On a warm August afternoon a man in his fifties is enjoying a game of bowls in the affluent English town of Tunbridge Wells. Suddenly he passes out and falls to the ground, apparently dead. If this scene were unfolding today, an ambulance would probably arrive in a few minutes, and paramedics would attempt resuscitation before whisking the poor man off to hospital for urgent treatment. But what might have happened three hundred years ago?
Thanks to an extraordinary document in the Bodleian Library in Oxford, reproduced in the Provincial Medical and Surgical Journal in 1846, we have a pretty good idea.
In 1702 the doctor Charles Goodall was staying with friends in Tunbridge Wells when his professional services were unexpectedly requested.
Wellcome Library, London [CC BY 4.0]
The most considerable accident which happened this season was the most sudden and surprising death of that great and eminent peer, the Earl of Kent, the true and full history of whose case is the following.
This was Anthony Grey, the 11th Earl of Kent, then aged 57.
His Lordship came very well to Tunbridge Wells, and continued so for about twelve days. He used no manner of exercise while he stayed, but only walking after morning prayers, for one hour or two, and sometimes after evening prayers, or on the bowling green at Mount Sion. On his Lordship’s last and fatal day, I walked with him from the chapel two or three turns on the walks; he then made an appointment to meet at five in the evening to play at bowls, which he had not done before, nor drunk the waters during his continuance with us. I went at the time appointed, and found my Lord on the green before I got thither, engaged in bowls (if I mistake not), with the Lord George Howard, Lord Kingsale, and Sir Thomas Powis.
A suitably aristocratic foursome.
I gave him an account of some news of which he had not heard, which occasioned some discourse betwixt us; then he went to his bowls, and played (I suppose), two or three games. I went to the other end of the bowling green, and played one game and part of a second, when on the sudden there was a cry, “A Lord is fallen! A Lord is fallen! A surgeon! A surgeon?” upon which I left my bowls, and ran up to his Lordship, and found him dead on the ground, he having neither pulse nor breath, but only one or two small rattlings in the throat, his eyes being closed.
‘Neither pulse nor breath’ seems pretty final: respiratory and cardiac arrest. Today any competent first-aider would administer CPR, but this is a surprisingly modern technique, first described as late as 1958. I at first assumed that an 18th-century medic would realise the case was hopeless, but Dr Goodall was not so easily defeated.
He was bled immediately on both arms to the quantity of ten or twelve ounces, as computed.
Slightly more than half a pint. The fact that they were able to extract so much blood suggests that total cardiac arrest had not yet occurred; it is possible that although the pulse was too faint to be detectable at the wrist, the heart was still pumping, albeit weakly.
In the meantime I put up the strongest snuff and spiritus salis armoniaci into both nostrils, and ordered two ounces of vinum benedictum to be brought with all speed. The apothecary (Mr. Thornton) sent for three ounces, which he poured down his throat, not spilling one drop.
‘Spiritus salis armoniaci’ is sal ammoniac, a crystalline form of ammonium chloride, an expectorant. ‘Vinum benedictum’ is antimonial wine, wine adulterated with the toxic metal antimony and used as an emetic. The doctor hoped to shock the earl back to life by provoking an extreme reaction: sneezing, coughing or vomiting.
As soon as this was done we carried my Lord (in a chair) off the bowling green through the dancing-room into a very sorry bedchamber, one pair of stairs. I supported his Lordship’s head (which otherwise would have fallen on one side, or backwards, or forwards) with my hands and breast, till he was placed on a bed in a little room; when this was done, I cried out for a surgeon to apply six or eight cupping glasses to his Lordship’s shoulders with deep scarification; but no surgeon or apothecary (although one of the former and one of the latter were present) had any, neither was there any to be had on the walks, (as was answered by the surgeon or apothecary present), nor could have been procured if the Queen’s life had lain at stake on Tunbridge Wells.
Scarification with cupping was a mild form of bloodletting: small incisions were made in the skin, and the cupping glasses drew out a small amount of blood through suction.
When I found myself thus unhappily disappointed, I ordered his head to be shaved, and a large blister to be applied to capiti raso, as also another to the breadth of neck and shoulders.
