Feature Christmas 2010: History

Acting on evidence

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5168 (Published 14 December 2010) Cite this as: BMJ 2010;341:c5168
  1. John Powell, associate clinical professor in epidemiology and public health
  1. 1Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
  1. Correspondence to: john.powell{at}warwick.ac.uk

How the BMJ archive was used to raise three ghosts of The London Hospital

The arrogant junkie surgeon, the maverick heart throb, and the pioneering genius: it could be a roll call for the medical department of any teaching hospital. Casualty 1909 was a BBC1 drama series (14 June–19 July 2009) set in The London Hospital in Edwardian times. The series made extensive use of the BMJ archive to construct convincing medical storylines from the first decade of the twentieth century, and to put flesh on the bones of the principal medical characters, who were based on real doctors of the period.

Figure1

Fig 1 One of the prosthesis artists puts the finishing touches to a perforated femoral vein. With permission from Stone City Films

Henry Percy Dean

In 1909, Henry Percy Dean was a surgeon and teacher of operative surgery at The London Hospital.1 As his obituary in the BMJ noted, Dean was a brilliant medical student at University College London1 and became one of the leading figures in the introduction of spinal anaesthesia, authoring a classic paper on the use of stovaine in the BMJ of 1906.2 The sentiment of this paper was succinctly paraphrased in Dean’s line, as used in the BBC series: “Observe how the possibility of surgical shock previously common in abdominal surgery has been all but eliminated by the use of stovaine anaesthesia via lumbar injection.” Unfortunately Dean’s predilection for tropane alkaloids extended beyond his professional practice and his cocaine addiction became an open secret at The London.

Sir Arthur Keith, responding to the announcement of Dean’s death, gave this revealing portrait in a letter to the BMJ of 1931: “If he had fulfilled the promise which we who were associated with him at the London Hospital thirty-five years ago perceived, he would have died the leading surgeon of his time .… He seemed destined to reap the highest rewards his profession could confer on its most distinguished votaries. What happened? I cannot tell. All I know is that some tragedy in his life robbed modern surgery of a man who, if things had been otherwise, would have left on its progress an enduring memorial.”3

In the drama of Casualty 1909, the story of the early days of spinal anaesthesia is interwoven with Dean’s personal struggles. Dean’s professional performance begins to suffer and ultimately one of his ward nurses turns whistle-blower. In his own case reports Dean acknowledged the incidence of headache following spinal anaesthesia,2 a finding replicated in other contemporary case series,4 and in Casualty 1909 Dean’s patients increasingly complain of this side effect. Dean makes a (fictionalised) mistake in the administration of spinal anaesthesia in one patient, who does not regain movement in his lower limbs, and subsequently misses the diagnosis of a ruptured urethra while operating on a patient with a fractured pelvis and punctured femoral vein. Figure 2 shows the reconstruction of the surgery.

Figure2

Fig 2 Mr Dean (actor Paul Hilton) operates under spinal anaesthesia to remove a spicule of bone from the vein. With permission from Stone City Films

Disappointingly, reference to Poupart’s ligament (the inguinal ligament), which appeared in the initial script, did not make the final draft. Other details from the 1912 BMJ source article were used by the prosthetics department to construct the pelvic model for the procedure: “A longitudinal incision about 4 in long was made over the tumour. On cutting through the integument and deep fascia, dark clots and about a pint of dark fluid blood were turned out”5

Although Dean’s struggle with cocaine would cost him his role as full surgeon at The London, he won a victory in the battle over the introduction of spinal anaesthesia. In a key scene he persuades the house committee of The London to release an unprecedented statement in support of this innovative method. This announcement was noted in the BMJ of 12 June 1909 by hospital surgeon Lawrie McGavin.6 In fact, the BMJ archive revealed that 1909 was a key year in the regulation of anaesthetic practice and the emergence of the specialty of anaesthetics. As well as reports of the passage of the Anaesthetic Bill7 and the accompanying debate, in the Christmas 1909 issue of the BMJ, one correspondent, the eminent anaesthetist Sir Frederic Hewitt, again of The London, also drew attention to the dangers of single handedly anaesthetising and operating.8

Millais Culpin

Millais Culpin worked in the receiving room of the London Hospital in the early 1900s,9 and he was later to become a leading figure in psychology. Culpin was one of the first to recognise the benefits of psychological treatment for post-traumatic stress disorder (in people with shell shock from the first world war).10 Culpin’s early interests in hysteria and so called functional disorders11 12 are dramatised through his dealings with the psychological issues affecting many of the patients passing through the receiving room.

