Who killed Ramesses III?

12 Pages·2012·1.18 MB·English

YESTERDAY’S WORLD
Invention of toilet
paper: something
else the Romans
didn’t do for us, p 41
Who killed Ramesses III?
Zahi Hawass and colleagues shed new light on the harem conspiracy
Introduction sination was successful. The Judicial Papyrus
The end of Ramesses III’s life has long been recounts four separate trials and lists the pun-
debated among Egyptologists. A series of his- ishments meted out to those involved in the con-
torical documents, of which the most impor- spiracy. Chief conspirators included a secondary
tant is the Judicial Papyrus of Turin,1  2 clearly queen Tiy, and her son Prince Pentawere.1
state that in the year 1155 BC, members of his The ancient documents refer to Ramesses
harem made an attempt on his life as part of a III as “the Great God,” and imply that he had
palace coup. According to the documents, the died before or during the trials. However, the
coup failed, but it is unclear whether the assas- texts also imply that the court received direct
instructions from the king, who must therefore Fig 4 | Neck region of unknown man E.
have survived the original attack.1 The only line Arrows=skin folds and wrinkles under right
specifically interpreted by Egyptologists as a mandible and neck region
possible metaphor for an assassination is the
“overturning of the royal bark.”2 Such circum- tissue areas in the anterior side of the neck
locution regarding the cause of a king’s death ( fig 2). The trachea was clearly cut and its proxi-
has long been considered to be part of the mal and distal ends were retracted and separated
pr otocol of ancient Egyptian literature. by about 30 mm. A small, focal cortical interrup-
Owing to the inconclusive nature of this tion at the anterior surface of vertebral body was
textual evidence, and the lack of any obvious visible, at the seventh cervical vertebra (fig 2).
cause of death found in previous forensic stud- Accordingly, all organs in this region (such as the
ies of the king’s mummy,3 scholars have argued trachea, oesophagus, and large blood vessels)
Fig 1 | Axial CT section image of the neck of Ramesses a variety of possibilities: the king was injured as were severed. The extent and depth of the wound
III. Stars=wound margins. Arrow=homogeneous part of the plot and later died from his wounds, indicated that it could have caused the immediate
embalming material seeping into wound and bone the plot was foiled entirely, or the attempt was death of Ramesses III.
successful.4 Moreover, the mummy of Prince A flat, irregular foreign object was lodged in
Pentawere has not been definitively identified. the right lower rim of the wound; it was roughly
However, scholars have considered the mummy 15 mm in diameter with a high CT density (2200
of unknown man E as a possible candidate, who HU), similar to a semiprecious stone (fig 2).
was found, like Ramesses III, in the royal cache Reconstruction of this foreign object showed a
at Deir el Bahari. Unknown man E’s contorted wedjet (or Horus eye) amulet (fig 3). The eye of
expression, unusual mummification process, Horus is a magical amulet that served as a meta-
and goat skin were noted during the unwrapping phor of royal power, protection, and good health
of the mummy in 1886.5 There has also been in ancient Egypt.10
much speculation about the cause of his death, We estimated unknown
with poison or burial alive mentioned as possi- man E to be about 18-20
bilities, but no conclusive evidence for either.3 years old, based on the
To gather more information about the harem incomplete fusion of
conspiracy and the fates of Ramesses III and the epiphyseal lines in
suspected conspirator involved in his assassina- the long bones, as
tion, we analysed the mummies of Ramesses seen in CT scans.
III and unknown man E using anthropological, Unknown man
forensic, radiological, and genetic methods. E underwent an
unusual process
Results of mummification
The CT investigation revealed a serious wound for the 20th dynasty
Fig 2 | Sagittal CT section image of the neck of
in the throat of Ramesses III’s mummy, directly of ancient Egypt
Ramesses III. Arrow=foreign object. Stars=wound
under the larynx (fig 1). The injury was roughly (1186-1070
margins; embalming material has seeped into
70 mm wide and extended to the bones (fifth BC),
wound and bone. Triangles=skin above and below
the wound to seventh cervical vertebrae), severing all soft
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YESTERDAY’S WORLD
Our analysis showed that Ramesses III and
Table 1 | Genetic kinship analysis
unknown man E shared the same paternal line-
Y chromosomal data
age and had identical alleles at autosomal mark-
DYS DYS DYS YGATA DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS DYS
Sample 448 438 437 H4 392 635 439 391 393 385a,b 19 458 389II 390 389I 456 ers, strongly suggesting that they were father
Ramesses III 20 10 14 13 17 — — 8 8 20 19 — 33 21 13 13 and son. However, based on the genetic testing,
Unknown 20 10 14 13 17 — — 8 8 20 19 — 33 21 13 13 any differentiation among the several sons of
man E Ramesses III was not possible. Historically, Pen-
Controls* tawere was the only son who revolted against his
Control 19 12 15 13 13 24 12 11 13 11,14 15 17 29 24 13 15
father in contrast to all his brothers. According
DNA 007
to the Judicial Papyrus of Turin, Pentawere was
Staff 1 19 12 15 12 13 23 12 11 12 11 14 15 29 24 13 16
involved in the harem conspiracy, was found
Staff 2 19 11 14 11 11 25 12 10 12 13 13 19 27 24 11 14
Staff 3 19 12 15 12 13 23 12 11 12 11 14 15 29 24 13 16 guilty at trial, and then took his own life.
DYS=DNA Y chromosome short tandem repeats (repeating DNA sequences of 4-5 base pairs). Data are number of repetitions of each The unusual mummification process of
short sequence; overall, they represent a Y chromosomal genetic fingerprint that can be used to test the paternal relation of Ramesses III unknown man E, including the ritually impure
and unknown man E and moreover predict the Y chromosomal haplogroup.
use of a goat skin to cover the body, could be
*Data from control DNA (provided with chemicals for DNA analysis; refers to an unknown European sample) and male staff members also
supplied for comparison. interpreted as evidence for a punishment in the
because there was no evidence of removal of the form of a non-royal burial procedure. Together
inner organs or brain.11 The skin has a reddish with the genetically proved family relationship
colour and the body was covered by a goat skin. with Ra messes III, we therefore believe that
Use of goat or sheep skins in dynastic burials was unknown man E is a good candidate for Pen-
rare because these materials were regarded ritu- tawere. Unknown man E’s cause of death has
ally impure.12  13 The red coloration of the mum- to remain a matter of speculation. His inflated
my’s skin could have been caused by a mixture of thorax and the skinfolds around his neck may
natron, crushed resin, and lime, which had been point to violent actions that led to death, such as
detected under a layer of bandages during the strangulation. However, the lack of further evi-
unwrapping in 1886.5 dence for strangulation (such as fractures in the
Unusual compressed skin folds and wrinkles Fig 5 | Axial CT image of the lower thoracic region of laryngeal skeleton)17 and the gas formation in the
were seen directly under the right mandible and unknown man E. Thorax is filled with air (stars) and body caused by decomposition processes do not
appears to be inflated. Residue in the diaphragm
at the right and left neck regions (fig 4). CT scans allow any clear conclusions regarding the cause
and organs (arrows) are present at the dorsal site
confirmed residue in the brain and inner organs, of death of unknown man E.