A blister was just what it sounds like: a harsh inflammatory substance was applied to the skin, usually on a plaster, in an attempt to provoke blistering and force toxins out of the body. The doctor also administered several spoonfuls of buckthorn syrup, a laxative. He was then joined by a colleague, one Dr Branthwait, who had heard the news and hurried to offer his assistance. He suggested giving the dying man a ‘proper julep’ (a refreshing infusion of herbs). The two medics certainly intended to be thorough. But the treatment was about to get still more extreme:
Then Doctor West came, who advised a frying pan made red hot to be applied to the head…
This sounds like desperation, and probably was.
…however there appeared not the least breath, pulse, or life in my Lord, (though one or two physicians thought that there was some little umbrage thereof), so that in short we had very slender hopes of his Lordship’s case, or little or no encouragement from any application used.
At this point Dr Goodall became frustrated that the room was ‘crowded with lords and gentlemen’, and asked them all to leave. One, the Bishop of Gloucester, went to break the news to the Earl’s daughter, who lived a mile away.
She was (as must be imagined) upon the hearing of this news in a very great passion, crying out, “Is my Lord dead? is my Lord dead? tell me, my Lord, plain truth”; which being owned by the Bishop that his Lordship was dead, and of an apoplexy, she asked him whether cupping-glasses had been applied, and resolved to go to her dear father. But that being prudently prevented, she positively told the Bishop that she neither could nor should be satisfied unless her father was brought to his own lodging, which was both promised and performed, it being my judgment that the motion of the coach, with the warmth of my Lord’s servant, who kept his body in an upright erect position by grasping him round the waist, might conduce to the operation of the vomit and purge which had been given him some hours before, if there was the least warmth or life left in his stomach or bowels, which might be so, though indiscernible to us.
This was surely a forlorn hope: it sounds as if the poor man had died within minutes of his original collapse. Nevertheless, the earl’s corpse (presumably) was propped up in a coach and taken to his own lodgings. Even now the treatments continued:
As soon as his Lordship was put into his warm bed we ordered several pipes of tobacco thoroughly lighted to be blown up the anus, which we thought might be of use, when we could not have the advantage of tobacco glysters.
A ‘glyster’ is an enema. Tobacco enemas were widely used at this date in resuscitation – the standard treatment in cases of drowning. So although blowing tobacco smoke up a dead man’s bottom may sound eccentric, it was perfectly orthodox therapy. The doctors were now at their wits’ end, so tried one more extreme treatment as last resort.
After this was done, upon a suggestion of Sir Edmund King’s, the bowels of a sheep killed in the house were applied to his Lordship’s stomach and belly, but all without the least success, though we were reasonably encouraged to make use of all proper remedies in so great a case, many apoplecticks having come to life a considerable time after they appeared dead to all human sense.
An ‘apoplectick’ is one who suffers apoplexy – what we would call a stroke or cerebrovascular accident (CVA). Stroke patients do indeed sometimes lapse into a coma and later recover, and three hundred years ago medics often had great difficulty telling the difference between coma and death. Without a stethoscope it was impossible to be absolutely sure that the heart had stopped beating; in some cases it was only safe to declare that death had occurred once rigor mortis had set in. In that context, Dr Goodall’s perseverance in his resuscitation efforts is quite understandable.
The letter concludes with a lengthy discussion of the differential diagnosis. Dr Goodall was strongly of the opinion that he had ‘died of an apoplexy’, i.e. a stroke. On the face of it this seems a reasonable conclusion: a massive bleed into the brain might cause more or less instant cardiac arrest and death shortly afterwards. There are, of course, many other possibilities: a heart attack or cardiac arrhythmia, or a burst aneurysm, for instance. But several of his colleagues dissented from his view:
Some were of an opinion that his Lordship did not die of an apoplexy, but of a syncope, or imposthume.
‘Syncope’ means little more than ‘loss of consciousness’ – meaningless as a diagnosis, since it is a symptom rather than the underlying cause. An impostume is an abscess, implausible as a sudden cause of death; as Dr Goodall rightly points out, even if the abscess were pressing on the brain it would be likely to provoke symptoms of infection long before the terminal event. In a detailed discussion of apoplexy, he observes that his colleagues fail to distinguish between a ‘total’ and ‘partial’ apoplexy. True, some stroke patients are only slightly affected, maybe with a degree of paralysis, and remain conscious; but others are so catastrophically damaged that
the patient is (as it was) planet-struck, or knocked down by a club, or butcher’s axe, never more to move hand or foot after.
Into this category, he argues, fell the unfortunate Earl of Kent.
Thus fell this great and noble peer, much lamented by all who knew his Lordship.
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