, for a well known and respected writer recently used a variation of the self-innoculation tale as an integral part of the plot in a new novel about John Hunter and the Irish giant whose skeleton he coveted[19]. Society’s appetite for salacious material, it seems, must continue to be fed.

False trails are part of history, and no less so of medical history. It is surely time that we abandoned the trail laid by d’Arcy Power, remembering the great pioneer from Long Calderwood instead for the wealth of his achievements, and pondering on the remarkable insight behind his words from the eighteenth century:

By adhesive inflammation different parts of the body may be united to one another by coming into contact .… but the most extraordinary union is that of removing parts from one body and uniting them with another[20].

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