and the absence of embalming material inside rounding Ramesses III, and finally reveals its Zahi Hawass egyptologist, Supreme Council of
Antiquities, Zamalek, Cairo, Egypt
body cavities (fig 5). The scans also revealed tragic outcome. Our CT analysis provides evi-
Somaia Ismail professor of molecular biology,
taphonomical changes in the mummy, as shown dence that conspirators killed Ramesses III by cut-
Department of Medical Molecular Genetics, National
by gas formation in the abdominal cavity, urinary ting his throat. The large and deep cut wound in Research Center, Cairo, Egypt and Ancient DNA
bladder, hip, and lower neck (fig 5). The thorax his neck must have been caused by a sharp knife Laboratory, Egyptian Museum, Cairo, Egypt
Ashraf Selim professor of radiology
also seemed to be strongly inflated with air, or other blade. Damage to the throat after death
Sahar N Saleem professor of radiology, Department
together with widened intercostal spaces and a appears to be unlikely, because the collar around
of Radiology, Kasr Al Ainy Faculty of Medicine, Cairo
lateral shifting of the scapulae (fig 6, bmj.com). the mummy’s neck was intact and undamaged University, Cairo, Egypt
This effect could be due to postmortem processes at the unwrapping in 1886, where a thick layer Dina Fathalla molecular biologist, Ancient DNA
Laboratory, Egyptian Museum, Cairo, Egypt
of degradation in the mummy, but other reasons of bitumen was removed with a hammer from the
Sally Wasef molecular biologist, Learning Resource
for the thorax widening should be considered. mummy.15 It is a possibility that the throat was cut Center, Kasr Al Ainy Faculty of Medicine, Cairo University,
In modern cases, diseases such as emphysema during the mummification process. Embalmers Egypt
or death by suffocation can lead to overinflation often restored damages during mummification, Ahmed Z Gad molecular biologist
of the lungs.14 by inserting wooden sticks or replacing missing Rama Saad molecular biologist
Suzan Fares molecular biologist, Ancient DNA
Genetic kinship analyses revealed identical body parts;16 however, a treatment in which the Laboratory, Egyptian Museum, Cairo, Egypt
haplotypes in both mummies (table 1); using throat was cut by the embalmers has not been Hany Amer assistant professor of pharmacology,
the Whit Athey’s haplogroup predictor, we described in any other Egyptian mummy. Department of Animal Reproduction, National Research
Center, Egypt
determined the Y chromosomal haplogroup Further evidence of an assassination comes
Paul Gostner radiologist, Department of
E1b1a. The testing of polymorphic autosomal from the presence of a Horus eye amulet in Radiodiagnostics, Central Hospital Bolzano, Bolzano, Italy
microsatellite loci provided similar results in at the wound. The presence of the amulet deep Yehia Z Gad professor of molecular genetics,
least one allele of each marker (table 2, bmj.com). in the soft tissue of the wound together with Department of Medical Molecular Genetics, National
Research Center, Cairo, Egypt
Although the mummy of Ramesses III’s wife Tiy the homogeneous material that penetrated the
Carsten M Pusch molecular biologist, Institute of
was not available for testing, the identical Y chro- wound up to the bone substantiate the supposi- Human Genetics, Division of Molecular Genetics,
mosomal DNA and autosomal half allele sharing tion that the wound was already present at the University of Tübingen, Tübingen, Germany
of the two male mummies strongly suggest a time of embalming. Most probably, the ancient Albert R Zink paleopathologist, Institute for Mummies
and the Iceman, European Academy, 39100 Bolzano, Italy
father-son re lationship. Egyptian embalmers tried to restore the wound
[email protected]
during mummification by inserting the amulet
We thank the Supreme Council of Antiquities of Egypt for
Discussion (generally used for healing purposes) and by their generous support of this study.
For more details of contributors, funds, competing interests,
This study gives clues to the authenticity of the covering the neck with a collar of thick linen
and references, see bmj.com.
historically described harem conspiracy sur- layers (fig 7, bmj.com). Cite this as: BMJ 2012;345:e8268
40 BMJ | 22-29 DECEMBER 2012 | VOLUME 345
YESTERDAY’S WORLD
Toilet hygiene in the classical era
Philippe Charlier and colleagues describe what the Greeks
and Romans used instead of toilet paper
The first mention of toilet paper It therefore seems likely found during
in the Western world comes from that Trygaeus is referring the American
the 16th century, with a short to the Greek proverb: excavation
description by the French novelist on the Athens
“Three stones are enough
(and physician) François Rabelais agora, for
to wipe one’s arse”
arguing its ineffectiveness.1 China, example,
however, had toilet paper in the “Arms dealer (displaying a are described
2nd century BC,2 and the Japanese cuirass): And what, alack, shall as 3-10.5 cm in REN)
used chuugi (20-25 cm wooden I do with this rounded cuirass, a diameter and 0.6-2.2 WAR
sticks) during the Nara period beautiful fit, worth ten minas? cm thick and having been RY
R
(8th century AD) for both external Trygaeus: Well, that one will not re-cut from old broken ceramics D PE
R
and internal cleaning of the anal make a loss for you, anyway. Give to give smooth angles that would WA
ctisoa ionlefattel .pn Oa ntphoeetr ,re pcauaslirtltyuly ra ebvsea dcilaoaub nsloeet. puAasnpeae l r mcoenA tvrhmeansti eadnte cta otloes rtc: pr Sartipoc eipn. t I.ht . iw .s i ilml bpeu vdeeryn t mpkyeilnsixsim o(wsis icneae an cn suatpill t)l r bcaoeun msseaee.rn4v Ueodsne ian o Gtfh raee e k bcoefy n dHtrouy rraayn cBdeC io)n—ld h“ biasu n8t tatohsc sek pasot m tdhieme ( c1icesknti tnreg N (GIFT OF ED
O
cleaning can be carried out in mockery of my goods! Museum of Fine Arts in Boston that of a defecating cow”— refers ST
O
various ways according to local Trygaeus (placing the cuirass (above). The cup, dating from 6th to complications arising from S, B
cweuxitashtmo wpmaleste )a,r n l(eudas cvilneimgs, aa g tbreai,ds isen,tc ,sl futoodrni negs, oayonnud t h pseuq tgu trahotruteinnedg s lotioknne i eta)s: c Lbhiekasemi dtbheei sirt ,p. i Iofs t i,t cIsteqanulyta,u tartynin dBg Cs wh, iwothwa shs fiaso muclnoadnth i,n isn eOgmr rvaii-iesteod, . sPfohureiclnihps piace nm Caehld aiirrcrliiinetear ataisnosdins at.an8ntht rporpoofelosgsoisrt ,in M OF FINE ART