One fictionalised case is that of a Mrs Anderson, a woman with depressive symptoms and a fondness for gin who is admitted after ingesting a questionable anti-corpulent preparation. Such “secret remedies” were a widespread phenomenon of the period, as recorded in a series of BMJ articles and a book published by the BMA in 1909.13 14 In Casualty 1909, Culpin takes a keen interest in cases of attempted suicide (illegal in England and Wales until 1961) and in one incident deals with a case of caustic soda ingestion. The symptoms and treatment (“gastric lavage and lemon juice”) were recorded in a BMJ case study.15 In another case, continuing his encounters with the social and legal issues of the time, Culpin completes an abortion in a prostitute who has only partly succeeded in undertaking the procedure herself. The woman has symptoms of lead poisoning, having consumed lead pills as an abortifacient. The archive revealed this was a common practice of the time.16 Culpin’s work in the receiving room is also useful to demonstrate some now outmoded treatments revealed by the archive, for example, the use of strychnine as a “vascular tonic” in heart disease.17

All dramas require romance, and in Casualty 1909 this is provided by a nurse Ethel Bennett. One passionate kiss is as far as the relationship between Culpin and Bennett progresses on screen, but from his BMJ obituary we know that, “In 1913 Dr. Culpin married Miss Ethel Maude Bennett, daughter of Mr. E. Dimery Bennett.”9 The production company were also able to trace the couple’s descendants and read Nurse Bennett’s own diaries from the time. In the series, Ethel’s brother dies following an appendicectomy, an operation which at the time had “an acknowledged mortality of 3.3 per cent.”18

Henry Head

The appositely named Henry Head is a key figure in the history of neurology, in particular for his pioneering work on sensation.19 In 1909 he was assistant physician at The London Hospital. Head is perhaps best known for his experiment in nerve regeneration when, as Head himself related in the BMJ, he “determined to bring clinical results to an experimental test by dividing the radial and external cutaneous nerves.”20 Head undertook the procedure on his own arm and the (in)famous scene is re-enacted in Casualty 1909. In the years following this pioneering self-experiment, Head and his renowned colleague W H R Rivers meticulously documented the slow recovery of sensation.19

Head’s discursive papers in the BMJ, such as an essay on the nomenclature of disease,21 and an address on the nature of pain,22 reveal something of the philosophical character of this Renaissance man, who was also a published poet and close friend of Siegfried Sassoon. Indeed, he coauthored a letter in the BMJ, affirming that “philosophic studies would be of advantage to many medical men, both by expanding and defining their outlook in relation to general or individual experiences and by affording assistance in the solution of practical difficulties.”23 Like Culpin, Head had an early interest in psychology and in the relation between mental states and physical illness. In an address on hysteria, he wrote, “the general physician is scarcely familiar with the psychical aspect of medicine; he and his colleague, the surgeon, rarely consider how large a part the mind plays even in the symptoms of gross structural disease.”24

In Casualty 1909, Head’s thoughtful nature and clinical acumen are illustrated in his astute diagnosis of polio in a recent immigrant (unusual in London at that time, although sporadic cases did occur)25; in his treatment of an unusual case of disseminated sclerosis (multiple sclerosis, treated with strychnine); and in his dealings with a histrionic young actress who has concealed her identity and thrown herself under a horse tram.

Postscript

Henry Percy Dean retired from the active staff of the London Hospital in 1913 at the age of 49, to take up the teaching post of consulting surgeon.1 He died 16 years later having never fulfilled his early promise.3 Millais Culpin went on to hold the chair in medical and industrial psychology at the London School of Hygiene and Tropical Medicine and became president of the British Psychological Society.9 He died in 1952, aged 78. Henry Head continued to practise and teach medicine, and to undertake neurological research, until his retirement in 1925, aged 64, when Parkinson’s disease began to take its toll. He received a knighthood in 1927 and died in 1940.19 With the assistance of the BMJ archive, Sir Henry Head and his colleagues were able to walk the wards of The London once again.

Notes

Cite this as: BMJ 2010;341:c5168

Footnotes

  • JP worked as medical adviser to Casualty 1909 and undertook research on the BMJ archive to inform the work of the writers and script executive. Casualty 1909 was produced by Bryn Higgins and executive produced by Clare Duggan as a Stone City North production for BBC1. It was written by Colin Heber-Percy, Lyall B Watson, Stephen Davies, and Simon Block. The script executive was Hilary Norrish. The London Hospital archives were researched by Jonathan Evans, archivist at The Royal London Hospital.

  • The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the author) and declares no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and that he worked for Stone City Films as medical adviser to Casualty 1909.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

References