corn cobs, animal furs, sticks, not clever?”5 The man is maintaining his balance Department of Forensic Medicine and SEU
snow, seashells, and, lastly, hands. This conversation is clearly with a cane in his right hand and is PPaotinhcoalorég yB, oUunleivvearrsdit,y F H-9o2s3pi8ta0l ,G 1a0rc4h Re s, X), MU
During the Greco-Roman period, scatological (as often in clearly wiping his buttocks using a France and Laboratory of Medical Ethics, KYLI
awa fastepsr ou dnsegefede cftioax tecidole ntao;n ta ht hsete si cbpkuo (tnttegorecs kowsra ius m) Abweriipfsoitnroegp athhnaedn beausft)te,t ora ctnhkdiss t. h qIteu t ohlitneere ersef oferer to posetSsrsaookmsae ,w ssimtchha hollli asp rlisee fcsteu hsga gonefd sb.tr othkaetn FpLauhcc_u cBlhtryua onrlf i pMeare@thdoyicalionhgeoi,so Pt. a,f rDrise,p Farratnmceen t of OS PAINTER (
then replaced in a bucket filled seems likely that Trygaeus is ceramic inscribed with names Pathology, University Hospital, Parakou, ROSI
wAnitoht shaelrt twecahtenri oqru vei nweagsa tro w uastee ro.3v al r“eTfherrerien sgt toon tehse a Grere eenko purgohv etorb w: ipe tohsatrta tchies eG trheeeikrs e unseemdi etos ,v cooteu ltdo also BCLilelalner ii3ns s Uen Pivreêrtsreit yr,e Vsiellaerncehuevr,e H dA’ALsMcqA,- IFPraEnL,c e THE AMB
or circular fragments of ceramic one’s arse,” although some have have been used as pessoi, literally Isabelle Huynh-Charlier radiologist,
known as “pessoi” (meaning suggested the stones were for putting faecal matter on the name Department of Radiology, University
pebbles),4 a term also used to balancing the cuirass. of hated individuals. (Examples of Hospital Pitié-Salpêtrière, Paris, France
denote an ancient board game. Many pessoi have been found ostraka with the names of Socrates, Competing interests: None declared
Aristophanes referred to the use within the faecal filling of Greek Themisthocles, and Pericles have Contributors: PC initially conceived, headed
the research, and wrote the majority of the
of pessoi for sanitary purposes in and Roman latrines all around the been found in Athens and Piraeus). manuscript with critical input from LB, CP,
Peace (5th century BC): Mediterranean world (fig 1).6 Pessoi The two pessoi in figure 1 and IHC. All authors had full access to all of
belong to a private collection. the data and are guarantors.
Their precise archaeological origin Provenance and peer review: Not
commissioned; externally peer reviewed.
(discovered in the filling of latrines
1 Rabelais F. Gargantua et Pantagruel, 1, 13.
close to deposits of excrement) 2 Needham J. Science and civilization in China.
and their morphology (rounded Vol 5. Chemistry and chemical technology.
Part 1: paper and printing. Caves Books,
form with the edges recut) clearly
1986:122.
indicate their use for anal cleaning. 3 Seneca. Letters to Lucilius, 70, 20.
Solidified and partially mineralised 4 Papadopoulos JK. A contextual approach to
pessoi (gaming pieces, counters or convenient
excrement can still be seen on the
wipes?). Hesperia 2002;71:423-7.
non-cleaned and lateral surfaces, 5 Aristophanes. Peace [Translation by A
which has been confirmed by Sommerstein]. In: The birds and other plays.
Penguin Classics, 1998.
microscopy (fig 2, bmj.com). 6 Charlier P. Le péril fécal dans l’Antiquité :
The abrasive characteristics of autopsie d’une latrine romaine de Délos.
Feuillets de Biologie 2011;52(299):61-5.
ceramic suggest that long term
7 Colozier E. Quelques monuments inédits
use of pessoi could have resulted d’Utique. Mélanges d’Archéologie et d’Histoire
Fig 1 | Examples of terracotta pessoi (probably from amphora) found in Roman
in local irritation, skin or mucosal 1952;64(64):67-86.
latrines dating from the 2nd century AD. The one on the left comes from Utica 8 Janicke DM, Pundt MR. Anorectal
damage, or complications of
(Sicily), has a diameter of 4.7 cm and a thickness of 1.7 cm, and has been re-cut disorders. Emerg Med Clin North Am
as an octagon.7 The pessos on the right was found in Gortyn (Crete) and has a external haemorrhoids. Maybe 1996;14(4):757-88.
diameter of 6 cm and a thickness of 1.3 cm this crude and satiric description Cite this as: BMJ 2012;345:e8287
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YESTERDAY’S WORLD
John Collins Warren (1778-1856):
An American surgeon in London
David K C Cooper finds that the writings of American surgeon John Collins
Warren provide an insight into medical practice in early 19th century London
J
ohn Collins Warren was born in merely see what is done [that is, act as mere
Boston, Massachusetts, in 1778, observers]. Of course, the former have vastly
into a family noted for its many the greatest opportunities: but the expense is
eminent medical practitioners (web likewise double; as the walker pays £25, the
appendix).1 These included Warren’s dresser £50. Though I do not like to pay so
N
O uncle, a doctor killed in the early much money for one object, I believe I shall
CTI
OLLE stages of the War of American Independence, enter as a dresser; for, as I intend to become
VATE C aMnedd ficaathl eSrc,h oonoel .o Af ltthheo fuoguhn pdreorfse osfs iHoanravlalyr d aa nsdu rsgteeoandi,n I ethssin ink mthaen aucaqlu oirpienrga [toiofn] a o ffa tchieli ty
RI
P successful and respected (box), Warren was utmost importance.”2
John Collins Warren as a young man
a reserved and disciplined man, and few in He was clearly a serious student: “It will
Boston had much affection for him. be necessary . . . to give up every idea of
John Collins Warren’s medical career Warren began to study medicine under amusement and company; for a student who
1778: Born 1 August 1778, in Boston, his father. In 1799, with no hospital or is tolerably disposed to be industrious will find
Massachusetts official medical school in Boston at that every moment of his time fully occupied.”2
time, Warren chose to continue his studies Indeed, dining out at the weekend and an
1797: Graduated from Harvard College
in Europe, beginning in London. In the US, occasional visit to a London theatre were the
1799-1802: Continued medical studies in
surgery remained fairly basic, but because of only breaks Warren allowed himself.
London, Edinburgh, and Paris
the recent studies of John Hunter, surgery in Warren was appointed as dresser to William
1802: Entered surgical practice in Boston
London was becoming an established branch Cooper (circa 1724-1800), who Warren
1806: Adjunct professor in anatomy and surgery of scientific medicine. described as one of the best of men and most
at Harvard College
eminent surgeons in London. Warren was
1810: Lobbied for Harvard Medical School to Impressions of London “immediately put in charge of about forty
move from the “college town” of Cambridge Of London, Warren wrote to his father: “You patients, comprising as interesting a collection
over the river to Boston, which had a much have no idea sir, what a shocking place this of surgical accidents and diseases as could
larger population of potential patients
is in winter. No cold weather, for the grass is be desired. A large number of these patients
1815: Promoted to full professor, on the death perfectly green; but a constant drizzling, that required daily dressing, which I practiced for
of his father. Also gave lectures on physiology keeps the town dirty as a kennel . . . The air is a year faithfully. During my week [on call],
and midwifery
thickened with smoke and vapors, so that it I slept in the hospital . . . I am pitched into a
1816-19: First dean of Harvard Medical School is scarcely respirable; and as for the sun, no surgeon. Obliged to do things of which I never
1812: A founder (and an editor) of the New one can tell you when he was seen. The days saw a case, nor had an idea of, and I think I do
England Medical Journal are five hours long; or, more strictly speaking, very well.”2
1819: Honorary medical degree bestowed on there are five hours of twilight: On his living conditions, Warren wrote: “My
him by Harvard University, his only medical . . . I have, within this week, been obliged to residence, while at Guy’s Hospital, was in St.
qualification stop almost every day, at some part of it, so Thomas Street, close to the hospital. I lived at
1821: A founder of the Massachusetts General totally dark was it.”2 There were, however, a cork-cutter’s, and had two small rooms on
Hospital, serving as its first surgeon “plenty of amusements here: in truth, there is the third story . . . I lived in the usual manner
amusement at every step through the streets of of medical students; that is, entirely by myself.
1837: Second visit to London
London. I constantly meet something new and Food being provided by the landlady, I took it
1845: On 20 January, performed operation
interesting in this wonderful place.”2 in my room. We breakfasted at nine, dined at
under unsuccessful nitrous oxide anaesthesia
three, and drank tea irregularly.”2 (Presumably,
(administered by Horace Wells)
Surgical training in London he returned to work after dining.)
1846: On 16 October, performed the first
Warren spent his most important formative William Cooper left patients largely in the
operation under successful ether anaesthesia
period in surgery at Guy’s Hospital, of which care of his assistants, which suited Warren,
(administered by William Morton)
he considered himself an alumnus. Warren who was keen to gain as much experience as
1847: Presented his collection of anatomical
wrote: “There are two kinds of students in the possible. Twice a week, Cooper “walked round
and pathological specimens to Harvard
hospitals . . . the one called ‘dressers’, and the with his dresser in a very quiet way, making
University, forming the basis of the Warren
other ‘walkers’. The first have the advantage amusing and instructive remarks. He had no
Anatomical Museum
of practicing on all the simple surgical cases, great respect for America, considering her
1851: Third visit to London
and dressing all wounds themselves [that is, as having separated from the British Empire
1856: Died 4 May, in Boston, Massachusetts receive a hands-on experience]: the others before maturity . . . He was a very pleasant
42 BMJ | 22-29 DECEMBER 2012 | VOLUME 345
YESTERDAY’S WORLD
man, however, and occasionally asked me to One evening, Warren dined with a group of
dine with him.”2 physicians whose conversation related to the
Within a few months, William Cooper standing of the medical profession in the UK,
retired and was succeeded by his nephew, which was considered not as high as law. “Mr.
Astley Cooper (1768-1841), who Warren Key [probably Charles Aston Key (1793-1849)
described as “one of the handsomest men of Guy’s Hospital4] complained of their being
I ever saw . . . a young man of the greatest unable to attain the highest honors. Lawyers
natural abilities, and almost adored at the have precedence.”1
hospitals. The obligations I am under to Mr.
Cooper are infinite. He has always treated Warren and anaesthesia
me with the most particular attention, and In his later career in Boston, Warren
suffered no opportunity of instructing me to participated as surgeon in two pioneering
pass by. I wish it were possible to return, in the efforts of anaesthesia at Massachusetts
smallest degree, the favors with which he has General Hospital, both initiated by dentists
loaded me.”2 (box).5 The first effort, using nitrous oxide,
Warren wrote to his father: “There are was unsuccessful. But on 16 October 1846,
operations almost every day . . . the stone, Warren performed an operation for a neck
M
hydrocele, cataract, and amputations NIH/NL tumour under successful ether anaesthesia.
innumerable; but Mr. Cline’s operations (at St. Warren became an enthusiastic advocate of
Warren, circa 1850
Thomas’s) for aneurism and hernia are grand. this major innovation.
It is a pleasure to see him take up or turn his “It was very interesting to me to go
knife. The lectures have gratified me very over the ground I trod more than London, 1851
much; they have such immense advantages fifty years ago, and to compare the In September, Warren revisited Guy’s Hospital
from these (anatomical) preparations. Not a feelings of the period with those of with a student. They examined the museum,
part but is elegantly prepared; some injected the present” dissecting room, library (which he noted to
with quicksilver, some with wax, dried contain some of his books, but none of those
and wet. Every morbid appearance is here London, 1837 on ether), and the room where he used to
preserved . . . You well know how much clearer Arriving in Liverpool, accompanied by his sleep. They also found, in what was described
an idea is conveyed by these specimens than wife and a daughter, Warren soon moved on as the “accident ward,” the sister or nurse—
can be done by a dead, flaccid body. If I had to London. “As we came within the ten miles, the only surviving person who was at the
time, I should make many [specimens] myself; and witnessed the bustling of carriages, hospital when he was a dresser.
but I despair of doing a quarter of what I the continuous line of houses, and saw the Describing the experience in his diary,
wish, here. Dissection is carried on in style: black smoke rising at a distance—although I Warren also wrote: “Finally, I visited what
twelve or fifteen bodies in a room; the young had been formerly a resident, I was in some I never did when there—the chapel of the
men at work on them in different ways . . . measure oppressed by the idea of entering hospital, and the splendid monument of Guy,
The people called resurrection-men [that is, this world with my family.”2 who founded it . . . It was very interesting to
body snatchers] supply us abundantly . . . The One of the first things Warren did was call me to go over the ground I trod more than fifty
surgeons here, considering themselves at the on Astley Cooper, now knighted, who had years ago, and to compare the feelings of the
head of their profession, dare to differ from written: “My old friend Dr. Warren carries in period with those of the present; but, though
everybody else, if they think they have truth his excellent head all the knowledge of the no doubt the balance would be in favor of
with them.”2 Old and New World. I shall be delighted to the first, it was very fascinating, from the
In late 1800, after more than a year at Guy’s see him.”2 Warren presented Cooper with a uncertainty of success, and the predominant
Hospital, Warren left London for Edinburgh copy of his book on tumours. Warren noted feeling that my life would be short.”2
and, six months later, continued his studies in that, at this late stage of Cooper’s career, John Collins Warren—a “Guy’s man”—died
Paris. He returned to Boston in 1802, where “having acquired an ample fortune, he has in Boston, aged 77.
he joined his father in practice. no occasion to submit to the laborious and David K C Cooper professor of surgery, University of
responsible duties of the profession; but Pittsburgh, Thomas E Starzl Transplantation Institute,
Surgical practice in Boston he is ready at stated hours to give advice to Pittsburgh, PA 15261, USA
[email protected]
In 1837, Warren published Surgical those who apply, both at his own house and
Competing interests: None declared.
Observations on Tumors, an illustrated volume in the town. He rises early, and employs two
Provenance and peer review: Not commissioned; not
of over 600 pages. The British and Foreign or three hours in anatomical and surgical
externally peer reviewed.
Medical Review remarked in the book’s review investigations before breakfast; afterwards 1 Truax R. The Doctors Warren of Boston. Houghton Mifflin, 1968.
that “the author proves himself to be a worthy he receives patients at his house till two; then 2 Warren E, ed. The life of John Collins Warren, MD, compiled
chiefly from his autobiography and journals. Volumes 1 and 2.
disciple of the school in which he received his visits till six or seven—the common hour of
Ticknor and Fields, 1860.
early instruction [Guy’s Hospital]; and which, dinner . . . He does not regularly attend any 3 Anonymous. Memoir of John Collins Warren, MD. New England
Historical and Genealogical Register, 1865:XIX,1-12.
connected as it is with the names and celebrity hospital; though, as consulting surgeon of
4 Wilks S, Bettany GT. A biographical history of Guy’s Hospital.
of Cooper, Bright, and others of hardly less Guy’s he is ready to visit when he can be Ward, Lock, Bowden, 1892.
eminence, he seems proud to acknowledge as useful; and his attendance is hailed with 5 Fenster JM. Ether day—the strange tale of America’s greatest
medical discovery and the haunted men who made it. Harper
his alma mater. And surely that school need be pleasure by the surgeons, as a gratifying Collins, 2001.
no less proud to claim him as a pupil.”3 occurrence.”2 Cite this as: BMJ 2012;345:e8251
BMJ | 22-29 DECEMBER 2012 | VOLUME 345 43
YESTERDAY’S WORLD
Placebos in 19th century medicine
Jacqueline E Raicek and colleagues mine the BMJ’s online archive to chart the diverse uses of the placebo effect
Objective To provide the first quantitative data on war with the development and adoption of the on our hypochondriacal and fanciful patients.”7
the use of the term “placebo” in the 19th century. randomised controlled trial.3  4 It is thought that The idea of an ineffective placebo was also
Design Computer search of BMJ’s archival in earlier periods placebos were deceptively and emphasised in pejorative descriptions of unor-
database from January 1840 (the first issue) routinely used in clinical practice and considered thodox practitioners. “It is not an uncommon
through December 1899 for uses of the words an innocuous “pious fraud” to placate “igno- occurrence for a sick person to go to the near-
“placebo(s).” Grounded theory was used to rant . . . disappointed . . . and incurable cases.”5 est apothecary, and get one of the assistants to
categorise the implications of uses of the term. Patients reporting improvements from placebo prescribe some placebo for the more trivial com-
Results 71 citations contained the term were experiencing “imaginary” symptoms.3 This plaints.”8 Homeopathic medicine gives “globules
“placebo(s).” Of these, 22 (31%) used the term understanding of placebo history is based on as placebos.”9 We decided to combine “no effect”
to mean “no effect” or as a general pejorative non-systematic archival evidence and qualitative and “pejorative” because it was often difficult to
term, 18 (25%) portrayed placebo treatment as descriptions. We sought to provide quantitative decide whether any distinction we might perceive
permitting the unfolding of the natural history (the historical data on placebo use in the 19th century. was the intent of the authors.
normal waxing and waning of illness), 14 (20%) Natural history—In this category placebo
described placebo as important to satisfy patients, Methods treatment was equated with the opportunity for
7 (10%) described it as fulfilling a physician’s We included all BMJ articles, reports, and let- allowing patients to use their own ability to get
performance role, 3 (4%) described its use to buy ters between the dates of January 1840, the first well, often within the context of getting good
time, 3 (4%) described its use for financial gain, year of the journal’s publication, and December sleep, eating a healthy diet, and proper care. For
2 (3%) used it in a manner similar to a placebo 1899. We chose the BMJ for the availability of example, physicians wrote that giving placebos
control, and only one implied that placebo could its online historical database, its prominence, provided an opportunity “to place the patient
have a clinical effect. Only one citation mentioned and the likelihood that it represented the medi- in circumstances as favorable as possible to the
telling the patient about his placebo treatment. cal profession’s practices and attitudes. We sanative operations of nature.”10 Another physi-
Conclusion Nineteenth century physicians had searched the BMJ database with the terms “pla- cian reports on a visit to Persia, where a tradi-
diverse a priori assumptions about placebos. cebo” “placebos” and “placebo effect.” We used tional healer, or hakim, “leaves his patient very
These findings remind us that contemporary methods from grounded theory to categorise much to nature, prescribing merely placebos.”11
medicine needs to use rigorous science to citations according to theme.6 (See supplemen- Satisfy patient—We put an article into this cat-
separate fact from its own beliefs concerning the tary material on bmj.com for list of of full meth- egory when there was some indication that the
“provision of care.” As in previous generations, ods, all citations found, and types of article) desire for a treatment came from the patient. For
ethical issues concerning placebos continue to example, a fever was treated with “a saline mix-
challenge medicine. Results ture, with nitric aether, (more as a placebo than
We found 71 citations for “placebo.” All queries because he really seemed in want of medicine).”12
Introduction for “placebos” yielded the same 71 articles, and A bandage was applied to a man’s arm “as a pla-
Currently, placebos are integral to the methodol- we found no articles that mentioned “placebo cebo to satisfy the patient.”13 Included in this cat-
ogy of scientific research. Additionally, placebo effect.” Forty seven of the citations (66%) were egory are cases where the physician dispenses a
treatments are generally thought to affect health in specific sections of the BMJ (such as “Corre- placebo to calm the patient. A physician described
outcomes, especially those based on subjec- spondence” (10%), “Original communications” other physicians treating patients with diarrhoea
tive self appraisal.1 Furthermore, administering (10%), and “Reports of societies” (4%), with the from the “fear only” of cholera, “who upon dis-
placebos deceptively, outside of the concealed remaining 42% distributed among 23 other cat- covering this, gave mere placebos to their patients,
context of clinical trials with informed consent, egories). Twenty four of the citations (34%) were who flocked to them in shoals during the panic.”14
is considered unethical.2 Historians have noted in non-specified sections. Performance—In these citations physicians
that such contemporary notions of placebo Using grounded theory, we distinguished nine described their use of placebo as fulfilling the
gained acceptance only after the second world categories for the use of “placebo” in the 71 arti- requirements of their professional role. There
cles (although there were 75 individual mentions was no contextual implication of patient request;
Primary categories of use of the term “placebo” in of “placebo” in all): no effect or pejorative (31%), the behaviour seemed self generated. When “the
71 citations in BMJ 1840–99 natural history (25%), satisfy patient (20%), patient suffered from disease in which the organs
Category No (%) of citations medical performance (10%), buy time (4%), were so profoundly altered that it was little use
No effect or pejorative 22 (31%) financial gain (4%), placebo control (3%), has attempting to prescribe anything more than a
Natural history 18 (25%) clinical effect (1%), and unclear (1%) (see table). series of placebos.”15 Another physician reports
Satisfy patient 14 (20%) These categories are further explained and con- “while examining her she passed a watery evacu-
Performance 7 (10%) nected with illustrative examples below. ation involuntarily on her bed. I had to do some-
Buy time 3 (4%)
No effect or pejorative—The commonest use of thing, so I resorted to the blister over the vagus,
Financial gain 3 (4%) “placebo” was in a derogatory manner to denote and left a lavender water placebo to be given.”16
Placebo control 2 (3%)
therapy that was ineffective or harmless or valu- Buy time—Three citations described situa-
Has an effect 1 (1%)
able only for imaginary therapies. A typical com- tions where placebo was given to patients for
Unclear 1 (1%)
ment was placebos are an “innocent deception extended periods of time or to extend the time
44 BMJ | 22-29 DECEMBER 2012 | VOLUME 345
YESTERDAY’S WORLD
Discussion
Limitations
Our sample is limited to a single journal, the
BMJ. We selected it because it is one of the old-
est continuous medical journals in the world
with an electronically searchable database,
and because of its affiliation with the British
Medical Association (BMA). We could have
expanded our numbers by using the databases
of other journals, but we decided that limiting
S
GE our search to a single journal would provide a
A
M
Y I valuable proof of principle that quantitative
GETT methods could illuminate the history of place-
MA, BAL/ bsiobsl.e V joeurirfincaaltsi oisn w ina rorathneter de.lectronically acces-
DE
A-TA
M Conclusions
CE AL A priori beliefs concerning dummy treatments
N
RE have been rampant throughout history. In the
W
R” BY LA 1h9avthe cneon itmurpy,a pcth oysni ccilainnisc caol nosuidtceormede ps.l aTcheeb oidse toa
O
CT of what Stuart Wolf first called, in 1950, “the
O
MY D placebo effect” did not exist.26  27 Recently, there
PS, has been interest in the effects of placebo treat-
P
N E ment and the ritual that surrounds all active or
O
NGT inactive medical interventions. Given the recent
ASHI interest in placebo studies,1 there is hope that
W
R rigorous scientific research will correct our own
D
OF contemporary a priori beliefs concerning pla-
RAIT cebos and the “provision of care.” Discovering
RT
PO exactly what effect the ritual of medicine has is
“
Buying time important for a full understanding of clinical
practice and healthcare policy. An expanded
for the physician to make a diagnosis. One phy- equally good results.”21 Another experiment, per- understanding of the underlying neuroscience
sician describes how he used a placebo for three formed in 1889, tested whether mercuric iodide of placebo effects should also help to make
years while he experimented to make lax tym- had value for scarlet fever. The physician “treated vague beliefs more precise.28 Furthermore the
panic membranes tense.17 In order to determine three series of eight cases each simultaneously, absence of an ethical discussion on placebo use
a patient’s “type of appendicitis,” another doctor with iron, mercuric chloride, and a placebo, and, in the 19th century and our own hidden use of
advocated “a carminative placebo” and making on the whole, the latter series did best.”22 placebos in clinical practice29 should remind us
a second visit four hours later.18 Has an effect or unclear—Only one citation that an ethical examination of placebo remains
Financial gain—Three articles clearly sug- was categorised as having an effect on clinical a critical challenge for medicine.
gested that placebos concerned financial incen- outcomes. It was mentioned that in cases of sleep Jacqueline E Raicek researcher, Program in Placebo
tives. One physician described how “some anxiety, “a placebo administered with the assur- Studies and Therapeutic Encounter, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA
medical men” with “starving families” would ance that it is a powerful hypnotic” was “often
02215, USA and University of New England College of
“give globules as placebos.”19 While the author successful.”23 The implication of placebo in one
Osteopathic Medicine, Biddeford, ME 04005, USA
expressed compassion for his peers, he stressed citation could not be ascertained.24 Bradley H Stone researcher
drawing a “broad line between medicine and Ted J Kaptchuk director, Program in Placebo Studies and
homeopathy” and reminded his peers to not bar- Ethical considerations Therapeutic Encounter, Beth Israel Deaconess Medical
ter “principle for pelf [wealth].” Another article Ethical issues (such as administering ineffective Center, Harvard Medical School, Boston, MA 02215, USA
described the opportunity of some physicians to medicine, quackery, earning extra money) were We thank Iain Chalmers for advice.
Contributors: TJK and JER designed the study, analysed the
“swell up the bill” and prescribe an “aqua col. or an overlapping underlying theme in many of the
data, and prepared the manuscript. BHS analysed the data
placebo prescription.”20 articles. Our impression is that placebos were and contributed to the manuscript. TJK is the guarantor.
Placebo control—Two articles used placebo as largely administered deceptively, and patients Funding: The paper is supported in part from NIH NCCAM
a research tool, probably to ensure blind assess- were never told of the “pious fraud.” Only one grants K24 AT004095, R01 AT004662, R01AT005280,
R01 AT006364, and P01 AT006663.
ment. Both took place in the late 19th century case reported disclosure. A placebo disguised as
Competing interests: None declared.
when orthodox medicine began to have interest morphine was given to a patient with morphine
References are in the version on bmj.com.
in blind assessment.4 In one experiment, con- addiction. Three months later, during the follow-
Accepted: 27 November 2012
cerning amblyopia (n=20), performed in 1886, up visit, the physician reported having “a good
Correspondence to: T J Kaptchuk
a physician gave “half the cases strychnine” and laugh [with the patient] over the pious fraud of [email protected]
“in the other half a placebo, with apparently the water hypodermic injection.”25 Cite this as: BMJ 2012;345:e8326
BMJ | 22-29 DECEMBER 2012 | VOLUME 345 45
YESTERDAY’S WORLD
Surgical thimbles
William H Isbister discusses the usefulness of
the humble thimble and its derivatives in a variety
of surgical situations
1
As a child, Christmas meant good pushing a finger through the valve to
food, especially nuts and chocolate, break down the adhesions or by sharp
lots of presents, and party games. We dissection, although this may result in
often played “hunt the thimble,” and valvular insufficiency postoperatively.
sometimes the thimble was hidden Glenn described how a thimble, worn
behind my father’s pile of brown paper on the first finger of the operator’s
wrapped, unopened BMJs. hand, can facilitate and standardise
By 1975 I was married with three this process. To prevent the thimble
children. Our Christmases still involved becoming stuck in or below the valve,
5
fine food and presents but my wife tapes were looped around the thimble
had become a thimble collector and under the surgeon’s glove (fig 1). If it
instead of hunting the thimble I was was difficult to extract the thimble or the ends of the fingernails and Fig 1 | System used to dilate the
heart valves during open heart
“gifting the thimble.” Over the next finger, an assistant pulled on the tapes. underneath the vein. The finger was
surgery2
years, as I travelled to meetings and In his first series, Glenn reported 250 protected from the pin by a thimble.
Fig 2 | Finger protector
conferences, I had the opportunity patients in whom this system had been A ligature was wound around the pin
Fig 3 | Metal thimbles for the left
to seek thimbles out from all over the used with good results. and drawn tight. This process was
forefinger and thumb to facilitate
world, and over time I too became repeated for every dilated vein, so making cotton wool mops3
interested in them. I have devoted my Ear, nose, and throat surgery from eight to 15 pins may have been
Fig 4 | Millard surgical hook retractor
retirement to the hobby of thimble Finger protectors (fig 2) can prevent needed between the ankle and the
Fig 5 | Different types of retractor
collecting and thought that, as a accidental biting injury during intraoral knee. The ligatures and pins were not
based on the tailor’s type open
surgeon, close to Christmas, it might procedures. They might also have removed until the vein had become thimble
be interesting to review the use of the been used by staff trying to secure an necrotic (around 12 days). If the Fig 6 | Device for introducing a pelvic
humble thimble in surgical practice. oral airway during a fit in patients with eschar had not detached by this time drain5  6
epilepsy. it was removed. Velpeau claimed Fig 7 | Thimble for protecting against
Searching for thimbles In 1906, Cresswell Baber developed to have used this method in private finger injury
I searched the BMJ archive for the word metal thimbles for the left forefinger and public practice and that only one Fig 8 | Thimble and wire saw for use
“thimble” and searched on Google and thumb to facilitate making cotton patient died after the procedure. in obstructed labour with a dead
for “surgical thimble.” I excluded wool mops for use in ear, nose, and In 1921 De C Wheeler, vice fetus
thimbles mentioned as foreign bodies throat surgery (fig 3).3 The thimbles president of the Royal College of and it is troublesome to separate one
in the oesophagus or trachea and were flattened and had several Surgeons, Ireland, reported that a from the other.” Surgeons must avoid
non-surgical uses of thimbles. Of 113 shallow and one deeper groove on thimble was “of great assistance cutting too boldly on an unguarded finger
articles identified in the BMJ archive, 11 the opposing surfaces, where the in making a suprapubic opening in the presence of septic peritonitis.
detailed the use of surgical thimbles or metal was dull rather than polished. for drainage in cases of septic A similar technique has been
thimble shaped instruments. According to Baber, “with a little peritonitis.”5 He said that “Before used for draining axillary abscesses
practice mops of any size can be rapidly the primary wound is closed, the after mastectomy. In 1938 the same
The many uses of thimbles made.” The thimbles fitted on to a metal finger guarded with the thimble is technique was described using an
Although surgeons used thimbles for stand and could be boiled before use to introduced into the abdomen and ordinary sewing thimble.7
sewing in the past,1 with the advent reduce the risk of infection. The handles seeks the interval between the recti Surgeons operating in deep cavities
of needle holders this is no longer the were for lifting them off the stand. muscles just above the pubes. With sometimes use the index finger of the
case. Thimbles or thimble derivatives, The Millard surgical hook retractor is the thimble as a guide a stab wound is non-dominant hand to guide the tip of a
however, are used in other surgical used in fine work such as rhinoplasty. rapidly made, dividing all the tissues needle into the correct position. During
situations. The thimble may be worn on the thumb down to the peritoneum. The latter is this process the guiding finger may be
(fig 4) or other finger. Small hooks have pushed forward and is opened by a injured. Accidental finger stick injuries
Cardiac surgery been attached to a tailor’s type open nick of a sharp pointed knife between can occur during normal suturing, as can
In the 1950s, a cardiac surgeon, thimble (fig 5) to create a retractor; the bars carrying the round knob. A scalpel cuts during dissection. Because
William Glenn,2 described the use of several versions are available. drainage tube (Keith’s glass tube for of the risk of HIV infection and hepatitis,
a tailor’s thimble to dilate or split the preference) is fitted to the top of the surgeons usually wear two pairs of gloves
mitral valve during open heart surgery. General surgery thimble and is guided with great ease and some also wear a thimble on the
In patients with severe mitral valve In 1842 Velpeau lectured on his to the bottom of Douglas’s pouch [fig index finger under the glove. A more
stenosis needing surgery, the cusps of method of ligating varicose veins.4 6].” He adds: “If the unguarded finger complex type of thimble, which is worn
the valve are sometimes tightly stuck The trunk of the vein was raised with is used as a guide, the peritoneum outside of the glove and held in place
together. They can be separated by the fingers and a pin passed below stretches itself over the rubber glove with a malleable handle, has recently
46 BMJ | 22-29 DECEMBER 2012 | VOLUME 345
YESTERDAY’S WORLD
2 3 4
6 7 8
been described (fig 7). Thimbles Ophthalmology Thimble splints have been used to testes in the scrotum after surgery for
modified with a “pushing rod” can be Ophthalmologists have used a immobilise fractures that are confined undescended testis. Usually a loop
used to facilitate knot tying in deep thimble with an extension to facilitate to the distal phalanx.11 A plaster of suture is placed in tissue adjoining
cavities with not enough room to tie the eversion of the upper eye lid Paris thimble enclosing the whole digit the testis and brought out through the
a normal knot. The first throw of the (fig 9). This technique was not widely provides adequate immobilisation. scrotal skin. To prevent the tied suture
knot is tied outside the cavity and then used and these thimbles are rare. Aluminium thimbles have also been from cutting through the scrotal skin,
slid down one of the suture ends until used for this purpose (fig 10). the suture is tied over something more
tight using a pusher. The next throw is Orthopaedic surgery substantial. Special buttons, pieces of
similarly tied and then pushed down In the 1930s Nordenbos used fibular Plastic surgery rolled gauze, and even thimbles have
to tighten. Many other simple pushing bone to stabilise femoral neck fractures Breast plastic surgery often involves been used.
devices are also in use, so the thimble in much the same way as Küntscher extensive finger dissection to separate
pusher is not very popular. nails were used later.10 A thimble was breast tissue from surrounding Dental applications
placed over the end to prevent the graft structures, and a thimble has been In 1971, a pair of thimbles was
Obstetrics from shattering as it was hammered devised to facilitate this process. patented that facilitated the use of
In 1875 Gordon described an into the drilled out track between the dental floss (fig 11). The thimbles
“obstetric thimble” for rupturing the greater trochanter and the femoral Urology clamped the floss to the fingers by
amniotic membranes.8 The thimble, head. Thimbles have been used to fix the friction, thus avoiding the need to
which fits on the index finger, had a wrap the floss around the fingertips.
sharp point that curved over the free Floss was held in a container and fed
edge of the nail and which facilitated between the finger and thimble and
the rupture of the membranes. out through an aperture in the top of
In obstructed labour with a the thimble.
dead fetus, it may be necessary to
decapitate the fetus to facilitate Concluding remarks
vaginal delivery. A special thimble has Thimbles have been part of my
10
been devised that allows the fetal neck life at Christmas for many years,
to be encircled with a wire saw (Blond but surprisingly I have never used
Haidler saw). The saw has ball ends a thimble in a surgical procedure
and the thimble has a small opening in myself. The BMJ archive is testimony
one side with a hole at its end to the many uses of thimbles in
(fig 8). The saw ball is inserted into this surgery over the years, and this
opening and the thimble is worn by article attempts to illustrate many
the obstetrician. The thimble bearing of them.
finger is introduced into the vagina and William H Isbister retired professor
passed around the fetal neck. The saw of surgery, Hangstrasse 4, Feucht-
handles are attached after removal of Moosbach 90537, Germany
[email protected]
the thimble. 9 11
Competing interests: None declared.
In 1903 a cocoa butter and cocaine
Provenance and peer review: Not
thimble was used to rapidly dilate the Fig 9 | Thimble with an extension to facilitate the eversion of the upper eye lid commissioned; externally peer reviewed.
cervical os during the first stage of Fig 10 | Thimble splint References are in the version on bmj.com.
labour.9 Fig 11 | Pair of thimbles for facilitating the use of dental floss Cite this as: BMJ 2012;345:e8447
BMJ | 22-29 DECEMBER 2012 | VOLUME 345 47
YYEESSTTEERRDDAAYY’’SS WWOORRLLDD
Barbara Hepworth’s
hospital drawings
Richard Cork shows that artistic inspiration can come
from the most unlikely places
N
obody could have guessed that clear that observing “any element of catastrophe
Barbara Hepworth’s contact with a would be impossible for me,” Hepworth decided
surgeon would suddenly produce, to push aside her misgivings, take up Capener’s
after the second world war, an offer, and scrutinise an operation in Exeter.
outstanding series of drawings The experience was so compelling that Hep-
inspired by hospital operations.1 She was, worth went on to observe further operations at
after all, renowned for her controversial the National Orthopaedic Hospital in London
achievements as an abstract sculptor. So why and the London Clinic. Having produced her first
did she start work on these powerful images hospital drawing in November 1947, Hepworth
of surgeons, while tirelessly visiting operating devoted a prodigious amount of her energy and
theatres in Exeter and London as her fascination imagination to make nearly 80 drawings over the
with the subject deepened? next couple of years. By that time, the National
Hepworth’s involvement with surgery began Health Service had been created, and her strong
in 1944, when her young daughter Sarah had support for this crucial postwar initiative must
osteomyelitis. After Sarah was bandaged “in plas- have added to the extraordinary intensity of her
ter of Paris from head to toe,” Hepworth’s anxiety hospital images.
became intense. But even then she was fascinated Over two decades earlier, the young Hepworth STATE
enough to notice that “the moulding of plaster had made her first contribution to art in a medical RTH E
jackets . . . was very near to my own profession.” context, while still a student at the Royal College WO
P
As Sarah’s illness became protracted, Hepworth of Art in London. As an entry for a scholarship to HE
and her husband, Ben Ni cholson, found the study in Rome, she made a proposal for a “panel NESS,
W
medical bills ever more daunting. Yet she received sculpture” above the main entrance of a hospital. O
B
heartwarming sympathy and support from the The traditional style she adopted bore no relation
Fig 1 | Prelude II
surgeon Norman Capener. Unlike so many British to her subsequent work as a highly audacious art-
art lovers of that period, he relished modern art at ist, who shared Henry Moore’s determination to
its most adventurous. Capener was an amateur revitalise British sculpture. Hepworth became All these drawings show Hepworth’s will-
painter and was particularly fascinated by the one of few women to achieve a prominent posi- ingness to simplify the surgeons and patients
mutually rewarding relation between avant-garde tion as a modernist during the interwar period. alike. Their bodies are purged of all unnecessary
art and music. He told Nicholson that Hepworth’s And now, in the late 1940s, her involvement with detail and reduced to essential forms. But this
sculpture had “a very striking similarity to Bach’s surgical operations proved that drawing could search for minimal reduction does not mean
more abstract work.” Capener began purchasing have a major role in her mature output. that Hepworth lost sight of communicating the
her art, and he also backed up their friendship by Hepworth visited hospitals armed with a pen, fundamental meaning inherent in the medical
waiving his surgeon’s fee. pencil, and sterilised pad. They enabled her to scenes she had studied at first hand. In her exhi-
make swift sketches and notes while scrutinising bition at The Hepworth Wakefield, Wakefield,
Seeing surgeons in action the surgeons as they went through the various the expertise and dedication of the surgeons is
In the summer of 1947, Capener sensed that stages of intricate bone operations. All her ini- clearly evident.
Hepworth’s central involvement with the struc- tial misgivings disappeared, and she grew capti-
ture of the human body might mean that she vated by the spectacle unfolding in front of her. Long and distinguished tradition
would find stimulus in observing an operation. “From the moment when I entered the operating Hepworth takes her place in a long and distin-
He had transferred the ailing Sarah from a mod- theatre,” she remembered, “I became completely guished tradition of great artists who became
est Cornish hospital, near Hepworth’s home absorbed by two things.” The first thing was “the enthralled by the skill and commitment of
in St Ives, to the far larger Princess Elizabeth extraordinary beauty of purpose and coordina- medical practitioners. In my book, The Healing
Orthopaedic Hospital in Exeter. Capener seized tion between human beings all dedicated to the Presence of Art, I single out doctors’ portraits
his moment when he stayed in St Ives to recover saving of life, and the way that unity of idea and by painters as eminent as Francisco de Goya,
from jaundice. Visiting Hepworth, he asked her purpose dictated a perfection of concentration, Vincent Van Gogh, Henri de Toulouse-Lautrec,
if she would like to attend an operation in Exeter movement, and gesture.” Secondly, she was and Frida Kahlo.2 In 1820, Goya painted a mov-
and “see directly the work of surgeons in action.” awed “by the way this special grace (grace of ing Self Portrait with Doctor Arrieta.3  4 Here the
At first, Hepworth reacted with horror and mind and body) induced a spontaneous space stricken, 73 year old Goya is supported by a phy-
denounced his suggestion as “a grim idea.” composition, an articulated and animated kind sician who clasps him while offering a lifesaving
Sarah’s illness still haunted her, and she turned of abstract sculpture very close to what I had glass of medicine. A similar respect distinguishes
down Capener’s proposal. But then, after making been seeking in my own work.” Van Gogh’s Portrait of Trabuc, the head attendant
48 BMJ | 22-29 DECEMBER 2012 | VOLUME 345